Clinical Pathways
Clinical Pathways
Suspected Facial/Alveolar Ridge Fractures
Suspected Facial/Alveolar Ridge Fractures

Suspected Facial/Alveolar Ridge Fractures

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Action

  1. Order x-rays/panoramic x-ray/CT (Class I)
    • CT may not be possible in all urgent care settings. The development of protocols to standardize patient management is recommended, along with communication with emergency department staff and specialty teams.
  2. Consult specialist as indicated (Class II)
  3. Treat injury:
    • Enamel injury: File or smooth as necessary. (Class II)
    • Dentin injury:
      1. Perform supraperiosteal infiltration;
      2. Cover with calcium hydroxide paste;
      3. Arrange follow-up care within 24 hours with dentist. (Class I)
    • Pulp injury: Same as dentin except with immediate dental consultation in the ED. (Class I)
    • Avulsion*:
      1. Replace if <1 hour of dry time since avulsion. Consider chest x-ray/panoramic x-ray if tooth whereabouts unknown;
      2. Splint with periodontal paste, self-cure composite, or bonding materials;
      3. Prescribe doxycycline or penicillin. (Class I)

        4. *Do not replace avulsed tooth if alveolar ridge fractures are present. *Do not replace avulsed primary teeth.

    • Intrusion: X-ray if necessary to find intruded tooth. (Class I)
    • Subluxation/luxation: If significant mobility, splint as above. (Class I)
  4. Repair any mucosal injury, if indicated, with absorbable suture (Class II)

Background

Alveolar Ridge Fractures

Alveolar ridge fractures require urgent rigid splinting of the affected segment by a specialist since more severe alveolar ridge fractures have the potential for displacement of the segment and subsequent aspiration risk. If the fracture is small, not grossly mobile, and the patient is reliable, an urgent follow-up with a specialist within 24 hours is reasonable.

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References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study is included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the authors, are noted by an asterisk (*) next to the number of the reference.

  1. Ulusoy AT, Onder H, Cetin B, et al. Knowledge of medical hospital emergency physicians about the first-aid management of traumatic tooth avulsion. Int J Paediatr Dent. 2012;22(3):211-216. (Survey; 69 emergency physicians)
  2. Needleman HL, Stucenski K, Forbes PW, et al. Massachusetts emergency departments' resources and physicians' knowledge of management of traumatic dental injuries. Dent Traumatol. 2013;29(4):272-279. (Survey; 74 physicians)
  3. Wall T, Vujicic M. Emergency department use for dental conditions continues to increase. April 2015. (Research brief)
  4. Goettems ML, Thurow LB, Noronha TG, et al. Incidence and prognosis of crown discoloration in traumatized primary teeth: a retrospective cohort study. Dent Traumatol. 2020;36(4):393-399. (Retrospective cohort study; 335 patients)
  5. Herrera D, Alonso B, de Arriba L, et al. Acute periodontal lesions. Periodontol 2000. 2014;65(1):149-177. (Review)
  6. Magraw CB, Golden B, Phillips C, et al. Pain with pericoronitis affects quality of life. J Oral Maxillofac Surg. 2015;73(1):7-12. (Survey; 113 patients)
  7. Klasser GD, Kugelmann AM, Villines D, et al. The prevalence of persistent pain after nonsurgical root canal treatment. Quintessence Int. 2011;42(3):259-269. (Survey; 250 patients)
  8. Schott CK, Counselman FL, Ashe AR. A pain in the neck: non-traumatic adult retropharyngeal abscess. J Emerg Med. 2013;44(2):329-331. (Case report)
  9. Huang TT, Tseng FY, Liu TC, et al. Deep neck infection in diabetic patients: comparison of clinical picture and outcomes with nondiabetic patients. Otolaryngol Head Neck Surg. 2005;132(6):943-947. (Retrospective; 185 patients)
  10. Liu CF, Weng SF, Lin YS, et al. Increased risk of deep neck infection among HIV-infected patients in the era of highly active antiretroviral therapy--a population-based follow-up study. BMC Infect Dis. 2013;13:183. (Retrospective case control study; 9888 HIV patients matched with 49,440 controls)
  11. Noy D, Rachmiel A, Levy-Faber D, et al. Lemierre's syndrome from odontogenic infection: Review of the literature and case description. Ann Maxillofac Surg. 2015;5(2):219-225. (Literature review)
  12. Karkos PD, Asrani S, Karkos CD, et al. Lemierre's syndrome: a systematic review. Laryngoscope. 2009;119(8):1552-1559. (Systematic review; 84 studies) DOI: 10.1002/lary.20542
  13. Patel SB, Boros AL, Kumar SK. Atypical odontalgia--an update. J Calif Dent Assoc. 2012;40(9):739-747. (Review)
  14. Hiremath G, Kidiyoor KH. Avulsion and storage media. J Investig Clin Dent. 2011;2(2):89-94. (Review)
  15. Poi WR, Sonoda CK, Martins CM, et al. Storage media for avulsed teeth: a literature review. Braz Dent J. 2013;24(5):437-445. (Literature review; 234 papers screened and 39 reviewed) DOI: 10.1590/0103-6440201302297
  16. Mousavi B, Alavi SA, Mohajeri MR, et al. Standard oral rehydration solution as a new storage medium for avulsed teeth. Int Dent J. 2010;60(6):379-382. (In-vitro study; 75 teeth)
  17. Adnan S, Lone MM, Khan FR, et al. Which is the most recommended medium for the storage and transport of avulsed teeth? A systematic review. Dent Traumatol. 2018;34(2):59-70. (Systematic review; 67 articles)
  18. Malmgren B, Andreasen JO, Flores MT, et al. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 3. Injuries in the primary dentition. Dent Traumatol. 2012;28(3):174-182. (Guidelines) DOI: 10.1111/edt.12576
  19. Miller WD, Furst IM, Sandor GK, et al. A prospective, blinded comparison of clinical examination and computed tomography in deep neck infections. Laryngoscope. 1999;109(11):1873-1879. (Prospective blinded comparison; 35 patients)
  20. Caputo ND, Raja A, Shields C, et al. Re-evaluating the diagnostic accuracy of the tongue blade test: still useful as a screening tool for mandibular fractures? J Emerg Med. 2013;45(1):8-12. (Prospective trial; 190 patients)
  21. Chayra GA, Meador LR, Laskin DM. Comparison of panoramic and standard radiographs for the diagnosis of mandibular fractures. J Oral Maxillofac Surg. 1986;44(9):677-679. (Retrospective; 88 fractures compared Panorex versus hospital mandibular series)
  22. Pollack CV, Jr. Coagulation assessment with the new generation of oral anticoagulants. Emerg Med J. 2016;33(6):423-430. (Review)
  23. Christensen BJ, Park EP, Suau S, et al. Evidence-based clinical criteria for computed tomography imaging in odontogenic infections. J Oral Maxillofac Surg. 2019;77(2):299-306. (Prospective cohort study; 129 patients) DOI: 10.1016/j.joms.2018.09.022
  24. Christensen BJ, Park EP, Nelson S, et al. Are emergency medicine physicians able to determine the need for computed tomography and specialist consultation in odontogenic maxillofacial infections? J Oral Maxillofac Surg. 2018;76(12):2559-2563. (Retrospective case series; 72 patients)
  25. Weyh A, Busby E, Smotherman C, et al. Overutilization of computed tomography for odontogenic infections. J Oral Maxillofac Surg. 2019;77(3):528-535. (Retrospective cross-sectional study; 470 patients)
  26. Becker DE. Pain management: part 1: managing acute and postoperative dental pain. Anesth Prog. 2010;57(2):67-78. (Review)
  27. Van Dyke T, Litkowski LJ, Kiersch TA, et al. Combination oxycodone 5 mg/ibuprofen 400 mg for the treatment of postoperative pain: a double-blind, placebo- and active-controlled parallel-group study. Clin Ther. 2004;26(12):2003-2014. (Prospective double-blind study; 498 patients) DOI: 10.1016/j.clinthera.2004.12.002
  28. Forbes JA, Kehm CJ, Grodin CD, et al. Evaluation of ketorolac, ibuprofen, acetaminophen, and an acetaminophen-codeine combination in postoperative oral surgery pain. Pharmacotherapy. 1990;10(6 ( Pt 2)):94S-105S. (Double-blinded randomized trial; 206 patients)
  29. Shahakbari R, Eshghpour M, Rajaei A, et al. Effectiveness of green tea mouthwash in comparison to chlorhexidine mouthwash in patients with acute pericoronitis: a randomized clinical trial. Int J Oral Maxillofac Surg. 2014;43(11):1394-1398. (Randomized trial; 97 patients)
  30. Lynch MT, Syverud SA, Schwab RA, et al. Comparison of intraoral and percutaneous approaches for infraorbital nerve block. Acad Emerg Med. 1994;1(6):514-519. (Prospective randomized crossover; 12 patients)
  31. Agnihotry A, Thompson WF, Z, van Zuuren E, et al. Antibiotic use for irreversible pulpitis. Cochrane Database Syst Rev. 2019;5(5):CD004969. (Cochrane review) DOI: 10.1002/14651858.CD004969.pub4
  32. Ellison SJ. An outcome audit of three day antimicrobial prescribing for the acute dentoalveolar abscess. Br Dent J. 2011;211(12):591-594. (Prospective study; 188 patients)
  33. Kouassi YM, Janvier B, Dufour X, et al. Microbiology of facial cellulitis related to dental infection. Med Mal Infect. 2011;41(10):540-545. (Prospective observational study; 100 patients)
  34. Tsilingaridis G, Malmgren B, Andreasen JO, et al. Intrusive luxation of 60 permanent incisors: a retrospective study of treatment and outcome. Dent Traumatol. 2012;28(6):416-422. (Retrospective; 60 intruded teeth)
  35. Trope M. Avulsion of permanent teeth: theory to practice. Dent Traumatol. 2011;27(4):281-294. (Review)
  36. Day PF, Duggal M, Nazzal H. Interventions for treating traumatised permanent front teeth: avulsed (knocked out) and replanted. Cochrane Database Syst Rev. 2019;2(2):CD006542. (Systematic review; 4 studies, 183 patients) DOI: 10.1002/14651858.CD006542.pub3
  37. Ritter AL, Ritter AV, Murrah V, et al. Pulp revascularization of replanted immature dog teeth after treatment with minocycline and doxycycline assessed by laser Doppler flowmetry, radiography, and histology. Dent Traumatol. 2004;20(2):75-84. (Canine trial; 38 teeth)
  38. Andersson L, Andreasen JO, Day P, et al. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth. Dent Traumatol. 2012;28(2):88-96. (Guidelines)
  39. Tsilingaridis G, Malmgren B, Skutberg C, et al. The effect of topical treatment with doxycycline compared to saline on 66 avulsed permanent teeth--a retrospective case-control study. Dent Traumatol. 2015;31(3):171-176. (Retrospective case-control study; 66 teeth in 50 patients)
  40. Hile LM, Linklater DR. Use of 2-octyl cyanoacrylate for the repair of a fractured molar tooth. Ann Emerg Med. 2006;47(5):424-426. (Case report)
  41. Daly B, Sharif MO, Jones K, et al. Local interventions for the management of alveolar osteitis (dry socket). Cochrane Database Syst Rev. 2022;9(9):CD006968. (Cochrane review)
  42. Jesudasan JS, Wahab PU, Sekhar MR. Effectiveness of 0.2% chlorhexidine gel and a eugenol-based paste on postoperative alveolar osteitis in patients having third molars extracted: a randomised controlled clinical trial. Br J Oral Maxillofac Surg. 2015;53(9):826-830. (Randomized trial of chlorhexidine vs eugenol vs control; 270 patients)
  43. Rodríguez Sánchez F, Rodríguez Andrés C, Arteagoitia Calvo I. Does chlorhexidine prevent alveolar osteitis after third molar extractions? Systematic review and meta-analysis. J Oral Maxillofac Surg. 2017;75(5):901-914. (Systematic review and meta-analysis; 23 studies, 2824 extractions)
  44. Cheng D. Unified hands technique for mandibular dislocation. J Emerg Med. 2010;38(3):366-367. (Case report)
  45. Gorchynski J, Karabidian E, Sanchez M. The "syringe" technique: a hands-free approach for the reduction of acute nontraumatic temporomandibular dislocations in the emergency department. J Emerg Med. 2014;47(6):676-681. (Prospective convenience sample, multicenter study)
  46. Torabinejad M, Dinsbach NA, Turman M, et al. Survival of intentionally replanted teeth and implant-supported single crowns: a systematic review. J Endod. 2015;41(7):992-998. (Meta-analysis and systematic review)
  47. Martins-Junior PA, Franco FA, de Barcelos RV, et al. Replantation of avulsed primary teeth: a systematic review. Int J Paediatr Dent. 2014;24(2):77-83. (Systematic review; 891 papers screened and 19 reviewed)
  48. Kahler B, Heithersay GS. An evidence-based appraisal of splinting luxated, avulsed and root-fractured teeth. Dent Traumatol. 2008;24(1):2-10. (Systematic review; 12 studies)

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