Management of trauma to supporting dental structures

Teeth, periodontium, and supporting alveolar bone are frequently involved in trauma and account for approximately 15% of all emergency room visits. The cause of the dentoalveolar trauma varies in different demographics but generally results from falls, playground accidents, domestic violence, bicycle accidents, motor vehicle accidents, assaults, altercations, and sports injuries. Dentoalveolar injuries should be considered an emergency situation because successful management of the injury requires proper diagnosis and treatment within a limited time to achieve better outcomes.

Intimate partner violence: implications for critical care nursing

IPV presents a serious health risk to many women. Emergency and critical care nurses are in a prime position for identification of and intervention with these women. Careful assessment and recognition of symptoms and conditions associated with IPV helps nurses to identify victims and potential victims. Building a trusting and supportive environment, where women feel comfortable disclosing abuse, precedes effective intervention. Nursing practice can incorporate the myriad resources and successful programs to provide victims with quality care. Before discharge from the critical care unit or ED, nurses can help women to identify their risk and plan for safety. Effective nursing care in IPV combines the traditional critical care nursing skills synergistically with provision for the biopsychosocial needs of patients.

Treatment and prevention of alveolar fractures and related injuries

Dentoalveolar trauma does not pose a significant morbid risk for the trauma patient. However, the long-term consequences of mismanagement can be devastating. Early, correct diagnosis, and appropriate referral of these injuries can affect the success of treatment. Failure to recognize or obtain appropriate consultation can result in premature tooth or alveolar bone loss, resulting in problematic prosthetic rehabilitation. The purpose of this article is to review the concepts of recognition, management, and prevention of dentoalveolar trauma. In situations where the possibility of trauma is likely, such as in athletics, dentoalveolar and related fractures can be prevented through the use of mouthguards fabricated by health care professionals.

[Tooth and jaw injuries following violence--diagnosis and treatment in emergency department]

Research over the last decade has confirmed that facial injuries caused by violence occur most frequently among young males, often under the influence of alcohol, and less frequently in women and children following domestic violence. Evidence of injuries may be used in court or in claims for compensation, and must be carefully documented. Facial asymmetry, deviation of the mandible in opening, altered occlusion and/or abrasions under the chin may be indications of jaw fractures; such patients are referred to oral surgery units for further treatment. Lacerations and ulceration in the oral mucous membrane should be treated as skin wounds. A fractured tooth should be referred to a general dental practitioner. Luxated teeth should be carefully replaced and immediately referred to a dentist for fixation. Completely avulsed teeth should immediately be replaced, preferably at the site of the accident, or immediately upon arrival at the clinic. Prompt referral to a dental practitioner for follow-up treatment is essential for the success of replantations. Additional documentation of the injury may be provided by photographs, radiographs and drawings. The letter of referral to the dentist should contain the following information: data on the patient, the circumstances, clinical findings, treatment performed and prescriptions given, together with advice given to the patient.

Fractures of the maxilla

A basic understanding of midface fractures is essential for those involved in the initial evaluation, emergency and general management, diagnosis, specialty consultation, and maxillofacial surgery of patients with fractures of the maxilla. To achieve the goal of restoring proper form and function to the upper jaw and face, one must be able to recognize, diagnose, and treat maxillary fractures. This requires knowledge of the anatomy and physiology of the midface, as well as modalities of evaluation and treatment. Each of these topics are summarized in this paper.

A management strategy for palatal fractures: a 12-year review

Fractures of the palate are frequently associated with the more common and well-described Le Fort fractures. Palatal fractures may present diagnostic and exposure challenges and, if not satisfactorily treated, will result in occlusal problems after surgery. From 1986 through 1998, 116 complex maxillary fractures were treated at the authors' center. Among these, 13 patients were diagnosed with fracture of the palate. Patients with gunshot wounds to the face were excluded from the present study. Open reduction and internal fixation of the palatal fractures were achieved through elevation of the entire palatal mucoperiosteal flap to avoid late hardware exposure. This paper presents a unique approach to visualizing the whole bony palatal surface for accurate reduction and internal fixation of fractures.

Diagnosis and treatment of dental trauma in a children's hospital

A comprehensive review of 487 emergency dental trauma visits seen at a children's hospital during a 3-year period was performed to investigate aspects of trauma care that have not been previously reported. Patient characteristics, diagnoses, and injury treatment were analyzed. General patient characteristics and diagnoses were consistent with other studies. Young children were often injured in falls within the home whereas older children were often injured in sports and activities outside the home. The emergency visit was the first contact with the dentist for 80% of children 3.5 years old and younger. Maxillary incisors accounted for 84% of primary tooth injuries: examination and extraction were common treatments. Maxillary incisors accounted for 87% of permanent tooth injuries: bandage restorations and splint placement were frequent treatments. An assistive restraint device was used most often for children 4 years and younger who required extractions. The restraint was used more frequently during clinic hours with support staff present than after hours with a sole provider. Hospital facilities were not essential for treatment of the patients in this study.

Patients' experiences of injury as a result of epilepsy

PURPOSE

The increased risk of mortality among people with epilepsy is well documented; people with epilepsy are more likely than the general population to die as a result of an accident. Data about incidence of nonfatal accidents and associated factors are not so readily available, even though such accidents are more common than fatal injuries. We report the proportion of people who sustain various injuries during a seizure and the key variables predicting injury.

METHODS

Questionnaires were mailed to an unselected, community-based population of patients with epilepsy. The questionnaire included clinical and demographic details, previously validated scales of psychosocial well-being, and questions about seizure-related injuries.

RESULTS

Of patients who had had at least one seizure during the previous year, 24% sustained at least one head injury, 16% sustained a burn or scald, 10% a dental injury, and 6% some other fracture. Seizure type, seizure severity, and seizure frequency were key predictors of having sustained at least one of these four seizure-related injuries. Key predictors of burn/scald were seizure severity, seizure frequency and sex; those of head injury were seizure severity and type; that of dental injury was seizure severity; and those of some other fracture were seizure severity, duration of epilepsy, and three or more drug-related adverse effects.

CONCLUSIONS

These data help identify significant risk factors associated with seizure-related injuries and so facilitate sensible patient counseling about how the risks of such injuries can be minimized.

Oral diseases and veterinary dentistry

Oropharyngeal disease is common in dogs and cats. Signs are seldom apparent to the owner until the disease is well advanced, and often are not specific for a particular disease. Signs include inappetence, pawing at the mouth, drooling of saliva, dysphagia, and halitosis. These signs can result from primary oral disease, or from effects of systemic or skin disease. Oral examination requires a cooperative patient; sedation may be necessary so that the entire oral cavity can be examined without causing the animal pain or risking injury to the examiner.

Early treatment of facial trauma

Early local care of maxillofacial trauma involves identification and diagnosis of the injuries and early consultation with the appropriate specialists (ie, plastic surgeon, ophthalmologist, otolaryngologist, oral and maxillofacial surgeon). Treatment of the injuries should proceed from the inside mucosal surface toward the cutaneous surface of the face, after occlusal patterns have been established and preliminary fixation of maxillary and mandibular fractures has been effected. Closure of through-and-through lacerations from the inside out and establishment of the mandible as a stable plane against which the remainder of the face may be oriented (the "inside out and bottom up" approach) provide an excellent basis for later definitive rehabilitation.

Athletic facial injuries

Most facial injuries that occur during athletic activities are of a minor nature, consisting of lacerations, contusions, and abrasions. These are usually treated by a team physician or an emergency department physician. However, minor injuries must be differentiated from the more significant injuries, especially those involving facial bone fractures. Significant facial trauma must be diagnosed accurately and treated with precision to avoid permanent facial deformity. Soft-tissue trauma as well as fractures are included in this review, and evaluation of the injured athlete is emphasized. A systematic approach is developed for diagnosing and treating common facial injuries in athletes.

[Care of skull injuries in childhood]

Fractures and injuries of the face and jaws in children differ from those in adults with regard to common occurrence and seriousness of injury. Injuries occur predominantly at school or during sports, whereas car accidents are not significant. 7% of our children had fractures of the middle face , compared with a much higher incidence in adults. In such cases, it is always necessary to look for a fracture of the skull base. For the transport of the seriously injured child, respiration and circulation must be safeguarded . Intubation and treatment of haemorrhage must, in the case of serious injury, be placed first. It is only then that transport to a specialised clinic can be carried out. Special features of diagnosis and therapy in children are indicated.

Management of dental trauma in children and adolescents

The emergency treatment of dental trauma has traditionally been handled in the emergency rooms of medical centers, or in the dental office. With increasing emphasis on comprehensive medical care, and the tendency of more recent graduates to locate in rural areas, there is a growing trend for physicians to be involved in providing emergency care for traumatic injuries to the dental and oral tissues. The authors discuss the etiology of dental trauma and the highly psychologic impact of such injuries upon the patient and parents. Techniques for prevention and a comprehensive plan are outlined for systematic history taking and examination. A classification of eight levels of dental injuries (5), techniques for the emergency, and subsequent restorative care are given. Emphasis is placed upon immediate care which can, if necessary, be provided by the physician pending referral to a dentist.

[Facial injuries]

In spite of a certain reduction in their numbers, facial injuries still raise frequent problems for general surgeons. Car accidents are now less commonly responsible than motorcycle accidents. In the most complex cases, one may find lesions of the soft parts and bony lesions in association. The wounds should be examined carefully, all foreign bodies removed and should only be sutured if one is certain tht the subjacent structures are undamaged, e.g. facial bony canals are often damaged in vertical wounds of the cheek situated behind the anterior border of the masseter muscle. As far as bony lesions are concerned, they rarely give rise to typical breakdowns of the suture lines described by Lefort, but more commonly cause true dislocations which are impossible to describe. Fractures are often undiagnosed owing to oedema which masks them, e.g. those of the malar bone and of the orbit and even those of the nose. This failure to diagnose them is serious for, at a later stage, surgical correction is more difficult and the prejudice is then not only esthetic but also functional, e.g. causing diplopia. Clinical examination of a patient with trauma of the face includes a series of simple gestures which a general surgeion should carry out in order to avoid failure to diagnose such lesions. Although he may not treat them all, he sould recognise them and decide which have priority in the treatment of multiple injuries. Careful inspection and palpation usually permit one to detect bony lesions which XRays then demonstrate only by careful choice of appropriate views.