Examination of a patient with a dental trauma injury
A rational examination procedure is essential in order to establish a complete and correct diagnosis of all soft and hard tissue injuries (Andreasen and Andreasen 1985, Bakland and Andreasen 1996, Andreasen et al 2007).
- Clean the face and the oral cavity with water or saline. If there are soft tissue wounds, a mild detergent should be used. This cleaning will make the patient feel more comfortable and facilitate extraoral and oral examination.
- Make a short medical and dental history. The medical history should reveal possible allergies, blood disorders and other information that may influence treatment. The dental history should indicate previous dental traumas, information which may explain radiographic findings such as pulp canal obliteration or apical pathology.
Questions relating to the injury
- Where did the injury occur? This information may have legal implication for the patient and may
on occasion indicate the possibility of contamination.
- How did the injury occur? This may lead to identification of the impact zones i.e. a chin injury is often combined with crown
or crown-root fractures in premolar and molar regions.
- When did the injury occur? This information may be essential in relation to many injury types. In relation to a tooth avulsion the extent of time and the extraoral storage condition becomes very decisive for later treatment.
- Was there a period of unconsciousness? If so, for how long. Amnesia, nausea and vomiting are all signs of brain damage and require medical attention.
- Is there any disturbance in the bite? An affirmative answer may indicate a luxation injury with displacement, an alveolar or jaw fracture or a fracture of the condylar region.
- Is there any reaction in the teeth to cold and/or heat exposure? A positive finding indicates exposed dentin and/or pulp.
- Examine the face, lips and oral muscles for soft tissue lesions.
- Palpate the facial skeleton for signs of fractures.
- Inspect the dental trauma region for fractures, abnormal tooth position, tooth mobility, and abnormal response to percussion. Furthermore registration of direction of displacement in case of luxation injuries. In case of fractures their relation to the
gingival sulcus area is noted as well as possible pulp involvement.
- Pulp testing (usually electrometric) completes the clinical examination.
The completed clinical examination has now identified the trauma region and this site should now be examined with relevant radiographic techniques. Several clinical studies have shown that multiple radiographic procedures are needed to detect displacement of the tooth in its socket as well as presence of root fractures (Andreasen and Andreasen 1985, Andreasen and Andreasen 1988).
It’s essential to consider the radiographic film format used in order to achieve a high quality image of the traumatized tooth. A steep occlusal exposure (using a size 2 film (DF 58, EP 21)) of the traumatized anterior region gives an excellent view of most lateral luxations, apical and mid-root fractures and alveolar fractures. The standard periapical bisecting angle exposure of each traumatized tooth (using a size 1 film (DF 56, EP 11)) provides information about cervical root fractures as well as other tooth displacements. Thus a radiographic examination comprising one steep occlusal exposure and three periapical bisecting angle exposures of the traumatized region will provide sufficient information in determining the extent of trauma to an incisor region.
Radiographic examination of soft tissue lesions
In the presence of a penetrating lip lesion, a soft tissue radiograph is indicated in order to locate any foreign bodies. It should be noted that the orbicularis oris muscles close tightly around foreign bodies in the lip, making them impossible to palpate; they can only be identified radiographically. This is accomplished by placing a dental film between the lips and the dental arch and using 25% of the normal exposure time. If this exposure reveals foreign bodies (a radiographic examination will normally demonstrate foreign bodies such as tooth fragments, composite filling material, metal, gravel, whereas organic materials such as cloth and wood cannot be seen), a lateral radiograph can be added (at 50% normal exposure time) to visualize the foreign bodies in relation to the cutaneous and mucosal surfaces of the lips. With the combined information from the clinical and radiographic examinations, diagnosis, prognosis and treatment planning can then be accomplished.
Finally, photographic registration of the trauma is recommended, as it offers an exact documentation of the extent of injury and can be used later in treatment planning, legal claims or clinical research. Note that a patient consent is required.
Using the Dental Trauma Guide for treatment advice and prognosis estimation
The combined clinical and radiographic examination has now classified the injured tooth into the proper category (fractures or luxation). In case of a combined fracture-luxation injury, primarily enter the
actual luxation injury where an alternative “route” will indicate the relevant luxation-fracture combination and its treatment and prognosis.
- ANDREASEN FM, ANDREASEN JO. Diagnosis of luxation injuries: the importance of standardized clinical, radiographic and photographic techniques in clinical investigations.
Endod Dent Traumatol 1985;5:160-169.
- BAKLAND LK, ANDREASEN JO. Examination of the dentally traumatized patient.
Calif Dent Ass J 1996;24:35-44.
- ANDREASEN FM, ANDREASEN JO, TSUKIBOSHI M. Examination and Diagnosis of Dental Injuries.
In: Andreasen JO, Andreasen FM, Andersson L, (eds.). Textbook and Color Atlas of Traumatic Injuries to the Teeth (4th ed.). Oxford, Blackwell 2007. pp. 255-279.