eMedicine Specialties > Emergency Medicine > Ear, Nose, & Throat

Dental, Fractured Tooth: Treatment & Medication

Author: Lynnus F Peng, MD, Assistant Clinical Professor, Department of Anesthesia, University of California at Irvine; Chairman of Anesthesia, Department of Surgery, St Jude Medical Center at Fullerton
Coauthor(s): A Antoine Kazzi, MD, Chair and Medical Director, Department of Emergency Medicine, American University of Beirut, Lebanon; Willard Peng, MS, Doctor of Dental Surgery Candidate, Department of Oral Medicine, University of Southern California; Caleb Cheng, University of California at San Diego
Contributor Information and Disclosures

Updated: Aug 11, 2009

Treatment

Emergency Department Care

Provide adequate pain management and tetanus vaccination, and ensure proper follow-up care.

  • Ellis I fracture: Smooth rough corners with a dental drill or an emery board.
    • Treatment of fractures contained solely within the enamel alone requires no urgent care. The tooth can be repaired cosmetically at the convenience of the patient
  • Ellis II fracture: Cover exposed dentin with a layer of zinc oxide or calcium hydroxide paste (Dycal).
    • Dycal requires the tooth to be absolutely dry for adherence. Cover the tooth with a small piece of dental or aluminum foil. Exposure to humidity increases the rate at which the Dycal will set.
    • In patients younger than 12 years, coverage is especially important to prevent infection.
  • Ellis III fracture: Cover exposed dentin with a layer of zinc oxide or calcium hydroxide. Bleeding and moisture with this type of fracture usually makes it more difficult for these materials to adhere to the tooth. Cover with dental foil and expediently refer the patient to a dentist.
  • Root and dentoalveolar fractures require splinting by a dentist for several weeks.
  • Bone wax (Ethicon), which is a combination of beeswax and isopropyl palmitate, is not recommended for open dental fractures because it can cause inflammatory reactions of the surrounding soft tissues (eg, pulp).

Consultations

  • Consult a dental or oral maxillofacial surgeon.
  • Depending on the extent of the fracture, the dentist may do perform a root canal with calcium hydroxide followed by a gutta-percha filling or a partial pulpotomy.

Medication

Drugs used to treat dental fractures are generally nonsteroidal anti-inflammatory drugs (NSAIDs), analgesics, anxiolytics, and proper antibiotics.

Antibiotics

Therapy must cover all likely pathogens in the context of the clinical setting. Current recommendations by the American Heart Association 2007 for dental, oral, respiratory tract, or esophageal procedures, indicate prophylaxis if the patient has one of the following conditions:2

  • Prosthetic cardiac valve
  • Previous infective endocarditis
  • Congenital heart disease (CHD)
  • Unrepaired cyanotic CHD, including palliative shunts and conduits
  • Completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first 6 months after the procedure
  • Repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device (which inhibit endothelialization)
  • Cardiac transplantation recipients who develop cardiac valvulopathy


Penicillin VK (Veetids)

Inhibits biosynthesis of cell wall mucopeptide and is effective during active replication. Inadequate concentrations may produce only bacteriostatic effects.

Adult

250-500 mg PO q6h

Pediatric

50 mg/kg/d PO divided qid

Probenecid may increase effectiveness by decreasing clearance; tetracyclines are bacteriostatic, causing a decrease in the effectiveness of penicillins when administered concurrently

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in renal impairment


Erythromycin (EES, E-Mycin, Ery-Tab)

An alternative for patients allergic to penicillin. Because of possible GI irritation, advise patients to take this medication with food or milk if GI upset is noted.

Adult

200-500 mg PO q6h

Pediatric

30-50 mg/kg/d PO divided qid

Coadministration may increase toxicity of theophylline, digoxin, carbamazepine, and cyclosporine; may potentiate anticoagulant effects of warfarin; coadministration with lovastatin and simvastatin increases risk of rhabdomyolysis

Documented hypersensitivity; hepatic impairment

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in liver disease; estolate formulation may cause cholestatic jaundice; GI adverse effects are common (give doses pc); discontinue use if nausea, vomiting, malaise, abdominal colic, or fever occur


Amoxicillin (Amoxil, Polymox, Trimox)

Interferes with the synthesis of cell wall mucopeptide during active replication, resulting in a bactericidal activity against susceptible bacteria.

Adult

250-500 mg PO q8h

Pediatric

20-50 mg/kg/d PO divided q8h

Reduces efficacy of oral contraceptives

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in renal impairment

Analgesics

Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet, and enable physical therapy regimens. Many analgesics have sedating properties that benefit patients in pain.


Fentanyl citrate (Duragesic, Sublimaze)

A more potent narcotic analgesic with a much shorter half-life than morphine sulfate. DOC for conscious sedation analgesia.
With short duration (30-60 min) that is easy to titrate, an excellent choice for pain management and sedation. Easily and quickly reversed by naloxone.
After the initial dose, do not titrate subsequent doses more frequently than q3h or q6h thereafter.

Adult

0.5-1 mcg/kg/dose IV/IM q30-60min

Pediatric

<2 years: 2-3 mcg/kg/dose IV/IM q30-60min
2-12 years: 1-2 mcg/kg/dose IV/IM q60min

Phenothiazines may antagonize analgesic effects of opiate agonists; tricyclic antidepressants may potentiate adverse effects of fentanyl when both drugs are used concurrently

Documented hypersensitivity; hypotension or potentially compromised airway where establishing rapid airway control would be difficult

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in hypotension, respiratory depression, constipation, nausea, emesis, and urinary retention; idiosyncratic reaction, known as chest wall rigidity syndrome, may require neuromuscular blockade in order to increase ventilation


Meperidine (Demerol)

Narcotic analgesic with multiple actions similar to those of morphine. May produce less constipation, smooth muscle spasm, and depression of the cough reflex than similar analgesic doses of morphine.

Adult

50-150 mg PO/IV/IM/SC q3-4h prn

Pediatric

1-1.8 mg/kg (0.5-0.8 mg/lb) PO/IV/IM/SC q3-4h prn; not to exceed adult dose

Monitor for increased respiratory and CNS depression with coadministration of cimetidine; hydantoins may decrease effects of meperidine; avoid with protease inhibitors

Documented hypersensitivity; MAOls; upper airway obstruction or significant respiratory depression; during labor when delivery of premature infant is anticipated

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in patients with head injuries, since meperidine may increase respiratory depression and CSF pressure (use only if absolutely necessary); caution when using postoperatively and with history of pulmonary disease (suppresses cough reflex)
Substantially increased dose levels, due to tolerance, may aggravate or cause seizures even if no prior history of convulsive disorders; monitor closely for morphine-induced seizure activity with prior seizure history


Oxycodone and acetaminophen (Percocet)

Drug combination indicated for relief of moderate to severe pain. DOC for patients who are hypersensitive to aspirin.

Adult

1-2 tab or cap PO q4-6h prn

Pediatric

0.05-0.15 mg/kg/dose oxycodone PO; not to exceed 5 mg/dose of oxycodone q4-6h prn

Phenothiazines may decrease analgesic effects of this medication; toxicity increases with coadministration of either CNS depressants or tricyclic antidepressants

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Duration of action may increase in elderly persons; be aware of total daily dose of acetaminophen patient is receiving; do not exceed 4,000 mg/d of acetaminophen; higher doses may cause liver toxicity


Hydrocodone bitartrate and acetaminophen (Vicodin ES)

Drug combination indicated for relief of moderate to severe pain.

Adult

1-2 tab or cap PO q4-6h prn

Pediatric

<12 years: 10-15 mg/kg/dose acetaminophen PO q4-6h prn; not to exceed 2.6 g/d of acetaminophen or 5 mg of hydrocodone bitartrate/dose
>12 years: 750 mg acetaminophen PO q4h; not to exceed 5 doses/d acetaminophen or 10 mg of hydrocodone bitartrate/dose

Coadministration with phenothiazines may decrease analgesic effects; toxicity increases with CNS depressants or tricyclic antidepressants

Documented hypersensitivity; elevated intracranial pressure

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Tabs contain metabisulfite, which may cause hypersensitivity; caution in patients dependent on opiates because this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction


Acetaminophen (Tylenol, Panadol, Aspirin Free Anacin)

DOC for the treatment of pain in patients with documented hypersensitivity to aspirin or NSAIDs, in those with upper GI disease, or in those who are taking oral anticoagulants.

Adult

325-650 mg PO q4-6h or 1000 mg tid/qid; not to exceed 4 g/d

Pediatric

<12 years: 10-15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d
>12 years: 325-650 mg PO q4h; not to exceed 5 doses/d

Rifampin can reduce analgesic effects of acetaminophen; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity

Documented hypersensitivity; G-6-PD deficiency

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Hepatotoxicity possible in chronic alcoholics following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; acetaminophen is contained in many OTC products, and combined use with these products may result in cumulative acetaminophen doses exceeding recommended maximum dose

More on Dental, Fractured Tooth

Overview: Dental, Fractured Tooth
Differential Diagnoses & Workup: Dental, Fractured Tooth
Treatment & Medication: Dental, Fractured Tooth
Follow-up: Dental, Fractured Tooth
Multimedia: Dental, Fractured Tooth
References
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References

  1. Lieger O, Zix J, Kruse A, Iizuka T. Dental injuries in association with facial fractures. J Oral Maxillofac Surg. Aug 2009;67(8):1680-4. [Medline].

  2. Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation. Oct 9 2007;116(15):1736-54. [Medline].

  3. Bakland LK, Andreasen JO. Examination of the dentally traumatized patient. J Calif Dent Assoc. Feb 1996;24(2):35-7, 40-4. [Medline].

  4. Cvek M, Mejare I, Andreasen JO. Conservative endodontic treatment of teeth fractured in the middle or apical part of the root. Dent Traumatol. Oct 2004;20(5):261-9. [Medline].

  5. Devlin DH. A historical review of dental and facial skeletal trauma. J Calif Dent Assoc. Feb 1996;24(2):29-34. [Medline].

  6. Gutmann JL, Gutmann MS. Cause, incidence, and prevention of trauma to teeth. Dent Clin North Am. Jan 1995;39(1):1-13. [Medline].

  7. Harwood-Nuss A, Linden C, Luten R, eds. Dental injuries. In: The Clinical Practice of Emergency Medicine. 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 1996:418-421.

  8. Josell SD. Evaluation, diagnosis, and treatment of the traumatized patient. Dent Clin North Am. Jan 1995;39(1):15-24. [Medline].

  9. Josell SD, Abrams RG. Traumatic injuries to the dentition and its supporting structures. Pediatr Clin North Am. Jun 1982;29(3):717-41. [Medline].

  10. Krasner P, Rankow HJ. New philosophy for the treatment of avulsed teeth. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. May 1995;79(5):616-23. [Medline].

  11. Rosen P, Barkin R. Dental emergencies. In: Emergency Medicine Concepts and Clinical Practice. Vol 3. 3rd ed. St Louis: Mosby-Year Book; 1992: 2381-2398.

  12. Trope M. Protocol for treating the avulsed tooth. J Calif Dent Assoc. Mar 1996;24(3):43-9. [Medline].

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Further Reading

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Keywords

tooth fracture, broken tooth, traumatized maxillary teeth, postnormal occlusion, overjet, short upper lip, incompetent lip, mouth breathing, maxillofacial injuries, maxillofacial fractures, Ellis classification, Ellis I fractures, Ellis II fractures, Ellis III fractures, chipped tooth, chipped teeth, root fractures, dentoalveolar fractures, malocclusion, dental displacement, maxillary fractures, mandibular fractures, Panorex, zinc oxide, calcium hydroxide paste, Dycal, bone wax, Ethicon, gutta-percha filling, partial pulpotomy, tetanus prophylaxis

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Contributor Information and Disclosures

Author

Lynnus F Peng, MD, Assistant Clinical Professor, Department of Anesthesia, University of California at Irvine; Chairman of Anesthesia, Department of Surgery, St Jude Medical Center at Fullerton
Lynnus F Peng, MD is a member of the following medical societies: Alpha Omega Alpha and American Society of Anesthesiologists
Disclosure: Nothing to disclose.

Coauthor(s)

A Antoine Kazzi, MD, Chair and Medical Director, Department of Emergency Medicine, American University of Beirut, Lebanon
A Antoine Kazzi, MD is a member of the following medical societies: American Academy of Emergency Medicine
Disclosure: Nothing to disclose.

Willard Peng, MS, Doctor of Dental Surgery Candidate, Department of Oral Medicine, University of Southern California
Disclosure: Nothing to disclose.

Caleb Cheng, University of California at San Diego
Disclosure: Nothing to disclose.

Medical Editor

Michael Glick, DMD, Professor and Acting Chair, Department of Diagnostic Sciences, New Jersey Dental School, University of Medicine and Dentistry of New Jersey
Michael Glick, DMD is a member of the following medical societies: American Academy of Oral Medicine and American Dental Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Mark W Fourre, MD, Program Director, Department of Emergency Medicine, Maine Medical Center; Associate Clinical Professor, Department of Surgery, University of Vermont School of Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Barry E Brenner, MD, PhD, FACEP, Professor of Emergency Medicine, Professor of Internal Medicine, Program Director, Emergency Medicine, University Hospitals, Case Medical Center
Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
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