Acute Dental Problems Clinical Case #3

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Question 1 of 3

1. Question
You are working the sidelines as team physician for your local high school hockey team. George, a 14 year old freshman forward, has his facemask dislodged in a scuffle and is subsequently struck in the face by another player’s elbow. After the blood is cleaned up, he presents to you a few minutes later appearing as he does in this image.

ICOHP

The first priority in management of this situation is:
- Locate the missing tooth Locating the missing tooth is clearly important. It may be on the ice, swallowed, aspirated, or impacted in soft tissue such as the lip. However, it is not the first priority in management.
- Perform a complete intra-oral examination Performing a complete intra-oral examination in clearly important to assess for other injuries besides the avulsed tooth. However, attendance to airway difficulty or other more severe associated injuries is the first priority.
- Assess his airway
- Call an ambulance to take George to a hospital emergency department Unless a more severe associated facial injury is present ambulance transport or a visit to an emergency department is not necessary. The more appropriate referral source would be a dentist.
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Question 2 of 3

2. Question
After a search by other members of the hockey team, the missing tooth is found in a dusty corner of the boards resting underneath a stray puck.

What is the next most appropriate step in management?
- Scrub the dirt off the tooth Scrubbing the dirt off the tooth will disrupt or remove the adherent periodontal ligament cells and reduce the chance of successful reimplantation. If the tooth is dirty it can be rinsed with Hanks Solution, saliva, milk, or saline.
- Rinse the tooth with saline then replace it in the empty socket in George's mouth
- Put the tooth in a water bottle until George can get to a dentist Placing the tooth in tap water will dessicate the periodontal ligament cells and reduce the chance of successful reimplantation. If avulsed teeth need to be transported outside the mouth, isotonic solutions such as Hanks Solution, milk, or saline should be used.
- Throw the tooth away Discarding the avulsed tooth is not recommended as it makes it unavailable for reimplantation. Although the long-term outcomes of reimplantation of permanent teeth cannot be assured, such teeth can often provide extended periods of function.
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Question 3 of 3

3. Question
A month later George returns to play with his team. He and his parents are obviously quite concerned about preventing another oral injury. He has a mouth guard, but seldom wears it. He explains that the culture on his team and school in general is one of “mouth guards are for sissies,” and he finds his school-supplied stock mouth guard bulky and uncomfortable.

George’s mouth guard

ICCHP

What advice could you give them?
- Consider obtaining a more comfortable custom mouth guard fitted
- Wear a full face mask in place of a mouth guard A full face mask will provide protection against many facial injuries, and especially those due to direct impacts. However, it will not protect teeth or jaw against concussion or fracture in the same way that a mouth guard can.
- Change sports from hockey to basketball While basketball may carry with it intrinsically less risk of an oral injury than hockey, the risk is not substantially less, and protective equipment such as helmets, face masks, and mouth guards are not available.
- Confront the coach about his ineffectiveness in preventing sport-related injuries Blaming the coach for a larger school-wide cultural issue is probably not helpful. Instead, working in concert with his coach to create a culture within the team and then the larger school that more fully embraces the consistent use of protective equipment is much more likely to be productive.
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Acute Dental Problems

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