Dental presentations

Any person, 16 years and over, presenting with a dental injury and/or dental pain.

History prompts, signs and symptoms

These are not exhaustive lists. Maintain an open mind and be aware of cognitive bias.

Red flags

Recognise: identify indicators of actual or potential clinical severity and risk of deterioration.

Respond: carefully consider alternative ECAT protocol. Escalate as per clinical reasoning and local CERS protocol, and continue treatment.

Clinical assessment and specified intervention (A to G)

If the patient has any Yellow or Red Zone observations or additional criteria (as per the relevant NSW Standard Emergency Observation Chart), refer and escalate as per local CERS protocol and continue treatment.

Position

Assessment	Intervention
General appearance/first impressions	Position of comfort

Airway

Assessment	Intervention
Patency of airway	Maintain airway patency Consider airway opening manoeuvres and positioning

Breathing

Assessment	Intervention
Respiratory rate and effort Consider auscultation of chest (breath sounds) Oxygen saturation (SpO2)	Assist ventilation, as clinically indicated Consider oxygen if dyspnoeic, titrate oxygen to maintain SpO2 over 93% Patients at risk of hypercapnia, maintain SpO2 at 88–92% Respiratory distress associated with a dental injury may indicate an inhaled tooth/fragment

Circulation

Assessment	Intervention
Perfusion (capillary refill, skin warmth and colour) Pulse Blood pressure	Assess circulation Attach cardiac monitor if BP/HR are within the Yellow or Red Zones, or where clinically relevant, e.g. irregular pulse, palpitations, syncope, shock, respiratory compromise, cardiac history or clinical concern
IVC and/or pathology	Insert IV cannula, if trained If unable to obtain IV access, consider intraosseous, if trained See pathology section
Signs of shock: tachycardia and CRT 3 seconds and over and/or abnormal skin perfusion and/or hypotension	If signs of shock present and/or SBP less than 90 mmHg, give 250 mL of sodium chloride 0.9% IV/intraosseous bolus Repeat every 10 minutes (up to 1000 mL) until SBP over 90 mmHg or signs of shock have resolved

Disability

Assessment	Intervention
ACVPU	If ACVPU shows reduced level of consciousness, continue to GCS, pupillary response and limb strength
GCS, pupillary response and limb strength	Obtain baseline and repeat assessment, as clinically indicated
Pain	Assess pain. If indicated, give early analgesia as per analgesia section then resume A to G assessment

Exposure

Assessment	Intervention
Temperature	Measure temperature
Skin inspection, including posterior surfaces	Check and document any abnormalities

Fluids

Assessment	Intervention
Hydration status: last ate, drank, bowels opened, passed urine or vomited	Commence fluid balance chart as required
NBM	Consider clear fluids or NBM based on red flags and clinical severity
Nausea and/or vomiting	If present, see nausea and/or vomiting section

Glucose

Assessment	Intervention
BGL	Measure BGL, if clinically indicated If less than 4 mmol/L, consider hypoglycaemia protocol

Focused assessment

Complete dental focused assessment.

Precautions and notes

• Avulsed permanent teeth should be replanted into the socket as soon as possible, preferably within 60 minutes.
• Do not touch the root of the tooth.
• Submandibular infection can present as oral pain. It is defined as cellulitis of the sublingual or submandibular areas and may be either unilateral or bilateral. This cellulitis may cause an obstruction to the airway, Ludwig’s angina, or systemic sepsis.

Interventions and diagnostics

Specific treatment

Avulsion of secondary (permanent) tooth

• Complete avulsion of a permanent tooth is a medical emergency. For best prognosis, first aid should be provided within 60 minutes of avulsion
• Tooth should be reinserted into the socket
• Do not handle the root of the tooth. Hold by the crown and rinse with sterile saline solution to remove debris
• Other teeth should be gently moved back into position
• Ask patient to bite down on folded gauze to keep the tooth in place
• Alternatively, the tooth should be placed in milk or sodium chloride 0.9%
• Fractured fragments should be placed in milk (dairy only) until dental review

Bleeding socket

• Apply pressure by placing gauze in the socket and ask the patient to bite firmly for 15 minutes
• If bleeding persists, rinse socket with sodium chloride 0.9%. Then soak gauze with tranexamic acid solution, by dissolving 500 mg tablet in 10 mL of water, and place in extraction site. Ask patient to bite firmly on gauze for 30 minutes

Fractured tooth

• Fragments should be placed in milk until dental review
• Fractures with exposed pulp (pink) can be painful. Refer to dentist as soon as possible and administer analgesia

Intruded or displaced teeth

• Dental opinion required

Tooth abscess

• If fever, systemic features, facial swelling or erythema present, escalate as per local CERS protocol

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Analgesia

Select pain score:

• 1–3 (mild)
• 4–6 (moderate)
• 7–10 (severe)

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Nausea and/or vomiting

If nausea and/or vomiting is present, give:

• metoclopramide 10 mg orally or IV/IM once only (over 20 years only)
• or ondansetron 4 mg orally or IV/IM. If symptoms persist after 60 minutes, repeat once, maximum dose 8 mg
• or prochlorperazine 5 mg orally once only or 12.5 mg IV/IM once only

Choice of antiemetic should be determined by cause of symptoms.

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Tetanus

If patient has a ‘tetanus-prone’ wound, consider giving a tetanus booster vaccine.

• Diphtheria and tetanus (ADT booster) vaccine should be given as per the Australian Immunisation Handbook Guide for tetanus prophylaxis in wound management.
• If ADT booster is not available then diphtheria/tetanus/pertussis (Boostrix) vaccine can be used.
• If no documented history of a primary vaccination course (3 doses) with a tetanus toxoid-containing vaccine: refer to medical or nurse practitioner or nurse immuniser.
• If pregnant or breastfeeding: dTpa vaccine (diphtheria-tetanus-acellular pertussis) is recommended. Refer to medical or nurse practitioner or nurse immuniser.

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Radiology

Radiology will depend on the working diagnosis. It needs to be requested by a medical or nurse practitioner. If there is concern for urgent radiology, escalate as per local CERS protocol.

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Pathology

• Warfarinised: INR

Medications

The shaded sections in this protocol are only to be used by registered nurses who have completed the required education.

Medications with contraindications or requiring dose adjustment are marked:

• ^H for patients with known hepatic impairment
• ^R for patients with known renal impairment.

Escalate to medical or nurse practitioner.

Evidence informed	Information was drawn from evidence-based guidelines and a review of latest available research. For more information, see the development process.
Collaboration	This protocol was developed by the ECAT Working Group, led by the Agency for Clinical Innovation. The group involved expert medical, nursing and allied health representatives from local health districts across NSW. Consensus was reached on all recommendations included within this protocol.
Currency	Due for review: Jan 2026. Based on a regular review cycle.
Feedback	Email ACI-ECIs@health.nsw.gov.au