Any person, 4 weeks to 15 years, presenting with a dental injury and/or dental pain.
This protocol is intended to be used by registered and enrolled nurses within their scope of practice and as outlined in The Use of Emergency Care Assessment and Treatment Protocols (PD2024_011). Sections marked triangle or diamond indicate the need for additional prerequisite education prior to use. Check the medication table for dose adjustments and links to relevant reference texts.
Dental injuries are often associated with concurrent facial and head trauma. Complete A to G assessment before management of dental injury.
History prompts, signs and symptoms
These are not exhaustive lists. Maintain an open mind and be aware of cognitive bias.
History prompts
- Presenting complaint
- Mechanism of injury
- Time of injury
- Associated injuries
- Pain assessment
- Pre-hospital treatment, including first aid given to the patient, tooth and/or fragment
- Past admissions
- Medical and surgical history
- Dental history, including recent procedures or braces
- Current medications
- Known allergies
- Immunisation status, including tetanus
- Current weight
Signs and symptoms
- Head strike
- Tooth fracture, avulsion or displacement
- Facial and/or oral injuries
- Trismus
- Nausea
- Pain
- Bleeding or laceration
- Localised swelling along the gum
- Facial swelling or erythema
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.
Historical
- Delayed presentation
- Recent dental surgery
Clinical
- Bleeding not controlled with simple direct pressure
- Head strike with loss of consciousness
- Concomitant neck injury
- Suspicion of facial fractures
- Difficulty opening jaw
- Difficulty breathing or airway compromise
- Inhaled tooth
- Swelling of the face and/or neck
- Difficulty swallowing
- Trismus
- Inability to protrude the tongue
- Signs of sepsis
- Fever
Remember child or adolescent at risk: patient or carer concern, suspected non-accidental injury or neglect, multiple comorbidities or unplanned return.
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 work of breathing Consider auscultation of chest (breath sounds) Oxygen saturation (SpO2) | Assist ventilation as clinically indicated Apply oxygen to maintain SpO2 over 93% Respiratory distress associated with a dental injury may indicate an inhaled tooth/fragment. See specific treatment section |
Circulation
Assessment | Intervention |
---|---|
Perfusion (capillary refill, skin warmth and colour) Heart rate Blood pressure | Assess circulation |
IVC and/or pathology | Insert IV cannula, if trained and clinically indicated |
Disability
Assessment | Intervention |
---|---|
AVPU | If AVPU shows reduced level of consciousness, continue to assess 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 |
Head-to-toe inspection, including posterior surfaces | Check and document any abnormalities |
Fluids
Assessment | Intervention |
---|---|
Hydration status | Assess fluids, in and out. Document on fluid balance chart. Include gastrointestinal losses |
Nausea and/or vomiting | If present, see nausea and/or vomiting section |
Glucose
Assessment | Intervention |
---|---|
BGL |
Measure BGL, where clinically relevant or of concern. See medication table for 40% glucose gel dosing If BGL between 2 mmol/L and 3 mmol/L and NOT symptomatic (Yellow Zone criteria):
If BGL less than 2 mmol/L OR symptomatic (Red Zone criteria) OR unable to tolerate oral glucose:
|
Repeat and document assessment and observations to monitor responses to interventions, identify developing trends and clinical deterioration. Escalate care as required according to the local CERS protocol.
Focused assessment
Complete a dental focused assessment.
Consider a neurological focused assessment.
Precautions and notes
- Management of dental injuries will depend on whether it is a primary or secondary (permanent) tooth that is injured.
- Injured primary teeth should not be replanted, splinted or repositioned and may need removal if displaced or mobile.
- Injuries to primary teeth are managed to reduce the risk of problems associated with the eruption and formation of permanent teeth, not to save the primary tooth.
- Avulsed permanent teeth should be replanted into the socket as soon as possible, preferably within 60 minutes.
Interventions and diagnostics
Specific treatment
Avulsion of secondary (permanent) tooth
Complete avulsion of a permanent tooth requires urgent attention. For the best prognosis, the following should be provided as soon as possible, within 60 minutes of avulsion:
- The 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 the patient to bite down on folded gauze to keep the tooth in place.
- Alternatively, the tooth should be placed in dairy milk or 0.9% sodium chloride.
- If the tooth is not located consider possible ingestion, inhalation or embedded in soft tissue.
Fractured tooth
- Place fragments in dairy milk until dental review.
- Fractures with exposed pulp (pink) can be painful. Give analgesia.
Intruded or displaced teeth
- Give analgesia and await dental review.
Tooth abscess
- If fever, systemic features, facial swelling or erythema present, give analgesia and await medical or nurse practitioner review.
Analgesia
Select pain score:
Pain score 1–3 (mild)
Give paracetamol 15 mg/kg orally once only, maximum dose 1000 mg
and/or ibuprofen, if 3 months and over, 10 mg/kg orally once only, maximum dose 400 mg
Pain score 4–6 (moderate)
Give:
oxycodone (immediate release):
- 1–12 months: 0.05 mg/kg orally once only, maximum dose 0.5 mg
- 12 months and over: 0.1 mg/kg orally once only, maximum dose 5 mg
and/or paracetamol 15 mg/kg, orally once only, maximum dose 1000 mg
and/or ibuprofen, if 3 months and over, 10 mg/kg orally once only, maximum dose 400 mg
Pain score 7–10 (severe)
Give one of:
Fentanyl intranasal
- 12 months and over: 1.5 microg/kg intranasally, maximum single dose 75 microg and, if required, repeat once after 5 minutes, maximum total dose 3 microg/kg or 150 microg, whichever is less. Dose to be divided between nostrils
Note: ensure an extra 0.1 mL is drawn up for the first dose to account for the dead space in the mucosal atomiser device
Morphine IV
- 1–12 months: 0.05 mg/kg IV, maximum single dose 0.5 mg and, if required, repeat once after 5 minutes, maximum total dose 0.1 mg/kg or 1 mg, whichever is less
- 12 months and over: 0.1 mg/kg IV, maximum single dose 5 mg and, if required, repeat once after 5 minutes, maximum total dose 0.2 mg/kg or 10 mg, whichever is less
and/or paracetamol 15 mg/kg orally once only, maximum dose 1000 mg
and/or ibuprofen, if 3 months and over, 10 mg/kg orally once only, maximum dose 400 mg
If pain does not improve with medication, escalate as per local CERS protocol.
Consider non-pharmacological pain relief (appendix).
Nausea and/or vomiting
If nausea and/or vomiting is present and over 6 months give:
ondansetron:
- 8–15 kg: 2 mg, orally once only
- 15–30 kg: 4 mg, orally once only
- Over 30 kg: 8 mg, orally once only.
Tetanus
All patients must be considered for a tetanus booster if they have a tetanus-prone wound. Refer to medical or nurse practitioner or nurse immuniser to consider tetanus immunisation requirements.
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.
Pathology
Not usually indicated. If there is concern for urgent pathology, escalate care as per local CERS protocol.
Medications
The patient’s weight is mandatory for calculating fluid and medication doses.
The Broselow Tape or APLS weight table (appendix) can be used only in circumstances where the patient cannot be weighed.
The shaded sections in this protocol are only to be used by registered nurses who have completed the required education.
Drag the table right to view more columns or turn your phone to landscape
Drug | Dose | Route | Frequency |
---|---|---|---|
Fentanyl H, R | 12 months and over: Maximum single dose 75 microg | Intranasal | Pain score 7–10 Repeat once if required after 5 minutes to maximum dose |
Glucose 40% gel | 4 weeks–1 year: 1–5 years: 5 g 6–11 years: 10 g 12 years and over : 15 g | Buccal | Repeat after 15 minutes if required |
Ibuprofen H, R | 3 months and over: Maximum dose 400 mg | Oral | Pain score 1–10 Once only |
Morphine H, R | 1–12 months: 12 months and over: | IV | Pain score 7–10 Repeat once if required after 5 minutes to maximum dose |
Over 6 months and 8–15 kg: 15–30 kg: Over 30 kg: | Oral | Once only | |
1–12 months: 12 months and over: | Oral | Pain score 4–6 Once only | |
0.25–15 L/min, device dependent | Inhalation | Continuous | |
15 mg/kg Maximum dose 1000 mg | Oral | Pain score 1–10 Once only |
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.
References
- McTigue D, Azadani E. Evaluation and management of dental injuries in children. UpToDate: Walters Kluwer; 2021 [cited 10 March 2023]. Available from: https://www.uptodate.com/contents/evaluation-and-management-of-dental-injuries-in-children
- MIMS Australia. Clinical Resources. Australia: MIMS Australia Pty Ltd; 2022 [cited 2 Feb 2023]. Available from: https://www.mimsonline.com.au.acs.hcn.com.au/Search/Search.aspx
- NSW Health. Australian Medicines Handbook Children’s Dosing Companion Australia: Australian Government, NSW; 2023 [cited 28 Feb 2023]. Available from: https://childrens.amh.net.au.acs.hcn.com.au/?acc=36422
- Tewari N, Bansal K, Mathur VP. Dental Trauma in Children: A Quick Overview on Management. Indian J Pediatr. 2019 Nov;86(11):1043-7. DOI: 10.1007/s12098-019-02984-7
- The Royal Children's Hospital Melbourne. Management of tetanus-prone wounds. Australia: Victoria Health 2019 [cited 10 March 2023]. Available from: https://www.rch.org.au/clinicalguide/guideline_index/Management_of_tetanusprone_wounds
- The Royal Children's Hospital Melbourne. Dental conditions - non traumatic. Australia: Victoria Health 2020 [cited 10 March 2023]. Available from: https://www.rch.org.au/clinicalguide/guideline_index/Dental_conditions_non_traumatic/
- The Sydney Children's Hospital Network. Meds 4 Kids Dosing Guide. Australia: NSW Health; 2023 [cited 23 Feb 2023]. Available from: https://webapps.schn.health.nsw.gov.au/meds4kids/
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 |
Accessed from the Emergency Care Institute website at https://aci.health.nsw.gov.au/ecat/paediatric/dental-presentations