Winter Park Dentistry-Facial Trauma/Tooth Trauma
Dr. Ramzi Matar (Winter Park Dentistry): Hello everybody, welcome to this podcast episode. Today’s episode we have again recurrent guest, Dr. Don Tillery, oral maxillofacial surgeon, today we’re talking about dental tooth trauma. And I’ve got to intro this by getting a little bit into what you do, I’m going to kind of brag on you a little bit. Most people probably, at least when they ask me, they refer to an oral surgeon, and so I just want to preface something, because this is certainly important to today’s topic. Your training as OMFS, what that stands for is oral maxillofacial surgeon, and the reason that’s important is because you guys do a heck of a lot more than just take out teeth. You trained at Parkland, which I know is a very intense, you called the knife and gun club, it is a hardcore training program, I’m pretty sure it’s one of the best programs, if not the best program, in the heart of Dallas.
You guys train pretty much from the eyeball to the neck, you guys do fractures of the face, the jaw, the nose, a lot of stuff. Anytime somebody throughout this, or sees this video, or sees what OMFS is, it’s important to plug in that it’s oral maxillofacial surgery, there’s a heck of a lot more going on, and that’s why that you’re my guest today. Because with trauma, it’s not always localized to the tooth, clearly sometimes there’s jaw and other issues, and so let’s get into the first question. If I’m a patient watching this, or I’m learning from this, how do I know, if I just had a facial trauma, how do I know how serious it is? How do I know what to do and what’s the first thing everybody should think about?
Dr. Don E. Tillery, Jr: Sure. Well, obviously, if you’re on the basketball court, and you see somebody take an elbow to the face, it’s often the case. The first thing you want to do is check their level of consciousness, make sure they don’t have any neurological damage. You might at that point have an opportunity to check their ability to respond to questions, and those are the things that are the most critical. Certainly the next thing that you want to do, is if they’re bleeding somewhere, if they have some obvious bleeding from inside their mouth, that’s going to give you a clue, some of the questions that I usually ask a patient who’s sustained trauma is “do they have any numbness in any parts of the face?” the jaw, the lower lip, the chin, the cheek, or even up in the forehead. The nerves that enervate that part of the skin, exit through little holes in the skull that are called foramina. The foramina are the areas that are very susceptible to the track of a break, the cheekbone, right below the eye, which would result in numbness here and the area below their eye-socket of the skin, their lower lip and/or tongue is a very classic indicator that a person might have a jaw fracture.
Subjectively, in other words that the person might report that they have numbness, and they might report that their teeth don’t fit together right, or they may report that they’re missing a tooth, even though no tooth can be found on the scene. Those are classic indications for a more intense skeletal evaluation, that I should seek some professional care in those cases. Obviously if you are looking on the floor of the gym, and the whole play of the baseball field, and find a tooth that’s been knocked out, the very important part, is to gently wash that up, try your best to replace it right, where it was lost, before you can seek good care. Time is critical in those cases.
Dr. Ramzi Matar (Winter Park Dentistry): I appreciate you prefacing the level, I should have mentioned this… We’re not talking about people talking hurt in a car accident, we’re talking on a scale of things, more minor injuries, like a baseball to theft ace, or a basketball to the face, and you’re conscious. Clearly, if you’re lying on the ground unconscious, you need to get to the ER, teeth are secondary at that point, you need to make sure the person’s breathing, seeing, concussion, these are the high level things. Ok, now take me through the sequence. How does somebody seek care? You’re at the baseball field or whatever, you have the tooth, you’re fortunate enough to find it, you put it back in as best as youc an, you rinse it off. Where do I go next? Do I rush to the ER always? It seems to be just a tooth, everything else seems to be intact, where would somebody seek care?
Dr. Don E. Tillery, Jr: That’s kind of one of the most frustrating things that parents experience, and we as health care providers also. Emergency rooms are rarely equipped, staff wise and with the equipment necessary to maintain what we call dentoalveolar trauma, which is when a tooth or teeth get knocked out. Ideally, to have a relationship with your dentist, if there’s a dentist in your community, or an oral maxillofacial surgeon that you can contact right away. I can’t tell you how many personal friends that I have that might call me after sitting in the ER from 4 to 6 hours before they finally realize how ridiculous it’s getting, and they give me a call on the phone and we can meet at the office. And/or their general dentist, most of the time in an avulsed tooth, which is what we call a situation in which a person gets a tooth knocked out, which happens frequently. That condition is best treated by your general dentist, not only are they trained to, they’re capable of reinserting the tooth in the ideal position, but also your subsequent care, if the tooth’s survivability is reasonable. Is it not? They can make judgment calls as to what lengths need to be provided to you as a patient. For weeks and months and years to come, in order to either identify problems that are developing from that injury or to prevent them. That sustained relationship is a critical one.
Dr. Ramzi Matar (Winter Park Dentistry): It’s kind of interesting what you say, if somebody’s out there with a suspected jaw fracture, or maybe a check fracture, involving teeth, you as an oral maxillofacial surgeon can see them initially, treat it, take care of it, verify whether… Again, they’re not life threatening injuries, but you can manage that, you can manage a broken jaw from A to Z.
Dr. Don E. Tillery, Jr: Sure. And you know, often times we do, manage those patients. That’s what we call an outpatient within our facility. However, when we start talking about a true skeleton fracture, a person with a broken jaw for instance, so if they get that numbness of their lower lip, chin, cheek, and they can feel some actual mobility of that skeleton, that would be wise to seek ER evaluation. In those instances the person would be evaluated by the emergency room physician. Routinely a CT scan would be obtained, and allow that to identify the level of injury.
It’s very interesting that within trigger, what we call an ER consultation, where an ER physician will contact the maxillofacial surgeon on call, so in many instances the outcomes are the same, it just is a little bit more of an elaborate process to get it through, through the ER. As we all know ERs are becoming used more and more as primary care facilities, people are going there for everything, ac common called, an ingrown toenail, any of those aspects and things, and sometimes it gets in the way of people who do have some traumatic injuries that belong there. So it always helps to have a contact.
Dr. Ramzi Matar (Winter Park Dentistry): So let’s fast-forward a little more. Now we’ve gotten through the initial, yet stabilized numbing. Most often, I’m hearing and dealing with front teeth, you knock out a front tooth, what do you do? What is currently, what is your treatment if somebody knocks out a front tooth, how do you manage that, what are the options, what should people be looking for, from their oral surgeon or dentist or whoever?
Dr. Don E. Tillery, Jr: There are a couple of primary issues to deal with, what we call the survivability outcome. Those teeth that are lost. One of them is the age of the patient, the younger the patient is, the more open the pulp canal is of the root of a tooth, and so the survivability is much better for a youngster in those cases.
The second thing is time out of the mouth, there are a number of different mediums, there are liquids that we can use, a balanced salt solution, milk is one, saliva is another, where a tooth can be placed in that protection, it keeps them from drying out, but nothing is better than to try to replant the tooth, so even if you’re little squeamish, you’re a dad or a mom at the baseball field, you see that tooth knocked out, try to recover it, try to replace it. Then immediately contact your dentist so that they can evaluate that. One of the things that the dentist will do is assess the amount of time the tooth has been out of the person’s mouth, and basically the positioning of the tooth once it’s repositioned.
The challenges that we have in today’s environment is not just whether we can get the tooth to take immediately, but what is the long term, overall prognosis of that tooth. Even though a tooth may be replaced an repositioned, in many instances, a tooth will ultimately die or be lost due to conditions that we call internal or external resorption. And this may happen years after the trauma against it, and the frustrating part of that is, in many instances, when insurance comes to play, the patient, their funds or their assets, that are dealing with that, have been exhausted, so the question that comes up is at what point do we give up on the tooth, and go with an ultimate dental replacement of that lost missing tooth, and in many instances the tipping point may be the magnitude of the boning displacement that’s happened in that area, there’s significant crushing on the injury, we know the blood supply’s going to be compromised, and ultimately the tooth is at great risk.
So close assessment, time is of the essence, but the close assessment of the age, the size of the pulp canal, the displacement, and the subsequently how long it took that person to come in for management. Before they were assessed and managed. At some point the decision might be to extract or remove the tooth, graft that area with some bone…
Dr. Ramzi Matar (Winter Park Dentistry): So, replace the bone.
Dr. Don E. Tillery, Jr: That’s it. Maintain the bone in that area in order to make them a candidate, or do what we call sight development, or sight protection, to make them a candidate for a more aesthetic and positive dental implant outcome.
Dr. Ramzi Matar (Winter Park Dentistry): Most of the times, you can replace teeth, in the vast majority of times, if somebody’s lost a tooth or two, the take-home messages, you can put implants on it, you can replace it, you can make it pretty again and be ready for homecoming and all that kind of stuff.
Dr. Don E. Tillery, Jr: Absolutely. That is kind of where we are in the state of the art of things. But first and foremost we try to instruct parents and loved ones, just the individuals that are involved in those kind of wild little injuries, someone gets hit by a basketball and the teeth are out, put them back in immediately. Contact your dentist, get ahold of a professional that can help you, that’s trained to identify and recognize a tooth anatomy, a tooth location, bite, what we call the inclusion, have them analyze and stabilize that, and then having them follow you so they can give you appropriate advice as to whether or not it’s time to bail on the repositioning of the tooth.
Dr. Ramzi Matar (Winter Park Dentistry): I know you’ve been doing this for many years so you’ve seen a lot fo this. I do have one last question for you. If someone was to take a basketball to the face, and they were to lose one or two or three teeth, does the tooth fairy still give you money for it and is it more or less than if It was a baby tooth?
Dr. Don E. Tillery, Jr: *laughs* That’s a tough question. Google that one to see.
Dr. Ramzi Matar (Winter Park Dentistry): Well the jury’s still out on the fairy, but I really appreciate your time, I appreciate your insight. I think that people that get this feedback… Get that tooth back in, it’s very good advice, I really appreciate Dr. Tillery again, it’s always a pleasure, thank you.