Case #79 "Time is Tooth"
by Charlene Babcock Irvin, MD, FACEP
The chief complaint is "Fall", and as
you walk into the exam room, you see a 13
y/o female holding a bloody towel to her
mouth.
According to mom, she is a gymnast, and
fell off the uneven parallel bars onto her
face and cut her lip and knocked a tooth
out. Mom has the tooth in a tissue in her
purse.
There was no LOC, and she complains now
only of mouth pain.
ROS: No vomiting, nausea, change in
vision, lethargy, headache. Completely
unremarkable ROS except for mouth pain.
PMH: no hospitalizations, no surgeries, no
medical problems.
Meds: None
Allergies: None
PE: WDWN athletic female, in no distress,
but appears to have been crying.
VS: HR=98, RR=18, BP=100/60, Temp =98F
HEENT: PERRL, EOM intact, nl Fundi, TM nl,
no nasal septal hematoma, no nasal bleeding,
left front top incisor is missing, small
blood clot in the socket. Left lower front
incisor is chipped, and you can see a little
bit of pink exposed at the base of the chip.
Airway open, intact, bleeding controlled.
There is a 1 cm lip laceration on the lower
lip.
Except for the chipped lower tooth (which
was slightly loose) the other teeth were
stable. No obvious alveolar ridge fracture
identified, but front of maxilla was very
tender. No gross instability on palpation.
No point boney tenderness anywhere on the
face, except at the alvolear ridge of the
upper front teeth. Neck supple, non-tender.
Full ROB without pain/tenderness.
Heart: RRR
Lungs: Clear
Abd: Soft Non-tender
Ext: Normal
Neurologic Exam: Normal
Questions:
1. What is the numbering system for teeth?
2. Should you put the tooth back into place?
How? Is there any time you shouldn’t put the
tooth back?
3. Besides looking for a fracture, what else
do you need to rule out on the x-ray?
4. How do you describe the chipped tooth?
What is the Ellis classification? What are
the different layers of a tooth?
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