What are the treatment guidelines for a broken tooth in an urgent care setting?

Broken Tooth Treatment in Urgent Care

In urgent care, immediately assess the depth of the tooth fracture and presence of pulp exposure, as this determines whether the patient needs same-day dental referral or can be managed with conservative measures and follow-up within days.

Initial Assessment and Triage

Determine Fracture Type by Clinical Examination

• Enamel-only fractures appear as superficial cracks or chips without tooth sensitivity and can be managed conservatively 1
• Enamel-dentin fractures expose yellowish dentin beneath white enamel and typically cause temperature sensitivity 1
• Complicated crown fractures show visible red pulp tissue in the center of the fracture and require immediate dental referral 1, 2
• Crown-root fractures involve both the visible crown and root below the gumline, often with a mobile fragment that must be removed 1

Check for Associated Injuries Requiring Immediate Referral

• Multiple teeth moving together as a unit indicates alveolar bone fracture requiring immediate repositioning and splinting 2
• Severe tooth mobility with aspiration risk requires immediate evaluation 2
• Inability to close the jaw properly may indicate mandibular dislocation 2

Treatment Algorithm by Fracture Type

Enamel-Only Fractures (Uncomplicated)

These can be managed in urgent care without immediate dental referral.

• Smooth any sharp edges with a dental handpiece and polishing bur, or leave untreated if the fracture site is smooth to touch 1
• No sensitivity is expected with enamel-only fractures 1
• Instruct the patient to monitor for gray discoloration, swelling, or gum bumps (parulis) that would indicate delayed pulpal necrosis 2
• Routine dental follow-up is sufficient; immediate referral is unnecessary 1

Enamel-Dentin Fractures (Uncomplicated)

Refer to dentist within a few days to cover exposed dentin and prevent bacterial contamination.

• The more sensitive the tooth, the more urgent the dental referral should be 1
• Prescribe NSAIDs (ibuprofen) for pain control 3
• Advise soft diet for 10 days and avoidance of temperature extremes 3
• Apply cold compresses to reduce swelling 3
• The dentist will restore with tooth-colored composite material or rebond the tooth fragment if available 1

Common Pitfall: Do not delay referral beyond a few days, as exposed dentin increases risk of pulpal bacterial contamination and subsequent necrosis 1

Crown Fractures With Pulp Exposure (Complicated)

These require immediate same-day dental referral to preserve tooth vitality.

• Visible red pulp tissue in the fracture indicates need for urgent pulp therapy 1, 2
• Timeliness is particularly critical in young permanent teeth (within 3 years of eruption) to allow continued root development 1
• The dentist will perform pulpotomy or root canal therapy depending on tooth maturity 1
• If the patient cannot cooperate with pulp therapy, extraction becomes necessary 1

Crown-Root Fractures

Immediate dental referral is required.

• The mobile crown fragment must be removed by a dentist 1
• The remaining root fragment's viability determines whether the tooth can be saved or requires extraction 1
• In severe cases where the fracture extends deep into the root, extraction is indicated 1, 3

Root Fractures

Referral timing depends on mobility and aspiration risk.

• Excessive mobility with concern for aspiration requires immediate referral 1, 2
• Fractures closer to the root apex have better prognosis and may require no treatment 1, 3
• Fractures closer to the crown have poor prognosis, and the crown segment is usually removed 1, 3
• Obtain radiographs to confirm diagnosis and determine fracture location 1

Special Considerations for Avulsed Teeth

If the entire tooth is knocked out, this is the most serious dental emergency.

Permanent Teeth

• Immediate replantation at the injury site provides the best prognosis 1, 2
• Handle the tooth by the crown only, never touch the root 1
• If dirty, rinse briefly (10 seconds) under cold running water 1
• If replantation is not possible, store in cold milk, balanced salt solution, or saliva—never water 1, 4
• The patient should bite on cloth to hold the replanted tooth in position until reaching dental care 1
• After replantation, prescribe doxycycline for children >12 years or penicillin for children <12 years (clindamycin if penicillin-allergic) 1
• A flexible splint will be placed by the dentist for up to 2 weeks 1

Primary (Baby) Teeth

• Never replant an avulsed primary tooth, as this risks damage to the underlying permanent tooth 1, 2, 5
• No treatment is indicated for avulsed primary teeth 1
• If the tooth is not found, confirm it was not intruded or aspirated 1

Pain Management and Supportive Care

• Prescribe NSAIDs (ibuprofen) as first-line for pain control, with acetaminophen as alternative 3
• Recommend soft diet for 10 days after any dental procedure 6, 3
• Apply cold compresses to reduce swelling 3
• Advise avoiding temperature extremes with food and beverages 3
• Chlorhexidine rinses may be beneficial during healing 6
• Systemic antibiotics are not routinely indicated except for replanted avulsed teeth 1, 6

Red Flags Requiring Immediate Dental Referral

• Visible pulp exposure (red tissue in fracture) 1, 2
• Multiple teeth moving together as a segment 2
• Severe tooth mobility with aspiration risk 2
• Inability to close jaw properly 2
• Extensive gingival or facial swelling suggesting abscess 2
• Crown-root fractures 1

Follow-Up Monitoring

• All fractured teeth require monitoring for signs of pulpal necrosis, including gray discoloration, gum swelling with increased mobility, or parulis formation 1, 2
• Gray tooth discoloration developing after trauma indicates pulpal hemorrhage and requires dental referral within days 2
• Children may not report pain from necrotic teeth, so caregivers must watch for visual signs 2

Critical Pearl: In children younger than 5 years with severe dental trauma, suspect non-accidental injury, particularly if the mechanism is inconsistent with the injury pattern 6, 2