Rapid neurologic assessment and initial management for the patient with traumatic dental injuries.

Resident: Adam J. Bottrill
Region: Providence
Author(s): Croll, Theodore P. et al.
Journal: JADA
Volume #; Page #s: Volume 100 pp: 530-534
Year: 1980
Major topic: Rapid neurological assessment
Minor topic(s): None
Type of Article: Topic review and summary

Main Purpose: Suggested technique for dentists to assess neurological status.
Overview of method of research: Topical summary
Findings: N/A

Key points in the article discussion: The family dentist may be the first health professional to treat a pt who has sustained head trauma. Despite urgent dental needs, overall medical welfare of the patient should always be the primary concern. This paper proposes a protocol to aid the dental practitioner in an effective, yet rapid, neurologic evaluation. DENTAL TREATMENT SHOULD ONLY BEGIN AFTER A SATISFACTORY NEUROLOGIC STATE IS EVIDENT.

A. Sequelae to head trauma
1. Lacerations,
2. Linear/depressed skull fractures (with possible dural laceration and arachnoid herniation)
3. Hematoma (sub or extradural, intraventricula)
4. Brain stem injury
5. Vertebral fracture (with or without spinal cord injury)

B. Facts and figures (1975) 1. 10 mill people in US required med attention due to head injury.
2. 10% of school age children will suffer significant head injury
a. 33% of these children will require hospitalization.
3. NOTHING can be done to avoid the effects of the primary injury… (unless you want to wear a helmet all the time)
a. Therefore, neurosurgeons and neurologists can only direct their course of management towards preventing and treating the secondary injuries associated with trauma.
4. Dx tools include CAT scan, continuous ICP monitoring, MRI etc.
5. The tx of pediatric pt’s vs. adult pt’s varies significantly.

C. Categories and criteria: 1. Jennet and Bond (Long-term sequelae)
a. Good recovery (normal life)
b. Moderately disabled (independent but impaired)
c. Severely disabled (totally dependent on others)
d. Vegetative survival
e. Death
2. Meltzner and Frew (five diagnostic criteria)
a. Airway
b. State of consciousness
c. Vital signs
d. Reflexes (Oppenheim, Gordon, Gonda, Babinski, Chaddock)
e. Pupils
3. Taesdale and Jennet (Glasgow coma scale)



a. Recommend immediate referral for a pt who does not score optimally in any category.
4. Tyler (???)
a. Recommends cranial nerve exam by all dentists.

D. Recommendations: The authors don not believe a prolonged exam is either practical or required. HOWEVER, the dentist should be able to determine whether a pt should be immediately referred for neurological reasons.
1. Look for unusual motor activity or difficulties in communicating (Glasgow coma scale).
2. Assure pt’s airway
3. Hx of the injury
a. Updated tetanus? Cardiac Hx? Etc…
4. Vital signs
5. Observe for rhinorrhea or otorrhea
6. Cranial nerve exam



7. Neurologic impairment must be ruled out before analgesics are prescribed or inhalation sedation is commenced.
8. Follow-up and discharge recommendations

(Croll, Theodore P. et al., JADA, Volume 100 pp: 534 )

Summary of conclusions: If approached systematically and logically, the neurological assessment of head-trauma pt’s can be effective and rapid. If neurological impairment is suspected, immediate medical referral is indicated as impending neurological crisis of secondary injury may be prevented with early Dx and treatment.

Assessment of article: Applicable and well organized.