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paeds > dental trauma > Flashcards

dental trauma Flashcards

1
Q

gender ratio

A

M:F 3:1

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2
Q

what % aren’t treated and why?

A

70%

lots minor

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3
Q

commonest type in primary dentition

A

luxation (soft bone)

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4
Q

commonest type in permanent dentition

A

ED fracture

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5
Q

peak age

A

7-10yrs

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6
Q

what OJ doubles risk of trauma?

A

> 9mm

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7
Q

HPC

A

other symptoms - A and E, head injury/LOC
when
how
where are lost teeth/fragments

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8
Q

MH

A

rheumatic fever
congenital heart defects
immunosuppression

may need additional tx

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9
Q

EO exam

A 
laceration
haematomas
haemorrhage/CSF
 - straw coloured coming out of nostril medially/ear
subconjunctival haemorrhage
bony step deformities
 - mandible and zygomatic arch
mouth opening

rule out facial or jaw #s

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10
Q

IO exam

A

ST
alveolar bone
occlusion
teeth

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11
Q

foreign bodies

A

account for
check for ST damage
ST radiograph to check lacerations (puncture wounds)

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12
Q

trauma stamp components - longitudinal monitoring

A 
sinus
colour
TTP
mobility
sensibility tests - ECL, EPT
p note
radiograph
occlusion
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13
Q

what does TTP indicate?

A

PDL injury

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14
Q

what can mobility indicate?

A

tooth displacement
bone #
root #

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15
Q

tactile test with probe - what to look for

A 
# lines
pulpal involvement
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16
Q

what do sensibility tests test?

A

nerve

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17
Q

where should ECL be placed?

A

incisal 1/3 unless Rx

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18
Q

what should sensibility tests be compared with?

A

adjacent and opposing teeth (may be injured)
contralateral
continue for at least 2yrs

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19
Q

dull p note

A

root #

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20
Q

traumatic occlusion

A

demands urgent tx

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21
Q

what do you need for a vitality test?

A

laser doppler flowmetry

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22
Q

classification of C and R #s

A 
E#
ED#
EDP#
uncomplicated CR# - pulp not involved
root #
 - apical 1/3 - best
 - middle 1/3
 - coronal 1/3
complicated CR#
 - pulp involved
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23
Q

which type of root # is the best and why?

A

apical 1/3 - heal better, calcified tissue

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24
Q

prognosis of a traumatised tooth

A 
type of injury
if PDL is damaged too
time between injury and tx
infection
stage of root development
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25
Q

emergency tx aims

A

retain vitality ‘dentine bandage’
-composite/ (GI)
tx exposed pulp
reduction and immobilisation of displaced teeth
tetanus prophylaxis
- check up to date, if injury particularly dirty
(ABs? - immunocompromised)

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26
Q

intermediate tx

A

+/- pulp tx

Rx - min invasive

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27
Q

permanent tx

A 
apexigenesis
apexification
root filling +/- root extrusion
gingival and alveolar collar modification if required
coronal Rx
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28
Q

how to manage E#

A

bond fragment
grind sharp edges
composite Rx

take 2 PAs to rule out root # or luxation
follow up 6-8wks and 1yr

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29
Q

E# risk of pulpal necrosis

A

0%

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30
Q

ED# management

A

account for fragment
bond fragment
composite ‘bandage’ - line if close to pulp

2PAs to rule out root # or luxation
radiograph any lip/cheek lacerations to rule out embedded fragment
sensibility testing and evaluate tooth maturity
definitive Rx
follow up 6-8wks and 1yr

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31
Q

ED# risk of pulpal necrosis

A

5% at 10yrs

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32
Q

ED# accounting for fragment

A

ground
ST - radiograph any lip/cheek lacerations to rule out embedded fragment
swallowed
inhalation
- R bronchus - straighter
- coughing/wheezing - send for chest xray

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33
Q

clinical review

A

trauma stamp

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34
Q

radiographic review

A

root development - width of canal and length
comparison with other side
internal and external inflammatory resorption
PAP

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35
Q

effect of associated injuries on pulpal survival - ED# - concussion

A

open - 95%

closed - 85%

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36
Q

effect of associated injuries on pulpal survival - ED# - subluxation

A

open - 80%

closed - 50%

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37
Q

effect of associated injuries on pulpal survival - ED# - extrusion

A

open - 60%

closed - 20%

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38
Q

effect of associated injuries on pulpal survival - ED# - lat luxation

A

open - 65%

closed - 15%

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39
Q

effect of associated injuries on pulpal survival - ED# - intrusion

A

0% for open and closed

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40
Q

aim of EDP# tx

A

preserve pulp vitality

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41
Q

EDP# evaluating exposure

A

size
time since injury
associated PDL injury

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42
Q

EDP# tx options

A

pulp cap
partial pulpotomy (Cvek)
full coronal pulpotomy

avoid full extirpation unless tooth clearly non-vital

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43
Q

what is a full coronal pulpotomy?

A

remove all pulp up to cervical constriction

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44
Q

when is a direct pulp cap indicated for an EDP#?

A

tiny exposure 1mm
<24hrs
non-TTP and positive to sensibility tests

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45
Q

stages of a direct pulp cap

A

LA and dam
clean area with water then disinfect with NaOCl
apply CaOH (Dycal) / MTA white
composite Rx

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46
Q

direct pulp cap for EDP# review

A

6-8wks

1yr

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47
Q

when is a partial (Cvek) pulpotomy indicated for an EDP#?

A

larger exposure >1mm

>24hrs

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48
Q

stages of a partial (Cvek) pulpotomy?

A

LA and dam
clean area with water then disinfect with NaOCl
remove 2mm pulp with HS round diamond bur (SS pulls out too much)
place saline soaked CW pellet over exposure until haemostasis
- if no bleeding/can’t arrest proceed to full coronal pulpotomy
CaOH then Vitrebond (or white MTA)
composite

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49
Q

what is the ideal outcome after a partial pulpotomy?

A

continued root development

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50
Q

full coronal pulpotomy

A

start with partial pulpotomy
assess for haemostasis after application of saline-soaked CW
if hyperaemic or necrotic - remove all coronal pulp up to cervical constriction
CaOH in pulp chamber, GIC lining, Rx
reactive tertiary dentine barrier should form

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51
Q

success of pulpotomies

A

partial higher success - 97% vs 75%

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52
Q

aim of pulpotomies

A

keep vital pulp within canal to allow normal root growth (apexigenesis) both in length of root and D thickness

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53
Q

follow up of pulpotomies

A

6-8wks

1yr

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54
Q

EDP# non-vital - open apex

A

full pulpectomy

need apical stop to allow obturation with GP

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55
Q

apical stop to allow obturation with GP

A

CaOH to induce apexification (but porous)
MTA/Biodentine at apex to create cement barrier
- ideal
- microscope
- 5-6mm MTA apical plug
regenerative endo technique to encourage hard tissue formation at apex
- experimental. ABs, agitate PD area cells. Make it bleed, fill canal with blood. SCs differentiate into odontoblasts.

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56
Q

open apex pulpectomy

A 
dam and access
haemorrhage control: LA/sterile water
diagnostic radiograph for WL
file 2mm short of EWL
dry canal, nsCaOH, CW in pulp chamber
GI temp in access cavity and evaluate CaOH fill level with radiograph
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57
Q

pulpectomy final coronal Rx

A

once obturation complete
consider bonded composite short way down canal as well as in access cavity
bonded core
try to avoid post-crown

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58
Q

tx options for uncomplicated CR# - no pulp exposure

A 
1 - remove fragment and restore
2 - remove fragment and gingivectomy
   - indicated in CR# with palatal subgingival extension
3 - ortho extrusion of apical portion
   - endo, extrusion, post-crown
4 - surgical extrusion
5 - decoronation (preserve bone for implant)
6 - ext (rare)
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59
Q

follow up of uncomplicated CR#

A

6-8wks

1yr

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60
Q

tx options for complicated CR# - pulp exposure

A

can be temporised w composite for up to 2wks
1 - fragment removal and gingivectomy
- indicated in CR# with palatal subgingival extension
2 - ortho extrusion of apical portion
- endo, extrusion, post-crown
3 - surgical extrusion
4 - decoronation (preserve bone for implant)
5 - ext

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61
Q

classifying root #s

A 
position
 - apical/middle/coronal 1/3
displaced/undisplaced
stage of root development
 - mature/immature
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62
Q

prognosis of a root # tooth

A 
child age
degree of displacement
associated injuries
time between injury and tx
infection
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63
Q

what can happen in a displaced root # over a few hours?

A

can get a blood clot

may need pt to bite on gauze for 20mins to squeeze clot out

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64
Q

features of a root #

A

mobile
TTP
transient grey colour

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65
Q

root # special investigations

A

sensibility tests
radiographs from at least 2 angles
- often see 2 lines in a root # - 2D image

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66
Q

tx root #

A

clean area - water, saline, CHX
reposition tooth with digital pressure
splint - 2 normal teeth either side

LA usually not required
soft diet 1wk, good OH

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67
Q

review of a root #

A 
6-8wks
6m
1yr
until 5yrs
radiographs
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68
Q

splinting for a root #

A

2 normal teeth either side
apical/middle 1/3 - flexible 4wks
coronal 1/3 - flexible 4m (hardly any PDL holding tooth in)

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69
Q

“soft diet”

A

don’t need to change diet e.g. chop apple up
want to stimulate PDL cells e.g. soft sandwich
inactivity means bone cells more likely to take over

70
Q

root # healing outcomes

A 
calcified - ideal
CT - dark line
 - eburnation - rounding of # to remove sharp edges
calcified and CT
bone/osseous
 - see 2 distinct fragments, 2 PDL
 - healed but separate
71
Q

root # non-healing outcomes

A

GT - usually associated with loss of vitality

72
Q

if tooth becomes non-vital in a root # what is the chance of pulp necrosis?

A

20%

73
Q

if tooth becomes non-vital in apical and middle 1/3 root #s?

A

extirpate to # line
dress nsCaOH then MTA/Biodentine (make barrier to compact GP against) just coronal to # line
GP - root fill to # line

apical fragment of root

  • remain in situ with own PDL (keeps the bone)
  • resorb
  • if infected - ABs/apicectomy

if became non-vital likely to be coronal part - RCT coronal part
if apical part became non-vital try to access otherwise need an apicectomy

74
Q

why are splints flexible?

A

allow some movement to allow PDL cells to regenerate

75
Q

splint for subluxation

A

flexible 2 weeks

76
Q

splint for extrusion

A

flexbile 2wks

77
Q

splint for avulsion <60mins EADT

A

flexible 2wks

78
Q

flexible 2wks splint

A

subluxation
extrusion
avulsion <60mins EADT

79
Q

splint for luxation

A

flexible 4wks

80
Q

splint for apical/middle 1/3 root #

A

flexible 4wks

81
Q

splint for intrusion

A

flexible 4wks

82
Q

splint for dento-alveolar #

A

flexible 4wks

83
Q

splint for avulsion >60mins EADT

A

flexible 4wks

84
Q

flexible 4wks splint

A 
luxation
apical/middle 1/3 root #
intrusion
dento-alveolar #
avulsion - >60mins EADT
85
Q

splint for coronal 1/3 root #

A

flexible 4m

86
Q

flexible 4m splint

A

coronal 1/3 root #

87
Q

1st choice of splint

A

composite and wire

88
Q

when is an acrylic URA type splint useful?

A

when few abutment teeth

89
Q

PDL injuries

A 
concussion
subluxation
extrusion
lateral luxation
intrusion
avulsion
dento-alveolar #s
90
Q

concussion

A

injury to the supporting structures of a tooth without displacement or mobility of the tooth
TTP

91
Q

subluxation

A

injury to the supporting structures of a tooth
increased mobility but no displacement
bleeding from gingival sulcus

92
Q

extrusion

A

partial displacement of tooth out of socket

93
Q

lateral luxation

A

displacement of tooth other than axially

94
Q

intrusion

A

displacement of tooth into alveolar bone

95
Q

avulsion

A

complete displacement of tooth out of socket

96
Q

5yr pulpal survival - concussion

A

open - 100%

closed - 95%

97
Q

5yr pulpal survival - subluxation

A

open - 100%

closed - 85%

98
Q

5yr pulpal survival - extrusion

A

open - 95%

closed - 45%

99
Q

5yr pulpal survival - lateral luxation

A

open - 95%

closed - 25%

100
Q

5yr pulpal survival - intrusion

A

open - 40%

closed - 0%

101
Q

5yr pulpal survival - avulsion/replantation

A

open - 30%

closed - 0%

102
Q

5yr resorption - concussion

A

open - 1%

closed - 3%

103
Q

5yr resorption - subluxation

A

open - 1%

closed - 3%

104
Q

5yr resorption - extrusion

A

open - 5%

closed - 7%

105
Q

5yr resorption - lateral luxation

A

open - 3%

closed - 38%

106
Q

5yr resorption - intrusion

A

open - 67%

closed - 100%

107
Q

5yr resorption - avulsion/replantation

A

frequent for both open and closed apex

108
Q

symptoms of concussion

A

not mobile

TTP

109
Q

symptoms of subluxation

A

increased mobility
TTP
bleeding from gingival sulcus

110
Q

tx of concussion

A

occlusal relief

advice

111
Q

tx of subluxation

A

occlusal relief
flexible splint 2wks
advice

112
Q

advice

A

OHI with CHX and gentle brushing
soft diet
avoid contact sports

113
Q

radiographic follow up of concussion and subluxation

A

look for intact LD and continued root development
compare with other side
check no RR

114
Q

follow-up components of concussion and subuxation

A

radiographic
sensibility tests
trauma stamp

115
Q

what to do in cases of late presentation displaced teeth where the teeth are firm?

A

use URA splint to slowly move them back

116
Q

extrusion tx

A

reposition under LA - fingers
splint 2wks
if becomes necrotic extirpate to prevent root resorption

117
Q

tx of lateral luxation

A

reposition under LA - fingers
splint 4wks
if becomes necrotic extirpate to prevent RR

118
Q

diagnosis of lateral luxation

A

sensibility testing usually -
widened PDL space
high metallic (ankylotic) p note
tooth usually immobile

119
Q

what is tooth displacement in lateral luxation accompanied by?

A

comminution/# of either the labial or lingual alveolar bone

120
Q

treatment options for intrusion

A

allow spontaneous repositioning
ortho elastic and bracket - traction
forceps

need 2 X-rays
high risk of resorption

endo tx usually necessary with closed apex - interim CaOH dressing

121
Q

diagnosis of intrusion

A

immobile
- sensitivity
high metallic note

122
Q

intrusion - spontaneous repositioning monitoring

A

measure to check open apex tooth moving down - monitor each month. may need ortho extrusion after tooth given opportunity to re-erupt

123
Q

what reduces the prognosis in intrusion?

A

concurrent crown #

124
Q

open apex intrusion severity less than 7mm

A

spontaneous repositioning

125
Q

open apex intrusion severity more than 7mm

A

ortho or surgical repositioning

126
Q

closed apex intrusion severity <3mm

A

spontaneous repositioning

127
Q

closed apex intrusion severity 3-7mm

A

ortho or surgical repositioning

128
Q

closed apex intrusion severity >7mm

A

surgical repositioning

129
Q

what can endo prevent?

A

necrotic pulp from initiating infection-related root resorption

130
Q

when should endo be considered?

A

all cases with completed root formation where chance of pulp revascularisation is unlikely

131
Q

when should endo be carried out?

A

within 3-4wks

temp CaOH filling recommended

132
Q

critical factors avulsion

A

need min pulp and PDL damage
EADT
EAT - dry and medium
storage mediums

133
Q

avulsion storage mediums

A 
best - replant immediately
saliva
blood
milk
saline
propolis
last resort - keep in buccal sulcus
134
Q

pt attends with tooth replanted

A

don’t remove
splint etc
radiograph - root development
if wrong way round and few days ago - healing will have started so just use composite to fix

135
Q

avulsion public advice

A 
hold by crown only
wash in cold running water
replace in socket and child bites on tissue
or store in milk/saliva/saline
seek immediate dental advice
136
Q

PDL decision making avulsion

A

PDL mostly viable
- replanted immediately/very shortly after
PDL viable but compromised
- saline/milk
- EADT <60mins
PDL non-viable
- EADT >60mins - all PDL cells non-viable

137
Q

BSPD avulsion cut off

A

30mins EADT

138
Q

IADT avulsion cut off

A

EADT 60mins for potential PDL/cementum healing

139
Q

PD healing outcomes after avulsion

A

regeneration
PDL/cemental healing
bony healing
uncontrolled infection (may lead to resorption)

140
Q

pulpal outcomes after avulsion

A 
regeneration
controlled necrosis (elective disinfection)
uncontrolled infection (can lead to resorption)
141
Q

aim if EAT <60mins

A

PDL healing

142
Q

EAT <60mins initial tx

A

replant under LA
flexible splint 2wks - PDL cells stimulation to regenerate
consider ABs/tetanus status

143
Q

EAT <60mins open apex further tx

A

may revascularise
if don’t RCT monitor for signs of continued growth vs loss of vitality
if tooth non-vital - extirpate and refer to paeds specialist to make apical barrier - interdisciplinary management
review regularly

144
Q

EAT <60mins closed apex further tx

A 
pulp extirpation 0-10days (ASAP)
disinfect
Ledermix/odontopaste 2wks
 - antibiotic steroid paste
remove splint 2wks, clean, replace nsCaOH
GP within 4-6wks
refer to specialist for interdisciplinary management
review
145
Q

why don’t you use CaOH initially in avulsion endo?

A

high initial pH could leach out and damage PDL cells

146
Q

> 60mins EAT closed apex aim

A

bony healing by ankylosis

unlikely PDL healing

147
Q

> 60mins EAT closed apex tx

A 
scrub root clean of dead PDL cells
endo EO before replantation
replant LA
4wks flexible splint
consider ABs
review

if EO endo not done - extirpate 7-10days, nsCaOH for 4wks prior to GP obturation

148
Q

> 60mins EAT open apex potential healing

A

unlikely PDL healing

v small chance that pulp may still revascularise

149
Q

> 60mins EAT open apex tx

A

don’t RCT unless signs of loss of vitality on follow up
replant under LA
4wks flexible splint
consider ABs, check tetanus
monitor closely for signs of necrosis vs continued root development

150
Q

when not to replant?

A

almost never
- often replant as interim - temp space maintainer
if v immature apex and EAT >90mins (may still be best to replant)
immunocompromised
other serious injuries: A+E

151
Q

when would you use CaOH and how?

A

only in a v rural area as barrier full of holes

put in and replace every 3m for 9m - then can feel a barrier

152
Q

monitoring after avulsion

A

open apex teeth need close monitoring
if pulp necrosis detected - pulp extirpation ASAP to avoid inflammatory resorption
clinical - trauma stamp
radiographic
- root development: width of canal and length
- compare with other side
- internal and external inflammatory resorption

153
Q

dento-alveolar #s tx

A

LA
reposition
flexible splint 4wks
ABs

154
Q

avulsion open apex pulpectomy

A

extirpate
CaOH for <4-6wks after identified as non-vital (problems with CaOH apexification, makes dentine brittle)
MTA plug and heated GP obturation
angelus - sets in 15min. can put GP in on same day

155
Q

dento-alveolar #s monitoring

A

check for root development - canal width and length, compare, increased length and thickening of dentine walls, apical formation
check for signs of inflammatory resorption

156
Q

dento-alveolar #s risk of pulpal necrosis closed apex

A

50% at 5 years

157
Q

advice for all dental injuries

A

soft diet 7days
avoid contact sports whilst splint
- can’t wear gum shield
careful OH, CHX MW 0.1%

158
Q

types of resorption

A

external surface
external inflammatory
internal inflammatory
replacement-resorption ‘ankylosis’

159
Q

external surface resorption

A

damage to PDL which subsequently heals
non-progressive
not associated with trauma - excessive forces which are damaging PDL

160
Q

internal inflammatory resorption pathogenesis

A

initiated by non-vital pulp
- 1/2 dead, 1/2 alive - need live cells to eat away at D
progressive

161
Q

internal inflammatory resorption diagnosis

A

ballooning of canals
tramlines of RC indistinct
root surfaces intact

162
Q

internal inflammatory resorption tx

A

extirpation
nsCaOH, change for 4-6wks to try halt resorption
6wks obturate GP (heated to adapt to shape)
if resorption continues plan ahead for prosthetic replacement

163
Q

external inflammatory resorption pathogenesis

A

trauma-related
damage to PDL initially. Maintained and propagated by necrotic pulp tissue via dentinal tubules
progressive

164
Q

external inflammatory resorption diagnosis

A

root surfaces indistinct

tramlines of RC intact

165
Q

external inflammatory resorption tx

A

pulp extirpation
nsCaOH 4-6wks, then GP
if progressive resorption plan ahead for prosthetic replacement

166
Q

replacement resorption ankylosis pathogenesis

A

initiated by severe damage to PDL and cementum
don’t get normal repair - bone fused directly to dentine
progressive - tooth gradually resorbed as part of bone remodelling

167
Q

replacement resorption ankylosis diagnosis

A

loss of PDL and LD
dull p note
no mobility

168
Q

replacement resorption ankylosis tx

A

nil

169
Q

pulp canal obliteration pathogenesis

A

“nature’s own RC filling”
response of a vital pulp
progressive hard tissue formation within pulp cavity
gradual narrowing of pulp chamber and canal - total or partial obliteration
tooth can turn v yellow - lose translucency

170
Q

pulp canal obliteration tx

A

conservative - only 1% may give rise to PAP

171
Q

ideal outcome at radiographic follow up

A

continued root development

continued thickening of D in the root walls

paeds (7 decks)

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