dental trauma Flashcards
1
Q
gender ratio
A
M:F 3:1
2
Q
what % aren’t treated and why?
A
70%
lots minor
3
Q
commonest type in primary dentition
A
luxation (soft bone)
4
Q
commonest type in permanent dentition
A
ED fracture
5
Q
peak age
A
7-10yrs
6
Q
what OJ doubles risk of trauma?
A
> 9mm
7
Q
HPC
A
other symptoms - A and E, head injury/LOC
when
how
where are lost teeth/fragments
8
Q
MH
A
rheumatic fever
congenital heart defects
immunosuppression
may need additional tx
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
10
Q
IO exam
A
ST
alveolar bone
occlusion
teeth
11
Q
foreign bodies
A
account for
check for ST damage
ST radiograph to check lacerations (puncture wounds)
12
Q
trauma stamp components - longitudinal monitoring
A
sinus colour TTP mobility sensibility tests - ECL, EPT p note radiograph occlusion
13
Q
what does TTP indicate?
A
PDL injury
14
Q
what can mobility indicate?
A
tooth displacement
bone #
root #
15
Q
tactile test with probe - what to look for
A
# lines pulpal involvement
16
Q
what do sensibility tests test?
A
nerve
17
Q
where should ECL be placed?
A
incisal 1/3 unless Rx
18
Q
what should sensibility tests be compared with?
A
adjacent and opposing teeth (may be injured)
contralateral
continue for at least 2yrs
19
Q
dull p note
A
root #
20
Q
traumatic occlusion
A
demands urgent tx
21
Q
what do you need for a vitality test?
A
laser doppler flowmetry
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
23
Q
which type of root # is the best and why?
A
apical 1/3 - heal better, calcified tissue
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
25
emergency tx aims
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)
26
intermediate tx
+/- pulp tx
| Rx - min invasive
27
permanent tx
```
apexigenesis
apexification
root filling +/- root extrusion
gingival and alveolar collar modification if required
coronal Rx
```
28
how to manage E#
bond fragment
grind sharp edges
composite Rx
take 2 PAs to rule out root # or luxation
follow up 6-8wks and 1yr
29
E# risk of pulpal necrosis
0%
30
ED# management
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
31
ED# risk of pulpal necrosis
5% at 10yrs
32
ED# accounting for fragment
ground
ST - radiograph any lip/cheek lacerations to rule out embedded fragment
swallowed
inhalation
- R bronchus - straighter
- coughing/wheezing - send for chest xray
33
clinical review
trauma stamp
34
radiographic review
root development - width of canal and length
comparison with other side
internal and external inflammatory resorption
PAP
35
effect of associated injuries on pulpal survival - ED# - concussion
open - 95%
| closed - 85%
36
effect of associated injuries on pulpal survival - ED# - subluxation
open - 80%
| closed - 50%
37
effect of associated injuries on pulpal survival - ED# - extrusion
open - 60%
| closed - 20%
38
effect of associated injuries on pulpal survival - ED# - lat luxation
open - 65%
| closed - 15%
39
effect of associated injuries on pulpal survival - ED# - intrusion
0% for open and closed
40
aim of EDP# tx
preserve pulp vitality
41
EDP# evaluating exposure
size
time since injury
associated PDL injury
42
EDP# tx options
pulp cap
partial pulpotomy (Cvek)
full coronal pulpotomy
avoid full extirpation unless tooth clearly non-vital
43
what is a full coronal pulpotomy?
remove all pulp up to cervical constriction
44
when is a direct pulp cap indicated for an EDP#?
tiny exposure 1mm
<24hrs
non-TTP and positive to sensibility tests
45
stages of a direct pulp cap
LA and dam
clean area with water then disinfect with NaOCl
apply CaOH (Dycal) / MTA white
composite Rx
46
direct pulp cap for EDP# review
6-8wks
| 1yr
47
when is a partial (Cvek) pulpotomy indicated for an EDP#?
larger exposure >1mm
| >24hrs
48
stages of a partial (Cvek) pulpotomy?
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
49
what is the ideal outcome after a partial pulpotomy?
continued root development
50
full coronal pulpotomy
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
51
success of pulpotomies
partial higher success - 97% vs 75%
52
aim of pulpotomies
keep vital pulp within canal to allow normal root growth (apexigenesis) both in length of root and D thickness
53
follow up of pulpotomies
6-8wks
| 1yr
54
EDP# non-vital - open apex
full pulpectomy
| need apical stop to allow obturation with GP
55
apical stop to allow obturation with GP
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.
56
open apex pulpectomy
```
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
```
57
pulpectomy final coronal Rx
once obturation complete
consider bonded composite short way down canal as well as in access cavity
bonded core
try to avoid post-crown
58
tx options for uncomplicated CR# - no pulp exposure
```
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)
```
59
follow up of uncomplicated CR#
6-8wks
| 1yr
60
tx options for complicated CR# - pulp exposure
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
61
classifying root #s
```
position
- apical/middle/coronal 1/3
displaced/undisplaced
stage of root development
- mature/immature
```
62
prognosis of a root # tooth
```
child age
degree of displacement
associated injuries
time between injury and tx
infection
```
63
what can happen in a displaced root # over a few hours?
can get a blood clot
| may need pt to bite on gauze for 20mins to squeeze clot out
64
features of a root #
mobile
TTP
transient grey colour
65
root # special investigations
sensibility tests
radiographs from at least 2 angles
- often see 2 lines in a root # - 2D image
66
tx root #
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
67
review of a root #
```
6-8wks
6m
1yr
until 5yrs
radiographs
```
68
splinting for a root #
2 normal teeth either side
apical/middle 1/3 - flexible 4wks
coronal 1/3 - flexible 4m (hardly any PDL holding tooth in)
69
"soft diet"
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
root # healing outcomes
```
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
root # non-healing outcomes
GT - usually associated with loss of vitality
72
if tooth becomes non-vital in a root # what is the chance of pulp necrosis?
20%
73
if tooth becomes non-vital in apical and middle 1/3 root #s?
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
why are splints flexible?
allow some movement to allow PDL cells to regenerate
75
splint for subluxation
flexible 2 weeks
76
splint for extrusion
flexbile 2wks
77
splint for avulsion <60mins EADT
flexible 2wks
78
flexible 2wks splint
subluxation
extrusion
avulsion <60mins EADT
79
splint for luxation
flexible 4wks
80
splint for apical/middle 1/3 root #
flexible 4wks
81
splint for intrusion
flexible 4wks
82
splint for dento-alveolar #
flexible 4wks
83
splint for avulsion >60mins EADT
flexible 4wks
84
flexible 4wks splint
```
luxation
apical/middle 1/3 root #
intrusion
dento-alveolar #
avulsion - >60mins EADT
```
85
splint for coronal 1/3 root #
flexible 4m
86
flexible 4m splint
coronal 1/3 root #
87
1st choice of splint
composite and wire
88
when is an acrylic URA type splint useful?
when few abutment teeth
89
PDL injuries
```
concussion
subluxation
extrusion
lateral luxation
intrusion
avulsion
dento-alveolar #s
```
90
concussion
injury to the supporting structures of a tooth without displacement or mobility of the tooth
TTP
91
subluxation
injury to the supporting structures of a tooth
increased mobility but no displacement
bleeding from gingival sulcus
92
extrusion
partial displacement of tooth out of socket
93
lateral luxation
displacement of tooth other than axially
94
intrusion
displacement of tooth into alveolar bone
95
avulsion
complete displacement of tooth out of socket
96
5yr pulpal survival - concussion
open - 100%
| closed - 95%
97
5yr pulpal survival - subluxation
open - 100%
| closed - 85%
98
5yr pulpal survival - extrusion
open - 95%
| closed - 45%
99
5yr pulpal survival - lateral luxation
open - 95%
| closed - 25%
100
5yr pulpal survival - intrusion
open - 40%
| closed - 0%
101
5yr pulpal survival - avulsion/replantation
open - 30%
| closed - 0%
102
5yr resorption - concussion
open - 1%
| closed - 3%
103
5yr resorption - subluxation
open - 1%
| closed - 3%
104
5yr resorption - extrusion
open - 5%
| closed - 7%
105
5yr resorption - lateral luxation
open - 3%
| closed - 38%
106
5yr resorption - intrusion
open - 67%
| closed - 100%
107
5yr resorption - avulsion/replantation
frequent for both open and closed apex
108
symptoms of concussion
not mobile
| TTP
109
symptoms of subluxation
increased mobility
TTP
bleeding from gingival sulcus
110
tx of concussion
occlusal relief
| advice
111
tx of subluxation
occlusal relief
flexible splint 2wks
advice
112
advice
OHI with CHX and gentle brushing
soft diet
avoid contact sports
113
radiographic follow up of concussion and subluxation
look for intact LD and continued root development
compare with other side
check no RR
114
follow-up components of concussion and subuxation
radiographic
sensibility tests
trauma stamp
115
what to do in cases of late presentation displaced teeth where the teeth are firm?
use URA splint to slowly move them back
116
extrusion tx
reposition under LA - fingers
splint 2wks
if becomes necrotic extirpate to prevent root resorption
117
tx of lateral luxation
reposition under LA - fingers
splint 4wks
if becomes necrotic extirpate to prevent RR
118
diagnosis of lateral luxation
sensibility testing usually -
widened PDL space
high metallic (ankylotic) p note
tooth usually immobile
119
what is tooth displacement in lateral luxation accompanied by?
comminution/# of either the labial or lingual alveolar bone
120
treatment options for intrusion
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
diagnosis of intrusion
immobile
- sensitivity
high metallic note
122
intrusion - spontaneous repositioning monitoring
measure to check open apex tooth moving down - monitor each month. may need ortho extrusion after tooth given opportunity to re-erupt
123
what reduces the prognosis in intrusion?
concurrent crown #
124
open apex intrusion severity less than 7mm
spontaneous repositioning
125
open apex intrusion severity more than 7mm
ortho or surgical repositioning
126
closed apex intrusion severity <3mm
spontaneous repositioning
127
closed apex intrusion severity 3-7mm
ortho or surgical repositioning
128
closed apex intrusion severity >7mm
surgical repositioning
129
what can endo prevent?
necrotic pulp from initiating infection-related root resorption
130
when should endo be considered?
all cases with completed root formation where chance of pulp revascularisation is unlikely
131
when should endo be carried out?
within 3-4wks
| temp CaOH filling recommended
132
critical factors avulsion
need min pulp and PDL damage
EADT
EAT - dry and medium
storage mediums
133
avulsion storage mediums
```
best - replant immediately
saliva
blood
milk
saline
propolis
last resort - keep in buccal sulcus
```
134
pt attends with tooth replanted
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
avulsion public advice
```
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
PDL decision making avulsion
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
BSPD avulsion cut off
30mins EADT
138
IADT avulsion cut off
EADT 60mins for potential PDL/cementum healing
139
PD healing outcomes after avulsion
regeneration
PDL/cemental healing
bony healing
uncontrolled infection (may lead to resorption)
140
pulpal outcomes after avulsion
```
regeneration
controlled necrosis (elective disinfection)
uncontrolled infection (can lead to resorption)
```
141
aim if EAT <60mins
PDL healing
142
EAT <60mins initial tx
replant under LA
flexible splint 2wks - PDL cells stimulation to regenerate
consider ABs/tetanus status
143
EAT <60mins open apex further tx
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
EAT <60mins closed apex further tx
```
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
why don't you use CaOH initially in avulsion endo?
high initial pH could leach out and damage PDL cells
146
>60mins EAT closed apex aim
bony healing by ankylosis
| unlikely PDL healing
147
>60mins EAT closed apex tx
```
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
>60mins EAT open apex potential healing
unlikely PDL healing
| v small chance that pulp may still revascularise
149
>60mins EAT open apex tx
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
when not to replant?
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
when would you use CaOH and how?
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
monitoring after avulsion
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
dento-alveolar #s tx
LA
reposition
flexible splint 4wks
ABs
154
avulsion open apex pulpectomy
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
dento-alveolar #s monitoring
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
dento-alveolar #s risk of pulpal necrosis closed apex
50% at 5 years
157
advice for all dental injuries
soft diet 7days
avoid contact sports whilst splint
- can't wear gum shield
careful OH, CHX MW 0.1%
158
types of resorption
external surface
external inflammatory
internal inflammatory
replacement-resorption 'ankylosis'
159
external surface resorption
damage to PDL which subsequently heals
non-progressive
not associated with trauma - excessive forces which are damaging PDL
160
internal inflammatory resorption pathogenesis
initiated by non-vital pulp
- 1/2 dead, 1/2 alive - need live cells to eat away at D
progressive
161
internal inflammatory resorption diagnosis
ballooning of canals
tramlines of RC indistinct
root surfaces intact
162
internal inflammatory resorption tx
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
external inflammatory resorption pathogenesis
trauma-related
damage to PDL initially. Maintained and propagated by necrotic pulp tissue via dentinal tubules
progressive
164
external inflammatory resorption diagnosis
root surfaces indistinct
| tramlines of RC intact
165
external inflammatory resorption tx
pulp extirpation
nsCaOH 4-6wks, then GP
if progressive resorption plan ahead for prosthetic replacement
166
replacement resorption ankylosis pathogenesis
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
replacement resorption ankylosis diagnosis
loss of PDL and LD
dull p note
no mobility
168
replacement resorption ankylosis tx
nil
169
pulp canal obliteration pathogenesis
"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
pulp canal obliteration tx
conservative - only 1% may give rise to PAP
171
ideal outcome at radiographic follow up
continued root development
| continued thickening of D in the root walls
