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BDS3 Paediatrics > Dental Trauma > Flashcards

Dental Trauma Flashcards

1
Q

dental trauma in kids is mainly in what teeth

A

maxillary primary incisor teeth

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2
Q

concussion

A

tooth tender to touch but not displaced. PDL tissue affected, normal mobility but no bleeding into gingival sulcus

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3
Q

subluxation

A

tender to touch, mobility increased but not displaced, bleeding from gingival crevice noticed

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4
Q

3 types of luxation injuries

A
  1. lateral luxation
  2. intrusion
  3. extrusion
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5
Q

lateral luxation

A

tooth displaced in a palatal / lingual / labial direction i.e. any direction other than axial along with comminution or fracture of alveolar bone

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6
Q

intrusion

A

tooth displaced through labial bone plate into alveolar bone with comminution or fracture to alveolar bone, can impinge on permanent tooth bud

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7
Q

extrusion

A

partial displacement of tooth out of it’s socket

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8
Q

avulsion

A

tooth is completely out of the socket, can be found imbedded in lips, cheeks, tongue, ingested or inhaled

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9
Q

what should happen if an avulsed tooth is not found

A

child should be sent for a medical assessment in the emergency department

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10
Q

7 steps when managing a patient who comes in with trauma

A
  1. reassurance
  2. history
  3. exam
  4. diagnosis
  5. emergency treatment
  6. important information
  7. further treatment & review
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11
Q

what to look for in extraoral trauma exam

A
  • lacerations
  • haematoma
  • haemorrhage / CSF
  • subconjunctival haemorrhage
  • bony step deformities
  • mouth opening
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12
Q

what to look for in intraoral trauma exam

A
  • soft tissues
  • alveolar bone
  • occlusion
  • teeth
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13
Q

what is contained within a trauma stamp

A

mobility // colour // TTP // sinus // percussion note // radiograph

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14
Q

aftercare advice to give to parents

A
  1. analgesia - ibuprofen and/or paracetamol
  2. soft diet for 10-14 days
  3. brush with soft toothbrush after every meal
  4. topical chlorhexidine gluconate 0.12% mouth rinse applied topically 2x daily for 1 week
  5. warn re signs of infection
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15
Q

for an uncomplicated enamel dentine fracture

A

cover all exposed dentine with GI / composite, lost tooth structure can be restored immediately with composite or at a later visit

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16
Q

for a complicated crown fracture i.e. enamel, dentine, pulp

A

partial pulpotomy / extract
coronal / cervical pulpotomy = larger removal of pulp before CaOH, GIC and composite placement

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17
Q

action if crown root fracture but crown can be restored

A
  1. no pulp exposed - cover exposed dentine with GI
  2. pulp exposed - pulpotomy or endo
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18
Q

action if crown root fracture but crown is unrestorable

A
  1. extract loose fragments
  2. do not dig !
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19
Q

treatment for concussion

A

no treatment / observation

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20
Q

treatment for subluxation

A

no treatment / observation
may place passive flexible splint for 2wks if necessary

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21
Q

treatment for lateral luxation

A
  1. minimal / no occlusal interference = allow to reposition spontaneously
  2. severe displacement = extract OR reposition +/- splint but if splinting for 4wks caution should be taken to avoid damage to permanent successor
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22
Q

treatment for intrusion

A

allow to spontaneously reposition irrespective of direction of displacement

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23
Q

what radiographs should be used and why in an intrusion

A

use either periapical or lateral premaxilla (extra-oral film) to assess danger to permanent successor

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24
Q

treatment for extrusion

A
  1. not interfering with occlusion - allow for spontaneous repositioning
  2. excessive mobility or extruded >3mm then extract
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25
Q

treatment for avulsion of primary tooth

A

take radiograph to confirm avulsion but DO NOT REPLANT

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26
Q

treatment for alveolar fracture

A

reposition segment and stabilise with flexible splint for 4wks, teeth may need extracted after this

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27
Q

sequelae of trauma to primary tooth

A
  1. discolouration
  2. discolouration & infection
  3. delayed exfoliation
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28
Q

asymptomatic discolouration ( tooth can be vital / non vital )

A

mild grey - immediate discolouration may maintain vitality
opaque / yellow - pulp obliteration
no signs of pulp necrosis or infection
no treatment - review

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29
Q

symptomatic discolouration (non vital )

A

sinus, gingival swelling, abscess
increased mobility
radiographic evidence of periapical pathology
extract or endodontic treatment

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30
Q

what is enamel hypomineralisation

A

qualitative defect of enamel i.e. normal thickness but poorly mineralised, white / yellow defect

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31
Q

treatment of enamel hypomineralisation

A

no treatment
composite masking +/- localised removal
tooth whitening

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32
Q

what is enamel hypoplasia

A

quantitative defect of enamel i.e. reduced thickness but normal mineralisation, yellow / brown defect

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33
Q

treatment of enamel hypoplasia

A

no treatment
composite masking

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34
Q

what is dilaceration

A

abrupt deviation of the long axis of the crown or root portion of the tooth

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35
Q

crown dilaceration management options

A

surgical exposure & orthodontic realignment, improve aesthetics restoratively

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36
Q

root dilaceration / angulation / duplication management options

A

combined surgical and orthodontic approach

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37
Q

premature loss of a primary tooth can result in

A

delayed eruption of up to 1yr due to thickened mucosa

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38
Q

when would you take a radiograph to investigate delayed eruption

A

if > 6 month delay compared to contralateral tooth

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39
Q

management options of ectopic tooth

A

surgical exposure, orthodontic realignment, extraction

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40
Q

management options for arrested development of root

A
  1. endo - if favourable root length
  2. extraction
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41
Q

what is an odontoma

A

a slow growing, asymptomatic neoplasm found in the jaw usually associated with unerupted or impacted teeth

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42
Q

management of odontome formation

A

surgical removal

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43
Q

what is the most common injury in primary dentition

A

luxation injury

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44
Q

3 key aspects of MH that may influence treatment options

A
  1. rheumatic fever
  2. congenital heart defects
  3. immunosuppression
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45
Q

when carrying out tactile test with probe look for (2)

A
  • fracture lines; horizontal / vertical, transillumination can help
  • pulpal involvement
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46
Q

what is traumatic occlusion

A

can only bite on one displaced tooth - requires urgent treatment

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47
Q

how does percussion indicate root fracture

A

duller note may = root #

48
Q

key feature when sensibility testing & viewing root surfaces on radiographs

A

always compare injured tooth with the adjacent non injured tooth and opposing teeth

49
Q

5 things the prognosis depends on

A
  1. type of injury
  2. if PDL is also damaged
  3. time between injury & treatment
  4. presence of infection
  5. stage of root development
50
Q

how to manage enamel fracture

A
  • either bond fragment to tooth or grind sharp edges
  • take 2 periapicals to rule out root fracture or luxation
  • follow up 6/8wks, 6mths, 1yr
  • prognosis = 0% risk of pulp necrosis
    (no exposed tubules)
51
Q

how to manage enamel dentine fracture

A
  • account for fragment
  • bond fragment to tooth or place composite bandage
  • line restoration if fracture is close to pulp
  • take 2 periapicals to rule out root fracture / luxation
  • radiograph any lip / cheek lacerations to rule out embedded fragment
  • sensibility testing & evaluate tooth maturity
  • definitive restoration
  • follow up 6/8wks, 6mths, 1yr
  • prognosis = 5% risk of pulp necrosis at 10yrs
52
Q

when following up trauma case you are checking radiographs for

A
  1. root development - width & length of canal
  2. comparison with other side
  3. internal + external inflammatory response
  4. periapical pathology
53
Q

how to manage EDP fractures

A
  • evaluate size of exposure, time since and associated PDL injuries
  • choose between pulp cap / partial (Cvek) pulpotomy / full coronal pulpotomy
    aim is to preserve pulp vitality and aim to avoid full extirpation unless tooth is clearly non vital
54
Q

when would you carry out a direct pulp cap

A

if small exposure (1mm) and within 24hr window

55
Q

how to carry out direct pulp cap

A
  • trauma sticker & radiographic assessment
  • should be non TTP and +ve to sensibility tests
  • clean area with water, disinfect with sodium hypochlorite
  • apply CaOH (Dycal) or MTA white to pulp exposure or biodentine (a bioceramic)
  • restore
  • review 6/8wks, 6mths, 1yr
56
Q

when to carry out partial (Cvek) pulpotomy

A

larger exposure > 1mm, or 24+ hrs since trauma

57
Q

how to carry out partial (Cvek) pulpotomy

A
  • trauma sticker & radiographic assessment
  • clean area with saline, disinfect with sodium hypochlorite
  • remove 2mm of pulp using high speed round diamond bur
  • place saline soaked CW pellet over exposure until haemostasis achieved
  • if not achieved proceed to full coronal pulpotomy
  • apply CaOH then GI or white MTA then restore
  • review as with pulp cap
58
Q

how to carry out full coronal pulpotomy

A
  • begin with partial
  • assess for haemostasis after application of saline soaked cotton wool
  • if hyperaemic OR necrotic - proceed to remove all of coronal pulp
  • place CaOH in pulp chamber
  • seal with GIC lining and quality coronal restoration
59
Q

issue with root treatment in immature incisors

A

if tooth non vital , full pulpectomy required but there is no apical stop to allow obturation with GP

60
Q

options for full pulpectomy

A
  1. CaOH to induce apexification but no longer used as more likely to cause root fracture can place non setting CaOH but only for 4-6 wks after being identified as non vital
  2. MTA / BioDentine placed at apex of canal to create cement barrier
  3. regenerative endo technique to encourage hard tissue formation at apex
61
Q

MTA plug and heated GP obturation

A
  1. need working length radiograph of open apex
  2. 3-4mm radiopaque material (likely MTA) placed in canal and condensed using pluggers / paper points
  3. thermal obturation - cut short around ACJ to prevent shine through of orange / pink to cervical aspect of tooth
  4. seal off with vitrebond / RMGI
62
Q

why do thermal obturation

A

open apices = wide canals so cold lateral compaction is very time consuming

63
Q

crown root fracture with no pulp exposure treatment options

A
  1. fragment removal only & restore
  2. fragment removal & gingivectomy - indicated in c-r fractures with palatal subgingival extension
  3. orthodontic extrusion of apical portion (endo, extrusion, post-crown)
  4. surgical extrusion
  5. decoronation - preserve bone for future implant
  6. extraction
64
Q

crown root fracture with pulp exposure

A
  1. can be temporised with composite for up to 2wks
  2. fragment removal & gingivectomy - indicated in c-r fractures with palatal subgingival extension
  3. orthodontic extrusion of apical portion (endo, extrusion, post-crown)
  4. surgical extrusion
  5. decoronation - preserve bone for future implant
  6. extraction
65
Q

in supporting tissues have to consider impact of injury on (3)

A
  • surrounding bone
  • neurovascular bundle
  • root surface
66
Q

separation injury

A

extrusive luxation where major part of injury consists of cleavage of cellular components e.g. collagen

67
Q

crushing injury

A

intrusive luxation where extensive damage to cellular and intercellular systems

68
Q

in lateral luxation if incomplete root formation

A

spontaneous revascularisation may occur
if pulp becomes necrotic & signs of inflammatory infection related external resorption then start endo treatment

69
Q

in lateral luxation if complete root formation

A

pulp will likely become necrotic
start endo
corticosteroid antibiotic or CaOH as intra canal medicament to prevent development of inflammatory infection related external resorption

70
Q

lateral luxation and intrusion both have what kind of percussion sound

A

high ankylotic percussion tone

71
Q

treatment of intrusion in immature root

A

allow spontaneous repositioning
if no re eruption in 4wks - ortho repositioning
monitor pulp
spontaneous pulp revascularisation may occur
if it becomes necrotic / infected start endo

72
Q

treatment of intrusion in mature root

A

<3mm - spontaneous repositioning, if no re eruption in 8wks reposition surgically and splint for 4wks or reposition orthodontically before ankylosis develops
3-7mm - reposition surgically or ortho
>7mm - reposition surgically

73
Q

what often happens pulp in teeth with complete root formation after intrusion

A

pulp almost always becomes necrotic so start endo treatment at 2wks or as soon as tooth position allows to prevent development of inflammatory infection related external resorption

74
Q

what shouldn’t you measure during intrusion and why

A

don’t measure from gingival margin to incisal edge as gingival margin is subject to change upon healing

75
Q

follow up following intrusion

A

2/4/8/12 wks, 6mths, 1yr, annually for 5yrs

76
Q

what constitutes complete healing

A

revascularisation and can only be expected in teeth with open apices when a luxation injury has occurred

77
Q

what is a common complication following intrusion injury to teeth with closed apices

A

root resorption which may occur up to 5-10yrs after

78
Q

what is EADT

A

extra alveolar dry time i.e. time the avulsed tooth is out of the mouth

79
Q

what is EAT

A

extra alveolar time i.e. total time an avulsed tooth is out of the mouth either dry or in a storage medium

80
Q

what 3 PDL factors must be taken into consideration following an avulsed tooth

A
  1. if PDL is mostly viable - replanted immediately or v shortly after
  2. if PDL viable but compromised - kept in saline / milk, total dry time <60mins
  3. PDL non viable - dry time > 60mins regardless of what happened after this time all PDL cells are non viable
81
Q

what emergency advice to give when tooth avulsion

A
  1. ensure it is a permanent tooth
  2. hold by crown
  3. encourage attempt to place tooth immediately into socket - rinse gently in milk/saline/person’s saliva and replant
  4. bite on gauze to hold in place
  5. seek immediate dental advice
82
Q

appropriate storage mediums in order of decreasing suitability

A
  1. milk
  2. HBSS
  3. saliva
  4. saline
  5. water
83
Q

2 main factors to consider with an avulsed tooth

A
  1. maturity of the root
  2. PDL cell condition - depends on time spent out of the mouth and medium in which avulsed tooth is kept
84
Q

management for avulsed tooth with closed apex already replanted

A
  • clean injured area using chlorhexidine
  • verify replanted tooth position & apical status clinically & radiographically
  • leave in place unless malpositioned and if incorrect using digitation can reposition for up to 48hrs post avulsion
  • place passive flexible splint
  • suture gingival lacerations if present
  • consider antibiotics & check tetanus status
  • provide post op instruction
  • follow up
85
Q

management of avulsed tooth with closed apex & EADT <60mins

A

PDL cells may be viable but compromised
- remove debris using saline
- history & exam with tooth in storage medium
- correct position to be verified clinically & radiographically
- replant tooth under LA
- splint
- suture gingival lacerations if present
- consider antibiotics and check tetanus status
- provide post op instructions
- follow up

86
Q

management of avulsed tooth with closed apex & EADT >60mins

A

PDL cells likely to be non-viable
- remove debris & irrigate socket with sterile saline
- history & exam with tooth in storage medium
- correct position to be verified clinically & radiographically
- replant tooth under LA
- splint
- suture gingival lacerations if present
- consider antibiotics and check tetanus status
- provide post op instructions
- follow up

87
Q

endo treatment for avulsed permanent tooth with closed apex

A
  • should begin within 2wks
  • CaOH recommended as intracanal medicament for up to 1 mth
  • if corticosteroid / antibiotic corticosteroid mix is used as anti-inflam an anti-resorptive intracanal medicament should be placed immediately after and left in situ for at least 6wks
  • should be applied carefully to root canal itself and not crown as this can cause discolouration
88
Q

management of avulsed tooth with delayed replantation

A
  • poor long term prognosis; pdl becomes necrotic and not expected to regenerate so ankylosis-related root resorption
  • decision to replant almost always correct
  • refer to specialist / inter-disciplinary management
89
Q

what is the aim of replantation

A

to restore aesthetic and function temporarily while maintaining alveolar bone contour, width & height
ultimate goal is revascularisation

90
Q

management of avulsed tooth with open apex if tooth already replanted

A
  • clean using saline or chlorhexidine
  • verify replanted tooth position & apical status clinically + radiographically
  • correct malposition using digital pressure if necessary
  • place splint
  • suture gingival lacerations if present
  • consider antibiotics and check tetanus status
  • provide post op instruction
  • follow up
91
Q

management of open apex tooth with EAT > 60mins

A

PDL cells likely to be non-viable, likely outcome is ankylosis related root resorption
- remove debris and clean using saline or chlorhexidine
- replant under LA
- correct malposition using digital pressure if necessary
- place splint
- suture gingival lacerations if present
- consider antibiotics and check tetanus status
- provide post op instruction
- follow up

92
Q

is replanting the correct decision

A

even as a temporary space maintainer the right choice is usually to replant

93
Q

when should you not replant

A
  • child = immunosuppressed
  • other serious injuries requiring preferential emergency treatment
  • very immature apex and extended EAT >90mins
  • very immature lower incisors in young child finding it difficult to cope
94
Q

what is a dento-alveolar fracture

A

fracture of the alveolar bone which may or may not involve the alveolar socket

95
Q

clinical findings of a dento-alveolar fracture

A
  • complete alveolar fracture extending from the buccal to palatal bone in the maxilla and from the buccal to lingual bony surface in the mandible
  • segment mobility and displacement with several teeth moving together
  • occlusal disturbance
  • gingival laceration
96
Q

treatment for dento-alveolar fracture

A

reposition any displaced segment
stabilise with passive flexible splint for 4wks
suture gingival lacerations if present
monitor pulp condition & root development of all teeth involved

97
Q

advice to give following treatment for dento-alveolar fracture

A
  • soft diet for 7 days
  • avoid contact sport whilst splint is in place
  • careful oral hygiene with use of chlorhexidine gluconate mouthwash 0.12%
98
Q

what injuries would you splint for 2/52

A

subluxation
extrusive luxation
avulsion

99
Q

what injuries would you splint for 4/52

A

intrusive luxation
lateral luxation
root # - mid root & apical 1/3
dento-alveolar #

100
Q

what injuries would you splint for 4/12

A

root # - cervical 1/3

101
Q

why choose a splint

A
  1. flexible and passive
  2. ease of placement / removal
  3. facilitate sensibility testing / clinical monitoring
  4. allows oral hygiene
  5. aesthetic
102
Q

2 main categories of splint

A
  1. chair-side
  2. lab-made
103
Q

types of chair-side splint

A

composite & wire
titanium trauma splint
composite
orthodontic brackets & wire
acrylic

104
Q

types of lab-made splint

A

vacuum formed splint
acrylic

105
Q

composite & wire splint

A

stainless steel wire up to 0.4mm diameter
ensure passive
flexible = includes one tooth either side of traumatised tooth/teeth

106
Q

titanium trauma splint

A

rhomboid mesh structure
0.2mm thick
secured to teeth with composite resin

107
Q

4 main post trauma complications

A
  1. pulp necrosis & infection
  2. pulp canal obliteration
  3. root resorption
  4. breakdown of marginal gingiva & bone
108
Q

pulp canal obliteration

A
  • response of vital pulp
  • progressive hard tissue formation within pulp cavity
  • gradual narrowing of pulp chamber & canal; total or partial obliteration
  • commonly seen in luxation
  • affected tooth can take on opaque / yellow tinge
    treatment = conservative
109
Q

2 main types of root resorption

A
  1. external
  2. internal
110
Q

types of external root resorption

A
  1. surface
  2. external infection related IRR
  3. cervical
  4. ankylosis related RRR
111
Q

types of internal root resorption

A
  1. internal infection related IRR
112
Q

external surface resorption

A

superficial resorption lacunae repaired with new cementum
response to localised injury
not progressive

113
Q

external infection related IRR

A

non vital tooth
initiated by PDL damage; propagated by root canal toxins reaching external root surface via dentinal tubules
diagnosis - indistinct root surface; root canal tramlines intact

114
Q

external infection related IRR

A

rapid
remove stimulus & endo treatment; non setting CaOH for 4-6wks obturate with GP
cervical resorption

115
Q

ankylosis related RRR

A

initiated by severe damage to PDL & cementum; normal repair does not occur, bone cells than PDL fibroblasts
severe luxation or avulsion
root involved in remodelling - radiograph has ‘ragged’ root outline, no obvious PDL space
speed variable - infraocclusion due to alveolar bone development
treatment = plan loss

116
Q

decoronation & ankylosis related RRR

A

alveolar bone of affected region will move further in apical direction. once gingival margin of ankylosed tooth is >3mm compared to contralateral unaffected tooth, should consider decoronation of ankylosed tooth

117
Q

internal infection related IRR

A

due to progressive pulp necrosis - infected material via non-vital coronal part of canal propagates resorption
radiograph - symmetrical expansion of root canal walls, tramlines of root canal are indistinct, root surface intact
treatment = remove stimulus & endodontic treatment

BDS3 Paediatrics (5 decks)

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