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dental trauma Flashcards

1
Q

gender ratio

A

M:F 3:1

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2
Q

Guideline

A

IADT
international association of dental traumatology

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3
Q

what % aren’t treated and why?

A

70%

lots minor

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4
Q

commonest type in primary dentition

A

luxation (soft bone)

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5
Q

commonest type in permanent dentition

A

ED fracture

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6
Q

peak age

A

7-10yrs

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7
Q

what OJ doubles risk of trauma?

A

> 9mm

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8
Q

HPC

A

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

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9
Q

MH

A

rheumatic fever - IE risk
congenital heart defects - IE risk
immunosuppression - infection risk

may need additional tx

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10
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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11
Q

IO exam

A

ST
alveolar bone
occlusion
teeth

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12
Q

foreign bodies

A

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

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13
Q

trauma stamp components - longitudinal monitoring

8

A

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

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14
Q

what does TTP indicate?

A

PDL injury

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15
Q

what can mobility indicate?

A

tooth displacement
bone #
root #

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16
Q

tactile test with probe - what to look for

A 
# lines
pulpal involvement
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17
Q

what do sensibility tests test?

A

nerve

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18
Q

where should Ethyl Chloride be placed?

A

incisal 1/3 unless Rx

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19
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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20
Q

dull p note

A

root #

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21
Q

traumatic occlusion

A

demands urgent tx

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22
Q

what do you need for a real vitality test?

A

laser doppler flowmetry
LDF

measure the blood flow within the dental pulp

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23
Q

classification of C and R #s

A
  • E#
  • ED#
  • EDP#
  • CR#
  • root #
    • apical 1/3 - best
    • middle 1/3
    • coronal 1/3

complicated - pulp involved

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24
Q

which type of root # is the best and why?

A

apical 1/3 - heal better, calcified tissue

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25
Q

prognosis of a traumatised tooth depends on

5

A

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

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26
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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27
Q

intermediate tx

A

+/- pulp tx

Rx - min invasive

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28
Q

permanent tx

A 
apexigenesis
apexification
root filling +/- root extrusion
gingival and alveolar collar modification if required
coronal Rx
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29
Q

how to manage E#

A
  • bond fragment OR
  • grind sharp edges

/

take 2 PAs to rule out root # or luxation

/

follow up 6-8wks, 6mo and 1yr

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30
Q

E# risk of pulpal necrosis

A

0%

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31
Q

ED# management

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

/

  • 2 PAs 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 , 6mo and 1yr

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32
Q

ED# risk of pulpal necrosis

A

5% at 10yrs

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33
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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34
Q

clinical review

A

trauma stamp

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35
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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36
Q

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

A

open - 95%

closed - 85%

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37
Q

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

A

open - 80%

closed - 50%

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38
Q

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

A

open - 60%

closed - 20%

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39
Q

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

A

open - 65%

closed - 15%

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40
Q

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

A

0% for open and closed

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41
Q

aim of EDP# tx

A

preserve pulp vitality

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42
Q

EDP# evaluating exposure

A

size
time since injury
associated PDL injury

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43
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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44
Q

what is a full coronal pulpotomy?

A

remove all pulp in pulp chamber

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45
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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46
Q

stages of a direct pulp cap

A

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

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47
Q

direct pulp cap for EDP# review

A

6-8wks, 6mo, 1 year

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48
Q

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

A
  • larger exposure >1mm

or

  • 24 + hours since trauma
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49
Q

stages of a partial (Cvek) pulpotomy?

A
  • LA and dam
  • clean area with saline 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
  • ns CaOH then Vitrebond (or white MTA)
  • composite
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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
  • nsCaOH in pulp chamber, GIC lining, Rx
  • reactive tertiary dentine barrier should form
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51
Q

success of pulpotomies

A

partial (Cvek) - 97%
vs
Full coronal - 75%

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52
Q

aim of pulpotomies

A
  • keep vital pulp within canal to
  • allow normal root growth (apexogenesis) both in length of root and D thickness
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53
Q

follow up of pulpotomies

A

6-8wks, 6 mo, 1 year

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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
  • MTA/Biodentine at apex to create cement barrier
  • Regenerative endodontic technique
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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

what’s cons of CaOH apexification

A
  • increase risk of root #
  • increase brittleness of root
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58
Q

apexificaiton vs apexogeneis

A

apexification:

  • non vital tooth therapy
  • open apex
  • use MTA/ Biodentine/ (sCaOH) as apical plug for obturation

apexogenesis:

  • vital tooth therapy
  • open apex
  • use MTA/ sCaOH in chamber to encourage further root developemnt / apex closure
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59
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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60
Q

how long do you place the nsCaOH in canal?

A
  • no longer than 4-6 weeks
  • it’ll increase brittleness of root
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61
Q

best practice of pulpectomy open apex

A
  • MTA plug (instead of CaOH)
  • heated GP obturation (instead of cold lateral compaction)
62
Q

tx options for uncomplicated CR# - no pulp exposure

A

Initial

  • removal mobile fragment + RX
  • Cover the exposed dentin with GI
    or DBA + comp

Future Treatment Options:

  • Orthodontic extrusion +RX
  • Surgical extrusion
  • Extraction
  • Autotransplantation
63
Q

tx options for complicated CR# - pulp exposure

A

Initial tx

  • Until a treatment plan is finalized,
    temporary stabilization of the loose
    fragment to the adjacent tooth/teeth
    or to the non-mobile fragment should
    be attempted
  • Immature: partial pulpotomy with ns CaOH - preserve pulp
  • Mature: pulp extirpation +cover exposed dentine with GI/ DBA + comp

Future Treatment Options:

  • Completion RCT + Rx
  • Ortho extrusion
  • Surgical extrusion
  • Root submergence
  • Extraction
  • Autotransplantation
64
Q

classifying root #s

A

position

  • apical/middle/coronal 1/3

displaced/undisplaced
stage of root development

  • mature/immature
65
Q

prognosis of a injured tooth depends on

5

A

root development
type of injury
is PDL injured
time between injury and tx
infection

66
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

67
Q

features of a root #

A

mobile
TTP
transient grey colour

68
Q

root # special investigations

A

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

69
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
  • check reposition radiographically
70
Q

follow-up review of a root #

A
  • 4Weeks (splint removal)
  • 6-8 Weeks
  • 4 Months
  • 6 Months
  • 1 Year
  • 5 Years
71
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)

72
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

73
Q

root # favourable outcomes

A

● Positive response pulp test( false negative possible up to 3 months).
● Signs of repair between fractured segments
● Continue to next evaluation.

74
Q

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

A

20%

75
Q

tx- if coronal tooth becomes non-vital for root # in apical and middle 1/3

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
76
Q

why are splints flexible?

A

allow some movement to allow PDL cells to regenerate

77
Q

splinting times

A
78
Q

ideal splint properties

A
  • flexible
  • passive
  • ease of placement/ removal
  • facilitate sensibility test/ monitoring
  • allow OH
  • aesthetic
79
Q

1st choice of splint

A

composite and wire
Ti trauma splint

80
Q

types of splint

A

chairside

  • composite & wire
  • titanium trauma splint
  • composite
  • ortho bracket and wire
  • acrylic

lab-made

  • vacuum-formed splint
  • acrylic
81
Q

Composite and wire

A
  • SS wire up 0.4mm in diameter
  • Flexible: included 1 tooth either side of trauma tooth
  • Passive

bond and comp away from gingivae

82
Q

Titanium trauma splint

A

rhomboid mesh structure
0.2mm thick
1.secured with comp resin

83
Q

when is an acrylic URA type splint useful?

A

when few abutment teeth

  • full palatal coverage
  • extended to incisal edge and labial surface of ant teeth
84
Q

PDL injuries

A 
concussion
subluxation
extrusion
lateral luxation
intrusion
avulsion
dento-alveolar #s
85
Q

2 nature of trauma

A
  • separation injury - heal faster - extrusive
  • crushing injury - heal slower - intrusive
86
Q

concussion and symtoms

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

TTP

87
Q

subluxation

A

injury to the supporting structures of a tooth
increased mobility but no displacement

88
Q

extrusion

A

axial displacment partially out of socket

89
Q

extrusion clinical findings

A
  • tooth appears elongated
  • usually displaced palatally
  • tooth mobile
  • radiographically increased PDL space apically
  • likely negative sensibility test
90
Q

lateral luxation

A
  • displacement of tooth other than axially,
  • usually with fracture of alveolar process
91
Q

clinical findings of lat luxation

A
  • tooth appears displaced in socket
  • tooth immobile
  • high metallic percussion tone (ankylotic)
  • root apex may be palpable in sulcus
  • likely negative sensibility test
  • radiographically widened PDL space
92
Q

intrusion

A

displacement of tooth axially and lcoked into bone

93
Q

clinical finding of intrusion

A
  • crown appear shortened
  • (bleedign from gingivae)
  • tooth is immobile
  • high ankylotic, metallic percussion tone
  • likely negative sensibility test
  • x-ray: absence of PDL space
94
Q

avulsion

A

complete displacement of tooth out of socket

95
Q

5yr pulpal survival - concussion

A

open - 100%

closed - 95%

96
Q

5yr pulpal survival - subluxation

A

open - 100%

closed - 85%

97
Q

5yr pulpal survival - extrusion

A

open - 95%

closed - 45%

98
Q

5yr pulpal survival - lateral luxation

A

open - 95%

closed - 25%

99
Q

5yr pulpal survival - intrusion

A

open - 40%

closed - 0%

100
Q

5yr pulpal survival - avulsion/replantation

A

open - 30%

closed - 0%

101
Q

5yr resorption - concussion

A

open - 1%

closed - 3%

102
Q

5yr resorption - subluxation

A

open - 1%

closed - 3%

103
Q

5yr resorption - extrusion

A

open - 5%

closed - 7%

104
Q

5yr resorption - lateral luxation

A

open - 3%

closed - 38%

105
Q

5yr resorption - intrusion

A

open - 67%

closed - 100%

106
Q

5yr resorption - avulsion/replantation

A

frequent for both open and closed apex

107
Q

symptoms of concussion

A

not mobile
ttp

108
Q

symptoms of subluxation

A
  • increased mobility
  • TTP
  • bleeding from gingival crevice
109
Q

tx of concussion and follow up

A
  • no tx
  • 4 weeks, 6-8w, 1 year (clinic + radiograph)
110
Q

tx of subluxation + follow up

A
  • no tx
  • flexible splint 2wks if excessive mobility
  • 2 weeks (splint removal) , 4w, 6-8w, 6 mo, 1 year
111
Q

advice

A

OHI with CHX and gentle brushing
soft diet
avoid contact sports

112
Q

radiographic follow up of concussion and subluxation

A

continued root development
compare with other side
check no RR

113
Q

follow-up components of concussion and subuxation

A

radiographic
sensibility tests
trauma stamp

114
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

115
Q

extrusion tx + follow up

A

reposition under LA - fingers
splint 2wks
follow up:

  • 2 weeks (splint removal), 4w,8w,12w,6mo,1 year
  • anually for 5 years
116
Q

tx of lateral luxation and follow up

A

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

follow-up

  • 2 weeks (endo evaluation) ,4w (splint removal) ,8w,12w,6mo,1 year,
  • annually for 5 years
117
Q

lat luxation - 2 weeks endo evaluation options

A

incomplete root formation

  • spontaneous revascularisation may occur
  • if necrotic pulp/ signs of EIR, commence endo asap

complete root formation

  • pulp likely become becrotic
  • commence endo
  • corticosteorid-antibiotic / CaOH to prevent EIR
118
Q

treatment options for intrusion- immature root formation

A
  • allow spontaneous repositioning
  • if no re-eruption in 4 weeks, orthodontic repositioning
  • monitor pulp condisiotn
  • spontaneous pulp revascularization may occur
  • if pulp necrotic/ infected/ signs of EIR, commence endo tx asap/ when position allow
119
Q

treatment options for intrusion- mature root formation

A

< 3mm

  • spontaneous repositioning
  • if no re-eruption within 8w, reposition surgically and splint for 4 weeks OR
  • reposition orthodontically before ankylosis develops

3-7mm

  • reposition surgically or orthodontically

>7mm

  • reposition surgically
120
Q

tx at 2 weeks review - intrusion with mature root formation

A
  • pulp almost always become necrotic
  • start endo tx at 2 weeks / asap as tooth position allow
121
Q

intrusion follow up

A

2weeks, 4w (splint) ,8w,12w,6mo,1 year
annually for at least 5 years

122
Q

monitoring spontaneous eruption

A
  • measure distance of incisal edge of intruded tooth to adjacent tooth

mixed dentition

  • study model/ clincial photograph
  • no constant landmark (exfoliation/ eruption)

gingival margin will change after trauma, dont use

123
Q

what reduces the prognosis in intrusion?

A

concurrent crown #

124
Q

what can endo prevent?

A

necrotic pulp from initiating external inflammatory root resorption

125
Q

when should endo be considered?

A

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

126
Q

when should endo be carried out?

A

within 3-4wks

temp CaOH filling recommended

127
Q

critical factors avulsion

A

EADT
EAT
storage mediums

128
Q

avulsion clinical findings

A

socket empty or filled with coagulum

129
Q

avulsion storage mediums

A

best - replant immediately
milk
HBSS (Hanks balanced salt solution)
saliva
saline
water (poor)

130
Q

pt attends with tooth replanted - inital tx

A
  • don’t remove - unless malpositioned
  • clean injured area
  • splint (2 weeks)
  • radiograph - root development
  • suture gingival laceration
  • consider ABX/ check tetanus status
  • post - op instructions
  • follow up
131
Q

avulsion public advice

A
  • hold by crown only
  • wash in cold running water/ saliva/ milk
  • don’t rub/ scrub
  • replace in socket and child bites on gauze
  • seek immediate dental advice
    *
132
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
133
Q

aim if EAT <60mins

A

PDL healing

134
Q

closed apex follow- up- avulsion

A
  • 2 weeks (splint removal +endo)
  • 4weeks
  • 3 months
  • 6 moths
  • 1 year
  • annually for at least 5 years

trauma stamp

135
Q

avulsion not yet reimplanted initial tx

A
  • remove debris
  • history & exam
  • replant under LA
  • flexible splint 2wks
  • suture ging laceration
  • consider ABs/tetanus status
  • pot-op ins
  • follow up
136
Q

open apex further tx

A
  • close monitoring (hish risk of external IRR)
  • endo tx if definite signs of pulp necrosis/ infected root canal
137
Q

open apex tx aim and risk

A
  • revascularisation and further development

risk

  • External inflammatory root resorption
  • external replacement root resorption (ankylosis)
138
Q

closed apex further tx after replantation

A
  • pulp extirpation within 2 weeks (ASAP)
  • Intra-canal medicament
    • CaOH up to 1 month OR
    • corticosteorid/ ABX paste for 6 weeks
  • follow-up
  • (delayed replant refer to paeds specialist)

avoid medicament placement on crown - discoloration

139
Q

> 60mins EAT closed apex high risk of, and tx aim

A
  • Ankylosis
  • Replacement Root Resorption

tx aim

  • restore aesthetic
  • function temporarily
  • maintain alveolar bone contour width/ height

PDL likely necrotic

140
Q

when not to replant?

A

almost never (temp space maintainer)
but

  • immunocompromised
  • other serious injuries: A+E
  • very immature apex + extended EAT
  • very immature lower incisor in young child ( diff to cope)
141
Q

open apex requiring endo - technique

A
  • MTA - mineral trioxide aggregate as apical plug
  • heated GP obturation
142
Q

follow-up period for open apex - avulsio

A
  • 2 weeks (splint removal)
  • 4 weeks
  • 2 months
  • 3 months
  • 6 months
  • 1 year
  • anually for at least 5 years

frequent!! risk of IRR

143
Q

IRR +RRR (external) signs

A

IRR:

  • root/ bone resorption

RRR:

  • absence of PDL space
  • replacement of root structure by bone
  • metallic percussion note
144
Q

dento-alveolar #s tx

A
  • LA
  • reposition
  • flexible splint 4wks
  • suture gingival laceration
  • monitor pulp condition of all teeth involved (sensibility test)
145
Q

dento-alveolar # clinical findings

A
  • segment mobility and displacement ( sev teeth moving tgt)
  • occlusal disturbance
  • gingival laceration
146
Q

dento-alveolar #s monitoring aspect

A
  • Root development - canal width and length, compare
  • Resorption
147
Q

dento-alveolar #s risk of pulpal necrosis closed apex

A

50% at 5 years

148
Q

advice for all dental injuries

A
  • soft diet 7days
  • avoid contact sports whilst splint
  • careful OH, CHX MW 0.12%
149
Q

follow up for dento-alveolar #

A
  • 4 weeks (spint removal)
  • 6-8weeks
  • 4 months
  • 6 months
  • 1 year
  • anually at least 5 years
150
Q

main post-trauma complication

A
  • pulp necrosis & infection
  • pulp canal obliteration
  • root resorption
  • breakdown of marginal gingivae and bone
151
Q

pulp canal obliteration

A
  • response of vital pulp
  • progressive hard tissue formation within pulp cavity
  • total/ partial obliteration
  • yellow/ opaque color on crown
  • narrowing of canal/ chamber (x-ray)
152
Q

pulp canal obliteration tx

A

conservative - only 1% may give rise to PAP

paeds (7 decks)

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