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BDS3 Paediatrics > Dental Trauma Permanent teeth > Flashcards

Dental Trauma Permanent teeth Flashcards

1
Q

What is avulsion?

A
  • Tooth totally displaced from socket

Clinical findings;
- Socket empty or filled with coagulum

One of only few real emergency situations in dentistry as successful healing can occur if only minimal damage to pulp and PDL

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2
Q

What are the critical factors related to an avulsion injury?

A
  • Extra-alveolar dry time (EADT)
  • Extra-alveolar time (EAT)
  • Storage medium

Decide if;
- PDL viable mostly (replanted immediately or v shortly after)
- PDL viable but compromised (kept in saline/milk, total dry time <60 mins)
- PDL non-viable (dry time >60 mins regardless of what happened after this time)
- After dry time of 60 mins or more, ALL PDL cells are NON VIABLE

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3
Q

What is the emergency advice for an avulsed tooth?

A
  • Ensure permanent tooth
  • Hold by crown
  • Encourage attempt to place tooth immediately into socket
  • If the tooth dirty, rinse it gently in milk, saline or in the patient’s saliva and replant
  • Bite on gauze/handkerchief to hold in place once replanted
  • Seek immediate dental advice
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4
Q

What are the only storage medium you should place an avulsed tooth into?

A
  • Milk (Most preferred)
  • HBSS (Hanks balanced salt solution)
  • Saliva
  • Saline
  • Water (poor medium and least preferred)
    Avoid dehydration of tooth tissue
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5
Q

How to manage an avulsed tooth with a closed apex that has already been replanted?

A
  • Clean the injured area
  • Verify replanted tooth position and apical status
  • Clinical & radiographic
  • Place splint
  • Suture gingival lacerations, if present
  • Consider antibiotics and check tetanus status
  • Provide post-operative instructions
  • Follow up 2weeks/4weeks splint removal/3months/6months/1year/annually for 5years

Commence endodontic treatment within 2weeks
CaOH in intracanal up to 1month or corticosteroid antibiotic paste for 6weeks

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6
Q

How to manage an avulsed tooth with EADT<60mins?

A
  • PDL cells may be viable but compromised
  • Remove debris
  • History & examination with tooth in storage medium
  • Replant tooth under LA
  • Splint
  • Suture gingival lacerations, if present
  • Consider antibiotics and check tetanus status
  • Provide post-operative instructions
  • Follow up 2weeks/4weeks splint removal/3months/6months/1year/annually for 5years

Commence endodontic treatment within 2weeks
CaOH in intracanal up to 1month or corticosteroid antibiotic paste for 6weeks

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7
Q

How to manage an avulsed tooth with closed apex with EADT > 60mins?

A
  • PDL cells likely to be non-viable
  • Remove debris
  • Replant tooth under LA
  • Splint
  • Suture gingival lacerations, if present
  • Consider antibiotics and check tetanus status
  • Provide post-operative instructions
  • Follow up 2weeks/4weeks splint removal/3months/6months/1year/annually for 5years

Commence endodontic treatment within 2weeks
CaOH in intracanal up to 1month or corticosteroid antibiotic paste for 6weeks

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8
Q

How does delayed replantation affect prognosis on permanent tooth with closed apex?

A
  • Poor long term prognosis (ankylosis-related root resorption)
  • Decision to replant almost always correct
  • Referral to Paediatric Specialist/ Inter-disciplinary management
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9
Q

How to manage an avulsed permanent tooth with an open apex that has already been replanted?

A
  • Clean the injured area
  • Verify replanted tooth position and apical status
  • Clinical & radiographic
  • Place splint
  • Suture gingival lacerations, if present
  • Consider antibiotics and check tetanus status
  • Provide post-operative instructions
  • Follow up 2weeks splint removal/1month/2month/3month/6month/1year/annually for 5years
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10
Q

How to manage an avulsed tooth with open apex that has EAT < 60mins?

A
  • Has potential for spontaneous healing
  • Remove debris
  • History & examination with tooth in storage medium
  • Replant tooth under LA
  • Splint
  • Suture gingival lacerations, if present
  • Consider antibiotics and check tetanus status
  • Provide post-operative instructions
  • Follow up 2weeks splint removal/1month/3month/6month/1year/annually for 5years
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11
Q

How to manage an avulsed tooth with open apex with EAT >60mins?

A
  • PDL cells likely to be non-viable
  • Likely outcome is ankylosis-related (replacement) root resorption
  • Remove debris
  • Replant tooth under LA
  • Splint
  • Suture gingival lacerations, if present
  • Consider antibiotics and check tetanus status
  • Provide post-operative instructions
  • Follow up 2weeks splint removal/1month/3month/6month/1year/annually for 5years
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12
Q

What is the aim of an avulsed tooth with open apex?

A

Revascularisation!
- Further development vs risk of external infection-related (inflammatory) root resorption
- Close monitoring
- Endodontic treatment if definite signs of pulp necrosis and infection of root canal system

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13
Q

How does delayed replantation affect prognosis of avulsed tooth with open apex?

A
  • Poor long-term prognosis: ankylosis-related (replacement) root resorption
  • Decision to replant almost always correct
  • Referral to Paediatric Specialist/ Inter-disciplinary management
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14
Q

When do you not replant an avulsed permanent tooth?

A

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

Medical contraindications?
- Child immunocompromised
- Other serious injuries requiring preferential emergency treatment

Dental contraindications?
- Very immature apex and extended EAT (>90mins)?
- Very immature lower incisors in young child finding it difficult to cope?

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15
Q

What is the 5year pulp survival rate of avulsion for open apex and closed apex?

A

Open - 30%
Closed - 0%

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16
Q

What are the clinical findings of a dento-alveolar fracture of permanent tooth?

A
  • Fracture of alveolar bone which may or may not involve the alveolar socket
  • Complete alveolar fracture extending from the buccal to the palatal bone in the maxilla and from the buccal to the lingual bony surface in the mandible
  • Segment mobility and displacement with several teeth moving together
  • Occlusal disturbance
  • Gingival laceration
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17
Q

How to manage a dento-alveolar fracture?

A
  • Reposition any displaced segment
  • Stabilise by splinting
  • Suture gingival lacerations if present
  • Monitor the pulp condition of all teeth involved

Monitor clinically and radiographically
- Root development including canal width and length, compare with neighbouring unaffected tooth
- Resorption

Follow up 4weeks inc splint removal/6-8weeks/4months/6months/1year/annually for 5years

Risk of pulpal necrosis if closed apex is 50% at 5 years

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18
Q

Post-op advice for dento-alevolar fracture?

A
  • Soft diet for 7 days
  • Avoid contact sport whilst splint in place
  • Careful oral hygiene with use of chlorhexidine gluconate mouthwash 0.12%
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19
Q

What are the splinting times for each injury to permanent teeth?

A

Subluxation - 2weeks
Extrusive luxation - 2 weeks
Intrusive luxation - 4weeks
Avulsion - 2weeks
Lateral luxation - 4weeks
Root fracture (mid root and apical third) - 4weeks
Root fracture (cervical third) - 4months
Dento-alevolar fracture - 4weeks

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20
Q

What are the splint properties?

A
  • Flexible and passive
  • Ease of placement/ removal
  • Facilitate sensibility testing/ clinical monitoring
  • Allow oral hygiene
  • Aesthetic
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21
Q

What are the types of splint?

A

Chair side
- Composite & wire
- Titanium trauma splint
- Composite
- Orthodontic brackets & wire (must be passive to avoid extra trauma to teeth)
- Acrylic

Lab-made
- Vacuum-formed splint
- Acrylic (useful when few abutment teeth)

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22
Q

What is a composite and wire splint?

A
  • Stainless steel wire up to 0.4mm in diameter
  • Quick and easy
  • Ensure placed passively
  • Flexible (include one tooth either side of traumatised tooth/teeth)
  • Don’t place near gingival margin as this can be plaque retentive factor
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23
Q

What is a titanium trauma splint (TTS)?

A
  • Rhomboid mesh structure
  • Passive and flexible
  • 0.2mm thick
  • Easily adaptable with fingers
  • Secured with composite resin
24
Q

What are the main post-trauma complications?

A
  • Pulp Necrosis & Infection
  • Pulp Canal Obliteration
  • Root Resorption
  • Breakdown of Marginal Gingiva and Bone
25
Q

What is pulp canal obliteration (PCO)?

A
  • Response of a vital pulp to traumatic injury
  • Progressive hard tissue formation within pulp cavity
  • Gradual narrowing of pulp chamber and pulp canal - Result in total or partial obliteration
  • Can become opaque or slightly yellow
    Treatment:
  • Conservative management, only 1% may give rise to PAP
26
Q

What are the types of root resorption?

A

External
- Surface
- External infection related IRR (inflam root resorption)
- Prev known as external inflammatory resorption
- Cervical
- Ankylosis related RRR (root related resorption)

Internal
- Internal infection related IRR (inflam root resorption)
- Prev known as internal inflammatory resorption

27
Q

What is external surface resorption?

A
  • Superficial resorption lacunae are repaired with new cementum
  • Response to localised injury in vital teeth
  • Not progressive
28
Q

What is external infection related Inflammatory root resorption (IRR)?

A
  • Occurs in Non-vital tooth with infected pulp canals

Initiated by PDL damage following trauma
- But Propagated by root canal toxins reaching external root surface through patent dentinal tubules

  • Rapid
  • Can cause cervical resoprtion
    Diagnosis:
  • Indistinct root surface; root canal tramlines intact
  • External contour of root
29
Q

How to manage external infection related IRR?

A
  • Remove stimulus by removing infected canal and lesion will arrest
    Endodontic treatment
  • Non-setting CaOH for 4-6 weeks
  • Obturate with GP
30
Q

What is ankylosis related RRR?

A

Initiated by severe damage to PDL and cementum.
- Normal repair does not occur
- Bone cells faster than PDL fibroblasts

Severe luxation or avulsion

Root involved in remodelling
- Radiograph: ‘Ragged’ root outline; no obvious PDL space

Speed of progression is variable and infraocclusion due to alveolar bone development

Treatment - No effective treatment and plan for loss once discrepancies in gingival margins of affected tooth compared to contralateral tooth is lower than 3mm then plan loss - assessed by multidisciplinary team

31
Q

What is internal infection related IRR?

A
  • Due to progressive pulp necrosis
  • Infected material via non-vital coronal part of canal propagates resorption by underlying tissue and rapid tissue destruction follows

Radiographic
-Symmetrical expansion of root canal walls (‘ballooning’ of canal)
- Tramlines of root canal are indistinct; root surface intact

32
Q

How to manage internal infection related IRR?

A
  • Remove stimulus of infected canal
  • Endodontic treatment prompt after diagnosis
  • Non-setting CaOH for 4-6 weeks
  • Obturate with GP
  • If progressive, plan for loss
33
Q

How to manage a concussion injury for permanent teeth?

A
  • Injury to tooth supporting structures without abnormal loosening or displacement of tooth

Clinical findings;
- Pain on percussion

No treatment

Follow up - Clinical and radiographic, 1month/1year

34
Q

What are the clinical findings of subluxation injury to permanent teeth?

A
  • An injury to the tooth-supporting structures with abnormal loosening, but without tooth displacement

Clinical findings
- Increased mobility
- Tender to percussion
- Bleeding from the gingival crevice may be present

35
Q

How to manage a subluxation injury?

A
  • Normally not required
  • Splint if excessive mobility or tenderness when biting

Follow up
- Clinical and radiographic
- 2weeks inc splint removal/ 3months/6months/1year

36
Q

How to monitor a concussion/subluxation injury?

A

Trauma Stamp

Sensibility tests:
- Thermal and electrical (At time of injury)
- False negative response is possible (Can relate to future pulp necrosis)

Radiographs:
- Root development
- Comparison with contralateral tooth
- Resorption

37
Q

What is included in a trauma stamp?

A
  • Sinus
  • Colour
    -Mobility
  • TTP
  • Percussion
  • Ethyl chloride
  • EPT (Electric pulp test)
  • Radiograph
38
Q

What is the 5year pulp survival rate of concussion injury?

A

Open apex - 100%
Closed apex - 95%

39
Q

What is the 5year pulp survival rate of subluxation injury?

A

Open apex - 100%
Closed apex - 85%

40
Q

What is the 5year resorption rate of concussion injury?

A

Open apex - 1%
Closed apex - 3%

41
Q

What is the 5year resorption rate of subluxation injury?

A

Open apex - 1%
Closed apex - 3%

42
Q

What are the clinical findings of extrusion injury?

A
  • An injury in which the tooth suffers axial displacement partially out of the socket

Clinical findings:
- Tooth appears elongated
- Usually displaced palatally
- Tooth mobile
- Bleeding from gingival sulcus

43
Q

How to manage an extrusion injury?

A
  • Reposition the tooth by gently pushing It back into the tooth socket under local anaesthesia
  • Splint

Follow up 2weeks inc splint removal/4weeks/2months/3months/6months/1year/annually for 5years

44
Q

What is the 5year pulp survival rate of extrusion injury?

A

Open apex - 95%
Closed apex - 45%

45
Q

What is the 5year resorption rate of extrusion injury?

A

Open apex - 5%
Closed apex - 7%

46
Q

What are the clinical findings of lateral luxation?

A
  • Displacement of a tooth in socket in a direction other than axially; accompanied by comminution or fracture of alveolar bone plate

Clinical findings:
- Tooth appears displaced in socket
- Tooth immobile
- High ankylotic percussion tone
- May be bleeding from gingival sulcus
- Root apex may be palpable in sulcus

47
Q

How to manage lateral luxation injury?

A
  • Reposition under local anaesthesia
  • Splint
  • Monitor
  • Endodontic evaluation (approx. 2/52 post-injury)

Follow up 2weeks/4weeks splint removal/2months/3months/6months/1year/annually 5years

48
Q

What happen when tooth with lateral luxation injury has incomplete root formation?

A
  • Spontaneous revascularisation may occur
  • If the pulp becomes necrotic and signs of inflammatory (infection-related) external resorption commence endodontic treatment
49
Q

What happens when tooth with lateral luxation injury has complete root formation?

A
  • The pulp will likely become necrotic
  • Commence endodontic treatment
  • Corticosteroid-antibiotic or calcium hydroxide as intra-canal medicament to prevent the development of inflammatory (infection-related) external resorption
50
Q

What is the 5year pulp survival rate of lateral luxation injury?

A

Open apex - 95%
Closed apex - 25%

51
Q

What is the 5year resorption rate of lateral luxation injury?

A

Open apex - 3%
Closed apex - 38%

52
Q

What are the clinical findings of an intrusion injury?

A
  • Tooth forced into socket in axial direction and locked into bone

Clinical findings:
- Crown appears shortened
- Bleeding from gingivae
- Ankylotic high, metallic percussion tone

53
Q

How to manage an intrusion injury with immature root formation?

A
  • Spontaneous repositioning independent of the degree of intrusion
  • If no re-eruption within 4 weeks: orthodontic repositioning
  • Monitor the pulp condition
  • Spontaneous pulp revascularisation may occur
  • If pulp becomes necrotic and infected or signs of inflammatory (infection-related) external resorption: endodontic treatment, as soon as possible when the position of the tooth allows

Follow up 2weeks/4weeks inc splint removal/2months/3months/6months/1year/annually 5years

54
Q

How to manage intrusion injury with mature root formation?

A

<3mm:
- Spontaneous repositioning
- If no re- eruption within 8 weeks: reposition surgically and splint for 4 weeks OR reposition orthodontically before ankylosis develops

3 -7mm:
- Reposition surgically (preferably) or orthodontically

> 7mm:
- Reposition surgically

Pulp almost always becomes necrotic so start Endodontic treatment at 2weeks or as soon as tooth position allows and aim to prevent development of inflammatory (infection-related) external resorption

Follow up 2weeks/4weeks inc splint removal/2months/3months/6months/1year/annually 5years

55
Q

What is the 5year pulp survival rate of intrusion injury?

A

Open apex - 40%
Closed apex - 0%

56
Q

What is 5year resorption rate of intrusion injury?

A

Open apex - 67%
Closed apex - 100%

BDS3 Paediatrics (14 decks)

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