Dentoalveolar trauma 4

Question 1

What are the general principles for managing dentoalveolar trauma?

Answer 1

History, examination, assessment

Protection (Pulp + root surface)

Resposition (Immediately)

Stabilisation (splint + soft tissues sutures etc)

Temporary restorations

Medications (Systemic + local)

Follow-up

This isn’t a strict order (eg sometimes circumstances call for splinting immediately before the next step)

Question 2

Someone comes into your clinic with a dental injury what should you do?

Answer 2

Full assessment of all injuries is necessary. How, when, why, and where it happened.

History, examination, tests, radiographs.

Question 3

What tests should be done following injury?

Answer 3

Mobility, percussion, palpation, etc

Pulp sensibility tests (may indicate other teeth damaged and can be used as baseline for later comparison)

Radiographs: 3x PAs and 1x occlusal on opposing arch as well minimum

Question 4

When should pulp sensibility testing be done? Why?

Answer 4

It is essential to perform at the emergency visit.

It can indicate teeth that have been injured where there are no other obvious signs

Best predictor for subsequent pulp necrosis

Baseline data for later comparison

Question 5

Why should both CO2 and EPT test be used following trauma?

Answer 5

After trauma patient may react only to one of them. Lack of response associated with later pulp necrosis.

Question 6

Why is an occlusal as well as a PA needed following trauma?

Answer 6

It is important to take both radiographs in order to visualize the socket if there is a luxation.

Question 7

Why is it important to take minimum 3 radiographs following dentoalveolar trauma?

Answer 7

Movement within the socket can only be visualized when the tooth is looked at from several angles. One angle may cause dentist to miss the injury.

Fracture can appear like 2 fractures from a certain angle and like one from another if it is diagonal.

Question 8

How can the pulp be protected?

Answer 8

Pulp capping

Pulpotomy (partial/cervical)

Pulpectomy (partial)

Question 9

What is the prognosis of the different pulp protection methods?

Answer 9

Success rates are:

Pulp capping = 72 - 81%

Partial pulpotomy = 94 - 96%

Cervical pulpotomy = 72 - 79%

Question 10

Why is a diamond bur preferred over a tungsten carbide bur for treatment of pulp?

Answer 10

Diamond bur creates an abrasive surface for healing whereas tungsten carbide lacerates the soft tissue of the pulp so it doesn’t heal as well.

Question 11

Which material should be used for pulp capping?

Answer 11

Ca(OH)2

Corticosteroid/Antibiotic

MTA - ProRoot

Question 12

What are the aims of protecting the root surface?

Answer 12

Reduce damage to the root

Reduce chances of root resorption

Provide best chance for repair

Question 13

How can the root surface be protected?

Answer 13

Handle the tooth from the crown and not from the root.

Question 14

Which injuries create the most damage to the root surface?

Answer 14

Concussion and subluxation = never

Extrusion and lateral luxation = more common than concussion and subluxation

Intrusion and avulsion = most common

Question 15

How can root surface be protected after injury?

Answer 15

Don’t allow root to dry out (PDL cells will die)

Storage media should be used (milk, tissue culture are the best followed by saliva, saline, or plastic wrap)

Question 16

How can root surface be protected after injury?

Answer 16

Don’t allow root to dry out (PDL cells will die)

Storage media should be used (milk, tissue culture are the best followed by saliva, saline, or plastic wrap) AVOID WATER

Replant/reposition then use physiological splint

Inflammatory resorption can then be prevented by using antibiotics and endodontic treatment.

Question 17

What are the types of external replacement resorption and how are they related to damage to the PDL?

Answer 17

Transient which is associated with minor areas of damage which later disappears.

Progressive which is associated with drying or removal of the PDL and gradually involves the whole root.

Question 18

How is external replacement resorption treated?

Answer 18

Transient doesn’t need any treatment but is difficult to assess whether it is transient or progressive.

Progressive can not be arrested and needs extraction eventually, Aim to prevent or minimize occurrence

Question 19

How can external replacement resorption e prevented?

Answer 19

Extra alveolar time

Storage conditions

Damage during avulsion and replant

Splinting

Endodontic treatment

Question 20

Which injuries is it predictable will experience root surface damage, PDL damage, and pulp necrosis in a FULLY DEVELOPED TOOTH?

Answer 20

Avulsion

Intrusion

Lateral luxation + crown fracture

Extrusion + crown fracture

Question 21

Which injuries is it predictable will experience root surface damage, PDL damage, and pulp necrosis in an INCOMPLETELY DEVELOPED TOOTH?

Answer 21

Intrusion + crown fracture

Avulsion + crown fracture

Question 22

Since root surface and PDL damage are predictable for some injuries, what can we do for this information?

Answer 22

A preventative approach is taken with these injuries to prevent external inflammatory resorption.

Question 23

How can stabilisation be done?

Answer 23

Using rigid or flexible splints

Question 24

When should a flexible splint be used?

Answer 24

Preferred IF no root or bone fractures

Allows functional healing of the PDL and reduces ankylosis and replacement resorption

Question 25

How long should a flexible splint be used following injury?

Answer 25

7 - 10 days only

Question 26

How should a rigid splint be used?

Answer 26

Only use if a bone or root fracture:

If bone - 6 weeks

If root - 3 months

Question 27

How should lacerations be treated?

Answer 27

Suture all lacerations for optimal healing, to maintain tissue position, and to prevent gingival recession

Question 28

What can occur if sutures are not placed?

Answer 28

Poor healing would occur as well as gingival recession + bone loss

Question 29

Why should palatal tissue be looked at in any subluxation, intrusion, avulsion, etc?

Answer 29

It can look like it’s in the normal position but it isn’t leading to poor repair if not sutured and as a result can undergo recession.

Question 30

When should temporary restorations be used in response to trauma? What material should be used?

Answer 30

Cover dentine + protect the pulp.

Aesthetic material such as GIC and composite bandage might be more ideal (cover dentin)

Question 31

What systemic medications should be provided for dentoalveolar trauma?

Answer 31

Tetanus toxoid -> Check status

ABs when trying too prevent inflam resorption. Can help pulp healing (rarely and immature teeth). Use tetracyclines if not then amoxycillin

NSAIDs: Ibuprofen/tetracyclines (synergy)

Analgesics (Use NSAIDs for analgesic + anti-inflammatory effect)

Question 32

What local medications should be provided for dentoalveolar trauma?

Answer 32

Intra-canal dressings: Ledermix paste initially. Ca(OH)2. 50:50 mix

Chlorhex mouthwash after each meal until 2 days after suture removal. Avoid tannin to avoid tooth staining.

Chlorhex gel. Apply with cotton bud 2 - 3 times a day for 2 - 3 weeks

Question 33

How should trauma injuries be followed up?

Answer 33

Examine soft tissues and teeth. (Percussion, palpation, mobility, colour changes)

Pulp sensibility tests

PA radiographs

Question 34

What kind of schedule should be in place for follow ups?

Answer 34

Will depend on types of injuries present.

Removal of sutures and splint would need an appointment

Question 35

How long after first appointment should sutures be removed?

Answer 35

5 - 6 days

Question 36

How long after first appointment should flexible splint be removed?

Answer 36

7 - 10 days

Question 37

How long after first appointment should rigid splint be removed?

Answer 37

6 weeks to 3 months.

Question 38

When should follow up visit be if endodontics is not required?

Answer 38

2 weeks

1 month

2 months

3 months

6

9

1 year

annually for 5 years

then every 3 years