Dentoalveolar trauma 4 Flashcards
What are the general principles for managing dentoalveolar trauma?
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)
Someone comes into your clinic with a dental injury what should you do?
Full assessment of all injuries is necessary. How, when, why, and where it happened.
History, examination, tests, radiographs.
What tests should be done following injury?
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
When should pulp sensibility testing be done? Why?
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
Why should both CO2 and EPT test be used following trauma?
After trauma patient may react only to one of them. Lack of response associated with later pulp necrosis.
Why is an occlusal as well as a PA needed following trauma?
It is important to take both radiographs in order to visualize the socket if there is a luxation.
Why is it important to take minimum 3 radiographs following dentoalveolar trauma?
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.
How can the pulp be protected?
Pulp capping
Pulpotomy (partial/cervical)
Pulpectomy (partial)
What is the prognosis of the different pulp protection methods?
Success rates are:
Pulp capping = 72 - 81%
Partial pulpotomy = 94 - 96%
Cervical pulpotomy = 72 - 79%
Why is a diamond bur preferred over a tungsten carbide bur for treatment of pulp?
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.
Which material should be used for pulp capping?
Ca(OH)2
Corticosteroid/Antibiotic
MTA - ProRoot
What are the aims of protecting the root surface?
Reduce damage to the root
Reduce chances of root resorption
Provide best chance for repair
How can the root surface be protected?
Handle the tooth from the crown and not from the root.
Which injuries create the most damage to the root surface?
Concussion and subluxation = never
Extrusion and lateral luxation = more common than concussion and subluxation
Intrusion and avulsion = most common
How can root surface be protected after injury?
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)
How can root surface be protected after injury?
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.
What are the types of external replacement resorption and how are they related to damage to the PDL?
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.
How is external replacement resorption treated?
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
How can external replacement resorption e prevented?
Extra alveolar time
Storage conditions
Damage during avulsion and replant
Splinting
Endodontic treatment
Which injuries is it predictable will experience root surface damage, PDL damage, and pulp necrosis in a FULLY DEVELOPED TOOTH?
Avulsion
Intrusion
Lateral luxation + crown fracture
Extrusion + crown fracture
Which injuries is it predictable will experience root surface damage, PDL damage, and pulp necrosis in an INCOMPLETELY DEVELOPED TOOTH?
Intrusion + crown fracture
Avulsion + crown fracture
Since root surface and PDL damage are predictable for some injuries, what can we do for this information?
A preventative approach is taken with these injuries to prevent external inflammatory resorption.
How can stabilisation be done?
Using rigid or flexible splints
When should a flexible splint be used?
Preferred IF no root or bone fractures
Allows functional healing of the PDL and reduces ankylosis and replacement resorption
How long should a flexible splint be used following injury?
7 - 10 days only
How should a rigid splint be used?
Only use if a bone or root fracture:
If bone - 6 weeks
If root - 3 months
How should lacerations be treated?
Suture all lacerations for optimal healing, to maintain tissue position, and to prevent gingival recession
What can occur if sutures are not placed?
Poor healing would occur as well as gingival recession + bone loss
Why should palatal tissue be looked at in any subluxation, intrusion, avulsion, etc?
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.
When should temporary restorations be used in response to trauma? What material should be used?
Cover dentine + protect the pulp.
Aesthetic material such as GIC and composite bandage might be more ideal (cover dentin)
What systemic medications should be provided for dentoalveolar trauma?
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)
What local medications should be provided for dentoalveolar trauma?
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
How should trauma injuries be followed up?
Examine soft tissues and teeth. (Percussion, palpation, mobility, colour changes)
Pulp sensibility tests
PA radiographs
What kind of schedule should be in place for follow ups?
Will depend on types of injuries present.
Removal of sutures and splint would need an appointment
How long after first appointment should sutures be removed?
5 - 6 days
How long after first appointment should flexible splint be removed?
7 - 10 days
How long after first appointment should rigid splint be removed?
6 weeks to 3 months.
When should follow up visit be if endodontics is not required?
2 weeks
1 month
2 months
3 months
6
9
1 year
annually for 5 years
then every 3 years
