IADT Dental trauma Guidelines Flashcards
What first aid advice should you give if a parent called your practice and said their child lost their tooth?
Keep the patient calm.
* Find the tooth and pick it up by the crown (the white part). Avoid touching the root.
* If the tooth is dirty, wash it briefly (max 10 seconds) under cold running water and
reposition it. Try to encourage the patient/guardian to replant the tooth. Once the
tooth is back in place, bite on a handkerchief to hold it in position.
* If this is not possible, or for other reasons when replantation of the avulsed tooth is
not possible (e.g. an unconscious patient), place the tooth in a glass of milk or
another suitable storage medium and bring with the patient to the emergency clinic.
The tooth can also be transported in the mouth, keeping it inside the lip or cheek if
the patient is conscious. If the patient is very young, he/she could swallow the tooth
– therefor it is advisable to get the patient to spit in a container and place the tooth
in it. Avoid storage in water!
* If there is access at the place of accident to special storage or transport media (e.g.
tissue culture/transport medium, Hanks balanced storage medium (HBSS or saline)
such media can preferably be used.
* Seek emergency dental treatment immediately.
What is the txt for an avulsed permanent tooth with closed apex?
Tooth has been replanted before pts arrival at clinic
- Leave the tooth in place.
- Clean the area with water spray, saline or chlorhexidine.
- Suture gingival lacerations, if present.
- Verify normal position of the replanted tooth both clinically and radiographically.
- Apply a flexible splint for up to 2 weeks
- Administer systemic antibiotics.
- Check tetanus protection .
- Give patient instructions
- Initiate root canal treatment 7–10 days after replantation and before splint removal
- Follow up 4w, 3m,6m, 1y, 1y for 5yrs
What is the txt option of an avulsed tooth with closed apex that has been kept in a physiological storage medium or osmolality balanced med and/or stored dry and E/O dry time <60mins?
- Clean the root surface and apical foramen with a stream of saline and soak the tooth in saline
thereby removing contamination and dead cells from the root surface. - Administer local anesthesia.
- Irrigate the socket with saline.
- Examine the alveolar socket. If there is a fracture of the socket wall, reposition it with a suitable
instrument. - Replant the tooth slowly with slight digital pressure. Do not use force.
- Suture gingival lacerations, if present.
- Verify normal position of the replanted tooth both clinically and radiographically.
- Apply a flexible splint for up to 2 weeks, keep away from the gingiva.
- Administer systemic antibiotics
- Check tetanus protection
- Give patient instructions
- Initiate root canal treatment 7–10 days after replantation and before splint removal
- Follow up 4w, 3m,6m, 1y, 1yfor 5yrs
What is the txt option of avulsed tooth with closed apex and dry time longer 60mins or other reasons suggest non viable cells?
Remove attached non‐viable soft tissue carefully e.g. with gauze. The best way to this has not
yet been decided (See Future areas of research).
* Root canal treatment to the tooth can be carried out prior to replantation or later (See
Endodontic considerations).
* In cases of delayed replantation, root canal treatment should be done either on the tooth prior
to replantation, or it can be done 7–10 days later like in other replantation situations (See
Endodontic considerations).
* Administer local anesthesia.
* Irrigate the socket with saline.
* Examine the alveolar socket. If there is a fracture of the socket wall, reposition it with a suitable
instrument.
* Replant the tooth.
* Suture gingival lacerations, if present.
* Verify normal position of the replanted tooth clinically and radiographically.
* Stabilize the tooth for 4 weeks using a flexible splint
* Administration of systemic antibiotics
* Check tetanus protection
* Give patient instructions
- follow up 4w, 3m, 6m, 1y, 1y for 5yrs
Why does delayed replantation of an avulsed tooth has poor long term prognosis? Why do you replant the tooth?
- PDL necrotic and not expected to heal
- Replantation restores aesthetic , function and or psychological reason but also maintains alveolar bone contour
- Eventual outcome is ankylosis and resorption of root and tooth eventually lost
What is the txt options of an avulsed tooth with open apex that has be replanted before pts arrival on clinc?
Leave the tooth in place.
* Clean the area with water spray, saline or chlorhexidine.
* Suture gingival lacerations, if present.
* Verify normal position of the replanted tooth both clinically and radiographically.
* Apply a flexible splint for up to 2 weeks
* Administer systemic antibiotics
* Check tetanus protection
* Give patient instructions
* The goal for replanting still‐developing (immature) teeth in children is to allow for possible
revascularization of the pulp space. If that does not occur, root canal treatment may be
recommended
- Follow up 4w, 3m, 6, 1y , 1y for 5yrs
What is the txt for avulsed tooth with open apex that has been kept in physiological storage medium or osmolality balanced medium and/or stored dry and E/O <60mins?
If contaminated, clean the root surface and apical foramen with a stream of saline.
* Topical application of antibiotics has been shown to enhance chances for revascularization of
the pulp and can be considered if available (See Antibiotics).
* Administer local anesthesia.
* Examine the alveolar socket.
* If there is a fracture of the socket wall, reposition it with a suitable instrument.
* Remove the coagulum in the socket and replant the tooth slowly with slight digital pressure.
* Suture gingival lacerations, especially in the cervical area.
* Verify normal position of the replanted tooth clinically and radiographically.
- Apply a flexible
splint for up to 2 weeks
* Administer systemic antibiotics
* Check tetanus protection
* Give patient instructions
* The goal for replanting still‐developing (immature) teeth in children is to allow for possible
revascularization of the pulp space. The risk of infection related root resorption should be
weighed up against the chances of revascularization. Such resorption is very rapid in teeth of
children. If revascularization does not occur, root canal treatment may be recommended
- Follow up 4w, 3m, 6m, 1y, 1yr 5yrs
What is the txt option of avulsed tooth with dry time >60mins or other reasons suggesting non viable cells?
Remove attached non‐viable soft tissue carefully e.g. with gauze. The best way to this has not
yet been decided
* Root canal treatment to the tooth can be carried out prior to replantation or later
* Administer local anesthesia.
* Remove the coagulum from the socket with a stream of saline. Examine the alveolar socket. If
there is a fracture of the socket wall, reposition it with a suitable instrument.
* Replant the tooth slowly with slight digital pressure. Suture gingival laceration. Verify normal
position of the replanted tooth clinically and radiographically.
* Stabilize the tooth for 4 weeks using a flexible splint
* Administer systemic antibiotics
* Check tetanus protection (
* Give patient instructions
- Follow up 4w, 3m, 6m ,1y, 1yfor 5yrs
What topical and systemic AB can be given to pts and why are they done?
Topical (immature teeth)
- Experimental studies shown positive effects on periodontal and pulpal healing
- Doxycycline 1mg per 20ml saline for 5 min soak
Systemic
- Pen V 500mg x4 a day 12-17
- Pen V 250mg X4 a day 6-11
Why may a child need tetanus cover if avulsed tooth?
- Refer pt to physician for eval of need for tetanus booster if avulsed tooth contacted soil or tetanus coverage if uncertain
Why do you splint replanted teeth?
- Maintain repos tooth in correct pos, provide pt comfort and improve function
- Periodontal healing and pulpal healing promoted if tooth given chance for slight motion and splinting time not too long
- Place on buccal surfaces of max teeth to enable lingual access for endo and avoid occlusal interference
What pt instructions do you give for avulsed tooth that has been repplanted?
- Pt compliance with follow up vists and home care required for healing
- Avoid contct sports
- Soft diet 2 weeks then normal function ASAP
- Brush teethw ith soft toothbrush after each meal
- 0.1% CH twice a day 1 week
What endodontic considerations is there for an avulsed tooth?
- If closed apex RCT 7-10 replantation
- CaOH as intra canal medication for up to 1 month (antimicrobial)
- Or can use ledermix which is anti-inflam corticosteroid with anti-clastic properties and left 2 weeks
- Do not use CaOH and ledermix together
What is a favourable outcome of avulsed tooth with open and closed apex ?
Closed apex
- Asymp
- Norm mob
- Norm percussion sound
- No radio evi resorption or periradicular osteitis
- Lamina dura norm
Open apex
- Asymp
- Norm mob
- Norm percussion sound
- radio evi of arrested or continued root formation and eruption
- Pulp canal obliteration expected
What is pulp canal obliteration ?
- Hard tissue deposited on the internal walls of pulp canal leaving it narrowed and restricted
- May show a yellow discolouration of clinical crown
What is an unfavourable outcome of avulsed tooth for open or closed apex?
Open and Closed apex
- Symptomatic
- Excessive or no mobility (ankylosis) with high pitched percussion sound
- radio evi of resoprtion (inflam, infection related, ankylosis)
- Infrapos of crown when ankylosis occurs (leading to distrubance in alveolar and facial growth over short, med and long term)
Give the clinical , radiographic findings of an Infraction of a permanent tooth. What is the txt and the follow up?
Clinical
- Incomplete fracture (crack) of enamel without loss of tooth structure
- Not tender *
Radio
- No abnormalities
- PA recommended
Txt
- If marked infraction then can etch and seal with resin to prevent discolouration of infracation lines
Follow up
- No follow up needed unless ass with other injury
What is the clinical and radiographic findings of a enamel fracture in permanent tooth? Give the txt and follow up protocol
Clinical
- Complete fracture of enamel
- Loss of enamel but no vis signs of exposed dentin
- Not tender
- Normal mobility
- Sensibility to pulp test usually pos
Radio
- Enamel loss vis
- PA, occlusal and eccentric exposures (rule out presence of root fracture or luxtion injury)
- Radio of lip or cheek to search for tooth fragments or foreign material
Txt
- If tooth fragment available bond to tooth
- Contouring or restoration with comp resin
Follow up
- 6-8weeks
- 1year
What are the clinical and radiographic findings of enamel-dentin fracture in permanent tooth? Give the txt and follow up procedure
Clinical findings
- fracture confined to enamel and dentin with loss of tooth structure but not exposing pulp
- Not tender
- Norm mobility
- Pos sensibility test
Radio
- Enamel-dentin loss vis
- PA , occlusal and eccentric to rule out root fracture or displacement
- radio of lip or cheek for fragments or foreign objects
Txt
- If fragment available bond to tooth
- If not cover exposed dentin with GIC as provisional or bonding agent and comp resin as defin
- If exposed dentin within 0.5mm pulp (pink , no bleeding) place CaOH indirect pulp cap and cover with RMGIC
Follow up
- 6-8weeks
- 1 yr
What is the clinical and radiographic findings of enamel-dentin-pulp fracture of permanent tooth? Give the txt and follow up protocal
Clinical
- Fracture involving enamel and dentin with loss of tooth structure and exposure of pulp
- Norm mobility
- Not tender
- Exposed pulp sensitive to stimuli
Radio
- enamel-dentin loss vis
- PA, occlusal and eccentric to rule out displacement or root fracture
- Radio of lip or cheek lacerations for fragments or foreign mat
Txt
- Open apex or young pts with closed apex = pulp cap or partial pulpotomy to preserve pulp vitality (CaOH direct cap)
- Closed apex = RCT or pulp cap or partial pulpotomy
- Bond fragment of tooth or comp resin restoration
Follow up
- 6-8 weeks
- 1yr
What are the clinical and radiographic findings of crown-root fracture without pulp exposure of permanent tooth? Give the txt and follow up protocal
Clinical
- Fracture involving enamel, dentin and cementum with loss of tooth structure but not exposing pulp
- Crown fracture extending below gingival margin
- Tender to percussion
- Coronal fragment mobile
- Pos sensibility for apical fragment
Radio
- Apical extension us not vis
- PA, occlusal and eccentric to detect fracture lines in root
Txt
- Emergency txt = stabilise loos segment to adjacent teeth until definitive txt plan
Non emergency
1. Removal of coronal crown-root fragment and restoration of apical fragment above gingival level
2. Removal coronal crown root segment , endo txt with post retained crown
3. Removal of coronal segment, endo txt and ortho extrusion of remaining root to sufficient length to support post-retained crown
4. Removal mobile fracture fragment with surgical repositioning of root in more coronal pos
5. Implant planned
6. XLA with immediate or delayed denture / bridge
Follow up
- 6-8 weeks
- 1 yr
What is the clinical and radiographic features of crown-root fracture with pulp exposure in permanent teeth? Give the txt and follow up
Clinical
- Fracture involving enamel, dentin and cementum and exposing pulp
- Tender to percussion
- Coronal fragment mobile
Radio
- Apical extension of fracture not us vis
- PA and occlusal exposure
Txt
Emergency
1. Splint to temp stabilise loose segment to adjacent teeth
2. Open apex or young pt with closed apex = partial pulpotomy to preserve pulp vitality
3. Closed apex = RCT
Non emergency
1. Fragment removal and endo and post retained crown
2. Fragment removal, endo, ortho extrusion of apical root to sufficient length for post-retained crown
3. Fragment removal and surgical repositioning of root more coronally
4. Root fragment left in situ and implant planned
5. XLA - immediate or delayed bridge
Follow up
- 6-8 weeks
- 1yr
Give the clinical and radiographic findings of root fracture in permanent tooth. Give the txt and follow up
Clinical
- Coronal segment may be mobile or displaced
- Tooth tender to percussion
- Bleeding form gingival sulcus
- Sensibility testing may give -ve result initially , indicating transient or perm neural damage
- Transient crown discoloration (red or grey)
Radio
- Fracture involves root of tooth in horizontal or oblique plane
- Horizontal fracture detected via PA (90degree angle file with central beam through tooth)
- Oblique fracture (more comm apical third) use occlusal view
Txt
- Reposition coronal segment if displaced
- check pos radio
- Stabilise tooth with flexible splint 4 weeks
- If root fracture near cervical area of tooth (stabilisation of up to 4 months beneficial)
- Monitor pulpal statur for at least one year and if pulp necrosis occurs = RCT or coronal segment
Follow up
- 4w splint removal
- 6-8 w
- 4m
-6m
-1y
- yeraly for 5yrs
Give the clinical and radiographic findings of alveolar fracture in permanent teeth. Give the txt and follow up
Clinical
- Fracture involves alveolar bone and may extend to adjacent bone
- Segment mobility and dislocation with several teeth moving together
- Occlusal change due to misalignment of fractured alveolar segment
- Sensibility may or may not be pos
Radio
- Fracture lines located any level
- PA, occlusal and eccentric and OPT for pos of fracture lines
Txt
- Reposition displaced segment and flex splint 4 weeks
- Suture gingival lacerations if present
Follow up
- 4w
- 6-8w
- 4m
- 6m
-1y
-5yrs
