Paediatrics Flashcards
Risks for paediatric trauma [6]
Increased overjet No lip closure Epilepsy Poor motor control Does contact/dangerous sports History of dental trauma Obesity
Primary/emergency management of paediatric trauma
Try and reimplant the tooth, or store in saline/milk Full history - What happened - MH - Other injuries - Where is the tooth/fragment E/O and I/O - Soft tissue injuries - Occlusion - TTP, EC, EPT, mobility - Xrays
Which radiographs are best for paediatric trauma [3]
PAs
Upper/lower standard occlusals
OPT
Types of tooth injury (paediatric trauma)
Concussion Subluxation Luxation - Intrusion - Extrusion - Lateral luxation - Avulsion Enamel infraction Uncomplicated enamel/dentine fracture Complicated fracture (involves pulp) Crown+root fracture Root fracture - Coronal third - Mid third - Apical third Alveolar fracture
What is a tooth concussion
Injury to tooth-supporting structures but the tooth hasn’t moved
- Pain and bleeding, sensitivity
- Monitor in 4 weeks and 1 year
What is a tooth subluxation injury and management
Injury/damage to tooth-supporting structures and some tooth mobility but no displacement of the tooth
- Pain, bleeding, sensitivity
- Splint for 2-4 weeks
- Review regularly for 1 year
What is a tooth luxation injury and types
The tooth has been displaced
Intrusion
- Tooth displaced in
- Severe injury, causing damage to PDL cells and neurovascular bundle
Extrusion
- Tooth displaced out of the socket a bit
- Might be mobile
- Damage to PDL cells
Lateral luxation
- Tooth displaced buccally or palatally so might not be mobile and have dull percussion
- Damage to PDL cells and neurovascular bundle
- Can get locked in bone
Avulsion
- Tooth falls out
- Death of PDL cells and neurovascular bundle
Intrusion injury permanent tooth management
Tooth displaced in. Need radiographs to see where it is (parallax, SLOB)
If immature apex
- Allow it to re-erupt for 2 weeks
- If no movement can use ortho or surgical extrusion
- Splint for 4-8 weeks (if marginal bone breakdown)
- Monitor to check pulp vitality. RCT + apical plug if pulp dies.
If mature apex
- <3mm intrusion, allow to re-erupt
- Ortho if this doesn’t work after 4 weeks
- > 7mm, surgically/ortho extrusion and RCT
- Splint for 4-8 weeks
Monitor and review regularly for 5 years
Extrusion injury permanent tooth management
Reposition and splint for 2-6 weeks (if marginal bone breakdown)
Monitor for 5 years and check pulp vitality
Lateral luxation injury and Permanent tooth management
Reposition and disengage from the bony lock
Splint for 4-8 weeks (if marginal bone breakdown)
Regular monitoring for 5 years to check pulp status
- If mature apex, it will likely lose vitality so do RCT
Avulsion injury - prognosis and patient instructions
Reimplant as soon as possible
- If <15 mins, good prognosis
- If exposed for <60 mins, guarded prognosis
- If exposed for >60 mins, poor prognosis
- PDL cells will have died
Hold the tooth by the crown, wash and store in milk/saline/reimplant and bite down.
Prognosis of dental trauma depends on ? [4]
Age of patient
Stage of tooth development
Type of injury
Any other injuries to the tooth
Types of pulp healing/responses after trauma [3]
- Complete healing - vital pulp
- Secondary dentine and pulp sclerosis/obliteration and loss of vitality
- Pulp necrosis, infection +/- inflammatory resorption
Types of tooth resorption
Internal resorption
- Will continue until the tooth is non-vital
- Starts from the pulp canal
External cervical resorption
- PDL cells are dead so inflammatory cells come to remove them and continue removing the tooth.
- Necrotic pulp so will continue until all the pulp/bacteria has been removed.
External replacement resorption
- Oc get activated by trauma and are in contact with the root surface bc dead PDL cells so remodelling the root into bone
- Will continue until all root is replaced, then the crown falls off
- Happens quicker in chidlren
General treatment after paediatric trauma
Xrays and images Reposition tooth Splint Regular monitoring \+/- RCT
Advantages of replanting avulsed teeth
Aesthetics
Avoid restorative work for a while
Psychological benefit
Preserve bone levels and gingival levels
Disadvantages of replanting avulsed teeth
Lots of monitoring and appointments
The tooth will need extraction eventually
Infraoccluded/external resorption = loss of verticle height and gingival contour
Risk of tooth necrosis, pain, infection
Discolouration
Contraindications of replanting avulsed teeth
Immunocompromised or severe heart condition
If have supernumerary teeth or severe anterior crowding
Can’t commit to multiple appointments e.g. learning disability
How to replant avulsed teeth (steps)
Xrays and emergency management
Gently clean tooth (handle from the crown) and keep in saline
- Measure root for future RCT
Analgesia/numb socket
Irrigate socket and remove debris e.g. any bone, blood clot
Insert the tooth into the socket but don’t force it in bc will shred PDL cells
Splint
Review
POIG
Antibiotics if worried about infection
- Amoxicillin or doxycycline (if older than 12)
Splinting after dental trauma (steps and types of splints)
Direct splints
- More hygienic
- Flexible so allow tooth and PDL to move like normal
- NiTi, orthodontic wires,
- Can composite bond or use ortho brackets
Indirect
- Would need to take imp
- Tooth can’t move, less hygienic, not fixed
Enamel infraction and permanent tooth management
Seal
Fluoride varnish
- Can use transillumination to diagnose
Uncomplicated enamel/dentine fracture and permanent tooth management
Xray
Restore bc exposed dentine will be sensitive and can get caries
- GIC, composite, crown
Review
Complicated tooth fracture and permanent tooth management
Xray Pulp cap if small exposure (<0.5mm, <24h) - use MTA, Biodentine, non-setting CaOH Or partial pulpotomy (remove the infected pulp, until no more bleeding/control the bleeding using pledgets) Or complete pulpectomy (RCT) - if bleeding doesn't stop - mature apex - symptoms - prolonged exposure/large exposure Restore (Crown, composite, temporary) Review
Crown and root fracture and permanent tooth management
Complicated - Crown lengthening procedure or ortho extrusion and restore
Root fractures and permanent tooth management
Xrays to see where the fracture is (Parallax/SLOB)
Need hard tissue healing between the 2 segments
- Bone and CT, CT, or granulation tissue (a sign of inflammation)
Apical third - Apical fragment can be left usually - RCT coronal third if it loses vitality - Splint if mobile or displaced Middle third Coronal third - Poorer prognosis - Splint for 4 weeks
Verticle fractures vs horizontal fractures
Alveolar fractures and management
Plain film Xrays Fractured section of alveolar bone - multiple teeth moving together - Soft tissue/gingival lacerations Reposition and splint for 4 weeks
Sequelae of trauma to immature permanent teeth and management
Can get pulp necrosis - inflammation and PAP or inflammatory resorption or ankylosis
Open apex, a large pulp and thin dentine walls
RCT will need an apical plug
- MTA/Biodentine = quicker, effective
- apexification using non-setting CaOH plugs replaced every few weeks for months - takes ages, dehydrates the dentine and can cause #
Remove pulp and use irrigants only (no mechanical prep)
Infraoccluded incisors and management
External replacement resorption
Oc remodel the root into bone after PDL cell death
Incisors can look submerged if it happens before complete tooth formation = aesthetic concerns, loss of verticle height and gingival contour
Tx = Extract, coronal build-up, crown, orthodontic or surgical extrusion, decoronation
Indications for tooth auto transplantation
Ectopic teeth
Supernumerary teeth and gaps/hypodontia
Avulsed teeth
- Ideally multirooted teeth with open apices
Complications with dental trauma to primary teeth
Larger pulp, open apex, not fully erupted, will affect permanent successor.
If mobile then causes risk of inhalation so XLA if worried
Uncomplicated fractures or enamel infractions in primary teeth (management)
OHE, diet advice, analgesia
Smooth or cover
Crown/root fractures in primary teeth
OHE, diet advice, analgesia
Uncommon bc root would have to be not resorbed so the patient would need to be young
XLA and maintain space
or leave coronal segment/splint if not causing problems
Management of complicated tooth fractures in primary teeth (pulp)
OHE, diet advice, analgesia
XLA and maintain space
Or pulp management (pulp cap, pulpotomy, RCT)
Management of concussion and subluxation injuries in primary teeth
OHE, diet advice, analgesia
Splint if mobile
Reassurance
Management of intrusion injuries in primary teeth
Xray to see where it is
If not affecting permanent tooth germ - allow to re-erupt for 2-4 months
If affecting permanent tooth germ, XLA and maintain space
Mobile teeth = risk of inhalation
Management of lateral luxation injuries to primary teeth
If buccally displaced, more likely to be affecting permanent tooth germ (root displaced palatally)
Reposition and splint
Or XLA and maintain space
Mobile teeth = risk of inhalation
Sequalae of trauma primary teeth
- primary teeth and permanent teeth
Primary teeth
- Discolouration
- Pulp necrosis, infection, abscess, pain
- Loss of tooth
- Pain
- Delayed exfoliation
- Infraoccluded
Permanent teeth
- Delayed or no eruption
- Displaced (Impacted or ectopic)
- Rotated
- Discoloured - opacities or brown, irregularities
- Hypomineralisation, hypoplastic
- Altered or stopped tooth development
