Paediatrics: Trauma Flashcards
What is the epidemiology of primary tooth trauma?
prevalence: 16-40%
peak incidence: 2-4 years
Maxillary primary incisor teeth
Male>Female
What is the aetiology of primary tooth trauma?
- falling
- bumping into objects
- non-accidental
Name the 5 classifications of injury’s to the Dental hard tissues and pulp?
- Enamel fracture (uncomplicated)
- enamel dentine fracture (uncomplicated)
- Enamel dentine and pulp fracture (complicated)
- Crown root fracture
- root fracture
Name the 5 classifications of injury’s to the supporting tooth tissues?
- concussion
- subluxation
- lateral luxation
- intrusion
- extrusion
- Avulsion
- alveolar bone fracture
What parts of the tooth are involved in a crown-root fracture?
- enamel, dentine and root
- pulp may or may not be involved (complicated or uncomplicated)
Describe a concussion injury?
- PDL injury, tooth tender to touch but has not been displaced
Describe a subluxation injury?
- tooth tender to touch and has increased mobility but has not been displaced (bleeding from the gingival crevice may be noted)
Describe a lateral luxation injury?
- tooth has been displaced usually in a palatal or labial directions
- commission or fracture of the alveolar bone
Describe a intrusion injury?
- tooth usually displace through the labial bone plate or it can impinge on the permanent tooth bud
- commission or fracture of the alveolar socket
Describe an extrusion injury?
partial displacement of a tooth out its socket
Describe an avulsion injury?
tooth is completely out its socket
Describe an alveolar bone fracture injury?
- fracture involves the alveolar bone ( labial and palatal/lingual) and may extend to the adjacent bone
What is the most common injury in the primary dentition?
luxation (62-69%)
What are the 7 steps in the management of Dental trauma?
- Reassurance
- History
- Examination
- Diagnosis
- Emergency Treatment
- Important information
- Further Treatment and Review
When Obtaining a history for a trauma patient what information do you want to know?
- Injury history
- where, when, how, lost teeth fragments, other symptoms or injuries - Medical History
- allergies, tetanus immunisation, bleeding disorders, medications, underlying health conditions - Dental History
- previous trauma, treatment experience, legal guardian/child relationship
What sort of things would you be looking for in a extra oral examination for a dental trauma patient?
Lacerations
Haematoma
Haemorrhage / CSF
Subconjunctival haemorrhage
Bony step deformities
Mouth opening
What would you be looking for in a intra-oral examination in a dental trauma patient?
- soft tissue damage: penetrating wounds/ foreign bodies
- Tooth mobility: may indicate tooth displacement or bone fracture
- transillumination: may show fracture lines in teeth, pulpal degeneration or caries
- Tactile test with probe: may help detect horizontal/vertical fractures and pulpal involvement
- Percussion: duller not may indicate root fracture
- Occlusion: traumatic occlusion needs urgent treatment
What investigation does a trauma stamp include?
-Mobility
- colour
- TTP
- sinus
- percussion note
- radiograph
During dental trauma of a primary tooth what is usually the most suitable emergency treatment?
observation
What important information do you need to provide the parent or care giver of the child after a dental trauma?
- care for the injured tooth to optimise heeling and prevent further damage
What homecare instructions would you give the parent or care giver for looking after a child’s injured tooth?
- Analgesia (paracetamol/ibuprofen)
- Soft diet for 10-14days( can be normal diet but food cut very small)
- brush teeth with soft toothbrush after every meal
- apply topical chlorohexidine gluconate ) 0.12% mouth rinse twice a day for 1 week
- warn about signs of infection
What would be the reconstructive treatment for an uncomplicated enamel fracture?
Smooth sharp edges with a soft flex disk
What would be the treatment for an uncomplicated enamel dentine fracture?
- cover all exposed dentine with glass ionomer or composite
- can be restored immediately with composite or at a later visit
How would you treat a complicated crown fracture (enamel dentine and pulp)?
Either:
1. partial pulpotomy
2. Extract
Depends of co-operation of the child and discussion with parent
How would you do a partial pulpotomy?
- LA
- remove pulp tissue
- arrest bleeding with ferric sulphate
- non-setting calcium hydroxide paste placed over pulp
- thin layer of GI cement on top
- tooth restored with composite
What are the treatment options for a crown-root fracture?
- Remove the loose fragment and determine if crown can be restored
If restorable:
No pulp exposed: cover exposed dentine with glass ionomer
Pulp exposed: pulpotomy or endodontic treatment
If unrestorable:
Extract loose fragments
! Don’t dig!
How would you treat a root fracture?
Coronal fragment not displaced
- No treatment
Coronal fragment displaced but not excessively mobile
- Leave coronal fragment to spontaneously reposition even if some occlusal interference
Coronal fragment displaced, excessively mobile and interfering with occlusion:
Option A: Extract only the loose coronal fragment
Option B: Reposition the loose coronal fragment +/- splint
How would you treat a concussion injury?
- No Treatment
- observation
How would you treat a subluxation injury?
- No treatment
- observation
How would you treat a lateral luxation injury?
if minimal with no occlusal interference
- allow to spontaneously reposition
Severe displacement:
1. Extraction
2. Reposition +/- a splint
How would you treat an intrusion injury?
- allow tooth to spontaneously reposition
How long can it take for a tooth that’s suffered an intrusion injury to reposition?
6months-1year
What radiographs are best for determining direction of movement in an intruded tooth?
periapical or lateral premaxilla (extra oral film)
Why is it important to determine the direction the intruded tooth has moved?
helps to assess danger to the permanent tooth germ and allows better counselling regarding prognosis
How would you treat and extruded tooth?
Not interfering with occlusion
- Spontaneous repositioning
Excessive mobility or extruded >3mm
- Extract
How would you treat an avulsed tooth?
radiograph to confirm avulsion
- do not re-implant
How would you treat an alveolar bone fracture?
Reposition segment
Stabilize with a flexible splint to the adjacent uninjured teeth for 4 weeks
Teeth may need to be extracted after alveolar stability has been achieved
What can occur to the primary tooth after dental trauma?
- Discolouration
- Discolouration and infection
- Delayed exfoliation
Why can a primary tooth start to appear more yellow and opaque after a dental trauma?
pulpal obliteration: pulp lays down more layers of dentine to try protect itself and this causes the discolouration
If a primary tooth starts to discolour (grey or yellow) after a dental trauma but is asymptomatic how would you treat it?
- if there is no signs of pulpal necrosis or infection no treatment is required
- review
If a primary tooth starts to show signs of discolouration and infection after under going a dental trauma how would you treat this?
Extract or endodontic treatment
A primary tooth that has under gone a trauma may have delayed exfoliation. What are the consequences of this?
- ectopic eruption of permanent successor
- delayed eruption…
- prevent eruption…
This can have effects on occlusion and aesthetics of the permanent dentition
What type of supporting tissue trauma injury is most likely to damage the permanent successor?
intrusion injuries
At what age is there the greatest risk of trauma to a primary tooth causing damage to the permanent successor?
0-2years (63%)
What is the most frequent injury/anomaly to occur to the permanent successor following trauma to the primary tooth?
enamel defect (44%)
Name two enamel defects?
enamel hypoplasia
enamel hypo mineralisation
What is enamel hypo mineralisation?
- qualitive defect of enamel where the enamel is normal thickness but poorly mineralised
- tooth is more white/yellow in colour
How can you treat hypomineralised teeth?
- no treatment
- composite masking
- tooth whitening
What is enamel hypoplasia?
- quantitative defect
- reduced thickness of enamel but normal mineralisation
- yellow/ brown colour
What is the treatment for enamel hypoplasia?
- no treatment
- composite masking
Name two abnormal crown/root morphology defects that can be caused due to trauma to the primary tooth?
- Dilaceration
- crown-root dilaceration
What is dilaceration?
Abrupt deviation of the long axis of the crown or root portion of the tooth
What is the treatment for a crown dilaceration?
- surgical exposure and orthodontic alignment
- improve aesthetics restoratively
What is the treatment for a root dilaceration/ angulation/duplication?
- combined surgical and orthodontic approach
Why can premature loss of a primary tooth cause delayed eruption of the permanent successor?
thickened mucosa
What would you do if there was >6month delay in the eruption of the contralateral tooth?
- radiograph
- surgical exposure and orthodontic alignment
How would you treat an ectopic unerupted tooth position?
surgical exposure and orthodontic alignment
How would you treat a tooth that had arrested development?
- endodontic treatment if sufficient root development
- extraction if severe under development
How would you treat a tooth germ that has failed to develop into a tooth?
- it may sequestrate spontaneously
- or require removal
How would you treat an odontome?
- removal
What is the most common injury in the permanent dentition?
Crown fractures (enamel/dentine)
What age is the peak period for dental trauma to the permanent teeth?
7-10 years
What can greatly increase the chance of trauma to the permanent dentition?
large OJ >9mm
What medical health conditions do you want to take special care for when treating a dental trauma patient?
- congenital heart defects
- immunosuppression
- rheumatic fever
What tests are on a trauma stamp for trauma to permanent teeth that you would carry out when doing an intra-oral exam?
- mobility
- colour
- TTP
- EPT
- ECT
- percussion note
- occlusion
- Radiographs
What 3 things is mobility to a traumatised tooth an indication of?
- displacement of tooth
- root fracture
- bone fracture
How would you carry out a sensibility test?
- compare injured tooth with adjacent non -injured tooth
- test with ethyl chloride/gutta percha and EPT and note response
- continue to do sensibility tests for 2 years after the injury
What are the aims and principles of emergency treatment to a traumatised tooth?
- maintain tooth vitality by protecting exposed dentine
- treat exposed pulp tissue
- reduction and immobilisation of displaced teeth
- tetanus prophylaxis
What are the aims and principles of immediate treatment to a permanent traumatised tooth?
- +/- pulp treatment
- restoration
What are the aims and principles of permanent treatment to the traumatised tooth?
Apexigenesis
Apexification
Root filling +/- root extrusion
Gingival and alveolar collar modification if required
Coronal restoration
How would you manage an enamel fracture in a permanent tooth?
- either bond fragment to tooth or smooth sharp edges
- take 2 periapical radiographs to rule out root fracture or luxation
- follow up appointment at 6-8weeks, 6months and 1 year
What is the prognosis of an enamel fracture?
0% risk of pulpal necrosis
How would you manage an enamel dentine fracture?
- either bond fragment to tooth or place a composite bandage (use liner if close to pulp)
- take 2 periapical radiographs to rule out root fracture
- radiograph any laceration to rule out embedded fragment
- sensibility test and evaluate tooth maturity
- definitive restoration
- follow up at 6-8weeks, 6months and a year
What is the prognosis of a enamel dentine fracture?
5% risk of pulpal necrosis in 10years
What would you do at a review appointment for a post dental trauma patient?
- use trauma sticker for clinical review
Radiographs to check for:
- root development (canal width and length)
- comparison with other side
- internal and external inflammatory resorption
- periapical pathology
What are the 3 treatment options for a enamel-dentine-pulp fracture?
- pulp cap
- pulpotomy
- pulpectomy
What factors help decide how to treat an exposed pulp in a traumatised tooth?
- size of pulp exposure
- time since injury
- Associated PDL injuries
When would a direct pulp cap be a suitable option in a traumatic pulp exposure?
- tiny pulp exposure (1mm)
- less than 24hrs since exposure
- should be non TTP and positive to sensibility testing
How would you do a direct pulp cap?
- LA and rubber dam
- clean area with water and disinfect with sodium hypochlorite
- apply calcium hydroxide (dycal) or MTA to pulp exposure
-restore tooth with composite restoration - review 6-8 weeks, 6 months and a year
What are the dental indications that a partial pulpotomy (Cvek) would be the most suitable treatment for a traumatic pulp exposure?
- larger exposure (>1mm)
- > 24hrs since injury
- positive to sensibility tests and non TtP
How would you carry out a partial pulpotomy?
- LA and dental dam
- Clean with saline and disinfect with sodium hypochlorite
- remove 2mm of pulp with high speed diamond bur
- place saline soaked cotton pellet over exposure until haemostasis achieved
- apply CaOH then GI then restore with composite
- if homeostasis not achieved continue with full pulpotomy
When would you carry out a full pulpotomy after a pulp exposure?
- if pulp is hyperaemic or necrotic
What is the success rate of a partial pulpotomy (cvek)?
97% success
what is the success rate of a full pulpotomy?
75%
What is the aim of a partial pulpotomy?
- to keep tooth vital to allow normal root growth (apexogenesis) both in the length of the root and the thickness of dentine
what is the clinical problem in performing a pulpotomy if a tooth is non-vital but has open apices?
- no apical stop to allow obturation with GP
what are the options when carrying out a pulpotomy in a tooth with open apices?
- CaOH placed in the canal aiming to induce a hard tissue barrier to form (apexification)
-or MTA/BioDentine placed at apex of canal to create cement barrier - Or Regenerative Endodontic Technique to encourage hard tissue formation at apex
Describe how you would carry out a pulpotomy in a tooth with open apices?
CaOH apexification
- Rubber dam
- drill Access
- Haemorrhage control - LA / sterile water
- Diagnostic radiograph for WL
- File 2mm short of estimated WL
- Dry canal, Non-setting Ca(OH)2 , CW in pulp - chamber
- Glass-ionomer temporary cement in access cavity and evaluate calcium hydroxide fill level with radiograph
- Extipate pulp and place CaOH for no longer than 4-6 weeks after identified as non-vital
- use MTA plug and hot gutta percha for obturation if apexogenesis fails
What are the 6 treatment options for a crown-root fracture with no pulp exposure?
- extraction
- fragment removal only
- fragment removal and gingivectomy
- decornation
- orthodontic extrusion of apical portion
- surgical extrusion
