PEADS - Trauma Flashcards
If a tooth gives off a dull note when percussed, what would that indicate about the health of the tooth?
A dull note suggests root fracture
What is a dental sinus?
This is an abnormal channel that drains longstanding dental abscesses and is commonly associated with dead or necrotic teeth.
What are the 8 categories in a trauma sticker?
Colour sinus tract Radiograph TTP Precussion (sound) EPT Ethyl chloride Mobility
When is the trauma sticker used?
It is used on the initial visit and then every subsequent visit for comparison.
What are the 6 classifications of crown and root fractures?
Enamel Enamel and dentine Enamel, dentine, and pulp Uncomplicated crown and root fracture Complicated crown and root fracture Root fracture, coronal, middle, and apical 1/3
What are the 5 key factors which influence the prognosis of a tooth after an injury?
ROOT development Type of injury Time - how long between the injury and treatment PDL - damage Infection - the presence of infection
When treating a patient with a fracture injury what does the GDP do in the emergency stage?
Place an adhesive dentine bandage to cover up any exposed dentine. (if no time build-up tooth with composite)
Treat any exposed pulp
Reduce and immobilize the displaced tooth and return to the correct place
Give tetanus shot if indicated
Prescribe A.B
When treating a patient with a fracture injury what does the GDP do in the intermediate stage?
Carry out RCT if indicated
Provide minimal invasive restoration
When treating a patient with a fracture injury what does the GDP do in the permanent stage?
If apexogenis has occurred (take radiographs) and the root is continuing to grow or the dentine wall is thickening, then this is the ideal situation.
Apexification - the tooth is no longer vital and the root of the tooth has not continued to grow. A man-made apex must be made in order for RCT to be carried out. This can be done with MTA. These teeth however have a poor prognosis as dentine walls are thin.
Root filling
Final coronal restoration
For an enamel crown fracture, there are 3 treatment options.
Place the fractured crown back onto the tooth.
Place a small amount of composite
File down any sharp edges
Why do you take two peri apicals for enamel and enamel and dentine fractures?
To rule out luxation and root fracture
What is the recall interval for crown fractures?
6-8w and 1 year
If part of a tooth is fractured and unaccounted for, where might you check?
Take a radiograph of the soft tissues and check for any lacerations.
For an enamel and dentine fracture, what are your treatment options?
If you can account for the fractured part of the tooth, you can stick it back on (this can discolour over time)
Or you can build up with composite.
What other tests might you do on an E&D F
Sensibility tests
Assess the maturity of the tooth
At the follow-up appointments, what is carried out at both 6-8w and 1y?
Trauma sticker and then compared to the contralateral tooth if the tooth was mature to check root development.
Check for any periapical pathology
There are 3 main factors to consider in your assessment of an E, D, P fracture.
PDL damage
SIze of exposure
TIme since exposure
What are the 3 options of treatment for an E, D, and P fracture?
Pulp cap
Partial pulpotomy
Full pulpotomy
Describe the stages involved in a pulp cap and what the indications are for choosing this treatment.
If the exposure is <1mm and <24hrs has passed since exposure then pulp cap.
Also, a trauma sticker has been carried out and the tooth isn’t TTP and positive EPT.
LA and dam
Water and SH to clean and disinfect the area.
Then setting CaOH (dycal) placed with a nice composite restoration
Describe the stages involved in a partial pulpectomy and what the indications are for choosing this treatment.
Exposure is > 1mm and > 24hrs has passed.
LA and rubber dam
2mm of pulp removed with HS round diamond
Water and SH to clean and disinfect.
Saline-soaked cotton wool is then used. (if the bleeding doesn’t stop or pulp never bleeds then FULL pulpotomy indicated).
Apply setting CaOH (dycal) and GI (vitrebond) or MTA and restore with composite.
Follow up with full clinical and radiographic assessment at 6-8w and 1y
Do you ever start with a full pulpectomy?
No
Always partial and then if bleeding doesn’t stop or no bleeding. then proceed with full
Crown and root fracture treatment options?
Ex - rarely done
Decoration - preserves root from implants
Fragment removal and restore
Fragment removal and gingivectomy
Classification of root fractures?
Position; - apical, middle, and coronal 1/3 Displacement of fragments - displaced or undisplaced Root development - mature or immature
For root, F what does the prognosis depend on?
Age of child - Root development Degree of displacement Associated injuries Time Presence of infection
Of all the root F which has the best prognosis?
Apical
When repositioning a tooth after trauma, what should you always do afterwards to check it has been repositioned correctly?
Take a radiograph
Outline the stages of treatment for an apical and middle 1/3 root fracture.
Clean area with saline or chlorhexidine
Then reposition the tooth with digital pressure.
Place a flexible splint for 4 weeks
Stress the importance of OH compliance and a soft diet but not too soft that the PDL isn’t stimulated (as this can cause the tooth to heal poorly and become ankylosed to the bone)
Then review at 6-8w, 6m, and yearly for 5years with radiographs
What is the difference between treatment for apical/middle and coronal root fractures?
The flexible may have to be worn for up to 4 months.
What are the 4 different types of healing outcomes for RF?
Calcified tissue union across the fracture line
Connective tissue
Calcified + connective tissue
Bone/osseous healing
Non-healing outcomes for RF?
Granulation tissue (associated with loss of vitality) Radiolucency is seen on radiograph around the fracture line
What type of healing is desirable?
Calcified healing union across the fracture line
What treatment is carried out if the RF tooth becomes non-vital?
Extirpate the pulp to the fracture line and irrigate with SH. Dress with CaOH Make a barrier with MTA or Biodentine. Fill with GP Restore tooth as normal
How long do you splint these types of injuries?
- Subluxation
- Extrusion
- Avulsion open and closed apex <60mins EADT
2 weeks
What are the 7 types of PDL injuries classified as?
Concussion Subluxation Extrusion Lateral luxation Intrusion Avulsion Dentoalveolar fractures
What is a concussion trauma?
The tooth has been bumped slightly but there has been no damage to the PDL
How would a concussion present and what would you do to treat it?
Present with some bleeding and numbness. May not pass sensibility tests
Would just suggest analgesia and then monitor
What is a subluxation?
An injury to the tooth where the PDL has been damaged but the tooth hasn’t been displaced.
What is an extrusive luxation?
The tooth has been displaced out of the socket and torn the PDL.
What is a lateral luxation?
This is an injury to the PDL where PDL is crushed on one side and torn on the other, as the tooth moves in one direction.
With PDL injuries do open apex or closed apex teeth have a better prognosis?
Open
What are some possible reasons for PDL injuries?
Trauma due to contact sports or falling.
How would you treat a lateral luxation injury?
Give LA
Reposition the tooth
Flexible splint for 4 weeks
Review radiographically and clinically ar 4we, 6-8w, 6m and yearly for 5y.
Checking for root resorption and radiolucencies
What do you check for when following up with PDL trauma patients?
Checking for root resorption and radiolucencies
Intrusion injury?
This is a crushing injury of the PDL as the tooth pushed up into bone.
What is a common side effect of severe PDL injuries?
Root resorption
What advice would you give for all luxation injuries in terms of OHI, daily life, and diet?
Instruct them to brush gently but keep the area clean with 0.1% chlorhexidine gluconate mouthwash ( or 0.2 CH).
Avoid contact sports
Have a soft diet but not too soft as need to stimulate PDL otherwise won’t heal properly. Suggest foods like bread.
In open apex teeth, what are the 3 treatments for intruded teeth?
If it is less than 7mm then natural re-eruption but for more.
Rapid orthodontics or surgical repositioning (with forceps)
For intrusion injuries of closed apex teeth. There is no need to slowly reposition the tooth to preserve vitality. Why is this?
Cause there is a 0% of pulpal survival. Therefore surgical reposition and RCT indicated.
Treatment for intrusion?
Reposition depending on the root development.
Flexible splint of 4weeks (a temporary filling of CaOH recommended)
RCT (show be completed within 3-4weeks)
Why is CaOH recommended for intrusion injuries?
Due to its;
Antimicrobial properties
Inhibits root resorption
Induces repair by hair tissue formation
What does EADT mean?
Time tooth has been out the mouth and not been in a suitable storage medium
What does EAT?
Total time tooth has been outside the mouth (including in a suitable storage medium)
What are some examples of appropriate storage mediums?
Cold Milk
Saliva
Blood
Saline (physiological)
If a teacher calls you in an emergency with a child that has an avulsed tooth, what advice would you give her?
Firstly if hold the tooth by the crown and not the root.
Clean any debris off the tooth under cold water for no more than 10 seconds then reimplant the tooth and get the child to bite down on some tissue.
If this isn’t possible then store in an appropriate medium such as cold milk, saline, or blood.
Then seek immediate dental advice.
What the PDL healing outcomes for Avulsion.
Regeneration
PDL/cemental healing
Boney healing
Uncontrolled infection
What the pulpal healing outcomes for Avulsion.
Regeneration
Controlled necrosis (RCT)
Uncontrolled necrosis
What is the most important factor in the prognosis of avulsed teeth?
The EADT
What is the treatment for an avulsed tooth of an EDT < 60mins?
Reposition the tooth under LA
Splint for 2 weeks
Consider tetanus shot and AB
Carry out RCT on the tooth as soon as possible unless it’s an open apex then there is a chance of revascualrisation.
Talk through the stages of RCT for a closed apex avulsed tooth?
Tooth has been repositioned under LA
A splint has been placed for 2 weeks.
The pulp has been extirpated and disinfected (SH)and an AB steriod paste has been placed as an intracanal medicament.
At two weeks the AB steroid intracanal medicament is replaced by NSCaOH.
Then left for a further 2weeks when obturation with GP is carried out.
Review at 3m, 6m, and yearly for 5y and refer to pediatric specialists.
What is the difference between EAT > 60 mins when compared to EAT< 60mins?
Splint for 4 weeks instead of 2
The prognosis of the tooth is a lot worse
When would you not reimplant a tooth?
Almost never but
If a child is immunocompromised
If they had other serious injuries that needed more serious attention.
If the tooth has an open apex and the EAT< 60mins so you decide to reimplant and splint (2w) without RCT. What must you look for at follow-up appointments and why?
Must look for pulpal necrosis as can cause inflammatory resorption.
In this case, the pulp must be RCT ASAP
Treatment of a dentoalveolar fracture?
LA
Reposition (may have to lift up and over an apical block)
Then splint for 4 weeks
Prescribe AB
Review 4w, 6-8w, 4m, 6m, and yearly for 5y
