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Paeds > Primary Dentition Trauma > Flashcards

Primary Dentition Trauma Flashcards

1
Q

Injuries to baby teeth occur most commonly at what age?

A

1.5 to 2.5 years old

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1
Q

Which teeth are most commonly injured?

A

Upper central incisors

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2
Q

Two types of injury to primary dentition

A
  1. Soft tissue injury
  2. Hard tissue injury
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3
Q

IADT dental trauma guide

A
  1. Crown fracture
  2. Crown-root fracture
  3. Concussion
  4. Subluxation
  5. Intrusion
  6. Lateral luxation
  7. Extrusion
  8. Root fracture
  9. Alveolar fracture
  10. Avulsion
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4
Q

Clinical Presentation of Concussion

A
  1. Tooth is tender to touch but no displacement
  2. Normal mobility and no sulcular bleeding
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5
Q

Treatment of Concussion

A
  1. Soft Diet
  2. Observation
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6
Q

Patient Education for Concussion

A

Soft brush or cotton swab with an alcohol-free 0.1-0.2% mouth rinse chlorhexidine gluconate applied topically twice a day for one week

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7
Q

Follow-up for Concussion?

A

1 week
6-8 weeks

Radiographic follow-up only indicated where clinical findings suggest pathology

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8
Q

Clinical Presentation of Subluxation

A
  1. Tooth mobile but not displaced
  2. Sulcus bleeding
  3. Tender to touch
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9
Q

Treatment of Subluxation

A
  1. Clean
  2. Soft diet
  3. Analgesics
  4. Monitor
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10
Q

Radiographic Recommendations and Findings for Subluxation

A

PA will show normal to slightly widened PDL space

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11
Q

Follow-up for Subluxation

A

1 week
6-8 weeks

Radiographic follow-up only indicated where clinical findings suggest pathology

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12
Q

When do we NOT manage lateral luxation tooth?

A
  1. Stable
  2. No interference with bite
  3. Can spontaneously reposition
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13
Q

When do we EXTRACT lateral luxation tooth?

A
  1. Tooth pushed into developing tooth bud
  2. Occlusal interference, reposition not possible
  3. Excess mobility, increased risk of aspiration
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14
Q

Immediate Repositioning of Lateral Luxation

A
  1. Clean the area with water spray, saline or chlorhexidine
  2. Apply LA
  3. Suture gingival lacerations
  4. Reposition tooth with gentle combined labial and palatal pressure
  5. If the tooth is unstable, stabilize with flexible splint for 4 weeks
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15
Q

Clinical Presentation of Lateral Luxation

A

Tooth is displaced, usually in a palatal/lingual or labial direction

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16
Q

Radiographic Recommendations and Findings of Lateral luxation

A

PA shows increased PDL space

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17
Q

Treatment for Lateral Luxation

A
  1. Spontaneous repositioning within 6 months
  2. Extract when there is a risk of aspiration
  3. Gently reposition the tooth +/- splint for 4 weeks
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18
Q

Clinical Findings of Intrusion

A

Tooth submerged into gums

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19
Q

Treatment of Intrusion

A
  1. Take a good history
  2. PA or occlusal to rule out
  • Avulsion
  • Aspiration
  • Embedding into soft tissues
  1. Leave alone unless infection or failure to re-erupt
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20
Q

Radiographic Recommendations and Findings of Intrusion

A

PA

Foreshortened image of luxated tooth implies root apex labial -> Safer

Elongated image, tooth has gone palatally towards tooth germ -> May need to extract

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21
Q

Will intruded teeth erupt?

A
  1. Spontaneous improvement in the position occurs within 6 months - 1 year
  2. Rapid referral
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22
Q

Follow-up for intrusion

A

1 week
6-8 weeks
6months
1 year
Further follow-up at 6 years for severe intrusion, to monitor eruption of permanent tooth

Radiograph follow-up indicated where clinical findings suggest pathology

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23
Q

Clinical Findings of Extrusion

A
  1. Tooth mobile
  2. Displaced out of socket
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24
Q

Radiographic recomendations and findings of Extrusion

A

PA shows increased PDL space apically

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25
Q

Treatment of Extrusion

A

If extrusion 1-2mm, no occlusal interference -> Observe and let the tooth spontaneously reposition itself

If extrusion >3mm, occlusion affected -> Extract

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26
Q

Follow-up for extrusion

A

1 week
6-8 weeks
1 year

Radiographic follow up only indicated where clinical findings suggest pathosis

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27
Q

Clinical Findings of Avulsion

A

Tooth is completely out of socket

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28
Q

Radiographic Recommendations and Findings for Avulsion

A

PA shows empty socket -> Must account for that tooth -> Send to A&E to get a chest x-ray

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29
Q

Treatment of Avulsed Tooth

A

DO NOT re-implant

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30
Q

Follow-up of Avulsed Tooth

A

6-8 weeks

6 years of age to monitor eruption of permanent tooth

Radiographic follow-up indicated when clinical findings suggest pathology

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31
Q

Management of Root Fractures

A

Stable -> Monitor

Unstable -> Reposition and splint for 4 weeks

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32
Q

Management of Crown Fractures: No pulp exposure

A
  1. Leave
  2. Smoothen sharp edges
  3. Composite restoration (strip crown)
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33
Q

Management of Crown Fractures: Pulp exposed

A
  1. Pulpotomy/pulpectomy
  2. Extraction
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34
Q

Management of Crown-root fractures: No pulp involvement

A

Remainder tooth large enough to allow coronal restoration: Remove the mobile fragment and cover exposed dentine with glass ionomer

Otherwise: Extract

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35
Q

Management of Crown-root fractures: Pulp involvement

A

Stable fragment large enough to allow coronal restoration: Pulpotomy or RCT

Otherwise: Extract

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36
Q

Management of Alveolar Fracture

A
  1. Sedation or GA
  2. Stabilise the segment with flexible splinting for 4 weeks
  3. Monitor teeth in fracture line
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37
Q

Ways to examine or treat young injured child

A
  1. Knee-to-knee
  2. Seated on parent
  3. Restraint and sedation
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38
Q

Extraoral Orofacial Signs of Physical Abuse

A
  1. Bruising of face, ears
  2. Abrasians and lacerations
  3. Burns and bites
  4. Choke or cord marks
  5. Eye injuries
  6. Hair pulling
  7. Fractures (Nose> Mandible > Zygoma)
39
Q

Intraoral Orofacial Signs of Physical Abuse

A
  1. Contusions
  2. Bruises
  3. Abrasians and lacerations
  4. Burns
  5. Tooth trauma
  6. Frenal injuries
40
Q

Signs of Non-accidental Injury (NAI)

A
  1. History of multiple injuries in different areas
  2. Injuries at protected sites: Behind the ears
41
Q

Torn labial frenum was previously associated with?

A

Force feeding

42
Q

What is a bite mark?

A

A bite mark is a mark made by the teeth acting either alone or in combination with other mouth parts

43
Q

Management of Suspected NAI

A
  1. Photography
  2. Avoid definitive opinion but consult expert ASAP
44
Q

Risk factors of NAI

A
  1. Parents’ background
  2. Society and culture
  3. Family environment
  4. Socio-economic environment
45
Q

Instructions after treatment

A
  1. Soft diet to prevent further trauma to injured tooth
  2. Oral hygiene measures to encourage gingival healing
  • Support tooth when brushing
  • Clean affected area with soft brush or cotton swab
  • Alcohol-free 0.1% chlorhexidine gluconate mouth rinse applied topically twice a day for one week
  1. Inform about possible effects on permanent tooth
46
Q

Sequelae of Injury to Primary Tooth

A
  1. Discolouration
  2. Loss of vitality
  3. Damage to permanent successor
47
Q

Unfavourable Outcomes after treatment of trauma to primary tooth

A
  1. Sinus tract, gingival swelling, abscess or increased mobility
  2. Persistent dark grey discolouration
  3. Radiographic signs: Periapical pathology or infection-related resorption
48
Q

Signs of loss of vitality

A
  1. Chronic Abscess
  2. Periapical pathology
  3. Pain, mobility, discolouration
49
Q

What is the cause of yellow tooth discolouration?

A

Pulp canal obliteration

50
Q

What are the causes of Grey tooth discolouration?

A
  1. Probably hemorrhage
  2. Happens quickly with subsequent gradual resolution
  3. In isolation, not a sign of loss of vitality
51
Q

What are the chances of damage to permanent successor?

A

More likely following intrusion/avulsion

< 2 years old: 63%
>5 years old: 25%

52
Q

Other possible sequelae after trauma to primary teeth?

A
  1. White or brown discolouration
  2. Root dilaceration
  3. Odontome-like malformation
  4. Failure of tooth development
53
Q

Aims of Treatment

A
  1. Prevent further damage to permanent successor
  2. Treat pain
  3. Restore function
  4. Restore aesthetics
54
Q

Child ended up with abscess following non-treatment after crown fracture. What should you do?

A
  1. Extract
  2. Pulpectomy + Strip-crown restoration
55
Q

When do we restore or leave alone?

A
  1. Behaviour
  2. Parental choice
  3. Medical history: Cyanotic heart disease leading to increased risk of IE -> RCT or not?
  4. Type of injury
56
Q

What are the 3 main principles of luxation injury management?

A
  1. Reduction
    - Reposition teeth and tissues to their original position
  2. Fixation
    - Optimise healing outcomes for pulp and PDL
    - Improve function and provide comfort
  3. Endodontic monitoring
    - Pulpal status
    - Periodontal healing
57
Q

How to splint a tooth?

A
  1. Stabilize the tooth using a passive and flexible splint (CR wire splint)
  2. If breakdown of marginal bone or alveolar socket wall, split for an additional 4 weeks
58
Q

Clinical Findings of a Lateral Luxation

A
  1. Tooth displaced in palatal/lingual or labial direction
  2. Usually associated fracture of alveolar bone
  3. Immobile tooth as apex of root is locked in by the bone fracture
  4. Percussion will give a high metallic sound
  5. No response to pulp sensibility tests
59
Q

Recommended Radiographs and Findings of Lateral Luxation

A

Parallel PA + 2 additional radiographs of tooth taken with different vertical and/or horizontal angulations

Occlusal radiograph

Widened PDL space seen

60
Q

Treatment for Lateral Luxation

A
  1. Reposition tooth by disengaging it from its locked position and gently reposition it into its original location under LA
  • Palpate gingiva to feel apex
  • Use one finger to push downwards over the apical end of tooth and another finger to push tooth back into socket
  1. Stabilise for 4 weeks using passive and flexible splint. If fracture of alveolar socket wall, splint for an additional 4 weeks
61
Q

Follow-up for Lateral Luxation

A

Clinical and Radiographic Evaluations

2 weeks, 4 weeks, 8 weeks,12 weeks
6 months
1 year
Yearly for at least 5 years

62
Q

When do you start RCT for pulp necrosis in lateral luxation tooth?

A

PDL healing to withstand clamps of rubber dam

63
Q

How should RCT be started in lateral luxation tooth?

A

Corticosteroid-antibiotic or calcium hydroxide as an intracanal medicament to prevent the development of inflammatory external resorption

64
Q

12 severe lateral luxation with rotation

Diagnosis

Soft tissue lacerations + Alveolar fracture

#11 avulsion
#21 severe lateral luxation with possible intrusion
#22 severe lateral luxation with possible intrusion

What to do for short-term treatment 2 weeks post trauma?

A
  1. Pulp extirpation and calcium hydroxide
  2. Prevent inflammatory type root resorption
  3. Keep splint
65
Q

12 severe lateral luxation with rotation

Diagnosis

Soft tissue lacerations + Alveolar fracture

#11 avulsion
#21 severe lateral luxation with possible intrusion
#22 severe lateral luxation with possible intrusion

What to do for medium-term treatment 4 weeks post trauma?

A

Splint removal and issue partial denture

66
Q

12 severe lateral luxation with rotation

Diagnosis

Soft tissue lacerations + Alveolar fracture

#11 avulsion
#21 severe lateral luxation with possible intrusion
#22 severe lateral luxation with possible intrusion

Why do we monitor Long-term?

A

Loss of PDL space, Replacement resorption: Bone replacing the root

67
Q

Possible sequelae of incisor trauma

A
  1. Loss of vitality
  2. Internal and external root resorption
  3. Pulpal calcification/obliteration
  4. Ankylosis/Replacement resorption
68
Q

Why do we do endodontic monitoring?

A

If pulp necrosis occurs, stimulus from infected pulp space will transverse the root and sustain inflammation around the root

Inflammatory resorption will continue till whole root is resorbed

69
Q

What happens if you don’t extirpate the pulp within 1 hour?

A

Replacement Resorption will occur

70
Q

Pathogenesis of Endodontic Infection

A
  1. Protective layer (pre-cementum) is damaged during trauma
  2. Inflammation due to injury occurs
71
Q

What happens if PDL cells are viable?

A

Cemental healing can occur, resulting in surface resorption

72
Q

What happens if large surface of PDL is damaged?

A

Replacement resorption will take over inflammatory resorption

73
Q

Clinical Presentation of Replacement Resorption

A

Ankylosis/Infraocclusion

74
Q

What happens if you move a tooth with pulp canal obliteration?

A

Increase risk of tooth becoming non-vital due to very slender neuro-vascular bundle

75
Q

Types of Root Fracture

A
  1. Single/multiple
  2. Horizontal/vertical/oblique
  3. Level: apical third, middle third, coronal third
76
Q

How to Diagnose Root Fracture?

A
  1. Mobility/point of rotation
  2. Radiograph at two angles
  3. Note also degree of separation between fragments
77
Q

Difference between complicated and uncomplicated fracture

A

Touches pulp -> Complicated fracture

Does not touch pulp -> Uncomplicated fracture

78
Q

Clinical Findings of Root Fracture

A
  1. Coronal segment may be mobile and may be displaced
  2. Tooth may be tender to percussion
  3. Bleeding from sulcus
  4. Pulp sensibility may be negative initially, indicating transient or permanent neural damage
79
Q

Recommended radiographs and findings of root fracture

A

One parallel PA + 2 additional radiographs of tooth taken with different vertical and horizontal angulations

Occlusal radiograph

80
Q

Treatment of Root Fracture

A
  1. If displaced, the coronal fragment should be repositioned as soon as possible
  2. Check repositioning radiographically
  3. Stabilise the mobile coronal segment with a passive and flexible splint for 4 weeks
  4. Monitor healing for fracture and pulp status for at least one year
81
Q

Follow up for Root Fractures

A

Clinical and radiographic evaluations needed after 4 weeks, after 6-8 weeks, 4 months, 6 months, 1 year, then yearly for at least 5 years

82
Q

Diagnosis

11 concussion

21 mid-root horizontal root fracture (2mm separation) with enamel-dentine pulp fracture

22 enamel-dentine fracture with subluxation

What is the immediate management?

A
  1. Reduce fracture and splint
  2. Pulp protection

21 Cvek pulpotomy + CR bandage

22 CR bandage

83
Q

Steps of Cvek pulpotomy

A
  1. High speed + irrigation
  2. Achieve hemostasis with pressure and cotton pellet soaked in saline
84
Q

What are the pulp capping materials?

A
  1. Non-setting CaOH
  2. MTA causes discolouration
  3. Tricalcium silicate materials: Biodentine
85
Q

Diagnosis

11 concussion

21 mid-root horizontal root fracture (2mm separation) with enamel-dentine pulp fracture

22 enamel-dentine fracture with subluxation

What do we do in 4-week review?

A

Splint removal and restore aesthetics

86
Q

4 types of root fracture healing outcomes

A
  1. Hard tissue union
  2. Interposition of connective tissue
  3. Interposition of bone and connective tissue
  4. Granulation tissue: Coronal pulp necrosis
87
Q

What happens if you miss out on diagnosis of root fractures?

A

Transient apical breakdown usually due to moderate injury to pulp or PDL + pulp in mature teeth

It reflects repair processes taking place in the periapical area and pulp after trauma

Consistently followed by surface resorption and/or obliteration of pulp canal

88
Q

Clinical Features of Transient Apical Breakdown

A
  1. Grey discoloration and loss of sensibility: Otherwise no other symptoms
  2. Follows same course as TAB, return to normal with normalization of radiographic condition
89
Q

Diagnosis

11, 21 severe intrusion (2/3 crown) + enamel-dentine fracture

22 moderate intrusion (1/2 crown)

What is the recommended treatment plan?

A
  1. Surgical extrusion: Pull the tooth out with forceps
  2. Raise flaps for forceps to grip tooth sometimes
  3. Pulp extirpation
90
Q

Management of intruded teeth with complete root formation

A

Intrusion <3mm: Allow re-eruption within 8 weeks, reposition surgically and splint 2 weeks OR reposition orthodontically

Intrusion 3-7mm: Reposition surgically (preferable) or orthodontically

Intrusion >7mm: Reposition surgically

RCT started as soon as position of tooth allows using corticosteroid-antibiotic or CaOH as intracanal medicament

91
Q

Diagnosis

11, 21 severe intrusion (2/3 crown) + enamel-dentine fracture

22 moderate intrusion (1/2 crown)

What is the medium-term treatment plan?

A

Post RCT and composite restoration of crown

92
Q

Diagnosis

11, 21 severe intrusion (2/3 crown) + enamel-dentine fracture

22 moderate intrusion (1/2 crown)

What to monitor in the long term?

A

Internal root resorption and pulp vitality of 22

Root resorption of 11, 21, 22

93
Q

Classification of Root Resorption

A
  1. Replacement resorption: Root is resorbed and replaced by bone
  2. Inflammatory resorption: Infected pulp tissue act as constant stimulus for inflammation
  3. Surface resorption: Limited to surface of cementum or dentin
94
Q

What are our Treatment Aims?

A
  1. Doing our best for the child and providing highest possible standard of evidence-based care which provides excellent long-term outcomes
  2. Maintain dentition till adulthood for aesthetics and maximizing restorative treatment options

Paeds (10 decks)

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