Primary Tooth Trauma Flashcards
What is on the trauma stamp
- colour
- TTP
- mobility
- sinus
IGNORE After initial tx, review when?
1,3,6 monthly
- take radiographs 6 monthly if possible
Enamel or ED fracture
ENAMEL FRACTURE:
- smooth sharp edges
- Exercise care when eating not to further traumatize the injured tooth while encouraging a return to normal function as soon as possible
-Encourage gingival healing and prevent plaque accumulation by parents cleaning the affected area with a soft brush or cotton swab combined with an alcohol-free 0.1 to 0.2% chlorhexidine gluconate mouth rinse applied topically twice a day for 1 wk
ENAMEL DENTINE FRACTURE
- baseline rad optional, take rad of soft tissues if fractured fragment suspected to be in lips cheeks or tongue
- cover all exposed dentine with glass ionomer or composite
Same after case as enamel fracture
EDP fracture (complicated)
- tx depending on behaviour
- pulp therapy (partial pulpotomy or RCT) DIFFICULT!!!
- partial pulpotomy would be LA, remove partial pulp (cvek basically), non setting calcium hydroxide, covered with GIC then composite resin.
- extract
- Exercise care when eating not to further traumatize the injured tooth while encouraging a return to normal function as soon as possible
-Encourage gingival healing and prevent plaque accumulation by parents cleaning the affected area with a soft brush or cotton swab combined with an alcohol-free 0.1 to 0.2% chlorhexidine gluconate mouth rinse applied topically twice a day for 1 wk
Crown root fracture tx
PA rad using size 0 film or occlusal rad with size 2 taken at time of initial presentation for diagnostic purposes and to establish a baseline
No tx may often be best option in emergency situation but only where rapid referral within several days can be made to child orientated team
If tx considered at emergency appt, give LA
OPTION A:
- -If restorable and no pulp exposed, cover the exposed dentine with glass ionomer
-If restorable and the pulp is exposed, perform a pulpotomy (see crown fracture with exposed pulp) or root canal treatment, depending on the stage of root development and the level of the fracture
Option B:
-If unrestorable, extract all loose fragments taking care not to damage the permanent successor tooth and leave any firm root fragment in situ, or extract the entire tooth
Treatment depends on the child´s maturity and ability to tolerate the procedure. Therefore, discuss treatment options (including extraction) with the parents. Each option is invasive and has the potential to cause long-term dental anxiety. Treatment is best performed by a child-oriented team with experience and expertise in the management of pediatric dental injuries
- extract coronal fragment - don’t dig for apical portion, can damage permanent tooth, should resorb normally
Alveolar fracture tx
PA rad using size 0 film or occlusal rad with size 2 taken at time of initial presentation for diagnostic purposes and to establish a baseline
- further imaging may be needed to visualise extent of fracture but only where it’s likely to change tx provided
Reposition (under local anesthesia) any displaced segment which is mobile and/or causing occlusal interference
Stabilize with a flexible splint to the adjacent uninjured teeth for 4 wk
Treatment should be performed by a child-oriented team with experience and expertise in the management of pediatric dental injuries
Parent/patient education:
-Exercise care when eating not to further traumatize the injured teeth while encouraging a return to normal function as soon as possible
-To encourage gingival healing and prevent plaque accumulation, parents should clean the affected area with a soft brush or cotton swab combined with an alcohol-free 0.1%-0.2% chlorhexidine gluconate mouth rinse applied topically twice a day for 1 wk
LECTURE:
manual reposition or with forceps
- GA often indicated
- usually managed in hospital
- stabilise segment with flexible splint for 4 weeks
- monitor teeth in fracture line
Lateral luxation tx
- NO OCCLUSAL INTERFERENCE - allow to reposition spontaneously
Tooth usually displaced in palatal/lingual direction or labial direction
Tooth will be immobile
Occlusal interference may be present
PA rad using size 0 film or occlusal rad with size 2 taken at time of initial presentation for diagnostic purposes and to establish a baseline
FIRST OPTION:
If there is minimal or no occlusal interference, the tooth should be allowed to spontaneously reposition itself
^ Spontaneous repositioning usually occurs within 6 mo
In situations of severe displacement, two options are available, both of which require local anesthesia:
Option A:
-Extraction when there is a risk of ingestion or aspiration of the tooth
Option B:
-Gently reposition the tooth
-If unstable in its new position, splint for 4 wk using a flexible splint attached to the adjacent uninjured teeth
LECTURES:
OCCLUSAL INTERFERENCE - reposition
- 4 week splint flexible
OTHERWISE
- extract (if displaced and mobile, aspiration risk)
Intrusion tx and what you’d see on X-ray depending on Position.
Tooth usually displaced through manual or buccal bone plate or can impinge on permanent tooth bud
Tooth has almost or fully disappeared into socket and can be palpated labially
take X ray, USO or PA (tooth usually displaced through labial bone, can impinge on permanent tooth bud)
- if apical tip = shorter than contra lateral, = apex displaced toward/through buccal/labial plate
- if apical tip indistinct + tooth looks elongated, then apex = displaced toward permanent tooth germ
ALLOW SPONTANEOUS ERUPTION, irrespective of displacement direction
- ^ spontaneous improvement usually occurs within 6 months, sometimes can take up to 1 year
Rapid referral within couple of days to child orientated team should be arranged
Extrusive luxation (extrusion) tx
Partial displacement of tooth out of socket
Tooth appears elongated and can be excessively mobile
Occlusal interference may be present
PA rad using size 0 film or occlusal rad with size 2 taken at time of initial presentation for diagnostic purposes and to establish a baseline - slight increase to substantial widening of PDL space apically in
Treatment decisions are based on the degree of displacement, mobility, interference with the occlusion, root formation, and the ability of the child to tolerate the emergency situation
1)
- tooth is not interfering with the occlusion—let the tooth spontaneously reposition itself
2)
- If the tooth is excessively mobile or extruded > 3 mm, then extract under local anaesthesia
Treatment should be performed by a child-oriented team with experience and expertise in the management of pediatric dental injuries. Extractions have the potential to cause long-term dental anxiety
Parent/patient education:
-Exercise care when eating not to further traumatize the injured tooth while encouraging a return to normal function as soon as possible
-To encourage gingival healing and prevent plaque accumulation, parents should clean the affected area with a soft brush or cotton swab combined with an alcohol-free 0.1%-0.2% chlorhexidine gluconate mouth rinse applied topically twice a day for 1 wk
LECTURE:
No occlusal interference = spontaneous repositioning
Excessively mobile, or extruded >3mm, extract under LA
Side effects of trauma to primary teeth
- white or yellow discolouration (hypo mineralisation)
- discolouration + hypoplasia
- odontome like malformation
- root duplication
- crown dilaceration
- root dilaceration
- arrest of development
How long can premature loss of primary tooth delay permanent by
- about 1 year due to thickened mucosa
- take x ray if greater than 6 month delay compared with contra lateral
What colours are associated with different pulp statuses & time after trauma?
Immediate:
• reddish colour, may regress/remain and maintain vitality
Intermediate (weeks):
• brown/black, pulp breakdown products in tubules-non-vital
Long-term (months)
• yellow/opaque, pulp calcification
What would you do with a discoloured and vital primary tooth? After trauma
If vital, no treatment required
Tx for discoloured and non vital tooth? 2 options depending on…?
If sinus or PA pathology, RCT or XLA
If no sinus or PA pathology, monitor until exfoliation
What can occur with primary teeth after trauma, that can impact secondary tooth?
Primary tooth root may not resorb normally after trauma. Extraction may be necessary or permanent successor will erupt ectopically.
What can premature loss of a primary tooth lead to in terms of permanent tooth?
Premature loss of a primary tooth can result in delayed
eruption of about 1 year due to thickened mucosa.
When do you take an x ray with delayed eruption of permanent tooth
Take radiograph if greater than 6 month delay compared with the contralateral
Avulsion tx
Take Pa Size 0/occlusal size 2 rad if primary tooth not brought into clinic to ensure missing tooth hasn’t been intruded
Also helps provide baseline for assessment of developing permanent tooth and whether it’s been displaced
DO NOT REIMPLANT
Enamel fracture and ED fracture recall
Enamel fracture
- no clinical or rad follow up needed
ED:
- clinical exam after 6-8 weeks
- rad follow up only needed if signs of pathosis eg pulp necrosis/infection
- parents must watch for any unfavourable outcomes and bring child back if so
EDP fracture (complicated) follow up
1 week
6-8 weeks
1 year
Rad follow up at 1 yr after pulpotomy or RCT
Other rads only indicated if signs of pathosis
Crown root fracture follow up
Where tooth retained:
1 week
6-8 week
1 year
Clinical exams ^
Rad follow up after 1 yr following pulpotomy or RCT
Unfavourable outcomes of primary tooth trauma
unfavourable outcomes of primary tooth trauma:
- Symptomatic
- Crown discoloration
Signs of pulp necrosis and infection—such as:
-Sinus tract, gingival swelling, abscess, or increased mobility
-Persistent dark gray discoloration with one or more signs of root canal infection
- Radiographic signs of pulp necrosis and infection
No further root development of immature teeth
Potential impact negatively on development and or eruption of permanent successor
Root fracture tx
PA rad using size 0 film or occlusal rad with size 2 taken at time of initial presentation for diagnostic purposes and to establish a baseline
If the coronal fragment is not displaced, no treatment is required
If the coronal fragment is displaced and is not excessively mobile, leave the coronal fragment to spontaneously reposition even if there is some occlusal interference
If the coronal fragment is displaced, excessively mobile and interfering with occlusion, two options are available, both of which require local anesthesia
Option A:
Extract only the loose coronal fragment. The apical fragment should be left in place to be resorbed
Option B:
Gently reposition the loose coronal fragment. If the fragment is unstable in its new position, stabilize the fragment with a flexible splint attached to the adjacent uninjured teeth. Leave the splint in place for 4 wk
The treatment depends on the child´s maturity and ability to tolerate the procedure. Therefore, discuss treatment options with the parents.
Root fracture follow up
Where no displacement of coronal fragment
1 wk
6-8 wk
1 yr
- then each year until eruption of permanent
If coronal fragment repositioned and splinted, clinical exam
1 wk
4 wk for splint removal
8 wk
1 yr
If coronal fragment XLA, clinical:
1 yr
Alveolar fracture tx follow up
Clinical exam:
- 1 wk
- 4 wk for splint removal
- 8 wk
- 1 yr
Further follow up at 6y of age indicated to monitor eruption of permanent teeth
Rad follow up at 4 wk and 1 yr to assess impact on primary tooth and permanent tooth germs in line of alveolar fracture. Other rads only needed if clinical findings suggestive of pathosis
If fracture line at level of primary root apex, abscess can develop. PA radiolucency can be seen on rad
Concussion tx + follow up
Tooth tender to touch but not displaced
Normal mobility and no sulcular bleeding
No baseline rad needed
No tx
Observation
Exercise care when eating not to further traumatize the injured tooth while encouraging a return to normal function as soon as possible
-Encourage gingival healing and prevent plaque accumulation by parents cleaning the affected area with a soft brush or cotton swab combined with an alcohol-free 0.1 to 0.2% chlorhexidine gluconate mouth rinse applied topically twice a day for 1 wk
Clinical exam
- 1 wk
- 6-8 wk
Rad follow up only needed if signs of pathosis
Subluxation tx + follow up
Tooth tender to touch and has increased mobility but not displaced
Bleeding from gingival crevice may be noted
PA rad using size 0 film or occlusal rad with size 2 taken at time of initial presentation for diagnostic purposes and to establish a baseline - normal to slightly wide PDL will be visible
No tx needed
Observation
Exercise care when eating not to further traumatize the injured tooth while encouraging a return to normal function as soon as possible
-Encourage gingival healing and prevent plaque accumulation by parents cleaning the affected area with a soft brush or cotton swab combined with an alcohol-free 0.1 to 0.2% chlorhexidine gluconate mouth rinse applied topically twice a day for 1 wk
Follow up:
- 1 wk
- 6-8 wk
Rad follow up only if signs of pathosis
Patient parent education after trauma
Parent/patient education:
-Exercise care when eating not to further traumatize the injured tooth while encouraging a return to normal function as soon as possible
-To encourage gingival healing and prevent plaque accumulation, parents should clean the affected area with a soft brush or cotton swab combined with an alcohol-free 0.1%-0.2% chlorhexidine gluconate mouth rinse applied topically twice a day for 1 wk
Extrusion follow up
Clinical exam
- 1 wk
- 6-8wk
- 1 yr Further follow
Clinical follow up each year until eruption of permanent if concern that unfavourable outcome likely
Rad follow up only if indicated where clinical findings are suggestive of pathosis
General favourable outcomes after trauma
Asymptomatic
Pulp healing with:
-Normal color of the crown or transient red/gray or yellow discoloration and pulp canal obliteration
-No signs of pulp necrosis and infection
Continued root development in immature teeth
Realignment of the extruded tooth (extrusion)
No interference with the occlusion (extrusion)
No disturbance to the development and/or eruption of the permanent successor
Lateral luxation follow up
Clinical exam:
1 wk
6-8 wk
6 months
1 yr
If repositioned and splinted
- 1 wk
- 4 wk for splint removal
- 8 wk
- 6 months
- 1 yr
Intrusion follow up
Clinical exam
- 1 wk
- 6-8 wk
- 6 months
- 1 yr
Further follow up at 6 yr of age indicated for severe intrusion to monitor eruption of permanent tooth
Avulsion follow up
Clinical exam after
- 6-8 wk
Further follow up at 6 yr old to monitor eruption of permanent
All trauma injuries that require 6yr old follow up to assess permanent tooth eruption ?
Alveolar fracture
Intrusion
Avulsion
each Follow up timing and its associated fracture types:
Clinical exam ONLY 6-8 weeks:
- enamel dentine fracture (no pulp exposed)
- avulsion
1wk, 6-8wk:
- concussion
- subluxation
1 wk, 6-8wk, 1 yr:
- complicated crown fracture (pulp exposed, aka cvek tx)
- crown-root fractures
- root fractures (no displacement of coronal fragment)
- extrusion
1wk, 6-8wk, 6months, 1 yr:
- lateral luxation (if not repositioned)
- intrusion
1wk, 4wk (for splint removal), 8wk, 1 yr:
- root fractures (if coronal fragment repositioned and splinted)
- alveolar fractures
1wk, 4wk (splint removal), 8wk, 6mo, 1 yr
- lateral luxation (if repositioned and splinted)
Complication of intrusion primary tooth potential
Complications = loss of vitality, discolouration, need for
XLA, ankylosis, Turners hypoplasia
