review of dental trauma and sequelae Flashcards
what is clinical and radiographic presentations of loss of vitality?
> Clinically
- History
- Sulcus-swelling, tenderness, sinus
- Discoloured – often progressively grey
- TTP
- Mobile
- Negative to sensibility tests
- Majority are –ve immed after trauma
- Most will respond within 3 months
> Radiograph
- Periapical radiolucency
- Resorption (Int/ Ext)
- Arrested root development
when a tooth has loss of vitality, and you’re thinking of Endodontic therapy, how many clinical signs do you need before carrying out RCT?
> 2
what does sensibility testing test for?
> nerve supply, not blood supply
what is periapical inflammation - transient apical breakdown ?
> Transient apical breakdown is a sequelae of certain dental traumatic injuries where the injured tissues undergo a spontaneous process of repair with no permanent damage to the pulp. Misdiagnosis of this condition may result in unnecessary endodontic treatment
> 4% of mature teeth following luxation injuries
> Mimics apical resorption
> Ambivalent clinical + radiographic signs - delay endodontic treatment
> Monitor closely
> May be present up to 2-3 months after trauma
how does arrested root development occur and what are the radiographic signs?
> If necrosis affects root sheath before root development complete then no further growth
> Radiographically - majority- failure of pulp canal to mature and reduce in size will indicate loss of vitality
> If sequential radiographs not available compare to root development of contra lateral tooth
what are the categories of root resorption?
- Surface resorption
- Inflammatory
a. External
b. Internal
c . Cervical - Replacement resorption (ankylosis)
what is the aetiology of external inflammation?
> Aetiology - non vital pulp
- Mainly seen with avulsion and intrusion injuries (possible with lateral luxation, extrusion and subluxation)
- Initiated by PDL damage and propagated by necrotic pulp/ pdl
what is the radiographic appearance of external inflammation?
> Radiographically
- Punched out areas of resorption
- Loss of root surface, loss of adjacent bone, radiolucent area
- Pdl expansion
- May be evident from 3 weeks
what is the treatment for external inflammation?
> Extirpation
> debridement
> non-setting Calcium hydroxide
what is the aetiology of internal inflammation?
> chronic pulpal inflammation
what is the radiographic presentation of internal inflammation ?
> ballooning of walls of root canal
what is the progression of internal inflammation like?
> rapid, may cause perforation of root surface
what is the treatment of root resorption?
> extirpation
> debridement
> Non-setting Calcium Hydroxide dressing
what is cervial resorption?
> Damage to root surface in cervical region
> Propagated by necrotic pulp or perio disease
what is the treatment for cervical resorption?
> Curette defect and
> restore +/-RCT
what is the aetiology behind replacement resorption (ankylosis) ?
> extensive damage to PDL and cementum (Intrusion/avulsion)
> Results in bony union between alveolar socket and root surface
what is the radiographic appearance of replacement resorption (ankylosis) ?
> Loss of periodontal space, bone in direct contact with root
> Usually evident within 2 mths -1 yr
what is the clinical test which allows you to confirm ankylosis?
> detected by distinctive high “metallic” note on percussion
what is the treatment for ankylosis?
> no effective treatment
> Extraction/root burial
> Cannot be moved orthodontically
what is pulp can obliteration and when’s it more common?
> Progressive hard tissue formation within pulp cavity – narrowing of root canal
- Thin thread of pulp tissue remains
> More common in immature teeth and following luxation injuries
what is the clinical appearance of a tooth with pulp canal obliteration?
> Opaque/ yellow crown
> Reduced response to vitality testing
what is the treatment for pulp canal obliteration?
> conservative approach
what is the follow up for trauma injuries?
> Varies by injury in guidelines
> See IADT guidelines (essential reading)
> May increase if equivocal findings
when carrying out a trauma review what are key signs to look out for with regards to colour and soft tissues?
colour =
- Grey/brown- pulp necrosis
- Yellow- pulp canal obliteration
- Pink- internal resorption, bleed into dentine
soft tissues =
- Swelling
- Tenderness
- Erythema
- Sinus
when carrying out a trauma review what are you assessing regards to mobility and TTP/ tone?
mobility =
- Assess between 2 ends of metal instrument
- One labial, one palatal
- Vertical
TTP/ tone =
a. Check TTP with metal instrument
> Vertical
b. Tone
> Hi = Replacement resorption or intrusion
> Cracked cup = root fracture
when carrying out a trauma review how do you carry out an ethyl chloride and electrical pulp test? |(sensibility testing)
- ethyl chloride =
- Cotton wool held in tweezers applied to centre of labial surface of tooth (Avoid gingivae)
- Newly erupted teeth may not respond
- May need repetitions for reliability in children
- After injury up to 3/12 for response - electric pulp testing =
- Isolate teeth with cotton wool
- Lip electrode applied
- Tip dipped in toothpaste
- Raise hand on first sensation
- Avoid any restorations
when carrying out a trauma review what are key things to record in regards to the radiograph report and RCT?
- Radiograph report =
- Findings especially
- Periapical pathology
- Root development
- Periodontal ligament space
- Marginal bone levels
- Root canal outline - RCT
- ongoing
- obturated
what is uncomplicated crown fractures and what is the prognosis?
> Fractures confined to enamel/dentine
> Prognosis =
- Pulp necrosis 54% if no dentinal coverage, 8% if dentine protected
what is the treatment for complicated crown fracture and what is the success rate?
> Apexogenesis procedure - Vital/Cvek pulpotomy
> Success rates 80 – 96%
- Better prognosis than direct pulp cap for immature permanent teeth exposed>24 hrs
what are the 5 year survival rates for each type of trauma?
- Concussion
- open apex = 100%
- closed apex = 96% - Subluxation
- open apex = 100%
- closed apex =85% - Extrusion
- open apex = 95%
- closed apex =45% - Lateral lux
- open apex = 95%
- closed apex =25% - Intrusion
- open apex = 40%
- closed apex =0 - Avulsion
- open apex = 18-34% (time and storage dependent)
- closed apex =0
what are the outcomes after intrusion?
- Normal healing
- open apex = 33
- closed apex = 0 - Inflammatory resorption
- open apex =41
- closed apex =35 - Replacement resorption
- open apex =10
- closed apex =31
what is healing influenced by in root fractures?
> Position of fracture line
> Degree of displacement of coronal fragment
- Necrosis of pulp usually only coronal fragment and coronal to #line
> Coronal fracture
what are the healing outcomes of a root fracture?
> Hard tissue formation
> Fibrous
> Bone and connective tissue
> Non-union-inflammatory/granulation
- Necrosis of coronal portion
what is the survival rate of a root fractured tooth across ten year?
> apical 1/3 = 100%
> middle 1/3 = 75%
> gingival 1/3 = >50%
(prognosis increases as distance from gingival margin decreases)
what are avulsion outcomes?
> Extra – oral time is critical
> Storage medium important
- Dry storage - decreases prognosis
- Contamination – decreases prognosis
> Prolonged splint time increases replacement resorption
> PDL survival is critical- resorption at 1year best predictor of survival
> Pulp death is less important
why is informed consent important during a trauma case?
> Severe injuries – intrusions/avulsions
- At least 8 – 12 visits
- Time off school / parents work
- Cost to NHS
> Unpredictable outcome
> consider treatment options carefully
> Parents must be fully informed regarding nature of injuries, treatment, sequelae and long term prognosis
what are the most common complications to primary teeth as a result of trauma?
- Pulpal necrosis – commonest complication
- Root resorption
- Pulpal canal obliteration
- Replacement resorption
what is the clinical presentation of pulp necrosis in the primary dentition?
> Grey colour/ sulcus/ history/ mobile/ TTP
> Transient - intrapulpal bleed
- vital tooth, colour resolves
- persists, implies non vital (but may be uninfected)
what are the radiographic features of plural necrosis in the primary dentition?
> Failure of pulp cavity to reduce
> Periapical area
what is the treatment for plural necrosis in primary dentition?
> Extraction recommended
> Endodontic treatment occasionally- specialist
> Options discussed with parent
- Informed consent
how does a pulp canal obliteration present in the primary dentition?
> clinically = yellow/ opaque crown
> radiographically = pulp canal narrowing
what is the treatment of pulp canal obliteration in the primary dentition?
> Usually exfoliates
> If periapical inflammation - recommend extraction
> Discuss with parents – informed consent
how does replacement resorption/ ankylosis present in primary teeth?
> Clinically
- Below occlusal level
- Ensure no non-nutritive sucking
> Radiograph
- Confirm presence of replacement resorption
- Assess position of permanent tooth
what is the treatment of replacement resorption/ ankylosis?
> Monitor - may resorb
> Extraction
- If pathology, delayed eruption, displacement
what injuries can occur to developing dentition following trauma to primary teeth?
> Hypomin/ hypoplasia of enamel
> Crown / root dilaceration
> Odontoma – like formation
> Root duplication
> Arrest of root development
> Disturbance in eruption
> Sequestration of tooth germ
( - Studies suggest 12 – 69% of primary trauma affect successor
- Depends on type and severity of injury, high with intrusions
- Most damage occurs before 3 yrs of age during its developmental stage )
