review of dental trauma and sequelae

Question 1

what is clinical and radiographic presentations of loss of vitality?

Answer 1

> 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

Question 2

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?

Answer 2

> 2

Question 3

what does sensibility testing test for?

Answer 3

> nerve supply, not blood supply

Question 4

what is periapical inflammation - transient apical breakdown ?

Answer 4

> 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

Question 5

how does arrested root development occur and what are the radiographic signs?

Answer 5

> 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

Question 6

what are the categories of root resorption?

Answer 6

1. Surface resorption
2. Inflammatory
   a. External
   b. Internal
   c . Cervical
3. Replacement resorption (ankylosis)

Question 7

what is the aetiology of external inflammation?

Answer 7

> 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

Question 8

what is the radiographic appearance of external inflammation?

Answer 8

> Radiographically
- Punched out areas of resorption
- Loss of root surface, loss of adjacent bone, radiolucent area
- Pdl expansion
- May be evident from 3 weeks

Question 9

what is the treatment for external inflammation?

Answer 9

> Extirpation

> debridement

> non-setting Calcium hydroxide

Question 10

what is the aetiology of internal inflammation?

Answer 10

> chronic pulpal inflammation

Question 11

what is the radiographic presentation of internal inflammation ?

Answer 11

> ballooning of walls of root canal

Question 12

what is the progression of internal inflammation like?

Answer 12

> rapid, may cause perforation of root surface

Question 13

what is the treatment of root resorption?

Answer 13

> extirpation

> debridement

> Non-setting Calcium Hydroxide dressing

Question 14

what is cervial resorption?

Answer 14

> Damage to root surface in cervical region

> Propagated by necrotic pulp or perio disease

Question 15

what is the treatment for cervical resorption?

Answer 15

> Curette defect and

> restore +/-RCT

Question 16

what is the aetiology behind replacement resorption (ankylosis) ?

Answer 16

> extensive damage to PDL and cementum (Intrusion/avulsion)

> Results in bony union between alveolar socket and root surface

Question 17

what is the radiographic appearance of replacement resorption (ankylosis) ?

Answer 17

> Loss of periodontal space, bone in direct contact with root

> Usually evident within 2 mths -1 yr

Question 18

what is the clinical test which allows you to confirm ankylosis?

Answer 18

> detected by distinctive high “metallic” note on percussion

Question 19

what is the treatment for ankylosis?

Answer 19

> no effective treatment

> Extraction/root burial

> Cannot be moved orthodontically

Question 20

what is pulp can obliteration and when’s it more common?

Answer 20

> 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

Question 21

what is the clinical appearance of a tooth with pulp canal obliteration?

Answer 21

> Opaque/ yellow crown

> Reduced response to vitality testing

Question 22

what is the treatment for pulp canal obliteration?

Answer 22

> conservative approach

Question 23

what is the follow up for trauma injuries?

Answer 23

> Varies by injury in guidelines

> See IADT guidelines (essential reading)

> May increase if equivocal findings

Question 24

when carrying out a trauma review what are key signs to look out for with regards to colour and soft tissues?

Answer 24

colour =
- Grey/brown- pulp necrosis
- Yellow- pulp canal obliteration
- Pink- internal resorption, bleed into dentine

soft tissues =
- Swelling
- Tenderness
- Erythema
- Sinus

Question 25

when carrying out a trauma review what are you assessing regards to mobility and TTP/ tone?

Answer 25

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

Question 26

when carrying out a trauma review how do you carry out an ethyl chloride and electrical pulp test? |(sensibility testing)

Answer 26

1. 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 2. electric pulp testing = - Isolate teeth with cotton wool - Lip electrode applied - Tip dipped in toothpaste - Raise hand on first sensation - Avoid any restorations

Question 27

when carrying out a trauma review what are key things to record in regards to the radiograph report and RCT?

Answer 27

1. Radiograph report = - Findings especially - Periapical pathology - Root development - Periodontal ligament space - Marginal bone levels - Root canal outline 2. RCT - ongoing - obturated

Question 28

what is uncomplicated crown fractures and what is the prognosis?

Answer 28

> Fractures confined to enamel/dentine > Prognosis = - Pulp necrosis 54% if no dentinal coverage, 8% if dentine protected

Question 29

what is the treatment for complicated crown fracture and what is the success rate?

Answer 29

> Apexogenesis procedure - Vital/Cvek pulpotomy > Success rates 80 – 96% - Better prognosis than direct pulp cap for immature permanent teeth exposed>24 hrs

Question 30

what are the 5 year survival rates for each type of trauma?

Answer 30

1. Concussion - open apex = 100% - closed apex = 96% 2. Subluxation - open apex = 100% - closed apex =85% 3. Extrusion - open apex = 95% - closed apex =45% 4. Lateral lux - open apex = 95% - closed apex =25% 5. Intrusion - open apex = 40% - closed apex =0 6. Avulsion - open apex = 18-34% (time and storage dependent) - closed apex =0

Question 31

what are the outcomes after intrusion?

Answer 31

1. Normal healing - open apex = 33 - closed apex = 0 2. Inflammatory resorption - open apex =41 - closed apex =35 3. Replacement resorption - open apex =10 - closed apex =31

Question 32

what is healing influenced by in root fractures?

Answer 32

> Position of fracture line > Degree of displacement of coronal fragment - Necrosis of pulp usually only coronal fragment and coronal to #line > Coronal fracture

Question 33

what are the healing outcomes of a root fracture?

Answer 33

> Hard tissue formation > Fibrous > Bone and connective tissue > Non-union-inflammatory/granulation - Necrosis of coronal portion

Question 34

what is the survival rate of a root fractured tooth across ten year?

Answer 34

> apical 1/3 = 100% > middle 1/3 = 75% > gingival 1/3 = >50% (prognosis increases as distance from gingival margin decreases)

Question 35

what are avulsion outcomes?

Answer 35

> 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

Question 36

why is informed consent important during a trauma case?

Answer 36

> 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

Question 37

what are the most common complications to primary teeth as a result of trauma?

Answer 37

1. Pulpal necrosis – commonest complication 2. Root resorption 3. Pulpal canal obliteration 4. Replacement resorption

Question 38

what is the clinical presentation of pulp necrosis in the primary dentition?

Answer 38

> Grey colour/ sulcus/ history/ mobile/ TTP > Transient - intrapulpal bleed - vital tooth, colour resolves - persists, implies non vital (but may be uninfected)

Question 39

what are the radiographic features of plural necrosis in the primary dentition?

Answer 39

> Failure of pulp cavity to reduce > Periapical area

Question 40

what is the treatment for plural necrosis in primary dentition?

Answer 40

> Extraction recommended > Endodontic treatment occasionally- specialist > Options discussed with parent - Informed consent

Question 41

how does a pulp canal obliteration present in the primary dentition?

Answer 41

> clinically = yellow/ opaque crown > radiographically = pulp canal narrowing

Question 42

what is the treatment of pulp canal obliteration in the primary dentition?

Answer 42

> Usually exfoliates > If periapical inflammation - recommend extraction > Discuss with parents – informed consent

Question 43

how does replacement resorption/ ankylosis present in primary teeth?

Answer 43

> Clinically - Below occlusal level - Ensure no non-nutritive sucking > Radiograph - Confirm presence of replacement resorption - Assess position of permanent tooth

Question 44

what is the treatment of replacement resorption/ ankylosis?

Answer 44

> Monitor - may resorb > Extraction - If pathology, delayed eruption, displacement

Question 45

what injuries can occur to developing dentition following trauma to primary teeth?

Answer 45

> 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 )