Trauma 1

Question 1

when is peak period for trauma to permanent teeth

Answer 1

7-10 years

Question 2

when would you expect the apex of an upper central incisor to be closing

Answer 2

9-9.5 years

Question 3

when is trauma most common

Answer 3

children with a large overjet

if over jet is greater than 9mm then the incidence to trauma is double

Question 4

what causes trauma

Answer 4

○ Falls
○ Bike, skateboard, road traffic accidents
○ Sport
○ Fights

Question 5

what questions should be asked when taking a detailed history

Answer 5

• How did it happen?
• When did it happen exactly?
• Where are the lost teeth / fragments?
• Any other symptoms? 
○ That could be more pressing than the dental injury

Question 6

what things in a medical history do we need to be aware of that might influence dental treatment

Answer 6

○ Rheumatic fever
○ Congenital heart defects
○ Immunosuppression

• These conditions are not contraindications to treatment but appropriate additional treatment may need to be given
Such an antibiotic cover

Question 7

what should be included in the extra-oral examination

Answer 7

○ Lacerations - any tears of the soft tissues of the lips or the face
○ Haematomas
○ Haemorrhage / CSF
§ One of the ways to detect this is if the patient has a bleeding nose, see CSF in the nasal stream - blood would be a straw coloured liquid
○ Subconjunctival haemorrhage
○ Bony step deformities ~ feel for these
○ Mouth opening
§ Assess whether they could get their mouth open properly or not
○ Rule out facial / jaw fractures ~ Important these things are detected early

Question 8

what is included in the intra oral examination

Answer 8

look at / examine:
○ Soft tissue ~ any lacerations or tears
○ Alveolar bone ~ Feel for any steps,  displacement, mobility
○ Occlusion
○ Teeth

Question 9

where should you check for foreign bodies

Answer 9

• If fragments of teeth break off they are most likely to have fallen to the ground
• Check for soft tissue damage
  ○ Possibility there is a tooth fragment
• Penetrating wounds, foreign bodies
  ○ part of a tooth / bit of grit / glass
• Soft tissue radiograph to check lacerations

Question 10

when carrying out a tactile test with probe, what are you looking for?

Answer 10

○ Fracture lines
§ Horizontal or vertical
§ (transillumination from curing light can help)

○ Pulpal involvement

Question 11

what can tooth mobility indicate

Answer 11

• displacement of tooth (within socket)
• root fracture
• bone fracture (in this case it is more likely that there is more than just one mobile tooth)

Question 12

name sensibility tests

Answer 12

○ Thermal
§ Ethyl chloride (ECL)
§ Warm gutta-percha

○ Electrical
§ Electric pulp tester (EPT)

Question 13

why would you carry out sensibility tests?

Answer 13

Testing nerve of tooth to see if the nerve responds

if you have a positive response to the nerve then the blood vessel must be vital / alive

Question 14

how would you carry out a sensibility test using ethyl chloride

Answer 14

□ Put on cotton pellet
□ Wait until it looks frosty
□ Place this on the labial third of the tooth
□ Patient indicates to you whether or not they feel cold

Question 15

how would you carry out a sensibility test using EPT

Answer 15

□ Electric machine which is used on the labial third of the patient’s tooth to stimulate an electrical impulse into the tooth
□ Patient lets you know whether they can feel that or not (Like a pulsating or tapping on the tooth)
□ Patient creates a circuit by holding onto the rod of the EPT - they let go whenever they feel something and then get reading from metre

Question 16

what is a vitality test

Answer 16

Testing if something is vital means testing whether or not it has a blood supply

Question 17

how would percussion help aid diagnosis in an intra-oral exam

Answer 17

Duller note may indicate root fracture

Question 18

what is traumatic occlusion

Answer 18

Traumatic occlusion = when a patient cannot get their teeth back together normally

Traumatic occlusion demands urgent treatment
Very uncomfortable for the patient

Usually the tooth that has been damaged / traumatised / displaced is what is propping the occlusion open

Question 19

list suitable radiographs for trauma examinations

Answer 19

intra-oral
Occlusal
OPT
Soft tissue

Question 20

what is a trauma sticker / stamp

Answer 20

Something you tend to use in clinic to help you with long term trauma monitoring - gives a list of things you want to look at / examine every time a patient comes in

Question 21

a percussion note that is different to the adjacent teeth might indicate what

Answer 21

A percussion note that is different to the adjacent teeth might indicate a root fracture or indicate problem with resorption

Question 22

what teeth should you do sensibility tests on after trauma

Answer 22

Compare injured tooth with the adjacent non-injured tooth

Always test adjacent teeth and opposing teeth in addition to those obviously injured. These teeth might have received either direct or indirect concussive injuries

Question 23

how long after the injury should sensibility tests continue to be carried out

Answer 23

Continue sensibility tests for at least 2 years after an injury
If everything is well you can discharge them from a trauma point of view

Question 24

can you make clinical judgements on sensibility tests alone

Answer 24

no

Question 25

when is classifying a fracture complicated

Answer 25

when the pulp is involved

Question 26

when is classifying a fracture not complicated

Answer 26

when the pulp is not involved

Question 27

what are the different classifications of fracture

Answer 27

``` > enamel fracture > enamel-dentine fracture > enamel-dentine-pulp fracture > uncomplicated crown root fracture > root fracture > complicated crown root fracture ```

Question 28

what can root fractures be sub-categorised into

Answer 28

apical third middle third coronal third depending on where the fracture is

Question 29

what is an uncomplicated crown root fracture

Answer 29

fracture of the enamel, dentine and on into the root but still not affecting the pulp

Question 30

what does prognosis depend on

Answer 30

• Stage of root development ○ Teeth can still be immature / developing / in a vulnerable stage ○ Stage of root development can either positively or negatively affect the prognosis • Type of injury ○ Hierarchy of mild to severe * If PDL is damaged too * Time between injury and treatment • Presence of infection ○ If there is infection there then clearly the prognosis of the tooth is not going to be as good Even if you patch everything up and everything seems well it can be a good idea to give warning signs that not everything will be 100% in terms of prognosis

Question 31

what would you do in emergency treatment of a trauma patient

Answer 31

• Aim to retain vitality of any damaged or displaced tooth by protecting exposed dentine by an adhesive 'dentine bandage' ○ This is in relation to crown fractures * Treat exposed pulp tissue * Reduction and immobilisation of displaced teeth • Tetanus prophylaxis ○ Tetanus immunisation is something most children will have received but you will want to make sure that that is up to date ○ Iif a tooth came out on a muddy rugby field and the tooth landed in a pile of mud then making sure the tetanus is up to date is important in this case ○ Check this through liaising with the GP • Antibiotics ? ○ Depending on where it has happened and what kind of injury it is use trauma guidelines

Question 32

what is included under intermediate treatment for trauma patients

Answer 32

• + / - pulp treatment ○ Does the pulp need treatment? ○ Do we need to remove the pulp? [Partial pulp removal?] • Restoration Minimally invasive eg acid etch restoration

Question 33

what is included under permanent treatments for trauma patients

Answer 33

* Apexigenesis * Apexification * Root filling + / - root extrusion * Gingival and alveolar collar modification if required * Coronal restoration

Question 34

what is apexigenesis

Answer 34

refers to a vital pulp therapy procedure performed to encourage physiological development and formation of the root end

Question 35

what is apexification

Answer 35

defined as a method to induce development of the root apex of an immature, pulpless tooth we can we fix the tooth by doing apexification which is us intervening to provide an apex for the tooth so we are able to pack other restorative materials against that to hopefully make the tooth last longer

Question 36

how do you manage an enamel fracture

Answer 36

○ Bond fragment to tooth [Not likely as it is likely to be a tiny little bit] ○ Simply grind sharp edges ○ Can put a bit of composite onto it

Question 37

how can you rule out root fracture or luxation of an enamel fracture

Answer 37

• Take 2 periapical radiographs to rule out root fracture or luxation Don’t be satisfied in assuming it is just an enamel fracture - want to be confident that there is nothing else happening the tooth

Question 38

what is the follow up period for an enamel fracture patient

Answer 38

6-8 weeks 6 months 1 year

Question 39

what is the prognosis of an enamel fracture

Answer 39

0% risk of pulp necrosis | If there are no other injuries

Question 40

how do you manage an enamel-dentine fracture

Answer 40

• Account for fragment ○ If it is on the ground or someone has binned it or whatever then that is okay as well as at least you know where it is ○ Bond fragment to tooth [Must be of a big enough size] ○ Place composite "bandage" [This is if you don’t really have time] ○ Place proper composite restoration / build-up [Line the restoration if the fracture is close to the pulp]

Question 41

what is a sign that the tooth fragment has fallen into the patient's lungs

Answer 41

be coughing and wheezing and trying to get rid of that fragment In this case would send the patient for a chest x-ray

Question 42

what do you do if you find the fragment in soft tissues

Answer 42

need to do radiograph and obviously remove it

Question 43

how do you rule out root fracture or luxation in an enamel-dentine fracture injury

Answer 43

Take 2 periapical radiographs to rule out root fracture or luxation

Question 44

what tests would you want to do on a tooth with an enamel-dentine fracture

Answer 44

Sensibility testing | evaluate tooth maturity

Question 45

what is the follow up periods for an enamel-dentine fracture injury

Answer 45

6-8 weeks 6 months 1 year

Question 46

what is the prognosis after an enamel-dentine fracture

Answer 46

5% risk of pulp necrosis at 10 years Something you want to warn parents and child about but chances are that it is going to be fine

Question 47

what should you check radiographs for after injury

Answer 47

○ Root development § Width of canal § Length of canal § Whether or not you have an apex ○ Comparison with other side ○ Internal and external inflammatory resorption § Also replacement resorption ○ Periapical pathology

Question 48

what are signs that the tooth is immature

Answer 48

The root length is short Dentine walls are very thin Wide open apex

Question 49

why is there a better chance of pulp survival in an immature tooth when compared to a mature tooth

Answer 49

> A mature tooth with a complete apex - the nerve and BV for that tooth is going into the apex at a very narrow hole > An immature tooth with a wide open apex - there are lots of nerves and BVs going into that tooth so if this tooth is displaced in any way / faces any trauma then the chances of nerves and BVs staying alive, and others regenerating through that is much higher than just having a single point of entry

Question 50

how should enamel-dentine-pulp fractures be management

Answer 50

* Evaluate exposure * Choose from the following 3 options: 1. Pulp cap 2. Partial pulpotomy (Cvek Pulpotomy) 3. Full coronal pulpotomy • Avoid full extirpation unless the tooth is clearly non-vital

Question 51

what is meant by evaluate the exposure of an enamel-dentine-pulp fracture like what sort of things are you looking at

Answer 51

○ Size of pulp exposure ○ Time since injury ○ Associated PDL injuries

Question 52

when would you choose to do a pulp cap

Answer 52

- If exposure is less than 1mm | - If injury is less than 24 hours old

Question 53

when would you choose to do a partial pulpotomy (cvek pulpotomy)

Answer 53

- If injury is more than 24 hours old even if the pulp exposure is tiny - Or if the pulp exposure is bigger than 1mm

Question 54

when would you choose to do a full coronal pulpotomy

Answer 54

- Depends on how damaged the pulp is and how long it has been since the actual injury

Question 55

why would you want to avoid full extirpation

Answer 55

Want to keep the radicular pulp / some of the pulp in the root as we want this to stay alive so we can get the development seen on the radiographs above continuing this is especially important in an immature tooth

Question 56

explain how you would do direct pulp capping

Answer 56

• Trauma sticker and radiographic assessment [Should be non-TTP and positive to sensibility tests] * LA and rubber dam * Clean area with water (or sterile saline) then disinfect area with sodium hypochlorite • Apply calcium hydroxide (Dycal) or MTA white to pulp exposure [Should be setting calcium hydroxide] • Restore tooth with quality composite restoration • Review: ○ 6-8 weeks ○ 6 months ○ 1 year

Question 57

what does MTA stand for

Answer 57

MTA = mineral trioxide aggregate

Question 58

explain how you would do partial pulpotomy

Answer 58

* Trauma sticker and radiographic assessment * LA and dental dam * Clean area with saline then disinfect area with sodium hypochlorite * Remove 2mm of pulp using high speed, round diamond bur • Place saline soaked cotton wool pellet over exposure until haemostasis is achieved {[If no bleeding or can't arrest bleeding (hyperaemic) proceed to full coronal pulpotomy because you still have infected tissue there ~ Needs to be normal tissue] • Otherwise, apply CaOH then GI (or white MTA) then restore with quality composite resin

Question 59

explain how you would do full coronal pulpotomy

Answer 59

* Begin with partial pulpotomy * Assess for haemostasis after application of saline soaked cotton-wool • If hyperaemic or necrotic then proceed to remove all of the coronal pulp [Necrotic = no blood at all] * Place calcium hydroxide in pulp chamber * Seal with GIC lining and quality coronal restoration

Question 60

what is the aim of pulpotomy

Answer 60

The aim of pulpotomy is to keep vital pulp tissue within the canal to allow normal root growth (apexogenesis) both in the length of the root and the thickness of the dentine

Question 61

what is the follow up period after a pulpotomy procedure

Answer 61

6-8 weeks 6 months 1 year

Question 62

if the tooth is non-vital what root treatment is required

Answer 62

full pulpectomy is required

Question 63

if the tooth is immature and needs root treatment what is the clinical problem

Answer 63

no apical stop to allow obturation with GP There is nothing to stop our GP points spilling out of the end so we need some kind of barrier in this area

Question 64

what options do we have for creating an apical stop

Answer 64

○ CaOH placed in canal aiming to induce hard-tissue barrier to form (apexification) ○ MTA / BioDentine placed at apex of canal to create cement barrier ○ Regenerative Endodontic Technique to encourage hard tissue formation at apex

Question 65

what is the problem with using CaOH

Answer 65

Problem with this barrier is that it is like swiss cheese - there are lots of holes in it and can take 9 months to actually form a barrier to actually pack stuff against If we leave non-setting CaOH inside a tooth for more than 4-6 weeks then it will denature all of the dentine in the root and make the tooth all dry and brittle, meaning it is likely to snap off at a crown level [Causes you to lose the elasticity within the tooth]

Question 66

what is the regenerative endodontic technique and how is it done and what are the problems

Answer 66

Still a bit experimental at the moment >Go into the tooth, >remove all the necrotic soft tissue, > sterilise the tooth by sealing in antibiotic preparations > then go back in and agitate with a file beyond the apical tissues - this then allows the canal to fill up with a big blood clot > This encourages stem cells to come from the apical area into the blood scaffold inside the tooth and the stem cells differentiate into odontoblasts to allow root development to continue Has worked in some patients In other patients, the cells have differentiated into bone cells and caused bone to be laid down resulting in the tooth needing extracted

Question 67

explain the procedure for a pulpectomy in an open apex

Answer 67

* Rubber dam * Access * Diagnostic radiograph for WL [Remember there is not actually a working length] * File 2mm short of estimated WL • Dry canal ○ Non-setting Ca(OH)2 ○ Cotton wool in pulp chamber ○ Leave this in place for around 6weeks • Glass-ionomer temporary cement in access cavity ○ Evaluate calcium hydroxide fill level with radiograph

Question 68

how long should CaO be left in a tooth

Answer 68

place CaOH for no longer than 4-6 weeks after identified as non-vital

Question 69

when is the final coronal restoration done after the pulpectomy and what material is used

Answer 69

Once obturation is complete • Consider bonded composite short way down canal as well as in access cavity [Either remove some GP from canal or don’t completely fill to top with GP] • Bonded core ○ Strengthens the tooth in that area around the cervical margin Try to avoid post crown

Question 70

what is a crown root fracture

Answer 70

Fracture of the crown of the tooth that extends beyond the gingival margin into the root

Question 71

what are the treatment options for a crown root fracture with no pulp exposure

Answer 71

* Fragment removal only and restore * Fragment removal and gingivectomy * Orthodontic extrusion to gain access to supragingival margins * Surgical extrusion * Decoronation * Extraction

Question 72

when would we decide to remove the fragment and restore the tooth

Answer 72

○ If the fracture is only subgingival we can just retract a bit of the gingiva and restore ○ If we feel we can get rubber dam in the area to isolate the tooth and get the surfaces nice and dry and clean we can just bond on a restoration

Question 73

what is meant by fragment removal and gingivectomy

Answer 73

○ Take the fragment away and remove part of the gum so we can get access to restore that area

Question 74

what is meant by orthodontic extrusion to gain access to supragingival margins

Answer 74

○ Placing a bracket and extrude the tooth down until the margin is in a better area so you can actually place a proper restoration in it

Question 75

when would you do surgical extrusion

Answer 75

○ Depending on what sort of injury the patient has had - if it has been more severe and it has affected the tooth's positioning you might consider this ○ This would be loosening the PDL and moving the tooth down and putting it in a new place - quite a severe thing to do especially if the pulp is still alive

Question 76

what is meant by decoronation

Answer 76

○ Surgically removing the crown of the tooth ○ Then bury the rest of the root ○ This is good because the root is still there even with the gingivae closed over, and if the root remains in this position then all the alveolar bone will remain in that position which is useful for future implant placement ie preserves bone for future implant

Question 77

when is a fragment removal and gingivectomy indicated

Answer 77

in crown-root fractures with palatal subgingival extension

Question 78

what are the treatment for a crown root fracture with pulp exposure

Answer 78

> can be temporised with composite for up to 2 weeks > fragment removal and gingivectomy > orthodontic extrusion to gain access to supragingival margins > surgical extrusion > decoronation > extraction

Question 79

what else might be required if you choose the orhtodontic extrusion treatment option

Answer 79

may require endodontic treatment after orthodontic extrusion and consideration of a post retained crown (want to try and avoid a post retained crown however)

Question 80

what is the difference between the treatment options for a crown root fracture with pulp exposure compared to the options for a crown root fracture without pulp exposure

Answer 80

similar options but if it involves the pulp the fracture will be worse meaning everything we do will probably involve a pulpotomy or pulpectomy