Trauma 1 Flashcards
when is peak period for trauma to permanent teeth
7-10 years
when would you expect the apex of an upper central incisor to be closing
9-9.5 years
when is trauma most common
children with a large overjet
if over jet is greater than 9mm then the incidence to trauma is double
what causes trauma
○ Falls
○ Bike, skateboard, road traffic accidents
○ Sport
○ Fights
what questions should be asked when taking a detailed history
• 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
what things in a medical history do we need to be aware of that might influence dental treatment
○ 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
what should be included in the extra-oral examination
○ 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
what is included in the intra oral examination
look at / examine: ○ Soft tissue ~ any lacerations or tears ○ Alveolar bone ~ Feel for any steps, displacement, mobility ○ Occlusion ○ Teeth
where should you check for foreign bodies
- 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
when carrying out a tactile test with probe, what are you looking for?
○ Fracture lines
§ Horizontal or vertical
§ (transillumination from curing light can help)
○ Pulpal involvement
what can tooth mobility indicate
- 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)
name sensibility tests
○ Thermal
§ Ethyl chloride (ECL)
§ Warm gutta-percha
○ Electrical
§ Electric pulp tester (EPT)
why would you carry out sensibility tests?
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
how would you carry out a sensibility test using ethyl chloride
□ 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
how would you carry out a sensibility test using EPT
□ 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
what is a vitality test
Testing if something is vital means testing whether or not it has a blood supply
how would percussion help aid diagnosis in an intra-oral exam
Duller note may indicate root fracture
what is traumatic occlusion
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
list suitable radiographs for trauma examinations
intra-oral
Occlusal
OPT
Soft tissue
what is a trauma sticker / stamp
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
a percussion note that is different to the adjacent teeth might indicate what
A percussion note that is different to the adjacent teeth might indicate a root fracture or indicate problem with resorption
what teeth should you do sensibility tests on after trauma
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
how long after the injury should sensibility tests continue to be carried out
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
can you make clinical judgements on sensibility tests alone
no
when is classifying a fracture complicated
when the pulp is involved
when is classifying a fracture not complicated
when the pulp is not involved
what are the different classifications of fracture
> enamel fracture > enamel-dentine fracture > enamel-dentine-pulp fracture > uncomplicated crown root fracture > root fracture > complicated crown root fracture
what can root fractures be sub-categorised into
apical third
middle third
coronal third
depending on where the fracture is
what is an uncomplicated crown root fracture
fracture of the enamel, dentine and on into the root but still not affecting the pulp
what does prognosis depend on
• 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
what would you do in emergency treatment of a trauma patient
• 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
what is included under intermediate treatment for trauma patients
• + / - pulp treatment
○ Does the pulp need treatment?
○ Do we need to remove the pulp? [Partial pulp removal?]
• Restoration
Minimally invasive eg acid etch restoration
what is included under permanent treatments for trauma patients
- Apexigenesis
- Apexification
- Root filling + / - root extrusion
- Gingival and alveolar collar modification if required
- Coronal restoration
what is apexigenesis
refers to a vital pulp therapy procedure performed to encourage physiological development and formation of the root end
what is apexification
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
how do you manage an enamel fracture
○ 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
how can you rule out root fracture or luxation of an enamel fracture
• 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
what is the follow up period for an enamel fracture patient
6-8 weeks
6 months
1 year
what is the prognosis of an enamel fracture
0% risk of pulp necrosis
If there are no other injuries
how do you manage an enamel-dentine fracture
• 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]
what is a sign that the tooth fragment has fallen into the patient’s lungs
be coughing and wheezing and trying to get rid of that fragment
In this case would send the patient for a chest x-ray
what do you do if you find the fragment in soft tissues
need to do radiograph and obviously remove it
how do you rule out root fracture or luxation in an enamel-dentine fracture injury
Take 2 periapical radiographs to rule out root fracture or luxation
what tests would you want to do on a tooth with an enamel-dentine fracture
Sensibility testing
evaluate tooth maturity
what is the follow up periods for an enamel-dentine fracture injury
6-8 weeks
6 months
1 year
what is the prognosis after an enamel-dentine fracture
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
what should you check radiographs for after injury
○ 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
what are signs that the tooth is immature
The root length is short
Dentine walls are very thin
Wide open apex
why is there a better chance of pulp survival in an immature tooth when compared to a mature tooth
> 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
how should enamel-dentine-pulp fractures be management
- Evaluate exposure
- Choose from the following 3 options:
- Pulp cap
- Partial pulpotomy (Cvek Pulpotomy)
- Full coronal pulpotomy
• Avoid full extirpation unless the tooth is clearly non-vital
what is meant by evaluate the exposure of an enamel-dentine-pulp fracture like what sort of things are you looking at
○ Size of pulp exposure
○ Time since injury
○ Associated PDL injuries
when would you choose to do a pulp cap
- If exposure is less than 1mm
- If injury is less than 24 hours old
when would you choose to do a partial pulpotomy (cvek pulpotomy)
- If injury is more than 24 hours old even if the pulp exposure is tiny
- Or if the pulp exposure is bigger than 1mm
when would you choose to do a full coronal pulpotomy
- Depends on how damaged the pulp is and how long it has been since the actual injury
why would you want to avoid full extirpation
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
explain how you would do direct pulp capping
• 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
what does MTA stand for
MTA = mineral trioxide aggregate
explain how you would do partial pulpotomy
- 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
explain how you would do full coronal pulpotomy
- 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
what is the aim of pulpotomy
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
what is the follow up period after a pulpotomy procedure
6-8 weeks
6 months
1 year
if the tooth is non-vital what root treatment is required
full pulpectomy is required
if the tooth is immature and needs root treatment what is the clinical problem
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
what options do we have for creating an apical stop
○ 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
what is the problem with using CaOH
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]
what is the regenerative endodontic technique and how is it done and what are the problems
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
explain the procedure for a pulpectomy in an open apex
- 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
how long should CaO be left in a tooth
place CaOH for no longer than 4-6 weeks after identified as non-vital
when is the final coronal restoration done after the pulpectomy and what material is used
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
what is a crown root fracture
Fracture of the crown of the tooth that extends beyond the gingival margin into the root
what are the treatment options for a crown root fracture with no pulp exposure
- Fragment removal only and restore
- Fragment removal and gingivectomy
- Orthodontic extrusion to gain access to supragingival margins
- Surgical extrusion
- Decoronation
- Extraction
when would we decide to remove the fragment and restore the tooth
○ 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
what is meant by fragment removal and gingivectomy
○ Take the fragment away and remove part of the gum so we can get access to restore that area
what is meant by orthodontic extrusion to gain access to supragingival margins
○ 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
when would you do surgical extrusion
○ 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
what is meant by decoronation
○ 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
when is a fragment removal and gingivectomy indicated
in crown-root fractures with palatal subgingival extension
what are the treatment for a crown root fracture with pulp exposure
> 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
what else might be required if you choose the orhtodontic extrusion treatment option
may require endodontic treatment after orthodontic extrusion and consideration of a post retained crown
(want to try and avoid a post retained crown however)
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
similar options
but if it involves the pulp the fracture will be worse meaning everything we do will probably involve a pulpotomy or pulpectomy
