Trauma Flashcards
What is included in a trauma stamp?
EPT
Ethyl Chloride
Sinus
Colour
Percussion Sound
Mobility
TTP
Radiograph
Types of sensibility testing?
EPT - electric pulp testing which is where we use toothpaste as conducting medium, patient holds the EPT to complete the circuit and then tooth is tested
Ethyl chloride - cold stimulus applied to tooth, pt raises hand when can feel
What are the types of injury that can occur to the tooth? (7)
Enamel #
ED #
EDP #
Crown + root # - no pulpal involvement (uncomplicated)
Crown + root # with pulpal involvement (complicated)
Root # (coronal third, mid third, apical third)
Alveolar #
What are the injuries that can occur to the PDL? (6)
Concussion
Subluxation
Extrusive Luxation
Lateral Luxation
Intrusion
Avulsion
What is an enamel fracture?
This is when there is injury to the enamel only, tooth is not TTP, normal mobility, positive pulp testing, no exposure of dentine
What radiographs for enamel fracture?
PA - to rule out luxation or root fracture
Why do we take a PA for enamel fracture?
To rule out luxation or root fracture
What is the tx for enamel fracture?
- Do nothing
- Smooth over any sharp edges if small
- Flowable/regular comp resin to restore
- bond fragment back - may be difficult due to being small
What is the follow up protocol for enamel fracture?
6-8 weeks
1 year
What are favourable outcomes for enamel fracture?
Tooth stays asymptomatic, vital, cont root development, positive sensibility testing
What are the unfavourable outcomes for enamel fracture?
tooth becomes symptomatic, loss of vitality, necrosis and infection, loss of restoration, lack of continued root development
What is an enamel dentine fracture?
This is when both the enamel and dentine has been lost resulting in exposed dentine
Normal mobility, tooth not TTP, positive response to sensibility testing, tooth may be sensitive
Radiographs for ED #?
PA - to rule of luxation injury or root fracture
always account for missing fragment - if missing can do soft tissue radiograph
Tx for ED #?
- Rebond fragment (soak in water first for 20 mins)
- GIC or DBA over dentine then restore with comp
- if in close proximity with the pulp - indirect pulp cap (setting calcium hydroxide and GIC to restore)
If enamel dentine fracture is within close proximity to the pulp what do we do?
Indirect pulp cap
setting calcium hydroxide –> GIC –> restore
Review period for ED #?
6-8 weeks
6 months
1 year
Favourable outcomes for ED #? (4)
cont root development
asymptomatic
pos response to sensibility testing
good restoration, long lasting
Unfavourable outcomes for ED #
Root development to continued
necrosis + infection
symptomatic
apical periodontitis
What is an EDP #?
This is where there is loss of enamel and dentine and also a pulp exposure
normal mobility, not TTP, the exposed pulp can be sensitive to external stimuli
What radiographs for EDP#?
Parallel PA
What is the tx for EDP in developing teeth, open apex
PARTIAL PULPOTOMY, FULL PULPTOMY OR PULP CAP
What is the tx for EDP in adult, mature teeth?
Partial/full pulpotomy recommended in closed apex cases
Describe tx for EDP#
If exposure <1mm and within 24hrs a DIRECT PULP CAP can be done, this is where setting calcium hydroxide or MTA is applied followed by GIC and then the tooth is restored - not advised in adult, closed apex teeth
If exposure >1mm or >24 hrs = PARTIAL PULPOTOMY - this is where we remove the damaged, unhealthy pulp tissue (2mm) and leave the remaining healthy coronal pulp tissue in order to inc the change of the tooth healing and ensuring development continues
after 2mm of removal then use CW pellet soaked in saline and apply pressure until HA –> if no bleeding or bleeding won’t stop then proceed for PULPTOMY which is removal of the full coronal pulo
after this you then want to apply dycal/White MTA and then restore
If NV –> pulpectomy
Must monitor tooth response and warn pt it may become non-vital which is where there is loss of blood supply to the tooth and as a result tooth would need RCT
What are the review periods for EDP #?
6-8 weeks
3 months
6 months
1 year
Favourable outcomes for EDP # (4)
Tooth asymptomatic
Cont root development
positive response to sensibility testing
good restoration
Unfavourable outcomes for EDP# (5)
symptomatic
failure for root development to continue
neg response to sensibility testing
necrosis and infection
breakdown of resto
When is pulp cap used?
<1mm exposure, in 24hr window
What does pulp cap do?
Stimulates the pulp cells to lay down dentine and acts as a seal to protect the pulp
we use dycal (non setting calcium hydroxide), or white MTA
How to carry out a pulp cap?
- trauma sticker
- tooth must be non TTP and positive to sensibility testing
- LA –> Dam
- Irrigate with water and sodium hypochlorite
- Non setting CaOH, GIC
- Restore
When do we do a partial pulpotomy?
when pulp exposure >1mm, injury more than 24hrs ago
What is the aim of a partial pulpotomy?
it is where we remove 2mm of coronal pulp - more conservative, retains cell rich coronal pulp
How do we do a partial pulpotomy?
Trauma sticker
LA + Dam
Clean with saline, disinfect with sodium hypochlorite
Remove 2mm of coronal pulp with round diamond bur
place saline soaked CW pellet over until HA
If no bleeding tooth in necrotic and therefore pulpotomy required
if Haemostasis cant be achieved in 5 mins then full coronal pulpotomy required
What does a partial pulpotomy do?
Protects radicular pulp
aids healing and maintains dentine deposition in coronal area
What is a coronal pulpotomy?
This is where full coronal pulp is removed - radicular pulp left behind
eradicated all inflammatory pulp tissue
is done when H can be achieved or no bleeding
How to do coronal pulpotomy?
Trauma sticker
LA + Dam
Clean with saline, disinfect with sodium hypochlorite
Remove coronal pulp with round diamond bur
place saline soaked CW pellet over until HA
CaOH/white MTA, seal with GIC
Restore
What is an uncomplicated crown root #?
This is where the crown and root has fractured however no pulp exposure
the pulp testing is normally positive
Coronal/M/D fragment present and mobile
need to check if fracture is sub or supra alveolar
Radiographs for uncomplicated crown root #
Parallel PA
Occlusal
this is so we can see the extent of the fracture
What is the tx for uncomplicated crown root fracture?
We want to stabilise the loose fragment to adjacent tooth/ or to non mobile fragment
we then have the following options:
- remove coronal/mobile fragment and restore - DBA over exposed dentine
- fragment removal + gingivectomy
- orthodox extrusion and restore
- surgical extrusion
- decoration for preservation of bone for future implant
- xla
Clinical follow up for uncomplicated crown root fracture?
1 week
6-8 weeks
3 months
6 months
1 year
yearly for 5 years
Favourable outcomes for uncomplicated crown root fractures (4)
asymptomatic
cont root development
positive response to sensibility testing
good restoration
Unfavourable outcomes for uncomplicated crown root fractures? (5)
symptomatic
failure of cont root development
infection and necrosis
discoloured
loss/breakdown of restoration
What is a complicated crown root fracture?
this is where there is fracture of the crown and the root, with exposure of the pulp
pul testing usually positive
tooth tap
coronal/m/d fragment present and mobile
What radiographs for complicated crown root fracture?
parallel PA
Occlusal
to assess extent of fracture as usually cant see due to being sub gingival
What is the tx for complicated crown root fractures?
Temp - stabilise to non mobile adjacent teeth/fragment
in IMMATURE TEETH, OPEN APEX - partial pulpotomy, non setting caoh
in mature teeth, closed apex - pulp extirpate and cover exposed dentine with DBA and GIC then comp
FUTURE TX:
1. RCT and restore
2. Ortho extrusion
3. Surgical extrusion
4. Decoronation
5. XLa
Clinical follow up for complicated crown root fractures?
1 week
6-8 weeks
3 months
6 months
1 year
yearly for 5
Favourable outcomes for complicated crown root fractures (4)
asymptomatic
cont root development
positive response to sensibility testing
good restoration
Unfavourable outcomes for complicated crown root fractures (4)
symptomatic
failure of cont root development
infection and necrosis
discoloured
loss/breakdown of restoration
What is a root fracture?
This is where the root has fractured
Can be in coronal 1/3rd, middle 1/3rd or apical 1/3rd
Its location depends on the prognosis of the tooth
What does displaced/undisplaced mean in terms of root fracture?
Displaced = fragments are apart
Undisplaced = edges are together
What are the clinical findings of a root fracture?
The coronal segment may be mobile/displaced
tooth may be TTP
bleeding from gingival sulcus
response to sensibility testing can either be positive or negative
Describe prognosis for each type of root fracture
APICAL - best prognosis esp if no displacement, hard to see
MIDDLE - if displaced MUST reduce fracture
CORONAL - poor proboscis as little PDL to keep crown in position, very mobile, unfavourable crown to root ratio
Imaging for root fracture?
PA
Occlusal
What is the tx for a root fracture?
- If displaced, coronal fragment must be repositioned asap and checked via radiograph
- Clean area with saline/water/CHX
- reposition tooth with pressure
- then provide a flexible passive splint for 4 weeks (if cervicle fracture can splint for up to 4 months
- if pain –> LA
What is the post op advice following root fracture?
Soft diet - 1 week
Good OHI
In mature teeth if the cervicle fracture is above the alveolar crest and coronal aspect very mobile what can we do?
Remove the mobile fragment
RCT
Post and crown
What is the follow up for root #?
4 weeks –> removal of splint unless coronal and 4 months
6-8 weeks
4 months
6 months
1 year
yearly for 5
What are favourable outcomes for root #?
signs of fracture repair
positive response to pulp testing (may get false neg for several months)
normal/slight mobility
What are the healing outcomes for root #?
calcified tissue union - this is the best type of healing and is where dentine like material deposition occurs, hart to see # line
CT union: this is where fracture line is fuzzy, edges of fracture line known as eburnation which is where osteoblasts have nibbled edges of fracture line
Calcified and CT healing
Bone and osseous healing - this is where the diff segments become two unique entities with separate PDL
Unfavourable outcomes for root #? (5)
symptomatic
extrusion
excessive mobility
radiolucency at fracture line
necrosis + infection
What is an alveolar fracture?
This is where there is complete fracture of the alveolus - extends buccal to palatal bone
there is segment mobility, several teeth move, occlusal disturbances and neg response to pulp testing
Imaging for alveolar fracture?
Parallel PA
2x other angles
OPT
CBCT
What is the tx for alveolar fracture?
- reposition displaced segments
- apply passive flexible splint for 4 weeks
- suture any gingival lacerations
- monitor pulp, no RCT at emergency appt
Follow up for alveolar fracture?
4 weeks
6-8 weeks
4 months
6 months
1 year
Yearly for 5 years
What is a concussion injury?
This is where there is an injury to the tooth supporting structures without inc mobility or displacement
Tooth may be TTP
What is a subluxation injury?
Injury to tooth supporting structures, can be inc mobility, TTP and gingival bleeding but no displacement
What is extrusive luxation injury?
This is where there is injury to tooth with partial or total separation of the PDL - the tooth appears elongated, has excessive mobility and negative response to sensibility testing likely
What is lateral luxation?
Displacement of tooth in palatal/lingual/labial direction - there is crush and tear injuries to the PDL
tooth is immobile
percussion = high pitched ankolytic sound
communication/fracture of labial/palatal/lingual bone
What is intrusion?
This is where tooth is driven into alveolar process due to impact
Tooth is immobile, ankolytic
crush injury to the PDL
negative response to sensibility testing
What are the radiographic findings of a concussion injury
Usually none
is where there is damage to tooth supporting structures without any inc mobility or displacement bit tooth can be TTP
What tx is required for a concussion injury?
None but pulp is monitored for 1 year
What is the follow up for concussion injury?
4 weeks
6-8 weeks
1 year
What are favourable outcomes for concussion injury?
Asymptomatic
pos response to sensibility testing
cont root development
intact LD
What is an unfavourable outcome for concussion injury? (3)
Tooth becomes symptomatic
neg response to testing
no cont root development
apical periodontitis
What are the radiographic findings of subluxation injury?
usually none
this is where there is injury to tooth supporting structures - there is no displacement but tooth is TTP, inc mobility and gingival bleeding
Tx for subluxation?
Usually none
but if pt discomfort then can put passive flexible splint for 2 weeks
soft diet for 2 weeks
What is the follow up for subluxation?
2 weeks if splint
4 weeks
6-8 weeks
6 months
1 year
What are favourable outcomes for subluxation injury?
Asymptomatic
pos response to sensibility testing
cont root development
intact LD
What are the unfavourable outcomes for subluxation injury?
Tooth becomes symptomatic
Neg response to testing
No cont root development
Apical periodontitis
What are the radiographic findings of extrusive luxation?
widening of PDL apically
this is where there is injury to the tooth with total or partial separation of PDL, tooth is elongated, excess mobility, neg testing likely
What is the tx for extrusive luxation injury?
LA
Reposition with gentle pressure (LA buccal and palatal)
flexible splint, passive for 2 weeks
if tooth has closed apex, mature then pulp necrosis likely and will require RCT
What tends to happen in extrusive luxation injuries in closed apex, mature teeth?
Tooth will become necrosed and will require RCT
What is the follow up for extrusive luxation injuries?
2 weeks
4 weeks
6-8 weeks
6 months
1 year
yearly for 5
What are favourable outcomes for extrusive luxation injuries? 4
Asymptomatic
Normal/heaed periodontium
pos respinse to sensibility testing
cont root development
What are the unfavourable outcomes for extrusive luxation injuries? 4
symptomatic
apical periodontitis
negative testing
root resorption
What is lateral luxation radiographic findings?
widened PDL
this is where there is injury to the tooth where it is displaced laterally (Palatal, lingual,labial) and there are crush and tear injuries to PDL, tooth becomes immobile, percussion is ankolytic sounding, communication/fracture with bone
What is tx for lateral luxation?
reposition under LA with fingers/forceps
stabilise with flexible passive splint for 4 weeks and monitor pulp for signs of necrosis –> would require RCT
What is follow up for lateral luxation?
2 weeks
4 weeks
6-8 weeks
6 months
1 year
yearly for 5
What are the radiographic findings for intrusion injuries?
PDL space absent, ACJ is apical in this tooth as tooth has been driven inwards
This is where the tooth is driven into the alveolar process, has become immobile, ankolytic sound, crush injury to PDL, negative testing
What is tx for intrusion injury in open apex tooth?
if intruded up to 2mm = spontaneous eruption (however if non in 2-3 weeks ortho or surgical)
if >7mm then either ortho or surgical extrusion
What is tx for intrusion injury in closed apex tooth?
if < or equal to 3mm then spontaneous eruption (if no movement in 2/4 weeks then ortho/surgical)
3-7mm = ortho
> 7mm = surgical
THEN ROOT TREAT 2-3 WEEKS POST REPOSITION AND SPLINT FOR 4 WEEKS
Follow up for intrusion?
2 weeks
4 weeks for splint
6 months
1 year
5 yearly
What is avulsion?
This is where the tooth has been knocked out of the socket
First aid advice for avulsion
- keep pt calm
- find out if baby or adult tooth - dont reimplant primary tooth but permeant tooth reimplanted asap
- pick tooth up by the crown (white part that you can see - avoid touching root which is what sits under the gum
- if any debris, plug in sink and rinse under cold water for no more than 10s
- if possible reinsert the tooth and bite on tissue, if not then come see us asap
- if cant reimplant then place tooth in appropriate medium such as cold milk, saliva, blood, saline
SEEK EMERGENCY DENTAL TX
What does tx of avulsion depend on?
maturity of tooth (open/closed apex)
condition of PDL cells (storage medium used, EAT - time that the tooth is out of the mouth and in storage medium)
In immature tooth if EAT is <60 mins what do we do?
IF ALREADY REIMPLANTED:
- leave in situ, clean with saline/CHX
-suture any lacerations
-verify tooth position clinically and radiographically
-flexible splint for 2 weeks
-consider ABX and tetanus
-monitor for revasulcarisation, cont root development (root length inc, apex closing over, asymptomatic)
IF NOT IMPLANTED BY TIME IN SURGERY:
-if contaminated clean with saline
-LA and examine socket, remove any coagulum
-reimplant tooth with digital pressure and PA to verify position
-splint 2 weeks
In immature teeth what do we do if the EAT>60 minutes?
need to discuss with pt that this tooth has a poor prognosis, the PDL cells have likely died and unlikely to heal
The goal now is to restore tooth for aesthetics and function - will likely require RCT in near future
- remove attached NV soft tissue
- LA and examine socket
- Reimplant
- Splint 4 weeks
What do we do in mature teeth when EAT <60 mins
If tooth already in situ then verify position clinically and radiographically, splint for 2 weeks and then extirpate between 0-10 days and then RCT
if tooth in storage medium:
1. clean root surface
2. LA and irrigate
3. Re-implant
4. flexinle passibe splint 2 weeks
5. initiate RCT 7-10 days post tx but can do on day 0
5. for endo inter canal medicament 2 weeks, non setting calcium hydroxide 4-6 weeks and obturate within 4-6 weeks
What do we do in mature teeth when EAT >60 mins?
Discussion with pt, PDL cells damaged and healing unlikely, prognosis is poor, RCT needed
- scrub tooth pf PDL cells as now non-viable
- Endo pre/posy implant
- reposition clinically and radiographically
4 weeks flexile splint
endo tx - corticosteroid 2 weeks, non setting caoh 4 weeks and then obturate
How long to leave inter canal steroid medicament?
2 weeks - risk of discolouration
non setting calcium hydroxide - 4-6 weeks
obturate within 4-6 weeks
What are the favourable outcomes for open apex tooth?
asymptomatic
normal mobility
not ttp
cont root development
no root resorption
What healing do we aim for if EAT <60 mins
cemental/PDL healing
What healing do we aim for if EAT >60 mins
PDL healing unlikely to occur
What are unfavourable outcomes for open apex tooth?
Symptomatic
TTP
lack of root dev
resorption
infection and necrosis
What is the splinting protocol for subluxation?
2 weeks passive, flexible splint
Splinting protocol for extrusive luxation?
2 weeks
SPliting protocol for avulsion?
2 weeks if eat <60 mins
4 weeks if eat > 60 mins
Spliting protocol forr root fracture?
4 weeks
Spliting protocol for lateral luxation?
4 WEEKS
Splinting protocol for alveolar fracture?
4 weeks
Splinting protocol for intrusion?
4 weeks
