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BDS3 Paediatric Dentistry > Trauma I > Flashcards

Trauma I Flashcards

1
Q

What % of all school children experience dental trauma?

A

25%

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2
Q

What % of adults experience trauma in the permanent dentition?

A

33% - mostly before 19yrs of age

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3
Q

What is the ratio of boys to girls who experience dental trauma?

A

3:1

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4
Q

What % of dental trauma is not treated?

A

70%

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5
Q

What is the most common injury in the primary dentition?

A

Luxation injury (this is because the bone is really soft in younger children and the teeth tend to move within the bone)

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6
Q

What is the most common injury in the permanent dentition?

A

Enamel-dentine fracture

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7
Q

What is the peak period of trauma to the permanent dentition?

A
  • Peak period 7-10 years
  • This is very significant because at this stage the teeth are really immature
  • Wouldn’t expect the apex of an upper central incisor to be closing until about 9-9.5 years
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8
Q

When is trauma more common in the permanent dentition?

A
  • If the patient has a large overjet

- OJ> 9mm doubles the incidence

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9
Q

What % of dental trauma is cased by falls?

A

50%

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10
Q

What % of dental trauma is cased by bikes, skateboards or road traffic accidents?

A

17%-35%

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11
Q

What % of dental trauma is cased by sport?

A

14%-25%

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12
Q

What % of dental trauma is cased by fights?

A

3%

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13
Q

When taking a detailed history, what questions do we want to know the answers to? (4)

A
  • How did it happen?
  • When did it happen exactly?
  • Where are the lost teeth/fragments?
  • Any other symptoms
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14
Q

It is important to identify if any aspects of MH may influence treatment options. Which medical conditions should we be aware of? (3)

A

Be aware of:

  • Rheumatic fever
  • Congenital heart defects
  • Immunosuppression

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

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15
Q

In an extra-oral exam for trauma what are we looking for? (6)

A
  • Laceration (or tears in the soft tissue)
  • Haematomas
  • Haemorrhage/ Cerebral spinal fluid (if CSF leak then injury is very serious)
  • Subconjunctival haemorrhage (so want to look at patient’s eyes)
  • Bony step deformities (want to rule out any facial or jaw fractures)
  • Mouth opening
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16
Q

In an intra-oral exam for trauma what are we looking at? (4)

A
  • Soft tissue
  • Alveolar bone
  • Occlusion (are they biting the way that they normally bite?
  • Teeth
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17
Q

What do we need to look at to ensure they have no foreign bodies? (3)

A
  • Check for soft tissue damage
  • Penetrating wounds, foreign bodies
  • Soft tissue radiograph to check lacerations

Check if fragment has broken off and check where it is
- If there is soft tissue damage then there is a possibility that the bone fragment is in the soft tissue or any other foreign bodies e.g. glass

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18
Q

What might tooth mobility indicate? (3)

A
  • Displacement of tooth
  • Root fracture
  • Bone fracture (if there is a bone fracture then it is unlikely to be only 1 mobile tooth - likely to be several teeth on a segment of bone that are moving)
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19
Q

If there is tooth mobility we would do a tactile test with a probe. What are we looking for? (2)

A
  • Fracture lines - horizontal or vertical (transillumination can help)
  • Pulpal involvement
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20
Q

What are possible special tests we wold use for our detailed intra-oral examination? (5)

A

Sensibility tests (testing the nerve of the tooth)

  • Thermal: ethyl chloride or warm GP
  • Electrical: electric pulp tester (EPT)

Percussion:

  • Duller note may indicate root fracture
  • It is also a test we do further down the line to detect whether or not there is replacement resorption

Occlusion:
- Traumatic occlusion demands urgent treatment (traumatic occlusion is when a patient can’t get their teeth back together normally)

Radiographs:
- Intra-oral, occlusal, OPT, soft tissue

Classify the trauma:

  • Work out what is wring and label it
  • Give a proper diagnosis
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21
Q

What is included within a trauma sticker? (we use this in clinic for long term trauma monitoring) (8)

A
  • Sinus
  • Colour
  • TTP
  • Mobility
  • EPT
  • ECL
  • Percussion note
  • Radiograph
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22
Q

When taking sensibility tests of a traumatised tooth what should we compare it to?

A
  • Compare injured tooth with the adjacent non-injured tooth
  • This applies to both sensibility tests and when viewing root surface on radiographs
  • Always test adjacent teeth and opposing teeth in addition to those obviously injured. These teeth must have received either direct or indirect concussive injuries
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23
Q

For how long after injury should we continue sensibility tests for?

A
  • At least 2 years

- Never make clinical judgements on sensibility tests alone

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24
Q

What are the different classifications of crown and root fractures? (6)

A
  • Enamel fracture
  • Enamel dentine fracture
  • Enamel dentine pulp fracture
  • Uncomplicated crown root fracture
  • Complicated crown root fracture
  • Root fracture
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25
Q

What is a complicated crown root fracture?

A
  • Into the root and affecting the pulp
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26
Q

What is an uncomplicated crown root fracture?

A
  • Into the root but not affecting the pulp
27
Q

What are the subcategories of root fractures? (3)

A
  • Apical third
  • Middle third
  • Coronal third
28
Q

What does the prognosis of dental trauma depend on? (5)

A
  • Stage of root development
  • Type of injury (mild to severe)
  • If PDL is damaged too
  • Time between injury and treatment
  • Presence of infection
29
Q

What is the emergency treatment that may need to be provided for dental trauma? (5)

A
  • 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 (consider if this is needed)
  • Antibiotics? (depending on where it has happened and what kind of injury it is)
30
Q

What is the ‘immediate’ treatment that may need to be provided for dental trauma? (2)

A
  • +/- pulp treatment

- Restoration - minimally invasive e.g. acid etch restoration

31
Q

What is the ‘permanent’ treatment that may need to be provided for dental trauma? (5)

A
  • Apexigenesis (has this occurred? - this is the normal biological process of the tooth maturing and the dentine wall thickening and the root extending and forming an apex)
  • Apexification (this is us intervening to produce an apex for the tooth
  • Root filling +/- root extrusion
  • Gingival and alveolar collar modification if required
  • Coronal restoration
32
Q

How would we manage an enamel fracture?

A
  • Either: bond fragment of tooth (not likely as fragment is probably going to be too small) or simply grind the sharp edges or can put a bit of composite onto it ->
  • Take 2 periapical radiographs to rule out root fracture or luxation ->
  • Follow up: 6-8wks then 6 months then 1 year
33
Q

What is the likely prognosis of a tooth with an enamel fracture in relation to pulpal necrosis?

A
  • 0% risk of pulp necrosis
34
Q

How would we manage an enamel-dentine fracture? (7)

A
  • Account for fragment ->
  • Either - bond fragment to tooth or place composite bandage (line restoration if the fracture is close to the pulp) ->
  • Take 2 periapical radiographs to rule out root fracture or luxation ->
  • Radiograph any lip or cheek lacerations to rule out embedded fragment ->
  • Sensibility testing and evaluate tooth maturity ->
  • Definitive restoration ->
  • Follow-up: at 6-8wks, 6 months and 1 year
35
Q

What is the likely prognosis of a tooth with an enamel-dentine fracture in relation to pulpal necrosis?

A

5% risk of pulp necrosis at 10 years (something that you want to warn the patient and parent about)

36
Q

When doing follow up of a patient with dental trauma, what are we looking for in the radiographs? (3)

A
  • Root development - width of canal and length (as well as the apex)
  • Comparison with other side
  • Internal + external inflammatory resorption
  • Periapical pathology
37
Q

Are chances of pulpal survival better in teeth with immature or mature apexes?

A

Immature

38
Q

How would we manage enamel-dentine-pulp fractures?

A

Evaluate exposure:

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

Then choose from the following 3 options:
- Pulp cap: if exposure is less than 1mm in size an is less than 24 hrs old
- Partial pulpotomy: if the pulp exposure is more than 24hrs old even if it is tiny or if it is greater than 1mm
Full coronal pulpotomy: depending on how damaged the pulp is or how long it has been since injury

Avoid full extirpation unless the tooth is clearly non-vital (want some of the pulp to stay alive - especially in immature teeth so that development can continue)

39
Q

Explain the process of giving a direct pulp cap on a small exposure (1mm) within the 24 hour window?

A
  • Trauma sticker and radiographic assessment (should be non-TTP and positive to sensibility tests) ->
  • LA and rubber dam
  • Clean area with water then disinfect area with sodium hypochlorite ->
  • Apply calcium hydroxide (Dycal) or MTA (mineral trioxide aggregate) white to pulp exposure ->
  • Restore tooth with quality composite restoration ->
  • Review at 6-8wks, 6 months and 1 year
40
Q

When would you give a partial pulpotomy due to dental trauma?

A
  • When there has been a larger exposure (>1mm) or 24+ hours since trauma
41
Q

Explain the process of giving a partial pulpotomy due to dental trauma?

A
  • Trauma sticker and radiographic assessment
  • LA and rubber dam
  • Clean area with water then disinfect area with sodium hypochlorite
  • Remove 2mm of pulp with hi-speed, round diamond bur
  • Place saline soaked cotton wool pellet over exposure until haemostasis achieved (if no bleeding or can’t arrest bleeding proceed to full coronal pulpotomy)
  • Apply CaOH then Vitrebond (or white MTA) then restore with quality composite resin
42
Q

How would we carry out a full coronal pulpotomy due to dental trauma? (5)

A
  • Begin with partial pulpotomy
  • Assess for haemostasis after application of saline soaked cotton wool
  • If hyperaemic OR necrotic -> proceed to remove ALL of the coronal pulp
  • Place calcium hydroxide in pulp chamber
  • Seal with GIC lining and quality coronal restoration
43
Q

What is the success rate of a partial pulpotomy?

A

97% success

44
Q

What is the success rate for a full coronal pulpotomy?

A

75% success

45
Q

What is the aim of a pulpotomy?

A

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

46
Q

How would we root treat an immature incisor if the tooth was non-vital?

A
  • Full pulpectomy is required
47
Q

If the apex of an immature incisor is open the clinical problem is the need to have an apical stop to allow obturation with GP if doing a full pulpectomy. How can this be achieved? (3)

A
  • CaOH placed in canal aiming to induce hard tissue barrier to form (apexification)
  • or MTA/BioDentine placed at apex of canal to create cement barrier
  • Or regenerative Endodontic technique to encourage hard tissue formation at apex
48
Q

How would you carry out a pulpectomy on a tooth with an open apex?

A
  • Rubber dam
  • Access
  • Haemorrhage control - LA/sterile water
  • Diagnostic radiograph for WL
  • File 2mm short of estimated WL
  • Dry canal, non-setting Ca(OH)2, CW in pulp chamber
  • GI temporary cement in access cavity and evaluate calcium hydroxide fill level with radiograph
49
Q

Final coronal restoration slide? (4)

A
  • Once obturation complete
  • Consider bonded composite short way down canal as well as in access cavity
  • Bonded core
  • Try to avoid post crown
50
Q

What are the possible treatment options for a crown-root fracture with NO pulp exposure? (6)

A
  • Fragment removal only and restore
  • Fragment removal & gingivectomy (indicated in crown-root fractures with palatal subgingival extension)
  • Orthodontic extrusion of apical portion (1. endo 2. extrusion 3. post-crown)
  • Surgical extrusion
  • Decoronation (preserve bone for future implant)
  • Extraction
51
Q

What are the treatment options for a crown-root fracture WITH pulp exposure? (6)

A
  • Can be temporised with composite for up to 2wks
  • Fragment removal and gingivectomy (indicated in crown-root fractures with palatal subgingival extension)
  • Orthodontic extrusion of apical portion (1. endo 2. extrusion 3. post-crown)
  • Surgical extrusion
  • Decoronation (preserve bone for future implant)
52
Q

What is the clinical problem with doing a full pulpotomy in an immature tooth?

A

You then don’t have an apical barrier to pack your GP against

53
Q

Why is setting calcium hydroxide not great for using as an apical barrier?

A
  • It has lots of holes in it and it takes about 9 months to form the barrier
54
Q

Why do we now prefer to use some sort of cement e.g. MTA/biodentine as an apical barrier instead of setting calcium hydroxide?

A

It is an immediate barrier

55
Q

Regenerative endodontic techniques are still a bit experimental. What is this?

A
  • This is where you would go into the tooth, remove all of the necrotic soft tissue
  • You would sterilise the tooth by sealing in different antibiotic preparations and then go back in with a file and agitate beyond the apical tissues
  • This allows the canal to fill up with a blood clot and what hopefully happens is that stem cells come from the apical area and they come into the blood scaffold inside the tooth and the stem cells differentiate into odontoblasts and then root development can continue
56
Q

When placing setting calcium hydroxide into an immature tooth with an open apex, how long should we leave it for?

A
  • Leave in for 4-6 weeks (no longer)
57
Q

When doing a pulpectomy on a tooth with an open apex, what is the best practice? (2)

A
  • Extirpate pulp and place CaOH for no longer than 4-6 weeks after identified as non-vital
  • MTA plug and heated GP obturation
58
Q

Why do we use heated GP when filling immature teeth with open apices?

A
  • These immature teeth have large canals so they are not canals that a normal GP cone would fit so what we have is a cylinder of GP that goes into a gun and we heat it up to about 173 degrees then pump it into the area
59
Q

How do we place MTA?

A
  • Using MTA carriers

- They are disposable

60
Q

Why do we use MTA angelus a lot more now?

A
  • AS it sets in 15 mins (traditionally MTA you have to wait for 24 hours for it to set which means we would need 2 appointments and would place GP another time)
61
Q

Why when placing our final restoration do we sometimes remove a bit of GP from the canal or don’t completely fill the canal?

A
  • So we can bond some composite a short way up the canal so it is a bit like a bonded core - this strengthens the tooth in the area around the cervical margin
62
Q

What is a gingivectomy?

A
  • Where we remove part of the gum so that we can get in to actually restore the area
63
Q

When would we consider surgical extrusion as a treatment option?

A
  • Possibly if injury is really bad and tooth has moved position
64
Q

Read the dental trauma guide

A

:)

BDS3 Paediatric Dentistry (9 decks)

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