Trauma III Flashcards
What is avulsion
Displacement of the tooth from its socket in the alveolar bone due to trauma
When can successful healing occur
Successful healing can occur if there is only minimal damage to the pulp and the PDL
What are critical factors for replantation
- Extra-alveolar dry time (EADT) - this is the time that the tooth is just in the air and not in any storage medium or the sockets
- Extra-alveolar time (EAT) is the amount of time that the tooth is out of the mouth including time in any storage medium
- Type of storage medium
If a patient attends with a tooth already replanted what should be done
• Do not remove it - leave it as it is and follow the instructions regarding splinting (depending on circumstance e.g if there is lots of debris)
Radiograph important to establish status of root development
What is the help advice for avulsion
- Give advice over the phone
- Hold by crown only
- Wash in cold running water for up to 10 seconds only and put the plug in in case its dropped
- Replace in the socket and let child bite on tissue
- Or store in milk/saliva/normal saline
- Seek immediate dental advice
What is the healing likelihood for implantation
○ If the EADT is <30 minutes then there is a chance of cemental/PDL healing
○ If the EADT is >30 minutes then it is likely that healing will be by ankylosis
What are the periodontal outcomes
regeneration
pdl/cemental healing
bony healing
uncontrolled infection
What are the pulpal outcomes
○ Regeneration (more likely with an open apex)
○ Controlled necrosis (elective disinfection)
○ Uncontrolled infection
What is controlled necrosis
§ Where we know the tooth is going to become non vital and we take the live part of the tooth out before it dies and causes infection
What is uncontrolled infection
PDL is not healing at all and instead granulation tissue is made resulting in abscesses
What is the aim if the EAT <60 minutes
PDL healing
What is the procedure for EAT<60 minutes for an open apex
- If the decision is made not to root treat the tooth then it must be closely monitored clinically and radiographically for signs of continued growth vs loss of vitality
- If the tooth is found to be non vital then extirpate the pulp and refer to a paeds specialist
What is the review period for EAT <60minutes open apex
• Review interval is 2 weeks (splint removal), 4 weeks, 2 months, 3 months, 6 months then yearly
How is it easy to tell if there is regeneration on an open apex
• It is easy to tell if there is regeneration as the tooth can be compared to the contralateral side to see if there is a continuation of development
What is the procedure for EAT <60 min closed apex
- After replantation and splinting, remove the pulp ASAP (ideally day 0)
- Following extirpation and disinfection, place anti-biotic steroid paste as intra-canal medicament and leave in place for 2 weeks
- Remove the splint after 14 days
- At 2 weeks - clean and replace intracanal medicament with non setting calcium hydroxide
- Obturation with the gutta percha should take place within 4-6 weeks
- Refer to a specialist paeds team
When is the review for EAT <60 min closed apex
• Review 3 months, 6 months, 12 months then yearly
What is the aim for EAT >60 min open apex
- AIM: BONY HEALING
* Unlikely to get PDL healing
What is the procedure for EAT >60 min closed apex
- The aim is for bony healing (by ankylosis) so scrub the root clean of dead PDL cells so the body does not have to do it itself
- Extra-oral endodontics can be carried out prior to replantation
- Replant tooth under LA
- Splint: 4 weeks flexible splint
- Consider antibiotic prescription
• If extra-oral endodontics is not carried out then extirpate at 7-10 days and use non setting calcium hydroxide as the initial intra-canal medicament for 4 weeks prior to obturation with GP
What is the procedure for EAT >60 min open apex
- Unlikely to get PDL healing
- Very small chance the pulp may still revascularize
- Do not root tx unless signs of loss of vitality on follow up
- Splint for 4 weeks using a flexible splint
- Consider AB prescription
- Check the tetanus status
- Monitor closely for signs of necrosis vs continued root development
What is the review for EAT closed apex
• Review at 3, 6, 12 months then yearly
What is the review for EAT open apex
• Review interval: 2 weeks, 4 weeks (splint removal), 2 months, 3 months then 6 months yearly
When do you not replant
- Almost never
- If very immature apex and the EAT>90 minutes (may still be best to replant)
- Child is immunocompromised e.g as a result of active chemotherapy, immunosuppressant drugs
- The child has other serious injuries and warrant preferential emergency treatment and/or intensive care being dealt with
- Very immature lower incisors in young child finding it difficult to cope
- Even as a temp space maintainer - the right choice is usually to replant especially when guiding the position of the adjacent erupting tooth
How do you monitor avulsion
• Open apex teeth require close monitoring
• If pulpal necrosis is detected then pulp extirpation must be carried out as soon as possible to avoid inflammatory resorption
• Clinical tests should be done (trauma stamp)
Sensibility tests should be done (thermal and electrical
radiographs should be taken
When should sensibility tests be done
○ At time of injury
○ 1 month, 2 months, 3 months, then 6 monthly for an average of 2 years
Why should radiographs be taken to look for
○ Root development - width of canal and length
○ Comparison with other side
○ Internal and external inflammatory resorption
What is the best practice for open apex pulpecotmy
- Extirpate pulp and place CaOH for no longer than 4-6 weeks after identified as non-vital
- Problems with CaOH apexification
- MTA plug and heated GP obturation
What is the 5 year pulpal survival for avulsion
open apex - 30%
closed apex - 0%
What is the 5 year resorption for avulsion
frequent
What is a dentoalveolar fracture
- There is no displacement of teeth
- They have not moved in their sockets
- The damage is to alveolar bone
- A flexible splint needs to be placed for 4 weeks
What is the tx for dents-alveolar fractures
- Give LA
- Reposition - ‘apical lock’ may be present
- Place a flexible splint for 4 weeks
- Give antibiotics
What is the follow up for dents-alveolar fractures
• Monitor clinically and radiographically
○ Check for root development (canal width and length) and compare with neighbouring unaffected tooth
○ Check for signs of inflammatory resorption
○ Follow up at 2 weeks, 4 weeks, 8 weeks, 4 months, 6 months, 1 year and 5 years
○ Risk of pulpal necrosis where the apex is closed is 50% at 5 years
What is the advice for all dental injuries
○ Soft diet for 7 days
○ Avoid contact sport while splint in place
○ Careful OH with use of chlorhexidine gluconate mouthwash 0.1%
