Trauma III Flashcards
What is avulsion?
- Avulsion is where the tooth comes completely out of the socket
When can successful healing occur in avulsed teeth?
- Successful healing can occur if there is only minimal damage to the pulp and the PDL
What are critical factors for avulsed teeth? (3)
- Extra-alveolar dry time - EADT
- Extra-alveolar time - EAT
- Type of storage medium
What is EADT?
- This is the time the tooth is out of the mouth just in air (it is not in any storage medium)
What is EAT?
- The amount of time it is out of the mouth and dry including the time it has been in any type of storage medium
If a patient attends with an avulsed tooth that has already been replanted what would you do? (2)
- Do not remove. Leave as is and follow instructions regarding splinting etc dependent on circumstances
- Radiograph important to establish status of root development (want to know how much root is there, is it a mature or immature tooth - open or closed apex)
What advice would we give to the public if they had experienced an avulsed tooth? (6)
- Essential for parents/sports coaches/teachers
- Hold by crown only
- Wash in cold running water (if there is obvious debris this can be done for up to 10 seconds)
- Replace in socket and child bites on tissue
- Or store in milk/saliva/normal saline
- IF there is a lot of trauma then you could potentially store it in the patients blood
- Seek immediate dental advice
What is initial decision making about an avulsed tooth based on?
- Based on EADT (extra-alveolar dry time)
There are different things that we do depending on the time:
- EADT <30 mins
- EADT >30 mins
Will all avulsed teeth heal in the same way?
No
What are the possible periodontal outcomes of an avulsed tooth? (4)
- Regeneration
- PDL/cemental healing
- Bony healing
- Uncontrolled infection
When is the regeneration periodontal outcome likely to occur with an avulsed tooth?
- Most likely to occur if the tooth is put straight back in the socket
When is the PDL/cemental healing periodontal outcome likely to occur with an avulsed tooth?
- IF not put straight back in the socket
What is the bony healing periodontal outcome of an avulsed tooth?
- Where the bone is fused right up to the tooth and starts a replacement resorption process that may or may not take a long time
What is the uncontrolled infection periodontal outcome of an avulsed tooth?
- This is not healing at all - this would create granulation tissue, infection, abscesses etc
What are the possible pulpal outcomes of an avulsed tooth? (3)
- Regeneration
- Controlled necrosis (elective disinfection)
- Uncontrolled infection
Regeneration is the pulpal outcome that we want after avulsion. Why is this more likely to happen when we have a tooth with an open apex?
- When we thing about open apex - means the apex is really wide so have got lots of vessels in there that are coming into a wide area so this is more likely to regenerate than it is if you’ve got a closed apex (only have 1 nerve and 1 BV coming in so once it is ripped it is less likely to regenerate)
What is the pulpal outcome ‘controlled necrosis’?
- Where we know that the tooth is going to become non vital so the live bit of the tooth is taken out before it actually dies or causes infection
- So we are stopping the inevitable
What is the uncontrolled infection pulpal outcome?
- Where you have a necrotic pulp and this goes on to cause infection and other problems
What is out aim if EAT <60 mins?
- PDL healing
- If EAT is <60mins and stored in an appropriate storage medium (e.g. milk, physiological saline or saliva) then there is a chance of cemental/PDL healing
If we have an avulsed tooth with EAT <60 mins what would we do? (5)
- Replant tooth under LA
- Flexible splint for 14 days
- Consider antibiotics and check tetanus status
- Carry out pulp extirpation at 0-10 days UNLESS apex is open (immature root)
- Teeth with an open apex may revascularize
The good thing about immature teeth is that you can tell relatively soon whether or not there has been revascularization. How do we do this?
- You take an x-ray further down the line and can compare it to the adjacent tooth to see if there has been continued root development - so actually find out pretty quickly whether or not your tooth is in a good situation r whether the pulp is coming out
What would we do if we have an avulsed immature tooth (with open apex) with an EAT of <60mins?
- If the decision is not to root treat the tooth it must be closely monitored clinically and radiographically for signs of continued growth vs loss of vitality
- Review interval: 2 weeks (splint removal), 4 weeks, 2 months, 3 months, 6 months then yearly
- If the tooth is found to be non vital extirpate pulp and refer to paediatric specialist. Inter-disciplinary management is recommended
What would we do if we have an avulsed mature tooth (with closed apex) with an EAT of <60mins?
- After replantation and splinting, remove pulp as soon as possible (ideally day 0)
- Following extirpation and disinfection, place antibiotic-steroid paste as intra-canal medicament - leave in place for 2 weeks
- Remove splint after 14 days
- At 2 weeks - clean and replace intracanal medicament with NSCaOH (do not want this to be in for more than 4-6 weeks)
- Obturation with GP should take place within 4-6 weeks
- Refer to specialist paediatric dental team for interdisciplinary management
What would we do if we have an avulsed mature tooth (with closed apex) with an EAT of >60mins?
- Unlikely to get PDL healing
- The aim is for bony healing (by alkylosis) so scrub root clean of dead PDL cells
- 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 not carried out - extirpate at 7-10 days and use NSCaOH as initial intra-canal medicaments for 4 weeks prior to obturation with
GP - Review: 3,6,12 months then yearly
What is the aim of healing if we have an avulsed mature tooth (with closed apex) with an EAT of >60mins?
Aim = bony healing
What would we do if we have an avulsed tooth (with open apex) with an EAT of >60mins?
- Unlikely to get PDL healing
- Very small chance the pulp may still revascularize
- Do not root treat unless signs of loss of vitality on follow up
- Replant tooth under LA
- Splint: 4 weeks flexible splint
- Consider antibiotic prescription
- Check tetanus status
- Monitor closely for signs of necrosis vs continued root development
- Review interval at 2 weeks, 4 weeks (splint removal), 2 months, 3 months, 6 months then yearly
When should we not replant an avulsed tooth? (5)
- Almost never
- If very immature apex and EAT >90mins (may still be best to replant)
- Child is immunocompromised
- 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 come
Why is it usually the right choice to replant a tooth?
- Even as a temporary space maintainer - the right choice is usually to replant esp when guiding position of adjacent erupting tooth
How would we monitor avulsed/implanted teeth? (5)
- Open apex teeth require close monitoring
- If pulpal necrosis detected - pulp extirpation must be carried out as soon as possible to avoid inflammatory resorption
- Clinical tests - trauma stamp
- Sensibility tests: thermal + electrical
- Radiographs
When would we take sensibility tests when monitoring avulsed or replanted teeth?
- At time of injury
- 1 month, 2 months, 3 months, then 6 monthly for an average of 2 years
What are we looking for in radiographs when monitoring avulsed/replanted teeth? (3)
- Root development - width of canal and length
- Comparison with other side
- Internal + external inflammatory resorption
What is the best practice for doing a pulpectomy on an open apex tooth?
- 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 are dento-alveolar fractures?
- Dento-alveolar fractures are where you don’t have displacement of your teeth in their sockets
- There is some mobility but you are not moving teeth individually
- What has happened here is there has been displacement of the alveolar bone - which is the bone that is holding the teeth in
- This tends to happen in segmental ways - so would never happen to a single tooth, it would tend to be in blocks of 3 or 4 or more
Do we splint dento-alveolar fractures?
- Yes, would place a flexible splint for 4 weeks
What is the treatment of dento-alveolar fractures? (4)
- LA
- Reposition - Apical lock may be present (Where the bone cannot slot into its original place)
- Flexible splint for 4 weeks
- Antibiotics
How would we follow up with dento-alveolar fractures?
Monitor clinically and radiographically
- Checking for root development - canal width and length, compare with neighbouring unaffected tooth
- Check for signs of inflammatory resorption
- Follow up: 2 weeks, 4 weeks, 8 weeks, 4 months, 6 months, 1 year and yearly for 5 years
As with all dental injuries:
- Soft diet for 7 days
- Avoid contact sport whilst splint in place
- Careful OH with use of chlorhexidine gluconate mouthwash 0.1%
What is the risk of pulpal necrosis in closed apex teeth in a dento-alveolar fracture at 5 years?
50%
