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BDS3 Paediatric Dentistry > Trauma III > Flashcards

Trauma III Flashcards

1
Q

What is avulsion?

A
  • Avulsion is where the tooth comes completely out of the socket
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2
Q

When can successful healing occur in avulsed teeth?

A
  • Successful healing can occur if there is only minimal damage to the pulp and the PDL
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3
Q

What are critical factors for avulsed teeth? (3)

A
  • Extra-alveolar dry time - EADT
  • Extra-alveolar time - EAT
  • Type of storage medium
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4
Q

What is EADT?

A
  • This is the time the tooth is out of the mouth just in air (it is not in any storage medium)
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5
Q

What is EAT?

A
  • The amount of time it is out of the mouth and dry including the time it has been in any type of storage medium
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6
Q

If a patient attends with an avulsed tooth that has already been replanted what would you do? (2)

A
  • 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)
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7
Q

What advice would we give to the public if they had experienced an avulsed tooth? (6)

A
  • 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
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8
Q

What is initial decision making about an avulsed tooth based on?

A
  • Based on EADT (extra-alveolar dry time)

There are different things that we do depending on the time:

  • EADT <30 mins
  • EADT >30 mins
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9
Q

Will all avulsed teeth heal in the same way?

A

No

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10
Q

What are the possible periodontal outcomes of an avulsed tooth? (4)

A
  • Regeneration
  • PDL/cemental healing
  • Bony healing
  • Uncontrolled infection
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11
Q

When is the regeneration periodontal outcome likely to occur with an avulsed tooth?

A
  • Most likely to occur if the tooth is put straight back in the socket
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12
Q

When is the PDL/cemental healing periodontal outcome likely to occur with an avulsed tooth?

A
  • IF not put straight back in the socket
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13
Q

What is the bony healing periodontal outcome of an avulsed tooth?

A
  • 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
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14
Q

What is the uncontrolled infection periodontal outcome of an avulsed tooth?

A
  • This is not healing at all - this would create granulation tissue, infection, abscesses etc
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15
Q

What are the possible pulpal outcomes of an avulsed tooth? (3)

A
  • Regeneration
  • Controlled necrosis (elective disinfection)
  • Uncontrolled infection
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16
Q

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?

A
  • 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)
17
Q

What is the pulpal outcome ‘controlled necrosis’?

A
  • 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
18
Q

What is the uncontrolled infection pulpal outcome?

A
  • Where you have a necrotic pulp and this goes on to cause infection and other problems
19
Q

What is out aim if EAT <60 mins?

A
  • 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
20
Q

If we have an avulsed tooth with EAT <60 mins what would we do? (5)

A
  • 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
21
Q

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?

A
  • 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
22
Q

What would we do if we have an avulsed immature tooth (with open apex) with an EAT of <60mins?

A
  • 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
23
Q

What would we do if we have an avulsed mature tooth (with closed apex) with an EAT of <60mins?

A
  • 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
24
Q

What would we do if we have an avulsed mature tooth (with closed apex) with an EAT of >60mins?

A
  • 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
25
Q

What is the aim of healing if we have an avulsed mature tooth (with closed apex) with an EAT of >60mins?

A

Aim = bony healing

26
Q

What would we do if we have an avulsed tooth (with open apex) with an EAT of >60mins?

A
  • 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
27
Q

When should we not replant an avulsed tooth? (5)

A
  • 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
28
Q

Why is it usually the right choice to replant a tooth?

A
  • Even as a temporary space maintainer - the right choice is usually to replant esp when guiding position of adjacent erupting tooth
29
Q

How would we monitor avulsed/implanted teeth? (5)

A
  • 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
30
Q

When would we take sensibility tests when monitoring avulsed or replanted teeth?

A
  • At time of injury

- 1 month, 2 months, 3 months, then 6 monthly for an average of 2 years

31
Q

What are we looking for in radiographs when monitoring avulsed/replanted teeth? (3)

A
  • Root development - width of canal and length
  • Comparison with other side
  • Internal + external inflammatory resorption
32
Q

What is the best practice for doing a pulpectomy on an open apex tooth?

A
  • 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
33
Q

What are dento-alveolar fractures?

A
  • 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
34
Q

Do we splint dento-alveolar fractures?

A
  • Yes, would place a flexible splint for 4 weeks
35
Q

What is the treatment of dento-alveolar fractures? (4)

A
  • LA
  • Reposition - Apical lock may be present (Where the bone cannot slot into its original place)
  • Flexible splint for 4 weeks
  • Antibiotics
36
Q

How would we follow up with dento-alveolar fractures?

A

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%
37
Q

What is the risk of pulpal necrosis in closed apex teeth in a dento-alveolar fracture at 5 years?

A

50%

BDS3 Paediatric Dentistry (9 decks)

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