trauma in primary dentition Flashcards
assessment of pulpal survival
symtoms: pain, looseness, discolouration
clinical: mobility, colour, TTP, abscess, sinus
sensibility: EPT, ethyl chloride
radiographs: PDL widening, root development
prognostic factors
type of injury
extent of injury
maturity of root: open/closed apex
presence of resorption
how close tooth is to exfoliation
PDL damage
degree of displacement
mobility
interference with occlusion
pt co-operation
what history to conduct when a paeds pt presents with trauma
- check for head injury, loss of consciousness: concussion, headache, vomiting? refer to hospital immediately
- assess for non-accidental injury
- check who pt has come with and if they have PR
*do a scorates for pain assessment
- when? check time interval between injury and appointment
- how it happened?
- assess for tooth fragments, e.g. in lip
- PDH: cooperation
- MH: bleeding disorder and allergy to penicillin. ask about immunosuppression: may alter decision to reimplant tooth
allergies? when prescribing antibiotics important
aims of tx with trauma to primary dentition
preserve integrity of permenant successor
preserve primary tooth is cooperation is good
aims of tx with trauma to permanent dentition
preserve vitality of tooth to allow maturation of the root
restore the crown to prevent drifting, tilting and overeruption
general short term management principles of trauma to tooth
Elimination of pain
protection of pulp
reduction and immobilisation of teeth
suturing soft tissue lacerations with resorbable vicryl sutures intraoral. extraoral refer to hospital
antibiotics? check tetanus status. analgesics? chlorhexidine mouthwash
general medium term management principles of trauma to tooth
pulp therapy
consider ortho requirements and long term prognosis of damaged teeth
semi-permanent restorations
keep under review: suitable time period
general long term management principles for trauma to tooth
permenant tx
deferred until over 16 to allow pulpal and gingival recession and decrease the likelihood of further trauma, e.g. definitive crown
pulpal survival at 5 years after injuries involving the PDL: open vs closed apex
concussion
subluxation
extrusion
lateral luxation
intrusion
reimplantation
- open: 100%, closed: 96%
- 100%, 85%
- 95%, 45%
- 95%, 25%
- 40%, 0%
- 30%, 0%
special tests to carry out in permanent trauma teeth
mobility assessment
percussion: duller note may indicate root fracture, high pitched= ankylosis
sensibility tests: ethyl chloride, EPT, check in contralateral teeth and compare
photography
check for any discolouration
appropriate radiographs
prognostic factors
extent of damage
type of injury: crushing PDL injury is the worst
tooth maturity: high chance of resorption in closed apices, open apices have created blood supply to PDL
associated fracture
avulsion: advantages of reimplanting avulsed permanent teeth
functional immediate solution
natural tooth replacement rather than bridge/denture/implant
maintains bone, gingival contour, allows ortho tooth movement
allows revascularisation of the pulp and PDL healing without anklyosis
aesthetics
space maintenance
preserves alveolar bone
primary teeth: enamel fractures
clinical findings
radiographic recommendations
treatment
follow up
favourable outcomes
unfavourable outcomes
- fracture to enamel only
- no radiographs recommended
- tx: smooth sharp edges. pt education: exercise care and avoid contact sports, encourage gingival healing by parents cleaning area with soft brush or cotton swab with 0.2% chlorhexidine mouth rinse 2x a day for 1 week
- no follow up required
- favourable: asymptomatic, pulp healing with: normal colour of crown, no signs of pulp necrosis (greying), continued root development in immature teeth
- unfavourable: symptomatic, crown discolouration, signs of pulp necrosis + infection, e.g. sinus tract, gingival swelling, abscess, increased mobility, persistent dark grey discolouration with infection, radiographic signs of pulp necrosis and infection, no further root development of immature teeth
primary teeth: complicated crown fractures with pulp exposure
clinical findings
radiographic recommendations
treatment
follow up
favourable outcomes
unfavourable outcomes
-PA using the paralleling technique or occlusal radiograph should be taken immediately. radiograph of soft tissues if fragment suspected to be embedded
- preserve pulp by partial pulpotomy (cvek) remove 1-3mm of coronal pulp. LA, non-setting calcium hydroxide applied over pulp + seal with GIC then composite resin
-tx dependent on child’s cooperation, pt education, care with exercise, chlorhexidine 2x a day for 1 wk
-clinical exam: 1wkm 6-8wk, 1y (radiographic follow up 1yr following pulpotomy)
-favourable: normal crown colour, no signs of pulp necrosis + infection, continued root development
-unfavourable: symptomatic, crown discolouration, signs of pulp necrosis + infection, e.g. sinus tract, swelling, abscess, persistent dark grey discolouration, no further root development of immature teeth
primary teeth: enamel-dentine fractures
clinical findings
radiographic recommendations
treatment
follow up
favourable outcomes
unfavourable outcomes
- fracture involves enamel + dentine but no pulp exposure, account for the missing tooth fragments
-baseline radiograph optional, take radiograph of soft tissues if fractures fragment is suspected to be embedded in lips, cheek, tongue
-cover all exposed dentine with GIC, lost tooth fragment can be restored using composite immediately or later, pt education: exercise care to avoid further damage, encourage ginival healing and plaque accumulation clean area with soft brush of 0.2% chlorhexidine 2x a day for 1 week
-follow up: 6-8 weeks after clinical exam, no radiological follow up unless findings suggestive of pulp necrosis
-favourable: normal crown colour, no signs of pulp necrosis + infection, continued root development
-unfavourable: symptomatic, crown discolouration, signs of pulp necrosis + infection, e.g. sinus tract, swelling, abscess, persistent dark grey discolouration, no further root development of immature teeth
cvek vs coronal pulpotomy
cvek removes 2-3mm coronal pulp but full pulpotomy= removal of all cervical pulp. for larger pulp exposures
pulp cap: indications
exposure less than 1mm and happened less than 24 hrs, complete or incomplete root development. pul still vital
cvek pulpotomy: indications
exposure>1mm >24hrs
complete or incomplete root development. pulp still vital
large coronal pulpotomy: indications
large contaminated exposures
long duration
incomplete root development
coronal pulp demonstrates impaired vascularity
how to do full coronal pulpotomy
LA and rubber dam
open up pulp chamber and amputate coronal pulp to cervical level with excavator
apply ferric sulphate to radicular pulp with cotton pellet
place non setting CaOH and restore tooth with GIC. OR fill chamber with zinc oxide eugenol cement and place hall crown
leave 6-8 weeks then review symptoms and vitality
if tooth becomes non-vital: RCT
primary teeth: crown-root fracture
clinical findings
radiographic recommendations
treatment
follow up
favourable outcomes
unfavourable outcomes
-can be complicated or uncomplicated fractures (pulp may or may not be exposed)
-PAs taken using paralleling technique
-remove the loose fragment and determine restorability of crown. if restorable and no pulp exposed, cover with GIC, if restorable and pulp exposed, pulpotomy or RCT depending on stage of root development. if unrestorable, XLA of loose fragments or full tooth. tx depends on child’s cooperation, pt education on exercise and chlorhexidine
-where tooth is retained: clinical exam 1wk, 6-8wk, 1yr (radiographic 1yr following RCT)
primary teeth: enamel-dentine fractures
-favourable: normal crown colour, no signs of pulp necrosis + infection, continued root development
-unfavourable: symptomatic, crown discolouration, signs of pulp necrosis + infection, e.g. sinus tract, swelling, abscess, persistent dark grey discolouration, no further root development of immature teeth
primary teeth: root fractures
clinical findings
radiographic recommendations
treatment
follow up
favourable outcomes
unfavourable outcomes
-occlusal interferences may be present
-PAs: mid/apical third?
-no tx if coronal fragment is not displaced, or isn’t excessively mobile to spontaneously reposition even if some occlusal interference
-if coronal fragment excessively displaced, mobile, interfering with occlusion, LA and XLA of coronal fragment, apical fragment left to resorb or gently reposition coronal fragment + if unstable, use a flexible splint for 4wk
-where no coronal displacement, 1wk, 6-8wk, 1yr
-coronal been repositioned: 1wk, 4wk for splint removal, 8wk, 1yr
-favourable: normal crown colour or transient red/grey/yellow discolouration, no signs of pulp necrosis + infection, continued root development, resorption of apical fragment, no mobility, realignment of fractured root
-unfavourable: symptomatic, crown discolouration, signs of pulp necrosis + infection, e.g. sinus tract, swelling, abscess, persistent dark grey discolouration, no further root development of immature teeth, no improvement in position of fractured root
which injuries are most associated with development of abnormalities in permanent dentition?
intrusion and extrusion
impact of primary tooth trauma on permanent dentition
close spatial relationship between apex of the primary tooth root and underlying permanent tooth germ
tooth malformation, impacted teeth and eruption disturbances in the developing permanent dentition are some consequences
considerations affecting management of TDIs in primary dentition
a child’s maturity and co-operation
time for exfoliation of the injured tooth
occlusion
parental instructions for homecare
Successful healing following an injury to the teeth and oral tissues depends on good oral hygiene. To optimize healing, parents or caregivers should be advised regarding care of the injured tooth/teeth and the prevention of further injury by supervising potentially hazardous activities. Clean the affected area with a soft brush or cotton swab and use alcohol-free chlorhexidine gluconate 0.12% mouth rinse applied topically twice a day for one week to prevent accumulation of plaque and debris and to reduce the bacterial load. Care should be taken when eating not to further traumatize the injured teeth while encouraging a return to normal function as soon as possible.
Parents or caregivers should be advised about possible complications that may occur, such as swelling, increased mobility, or a sinus tract. Children may not complain about pain, but infection may be present. Parents or caregivers should watch for signs of infection such as swelling of the gums. If present, they should take the child to a dentist for treatment
primary teeth: concussion
clinical findings
radiographic recommendations
treatment
follow up
favourable and unfavourable outcomes
-tooth tender to touch but not displaced
-no radiographs
-no tx: observation, reassurance and soft diet + analgesics
-exam after 1wk, 6-8wk, 1 yr
primary teeth: subluxation
clinical findings
radiographic recommendations
treatment
follow up
favourable and unfavourable outcomes
-tooth is tender to touch + increased mobility, but not displaced
-PAs: normal to slightly widened PDL will be visible
-no tx: observation, reassurance and soft diet + analgesics
-if slight mobility, soft diet 1-2 weeks
primary teeth: lateral luxation
clinical findings
radiographic recommendations
treatment
follow up
favourable and unfavourable outcomes
-tooth is displaced in a palatal/lingual direction or labial
-tooth will be immobile, occlusal interference may be present
-PAs: increased PDL space
-minimal occlusal interference, tooth should be allowed to spontaneously reposition itself (usually within 6 months). if the crown is displaced palatally, the apex moves buccally and hence away from the permanent developing tooth germ.
-if crown displaced buccally, apex will be displaced towards permanent tooth bud + XLA required to avoid further damage to permanent successor + when risk of ingestion of the tooth
-or gently reposition tooth, if stable in new position, splint for 4wk using a flexible splint
-exam 1wk, 6-8wk, 6mo, 1y. if repositioned with splint: 1wk, 4wk for splint removal, 8wk, 6mo, 1yr
-radiographic review only when signs of infection or unfavourable outcomes: use ALAARA
-unfavourable: no improvement of position of laterally luxated tooth and negative impact on development and/or eruption of permanent successor
primary teeth: intrusion
clinical findings
radiographic recommendations
treatment
follow up
favourable and unfavourable outcomes
-tooth displaced through the labial bone plate + can impinge on permanent tooth bud, tooth disappeared into socket and can be palpated labially
-PAs, when apex displaced toward the permanent tooth germ, apical tip cannot be visualised and image of tooth will appear elongated, if apical tip can be seen it will appear shorter than contralateral tooth which shows it is displaced through labial bone instead
-tooth should be allowed to spontaneously erupt (usually within 1-6mo)
-if displaced toward tooth germ, XLA to avoid damage to permanent successor + if failure to re-erupt
- Must warn parent that there might be damage to successor
primary teeth: extrusion
clinical findings
radiographic recommendations
treatment
follow up
favourable and unfavourable outcomes
-partial displacement of tooth out of socket, seems elongated and excessively mobile, occlusal interference
-PA: widening of PDL
-tx based on: degree of displacement, mobility, interference with occlusion
-if no interference, let tooth reposition itself. if extruded >3mm or mobile, extract under LA
-rv: 1wk, 6-8wk, 1y
avulsion in primary teeth management
don’t reimplant due to risk of damage to permanent tooth germ development
the eruption of the permanent successor may be delayed up to 1 year as a result of abnormal thickening of connective tissue overlying the tooth germ
sequelae of injuries to the permanent dentition
-pulpal necrosis
-pulpal obliteration
-root resorption
-injuries to developing permanent teeth
sequelae of injuries to the permanent dentition: pulpal necrosis
most common complication of primary trauma
mild pink colour after trauma: intrapulpal bleeding with a vital pulp, may recede
if it persists, necrosis suspected
radiographic examination should be 3 monthly
failure of the pulp cavity to reduce in size is an indicator of pulpal death, teeth should be extracted to prevent damage to permanent successor
important to council patients about possibility of necrosis and to monitor signs including sinus formation which occurs in the absence of pain symptoms
sequelae of injuries to the permanent dentition: pulpal obliteration
tooth becomes yellow/opaque
annual radiography required
sequelae of injuries to the permanent dentition: root resorption
external inflammatory resorption is seen after intrusive injuries and internal resorption with subluxation and other luxation injuries
XLA advised for all root resorption
sequelae of injuries to the permanent dentition: injuries to permanent teeth
intrusive causes most damage
most damage occurs to the tooth bud under age of 3
can cause enamel defects: managed with a combination of microabrasion and/or composite
intrusion severity in open vs closed apex and its management
open:
-up to 7mm: spontaneous
-more than 7mm: ortho/surgical
closed:
-up to 3mm: spontaneous
-3-7mm: ortho/surgical
-more than 7mm: surgical
types of resorption
