Trauma to primary and permanent teeth Flashcards
What is the approach for dental trauma?
History Exam/DX Emergency TX Follow Up Definitive TX
What are the components of the general evaluation of a patient who has sustained trauma?
General appearance
Vital signs
Consciousness
What are the components of the extra oral examination of a patient who has sustained trauma?
Check for clear nasal fluid discharge Bruises Swelling Neck movements Steps at the border of bones Mandibular movements Lacerations
What are the components of the cranial nerve examination of a patient who has sustained trauma?
Eye movements- vision (double/blurred), pupil constriction
Olfactory- can they smell
Auditory- can they hear
Talk, swallow, open mouth, stick tongue out, raise eyebrows, squeeze eyelids, smile, pucker lips, shrug shoulders
What are the minimum questions to ask when a patient has sustained trauma?
Did the patient lose consciousness
Any vomiting since the injury happened
What are the 3 components of an intraoral exam?
1- soft tissue
2- occlusion- alignment, steps in occlusion
3- teeth- fractures, tooth displacement, all teeth present
Which injuries are hard tissue injuries?
Cracked teeth
Fractured teeth
Pulp exposure
Color change
Which injuries are supporting tissue injuries?
Displacement of teeth Mobility of teeth Mobility of alveolar fragments Occlusion abnormality Percussion sensitivity
What type of radiograph should be taken for primary dental trauma?
Occlusal films
What is the timeline for radiographic evidence of pathology?
2 wks- pulpal necrosis
3 wks- inflammatory resorption
6 wks- replacement resorption
What are the effects of trauma?
Pulpal hyperemia
Trauma effect:
May lead to cold sensitivity
What are the effects of trauma?
Internal hemorrhage
Trauma effect:
(Transient) discoloration
What are the effects of trauma?
Pulpal necrosis
Trauma effect:
Percussion + / Periapical radiolucency
What are the effects of trauma?
Pulp canal obliteration
Trauma effect:
Tooth turns yellow
What are the effects of trauma?
Inflammatory resorption
Trauma effect:
Radiographic appearance changes
Change in mobility
What are the effects of trauma? Replacement resorption (ankylosis)
Trauma effect:
Lack of mobility, dull percussion sound
T/F
Pulpal necrosis subsequent to PCO (pulp canal obliteration) was uncommon (1%)
True
What are the characteristics of replacement resorption?
Direct union of bone and root
Resorption of root and replacement with bone
Direct result of loss of vital PDL
What are the two main goals of emergency management of dental trauma?
Cover fractured teeth temporarily
Reposition luxated teeth and stabilize
This leads to need for follow up plan
Cold test and EPT should NOT be considered in which cases?
Testing:
Children
Open apices
Shortly after trauma
Which are the most reliable forms of diagnostic testing for dental trauma initially?
Testing: Radiography Percussion Palpation Mobility Swelling
Which tests are primarily best for teeth with closed apices?
Testing:
EPT
Cold Test
Which tests are used as diagnostic and to determine a baseline record?
Testing:
Radiography
Swelling
Which tests are used to evaluation the severity of luxation injuries?
Testing:
Palpation
Mobility
Which test is used to evaluate concussion to tooth injuries?
Testing:
Percussion
What are the primary categories of dental trauma?
Fracture
Luxation
What is an enamel infarction?
Crack
What is an uncomplicated crown fracture?
Fracture of enamel and/or dentin in the crown without pulp exposure
aka Class I and II
What is a complicated crown fracture?
Fracture of enamel/dentin in the crown with pulp exposure
aka Class III
What is an uncomplicated crown-root fracture?
Fracture of enamel and/or dentin of crown and root without pulp exposure
What is a complicated crown-root fracture?
Fracture of enamel and/or dentin of crown and root with pulp exposure
What is an isolated root fracture?
Fracture of root only
What is the emergency treatment for class I fractures in primary teeth?
Emergency Tx:
Do nothing
Smooth rough edges
Restore with composite
What is the emergency treatment for class I fractures in permanent teeth?
Emergency Tx: Do nothing Smooth rough edges Restore with composite Follow up in 4 wks
What is the emergency treatment for class II fractures in primary teeth?
Emergency Tx: Do nothing Composite/GI band-aid Monitor for symptoms Restore with composite/GI
What is the emergency treatment for class II fractures in permanent teeth?
Emergency Tx: Do nothing Bond fragement if available Composite/GI band-aid Monitor for symptoms Restore with composite/GI Follow up in 4 wks
What is the emergency treatment for class III fractures in primary teeth?
Emergency Tx: Dependent primarily on behavior Tx options include-- Partial pulpotomy Pulpectomy Extraction
What is the emergency treatment for class III fractures in permanent teeth?
Emergency Tx: Dependent on stage of tooth maturity Young tooth- open apex or close apex --Direct pulp cap --Partial pulpotomy (Cvek technique) Mature tooth with closed apex --Pulpectomy
When does apex closure occur for:
Max centrals
Apex closure Mx:
10 years
When does apex closure occur for:
Max laterals
Apex closure Mx:
11 years
When does apex closure occur for:
Max canines
Apex closure Mx:
13-15 years
When does apex closure occur for:
Mandibular centrals
Apex closure Md:
9 years
When does apex closure occur for:
Mandibular laterals
Apex closure Md:
10 years
When does apex closure occur for:
Mandibular canines
Apex closure Md:
12-14 years
What are the criteria for success for Cvek partial pulpotomy?
No clinical signs or symptoms No radiographic pathology Continued development of immature roots Formation of calcific barriers Sensitivity to EPT
What are the typical sequelae of dental trauma?
Discoloration of teeth
Acute pain
Abscess or inflammation due to necrosis of tooth
Tooth mobility
Sensitivity to cold/hot foods
Gingival irritation or inflammation
Damage to developing tooth (if damage is done to primary tooth)
What do we ask parents to watch out for in terms of dental trauma?
For the tooth to start hurting --Waking up at night --Stops eating and drinking Color change Swelling --Facial swelling --Pimple of pus on the gums above the tooth Tooth getting loose
What is the appropriate treatment for discoloration of primary teeth?
NO TREATMENT NECESSARY
What are the primary results of chin trauma?
Posterior crown fractures
Mandibular condylar fractures
Cervical spine injury
What is the treatment for isolated root fractures?
No tx
Splint (if increased mobility) for 4 wks
Splint for 4 months if the fracture is more cervical
When there are more traumatic injuries than one in a patient, what determines the follow-up?
The most critical injuries determine follow-up duration
Always take initial x-ray from all traumatized teeth
What is the emergency treatment for a primary tooth concussion?
Emergency tx:
No emergency tx
Discuss potential sequelae with parents
Monitor for symptoms
What is the emergency treatment for a permanent tooth concussion?
Emergency tx: No emergency tx Discuss potential sequelae with parents Monitor for symptoms Follow up in 4 wks
What is subluxation?
An injury to tooth-supporting structures with abnormal loosening, but without displacement of the tooth
What is the emergency treatment for subluxation of a primary tooth?
Emergency tx:
No emergency tx
Monitor for symptoms
Tooth may tighten
What is the emergency treatment for subluxation of a permanent tooth?
Emergency tx: No emergency tx Monitor for symptoms Tooth may tighten Follow up in 4 wks
What is the follow-up for subluxation?
Follow up:
2-4 wks
Radiograph 1 month
What is intrusive luxation?
displacement of the tooth into the alveolar bone
this injury is typically accompanied by comminution or fracture of the alveolar socket
What is the emergency treatment for intrusion of primary teeth?
Emergency tx:
If the tooth was displaced labially- allow for spontaneous eruption
If the tooth was displaced into the developing tooth bud, then extract
Labial displacement of intruded primary teeth in an occlusal radiograph will appear…
Elongated in occlusal radiograph
Lingual displacement, towards a developing tooth bud, of an intruded primary tooth in an occlusal radiograph will appear…
Shortened in occlusal radiograph
What to expect when developing teeth are damaged?
Discoloration Enamel hypoplasia Crown or root dilaceration Arrested development Disturbance in eruption
What ages hold the greatest risk for damage to developing teeth?
1-3 years old
What is the emergency treatment for intrusion of permanent teeth with an open apex?
Emergency tx:
Open apex- up to 7mm- spontaneous eruption
Open apex- more than 7mm- orthodontic or surgical repositioning
What is the emergency treatment for intrusion of permanent teeth with a closed apex?
Emergency tx:
Closed apex- up to 3mm- spontaneous eruption
Closed apex- 3-7mm- orthodontic or surgical repositioning
Closed apex- more than 7mm- surgical repositioning
What is the follow up treatment for permanent teeth that experience intrusion?
Pulpectomy- remove pulp and fill with CaOH within 7-14 days
Complete gutta percha fill in 2 months if no inflammatory resorption
What is the emergency treatment for extruded primary teeth?
Emergency tx: <3mm --Reposition no splint --Spontaneous alignment Severe --Extract
considerations: occlusal interference, aspiration risk
What is the emergency treatment for extruded permanent teeth?
Emergency tx:
Reposition with digital pressure
Flexible splint for 2 wks
Rx chlorhexidine mouth rinse
Pulpectomy: remove pulp and fill with CaOH within 7-14 days
Complete gutta percha fill in 2mo if no inflammatory resorption
What is the emergency treatment for primary teeth that are laterally luxated?
Emergency tx:
Retrusion
–If no occlusal interference, allow for spontaneous repositioning
–With occlusal interference- must be repositioned/extracted (no splint)
Protrusion
–Extract (may contact developing tooth bud)
What is the emergency treatment for permanent teeth that are laterally luxated?
Emergency tx: Reposition with digital pressure Flexible splint for 4 wks Rx chlorhexidine mouth rinse Pulpectomy- CaOH fill within 7-14 Complete gutta percha obturation in 2-4 mo if no resorption
What is emergency treatment for avulsion of primary teeth?
None, NEVER reimplant primary teeth
What is the emergency treatment for avulsion of permanent teeth?
Emergency tx:
Reimplant as soon as possible (every minute counts)
Flexible splint- 2 wks
Medications: systemic antibiotics, CHX mouth rinse, ibuprofen: pain + inhibition of bone resorption, tetanus
Prognosis:
Open apex vs. Close apex
Dry time
How to manage root surface of avulsed permanent teeth?
Maintain PDL cell vitality
Keep moist in HBSS
Do not handle root surface
Gently remove persistent debris
How to manage socket of avulsed teeth?
If clot present use saline irrigation
Do not curette socket
If alveolar bone collapsed, use blunt instrument to reposition
Manually compress bony plates after replantation
How to manage soft tissue around avulsed teeth?
After repositioning…
Tight suture any soft tissue lacerations, particularly in the cervical region
How to splint teeth?
Use fish line/acid-etch resin; soft arch wire/resin; ortho brackets with passive arch wire; suture as last resort
Maintain splint up to 2 wks, longer if tooth is still excessively mobile
What are the home care instructions for splinted teeth?
NO BITING on splinted teeth
Soft diet
Good oral hygiene
What is the follow up for avulsed permanent teeth?
Pulpectomy- remove pulp, place CaOH within 7-14 days
Complete gutta percha obturation fill in 2-12 mo (don’t complete endo if it becomes ankylosed)
How to manage avulsion of immature permanent teeth?
Replant ASAP
Splint
Recall every 3-4 wks
At first sign of necrosis, extirpate pulp and do revascularization procedure
What is the revascularization procedure?
Stimulation of bleeding through apex
Place MTA on top of clot
Allows continued root development and root wall thickening
What is the main thing to consider after a tooth fracture?
Where is the tooth fragment
- -Ground
- -Imbedded in soft tissue
- -Ingested
- -Aspirated
What are the clinical signs of aspiration?
No symptoms Initial choking and coughing Irritating cough Wheezing Unilateral obstructive emphysema Atelectasis Pulmonary suppuration
