Treatment Of Trauma Injuries Flashcards

Question

What must be remembered in terms of avulsion? (2) to do with closed apex & EADT etc

Answer 1

Teeth with closed apices will always become non-vital and should undergo root canal treatment Even teeth with a very poor prognosis (prolonged EADT or very immature) should be reimplanted if possible - to restore aesthetics and functions (even for the short term) before being referred for mutli-disciplinary assessment.

Answer 2

Direct pulp capping • Cvek's (partial) pulpotomy • Coronal pulpotomy • Pulpectomy

Answer 3

Prognosis depends on the size and age of the exposure Outcome = management of the contamination at the exposure site Treat the exposed pulp ASAP! Allow further root development

Answer 4

Pinpoint exposure Not grossly contaminated • Within 24 hours • Procedure: • Ca(OH)2+ GIC + Composite • Success rate: 71-88% (Andreasen)

Answer 5

Exposure not compromising coronal pulp • Both mature and immature teeth • No history of spontaneous pain • No mobility ,TTP, swelling • Bleeding stops from amputated pulp in 2 minutes • Ideally within 9 days

Answer 6

Keep the patient calm. Find the tooth and pick it up by the crown (the white part). Avoid touching the root. Attempt to place it back immediately into the jaw. If the tooth is dirty, rinse it gently in milk, saline or in the patient's saliva and replant or return it to its original position in the jaw. It is important to encourage the patient/guardian/teacher/other person to replant the tooth immediately at the emergency site. Once the tooth has been returned to its original position in the jaw, the patient should bite on gauze, a handkerchief or a napkin to hold it in place. If replantation at the accident site is not possible, or for other reasons when replantation of the avulsed tooth is not feasible (eg, an unconscious patient), place the tooth, as soon as possible, in a storage or transport medium that is immediately available at the emergency site. This should be done quickly to avoid dehydration of the root surface, which starts to happen in a matter of a few minutes. In descending order of preference, milk, HBSS (hanks balanced salt solution), saliva (after spitting into a glass for instance), or saline are suitable and convenient storage mediums. Although water is a poor medium, it is better than leaving the tooth to air-dry.28, 29 The tooth can then be brought with the patient to the emergency clinic. See a dentist or dental professional immediately.

Answer 7

CVEK STEPS: - Local Anaesthetic, rubber dam • Remove non vital tissue 2-4mm (tungsten carbide, 2mm flute) • Calcium Hydroxide (Non setting powder) or Biodentine/ MTA? (may discolour) - then GIC • and Restore with composite • Success rate: 96% (Cvek, 1998) • Allows completion of root growth IDEALLY DONE WITHIN 9 DAYS

Answer 8

WITHOUT PULP EXPOSURE: - these typically extend below gingival margin - involving enamel dentine and cementum - TTP - fragment usually present and mobile - extent of fracture should be evaluated RADS - take soft tissue rads if fragments missing + soft tissue injuries - 1 parallel PA rad, 2 additional rads with different vertical/horizontal angulations - occlusal rad - CBCT may be considered for better visualisation of fracture path extent and relationship to marginal bone TREATMENT: - until plan finalised, temporary stabilisation of loose fragment to adjacent teeth/to non mobile fragment attempted - consider removal of coronal or mobile fragment and restoration - cover exposed dentine with glass ionomer or bonding agent + composite FUTURE TX OPTIONS: - ortho extrusion of apical/non-mobile fragment then restoration - surgical extrusion - RCT + restoration if pulp necrotic - root submergence - intentional re plantation with or without rotation of root - XLA - auto transplantation

Answer 9

1) The PDL cells are most likely viable. The tooth has been replanted immediately or within a very short time (about 15 minutes) at the place of accident. 2) The PDL cells may be viable but compromised. The tooth has been kept in a storage medium (eg, milk, HBSS (Save-a-Tooth or similar product), saliva, or saline, and the total extra-oral dry time has been <60 minutes). 3)The PDL cells are likely to be non-viable. The total extra-oral dry time has been more than 60 minutes, regardless of the tooth having been stored in a medium or not.

Answer 10

The tooth has been replanted at the site of injury or before the patient's arrival at the dental clinic - Clean the injured area with water, saline, or chlorhexidine. - Verify the correct position of the replanted tooth both clinically and radiographically. - Leave the tooth/teeth in place (except where the tooth is malpositioned; the malpositioning needs to be corrected using slight digital pressure). - Administer local anesthesia, if necessary, and preferably with no vasoconstrictor. - If the tooth or teeth were replanted in the wrong socket or rotated, consider repositioning the tooth/teeth into the proper location up to 48 hours after the traumatic incident. - Stabilize the tooth for 2 weeks using a passive flexible splint such as wire of a diameter up to 0.016” or 0.4 mm bonded to the tooth and adjacent teeth. Keep the composite and bonding agents away from the gingival tissues and proximal areas. - Alternatively, nylon fishing line (0.13-0.25 mm) can be used to create a flexible splint, using composite to bond it to the teeth. Nylon (fishing line) splints are not recommended for children when there are only a few permanent teeth for stabilization of the traumatized tooth. This stage of development may result in loosening or loss of the splint. - In cases of associated alveolar or jawbone fracture, a more rigid splint is indicated and should be left in place for about 4 weeks. - Suture gingival lacerations, if present. - Initiate root canal treatment within 2 weeks after replantation Administer systemic antibiotics Check tetanus status Provide post-operative instructions. (see: “Patient instructions”) Follow up. (see: “Follow-up procedures”)

Answer 11

- If there is visible contamination, rinse the root surface with a stream of saline or osmolality-balanced media to remove gross debris. - Check the avulsed tooth for surface debris. Remove any debris by gently agitating it in the storage medium. Alternatively, a stream of saline can be used to briefly rinse its surface. - Put or leave the tooth in a storage medium while taking a history, examining the patient clinically and radiographically, and preparing the patient for the replantation. - Administer local anesthesia, preferably without a vasoconstrictor - Irrigate the socket with sterile saline. - Examine the alveolar socket. If there is a fracture of the socket wall, reposition the fractured fragment into its original position with a suitable instrument.(eg flat plastic) - Removal of the coagulum with a saline stream may allow better repositioning of the tooth. - Replant the tooth slowly with slight digital pressure. Excessive force should not be used to replant the tooth back into its original position. - Verify the correct position of the replanted tooth both clinically and radiographically. - Stabilize the tooth for 2 weeks using a passive, flexible wire of a diameter up to 0.016” or 0.4 mm.32 Keep the composite and bonding agents away from the gingival tissues and proximal areas. Alternatively, nylon fishing line (0.13-0.25 mm) can be used to create a flexible splint, using composite to bond it to the teeth. Nylon (fishing line) splints are not recommended for children when there are only a few permanent teeth as stabilization of the traumatized tooth may not be guaranteed. - In cases of associated alveolar or jawbone fracture, a more rigid splint is indicated and should be left in place for about 4 weeks. - Suture gingival lacerations, if present. - Initiate root canal treatment within 2 weeks after replantation (refer to “Endodontic Considerations”).38, 39 Administer systemic antibiotics.34, 35 (see: “Antibiotics”) Check tetanus status.36 (see: “Tetanus”) Provide post-operative instructions. (see: “Post-operative instructions”) Follow up. (see: “Follow-up procedures”)

Answer 12

- Remove loose debris and visible contamination by agitating the tooth in physiologic storage medium, or with gauze soaked in saline. Tooth may be left in storage medium while taking a history, examining the patient clinically and radiographically, and preparing the patient for the replantation. - Administer local anesthesia, preferably without vasoconstrictor. - Irrigate the socket with sterile saline. - Examine the alveolar socket. - Remove coagulum if necessary. - If there is a fracture of the socket wall, reposition the fractured fragment with a suitable instrument. - Replant the tooth slowly with slight digital pressure. The tooth should not be forced back to place. - Verify the correct position of the replanted tooth both clinically and radiographically. - Stabilize the tooth for 2 weeks flexible splint (same splinting options as prior cards with the whole nylon thing) - A more rigid splint is indicated in cases of alveolar or jawbone fracture and should be left in place for about 4 weeks. - Suture gingival lacerations, if present. - Root canal treatment should be carried out within 2 weeks (refer to Endodontic Considerations). Administer systemic antibiotics.34, 35 (see: “Antibiotics”) Check tetanus status.36 (see: “Tetanus”) Provide post-operative instructions. (see: “Post-operative instructions”) Follow up. (see: “Follow-up procedures”)

Answer 13

Delayed replantation has a poor long-term prognosis. The periodontal ligament becomes necrotic and is not expected to regenerate. The expected outcome is ankylosis-related (replacement) root resorption. The goal of replantation in these cases is to restore, at least temporarily, esthetics and function while maintaining alveolar bone contour, width and height. Therefore, the decision to replant a permanent tooth is almost always the correct decision even if the extra-oral dry time is more than 60 minutes. Replantation will keep future treatment options open. The tooth can always be extracted, if needed, and at the appropriate point following prompt inter-disciplinary assessment. Parents of pediatric patients should be informed that decoronation or other procedures such as autotransplantation might be necessary later if the replanted tooth becomes ankylosed and infra-positioned, depending on the patient's growth rate and the likelihood of eventual tooth loss. The rate of ankylosis and resorption varies considerably and can be unpredictable.

Answer 14

- Clean the area with water, saline, or chlorhexidine. - Verify the correct position of the replanted tooth both clinically and radiographically. - Leave the tooth in the jaw (except where the tooth is malpositioned; the malpositioning needs to be corrected using slight digital pressure). - Administer local anesthesia, if necessary, and preferably with no vasoconstrictor. - If the tooth or teeth were replanted in the wrong socket or rotated, consider repositioning the tooth/teeth into the proper location for up to 48 hours after the trauma. - Stabilize the tooth for 2 weeks using a passive and flexible wire of a diameter up to 0.016” or 0.4 mm. Short immature teeth may require a longer splinting time. - In cases of associated alveolar or jawbone fracture, a more rigid splint is indicated and should be left in place for 4 weeks. - Suture gingival lacerations, if present. - Pulp revascularization, which can lead to further root development, is the goal when replanting immature teeth in children. The risk of external infection-related (inflammatory) root resorption should be weighed against the chances of revascularization. Such resorption is very rapid in children. If spontaneous revascularization does not occur, apexification, pulp revitalization/revascularization, or root canal treatment should be initiated as soon as pulp necrosis and infection is identified (refer to Endodontic Considerations). Administer systemic antibiotics.34, 35 (see: “Antibiotics”) Check tetanus status.36 (see: “Tetanus”) Provide post-operative instructions. (see: “Post-operative instructions”) Follow up. (see: “Follow-up procedures”)

Answer 15

- Clean the area with water, saline, or chlorhexidine. - Verify the correct position of the replanted tooth both clinically and radiographically. - Leave the tooth in the jaw (except where the tooth is malpositioned; the malpositioning needs to be corrected using slight digital pressure). - Administer local anesthesia, if necessary, and preferably with no vasoconstrictor. - If the tooth or teeth were replanted in the wrong socket or rotated, consider repositioning the tooth/teeth into the proper location for up to 48 hours after the trauma. - Stabilize the tooth for 2 weeks using a passive and flexible wire of a diameter up to 0.016” or 0.4 mm.32 Short immature teeth may require a longer splinting time. Keep the composite and bonding agents away from the gingival tissues and proximal areas. - In cases of associated alveolar or jawbone fracture, a more rigid splint is indicated and should be left in place for 4 weeks. - Suture gingival lacerations, if present. If spontaneous revascularization does not occur, apexification, pulp revitalization/revascularization or root canal treatment should be initiated as soon as pulp necrosis and infection is identified (refer to Endodontic Considerations). Administer systemic antibiotics.34, 35 (see: “Antibiotics”) Check tetanus status.36 (see: “Tetanus”) Provide post-operative instructions. (see: “Post-operative instructions”) Follow up. (see: “Follow-up procedures”)

Answer 16

- Check the avulsed tooth and remove debris from its surface by gently agitating it in the storage medium. Alternatively, a stream of saline can be used to rinse its surface. - Place or leave the tooth in a storage medium while taking the history, examining the patient clinically and radiographically and preparing the patient for the replantation. - Administer local anesthesia, preferably with no vasoconstrictor. - Irrigate the socket with sterile saline. - Examine the alveolar socket. If there is a fracture of the socket wall, reposition the fractured segment with a suitable instrument eg flat plastic. - Replant the tooth slowly with slight digital pressure. - Verify the correct position of the replanted tooth both clinically and radiographically. - Stabilize the tooth for 2 weeks using a passive and flexible wire of a diameter up to 0.016” or 0.4 mm.32 Keep the composite and bonding agents away from the gingival tissues and proximal areas. - In cases of associated alveolar or jawbone fracture, a more rigid splint is indicated and should be left for about 4 weeks. - Suture gingival lacerations, if present. If spontaneous revascularization does not occur, apexification, pulp revitalization/revascularization, or root canal treatment should be initiated as soon as pulp necrosis and infection is identified (refer to Endodontic Considerations). Administer systemic antibiotics.34, 35 (see: “Antibiotics”) Check tetanus status.36 (see: “Tetanus”) Provide post-operative instructions. (see: “Post-operative instructions”) Follow up. (see: “Follow-up procedures”)

Answer 17

Amoxicillin or penicillin due to effectiveness against on oral flora and low incidence of side effects Alternative abx should be consider for pts with allergy to penicillin Doxicycline appropriate to use bc of Antimicrobial anti inflammatory and anti resorptive effects BUT NOT FOR UNDER 12 YRS OF AGE due to potential discolouration of permanent teeth