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BDS3 Paediatrics > Dental Trauma of Primary teeth > Flashcards

Dental Trauma of Primary teeth Flashcards

1
Q

What is the epidemiology of primary tooth trauma?

A
  • Prevalence is 16-40%
  • Male > Female
  • Peak incidence 2-4years
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2
Q

What is the aetiology of primary tooth trauma?

A
  • Falls
  • Bumping into objects
  • Non-accidental
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3
Q

What dental hard tissues and pulp can be injured?

A

Enamel fracture (uncomplicated crown fracture)

Enamel and dentine fracture (uncomplicated crown fracture)

Enamel, dentine and pulp fracture (complicated crown fracture)

Crown-root fracture

Root fracture

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4
Q

What is a crown root fracture?

A
  • Fracture involves enamel, dentine and root
  • Pulp may or may be involved
  • Complicated or uncomplicated
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5
Q

What specific types of injury can occur?

A
  • Concussion
  • Subluxation
  • Lateral luxation
  • Intrusion
  • Extrusion
  • Avulsion
  • Alveolar fracture
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6
Q

What is a concussion injury?

A
  • PDL injury
  • Tooth tender to touch but not displaced from arch
  • Normal mobility and no bleeding into gingival sulcus
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7
Q

What is subluxation injury?

A
  • Tooth tender to touch
  • Has increased mobility but not been displaced from line of arch
  • Bleeding from gingival crevice can be noted
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8
Q

What is lateral luxation injury?

A
  • Tooth displaced usually in palatal/lingual or labial direction
  • Fracture of alveolar socket
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9
Q

What is intrusion injury?

A
  • Type of luxation injury
  • Tooth usually displaced through labial bone plate
  • It can impinge on permanent tooth bud
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10
Q

What is an extrusion injury?

A
  • Type of luxation injury
  • Partial displacement of tooth out its socket
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11
Q

What is an avulsion injury?

A
  • Tooth completely out of the socket
  • Location of missing tooth should be determined in history taking
  • Risk of being embedded into soft tissues or more seriously inhaled
  • If tooth not found send child for medical assessment in emergency department, esp if child has respiratory issues
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12
Q

What is in alveolar fracture injury?

A
  • Fracture involved alveolar bone (labial and palatal/labial)
  • May extend to adjacent bone
  • Mobility and dislocation of segment with several teeth moving together is common
  • Occlusal interference usually present
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13
Q

What is the injury prevalence of different types of injury in primary dentition?

A

Luxation - 62-69%
Avulsion and ED fracture - 7-13%
Root fracture - 2-4%
Crown root fracture - 2%

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14
Q

What are the steps when managing a patient with trauma?

A
  1. Reassurance
  2. History
  3. Examination
  4. Diagnosis
  5. Emergency treatment
  6. Important info
  7. Further treatment and review
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15
Q

suWhat is included in a trauma history?

A

Injury
- When?
- Where?
- How?
- Any other symptoms or injuries?
- Lost teeth/fragments?

Medical History
- Congenital heart disease
- History of rheumatic fever or immunosuppression
- Bleeding disorders (haematology team contact)
- Allergies (short course of antibiotics may be required)
- Tetanus immunisation status (may need booster - contact health advisor)
- (Liase with GP)

Dental History
- Previous trauma (may raise concerns about physical abuse or neglect)
- Treatment experience
- Legal guardian/child attitude

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16
Q

What is included in the extraoral part of trauma examination?

A

Extraoral
- Lacerations/ swelling/ bruising (may require suturing or debridement
- Haematoma
- Haemorrhage / CSF
- Subconjunctival haemorrhage
- Bony step deformities
- Mouth opening (may be jaw fracture)

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17
Q

What is included in the intraoral part of trauma examination?

A
  • Soft tissues (penetrating wounds, foreign bodies etc)
  • Alveolar bone for any evidence of fracture
  • Occlusion (traumatic occlusion demands urgent treatment)
  • Teeth (mobility may indicate displacement, root or bone fractures)
  • Transillumination may show lines in teeth (crazing), pulpal degeneration, caries
  • Tactile test with may help detect horizontal and or vertical fractures, pulpal involvement
  • Percussion (duller note indicate fracture)
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18
Q

What special investigations can be used in a trauma examination?

A
  • Radiographs
  • May include a trauma stamp of 52,51,61,62
  • Mobility - Noted via +/-
  • Colour (Normal, Grey, Yellow, Pink)
  • TTP (Tender to percussion) - Noted via +/-
  • Sinus - noted via +/-
  • Percussion note (Normal or Dull)
  • Radiograph - Noted via =/-
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19
Q

What radiographs can you request in trauma examination?

A
  • Periapical
  • Anterior occlusal
  • Lateral pre-maxilla
  • Panoramic
  • Soft tissue
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20
Q

What are the possible diagnosis’ that can be made for each traumatic tooth?

A

Fracture
- Enamel (Uncomplicated crown fracture)
- Enamel-Dentine (Uncomplicated crown fracture)
- Enamel-Dentine-Pulp (Complicated crown fracture)
- Crown-Root (Uncomplicated or complicated)
- Root
- Alveolar

Concussion

Subluxation

Luxation

Lateral / Intrusive / Extrusive

Avulsion

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21
Q

What to do during an emergency situation?

A
  • Observation is often most appropriate option in emergency situation
  • Unless risk of aspiration, ingestion or occlusal interferences
  • Provision of dental treatment depends on child’s maturity and ability to cope - don’t want to make child more anxious
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22
Q

What important info do you need to tell parent/carer ?

A
  • Advise parent/carer regarding care of injured tooth/teeth to optimise healing and prevent further healing
  • Analgesia to reduce dental pain like paracetamol
  • Soft diet for 10-14days (can be normal diet but cut everything small, chew with molars)
  • Brush teeth with soft toothbrush after every meal
  • Topical chlorhexidine gluconate 0.12% mouthrinse applied topically twice daily for one week
  • Warn about signs of infection
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23
Q

What is an enamel fracture?

A
  • Fracture of tooth involving only enamel
  • Uncomplicated injury
  • Best to smooth sharp edges using soft flex disc or bond fragment to tooth
  • Take 2 periapical radiographs to rule out root fracture or luxation
  • Follow up 6-8weeks/6months/1year
    Prognosis - 0% risk of pulp necrosis
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24
Q

What is an enamel-dentine fracture?

A
  • Fracture of tooth involving enamel and dentine
  • Uncomplicated crown fracture
  • Best to cover all exposed dentine with glass ionomer/dentine
  • Lost tooth structure can be restored immediately with composite resin or at a later visit
  • Clinical exam after 6-8weeks
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25
Q

What is an enamel-dentine-pulp fracture?

A
  • Fracture of tooth exposing pulp
  • Complicated crown fracture
    Options
  • Partial pulpotomy
  • Extraction

To encourage gingival healing and prevent plaque accumulation parent should clean affected area with cotton swab combined with alcohol free 0.1-0.2% chlorhexidine gluconate mouth rinse twice a day for two weeks

Both options involve LA and depend on child’s ability to manage treatment
- Discuss options with parent/carer
- Can cause dental anxiety
- Clinical exam after 1 week, 6-8weeks then 1year

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26
Q

How to manage a crown-root fracture?

A
  • Remove loose fragment and determine if crown can be restored

If restorable
- No pulp exposed, cover exposed dentine with glass ionomer
- Pulp exposed, pulpotomy or endodontic treatment

If Unrestorable
- Extract loose fragments
- Don’t dig

Where root is retained clinical exam after 1 week, 6-8weeks, 1year

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27
Q

How to manage a root fracture?

A
  • If coronal fragment not displaced then no treatment indicated. Clinical exam 1week/6-8weeks/1year
  • If coronal fragment displaced but not excessively mobile - Leave fragment to spontaneously reposition even if some occlusal interference
  • If coronal fragment displaced, excessively mobile and interfering with occlusion
    Option A - Extract only loose coronal fragment and clinically exam after 1 year
    Option B - Reposition loose coronal fragment with flexible splint. Clinical exam 1week/4week splint removal/8week/1year
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28
Q

How to manage a concussion injury?

A
  • Clinical findings - Pain on percussion
  • No treatment
  • Radiograph
  • Review 1 month/1year
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29
Q

How to manage a subluxation injury?

A
  • No treatment
  • Splint if excessive mobility or tenderness when biting
  • Radiographs
  • Review 2-4weeks splint removal/ 3months/ 6months/1year
30
Q

How to manage lateral luxation injury?

A

If minimal / no occlusal interference then allow to reposition spontaneously

If severe displacement
- Extraction
- Reposition with flexible splint

31
Q

How to manage an intrusion injury?

A
  • Allow to spontaneously reposition, irrespective of direction of displacement
32
Q

Based on radiographs what are the two scenarios of intrusion with respect to direction of displacement?

A

Scenario 1
- Apical tip of intruded tooth can be seen
- Tooth appears shorter (aka foreshortened) compared to contralateral tooth
- Apex displaced towards/through labial bone plate
- Less likely to impinge on other teeth

Scenario 2
- Apex of intruded tooth can’t be visualised
- Tooth appears elongated compared to contralateral
- Suggest Apex displaced toward permanent tooth germ and increased risk of damage to permanent tooth developing

33
Q

How to manage extrusion injury?

A

If not interfering with occlusion
- Spontaneous repositioning
- Gently push back into socket under LA
- Splint

Excessive mobility or extruded >3mm
- Extract

Follow up - 2-4weeks splint removal/ 2months/3months/6months/1year then annually for at least 5years

34
Q

How to manage avulsion injury?

A
  • Radiograph to confirm avulsion
  • In primary dentition a primary tooth should NOT be reimplanted
35
Q

How to manage an alveolar fracture?

A
  • Reposition segment that is mobile or causing occlusal interference
  • Stabilised with flexible splint to adjacent uninjured teeth for 4 weeks
  • Teeth may need to be extracted after alveolar stability has been achieved
  • Clinical exam after 1week/4week splint removal/8 week/1 year
36
Q

What are the 3 sequelae of trauma to primary tooth?

A
  1. Discolouration
  2. Discolouration and infection
  3. Delayed exfoliation
37
Q

How does discolouration of traumatic primary tooth present?

A

Asymptomatic but discoloured tooth may be vital or non vital

Mild grey - Immediate discolouration may maintain vitality and can recede
Opaque/yellow - May indicate pulp obliteration

If no signs of pulp necrosis or infection then no treatment required and review per injury

38
Q

What is pulp obliteration?

A
  • Condition characterised by pronounce deposition of hard tissue along internal walls of root canal that fills most of pulp system leaving it narrowed and restricted
39
Q

What to do when traumatic tooth presents with discolouration and infection?

A

Tooth is symptomatic and non-vital
- Sinus, gingival swelling, abscess
- Increased mobility
- Radiographic evidence of periapical pathology
- Extract or endodontic treatment

40
Q

Consequences of delayed exfoliation?

A

Delayed exfoliation can cause ectopic eruption of permanent successor, delay eruption, prevent eruption
- Have consequences on occlusion and aesthetics and confidence of child

41
Q

How are injuries to permanent teeth related to age of trauma in primary teeth?

A
  • Intrusion shows most disturbance to permanent dentition

0-2years has 63% chance of injury to permanent
3-4 = 58%
5-6 = 24%
7-8 = 25%

42
Q

What injuries can occur to permanent successor following trauma in primary dentition?

A
  • Enamel defects (most common)
  • Abnormal crown/root morphology
  • Delayed eruption
  • Ectopic tooth position
  • Arrested development
  • Complete failure of tooth to form
  • Odontome formation
43
Q

What is enamel hypomineralisation and how to treat?

A
  • Qualitative defect of enamel i.e. normal thickness but poorly mineralised
  • White/ yellow defect
    Treatment
  • No treatment
  • Composite masking with or without localised removal before composite mask
  • Tooth whitening
44
Q

What is enamel hypoplasia and how to treat it?

A
  • Quantitative defect of enamel i.e. reduced thickness but normal mineralisation
  • Yellow/brown defect
    Treatment
  • No treatment
  • Composite masking
45
Q

What is Dilaceration?

A
  • Abrupt deviation of long axis of crown or root portion of the tooth
46
Q

What are crown dilaceration management options?

A
  • Surgical exposure and orthodontic realignment
  • Improve aesthetics restoratively
47
Q

What are root dilaceration/angulation/duplication management options?

A
  • Combined surgical and orthodontic approach
48
Q

How to manage delayed eruption due to traumatic primary dentition?

A
  • Premature loss of a primary tooth can result in delayed eruption of around 1 year due to thickened mucosa
  • Radiograph if > 6 month delay compared to contralateral tooth
  • Surgical exposure and orthodontic alignment may be required
49
Q

How to manage ectopic tooth position?

A
  • Surgical exposure and orthodontic realignment
  • Extraction
50
Q

How to manage arrested development due to traumatic primary dentition?

A
  • Endodontic treatment
  • Extraction
51
Q

How to manage complete failure of tooth to form due to traumatic primary dentition?

A
  • Tooth germ may sequestrate spontaneously
  • Or require removal
52
Q

What is an odontome?

A
  • Growth in which both epithelial and mesenchymal cells exhibit complete differentiation with result that functional ameloblasts and odontoblasts form enamel and dentin
  • Only option is surgical removal
53
Q

What sensibility tests can you do on detailed intro-oral exam of trauma?

A

Thermal - Ethyl chloride (ECL) or warm Gutta-Percha
Electrical - Electric pulp tester (EPT)

  • Compare to adjacent non-injured tooth
  • Test on adjacent and opposing teeth as they can receive direct or indirect concussive injuries
  • Continue sensibility tests at least 2years after
54
Q

What does complicated and non complicated mean?

A

Complicated - pulp involved
Non-complicated - pulp not involved

55
Q

What does prognosis of the tooth depend on?

A
  • Presence of infection
  • Time between injury and treatment
  • If PDL is also damaged
  • Type of injury
  • Stage of root development
56
Q

General aim of emergency treatment?

A
  • Retain vitality of any damaged or displaced tooth by protecting exposed dentine by an adhesive ‘dentine bandage’
  • Treat exposed pulp tissue
  • Reduction and immobilisation of displaced teeth
  • Tetanus prophylaxis
  • Antibiotics?
57
Q

General aim of intermediate treatment?

A
  • +/- Pulp treatment
  • Restoration (Minimally invasive e.g. acid etch restoration)
58
Q

General aim of permanent treatment following trauma?

A
  • Apexigenesis (vital pulp therapy procedure performed to encourage phsysiological development and formation of root)
  • Apexification (induce a calcific barrier in root with incomplete formation or open apex of tooth with necrotic pulp)
  • Root filling +/- root extrusion
  • Gingival and alveolar collar modification if required
  • Coronal restoration
59
Q

How to manage enamel-dentine fracture?

A
  • Account for fragment
  • Either bond fragment to tooth or place composite bandage
  • Take 2 periapical radiographs to rule out root fracture or luxation
  • Radiograph any lip or cheek lacerations to rule out embedded fragment
  • Sensibility testing and evaluate tooth maturity
  • Definitive restoration
  • Follow up 6-8weeks/6months/1year

Prognosis - 5% risk of pulp necrosis at 10years

60
Q

How to manage enamel-dentine-pulp fractures?

A

Evaluate exposure
- Size of pulp exposure
- Time since injury
- Associated PDL injuries

Choose either
- Pulp cap
- Partial pulpotomy
- Full coronal pulpotomy

Avoid full extirpation unless tooth clearly non-vital

61
Q

When and how to perform a direct pulp cap?

A
  • If tiny exposure 1mm within 24hour period
  • Trauma sticker and radiographic assessment
  • Should be non-TTP and positive to sensibility tests
  • LA and rubber dam
  • Clean area with water then disinfect with sodium hypochlorite
  • Apply calcium hydroxide (Dycal) or MTA white to pulp exposure
  • Restore tooth with quality composite restoration
  • Review 6-8weeks/6months/1 year
62
Q

When and how to perform partial pulpotomy?

A
  • Larger exposure >1mm or 24hrs+ since trauma
  • Trauma sticker and radiographic assessment
  • LA and dental dam
  • Clean area with saline then disinfect with sodium hypochlorite
  • Remove 2mm of pulp with hi-speed round diamond bur
  • Place saline soaked CW pellet over exposure until haemostasis acheived
  • If no bleeding or can’t arrest bleeding proceed to full coronal pulpotomy
  • Apply CaOH then GI then restore with quality composite
    Follow up 6-8weeks/6months/1year
63
Q

When and how to perform full coronal pulpotomy?

A
  • Begin with partial pulpotomy
  • Assess for haemostasis after application of saline soaked cotton wool
  • If hyperaemic or necrotic proceed to remove all coronal pulp
  • Place calcium hydroxide in pulp chamber
  • Seal with GIC lining and quality coronal restoration
    Follow up - 6-8weeks/6months/1year
64
Q

What is the aim of pulpotomy?

A
  • To keep vital pulp tissue within the canal to allow normal root growth (apexogenesis) both in the length of the root and the thickness of the dentine
65
Q

How to manage root treatment for immature incisors?

A
  • If tooth non-vital then full pulpectomy required
    Clinical problem - no apical stop to allow obturation with GP

Options
- CaOH placed in canal aiming to induce hard-tissue barrier to form (apexification)
- MTA/BioDentine placed at apex of canal to create cemenet barrier
- Regenerative Endodontic technique to encourage hard tissue formation at apex

66
Q

What is the technique for Pulpectomy?

A
  • Rubber dam
  • Gain access
  • Haemorrhage control (LA/sterile water)
  • Diagnostic radiographic for WL
  • File 2mm short of estimated WL
  • Dry canal, Non-setting Ca(OH)2 , CW in pulp chamber
  • Glass ionomer temporary cement in access cavity and evaluate calcium hydroxide fill level with radiograph

Place CaOH no longer than 4-6weeks after identified as non vital as problems with CaOH apexification
- MTA plug and heated GP obturation

Final coronal restoration
- Once obturation complete
- Consider bonded composite short way down canal as well as in access cavity
- Bonded core
- Try to avoid post crown

67
Q

What are the treatment options for crown-root fracture no pulp exposure?

A
  • Fragment removal only and restore
  • Fragment removal and gingivectomy (indicated in crown-root fractures with palatal subgingival extension)
  • Extraction
  • Decoronation (Preserve bone for future implant)
  • Surgical extrusion
  • Orthodontic extrusion of apical portion (1. Endo 2. Extrusion 3. Post-crown)
68
Q

What are the treatment options for crown-root fracture with pulp exposure?

A
  • Can be temporised with composite for up to 2weeks
  • Fragment removal and gingivectomy (indicated in crown-root fractures with palatal subgingival extension)
  • Extraction
  • Decoronation (Preserve bone for future implant)
  • Surgical extrusion
  • Orthodontic extrusion of apical portion (1. Endo 2. Extrusion 3. Post-crown)
69
Q

What other structures can injury have an impact on?

A
  • Surrounding bone
  • Neurovascular structure
  • Root surface
70
Q

How can the nature of the trauma be described?

A
  • Separation injury
  • Crushing injury

BDS3 Paediatrics (14 decks)

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