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Paediatric Trauma in the Permanent Dentition Flashcards

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1
Q

During the MH assessment of the child, what specific things would set alarm bells off?

A

Bleeding disorders
Congenital heart defects
Immunosuppression
Rheumatic fever

Check tetanus immunisation status

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2
Q

What aspects of the trauma history would you want to know?

A

When did it happen?
What were you doing when it happened?
Do you have any other symptoms? Nausea? Amnesia? Headache?
Do you still have the tooth/fragment? Do you know where it is?

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3
Q

What aspects of E/O examination would you want to do in a child with dental trauma?

A

Haemorrhage
Subconjunctival Haemorrhage
CSF coming out nose
Bony step deformity
Lacerations
Mouth opening

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4
Q

What aspects of intra-oral examination would you want to explore?

A

Soft tissue- penetrating wounds, foreign bodies
- Palpate the soft tissues to feel any overlying lacerations.
Alveolar bone
Occlusion
Teeth

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5
Q

What is the paediatric trauma stamp?

A

Mobility
Colour
TTP
Sinus
Percussion
EPT
ECL
Radiograph

Also check occlusion- not part of the trauma stamp but it will influence treatment
- Ask the patient to bite together and ask them if it feels different.t

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6
Q

What would a duller or higher percussion note indicate?

A

Dull note- Root fracture
High note- ankylosis

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7
Q

How would you carry out a sensibility test of a traumatised tooth?

A

Cotton wool roll into the buccal sulcus
Dry the tooth with 3 in 1 or cotton wool roll.
Get patient to hold onto metal handle of the EPT machine, add the conductor to the probe and place it onto the tooth.
Tell patient to let go of the metal handle when they feel something on the tooth (feels like a tickle).

Same for the Ethyl Chloride
- spray the cotton wool pledget with ECL and place on tooth, ask patient to say if they feel something.

Always test adjacent teeth and opposing teeth as well.

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8
Q

How long after the injury should the tooth be sensibility tested?

A

2 years.

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9
Q

What factors influence the prognosis of a traumatised tooth?

A

Stage of root development
Type of injury
If PDL is damaged too
Time in between injury and treatment
Presence of infection

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10
Q

How would you manage an enamel fracture?

A

Account for the fragment.
Take a paralleling PA radiograph.
- May need supplemental radiographs if soft tissue injuries are present or if the fragment is not accounted for.

If fragment still present- bond back on.
If no fragment, smooth off edges or composite placed if a larger enamel fracture.

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11
Q

What is the recommended follow up for an enamel fracture?

A

6-8 weeks
1 year

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12
Q

How would you manage an enamel-dentine fracture?

A

Account for the fragment.

Take paralleling PA radiograph.
Lateral pre-maxilla to rule out any foreign objects embedded into the lip.

Trauma stamp.

Treatment- either bond the fragment back on- must be hydrated in water first for 20 mins before re-bonding.

or

Place composite bandage.
- If fracture is within 0.5mm of the pulp chamber- line with calcium hydroxide.

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13
Q

What is the follow up for an enamel-dentine fracture?

A

6-8 weeks
6 months
1 year

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14
Q

What would be reviewed at each review appointment?

A

Trauma stamp

Check radiographs for
- Root development- width of canal (want it to start to narrow) and length (increase in length)
Comparison with contralateral tooth
Internal and external inflammatory root resorption
Periapical pathology

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15
Q

What is the chance of pulpal necrosis 10 years post-injury for enamel fracture and enamel-dentine fracture?

A

Enamel- 0%
Enamel-dentine- 5%

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16
Q

What would be a favourable outcome following treatment of a traumatised tooth?

A

Continued root development
Thicker pulpal walls- dentine formation
Absence of PA pathology
Asymptomatic
Positive response to sensibility tests

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17
Q

What would be an unfavourable outcome following treatment of a traumatised tooth?

A

Symptomatic
Pulp necrosis and infection
Apical periodontitis
Lack of further root development
Breakdown of restoration

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18
Q

What clinical and radiographic features might suggest that a tooth is non-vital?

A

Clinical
- Negative sensibility tests
- Black/grey/brown colouration of tooth
- Sinus tract present
- Swelling
- TTP after asymptomatic period

Radiographic
- PA radiolucency
- Infection-related external root resorption

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19
Q

What factors influence treatment in an enamel-dentine-pulp fracture?

A

Size of exposure
Time since injury
Associated PSL injuries

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20
Q

What management options are there for an enamel-dentine-pulp fracture?

A

Pulp cap- exposure less than 1mm and less than 24 hours since injury

Cvek Pulpotomy- Exposure greater than 1mm or greater than 24 hours after injury.

Full coronal pulpotomy- only indicated if partial pulpotomy is started and the pulp is hyperaemia or necrotic.

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21
Q

Describe the procedure of a direct pulp cap?

A

A direct pulp cap is when a biocompatible material is placed over the pulp exposure prior to placement of a lining material and restoration.

LA (if required) and rubber dam applied
Clean area with water and then disinfect area with sodium hypochlorite
Apply calcium hydroxide or MTA to pulp exposure.
Restore with composite.

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22
Q

What are the advantages and disadvantages of a direct pulp cap?

A

Advantages- easy, less traumatic for the child, no LA required.

Disadvantages- Lower success rate compared to Cvek pulpotomy- increased risk of loss of vitality and arrested tooth development.

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23
Q

Describe the procedure of a Cvek pulpotomy?

A

Partial pulpotomy involves removing 1-3mm of the coronal pulp located directly adjacent to the pulp exposure.

Give LA
Apply dental dam
Remove 1-3mm of coronal pulp using a high speed bur or excavator- copious irrigation.
Irrigate the wound surface with sterile saline and dry with cotton wool pellet.
If haemostasis achieved- apply non-setting calcium hydroxide and use a cotton wool pledget to apply pressure.
If haemostasis not achieved- carried out full coronal pulpotomy.
Restore tooth with GI and then composite.

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24
Q

What are the advantages and disadvantages of a Cvek pulpotomy?

A

Advantages
- Good success rate in maintaining pulp vitality and allowing continuing maturation of the immature tooth.
- Sensibility testing can still monitor the tooth
- Likely to maintain aesthetics
- Preparation of the pulp canal space allows mechanical retention of pulpotomy agent.

Disadvantages
- Requires increased level of co-operation
- Technique sensitive.

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25
Describe the procedure of a full coronal pulpotomy.
Begin with partial pulpotomy- if you cannot achieve haemostasis or the pulp is necrotic- commence to full coronal pulpotomy. Removal full coronal pulp to the cervical area of the tooth. Saline-soaked cotton wool pellet placed over the pulp- check haemostasis. Non-settin calium hydroxide over the pulp. GIC Restore with composite.
26
What is the aim of a pulpotomy?
Keep vital pulp tissue within the canal to allow normal root growth both in length of the root and thickness of the dentine.
27
What follow up is required for an enamel-dentine-pulp fracture?
6-8 weeks 3 months 6 months 1 year
28
If a tooth is not vital in an immature incisor- what action is required?
Full pulpectomy.
29
What clinical problem is present in a non-vital tooth that is immature?
No apical stop to allow obturation with GP.
30
What management options exist for an immature tooth that is non-vital, in order to have an apical stop?
MTA/biodentine placed at apex of canal to create cement barrier. Regenerative endodontic technique to encourage hard tissue formation at apex.
31
Describe the procedure of a pulpectomy in an open apex tooth?
LA given Rubber dam applied (pulp canal contents will have already been removed) Haemorrhage control- LA/sterile water Diagnostic radiograph for WL Remove pulp canal contents to 2mm short of EWL. Irrigate with chlorhexidine. Dry canal, non-setting calcium hydroxide, CW in pulp chamber. GI cement in access cavity and evaluate calcium hydroxide fill level with radiograph. Leave the non-setting calcium hydroxide for no longer than 4-6 weeks. Then go back in with the MTA plus and heated GP obturation.
32
What would the final coronal restoration be for a root treated traumatised tooth?
Bonded core and then composite restoration.
33
What would you do with a crown-root fracture with no pulp exposure in a permanent tooth?
Account for the fragment. Fragment removal and restore Ortho extrusion of apical portion and then post-crown. Surgical extrusion Decoronation (reserve bone for future implant Extraction Fragment removal and gingivectomy- indicated in crown-root fractures with palatal subgingival extension.
34
What options are available for crown-root fracture with a pulp exposure?
Remove loose fragment and restore for up to 2 weeks before commencing RCT. Orthodontic extrusion of apical portion and post-crown. Surgical extrusion Decoronation Extraction
35
What is the follow up for a crown-root fracture?
1 week 6-8 weeks 3 months 6 months 1 year Every year until 5 years post-trauma
36
Do separation injuries or crushing injuries take longer to heal?
Crushing injuries take longer to heal because the damaged tissues must be removed by macrophages and osteoclasts first before the damage can be resolved. - This adds several weeks to the healing process.
37
What are the clinical findings of a concussion injury?
Pain on percussion but no increase in tooth mobility.
38
What is the treatment for a concussion injury?
No treatment Review clinically and radiographically- 4 weeks and 1 year.
39
What are the clinical findings of a subluxation injury?
Increased mobility TTP Bleeding from the gingival crevice may be present
40
What treatment is indicated for a subluxation injury?
Normally not required but can splint (passive flexible) for 2 weeks if excessive mobility or tenderness on biting. Review- 2 weeks (including splint removal, 12 weeks, 6 months and 1 year.
41
At the review appointment for a concussion or subluxation injury, what would you do?
Trauma stamp Radiographs- root development, comparison with contralateral tooth, resorption.
42
What are the % chance of pulp survival after 5 years with a concussion or subluxation injury?
Open apex- 100% Closed apex- 95% and 85% respectively.
43
What are the clinical manifestations of an extrusion injury?
Tooth appears elongated Usually displaced palatally Tooth mobile Bleeding from gingival crevice
44
What is the treatment for an extrusion injury?
Reposition the tooth gently by pushing it back into the tooth socket under LA. - Stabilise the tooth for 2 weeks with a flexible passive splint.
45
What is the follow up for an extrusion injury?
2 weeks 4 weeks 8 weeks 12 weeks 6 months 1 year Annually for at least 5 years
46
What is the 5 year pulp survival and resorption for a tooth that has been extruded?
Pulp survival - open apex- 95% - Closed apex- 45% Resorption - Open apex- 5% - Closed apex- 7%
47
What are the clinical findings of a lateral luxation injury?
Tooth appears displaced in the socket Tooth immobile High ankylotic percussion tone Bleeding from gingival sulcus Root apex may be palpable in the sulcus Radiograph- widening PDL space
48
What is the treatment for lateral luxation?
Reposition under LA- disengage the locked tooth and gently move the tooth back to its original position. - One finger used to push down over the apex of the tooth and the other finger is used to push the crown into its correct position. - Flexible passive splint for 4 weeks.
49
What is the follow up for a lateral luxation injury?
2 weeks- endo evaluation - PA radiograph- look for open or closed apex - Trauma stamp - Signs of necrosis 4 weeks (splint removal) 8 weeks 12 weeks 6 months 1 year Annually for at least 5 years
50
How does root formation influence treatment in a lateral luxation injury?
Incomplete root formation - Spontaneous revascularisation may occur. - If the pulp becomes necrotic and signs of infection-related external inflammatory resorption occur- commence endodontic treatment. Complete root formation - Pulp will likely become necrotic - Comence endodontic treatment. - Place calcium hydroxide as an intra-canal medicamentt to prevent the development of IRERR.
51
What is the 5 year pulp survival and resorption after a lateral luxation injury?
Pulp survival - Open apex- 95% - Closed apex- 25% Resorption - Open apex- 3% - Closed apex- 38%
52
What are the clinical and radiographic findings of an intrusive luxation?
Crown looks shorter Bleeding from gingivae Percussion tone high, metallic percussion tone PDL space may not be visible for all or part of the root CEJ is located more apically than in adjacent teeth
53
What is the treatment plan for an intrusive injury of an immature tooth?
Allow to spontaneously reposition, irrespective of the degree of intrusion. If no re-eruption within 4 weeks- orthodontic repositioning. Monitor pulp condition - if pulp becomes necrotic or if there are signs of IRERR- start endo treatment.
54
What is the treatment plan for an intrusive injury in a mature tooth?
less than 3mm extruded - Allow to spontaneously reposition. - If no eruption within 8 weeks- reposition surgical and splint for 4 weeks or reposition orthodontically before ankylosis develops. 3-7mm- reposition surgically or orthodontically Greater than 7mm- reposition surgically. Then start endo treatment at 2 weeks.
55
What is the follow up for an intrusive injury?
2 weeks 4 weeks 8 weeks 12 weeks 6 months 1 year Annually for 5 years
56
What measurements would you take for an intruded tooth to monitor re-eruption?
Clinical photographs Measure distance from incisal edge of the intruded tooth to the incisal edge of the adjacent tooth - do not measure from the gingival margin to the incisal edge of the tooth because the gingivae will be undergoing healing.
57
In a closed apex tooth, what is the 5 year pulp survival and root resorption?
Pulp survival- 0% Root resorption- 100%
58
What are the clinical findings of avulsion?
Socket empty or filled with coagulum
59
What critical factors determine successful re-implantation of an avulsed tooth?
Extra-alveolar dry time (EADT) Extra-alveolar time (EAT) Storage medium
60
What factors influence management of the avulsed tooth?
PDL cell condition Maturity of the root
61
What emergency advice would you give to a parent, who's child has just avulsed a tooth?
Keep the patient calm- reassurance Ensure it is a permanent tooth Get the tooth by the crown- do not touch the root. If the tooth is dirty- rinse gently in milk, saline or in the patient's saliva. Re-implant into socket ASAP. Get patient to bite down on gauze/handkerchief and hold in place once replanted. Seek dental advice If the tooth cannot be reimplanted at the site of the accident- place in storage medium- milk, saline, saliva, water. Bring the tooth tot he dentist ASAP.
62
What does PDL condition depend on?
Storage medium the tooth was kept in Extra-alveolar time
63
How does the clinician determine the condition of the PDL?
PDL cells likely to be viable - tooth reimplanted immediately or within 15 mins of accident. PDL cells may be viable but compromised - Tooth kept in storage medium and total EADT is less than 60 minutes. PDL cells are likely to be non-viable - Total extra-oral dry time has been more than 60 minutes, regardless of the tooth being stored in a medium or not.
64
What is the treatment for Avulsion of a permanent tooth with a closed apex?
If already implanted - clean the injured area - Verify re-implantation of the tooth and apical status - Place splint- 2 weeks - Suture gingival alcerations - Consider antibiotics and check tetanus status - Provide post-op instructions - Follow up If not re-implanted yet - Remove debris and clean tooth - History and examination in storage medium - Reimplant tooth under LA - Check clinically and radiographically that the tooth is in the correct position - Splint for 2 weeks - Suture gingival lacerations - Consider antibiotics and tetanus status Provide post-op instructions - Follow up Initiate root canal therapy after 2 weeks. - intra-canal medicament of calcium hydroxide for 1 months or corticosteroid/antibiotic paste for 6 weeks.
65
Although the prognosis of an avulsed tooth that has had an EADT of greater than 60 mins, if of poor prognosis. What are the benefits of still reimplanting it?
Restores aesthetics and function Maintains alveolar bone contour Alveolar bone height Keeps further restorative options open- i.e. implants. Tooth can still be extracted later down the line.
66
What is the follow up of an avulsed tooth?
2 weeks- splint removal 4 weeks 3 months 6 months 1 year Then annually for 5 years
67
What is the goal with re-implanting a tooth with an open apex?
Spontaneous revascularisation will occur to allow continued root development and root canal development. Keep the tooth asymptomatic and no signs of IRERR and pulp necrosis.
68
What is the management of a tooth with an open apex?
Remove debris History and examination with tooth in storage medium Replant tooth under LA Splint for 2 weeks Suture gingival lacerations Consider antibiotics and check tetanus status Provide post-op instructions Follow up
69
If there were signs of IRERR or pulp necrosis in an open apex tooth that had been re-implanted, what would you do?
Initiate RCT- would need MTA plug first because there would be no apical stop if the root was still immature.
70
What is the follow up for an avulsed tooth with an open apex?
2 weeks- splint removal 1 month 2 months 3 months 6 months 1 year
71
Under what circumstances, would you consider not re-implanting the tooth?
Child immunocompromised Other serious injuries requiring preferential emergency treatment Very immature apex and extended EAT greater than 90 mins
72
What type of antibiotics would you give a patient following an avulsion injury?
Phenoxymethylpenicillin- - 6-11 yo- 250mg 4 times per day - 12-17 yo- 500mg 4 times per day Check with Dr Richardson- guidelines says amoxicillin?
73
What post-op instructions would you give for an avulsion injury?
Avoid contact sports Soft diet for up to 2 weeks Brush teeth with a soft textured brush after each meal Use chlorhexidine mouthwash (0.12%) twice a day for 2 weeks- reduce bacterial load.
74
What type of splint is required for trauma cases?
Flexible passive splint - passive- no forces applied to the tooth. - Flexible- include one tooth either side of the traumatised tooth/teeth. Composite and stainless steel wire- up to 0.4mm. Titanium trauma splint- rhomboid mesh structure 0.2mm thick. Can also consider using acrylic wire or a vacuum formed splint.
75
How much MTA should be placed at the apex of a tooth?
5mm
76
Why might you want to use an intra-canal medicament of calcium hydroxide?
Induces a calcific barrier Reduces inflammatory resorption to an avulsed, re-implanted tooth.
77
Why is calcium hydroxide no longer recommended for use in apexification?
Root fracture Reduces mineral content of dentine
78
Describe the procedure for splinting of an avulsed tooth?
Measure the wire against the 3 teeth that will be placed on Cut the wire to the correct length using wire cutters Etch all 3 teeth for 10 seconds and wash off- high volume aspiration Bond applied- light cured Composite placed on the labial surface of teeth and wire placed on top- light cure Rough edges of wire or composite are polished using slow speed. Ensure wire and composite kept away from the gingivae.
79
What is a dento-alveolar fracture?
Fracture of the alveolar bone which may or may not involve the alveolar socket.
80
What are the clinical findings of a dento-alveolar fracture?
Complete alveolar fracture extending from the buccal to the palatal bone in the maxilla and from the buccal to the lingual bony surface in the mandible. Segment mobility and displacement with several teeth moving together Occlusal disturbance Gingival laceration
81
What is the treatment for a dento-alveolar fracture?
Reposition any displaced segment Stabilise by splinting for 4 weeks Suture gingival alterations Monitor pulp condition of al teeth involved- sensibility testing
82
What is the follow up for a dento-alveolar fracture?
Monitor clinically and radiographically - Root development including canal width and length, compare with neighbouring unaffected tooth - Resorption 4 weeks- splint removal 6-8 weeks 4 months 6 months 1 year Annually for at least 5 years
83

Paediatrics (13 decks)

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