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Primary Dentition Trauma Flashcards

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1
Q

Injuries to baby teeth occur most commonly at what age?

A

1.5 to 2.5 years old

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1
Q

Which teeth are most commonly injured?

A

Upper central incisors

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2
Q

Two types of injury to primary dentition

A
  1. Soft tissue injury
  2. Hard tissue injury
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3
Q

IADT dental trauma guide

A
  1. Crown fracture
  2. Crown-root fracture
  3. Concussion
  4. Subluxation
  5. Intrusion
  6. Lateral luxation
  7. Extrusion
  8. Root fracture
  9. Alveolar fracture
  10. Avulsion
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4
Q

Clinical Presentation of Concussion

A
  1. Tooth is tender to touch but no displacement
  2. Normal mobility and no sulcular bleeding
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5
Q

Treatment of Concussion

A
  1. Soft Diet
  2. Observation
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6
Q

Patient Education for Concussion

A

Soft brush or cotton swab with an alcohol-free 0.1-0.2% mouth rinse chlorhexidine gluconate applied topically twice a day for one week

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7
Q

Follow-up for Concussion?

A

1 week
6-8 weeks

Radiographic follow-up only indicated where clinical findings suggest pathology

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8
Q

Clinical Presentation of Subluxation

A
  1. Tooth mobile but not displaced
  2. Sulcus bleeding
  3. Tender to touch
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9
Q

Treatment of Subluxation

A
  1. Clean
  2. Soft diet
  3. Analgesics
  4. Monitor
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10
Q

Radiographic Recommendations and Findings for Subluxation

A

PA will show normal to slightly widened PDL space

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11
Q

Follow-up for Subluxation

A

1 week
6-8 weeks

Radiographic follow-up only indicated where clinical findings suggest pathology

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12
Q

When do we NOT manage lateral luxation tooth?

A
  1. Stable
  2. No interference with bite
  3. Can spontaneously reposition
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13
Q

When do we EXTRACT lateral luxation tooth?

A
  1. Tooth pushed into developing tooth bud
  2. Occlusal interference, reposition not possible
  3. Excess mobility, increased risk of aspiration
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14
Q

Immediate Repositioning of Lateral Luxation

A
  1. Clean the area with water spray, saline or chlorhexidine
  2. Apply LA
  3. Suture gingival lacerations
  4. Reposition tooth with gentle combined labial and palatal pressure
  5. If the tooth is unstable, stabilize with flexible splint for 4 weeks
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15
Q

Clinical Presentation of Lateral Luxation

A

Tooth is displaced, usually in a palatal/lingual or labial direction

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16
Q

Radiographic Recommendations and Findings of Lateral luxation

A

PA shows increased PDL space

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17
Q

Treatment for Lateral Luxation

A
  1. Spontaneous repositioning within 6 months
  2. Extract when there is a risk of aspiration
  3. Gently reposition the tooth +/- splint for 4 weeks
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18
Q

Clinical Findings of Intrusion

A

Tooth submerged into gums

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19
Q

Treatment of Intrusion

A
  1. Take a good history
  2. PA or occlusal to rule out
  • Avulsion
  • Aspiration
  • Embedding into soft tissues
  1. Leave alone unless infection or failure to re-erupt
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20
Q

Radiographic Recommendations and Findings of Intrusion

A

PA

Foreshortened image of luxated tooth implies root apex labial -> Safer

Elongated image, tooth has gone palatally towards tooth germ -> May need to extract

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21
Q

Will intruded teeth erupt?

A
  1. Spontaneous improvement in the position occurs within 6 months - 1 year
  2. Rapid referral
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22
Q

Follow-up for intrusion

A

1 week
6-8 weeks
6months
1 year
Further follow-up at 6 years for severe intrusion, to monitor eruption of permanent tooth

Radiograph follow-up indicated where clinical findings suggest pathology

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23
Q

Clinical Findings of Extrusion

A
  1. Tooth mobile
  2. Displaced out of socket
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24
Radiographic recomendations and findings of Extrusion
PA shows increased PDL space apically
25
Treatment of Extrusion
If extrusion 1-2mm, no occlusal interference -> Observe and let the tooth spontaneously reposition itself If extrusion >3mm, occlusion affected -> Extract
26
Follow-up for extrusion
1 week 6-8 weeks 1 year Radiographic follow up only indicated where clinical findings suggest pathosis
27
Clinical Findings of Avulsion
Tooth is completely out of socket
28
Radiographic Recommendations and Findings for Avulsion
PA shows empty socket -> Must account for that tooth -> Send to A&E to get a chest x-ray
29
Treatment of Avulsed Tooth
DO NOT re-implant
30
Follow-up of Avulsed Tooth
6-8 weeks 6 years of age to monitor eruption of permanent tooth Radiographic follow-up indicated when clinical findings suggest pathology
31
Management of Root Fractures
Stable -> Monitor Unstable -> Reposition and splint for 4 weeks
32
Management of Crown Fractures: No pulp exposure
1. Leave 2. Smoothen sharp edges 3. Composite restoration (strip crown)
33
Management of Crown Fractures: Pulp exposed
1. Pulpotomy/pulpectomy 2. Extraction
34
Management of Crown-root fractures: No pulp involvement
Remainder tooth large enough to allow coronal restoration: Remove the mobile fragment and cover exposed dentine with glass ionomer Otherwise: Extract
35
Management of Crown-root fractures: Pulp involvement
Stable fragment large enough to allow coronal restoration: Pulpotomy or RCT Otherwise: Extract
36
Management of Alveolar Fracture
1. Sedation or GA 2. Stabilise the segment with flexible splinting for 4 weeks 3. Monitor teeth in fracture line
37
Ways to examine or treat young injured child
1. Knee-to-knee 2. Seated on parent 2. Restraint and sedation
38
Extraoral Orofacial Signs of Physical Abuse
1. Bruising of face, ears 2. Abrasians and lacerations 3. Burns and bites 4. Choke or cord marks 5. Eye injuries 6. Hair pulling 7. Fractures (Nose> Mandible > Zygoma)
39
Intraoral Orofacial Signs of Physical Abuse
1. Contusions 2. Bruises 3. Abrasians and lacerations 4. Burns 5. Tooth trauma 6. Frenal injuries
40
Signs of Non-accidental Injury (NAI)
1. History of multiple injuries in different areas 2. Injuries at protected sites: Behind the ears
41
Torn labial frenum was previously associated with?
Force feeding
42
What is a bite mark?
A bite mark is a mark made by the teeth acting either alone or in combination with other mouth parts
43
Management of Suspected NAI
1. Photography 2. Avoid definitive opinion but consult expert ASAP
44
Risk factors of NAI
1. Parents' background 2. Society and culture 3. Family environment 4. Socio-economic environment
45
Instructions after treatment
1. Soft diet to prevent further trauma to injured tooth 2. Oral hygiene measures to encourage gingival healing - Support tooth when brushing - Clean affected area with soft brush or cotton swab - Alcohol-free 0.1% chlorhexidine gluconate mouth rinse applied topically twice a day for one week 3. Inform about possible effects on permanent tooth
46
Sequelae of Injury to Primary Tooth
1. Discolouration 2. Loss of vitality 3. Damage to permanent successor
47
Unfavourable Outcomes after treatment of trauma to primary tooth
1. Sinus tract, gingival swelling, abscess or increased mobility 2. Persistent dark grey discolouration 3. Radiographic signs: Periapical pathology or infection-related resorption
48
Signs of loss of vitality
1. Chronic Abscess 2. Periapical pathology 3. Pain, mobility, discolouration
49
What is the cause of yellow tooth discolouration?
Pulp canal obliteration
50
What are the causes of Grey tooth discolouration?
1. Probably hemorrhage 2. Happens quickly with subsequent gradual resolution 3. In isolation, not a sign of loss of vitality
51
What are the chances of damage to permanent successor?
More likely following intrusion/avulsion < 2 years old: 63% >5 years old: 25%
52
Other possible sequelae after trauma to primary teeth?
1. White or brown discolouration 2. Root dilaceration 3. Odontome-like malformation 4. Failure of tooth development
53
Aims of Treatment
1. Prevent further damage to permanent successor 2. Treat pain 3. Restore function 4. Restore aesthetics
54
Child ended up with abscess following non-treatment after crown fracture. What should you do?
1. Extract 2. Pulpectomy + Strip-crown restoration
55
When do we restore or leave alone?
1. Behaviour 2. Parental choice 3. Medical history: Cyanotic heart disease leading to increased risk of IE -> RCT or not? 4. Type of injury
56
What are the 3 main principles of luxation injury management?
1. Reduction - Reposition teeth and tissues to their original position 2. Fixation - Optimise healing outcomes for pulp and PDL - Improve function and provide comfort 3. Endodontic monitoring - Pulpal status - Periodontal healing
57
How to splint a tooth?
1. Stabilize the tooth using a passive and flexible splint (CR wire splint) 2. If breakdown of marginal bone or alveolar socket wall, split for an additional 4 weeks
58
Clinical Findings of a Lateral Luxation
1. Tooth displaced in palatal/lingual or labial direction 2. Usually associated fracture of alveolar bone 3. Immobile tooth as apex of root is locked in by the bone fracture 4. Percussion will give a high metallic sound 5. No response to pulp sensibility tests
59
Recommended Radiographs and Findings of Lateral Luxation
Parallel PA + 2 additional radiographs of tooth taken with different vertical and/or horizontal angulations Occlusal radiograph Widened PDL space seen
60
Treatment for Lateral Luxation
1. Reposition tooth by disengaging it from its locked position and gently reposition it into its original location under LA - Palpate gingiva to feel apex - Use one finger to push downwards over the apical end of tooth and another finger to push tooth back into socket 2. Stabilise for 4 weeks using passive and flexible splint. If fracture of alveolar socket wall, splint for an additional 4 weeks
61
Follow-up for Lateral Luxation
Clinical and Radiographic Evaluations 2 weeks, 4 weeks, 8 weeks,12 weeks 6 months 1 year Yearly for at least 5 years
62
When do you start RCT for pulp necrosis in lateral luxation tooth?
PDL healing to withstand clamps of rubber dam
63
How should RCT be started in lateral luxation tooth?
Corticosteroid-antibiotic or calcium hydroxide as an intracanal medicament to prevent the development of inflammatory external resorption
64
**Diagnosis** Soft tissue lacerations + Alveolar fracture #12 severe lateral luxation with rotation #11 avulsion #21 severe lateral luxation with possible intrusion #22 severe lateral luxation with possible intrusion What to do for short-term treatment 2 weeks post trauma?
1. Pulp extirpation and calcium hydroxide 2. Prevent inflammatory type root resorption 3. Keep splint
65
**Diagnosis** Soft tissue lacerations + Alveolar fracture #12 severe lateral luxation with rotation #11 avulsion #21 severe lateral luxation with possible intrusion #22 severe lateral luxation with possible intrusion What to do for medium-term treatment 4 weeks post trauma?
Splint removal and issue partial denture
66
**Diagnosis** Soft tissue lacerations + Alveolar fracture #12 severe lateral luxation with rotation #11 avulsion #21 severe lateral luxation with possible intrusion #22 severe lateral luxation with possible intrusion Why do we monitor Long-term?
Loss of PDL space, Replacement resorption: Bone replacing the root
67
Possible sequelae of incisor trauma
1. Loss of vitality 2. Internal and external root resorption 3. Pulpal calcification/obliteration 4. Ankylosis/Replacement resorption
68
Why do we do endodontic monitoring?
If pulp necrosis occurs, stimulus from infected pulp space will transverse the root and sustain inflammation around the root Inflammatory resorption will continue till whole root is resorbed
69
What happens if you don't extirpate the pulp within 1 hour?
Replacement Resorption will occur
70
Pathogenesis of Endodontic Infection
1. Protective layer (pre-cementum) is damaged during trauma 2. Inflammation due to injury occurs
71
What happens if PDL cells are viable?
Cemental healing can occur, resulting in surface resorption
72
What happens if large surface of PDL is damaged?
Replacement resorption will take over inflammatory resorption
73
Clinical Presentation of Replacement Resorption
Ankylosis/Infraocclusion
74
What happens if you move a tooth with pulp canal obliteration?
Increase risk of tooth becoming non-vital due to very slender neuro-vascular bundle
75
Types of Root Fracture
1. Single/multiple 2. Horizontal/vertical/oblique 3. Level: apical third, middle third, coronal third
76
How to Diagnose Root Fracture?
1. Mobility/point of rotation 2. Radiograph at two angles 3. Note also degree of separation between fragments
77
Difference between complicated and uncomplicated fracture
Touches pulp -> Complicated fracture Does not touch pulp -> Uncomplicated fracture
78
Clinical Findings of Root Fracture
1. Coronal segment may be mobile and may be displaced 2. Tooth may be tender to percussion 3. Bleeding from sulcus 4. Pulp sensibility may be negative initially, indicating transient or permanent neural damage
79
Recommended radiographs and findings of root fracture
One parallel PA + 2 additional radiographs of tooth taken with different vertical and horizontal angulations Occlusal radiograph
80
Treatment of Root Fracture
1. If displaced, the coronal fragment should be repositioned as soon as possible 2. Check repositioning radiographically 3. Stabilise the mobile coronal segment with a passive and flexible splint for 4 weeks 4. Monitor healing for fracture and pulp status for at least one year
81
Follow up for Root Fractures
Clinical and radiographic evaluations needed after 4 weeks, after 6-8 weeks, 4 months, 6 months, 1 year, then yearly for at least 5 years
82
**Diagnosis** 11 concussion 21 mid-root horizontal root fracture (2mm separation) with enamel-dentine pulp fracture 22 enamel-dentine fracture with subluxation What is the immediate management?
1. Reduce fracture and splint 2. Pulp protection 21 Cvek pulpotomy + CR bandage 22 CR bandage
83
Steps of Cvek pulpotomy
1. High speed + irrigation 2. Achieve hemostasis with pressure and cotton pellet soaked in saline
84
What are the pulp capping materials?
1. Non-setting CaOH 2. MTA causes discolouration 3. Tricalcium silicate materials: Biodentine
85
**Diagnosis** 11 concussion 21 mid-root horizontal root fracture (2mm separation) with enamel-dentine pulp fracture 22 enamel-dentine fracture with subluxation What do we do in 4-week review?
Splint removal and restore aesthetics
86
4 types of root fracture healing outcomes
1. Hard tissue union 2. Interposition of connective tissue 3. Interposition of bone and connective tissue 4. Granulation tissue: Coronal pulp necrosis
87
What happens if you miss out on diagnosis of root fractures?
Transient apical breakdown usually due to moderate injury to pulp or PDL + pulp in mature teeth It reflects repair processes taking place in the periapical area and pulp after trauma Consistently followed by surface resorption and/or obliteration of pulp canal
88
Clinical Features of Transient Apical Breakdown
1. Grey discoloration and loss of sensibility: Otherwise no other symptoms 2. Follows same course as TAB, return to normal with normalization of radiographic condition
89
**Diagnosis** 11, 21 severe intrusion (2/3 crown) + enamel-dentine fracture 22 moderate intrusion (1/2 crown) What is the recommended treatment plan?
1. Surgical extrusion: Pull the tooth out with forceps 2. Raise flaps for forceps to grip tooth sometimes 3. Pulp extirpation
90
Management of intruded teeth with complete root formation
Intrusion <3mm: Allow re-eruption within 8 weeks, reposition surgically and splint 2 weeks OR reposition orthodontically Intrusion 3-7mm: Reposition surgically (preferable) or orthodontically Intrusion >7mm: Reposition surgically RCT started as soon as position of tooth allows using corticosteroid-antibiotic or CaOH as intracanal medicament
91
**Diagnosis** 11, 21 severe intrusion (2/3 crown) + enamel-dentine fracture 22 moderate intrusion (1/2 crown) What is the medium-term treatment plan?
Post RCT and composite restoration of crown
92
**Diagnosis** 11, 21 severe intrusion (2/3 crown) + enamel-dentine fracture 22 moderate intrusion (1/2 crown) What to monitor in the long term?
Internal root resorption and pulp vitality of 22 Root resorption of 11, 21, 22
93
Classification of Root Resorption
1. Replacement resorption: Root is resorbed and replaced by bone 2. Inflammatory resorption: Infected pulp tissue act as constant stimulus for inflammation 3. Surface resorption: Limited to surface of cementum or dentin
94
What are our Treatment Aims?
1. Doing our best for the child and providing highest possible standard of evidence-based care which provides excellent long-term outcomes 2. Maintain dentition till adulthood for aesthetics and maximizing restorative treatment options

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