Trauma Flashcards
(118 cards)
1
Q
What guidelines should be consulted regarding trauma?
A
International Association of Dental Trauma
2
Q
Incidence of dental trauma has three peaks, what are they?
A
1) 2-3 years
2) 8-10 years
3) 15 years
3
Q
What injury is most common in preschool children?
A
luxation
4
Q
What occlusal factor can be a predisposing factor for trauma?
A
increased overjet with protrusion of upper incisors and incompetent lips
5
Q
Healing following trauma affects what tissues?
A
- pulp
- PDL
- apex formation
- bone
- gingivae/mucosa
6
Q
What kind of injury generally occurs as a result of a hard impact e.g. pavement, road, horse kick?
A
e.g. lightbulb and hammer = shatter
Chipping
7
Q
What kind of injury generally occurs as a result of a (relatively) soft impact e.g. fist, knee, elbow, dog?
A
e.g. lightbulb and boxing glove =. movement
displacement
8
Q
How quickly can junctional epithelium reattach?
A
within 5 days
9
Q
What does healing by primary intention mean?
A
2 sides of wound close and seal
10
Q
What does healing by secondary intention mean?
A
wider, scabbing and can scar
11
Q
What is anachoresis?
A
The transportation of foreign bodies via blood or lymph and subsequent collection at a site of inflammation
12
Q
Revascularisation of an apex is likely if the apex is of what diameter?
A
> _1mm
13
Q
Revascularisation of an apex is rare if the apex is of what diameter?
A
<_0.5mm
14
Q
What classification of dental injuries is used?
A
WHO 1995 classification
15
Q
Name the 7 types of dental injury in the WHO 1995 classification
A
1) enamel infraction
2) enamel fracture
3) enamel dentine fracture
4) enamel dentine pulp fracture
5) crown root fracture without pulp involvement
6) crown root fracture with pulp involvement
7) root fracture
16
Q
What is an enamel infraction?
A
incomplete crack of enamel without loss of tooth structure
- no tenderness or radiographic abnormalities
17
Q
Where is a fracture considered to be a root fracture?
A
cervical or mid 1/3
18
Q
What is an enamel fracture?
A
a complete fracture of the enamel, loss of enamel.
No visible signs of exposed dentine
19
Q
What are the signs of an enamel fracture?
A
- loss of enamel but no signs of exposed dentine
- not tender
- normal mobility
- radiographically enamel loss visible
- positive test to EPT
20
Q
What is an enamel dentine fracture (uncomplicated)?
A
confined to enamel and dentine with loss of tooth structure, but not exposing the pulp
21
Q
What are the signs of an enamel dentine fracture (uncomplicated)?
A
- confined to enamel and dentine, loss of structure but no pulpal exposure
- not TTP
- normal mobility
- sensibility test normally positive
- radiographically, loss of enamel and dentine
22
Q
If a tooth is tender, what should you evaluate the tooth for?
A
possible luxation or root fracture injury
23
Q
What is an enamel dentine pulp fracture (complicated)?
A
involving enamel and dentine with loss of tooth structure and exposure of the pulp
24
Q
What are the signs of an enamel dentine pulp fracture?
A
not TTP
Exposed pulp sensitive to stimuli
radiographically, enamel-dentine loss visible
25
What is a crown root fracture without pulp involvement?
involving enamel, dentine and cementum with loss of tooth structure, but not exposing the pulp
crown fracture extending below the gingival margin
26
What are the signs of a crown root fracture without pulp involvement?
- crown fracture extending below gingival margin
- TTP
- coronal fragment mobile
- sensibility test normally positive for apical fragment
- radiographically, apical extension of fracture usually not visible
27
What is a crown root fracture with pulp involvement?
- involving enamel, dentine and cementum exposing the pulp
28
What are the signs of a crown root fracture with pulp involvement?
TTP
coronal fragment mobile
radiographically, apical extension of fracture usually not visible
29
What is a root fracture?
fracture in cervical or mid 1/3 of tooth
30
What are the signs of a root fracture?
- coronal fragment may be mobile or displaced
- tooth may be TTP
- bleeding from gingival sulcus may be noted
- sensibility test may give negative results initially, indicating transient or permanent neural damage
- transient crown discolouration
- fracture in horizontal or oblique plane
31
A root fracture that is in the horizontal can usually be detected in what kind of radiograph?
regular periapical 90 degree angle film with central beam through tooth
horizontal plane common in cervical 1/3 of root
32
A root fracture in an oblique plane can usually be detected by what kind of radiograph?
oblique plane common in apical 1/3 fractures
- occlusal view or radiographs with varying horizontal angles more likely to demonstrate the fracture
33
What is an oblique plane?
any plane that is not in any of the coronal, sagittal, median or horizontal planes
34
What are the four main types of periodontal injury?
1) concussion
2) subluxation
3) luxation
4) avulsion
35
What is a concussion periodontal injury and what are the symptoms?
bruised
- no displacement
- TTP but no increased mobility
- no radiographic abnormalities
36
What is a subluxation periodontal injury and what are the symptoms?
loosened
- no displacement
- TTP and has increased mobility
- bleeding from gingival crevice may be noted
- sensibility testing may be negative initially due to transient pulpal damage
- no radiographic abnormalities
37
What is a luxation (extrusive) periodontal injury and what are the symptoms?
extrusive
- tooth appears elongated and excessively mobile
- sensibility tests likely negative
- radiographically, increased PDL space apically
38
What is a luxation (intrusive) periodontal injury and what are the symptoms?
intrusive
- displaced axially into the alveolar bone
- immobile and percussion may give high, metallic (ankylotic) sound
- sensibility tests likely negative
- radiographically, PDL space may be absent from all or part of root, CEJ located more apically in intruded tooth than adjacent non-injured tooth
39
What significance does the intrusion of a primary tooth have?
potential damage to developing tooth germ
40
What should be done if a primary tooth has been intruded but displaced labially?
displaced away from the tooth germ
monitor, measure and document amount of intrusion using fixed reference points to serve as baseline
41
What should be done if a primary tooth has been intruded palatally?
towards the permanent successor
extract
and explain possibility of damage to permanent successor to patient/parent
42
What is a lateral luxation injury?
tooth displaced in a palatal/lingual or labial direction
43
What are the signs of a lateral luxation?
tooth will be immobile and percussion usually gives high, metallic (ankylotic) sound
fracture of alveolus present
sensibilty tests negative
radiographically, widened PDL space seen on eccentric or occlusal exposures
44
How is the lateral luxation of a primary tooth managed?
- if no occlusal interference, tooth should be allowed to reposition spontaneously
- any doubt that root may be displaced toward (crown displaced labially) permanent tooth, then extract
- if root moves away from perm tooth, discuss with parents and consider monitoring/repositioning
- interference with occlusion - may be necessary to selectively grind tooth
45
What is an avulsion injury?
tooth knocked out
46
What is a degloving injury?
top layers of skin and tissue being torn away from the underlying muscle, connective tissue or bone
47
What kind of intra oral soft tissue injuries can occur?
- grazes/lacerations
- degloving injuries
- contusions (bruises)
48
What kind of extra oral soft tissue injuries can occur?
- grazes/lacerations
- contusions (bruises)
- inclusion of foreign bodies e.g. gravel, tooth fragments
49
What are four types of skeletal injury?
- alveolus - 2 or more teeth moving as a block
- mandible
- maxilla
- cranial injuries
50
What is an alveolar fracture?
- 2 or more teeth moving as a block
- fracture involves alveolar bone and may extend to adjacent bone
51
What are the signs of an alveolar fracture?
- segment mobility and dislocation with several teeth moving together
- occlusal change due to malalignment of fractured alveolar segment
- sensibility may or may not be positive
- radiographically, fracture lines at any level, from marginal bone to root apex and above apex.
52
What radiographs are commonly used to investigate alveolar fracture?
- in addition to the 3 angulations and occlusal film, additional views such as DPT can be helpful in determining course and position of fracture lines
53
What kind of preventions can be put in place for dental trauma?
difficult
- child with double digit overjet in mixed dentition consider early OJ reduction
- provide mouthguards/facemasks for children in contact sports
54
What is two phase over-jet reduction?
-first stage started age 7-11 years with functional appliance then second phase in adolescence, shows reduction in incisal trauma compared to one phase
55
What are the three types of gumshields?
1) stock (Type 1)
2) Boil and bite (Type II)
3) Custom-made (Type III)
56
What is a type I gumshield?
stock
bulky material/plastic
contact biting force to retain
57
What is a type II gumshield?
boil and bite
- thermoplastic moulded within mouth
- deform over time
58
What is a type III gumshield?
custom made
- ethylene vinyl acetate
- vacuum formed over stone cast
- 5mm thick and extend to distal 6s or further
- can be built in multiple layers (laminations)
- may also protect condylar head fracture
59
What is the most important rule when assessing a patient following trauma?
assess for signs of head trauma or other more urgent non-dental injuries first
assess for possible aspiration
60
If there is doubt of possible aspiration of tooth fragments what should be done?
contact local A&E/Hospital for further advice
61
What are battle signs?
bruising over mastoid process
62
What can mandibular deviation on opening be a possible sign of?
condylar fracture
63
What are the typical sites of accidental injury?
- head injuries tend to involve parietal bone, occiput or forehead
- nose, chin
- palm of hand
- elbows, knees, shins
64
Typical sites of non-accidental injury include what?
- ears - esp pinch marks
- "triangle of safety"
- inner aspect of arms
- back and side of trunk
- black eyes esp if bilateral
- soft tissues of cheeks
- IO injuries
- forearms when raised to protect
- chest and abdomen
- groin or genital injury
- inner aspect of thighs
- soles of feet
65
What is the "triangle of safety"?
- ear, side of face and neck, top of shoulders
accidental injuries in these areas are unusual
66
Concerns of non-accidental injury should be prompted by what?
- injuries on both sides of body
- injuries to soft tissues
- injuries with particular patterns
- any injury that does not fit explanation
- delays in presentation
- untreated injuries
67
If you have discussed a non-accidental injury concern with a manager, how quickly should you refer to social services by writing?
within 48 hours
68
What kind of complications do we review trauma patients for (primary teeth)?
- pulpal necrosis (most common)
- pulpal obliteration
- root resorption
- damage to successors
69
What should you look for when assessing for primary tooth pulpal necrosis?
- persistent grey colour that does not fade
- no reduction in size of pulp cavity
- radiographic signs of periapical inflammation
- clinical signs of infection - TTP, sinus, suppuration, swelling, symptoms, spacing around root
70
What are the 5 S's of pulpal necrosis?
Sinus
Suppuration
Swelling
Symptoms
Spacing around root
71
What should you do if there are signs of primary tooth pulpal necrosis?
extract if radiographic signs of inflammation or clinical signs of infection
72
What should you look for when assessing a tooth for signs of primary tooth pulpal obliteration?
clinically, tooth may become yellow/opaque colour
radiographically, chamber will shrink
73
What should you do is a tooth has signs of primary tooth pulpal obliteration?
nothing if asymptomatic
extract if radiographic signs and/or clinical signs of infection/inflammation
74
What should you look for when assessing a tooth for primary tooth root resorption?
- radiographic signs of root resorption
- possible clinical mobility
75
What should you do when a primary tooth has signs of root resorption?
extract if signs of infection
76
At what age does the maximum damage to successor teeth occur following trauma?
before 3 years of age because the tooth germ is still in developmental stage
77
What kind of injury carries the highest risk of damaging successor teeth?
Intrusive luxation
78
What kind of damage can occur to successor teeth following trauma and at what stage?
- white/yellow-brown enamel hypomineralisation; 2-7yrs
- white/yellow-brown enamel hypomineralisation and circular enamel hypoplasia; 2-7yrs
- crown dilaceration; approx 2yrs
- odontoma-like malformation; 1-3yrs
- sequestration of permanent tooth germs
79
Damage to the root of successor teeth can cause what presentations and at what age can this sort of damage occur?
- root duplication; 2-5yrs
- root dilaceration; 2-5yrs
- arrest of root formation - partial/complete; 5-7yrs
80
What is root dilaceration?
- deviation of root shape from the normal long axis formation
- has the potential to inhibit eruption
81
What should you look for when assessing a successor tooth for signs of root dilaceration?
- radiographic signs of root malformation/change in angulation
- delayed eruption/failure of eruption
82
How do you treat root dilaceration?
- depends on severity
- treatment planning may involve orthodontic and oral surgery input
- e.g. ortho realignment or possibly extraction
83
What kind of complications can we see in successor teeth following trauma?
- pulp necrosis
- resorption
- ankylosis (replacement resorption)
- external resorption
- internal resorption
- discolouration
84
What should you look for when assessing a permanent tooth for signs of pulpal necrosis?
- no response to sensibility testing
- greyish discolouration
- symptoms and history
- radiographic/clinical signs of periradicular inflammation/infection. In cases of immature teeth, no further signs of root development
85
What is transient apical breakdown?
sequelae of certain dental traumatic injuries where the injured tissues undergo a spontaneous process of repair (revascularisation) with no permanent damage to the pulp.
Increased cellular activity around apex can result in small radiolucent "cap" appearing on the 1/12 and 2/12 periapical views.
If radiolucency is only sign of non-vitality it may be prudent to wait and watch
86
If starting RCT within 2 weeks of reimplanting an avulsed tooth, what should you NOT use as the dressing and why?
CaOH as it can contribute to replacement resorption
87
How do you treat a permanent tooth with signs of pulpal necrosis when the tooth has a closed apex?
same as for adult tooth, begin endodontic treatment
88
How do you treat a permanent tooth with signs of pulpal necrosis with an open apex?
- we have no further root formation so no apical stop
- need to create apical stop/barrier or find way of encouraging root development (e.g. regenerative endo technique?)
- MTA apical barrier formation or CaOH apical barrier formation (MTA better)
89
Why is MTA considered better than CaOH as an apical barrier?
CaOH found to have drying effect on dentine, can cause fracture
90
What is the regenerative endodontic technique?
- works on principle of activating stem cells to recreate dental pulp
- intention is to allow continued root growth
91
What are the disadvantages of using CaOH as an apical barrier?
- time consuming to get a result
- incomplete apical barrier formation with vascular inclusions may lead to bacterial invasions
- changes in composition/structure of dentine; higher incidence of cervical root fractures as a result
92
Why is MTA the preferred treatment of choice for apical barrier formation?
- reliable
- considered gold standard for apexification
- shorter time
- confirmed hard barrier
93
How do you endodontically treat a tooth with a root fracture in the apical or mid 1/3/
root apical to fracture usually retains vitality
- apical 1/3 and mid 1/3 root fractures = treat up to point of fracture, DO NOT extend beyond fracture into apical portion
- MTA apical stop may be required at fracture line
- if apical portion becomes non-vital, may require surgical removal
94
How do you endodontically treat a tooth with a coronal 1/3 root fracture?
treatment options complicated due to unfavourable crown root ratio.
Options; splinting the coronal segment, extracting the coronal and apical portion, extracting the coronal portion
95
What does permanent tooth pulp canal obliteration occur due to?
arises from reactionary dentine formation in root canal and pulp chamber, causing space to narrow
96
What is the radiographic appearance of pulpal obliteration?
pulp chamber and root canal shrinking
97
What are the clinical signs of pulpal obliteration?
tooth may darken (yellowing) and will have a reduced response to sensibility tests
98
How do you treat a permanent tooth with pulpal canal obliteration?
monitor, can be difficult to access/find canal
- only treat if radiographic/clinical signs of periapical inflammation/infection
99
How can pulp canal obliteration cause pulpal necrosis?
reactionary dentine encroaches over time, narrowing canal
blood supply can become insufficient, causing pulpal necrosis
100
What are the four types of resorption seen in permanent teeth?
- external inflammatory resorption
- cervical resorption
- internal resorption
- replacement resorption
101
What is inflammatory resorption?
- caused by multi-nuclear giant cells
- these are stimulated as part of the inflammatory response. Sustained stimulation causes these cells to resorb tooth structure
102
What is external inflammatory resorption?
- occurs with teeth that have necrotic pulps and associated infection
- in external resorption, giant cells are activated in PDL and stimulus is the infected canal
- resorption can be rapid
103
How is external inflammatory resorption diagnosed?
radiographic - change in external contour of root
clinically - if excessive resorption, may have mobility
104
If a tooth with external inflammatory resorption is deemed restorable, how is it treated?
- commence RCT, dress with CaOH and monitor
review radiographically
105
What is cervical resorption?
- caused by damage to cervical region, inflammation caused by PDL microflora or infected root canal
- rare
- diagnosed in early stages radiographically
106
How is cervical resorption treated?
- for necrotic pulps, RCT
- for both necrotic and vital teeth, treatment may involve curettage of apical region and resorption defect
107
What is internal inflammatory resorption and how does it present?
- infected necrotic pulp may activate underlying vital tissue, resulting in resorption process
- can be seen as 'pink spot' discolouration if resorption affects coronal 1/3 of canal
- radiographically, can present as round, symmetrical radiolucency usually centred on canal
108
How is internal inflammatory resorption treated?
RCT, often tooth may be very vascular, dress with CaOH
109
When can replacement resorption (ankylosis) often occur?
- following large luxation or avulsion injury
110
What happens in replacement resorption (ankylosis)?
when more than 20% of the PDL is damaged before replanting or repositioning of tooth, bone cells are able to colonise the surface of the root faster than the PDL. Tooth becomes integrated in the bone and subsequently remodelled in the normal bone remodelling process
111
What happens to the mobility of a tooth following replacement resorption (ankylosis)?
as root unifies with surrounding bone, it will no longer have biological mobility and will appear solid
112
What is the radiographic appearance of a tooth with replacement resorption (ankylosis)?
no distinct demarcation between bone and tooth radiographically (absence of PDL)
113
In what age of the population does replacement resorption (ankylosis) occur quickest?
younger individuals where remodelling occurs more rapidly
114
What can a brownish colouring of the dentine following a trauma be a result of?
products of pulpal necrosis may permeate tubules and stain surrounding dentine. Initially pinkish, this may turn brownish due to haemosiderin from oxidising haemoglobin (rust)
115
Does discolouration indicate necrosis?
discolouration does not mean that the pulp is irreversibly necrotic, the tooth may revascularise and the colour improve
116
Comment on the mobility of recently erupted teeth
recently erupted teeth are normally more mobile than teeth in adult dentitions
117
What are the three classifications of mobility?
Class I - <1mm horizontal
Class II - >1mm horizontal
Class III - >1mm horizontal and vertical mobility
118
How should you review a previously traumatised tooth radiographically?
- reproduce same views as initial assessment
- radiograph the unaffected contralateral tooth of the same type to compare
- look for continued root development (narrowing of pulp space, continued root growth in an apical direction)
- signs of ankylosis, resorption, root fracture
