Trauma

Question 1

Describe first aid for tooth avulsion.

Answer 1

• make sure it is a permanent tooth
• keep the patient calm
• find tooth and pick it up by crown (white part), avoid touching the root
• attempt to place tooth back into jaw
• if tooth is dirty, rinse it gently in milk, saline or in the patient’s saliva then place tooth back into jaw asap
• once tooth in jaw, ask patient to bite on gauze, a handkerchief or napkin to hold it in place
• if replantation is not possible (e.g. unconscious patient), place tooth in a storage medium (milk, HBSS, saliva, saline, water)
• bring tooth with patient to emergency clinic
• see dentist immediately

Question 2

What materials are available to the public for dental trauma first aid?

Answer 2

“Save a Tooth” poster
“ToothSOS” app for mobile phones

Question 3

What is the extra-oral alveolar time that most PDL cells become non-viable?

Answer 3

30 mins

Question 4

How can the condition of PDL cells be assessed on an avulsed tooth?

Answer 4

PDL cells most likely viable
Tooth replanted immediately or within 15 mins at place of accident

PDL cells may be viable but compromised
Tooth kept in a storage medium (milk, HBSS, saliva or saline), and EADT is less than 60 mins

PDL cells are likely to be non-viable
Total EADT has been more than 60 mins

Question 5

What is the treatment guideline for an avulsed permanent tooth with a closed apex that has been replanted at the site of injury?

Answer 5

• clean injured area with water, saline or CHX
• verify correct position of replanted tooth both clinically and radiographically
• leave tooth in place, any malpositioning needs to be corrected using slight digital pressure
• administer LA without vasoconstrictor, if necessary
• stabilise tooth for 2 weeks with a passive, flexible splint (up to 0.4mm diameter wire)
• suture gingival lacerations, if present
• initiate RCT within 2 weeks after replantationn
• administer systemic antibiotics
• check tetanus status
• provide post-op instructions (avoid contact sports, soft diet for 2 weeka, soft TB after meals, use CHX 0.12% 2x daily for 2 weeks)
• follow-up at 2 weeks to remvoe splint, then at 4 weeks, 3 months, 6 months, 1 year and yearly thereafter for at least 5 years

Question 6

What is the treatment guideline for an avusled permanent tooth with a closed apex that has been kept in a storage medium (milk, HBSS, saline) with EADT less than 60 mins?

Answer 6

• rinse tooth in saline to remove any gross debris
• administer LA without vasoconstrictor
• irrigate socket with sterile saline
• examine socket, if there is a socket wall fracture, reposition the fragment into its original position
• replant tooth with slight digital pressure
• verify correct tooth position clinically and radiographically
• stabilise for 2 weeks with a passive, flexible wire (up to 0.4mm diameter)
• suture gingival lacerations, if present
• initiate RCT within 2 weeks after replantatiom
• administer systemic antibiotics
• check tetanus status
• provide post-op instructions (no contact sports, soft diet 2 weeks, soft TB after meals, CHX 0.12% 2x daily for 2 weeks)
• follow-up at 2 weeks to remvoe splint, then at 4 weeks, 3 months, 6 months, 1 year and yearly thereafter for at least 5 years

Question 7

What is the treatment guideline for an avulsed permanent tooth with a closed apex that has EADT longer than 60 mins?

Answer 7

• remove deris with saline-soaked gauze
• administer LA without vasoconstrictor
• irrigate socket with sterile saline
• examine alveolar socket, remove coagulum if necessary. If there is a socket wall fracture, reposition it
• replant tooth slowly with slight digital pressure
• verify position clinically and radiographically
• stabilise tooth for 2 weeks using passive, flexible wire (up to 0.4mm diameter)
• suture gingival lacerations, if present
• initiate RCT within 2 weeks
• administer systemic antibiotics
• check tetanus status
• provide post-op instructions (no contact sports, soft diet 2 weeks, soft TB after meals, CHX 0.12% for 2 weeks)
• follow-up at 2 weeks to remvoe splint, then at 4 weeks, 3 months, 6 months, 1 year and yearly thereafter for at least 5 years

Question 8

What is the prognosis for delayed replantation?

Answer 8

• poor long-term prognosis
• replacement root resorption (ankylosis)

Question 9

What is the treatment guideline for an avulsed permanent tooth with an open apex that has been replanted at the site of injury/before patient’s arrival at the clinic?

Answer 9

• clean area with water, saline or CHX
• verify tooth position clinically and radiographically
• leave the tooth in jaw, correct any malpositions using slight digital pressure
• administer LA without vasoconstrictor
• stabilise tooth for 2 weeks using passive, flexible wire (up to 0.4mm diameter)
• suture gingival lacerations, if present
• initiate RCT if spontaneous pulp revascularisation does not occur
• administer systemic antibiotics
• check tetanus status
• provide post-op instructions (no contact sports, soft diet 2 weeks, soft TB after meals, CHX 0.12% 2 weeks)
• follow-up at 2 weeks to remove splint, then at 4 weeks, 3 months, 6 months, 1 year and yearly thereafter for at least 5 years

Question 10

What is the treatment guideline for an avulsed permanet tooth with an open apex that has been kept in milk, HBSS, salinne or water with EADT of less than 60 mins?

Answer 10

• rinse tooth with saline to remove gross debris
• administer LA without vasoconstrictor
• irrigate socket with sterile saline
• check alveolar socket, remove coagulum if necessary. if there is a socket wall fracture, reposition it
• replant tooth with slight digital pressure
• verify position clinically and radiographically
• stabilise tooth for 2 weeks using passive, flexible wire (up to 0.4mm diameter)
• suture gingival lacerations, if present
• initiate RCT if spontaneous pulp revascularisation does not occur (asses at review)
• administer systemic antibiotics
• check tetanus status
• provide post-op instructions (no contact sports, soft diet 2 weeks, soft TB after meals, CHX 0.12% 2 weeks)
• follow up at 2 weeks to remove splint, then at 4 weeks, 3 months, 6 months, 1 year and yearly thereafter for at least 5 years

Question 11

What is the treatment guideline for an avulsed tooth with an open apex that has EADT longer than 60 mins?

Answer 11

• rinse tooth with saline to remove debris
• administer LA without vasoconstrictor
• irrigate socket with saline
• check socket, remove coagulum if needed. If there is a socket wall fracture, reposition it
• replant tooth slowly with slight digital pressure
• verify position clinically and radiographically
• stabilise tooth for 2 weeks using a passive, flexible wire (up to 0.4mm diameter)
• suture gingival lacerations, if present
• initiate RCT if spontaneous pulp revascularisation does not occur (check at review)
• administer systemic antibiotics
• check tetanus status
• provide post-op instructions (no contact sports, soft diet 2 weeks, soft TB after meals, CHX 0.12% for 2 weeks)
• follow up at 2 weeks to remove splint, then at 4 weeks, 3 months, 6 months, 1 year, and yearly thereafter for at least 5 years

Question 12

What are the main post-traumatic complications?

Answer 12

• pulp necrosis and infection
• pulp space obliteration
• root resorption
• breakdown of marginal gingiva and bone

Question 13

What does pulp canal obliteration (PCO) indicate?

Answer 13

Indicates the presence of viable tissue within the root canal

Question 14

Define an enamel infarction.

Answer 14

An incomplete frature (crack or crazing) of the enamel,
without the loss of tooth structure

Question 15

What is the treatment guideline for an enamel infarction in a permanent tooth?

Answer 15

No treatment is necessary unless severe.
If severe, etch and seal with bonding resin.

No follow up is needed.

Question 16

What is included in a dental trauma stamp?

(8)

Answer 16

• colour
• mobility
• displacement
• tenderness to percussion
• percussion note
• ECL
• EPT
• sinus

Question 17

What is the treatment guideline for uncomplicated crown fractures involving enamel only in a permanent tooth?

and follow-up regime?

Answer 17

• account for missing fragments
• if fragment is missing and there are ST injuries, take radiographs of the lip and/or cheek to search for missing fragment
• if tooth fragment available, bond back onto tooth

Alternatively:
* smoothen tooth edges
* composite restoration

Follow-up regime:
* after 6-8 weeks
* after 1 year

Question 18

What is the treatment guideline for uncomplicated crown fractures involving enamel and dentine in a permanent tooth?

and follow-up regime?

Answer 18

• account for missing fragments
• if fragment missing and there are ST inuries, take radiographs of the lips and/or cheeks to locate missing fragment
• if tooth fragment available, rehydrate by soaking in water/saline for 20 mins
• cover exposed dentine with GIC. If exposed dentine is within 0.5mm of pulp (pink but no bleeding) place a calcium hydroxide lining and cover with GIC
• bond fragment back to tooth

Follow-up regime:
* after 6-8 weeks
* after 1 year

Question 19

Define a complicated crown fracture.

Answer 19

A fracture confinned to enamel and dentine with pulp exposure.

Question 20

What is the treatment guideline for a complicated crown fracture in a permanent tooth?

and follow-up regime?

Answer 20

• account for missing tooth fragments
• if fragment missing and there are ST injuries, take radiograph of lip and/or cheeks to locate missing fragment
• hydrate fragment in water/saline for 20 mins

Immature tooth (open root apices):
* partial pulpotomy
* pulp capping

Mature tooth (closed root apices):
* partial pulpotomy
* root canal treatment

Follow-up regime:
* after 6-8 weeks
* after 3 months
* after 6 months
* after 1 year

Question 21

Define an uncomplicated crown-root fracture.

Answer 21

A fracture involving enamel, dentine and cementum, without pulp exposure

Question 22

What is the treatment guideline for an uncomplicated crown-root fracture in a permanent tooth?

and follow-up regime?

Answer 22

• account for missing fragments
• temporary stabilisation of loose fragment until treatment plan is finalised
• cover exposed dentine with GIC
• consider removing coronal/mobile fragment and then restore

Future treatment options:
* orthodontic extrusion of the apical or non-mobile fragment, then restore ± periodontal re-contouring surgery after extrusionn
* surgical extrusion
* RCT and restore if the pulp becomes necrotic
* root submergence
* intentional replantation with or without rotation of root
* extraction
* autotransplantation

Follow-up regime:
* after 1 week
* after 6-8 weeks
* after 3 months
* after 6 months
* after 1 year
* yearly for at least 5 years

Question 23

Define a complicated crown-root fracture.

Answer 23

A fracture involving enamel, dentine, cementum and the pulp.

Question 24

What is the treatment guideline for complicated crown-root fractures for permanent teeth?

and follow-up regimes?

Answer 24

• account for missing fragments
• temporary stabilisation of loose fragment until treatmet plan is finalised

Immature tooth (open apices):
* partial pulpotomy

Mature tooth (closed apices):
* root canal treatment

Future treatment options:
* completion of RCT and restore
* orthodontic extrusion of the apical segment ± periodontal re-contouring surgery after extrusion
* surgical extrusion
* root submergence
* intentional replantation with or without rotation of the root
* extraction
* autotransplantation

Follow-up regime:
* after 1 week
* after 6-8 weeks
* after 3 months
* after 6 months
* after 1 year
* yearly for at least 5 years

Question 25

What is the treatment guideline for root fractures in permenanent teeth?

and follow-up regime?

Answer 25

• if displaced, reposition the coronal fragment as soon as possible
• check position radiographically
• stabilise the coronal fragment with a passive and flexible splint (up to 0.4mm SS wire) for 4 weeks. If fracture is located cervically, stabilise for up to 4 months
• in mature teeth where fracture line is above the alveolar crest and coronal fragment is very mobile, remove the fragment. then RCT and restore

Follow-up regime:
* after 4 weeks to remove splint
* after 6-8 weeks
* after 4 months to remove splint
* after 6 months
* after 1 year
* yearly for at least 5 years

Question 26

What is the treatmet guideline for alveolar fractures in permanent teeth?

and follow-up regime?

Answer 26

• reposition any displaced segment
• stabilise the segment with a passive and flexible splint (up to 0.4mm SS wire) for 4 weeks
• suture any gingival lacterations
• monitor pulp conditions to determine whether RCT becomes necessary

Follow-up regime:
* after 4 weeks to remove splint
* after 6-8 weeks
* after 4 months
* after 6 months
* after 1 ywar
* yearly for at least 5 years

Question 27

What is the treatment guideline for a concussion injury to a permanent tooth?

and follow-up regime?

Answer 27

• no treatment needed
• monitor pulp condition for at least 1 year

Follow-up regime:
* after 4 weeks
* after 1 year

Question 28

Define a subluxation injury.

Answer 28

An injury to the tooth-supporting structures with abnormal loosening, but without displacement of the tooth.

Question 29

What is the treatment guideline for a subluxation injury in a permanent tooth?

and follow-up regime?

Answer 29

No treatment needed unless there is excessive mobility or tenderness when biting on the tooth.
In which case stabilise the tooth with a passive and flexible splint (0.4mm SS wire) for 2 weeks

Follow-up regime:
* after 2 weeks to remove splint
* after 12 weeks
* after 6 months
* after 1 year

Question 30

Define an extrusive luxation injury.

Answer 30

Displacement of the tooth out of its socket in an incisal/axial direction.

Question 31

What is the treatment guideline for an extrusive luxation in a permanent tooth?

And follow-up regime?

Answer 31

• reposition tooth by gently pushing it back into the socket under LA
• stabilise the tooth using a passive and flexible splint (0.4mm SS wire) for 2 weeks
• if there is a breakdown or fracture of the marginal bone, splint for an additional 4 weeks

Follow-up regime:
* after 2 weeks to remove splint
* after 4 week
* after 8 weeks
* after 12 weeks
* after 6 months
* after 1 year
* yearly for at leasy 5 years

Question 32

Define a lateral luxation injury.

Answer 32

Displacement of the tooth in any lateral direction, usually associated with a fracture or compression of the alveolar socket wall or facial cortical wall.

Question 33

What is the treatment guideline for a lateral luxation injury in a permanent tooth?

and follow-up regime?

Answer 33

• reposition the tooth under LA (palpate the gingiva to feel the apex of the tooth. Use one finger to push downwards over the apical end of the tooth, then use another finger or thumb to push the tooth back into its socket)
• stabilise with a passive and flexible splint (0.4mm SS wire) for 4 weeks
• if there is a breakdown/fracture of the marginal bone or alveolar socket wall, splint for longer
• endodontic evaluation at 2 weeks

Immature tooth (open root apices):
* if pulp necrosis or root resorptionn occurs, start RCT

Mature tooth (closed root apices):
* start RCT (pulp necrosis likely to happen)

Follow-up regime:
* after 2 weeks
* after 4 weeks to remove splint
* after 8 weeks
* after 12 weeks
* after 6 months
* after 1 year
* yearly for at least 5 years

Question 34

Define an intrusive luxation injury.

Answer 34

Displacement of the tooth in an apical direction into the alveolar bone.

Question 35

What is the treatment guideline for intrusive luxations on permanent teeth?

and follow-up regime?

Answer 35

Immature tooth (open apices):
* allow re-eruption without intervention
* if no re-eruption within 4 weeks, initiate orthodontic repositioning
* monitor pulp conditions
* if pulp becomes necrotic, begin RCT

Mature tooth (closed apices):
If tooth is intruded less than 3mm:
* allow re-eruption without intervention
* if no re-eruption within 8 weeks, reposition surgically and splint using passive and flexible splint (0.4mm SS wire) for 4 weeks
* start RCT

If tooth is intruded 3-7mm:
* reposition surgically (preferably) or orthodontically
* start RCT at 2 weeks

If tooth is intruded beyond 7mm:
* reposition surgically
* start RCT at 2 weeks

Follow-up regime:
* after 2 weeks
* after 4 weeks to remove splint (less than 3mm intrusion)
* after 8 weeks
* after 12 weeks
* after 6 months
* after 1 year
* yearly for at least 5 years