Trauma III Flashcards
(37 cards)
1
Q
What is avulsion?
A
- Avulsion is where the tooth comes completely out of the socket
2
Q
When can successful healing occur in avulsed teeth?
A
- Successful healing can occur if there is only minimal damage to the pulp and the PDL
3
Q
What are critical factors for avulsed teeth? (3)
A
- Extra-alveolar dry time - EADT
- Extra-alveolar time - EAT
- Type of storage medium
4
Q
What is EADT?
A
- This is the time the tooth is out of the mouth just in air (it is not in any storage medium)
5
Q
What is EAT?
A
- The amount of time it is out of the mouth and dry including the time it has been in any type of storage medium
6
Q
If a patient attends with an avulsed tooth that has already been replanted what would you do? (2)
A
- Do not remove. Leave as is and follow instructions regarding splinting etc dependent on circumstances
- Radiograph important to establish status of root development (want to know how much root is there, is it a mature or immature tooth - open or closed apex)
7
Q
What advice would we give to the public if they had experienced an avulsed tooth? (6)
A
- Essential for parents/sports coaches/teachers
- Hold by crown only
- Wash in cold running water (if there is obvious debris this can be done for up to 10 seconds)
- Replace in socket and child bites on tissue
- Or store in milk/saliva/normal saline
- IF there is a lot of trauma then you could potentially store it in the patients blood
- Seek immediate dental advice
8
Q
What is initial decision making about an avulsed tooth based on?
A
- Based on EADT (extra-alveolar dry time)
There are different things that we do depending on the time:
- EADT <30 mins
- EADT >30 mins
9
Q
Will all avulsed teeth heal in the same way?
A
No
10
Q
What are the possible periodontal outcomes of an avulsed tooth? (4)
A
- Regeneration
- PDL/cemental healing
- Bony healing
- Uncontrolled infection
11
Q
When is the regeneration periodontal outcome likely to occur with an avulsed tooth?
A
- Most likely to occur if the tooth is put straight back in the socket
12
Q
When is the PDL/cemental healing periodontal outcome likely to occur with an avulsed tooth?
A
- IF not put straight back in the socket
13
Q
What is the bony healing periodontal outcome of an avulsed tooth?
A
- Where the bone is fused right up to the tooth and starts a replacement resorption process that may or may not take a long time
14
Q
What is the uncontrolled infection periodontal outcome of an avulsed tooth?
A
- This is not healing at all - this would create granulation tissue, infection, abscesses etc
15
Q
What are the possible pulpal outcomes of an avulsed tooth? (3)
A
- Regeneration
- Controlled necrosis (elective disinfection)
- Uncontrolled infection
16
Q
Regeneration is the pulpal outcome that we want after avulsion. Why is this more likely to happen when we have a tooth with an open apex?
A
- When we thing about open apex - means the apex is really wide so have got lots of vessels in there that are coming into a wide area so this is more likely to regenerate than it is if you’ve got a closed apex (only have 1 nerve and 1 BV coming in so once it is ripped it is less likely to regenerate)
17
Q
What is the pulpal outcome ‘controlled necrosis’?
A
- Where we know that the tooth is going to become non vital so the live bit of the tooth is taken out before it actually dies or causes infection
- So we are stopping the inevitable
18
Q
What is the uncontrolled infection pulpal outcome?
A
- Where you have a necrotic pulp and this goes on to cause infection and other problems
19
Q
What is out aim if EAT <60 mins?
A
- PDL healing
- If EAT is <60mins and stored in an appropriate storage medium (e.g. milk, physiological saline or saliva) then there is a chance of cemental/PDL healing
20
Q
If we have an avulsed tooth with EAT <60 mins what would we do? (5)
A
- Replant tooth under LA
- Flexible splint for 14 days
- Consider antibiotics and check tetanus status
- Carry out pulp extirpation at 0-10 days UNLESS apex is open (immature root)
- Teeth with an open apex may revascularize
21
Q
The good thing about immature teeth is that you can tell relatively soon whether or not there has been revascularization. How do we do this?
A
- You take an x-ray further down the line and can compare it to the adjacent tooth to see if there has been continued root development - so actually find out pretty quickly whether or not your tooth is in a good situation r whether the pulp is coming out
22
Q
What would we do if we have an avulsed immature tooth (with open apex) with an EAT of <60mins?
A
- If the decision is not to root treat the tooth it must be closely monitored clinically and radiographically for signs of continued growth vs loss of vitality
- Review interval: 2 weeks (splint removal), 4 weeks, 2 months, 3 months, 6 months then yearly
- If the tooth is found to be non vital extirpate pulp and refer to paediatric specialist. Inter-disciplinary management is recommended
23
Q
What would we do if we have an avulsed mature tooth (with closed apex) with an EAT of <60mins?
A
- After replantation and splinting, remove pulp as soon as possible (ideally day 0)
- Following extirpation and disinfection, place antibiotic-steroid paste as intra-canal medicament - leave in place for 2 weeks
- Remove splint after 14 days
- At 2 weeks - clean and replace intracanal medicament with NSCaOH (do not want this to be in for more than 4-6 weeks)
- Obturation with GP should take place within 4-6 weeks
- Refer to specialist paediatric dental team for interdisciplinary management
24
Q
What would we do if we have an avulsed mature tooth (with closed apex) with an EAT of >60mins?
A
- Unlikely to get PDL healing
- The aim is for bony healing (by alkylosis) so scrub root clean of dead PDL cells
- Extra-oral endodontics can be carried out prior to replantation
- Replant tooth under LA
- Splint: 4 weeks flexible splint
- Consider antibiotic prescription
- If extra-oral endodontics not carried out - extirpate at 7-10 days and use NSCaOH as initial intra-canal medicaments for 4 weeks prior to obturation with
GP - Review: 3,6,12 months then yearly
25
What is the aim of healing if we have an avulsed mature tooth (with closed apex) with an EAT of >60mins?
Aim = bony healing
26
What would we do if we have an avulsed tooth (with open apex) with an EAT of >60mins?
- Unlikely to get PDL healing
- Very small chance the pulp may still revascularize
- Do not root treat unless signs of loss of vitality on follow up
- Replant tooth under LA
- Splint: 4 weeks flexible splint
- Consider antibiotic prescription
- Check tetanus status
- Monitor closely for signs of necrosis vs continued root development
- Review interval at 2 weeks, 4 weeks (splint removal), 2 months, 3 months, 6 months then yearly
27
When should we not replant an avulsed tooth? (5)
- Almost never
- If very immature apex and EAT >90mins (may still be best to replant)
- Child is immunocompromised
- The child has other serious injuries and warrant preferential emergency treatment and/or intensive care being dealt with
- Very immature lower incisors in young child finding it difficult to come
28
Why is it usually the right choice to replant a tooth?
- Even as a temporary space maintainer - the right choice is usually to replant esp when guiding position of adjacent erupting tooth
29
How would we monitor avulsed/implanted teeth? (5)
- Open apex teeth require close monitoring
- If pulpal necrosis detected - pulp extirpation must be carried out as soon as possible to avoid inflammatory resorption
- Clinical tests - trauma stamp
- Sensibility tests: thermal + electrical
- Radiographs
30
When would we take sensibility tests when monitoring avulsed or replanted teeth?
- At time of injury
| - 1 month, 2 months, 3 months, then 6 monthly for an average of 2 years
31
What are we looking for in radiographs when monitoring avulsed/replanted teeth? (3)
- Root development - width of canal and length
- Comparison with other side
- Internal + external inflammatory resorption
32
What is the best practice for doing a pulpectomy on an open apex tooth?
- Extirpate pulp and place CaOH for no longer than 4-6 weeks after identified as non-vital
- (Problems with CaOH apexification)
- MTA plug and heated GP obturation
33
What are dento-alveolar fractures?
- Dento-alveolar fractures are where you don't have displacement of your teeth in their sockets
- There is some mobility but you are not moving teeth individually
- What has happened here is there has been displacement of the alveolar bone - which is the bone that is holding the teeth in
- This tends to happen in segmental ways - so would never happen to a single tooth, it would tend to be in blocks of 3 or 4 or more
34
Do we splint dento-alveolar fractures?
- Yes, would place a flexible splint for 4 weeks
35
What is the treatment of dento-alveolar fractures? (4)
- LA
- Reposition - Apical lock may be present (Where the bone cannot slot into its original place)
- Flexible splint for 4 weeks
- Antibiotics
36
How would we follow up with dento-alveolar fractures?
Monitor clinically and radiographically
- Checking for root development - canal width and length, compare with neighbouring unaffected tooth
- Check for signs of inflammatory resorption
- Follow up: 2 weeks, 4 weeks, 8 weeks, 4 months, 6 months, 1 year and yearly for 5 years
As with all dental injuries:
- Soft diet for 7 days
- Avoid contact sport whilst splint in place
- Careful OH with use of chlorhexidine gluconate mouthwash 0.1%
37
What is the risk of pulpal necrosis in closed apex teeth in a dento-alveolar fracture at 5 years?
50%
