trauma in primary dentition

Question 1

assessment of pulpal survival

Answer 1

symtoms: pain, looseness, discolouration
clinical: mobility, colour, TTP, abscess, sinus
sensibility: EPT, ethyl chloride
radiographs: PDL widening, root development

Question 2

prognostic factors

Answer 2

type of injury
extent of injury
maturity of root: open/closed apex
presence of resorption
how close tooth is to exfoliation
PDL damage
degree of displacement
mobility
interference with occlusion
pt co-operation

Question 3

what history to conduct when a paeds pt presents with trauma

Answer 3

1. check for head injury, loss of consciousness: concussion, headache, vomiting? refer to hospital immediately
2. assess for non-accidental injury
3. check who pt has come with and if they have PR

*do a scorates for pain assessment

4. when? check time interval between injury and appointment
5. how it happened?
6. assess for tooth fragments, e.g. in lip
7. PDH: cooperation
8. MH: bleeding disorder and allergy to penicillin. ask about immunosuppression: may alter decision to reimplant tooth
   allergies? when prescribing antibiotics important

Question 4

aims of tx with trauma to primary dentition

Answer 4

preserve integrity of permenant successor
preserve primary tooth is cooperation is good

Question 5

aims of tx with trauma to permanent dentition

Answer 5

preserve vitality of tooth to allow maturation of the root
restore the crown to prevent drifting, tilting and overeruption

Question 6

general short term management principles of trauma to tooth

Answer 6

Elimination of pain
protection of pulp
reduction and immobilisation of teeth
suturing soft tissue lacerations with resorbable vicryl sutures intraoral. extraoral refer to hospital
antibiotics? check tetanus status. analgesics? chlorhexidine mouthwash

Question 7

general medium term management principles of trauma to tooth

Answer 7

pulp therapy
consider ortho requirements and long term prognosis of damaged teeth
semi-permanent restorations
keep under review: suitable time period

Question 8

general long term management principles for trauma to tooth

Answer 8

permenant tx
deferred until over 16 to allow pulpal and gingival recession and decrease the likelihood of further trauma, e.g. definitive crown

Question 9

pulpal survival at 5 years after injuries involving the PDL: open vs closed apex

concussion
subluxation
extrusion
lateral luxation
intrusion
reimplantation

Answer 9

1. open: 100%, closed: 96%
2. 100%, 85%
3. 95%, 45%
4. 95%, 25%
5. 40%, 0%
6. 30%, 0%

Question 10

special tests to carry out in permanent trauma teeth

Answer 10

mobility assessment
percussion: duller note may indicate root fracture, high pitched= ankylosis
sensibility tests: ethyl chloride, EPT, check in contralateral teeth and compare
photography
check for any discolouration
appropriate radiographs

Question 11

prognostic factors

Answer 11

extent of damage
type of injury: crushing PDL injury is the worst
tooth maturity: high chance of resorption in closed apices, open apices have created blood supply to PDL
associated fracture

Question 12

avulsion: advantages of reimplanting avulsed permanent teeth

Answer 12

functional immediate solution
natural tooth replacement rather than bridge/denture/implant
maintains bone, gingival contour, allows ortho tooth movement
allows revascularisation of the pulp and PDL healing without anklyosis
aesthetics
space maintenance
preserves alveolar bone

Question 13

primary teeth: enamel fractures

clinical findings
radiographic recommendations
treatment
follow up
favourable outcomes
unfavourable outcomes

Answer 13

• fracture to enamel only
• no radiographs recommended
• tx: smooth sharp edges. pt education: exercise care and avoid contact sports, encourage gingival healing by parents cleaning area with soft brush or cotton swab with 0.2% chlorhexidine mouth rinse 2x a day for 1 week
• no follow up required
• favourable: asymptomatic, pulp healing with: normal colour of crown, no signs of pulp necrosis (greying), continued root development in immature teeth
• unfavourable: symptomatic, crown discolouration, signs of pulp necrosis + infection, e.g. sinus tract, gingival swelling, abscess, increased mobility, persistent dark grey discolouration with infection, radiographic signs of pulp necrosis and infection, no further root development of immature teeth

Question 14

primary teeth: complicated crown fractures with pulp exposure

clinical findings
radiographic recommendations
treatment
follow up
favourable outcomes
unfavourable outcomes

Answer 14

-PA using the paralleling technique or occlusal radiograph should be taken immediately. radiograph of soft tissues if fragment suspected to be embedded
- preserve pulp by partial pulpotomy (cvek) remove 1-3mm of coronal pulp. LA, non-setting calcium hydroxide applied over pulp + seal with GIC then composite resin
-tx dependent on child’s cooperation, pt education, care with exercise, chlorhexidine 2x a day for 1 wk
-clinical exam: 1wkm 6-8wk, 1y (radiographic follow up 1yr following pulpotomy)
-favourable: normal crown colour, no signs of pulp necrosis + infection, continued root development
-unfavourable: symptomatic, crown discolouration, signs of pulp necrosis + infection, e.g. sinus tract, swelling, abscess, persistent dark grey discolouration, no further root development of immature teeth

Question 14

primary teeth: enamel-dentine fractures

clinical findings
radiographic recommendations
treatment
follow up
favourable outcomes
unfavourable outcomes

Answer 14

• fracture involves enamel + dentine but no pulp exposure, account for the missing tooth fragments
  -baseline radiograph optional, take radiograph of soft tissues if fractures fragment is suspected to be embedded in lips, cheek, tongue
  -cover all exposed dentine with GIC, lost tooth fragment can be restored using composite immediately or later, pt education: exercise care to avoid further damage, encourage ginival healing and plaque accumulation clean area with soft brush of 0.2% chlorhexidine 2x a day for 1 week
  -follow up: 6-8 weeks after clinical exam, no radiological follow up unless findings suggestive of pulp necrosis
  -favourable: normal crown colour, no signs of pulp necrosis + infection, continued root development
  -unfavourable: symptomatic, crown discolouration, signs of pulp necrosis + infection, e.g. sinus tract, swelling, abscess, persistent dark grey discolouration, no further root development of immature teeth

Question 15

cvek vs coronal pulpotomy

Answer 15

cvek removes 2-3mm coronal pulp but full pulpotomy= removal of all cervical pulp. for larger pulp exposures

Question 16

pulp cap: indications

Answer 16

exposure less than 1mm and happened less than 24 hrs, complete or incomplete root development. pul still vital

Question 17

cvek pulpotomy: indications

Answer 17

exposure>1mm >24hrs
complete or incomplete root development. pulp still vital

Question 18

large coronal pulpotomy: indications

Answer 18

large contaminated exposures
long duration
incomplete root development
coronal pulp demonstrates impaired vascularity

Question 19

how to do full coronal pulpotomy

Answer 19

LA and rubber dam
open up pulp chamber and amputate coronal pulp to cervical level with excavator
apply ferric sulphate to radicular pulp with cotton pellet
place non setting CaOH and restore tooth with GIC. OR fill chamber with zinc oxide eugenol cement and place hall crown
leave 6-8 weeks then review symptoms and vitality
if tooth becomes non-vital: RCT

Question 20

primary teeth: crown-root fracture

clinical findings
radiographic recommendations
treatment
follow up
favourable outcomes
unfavourable outcomes

Answer 20

-can be complicated or uncomplicated fractures (pulp may or may not be exposed)
-PAs taken using paralleling technique
-remove the loose fragment and determine restorability of crown. if restorable and no pulp exposed, cover with GIC, if restorable and pulp exposed, pulpotomy or RCT depending on stage of root development. if unrestorable, XLA of loose fragments or full tooth. tx depends on child’s cooperation, pt education on exercise and chlorhexidine
-where tooth is retained: clinical exam 1wk, 6-8wk, 1yr (radiographic 1yr following RCT)
primary teeth: enamel-dentine fractures
-favourable: normal crown colour, no signs of pulp necrosis + infection, continued root development
-unfavourable: symptomatic, crown discolouration, signs of pulp necrosis + infection, e.g. sinus tract, swelling, abscess, persistent dark grey discolouration, no further root development of immature teeth

Question 21

primary teeth: root fractures

clinical findings
radiographic recommendations
treatment
follow up
favourable outcomes
unfavourable outcomes

Answer 21

-occlusal interferences may be present
-PAs: mid/apical third?
-no tx if coronal fragment is not displaced, or isn’t excessively mobile to spontaneously reposition even if some occlusal interference
-if coronal fragment excessively displaced, mobile, interfering with occlusion, LA and XLA of coronal fragment, apical fragment left to resorb or gently reposition coronal fragment + if unstable, use a flexible splint for 4wk
-where no coronal displacement, 1wk, 6-8wk, 1yr
-coronal been repositioned: 1wk, 4wk for splint removal, 8wk, 1yr
-favourable: normal crown colour or transient red/grey/yellow discolouration, no signs of pulp necrosis + infection, continued root development, resorption of apical fragment, no mobility, realignment of fractured root
-unfavourable: symptomatic, crown discolouration, signs of pulp necrosis + infection, e.g. sinus tract, swelling, abscess, persistent dark grey discolouration, no further root development of immature teeth, no improvement in position of fractured root

Question 22

which injuries are most associated with development of abnormalities in permanent dentition?

Answer 22

intrusion and extrusion

Question 23

impact of primary tooth trauma on permanent dentition

Answer 23

close spatial relationship between apex of the primary tooth root and underlying permanent tooth germ
tooth malformation, impacted teeth and eruption disturbances in the developing permanent dentition are some consequences

Question 24

considerations affecting management of TDIs in primary dentition

Answer 24

a child's maturity and co-operation time for exfoliation of the injured tooth occlusion

Question 25

parental instructions for homecare

Answer 25

Successful healing following an injury to the teeth and oral tissues depends on good oral hygiene. To optimize healing, parents or caregivers should be advised regarding care of the injured tooth/teeth and the prevention of further injury by supervising potentially hazardous activities. Clean the affected area with a soft brush or cotton swab and use alcohol-free chlorhexidine gluconate 0.12% mouth rinse applied topically twice a day for one week to prevent accumulation of plaque and debris and to reduce the bacterial load. Care should be taken when eating not to further traumatize the injured teeth while encouraging a return to normal function as soon as possible. Parents or caregivers should be advised about possible complications that may occur, such as swelling, increased mobility, or a sinus tract. Children may not complain about pain, but infection may be present. Parents or caregivers should watch for signs of infection such as swelling of the gums. If present, they should take the child to a dentist for treatment

Question 26

primary teeth: concussion clinical findings radiographic recommendations treatment follow up favourable and unfavourable outcomes

Answer 26

-tooth tender to touch but not displaced -no radiographs -no tx: observation, reassurance and soft diet + analgesics -exam after 1wk, 6-8wk, 1 yr

Question 27

primary teeth: subluxation clinical findings radiographic recommendations treatment follow up favourable and unfavourable outcomes

Answer 27

-tooth is tender to touch + increased mobility, but not displaced -PAs: normal to slightly widened PDL will be visible -no tx: observation, reassurance and soft diet + analgesics -if slight mobility, soft diet 1-2 weeks

Question 28

primary teeth: lateral luxation clinical findings radiographic recommendations treatment follow up favourable and unfavourable outcomes

Answer 28

-tooth is displaced in a palatal/lingual direction or labial -tooth will be immobile, occlusal interference may be present -PAs: increased PDL space -minimal occlusal interference, tooth should be allowed to spontaneously reposition itself (usually within 6 months). if the crown is displaced palatally, the apex moves buccally and hence away from the permanent developing tooth germ. -if crown displaced buccally, apex will be displaced towards permanent tooth bud + XLA required to avoid further damage to permanent successor + when risk of ingestion of the tooth -or gently reposition tooth, if stable in new position, splint for 4wk using a flexible splint -exam 1wk, 6-8wk, 6mo, 1y. if repositioned with splint: 1wk, 4wk for splint removal, 8wk, 6mo, 1yr -radiographic review only when signs of infection or unfavourable outcomes: use ALAARA -unfavourable: no improvement of position of laterally luxated tooth and negative impact on development and/or eruption of permanent successor

Question 29

primary teeth: intrusion clinical findings radiographic recommendations treatment follow up favourable and unfavourable outcomes

Answer 29

-tooth displaced through the labial bone plate + can impinge on permanent tooth bud, tooth disappeared into socket and can be palpated labially -PAs, when apex displaced toward the permanent tooth germ, apical tip cannot be visualised and image of tooth will appear elongated, if apical tip can be seen it will appear shorter than contralateral tooth which shows it is displaced through labial bone instead -tooth should be allowed to spontaneously erupt (usually within 1-6mo) -if displaced toward tooth germ, XLA to avoid damage to permanent successor + if failure to re-erupt - Must warn parent that there might be damage to successor

Question 30

primary teeth: extrusion clinical findings radiographic recommendations treatment follow up favourable and unfavourable outcomes

Answer 30

-partial displacement of tooth out of socket, seems elongated and excessively mobile, occlusal interference -PA: widening of PDL -tx based on: degree of displacement, mobility, interference with occlusion -if no interference, let tooth reposition itself. if extruded >3mm or mobile, extract under LA -rv: 1wk, 6-8wk, 1y

Question 31

avulsion in primary teeth management

Answer 31

don't reimplant due to risk of damage to permanent tooth germ development the eruption of the permanent successor may be delayed up to 1 year as a result of abnormal thickening of connective tissue overlying the tooth germ

Question 32

sequelae of injuries to the permanent dentition

Answer 32

-pulpal necrosis -pulpal obliteration -root resorption -injuries to developing permanent teeth

Question 33

sequelae of injuries to the permanent dentition: pulpal necrosis

Answer 33

most common complication of primary trauma mild pink colour after trauma: intrapulpal bleeding with a vital pulp, may recede if it persists, necrosis suspected radiographic examination should be 3 monthly failure of the pulp cavity to reduce in size is an indicator of pulpal death, teeth should be extracted to prevent damage to permanent successor important to council patients about possibility of necrosis and to monitor signs including sinus formation which occurs in the absence of pain symptoms

Question 34

sequelae of injuries to the permanent dentition: pulpal obliteration

Answer 34

tooth becomes yellow/opaque annual radiography required

Question 35

sequelae of injuries to the permanent dentition: root resorption

Answer 35

external inflammatory resorption is seen after intrusive injuries and internal resorption with subluxation and other luxation injuries XLA advised for all root resorption

Question 36

sequelae of injuries to the permanent dentition: injuries to permanent teeth

Answer 36

intrusive causes most damage most damage occurs to the tooth bud under age of 3 can cause enamel defects: managed with a combination of microabrasion and/or composite

Question 37

intrusion severity in open vs closed apex and its management

Answer 37

open: -up to 7mm: spontaneous -more than 7mm: ortho/surgical closed: -up to 3mm: spontaneous -3-7mm: ortho/surgical -more than 7mm: surgical

Question 38

types of resorption