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Pedo. Lec 3 Dental trauma: examination, diagnosis and treatment planning of dental trauma.
Done by: Alaa Alsmadi.
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We will be talking about: 1- the principles of trauma management, 2- the diagnosis, and 3- the treatment planning aspects.

1st principles of trauma management: 1-Triage and stabilizing the patient : Triage means: is to prioritize things , for example: the level of consciousness assessment at the beginning is more important than noticing the crown fracture. Especially if you are working in a hospital; in emergency room and a patient came to you after road traffic accident, with oral and maxillofacial trauma or dental trauma ; there are principles that should follow to manage the patient. Stabilize: is to stabilize the patient regarding to the vital signs, be sure that the vital sign is ok, and the neurological signs is ok, then you go to other issues, {from the most important to the least important} , so you have to do neurological assessment; how do you do this?

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Neurological assessment:

You look for any sign of disorientation, amnesia, vomiting, nausea, drowsiness, all these indicate a neurological problem , Paresthesia of the lips or any were else, indicates an injury to the nerves. battle sign: mastoid hematoma , the mastoid process is swollen Raccoon sign: hematoma around the eye. Skull fracture : any Fracture or discharge of the cerebrospinal fluid {CSF}, especially from the nose or from the ears. Subjective assessment which you can obviously seen.

2- The second principle: is that you have to treat injury as soon as possible and avoid delays as much as you can. 3- you should be calm and professional in your approach; usually the patient will be panic and campaigning people with him so you have to be calm and reassuring them to finish the job properly, but if you were anxious and the patient anxious then you will never get the job done. 4-You have to do documentation, record everything, take photographs, take x-rays , so if the patient get any risks or consequences after his injury then you have documentation of how the injury was . ---------------------------------------------------------------------------------------------------2nd diagnosis: For the diagnosis to be performed you need to record everything then you reach the diagnosis , then you come up with treatment plane. A dental injury should always be considered an emergency and be treated immediately.
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$$ the rational of the treatment is to improve the prognosis. ##the aims of the treatment are: to relive pain, which is the most important. to enhance function esthetics.

History:

A series of questions must be asked to aid in diagnosis and treatment planning, and these include the following aspects: 1- Patients name, age, sex, address, and telephone number. 2- Medical history: if the patient has for example - bleeding disorders, it will affect the treatment or if he has - heart conditions , he might needs prophylaxis - Diabetes: delays wound healing, or may need insulin; you have to make sure that diabetes is under control. - Epilepsy: if the patient has continuous seizures it will also affect your treatment - Allergies: if the patient allergic to anything. - Medications that are being taken by the patient, if he takes certain medication every day then you have to make sure that he takes his medication. - Tetanus immunization:(tetanus:) Immunization is usually received at young age (2-2 ) years. We need a booster every 10 years. Immunization is indicated after trauma if the site is contaminated with soil if the patient hasnt received a booster in the last 5 years. So the 1st dose should be at 2 years, 2nd dose should be taken after 10 years (at age of: 12-13 years). If we have 14-15 years , we ask
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if he receive booster in the last 5 years, if he receive a booster then we dont have to give him any dose, if he didnt receive then you should immunize him against tetanus. Usually no one get booster after 10 years in our country, so we give him, if the wound contaminated. Tetanus is uncommon, infectious but non-communicable disease. Its caused by bacteria (clostridium tetani) which lives in soil and dust especially in agricultural land, so if we have soft tissue injury and its contaminated with soil then we have to check for tetanus immunization. This bacterium produces a type of neurotoxin which is called tetanospasmin it affects the muscles and causes spam of the muscles. Tetanus is dangerous and its mortality is from 10 60 %. **signs of tetanus infection: Massetric spasm: the jaw will become locked and this will lead to trismus. Facial spasms: leads to sardonic smile raised eyebrows , eyes closed Spasm of the spinal muscles leading to arched back Laryngeal spasm which is more dangerous than the previous spasms, leading to asphyxiation . Autonomic dysfunction leads to dysrhythmias. Death after 10 days due to asphyxia, bronchopneumonia or autonomic dysfunction.

3- When did the injury occur? 4- Where did the injury occur? 5- How did it occur? A fall or push by another classmate or during a fight or during traffic accident. 6- Was there a period of unconsciousness? And if so, How long?
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7- Have there been previous injuries to teeth? This is important because frequent injury to teeth will affect the prognosis of your treatment, the more frequent injury the prognosis become less and also in children it indicates child abuse, so keep this in mind. 8- Is there a disturbance in the bite? Its usually due to alveolar fracture. 9- Is there any reaction in teeth to cold and/or heat, sweet or sour foods? Its usually indicates dentin exposure or pulp injury. 10-Is there spontaneous pain from the teeth? Indicates injury to PDL or pulp involvement 11-Are the teeth tender to touch, or during eating? Then suspect luxation injuries.

You have to gather all signs or symptoms and analyze them; * If there is pain or reaction to thermal stimulant it means dentin or pulp exposure. * If there is disturbance in the bite it might be luxation or alveolar fracture. * If there is nausea or vomiting or any neurological sign , it indicate the cerebral involvement.

Clinical examination:

When the patient attends for treatment of dental trauma, the oral region is usually heavily contaminated, as we said, so how would you examine it? The first step is to wash the patients face, by a piece of gauze and wet it with normal saline then clean the wound or irrigate the wound in order to remove the debris and the soil or sand or any particles inside the wound .
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If there is soft tissue wounds, a mild detergent should be used A thorough examination of the injured area should include soft tissues and hard tissues examination. The use of standardized examination forms, so you dont forget what to ask about and we do have this in the clinics.

Clinical examination steps: 1234567Clean the patient wound. Record clinical findings; extraorally and intraorally. Soft tissue wounds Hard dental tissues. Mobility testing Percussion testing Sensibility testing (ethyl chloride, EPT)

(you already know about them in endo.) 8- Radiographic examination

Extraoral examination: You record any wound, do palpation of the facial skeleton; if there is any fracture in the bone, you check the mandible in all excursions, to identify any dislocation or fracture, then you palpate the TMJ looking for swellings or clicking. Intraoral examination:

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You go through the soft tissues and the hard tissues. In the soft tissues examination you remove all foreign bodies and record all the injuries and watch for any hematoma, especially under the tongue. In the hard tissue exam you clean the crowns of teeth and you examine them for any pulp exposure, fractures, changes in color, etc.. Always examine all the teeth, sometimes there is an injury in the posterior teeth were you didnt notice. Examine the alveolus for any mobility of fragments, displacement, disturbances in occlusion, and palpation of the alveolus. A typical sign of the alveolar fracture is movement of adjacent teeth when the mobility of a single tooth is tested; so when you put your finger on one tooth and test the mobility and you find that a whole group of teeth is moving with it, which mean that we have alveolar fracture.

Page 16,17,18: this is an example of history and examination forms. Page19-22: this is what we have in the pedo. Clinic in JUST. In these forms, we record the patients name, date of birth, file number, address, and referral source- if someone referred him to us. History of the injury, depending on how did it occurred, and if there is any previous injury, etc.. then we record the clinical examination. Slide 41: this table were you indicate which teeth have been injured and all details of the examination; the mobility the tenderness to percussion, and the sensibility testing, then the radiographic findings, sometimes you can draw the injury if there is fracture, and the radiographic report- after you take the x-rays you write the report; if there is root fracture, root resorption, PDL involvement.
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Page 22, this is the table where you write your diagnosis and treatment planning; *the diagnosis will be crown fracture involving the enamel and dentin. *The restorative treatment plan: cover the dentin with liner and build up the tooth with composite resin, *pulp therapy is not needed for that, *splinting, is not needed if there is no luxation. *Follow-up plan: you have to see the patient after 2 weeks from now, then 1 month, then 3 months, then 6 months, every year for the next 5 years. If the pulp is exposed you have to do cvek pulputomy and then build up the tooth , if there is luxation injury I need to splint the tooth for a week, or over 10 days, or over 3 weeks, according to the type of the luxation.

MOBILITY TEST:
Should determine the extent of the losing , especially axially, and you have learned the mobility test and the degree of the mobility(0,1,2,3) 0 = no loosening 1= horizontal loosening =< 1mm 2= horizontal loosening> 1mm 3= horizontal and axial loosening.

Sometimes 0 mobility could mean ankylosis, so you have to lessen to the percussion tone, the metallic sound indicate the ankylosis.

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While performing the mobility on the tooth you dont have to be harsh on the tooth, you put your finger against finger or other instrument and you push gently to test. The same thing with the percussion it should be gentle, if the tooth is tender to percussion, this may indicate an injury to the PDL, and if the percussion tone yields high, metallic sound it means the tooth is ankylosed. A high, metallic tone implies that the tooth is looked into bone- ankylosed. Page 25: this is the percussion testing.

PULPAL SENSIBILITY TEST:

We always perform the pulpal sensibility testing even if the response is not reliable. Generally speaking pulp testing is not very reliable, but it does give us some indication about the pulp status. So we do them at the beginning , and we record whatever we get and we repeat it after each review, to compare the status of the pulp at the beginning and later. So it yields information about the neurovascular supply to the pulp of involved teeth. Response at the time of injury provides a baseline value for comparison at later follow-up examinations. Sensibility testing in the primary dentition may yield inconclusive information, so we dont perform it. Note that teeth with incomplete root formation dont respond consistently to testing compared to teeth with complete root formation, because the pulp system wasnt complete.

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Technique of the vitality testing :

1234-

mechanical stimulation, by scratching dentin Thermal test: heated gutta percha, cold CO2, ethyl chloride. Electric tests: EPT Laser Doppler flowmetry: not found in the clinics. Its a machine works by the Dopplers effect. ******* ******** ******* ******

1- Mechanical testing: For example: imagine that we have crown with dentin-pulp exposed then sensibility can be tested by scraping with a dental probe, but if the pulp is exposed never put the probe in the pulp because you will contaminate it 2- Thermal tests: Its the most reliable, it includes: heated gutta percha, ethyl chloride, CO2 snow. 3- Electric tests 4- Laser Doppler flowmetry: not found in our clinics.

Radiographic examination:

We do a series of x-rays, we do extraoral and intraoral x-rays depending on the situation, and sometimes you do more than one x-rays of the same type. Types of radiographs available: Steep maxillary occlussal film: we do it in alveolar fractures, lateral or extrusive luxation, and in mid-apical 1/3 root fracture.
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 Pediatric maxillary occlusograph: in size 1 periapical film, in children used as maxillary occlussal, its big enough for a child. Bisecting angle periapicals Lateral maxillary RG: the same as the maxillary occlussal but we put it here laterally. Especially in case of intrusive or lateral luxation. OPG, sometimes valid. Submentovertx Chest x-ray: if the child inhales a tooth or fragment. Soft tissue radiograph : taken when there is a crown fracture and the lip injured, sometimes the fragment get impeded within the lip, so we need to do soft tissue x-ray to the lip to locate them. The exposure should be 25% of the normal exposure time. Page 30: example of soft tissue radiograph; with fragment impeded in the lip, this fragment can be tooth fragment or dust or sand or glass(especially in road terrific accident. In the radiographic exam you have to look for: Fractures in crowns, roots, socket, bone. Any foreign body embedded in tissue. Displaced teeth from socket PDL width. Root development; if it complete or not, because this will tell us what to do regarding pulp therapy, it tell also if the tooth is mature or immature. Size of pulp chamber Involvement of the permanent tooth bud. Signs of peri-apical resorption or pathosis.

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PHOTOS:
Offer exact documentation of the extent of injury, it can be used in treatment planning, may be required for legal claims, important in clinical research. ---------------------------------------------------------------------------------------------------3rd Treatment planning: We aim to restore the pulp, PDL and final tooth structure. It must consider the following: 1234Restorative treatment. Pulp therapy Splinting Follow-up plan.

Treatment priorities of dental trauma, which injury we want to approach immediately? And which can be delayed? 1- Acute approach: Tooth avulsion, you have to put the avulsed tooth- immediately to its socket. Alveolar fracture Extrusion, lateral luxation, roots fracture. 2- Subacute approach: Intrution, concussion, subluxation, crown fracture with pulp exposure. Primary teeth. 3- Delayed treatment:

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 Crown fractures without pulp exposure, and even its delayed you dont have to forget about it, but if you are in an emergency room, and the patient has skeletal fracture and loss of consciousness and other medical problems, then you can wait a week or so to treat this fracture.

Follow- up: You need to see your patient after 1 week in case of avulsion or after 3 weeks in other cases 1 month 3 months 6 months 1 year, for next 5 years. The end Note: you have to read the slides for extra information. Done by: ALAA ALSMADI
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