Resident: Jason Hencler
Date: 09/04/2009
Article title: Case Report:
Autotransplantation for a Missing Permanent Maxillary Incisor
Author(s): Rao DDS, MS; Fields DDS, MS, MSD; Chacon DDS, MS
Journal: Pediatric Dentistry V30/NO 2 2008
Major topic: Autotransplantation as treatment option
Type of Article: Case Report
Main Purpose:
To describe the treatment of loss of a permanent incisor using transplantation of a maxillary first premolar to the incisor position.
Current Treatment Modalities: Dentists have multiple options to treat missing permanent maxillary anterior teeth that are lost during the mixed dentition due to trauma, decay, or developmental factors. These options include FPD, RPD, implants, ortho space closure, and autotransplanted permanent teeth.
Case Description:
9yo female presents with a chief complaint of unerupted tooth #9. Radiographs revealed an ectopically erupting (inverted) #9 with delayed root development. Tx options included EXT followed by either: prosthetics, asymmetric ortho space closure, surgical uncovering followed by ortho repositioning, or autotransplantation of the inverted tooth to a more acceptable position followed by ortho repositioning.
Treatment:
Autotransplantation with ortho traction to reposition inverted #9 was selected as initial tx. #9 was surgically exposed and revealed a significant dilacerations of the root. Due to future problems of moving such a tooth, decision was made to EXT. Revised tx plan was autotransplantation of maxillary 1st PM. After the site was surgically prepared, the PM was EXT and transplanted with its mesial surface facing buccal. The site was allowed to heal for 2 mos. Eval at 8 wks demonstrated grade II mobility. The labial and lingual surfaces were reduced incrementally to avoid pulp irritation. The implanted tooth was extruded while the adjacent teeth were intruded.
Key points in the article discussion:
Most traumatic injuries to permanent incisors occur in the mixed dentition, which is when PM roots are developing. Since partial root formation (2/3-3/4) is one of the requirements for god prognosis, PMs are likely donors for autotransplantation of incisor sites. At ½ root formation there is an 80% chance of optimal root length and over 90% chance of pulpal and perio healing. The presence of open apices seems to be crucial for good prognosis. Recipient site bone area should be 1-2mm wider and deeper than the dimension of the donor root. Some authors recommend porcelain laminate veneers over composite build up for best esthetics. If the transplant fails, which is rare, final treatment with an implant can still be accomplished if the alveolar bone support was maintained. No definitive data has been reported for ideal post op stabilization period for transplanted teeth. Initial perio healing around a transplanted tooth takes about 4 wks and complete perio healing can be observed radiographically around 8 wks. Because pulpal necrosis and inflammatory resorption are noticed usually w/in 2 mos post surgery, a waiting period of at least 12 wks is best before applying ortho forces. Generally antibiotics are not required but anti plaque rinses are often used during healin periods. Ortho tx can be initiated w/in 3-4 mos of the transplantation. This allows for adequate perio healing prior to complete pulpal obliteration, thus preventing late pulpal necrosis. Light, continuous ortho forces are best.
Summary of conclusions:
With its high success rate and by following reliable techniques, autotransplantation of a permanent maxillary central incisor with a maxillary PM is a favorable option that should be considered.
Assessment of article:
This article was very interesting. Although autotransplantation is not a very popular in the USA, it should be considered in situations similar to the case presented in this article. As a pediatric dentist, we would undoubtedly see such cases. A multi disciplinary approach, working with other specialists should definitely be taken when considering autotransplantation.
Sunday, August 30, 2009
Friday, August 28, 2009
Guidelines for the Management of Traumatic Dental Injuries II-Avulsion of Permanent Teeth 8/28/09
LUTHERAN MEDICAL CENTER
Dental Residency Program
Literature Review Form
Resident: Murphy Date:8/28/09 Region: Prov.
Article title: Guidelines for the Management of Traumatic Dental Injuries II-Avulsion of Permanent Teeth
Author(s): Flores, Marie. Lars Andersson, et al.
Journal: Dental Traumatology
Volume #; Number; Page #s): 23, 130-136
Year: 2007
Major topic: How to treat permanent teeth avulsions
Type of Article: Clinical Review
Main Purpose: Discuss treatment options and modalities for permanent teeth avulsions
Overview of method of research; Review of Treatment options
Findings. Dental trauma occurs in 5% of adult injuries, and as high as 18% of pre school children injury. Avulsions of permanent teeth are the most serious of all dental injuries. The measures that were taken at the time of the accident or immediately following the accident greatly affect the prognosis. An appropriate treatment plan, depending on the circumstances are crucial for a good prognosis. The International Association of Dental Traumatology(IADT) has developed a consensus review after referencing the most current literature and group discussions. The IADT does not guarantee favorable outcomes from following the guidelines, but using them can maximize the chance of success. Guidelines can be accessed at www.iadt-dentaltrauma.org. As dentists, it’s important for us to give appropriate advice to the public about first aid for avulsed. First aid for avulsed teeth include keeping the patient calm, handling the tooth by the crown only, rinsing it briefly for 10 seconds, placing the tooth in HBSS or milk, and seeking emergency treatment immediately for pulp testing, radiographs, and splinting. Radiographs should include a shot at a 90 degree angle, an occlusal, and lateral view.
Tooth Re-implanted Prior to Arrival
-Irrigate area-apply flexible splint
-Administer antibiotics(doxycycline 2x daily for 1 week)
-Tetanua shot if needed-Initiate RCT 7-10 days after reimplantation
-Soft diet for 2 weeks, .1% Chlorhexidine Rinse daily
Tooth Kept in special storage <60 min
-Irrigate root surface and apical foramen with a stream of saline and place tooth in saline.
-Reimplant tooth slowly, suture gingival lacerations
-Follow tx above starting at admin. antibiotics
MORE TO COME
Key points in the article discussion:
Summary of conclusions: Assessment of article:
Dental Residency Program
Literature Review Form
Resident: Murphy Date:8/28/09 Region: Prov.
Article title: Guidelines for the Management of Traumatic Dental Injuries II-Avulsion of Permanent Teeth
Author(s): Flores, Marie. Lars Andersson, et al.
Journal: Dental Traumatology
Volume #; Number; Page #s): 23, 130-136
Year: 2007
Major topic: How to treat permanent teeth avulsions
Type of Article: Clinical Review
Main Purpose: Discuss treatment options and modalities for permanent teeth avulsions
Overview of method of research; Review of Treatment options
Findings. Dental trauma occurs in 5% of adult injuries, and as high as 18% of pre school children injury. Avulsions of permanent teeth are the most serious of all dental injuries. The measures that were taken at the time of the accident or immediately following the accident greatly affect the prognosis. An appropriate treatment plan, depending on the circumstances are crucial for a good prognosis. The International Association of Dental Traumatology(IADT) has developed a consensus review after referencing the most current literature and group discussions. The IADT does not guarantee favorable outcomes from following the guidelines, but using them can maximize the chance of success. Guidelines can be accessed at www.iadt-dentaltrauma.org. As dentists, it’s important for us to give appropriate advice to the public about first aid for avulsed. First aid for avulsed teeth include keeping the patient calm, handling the tooth by the crown only, rinsing it briefly for 10 seconds, placing the tooth in HBSS or milk, and seeking emergency treatment immediately for pulp testing, radiographs, and splinting. Radiographs should include a shot at a 90 degree angle, an occlusal, and lateral view.
Tooth Re-implanted Prior to Arrival
-Irrigate area-apply flexible splint
-Administer antibiotics(doxycycline 2x daily for 1 week)
-Tetanua shot if needed-Initiate RCT 7-10 days after reimplantation
-Soft diet for 2 weeks, .1% Chlorhexidine Rinse daily
Tooth Kept in special storage <60 min
-Irrigate root surface and apical foramen with a stream of saline and place tooth in saline.
-Reimplant tooth slowly, suture gingival lacerations
-Follow tx above starting at admin. antibiotics
MORE TO COME
Key points in the article discussion:
Summary of conclusions: Assessment of article:
Partial Pulpotomy in Permanent Incisors
Resident’s Name: Joanne Lewis Date: August 28, 2009
Article title: A clinical report on partial pulpotomy and capping with calcium hydroxide in permanent incisors with complicated crown fracture
Author(s): Miomir Cvek, DMD PhD
Journal: Journal of Endodontics
Volume (number): 4(8)
Date: August 1978
Major topic: parial pulpotomies on permanent incisors with pulpal exposures due to trauma
Type of Article: scientific article
Main Purpose: to assess the frequency of healing of accidentally exposed pulp treated by partial pulpotomy
Overview of method of research: The sample consisted of 60 incisors (51 maxillary and 9 mandibular) with complicated crown fracture treated by partial pulpotomy. Time interval between the accident and treatment ranged from 1 to 2160 hours, and size of pulp exposure ranged from 0.5 to 4.0 mm. 28 teeth had immature roots and 32 teeth had mature roots. Patient age ranged from 7 to 16 years of age. All teeth had a bleeding wound or a proliferated pulp tissue; no teeth demonstrated necrotic tissue disintegration. All teeth were treated as follows: rubber dam isolation, 0.5% chlorhexidine solution to clean field, removal of part of coronal pulp (approx. 2 mm) and surrounding dentin with a sterile diamond bur, copious irrigation and control of bleeding with sterile saline, covering of pulp with calcium hydroxide (Calasept) and sealing of the cavity with sterile ZOE. Clinical and radiographic examinations were done at 3 weeks, 3 months, and 6 months. When a continuous hard tissue barrier was seen radiographically, the ZOE and calcium hydroxide were removed under aseptic conditions, the barrier was clinically examined, and the tooth was restored with Dycal and composite.
Findings: 96% (58 teeth) demonstrated healing. Healing was defined as the following: no clinical symptoms, no radiographic pathologic changes, continued development of immature teeth, verifiable continuous hard tissue barrier, and sensitivity to electrical stimulation.
Key points/Summary: The following variables had no influence on the frequency of healing: interval between accident and treatment, size of pulpal exposure, and stage of root development.
Assessment of article: I found these results to be pretty amazing, especially since I thought these variables generally did affect the success of the partial pulpotomy. The key factor here seems to be that none of the pulps were necrotic. (Even after 2160 hours of exposure!?)
Thursday, August 27, 2009
Transplantation of Premolars as an Approach for Replacing Avulsed Teeth 8/28/09
Resident: Murphy
Date: 8/28/09
Article title: Transplantation of Premolars as an Approach for Replacing Avulsed Teeth
Author(s): Andreason, Jens. Ole Shwartz, etc.Journal: Pediatric Dentistry, Vol. 31, #2, pg 129-132
Major topic: Treatment modalities for transplanting premolars Type of Article: Clinical Review
Findings: The anterior maxilla is the primary site for dental traumas, with the peak incidence being from between 8 and 12 years old. 7-8% of these injuries involve an avulsed tooth, or a tooth that was not able to be re-implanted. Filling the space left by a lost tooth can be accomplished in many ways. Orthodontic closure, Removable appliance, conventional fixed bridge, acid etched bridge, implant, autotransplantation of premolars, and no treatment. Aside from Orthodontic closure, transplantation of premolars is the most biological approach. The space is filled with a vital tooth that will erupt in harmony with other teeth, won’t compromise the health of adjacent teeth, and has a good prognosis.
The most decisive factor affecting successful transplantation is the stage of root development, with a root with ¾ formed being the best. Studies show that this stage of root development is optimal for pulpal and PDL healing. This method has a 90% success rate.
Maxillary second and mandibular first and second premolars are the teeth that are used (excluding maxillary firsts due to their two roots). Teeth that are used as grafts have to be shaped with restorative procedures.
Key factors for success of the transplantation include minimal trauma to hertwigs root sheath during harvesting and re-implanting, pre/post op antibiotics, and using a tooth that’s root is in the correct developmental stage. Standard tooth removal techniques should not be used, and only clinicians who are familiar with the proper technique should attempt the treatment.
Complications include pulpal necrosis, root resorption, infection, and ankylosis(the worst). Ankylosis prevents eruption and leads to the replacement of root with bone. One option is to separate the crown from the root, leaving the root in the socket to preserve the growth of the alvelolar process.
Conclusions:
-Premolar transplantation is an excellent alternative treatment plan to other conventional options.
-Minimize trauma as much as possible to HRS, dental pulp, and PDL.
-Reimplanted teeth can be shaped with restorative options.
-Only professionals who are adept at doing this procedure so attempt it.
Assessment of article: It was an interesting article to read. For a subject that I thought would have extensive explanation on how to/not to do it, why to/not do it, it was extremely short. I think there should have been more of a discussion on how to do the treatment. Also, the article made some vague statements about how “studies show” that this treatment option is excellent, but don’t list any reasons why. Good article, could have been great.
Date: 8/28/09
Article title: Transplantation of Premolars as an Approach for Replacing Avulsed Teeth
Author(s): Andreason, Jens. Ole Shwartz, etc.Journal: Pediatric Dentistry, Vol. 31, #2, pg 129-132
Major topic: Treatment modalities for transplanting premolars Type of Article: Clinical Review
Findings: The anterior maxilla is the primary site for dental traumas, with the peak incidence being from between 8 and 12 years old. 7-8% of these injuries involve an avulsed tooth, or a tooth that was not able to be re-implanted. Filling the space left by a lost tooth can be accomplished in many ways. Orthodontic closure, Removable appliance, conventional fixed bridge, acid etched bridge, implant, autotransplantation of premolars, and no treatment. Aside from Orthodontic closure, transplantation of premolars is the most biological approach. The space is filled with a vital tooth that will erupt in harmony with other teeth, won’t compromise the health of adjacent teeth, and has a good prognosis.
The most decisive factor affecting successful transplantation is the stage of root development, with a root with ¾ formed being the best. Studies show that this stage of root development is optimal for pulpal and PDL healing. This method has a 90% success rate.
Maxillary second and mandibular first and second premolars are the teeth that are used (excluding maxillary firsts due to their two roots). Teeth that are used as grafts have to be shaped with restorative procedures.
Key factors for success of the transplantation include minimal trauma to hertwigs root sheath during harvesting and re-implanting, pre/post op antibiotics, and using a tooth that’s root is in the correct developmental stage. Standard tooth removal techniques should not be used, and only clinicians who are familiar with the proper technique should attempt the treatment.
Complications include pulpal necrosis, root resorption, infection, and ankylosis(the worst). Ankylosis prevents eruption and leads to the replacement of root with bone. One option is to separate the crown from the root, leaving the root in the socket to preserve the growth of the alvelolar process.
Conclusions:
-Premolar transplantation is an excellent alternative treatment plan to other conventional options.
-Minimize trauma as much as possible to HRS, dental pulp, and PDL.
-Reimplanted teeth can be shaped with restorative options.
-Only professionals who are adept at doing this procedure so attempt it.
Assessment of article: It was an interesting article to read. For a subject that I thought would have extensive explanation on how to/not to do it, why to/not do it, it was extremely short. I think there should have been more of a discussion on how to do the treatment. Also, the article made some vague statements about how “studies show” that this treatment option is excellent, but don’t list any reasons why. Good article, could have been great.
Orofacial trauma in child abuse: types, prevalence, management, and the dental profession's involvement
Department of Pediatric Dentistry
Lutheran Medical Center
Date: 08/28/2009
Article title: Orofacial trauma in child abuse: types, prevalence, management, and the dental profession's involvement
Author(s): Howard L. Needleman, DMD
Journal: Pediatric Dentistry
Volume (number): Vol 8
Month, Year: 1986
Major topic: Child abuse
Minor topics: dental trauma management
Type of Article: Review of Literature
Main Purpose: Review types of injuries to the primary dentition and present evidence based treatments
Overview of method of research: Review of Literature as well as professional opinion
Findings:
Trauma to the head and associated areas occurs in approximately 50% of cases of physically abused children.
Soft tissues are the most common injury in child abuse and are usually on the face
Injuries to the upper lip and frenum are common findings in severely abused children
As dentists make an effort to be aware of these injuries, abuse detection will increase.
Key points/Summary :
- Common abuse findings: Fractures, subdural hematomas, abrasions & lacerations, contussions & ecchymoses, bursns, bites, dental trauma.
- In the past, dentists have done a poor job reporting abuse; dentists have not always been aware that they are legally mandatory reporters.
- The primary goal in detection is to bring the needed social services to families to help them overcome their problems.
- How to detect abuse:
- Is the injury consistent with the history?
- Are there signs of previous traumas?
- Is there bruising at various levels of healing?
- Does the parent exhibit unusual behavior are does the child seem to be traumatized?
- Is there evidence of neglect or poor supervision?
- Make appropriate referrals when pathology presents you are uncomfortable treating
- If the injury is within your realm of specialty, then treat appropriately.
- Soft tissue: use ice packs
- Abrasions: cleanse and dress as needed
- Frenum tears: suture only if alveolar bone is exposed and the wound opens with lip movement
- Suture choice: 5-0 or 6-0 silk for skin removing them 4 days post-op; 3-0, 4-0 chromic gut for muscalature; 4-0, 5-0 plain gut for mucosa.
- Human bites: very serious, antibiotics recommended and don't close wound. (refer this)
- Facial fractures are relatively rare, but nasal fractures occur most frequently. Refer all alveolar and mandible fractures to an oral surgeon--even if treatment is not indicated.
Assessment of article: A solid review of child abuse as it pertains to pediatric dentistry, but a lot of the literature used is really dated. It would be nice to see a current article on this same topic.
Traumatic crown fractures in permanent incisors with immature roots: a follow-up study
Resident: Adam J. Bottrill
Date: 28AUG09
Region: Providence
Author(s): Cavalleri G., Zerman N.
Journal: Endodontics and Dental Traumatology
Volume #; Number; Page #s: Volume 11 pp: 294-296
Year: 1995
Major topic: Immature permanent incisor fracture
Minor topic(s): None
Type of Article: Topic review and summary
Main Purpose: Analyze the long term effect of treatment of crown fractures in permanent incisors with incomplete root formation in regard to pulp survival and aesthetics.
Overview of method of research: Prospective case comparison
Findings: What? Spoil the surprise????!!!
Key points in the article discussion: The most common dental injury at age 6-13 is crown fracture. This injury often involves immature teeth.
A. Clinical Materials and Methods:
1. 55 injured Pt’s (age 6-12) with 84 crown fractures in permanent teeth with incomplete root formation.
2. Follow-up over 5-yr period at Dental Clinic of the University of Verona Italy.
3. Crown fractures divided into 3 categories:
a. Fracture of enamel
b. Fracture of enamel and dentin with no pulpal involvement
c. Fracture of enamel and dentin WITH pulpal involvement.
4. Recorded data: personal data, med Hx, exam, trauma Hx, photos, lesions, occlusion, injured teeth, type of injury, color of teeth, mobility, general oral health, subjective symptoms, vitality tests, radiographs, Tx.
5. Various Tx:
a. Enamel fx: smoothing, composite
b. Enamel/Dentin fx: comp, CaOH pulp cap, bonding of frag
c. Enamel/Dentin with Pulp fx: pulp cap, pulpot
6. Follow-up:
a. E, E/D: 1,2,4 wk, 6 mo, 1yr, annually
b. E/D w/Pulp: 1,2 wk, 1,2,3,4,5,6 mo, 1 yr annually
B. Results:
Endodontic & Dental Traumatology
1995: 11: 294-296
1. Most injuries occurred in 8-y.o. children
2. Boys 3.6:1 over girls
3. 95% maxillary centrals
4. 40% occurred with maxillary overjets of >3mm
5. Note: 6 of the 8 teeth that experienced pulpal necrosis werer treated >24 hrs later.
6. 36 restored teeth considered aesthetically satisfactory
7. 34 restored teeth needed retreatment due to new trauma.
C. Extra Discussion:
1. The high percentage of retreatment because of new trauma emphasized importance of preventative measures (mouthgaurds from Dr. Brian etc…)
2. Bonding of tooth fragment seemed to have better long term prognosis than composite restorations.
Assessment of article: Applicable and well organized.
Date: 28AUG09
Region: Providence
Author(s): Cavalleri G., Zerman N.
Journal: Endodontics and Dental Traumatology
Volume #; Number; Page #s: Volume 11 pp: 294-296
Year: 1995
Major topic: Immature permanent incisor fracture
Minor topic(s): None
Type of Article: Topic review and summary
Main Purpose: Analyze the long term effect of treatment of crown fractures in permanent incisors with incomplete root formation in regard to pulp survival and aesthetics.
Overview of method of research: Prospective case comparison
Findings: What? Spoil the surprise????!!!
Key points in the article discussion: The most common dental injury at age 6-13 is crown fracture. This injury often involves immature teeth.
A. Clinical Materials and Methods:
1. 55 injured Pt’s (age 6-12) with 84 crown fractures in permanent teeth with incomplete root formation.
2. Follow-up over 5-yr period at Dental Clinic of the University of Verona Italy.
3. Crown fractures divided into 3 categories:
a. Fracture of enamel
b. Fracture of enamel and dentin with no pulpal involvement
c. Fracture of enamel and dentin WITH pulpal involvement.
4. Recorded data: personal data, med Hx, exam, trauma Hx, photos, lesions, occlusion, injured teeth, type of injury, color of teeth, mobility, general oral health, subjective symptoms, vitality tests, radiographs, Tx.
5. Various Tx:
a. Enamel fx: smoothing, composite
b. Enamel/Dentin fx: comp, CaOH pulp cap, bonding of frag
c. Enamel/Dentin with Pulp fx: pulp cap, pulpot
6. Follow-up:
a. E, E/D: 1,2,4 wk, 6 mo, 1yr, annually
b. E/D w/Pulp: 1,2 wk, 1,2,3,4,5,6 mo, 1 yr annually
B. Results:
Endodontic & Dental Traumatology
1995: 11: 294-296
1. Most injuries occurred in 8-y.o. children
2. Boys 3.6:1 over girls
3. 95% maxillary centrals
4. 40% occurred with maxillary overjets of >3mm
5. Note: 6 of the 8 teeth that experienced pulpal necrosis werer treated >24 hrs later.
6. 36 restored teeth considered aesthetically satisfactory
7. 34 restored teeth needed retreatment due to new trauma.
C. Extra Discussion:
1. The high percentage of retreatment because of new trauma emphasized importance of preventative measures (mouthgaurds from Dr. Brian etc…)
2. Bonding of tooth fragment seemed to have better long term prognosis than composite restorations.
Assessment of article: Applicable and well organized.
Multifaceted Use of ProRoot MTA Root Canal Repair Material
Resident’s Name: Brian Schmid DMD Date: 8/28/09
Article title: Multifaceted Use of ProRoot MTA Root Canal Repair Material
Author(s): Don Schmitt DDS, Jacob Lee DDS, George Bogen DDS
Journal: Pediatric Dentistry
Month, Year: November 2000
Major topic: Varied uses and superiority of MTA
Type of Article: Review
Findings: MTA has been demonstrated to have diverse applications inclding: direct pulp capping, repair of internal resorption, root end filling, apexification and repair of root perforations. MTA has been shown to have a better seal than other pulp capping medicaments. While bonding systems and newer composites have a better seal than in the past, all systems will have some marginal microleakage so it is essential to have as tight a seal on the capping material as possible. The main components of MTA are calcium phosphate and calcium oxide and comes in a fine powder which is activated by hydration. Bismuth oxide powder is added to achieve a radiopacity similar to gutta percha. Studies have shown that MTA is more biocompatible than amalgam, IRM and ZOE, including one study which demonstrated cementum growing over MTA introduced into root canal perforations even when overstuffed. MTA stimulates the release of cytokines and interleukins which initiate an immune response and potential regeneration. MTA sets very slowly so all irrigation should be completed before MTA is placed. MTA is more expensive and comes in a box of five 1 gram single use packets ($300). The instructions suggest that extra MTA can be preserved in sterilized film canisters for later use. Case selection is essential for any pulp capping patient. Spontaneous pain or a dull constant ache are signs of a necrotic pulp and signify a tooth that would requires pulp treatment. A previous study found no significant link to success of pulp capping than ease of hemostasis. The article reviews the method of re-entry direct pulp capping emphasizing avoiding displacement of the MTA and disinfection with NaOCl. The method if apexification is also reviewed and recommends initial placement of CaOH, followed one week later by placement of 3-4mm of MTA as an apical plug, followed by moist cotton pellet followed by IRM. Filling of the entire canal with MTA as a definitive treatment is suggested, but may lead to discoloration of teeth.
Key points/Summary: MTA has varied uses which require some departure from our usual methodology.
Assessment of article: A good review article, but seemingly attempts to sell you MTA to some extent. Still generally considered too expensive for everyday use in any environments.
Article title: Multifaceted Use of ProRoot MTA Root Canal Repair Material
Author(s): Don Schmitt DDS, Jacob Lee DDS, George Bogen DDS
Journal: Pediatric Dentistry
Month, Year: November 2000
Major topic: Varied uses and superiority of MTA
Type of Article: Review
Findings: MTA has been demonstrated to have diverse applications inclding: direct pulp capping, repair of internal resorption, root end filling, apexification and repair of root perforations. MTA has been shown to have a better seal than other pulp capping medicaments. While bonding systems and newer composites have a better seal than in the past, all systems will have some marginal microleakage so it is essential to have as tight a seal on the capping material as possible. The main components of MTA are calcium phosphate and calcium oxide and comes in a fine powder which is activated by hydration. Bismuth oxide powder is added to achieve a radiopacity similar to gutta percha. Studies have shown that MTA is more biocompatible than amalgam, IRM and ZOE, including one study which demonstrated cementum growing over MTA introduced into root canal perforations even when overstuffed. MTA stimulates the release of cytokines and interleukins which initiate an immune response and potential regeneration. MTA sets very slowly so all irrigation should be completed before MTA is placed. MTA is more expensive and comes in a box of five 1 gram single use packets ($300). The instructions suggest that extra MTA can be preserved in sterilized film canisters for later use. Case selection is essential for any pulp capping patient. Spontaneous pain or a dull constant ache are signs of a necrotic pulp and signify a tooth that would requires pulp treatment. A previous study found no significant link to success of pulp capping than ease of hemostasis. The article reviews the method of re-entry direct pulp capping emphasizing avoiding displacement of the MTA and disinfection with NaOCl. The method if apexification is also reviewed and recommends initial placement of CaOH, followed one week later by placement of 3-4mm of MTA as an apical plug, followed by moist cotton pellet followed by IRM. Filling of the entire canal with MTA as a definitive treatment is suggested, but may lead to discoloration of teeth.
Key points/Summary: MTA has varied uses which require some departure from our usual methodology.
Assessment of article: A good review article, but seemingly attempts to sell you MTA to some extent. Still generally considered too expensive for everyday use in any environments.
Sunday, August 23, 2009
Guidelines for the management of traumatic dental injuries. I. Fractures and luxations of permanent teeth
Resident: Jason Hencler
Date: 8/28/09
Article title: Guidelines for the management of traumatic dental injuries. I. Fractures and luxations of permanent teeth
Author(s): Flores et al.
Journal: Dental Traumatology 2007; 23: 66-71
Major topic: Fractures and luxation to permanent teeth
Type of Article: Guidelines
Main Purpose: To present guidelines that useful for delivering the best care possible in cases of fractures and luxations to permanent teeth. These guidelines represent the current best evidence, based on literature and professional opinion.
General Recommendations: Radiographic exam should include 90° horizontal angle, occlusal, and lateral views. Pulp testing such as electric pulp or cold test. Initial tests may yield negative results so follow up controls are required for definitive diagnosis. Good patient oral hygiene for good healing.
Treatment guidelines for fracture of teeth and alveolar bone:
• Uncomplicated Crown Fracture: Pulp not exposed. May involve dentin and enamel or enamel alone. Take 3 radiographs to rule out displacement or fracture of root. Soft tissue radiograph for tooth fragments or foreign material. Options: if tooth fragment available, it can be bonded back to tooth. Cover exposed dentin with GI or definitive treatment of final restoration. Monitor status of pulp recommended. Follow-up times 6-8wk and 1 yr.
• Complicated Crown Fracture: Involves enamel, dentin, and pulp exposure. Take 3 radiographs to rule out displacement or fracture of root. Soft tissue radiograph for tooth fragments or foreign material. Determine stage of root development due to pulp exposure. In young patients, preserve pulp vitality with pulp capping or partial pulpotomy using CaOH or MTA. Monitor status of pulp recommended. In older patients, RCT can be initiated, although pulp capping and partial pulpotomy may also be selected. If much time has elapsed between accident and treatment and pulp becomes necrotic RCT is indicated. Extensive crown fractures may indicate EXT if prognosis of other options is highly questionable or suspect. Follow-up times 6-8wk and 1 yr.
• Crown-Root Fracture: Involves enamel, dentin, and root structure, and may or may not include pulp exposure. Monitor status of pulp recommended if pulp involved. Need at least two radiographs to detect fracture lines in the root. Treatment recommendations same as for complicated crown fracture (see above). In addition, stabilization of loose segments of tooth with bonding is suggested until a definitive treatment plan is determined. Follow-up times 6-8wk and 1 yr.
• Root Fracture: Coronal segment may be mobile, displaced, or both. Tooth most likely percussion sensitive. Monitor status of pulp recommended. Tooth discoloration may occur. Horizontal fractures best detected with 90° radiograph, usually the case with fractures in the cervical 1/3. With traumatic diagonal fractures commonly found in apical or middle 1/3 of the root, an occlusal radiographic view is best to demonstrate the fracture. Reposition a displaced coronal segment asap and check radiographically. Stabilize with flexible splint for 4 weeks. If root fracture is cervical, may require stabilization for up to 4 months. Monitor status of pulp recommended for up to 1 year. If pulp necrosis develops, RCT of the coronal tooth segment to the fracture line is indicated. Follow-up times 4wk, 6-8wk, 4mo, 6mo, 1yr, and 5 yr.
• Alveolar Bone Fracture: Involves alveolar bone. Segment mobility and occlusal changes are common findings. Fracture lines may be located at any level from marginal bone to root tip. Pano recommended. Reposition displaced segment and stabilize for 4 weeks. Follow-up times 4wk, 6-8wk, 4mo, 6mo, 1yr, and 5 yr.
Treatment guidelines for luxation injuries:
• Concussion: Tooth sensitive to touch/percussion. Not displaced or mobile. No radiographic findings. No treatment indicated. Monitor status of pulp recommended for up to 1 year. Follow-up times 4wk, 6-8wk, 1yr.
• Subluxation: Tooth sensitive to touch/percussion and has increased mobility but not displaced. Bleeding from gingival crevice may be observed. Monitor pulpal status. Usually no radiographic findings. Flexible splint for up to 2 wks. Follow-up times 4wk, 6-8wk, 1yr.
• Extrusive Luxation: Tooth appears elongated and is very mobile. In mature teeth pulp revascularization sometime occurs. In immature teeth pulp revascularization usually occurs. Increase PDL space observed. Reposition tooth and stabilize with flexible splint for 2 wks. Monitor pulpal status. In immature developing teeth, revascularization can be confirmed by continued root formation and pulp canal obliteration. In fully formed teeth a lack of response to pulp testing is indicative of pulp necrosis. Follow-up times up to 2wk, 4wk, 6-8wk, 4mo, 6mo, 1yr, and 5 yr.
• Lateral Luxation: Displaced palatal, lingual, or labial direction. Tooth will be mobile and percussion gives a high metallic, ankylotic sound. In immature teeth pulp revascularization usually occurs. Increased or widened PDL space observed. Reposition tooth using forceps to disengage tooth from its bony lock into the original position and stabilize with a flexible splint for 4 wks. pulpal status. In immature developing teeth, revascularization can be confirmed by continued root formation and pulp canal obliteration. In fully formed teeth a lack of response to pulp testing is indicative of pulp necrosis. Follow-up times up to 2wk, 4wk, 6-8wk, 4mo, 6mo, 1yr, and 5 yr.
• Intrusive Luxation: Displaced axially into the alveolar bone. Tooth will be immobile and percussion gives a high metallic, ankylotic sound. In immature teeth pulp revascularization usually occurs. The PDL space may be absent. Teeth with incomplete root formation: allow spontaneous repositioning to occur. If no movement noted within 3 wks recommend rapid orthodontic extrusion. Teeth with complete root resorption: should be repositioned orthodontically or surgically asap. Pulp will likely become necrotic and require RCT using CaOH to retain the tooth. Follow-up times up to 2wk, 6-8wk, 4mo, 6mo, 1yr, and 5 yr.
Follow-up procedures and outcomes: See tables
Assessment of article: Great article. These guidelines would be very useful in any clinical situation dealing with these types of trauma.
See www.iadt-dentaltrauma.org
This is a great site with tons of clinically relavent material. It was easy to register and you get access to great reference material found in this article plus much more.
Date: 8/28/09
Article title: Guidelines for the management of traumatic dental injuries. I. Fractures and luxations of permanent teeth
Author(s): Flores et al.
Journal: Dental Traumatology 2007; 23: 66-71
Major topic: Fractures and luxation to permanent teeth
Type of Article: Guidelines
Main Purpose: To present guidelines that useful for delivering the best care possible in cases of fractures and luxations to permanent teeth. These guidelines represent the current best evidence, based on literature and professional opinion.
General Recommendations: Radiographic exam should include 90° horizontal angle, occlusal, and lateral views. Pulp testing such as electric pulp or cold test. Initial tests may yield negative results so follow up controls are required for definitive diagnosis. Good patient oral hygiene for good healing.
Treatment guidelines for fracture of teeth and alveolar bone:
• Uncomplicated Crown Fracture: Pulp not exposed. May involve dentin and enamel or enamel alone. Take 3 radiographs to rule out displacement or fracture of root. Soft tissue radiograph for tooth fragments or foreign material. Options: if tooth fragment available, it can be bonded back to tooth. Cover exposed dentin with GI or definitive treatment of final restoration. Monitor status of pulp recommended. Follow-up times 6-8wk and 1 yr.
• Complicated Crown Fracture: Involves enamel, dentin, and pulp exposure. Take 3 radiographs to rule out displacement or fracture of root. Soft tissue radiograph for tooth fragments or foreign material. Determine stage of root development due to pulp exposure. In young patients, preserve pulp vitality with pulp capping or partial pulpotomy using CaOH or MTA. Monitor status of pulp recommended. In older patients, RCT can be initiated, although pulp capping and partial pulpotomy may also be selected. If much time has elapsed between accident and treatment and pulp becomes necrotic RCT is indicated. Extensive crown fractures may indicate EXT if prognosis of other options is highly questionable or suspect. Follow-up times 6-8wk and 1 yr.
• Crown-Root Fracture: Involves enamel, dentin, and root structure, and may or may not include pulp exposure. Monitor status of pulp recommended if pulp involved. Need at least two radiographs to detect fracture lines in the root. Treatment recommendations same as for complicated crown fracture (see above). In addition, stabilization of loose segments of tooth with bonding is suggested until a definitive treatment plan is determined. Follow-up times 6-8wk and 1 yr.
• Root Fracture: Coronal segment may be mobile, displaced, or both. Tooth most likely percussion sensitive. Monitor status of pulp recommended. Tooth discoloration may occur. Horizontal fractures best detected with 90° radiograph, usually the case with fractures in the cervical 1/3. With traumatic diagonal fractures commonly found in apical or middle 1/3 of the root, an occlusal radiographic view is best to demonstrate the fracture. Reposition a displaced coronal segment asap and check radiographically. Stabilize with flexible splint for 4 weeks. If root fracture is cervical, may require stabilization for up to 4 months. Monitor status of pulp recommended for up to 1 year. If pulp necrosis develops, RCT of the coronal tooth segment to the fracture line is indicated. Follow-up times 4wk, 6-8wk, 4mo, 6mo, 1yr, and 5 yr.
• Alveolar Bone Fracture: Involves alveolar bone. Segment mobility and occlusal changes are common findings. Fracture lines may be located at any level from marginal bone to root tip. Pano recommended. Reposition displaced segment and stabilize for 4 weeks. Follow-up times 4wk, 6-8wk, 4mo, 6mo, 1yr, and 5 yr.
Treatment guidelines for luxation injuries:
• Concussion: Tooth sensitive to touch/percussion. Not displaced or mobile. No radiographic findings. No treatment indicated. Monitor status of pulp recommended for up to 1 year. Follow-up times 4wk, 6-8wk, 1yr.
• Subluxation: Tooth sensitive to touch/percussion and has increased mobility but not displaced. Bleeding from gingival crevice may be observed. Monitor pulpal status. Usually no radiographic findings. Flexible splint for up to 2 wks. Follow-up times 4wk, 6-8wk, 1yr.
• Extrusive Luxation: Tooth appears elongated and is very mobile. In mature teeth pulp revascularization sometime occurs. In immature teeth pulp revascularization usually occurs. Increase PDL space observed. Reposition tooth and stabilize with flexible splint for 2 wks. Monitor pulpal status. In immature developing teeth, revascularization can be confirmed by continued root formation and pulp canal obliteration. In fully formed teeth a lack of response to pulp testing is indicative of pulp necrosis. Follow-up times up to 2wk, 4wk, 6-8wk, 4mo, 6mo, 1yr, and 5 yr.
• Lateral Luxation: Displaced palatal, lingual, or labial direction. Tooth will be mobile and percussion gives a high metallic, ankylotic sound. In immature teeth pulp revascularization usually occurs. Increased or widened PDL space observed. Reposition tooth using forceps to disengage tooth from its bony lock into the original position and stabilize with a flexible splint for 4 wks. pulpal status. In immature developing teeth, revascularization can be confirmed by continued root formation and pulp canal obliteration. In fully formed teeth a lack of response to pulp testing is indicative of pulp necrosis. Follow-up times up to 2wk, 4wk, 6-8wk, 4mo, 6mo, 1yr, and 5 yr.
• Intrusive Luxation: Displaced axially into the alveolar bone. Tooth will be immobile and percussion gives a high metallic, ankylotic sound. In immature teeth pulp revascularization usually occurs. The PDL space may be absent. Teeth with incomplete root formation: allow spontaneous repositioning to occur. If no movement noted within 3 wks recommend rapid orthodontic extrusion. Teeth with complete root resorption: should be repositioned orthodontically or surgically asap. Pulp will likely become necrotic and require RCT using CaOH to retain the tooth. Follow-up times up to 2wk, 6-8wk, 4mo, 6mo, 1yr, and 5 yr.
Follow-up procedures and outcomes: See tables
Assessment of article: Great article. These guidelines would be very useful in any clinical situation dealing with these types of trauma.
See www.iadt-dentaltrauma.org
This is a great site with tons of clinically relavent material. It was easy to register and you get access to great reference material found in this article plus much more.
Luxation injuries of primary anterior teeth—prognosis and related correlates
Department of Pediatric Dentistry
Lutheran Medical Center
Resident’s Name: Craig Elice Date: 10/21/09
Article title: Luxation injuries of primary anterior teeth—prognosis and related correlates
Author(s): Soporowski NJ, Allred EN, Needleman HL
Journal: Pediatric Dentistry
Volume (number): 16(2)
Month, Year: March/April 1994
Major topic: Report of types of injuries to primary teeth, affects of treatment, and sequelae
Minor topic(s: None
Type of Article: Retrospective longitudinal research article
Main Purpose: The study reported the prognosis of sample of luxation injuries to primary anterior teeth and evaluated what variables may be associated with the prognosis.
Overview of method of research: 307 luxation injuries of primary anterior teeth in 222 children were found in a chart review in a private practice. Demographic information including age, gender, etiology of the accident, description of the injury, occlusion were recorded. Luxation injuries were categorized into intrusion, extrusions, lateral luxations, and avulsions.
Findings: 91.2% of the injuries occurred in the maxillary arch, and central incisors were affected 80.2%, while the lateral incisors were affected 19.2% of the time. Males sustained injuries more frequently with a 1.7:1 ratio of males to females. The average age of injury was 3.8 years of age. Younger children sustained more intrusions while older children sustained more extrusions and avulsions. Repositioning the teeth or no treatment was a more frequent treatment in the young, while extractions were more common in older children. Falls accounted for the majority of luxation injuries (71,6%) followed by bike accidents (11.5%), sports related accidents (3.7%), and miscellaneous. Bike accidents were more likely to result in extrusions and avulsions as well as extraoral injuries, and sports accidents resulted in lateral luxations. 57% of all luxation injuries were lateral luxations followed by avulsions (19.2%), intrusions(15.3%), and extrusions(8.5%). Root fractures were associated with lateral luxations. Occlusion like increased overjet or a distal step occlusion did significantly increase the risk of injury. However, overjet was increased in intrusions as compared to avulsions. About 55% of the injuries developed no sequelae after being followed for an average of 4.3 years. 26.3% became necrotic, 10.5% developed calcific degeneration, and 7.9% became ankylosed. No sequelae was associated with the type of injury. Treatment rendered was associated with sequelae of all luxation groups, lateral luxations, and intrusions. According to age groups, the oldest group >5 years of age, showed the least sequelae, with the youngest group next, and the 2-3 year age group being the worst. No significance was shown between the type of injury, sequelae, or treatment rendered on the outcome of the permanent successor. Hypoplasia was reported most commonly with intrusion injuries in 17.4% of the sample compared with 7.4% for lateral luxations, and 5.7% for avulsions.
Discussion: The authors suggest some explanations for timing and type of injuries. The average of injury was 3.8 years which is a time when children become more active. The type of injury could be related to the length of the root of the tooth. Older children were more likely to sustain avulsions, extrusions, and lateral luxations due possibly to less root structure due to physiologic resorption, and also to the increased participation in organized activities. Younger children had more intrusions possibly due to increased likelihood of falling. The age of injury and best sequelae could also be related to timing of root closure. In the younger age group the root apex is open, and in the oldest age group the root apex is open because of physiologic resorption. Interestingly repositioning of lateral luxations was associated with an increased risk of developing pulpal necrosis, while repositioning of intusions were less likely to become necrotic
Key points/Summary : Males sustained more injuries 1.7:1. Lateral luxations were the most common injury to the primary dentition.. Younger children sustained more intrusive injuries, and had larger overjets when compared to children who sustained other injuries. Root fractures were associated with lateral luxations. No post-trauma sequelae occurred in 56.8% of luxated primary incisors. Treatment rendered mainly repositioning a laterally luxated incisor was assocated with increased prevalence of pulpal necrosis, while intrusion showed decreased prevalence of sequelae. Children ,2 and >5 years of age had the best sequelae survival rate. Hypoplastic defects on permanent successors were noted in 7.7% of the cases
Assessment of article: Good article quantifying success rates. Helpful when discussing injuries with patients and parents..
Lutheran Medical Center
Resident’s Name: Craig Elice Date: 10/21/09
Article title: Luxation injuries of primary anterior teeth—prognosis and related correlates
Author(s): Soporowski NJ, Allred EN, Needleman HL
Journal: Pediatric Dentistry
Volume (number): 16(2)
Month, Year: March/April 1994
Major topic: Report of types of injuries to primary teeth, affects of treatment, and sequelae
Minor topic(s: None
Type of Article: Retrospective longitudinal research article
Main Purpose: The study reported the prognosis of sample of luxation injuries to primary anterior teeth and evaluated what variables may be associated with the prognosis.
Overview of method of research: 307 luxation injuries of primary anterior teeth in 222 children were found in a chart review in a private practice. Demographic information including age, gender, etiology of the accident, description of the injury, occlusion were recorded. Luxation injuries were categorized into intrusion, extrusions, lateral luxations, and avulsions.
Findings: 91.2% of the injuries occurred in the maxillary arch, and central incisors were affected 80.2%, while the lateral incisors were affected 19.2% of the time. Males sustained injuries more frequently with a 1.7:1 ratio of males to females. The average age of injury was 3.8 years of age. Younger children sustained more intrusions while older children sustained more extrusions and avulsions. Repositioning the teeth or no treatment was a more frequent treatment in the young, while extractions were more common in older children. Falls accounted for the majority of luxation injuries (71,6%) followed by bike accidents (11.5%), sports related accidents (3.7%), and miscellaneous. Bike accidents were more likely to result in extrusions and avulsions as well as extraoral injuries, and sports accidents resulted in lateral luxations. 57% of all luxation injuries were lateral luxations followed by avulsions (19.2%), intrusions(15.3%), and extrusions(8.5%). Root fractures were associated with lateral luxations. Occlusion like increased overjet or a distal step occlusion did significantly increase the risk of injury. However, overjet was increased in intrusions as compared to avulsions. About 55% of the injuries developed no sequelae after being followed for an average of 4.3 years. 26.3% became necrotic, 10.5% developed calcific degeneration, and 7.9% became ankylosed. No sequelae was associated with the type of injury. Treatment rendered was associated with sequelae of all luxation groups, lateral luxations, and intrusions. According to age groups, the oldest group >5 years of age, showed the least sequelae, with the youngest group next, and the 2-3 year age group being the worst. No significance was shown between the type of injury, sequelae, or treatment rendered on the outcome of the permanent successor. Hypoplasia was reported most commonly with intrusion injuries in 17.4% of the sample compared with 7.4% for lateral luxations, and 5.7% for avulsions.
Discussion: The authors suggest some explanations for timing and type of injuries. The average of injury was 3.8 years which is a time when children become more active. The type of injury could be related to the length of the root of the tooth. Older children were more likely to sustain avulsions, extrusions, and lateral luxations due possibly to less root structure due to physiologic resorption, and also to the increased participation in organized activities. Younger children had more intrusions possibly due to increased likelihood of falling. The age of injury and best sequelae could also be related to timing of root closure. In the younger age group the root apex is open, and in the oldest age group the root apex is open because of physiologic resorption. Interestingly repositioning of lateral luxations was associated with an increased risk of developing pulpal necrosis, while repositioning of intusions were less likely to become necrotic
Key points/Summary : Males sustained more injuries 1.7:1. Lateral luxations were the most common injury to the primary dentition.. Younger children sustained more intrusive injuries, and had larger overjets when compared to children who sustained other injuries. Root fractures were associated with lateral luxations. No post-trauma sequelae occurred in 56.8% of luxated primary incisors. Treatment rendered mainly repositioning a laterally luxated incisor was assocated with increased prevalence of pulpal necrosis, while intrusion showed decreased prevalence of sequelae. Children ,2 and >5 years of age had the best sequelae survival rate. Hypoplastic defects on permanent successors were noted in 7.7% of the cases
Assessment of article: Good article quantifying success rates. Helpful when discussing injuries with patients and parents..
Thursday, August 20, 2009
Sequelae and prognosis of intruded primary incisors: a retrospective study
Resident’s Name: Brian Schmid Date: 8/21/09
Article title: Sequelae and prognosis of intruded primary incisors: a retrospective study
Author(s): Gideon Holan DMD, Diana Ram Odo.
Journal: Pediatric Dentistry
Month, Year: March 1999
Major topic: See title.
Type of Article: Retrospective.
Overview of method of research: Chart analysis.
Findings: Teeth can be partially or completely intruded. The apex is most often pushed labially, but can be palatal. In most cases the tooth will re-erupt within 1-6 months without any pathologic sequences. Complications may include pulp necrosis, periapical inflammation, external root resorption, ankylosis, pulp canal obliteration (PCO) and fusion with the crown of the permanent tooth bud. Boys experience tooth luxation more often at a rate of 1.7:1. 57% had a single intruded primary incisor, 34% had two, 4% had three and 5% had four. 58% were partially intruded, 39% completely intruded. 80% of apices were pushed labially. 68% of the teeth survived more than 36 months. For those that required extraction the reasons were: periodontal breakdown 27%, repeated trauma 5%. Complete intrusion lead to periodontal breakdown more often than partial. Fracture of the labial plate did not affect the outcome. Of the teeth that survived, 88% re-erupted fully, 10% did not return to the occlusal plane and 2% failed to re-erupt due to ankylosis. 63% of teeth re-erupted to normal position, ectopic positioning occurred in the remaining 37%, rotation being the most common malposition but with no additional pathologic sequelae. There was no difference between partial and complete intrusion influencing the ability of the tooth to re-erupt. Radiographs of re-erupted teeth were also reviewed: 33% had normal pulps, 52% had PCO and was more likely to occur in completely intruded teeth vs. partially intruded (64% vs 40%). 7 teeth were suspected to have undergone pulp necrosis, 6 of which were extracted, 1 surviving post endodontic treatment. Antibiotics given post trauma did not affect the outcome. Hx of trauma prior to the accident did not affect the outcome. 27% of untreated teeth eventually required extraction.
Assessment of article: Very dry and is largely a list of percentages but with a respectable study size it is worth reviewing to support your treatment decisions and to inform parents.
Article title: Sequelae and prognosis of intruded primary incisors: a retrospective study
Author(s): Gideon Holan DMD, Diana Ram Odo.
Journal: Pediatric Dentistry
Month, Year: March 1999
Major topic: See title.
Type of Article: Retrospective.
Overview of method of research: Chart analysis.
Findings: Teeth can be partially or completely intruded. The apex is most often pushed labially, but can be palatal. In most cases the tooth will re-erupt within 1-6 months without any pathologic sequences. Complications may include pulp necrosis, periapical inflammation, external root resorption, ankylosis, pulp canal obliteration (PCO) and fusion with the crown of the permanent tooth bud. Boys experience tooth luxation more often at a rate of 1.7:1. 57% had a single intruded primary incisor, 34% had two, 4% had three and 5% had four. 58% were partially intruded, 39% completely intruded. 80% of apices were pushed labially. 68% of the teeth survived more than 36 months. For those that required extraction the reasons were: periodontal breakdown 27%, repeated trauma 5%. Complete intrusion lead to periodontal breakdown more often than partial. Fracture of the labial plate did not affect the outcome. Of the teeth that survived, 88% re-erupted fully, 10% did not return to the occlusal plane and 2% failed to re-erupt due to ankylosis. 63% of teeth re-erupted to normal position, ectopic positioning occurred in the remaining 37%, rotation being the most common malposition but with no additional pathologic sequelae. There was no difference between partial and complete intrusion influencing the ability of the tooth to re-erupt. Radiographs of re-erupted teeth were also reviewed: 33% had normal pulps, 52% had PCO and was more likely to occur in completely intruded teeth vs. partially intruded (64% vs 40%). 7 teeth were suspected to have undergone pulp necrosis, 6 of which were extracted, 1 surviving post endodontic treatment. Antibiotics given post trauma did not affect the outcome. Hx of trauma prior to the accident did not affect the outcome. 27% of untreated teeth eventually required extraction.
Assessment of article: Very dry and is largely a list of percentages but with a respectable study size it is worth reviewing to support your treatment decisions and to inform parents.
Extraoral management for electrical burns of the mouth
Resident: Roberts
Article title: Extraoral management for electrical burns of the mouth
Author: Josell, Stuart et al.
Journal: Journal of Dentistry for Children
Year: 1984, pages 47-51
Type of article: case review
Findings:
Electrical burns most often result from a child sucking or chewing on an electrical cord. This can result in scarring, constriction and deformity of the oral cavity. Oral splints can be fabricated to prevent or minimize tissue contracture or microstomia that often follow burn injuries. These devices can be intraoral, extraoral, removable, fixed, cemented or ligated. The dentist must decide which one to use and work to make sure the device is non traumatic, easy to insert and remove and well tolerated by the patient. Advantages and disadvantages exist to each kind of device. An intraoral device requires that an impression be taken prior to fabrication. Often times local anesthetic or means of sedation is required in order to comfortably take an accurate impression. When choosing a device that is removable it is important to remember that these devices often require more patient compliance than a fixed unit. Fixed units, though much easier for the patient to use often times can be more difficult for the dentist to adjust to the oral cavity if needed. Extraoral devices, can present difficulties at the time of eating, but require no initial impression to get started.
Case review:
A one year old sustained an electrical burn while chewing on a cord. The mother tried to treat the injuries with topical applications of hydrogen peroxide. 36 hours after the injury, the child was taken into the hospital for care. 5 days after being admitted to the hospital, pediatric dental was consulted and an intraoral splint was fabricated to assist in healing of the wound. Due to poor retention, an extraoral sling was attached to enhance retention. However, due to patient behavior (the child cont'd to try to suck his thumb) and insufficient stability an extraoral device was fabricated to replace the original intraoral splint. This time the child was able to suck his thumb improving patient tolerance, and stability was also achieved. The splint was worn between 8 and 13 hours per day. After 12 months, it was found that surgical intervention was not needed and most scar tissue that formed early on after the initial trauma disappeared over the course of the treatment.
Directions on how to fabricate these splints can be found in the article if interested.
Article title: Extraoral management for electrical burns of the mouth
Author: Josell, Stuart et al.
Journal: Journal of Dentistry for Children
Year: 1984, pages 47-51
Type of article: case review
Findings:
Electrical burns most often result from a child sucking or chewing on an electrical cord. This can result in scarring, constriction and deformity of the oral cavity. Oral splints can be fabricated to prevent or minimize tissue contracture or microstomia that often follow burn injuries. These devices can be intraoral, extraoral, removable, fixed, cemented or ligated. The dentist must decide which one to use and work to make sure the device is non traumatic, easy to insert and remove and well tolerated by the patient. Advantages and disadvantages exist to each kind of device. An intraoral device requires that an impression be taken prior to fabrication. Often times local anesthetic or means of sedation is required in order to comfortably take an accurate impression. When choosing a device that is removable it is important to remember that these devices often require more patient compliance than a fixed unit. Fixed units, though much easier for the patient to use often times can be more difficult for the dentist to adjust to the oral cavity if needed. Extraoral devices, can present difficulties at the time of eating, but require no initial impression to get started.
Case review:
A one year old sustained an electrical burn while chewing on a cord. The mother tried to treat the injuries with topical applications of hydrogen peroxide. 36 hours after the injury, the child was taken into the hospital for care. 5 days after being admitted to the hospital, pediatric dental was consulted and an intraoral splint was fabricated to assist in healing of the wound. Due to poor retention, an extraoral sling was attached to enhance retention. However, due to patient behavior (the child cont'd to try to suck his thumb) and insufficient stability an extraoral device was fabricated to replace the original intraoral splint. This time the child was able to suck his thumb improving patient tolerance, and stability was also achieved. The splint was worn between 8 and 13 hours per day. After 12 months, it was found that surgical intervention was not needed and most scar tissue that formed early on after the initial trauma disappeared over the course of the treatment.
Directions on how to fabricate these splints can be found in the article if interested.
The diagnostic value of lateral extraoral radiography for intruded maxillary primary incisors.
Resident: Adam J. Bottrill
Date: 21AUG09
Region: Providence
Article title: The diagnostic value of lateral extraoral radiography for intruded maxillary primary incisors.
Author(s): Holan, Gideon DMD et al.
Journal: Pediatric Dentistry
Volume #; Number; Page #s: Volume 24:1 pp: 38-42
Year: 2002
Major topic: Diagnostic radiographs for intruded maxillary primary incisors.
Minor topic(s): None
Type of Article: Comparative diagnostic study.
Main Purpose: Assess the contribution of a lateral extraoral radiograph for diagnosing the relation between the root of intruded maxillary primary incisors and their permanent successors.
Overview of method of research: Quantitative, clinically diagnostic study.
Findings: N/A
Key points in the article discussion: Intrusive luxation has been found by some authors to be the most common type of injury to the primary incisor region. The proximity of the primary incisor to the labial surface of the permanent successor increases the risk of damage to the developing bud from trauma. It is therefore very important to determine the relation between the root of the intruded primary root and the permanent successor.
A. Methods
1. Study group: all children with intruded primary incisors who presented to XC clinic of the Dept of Ped Dent at the Hadassah School of Dental Medicine in Jerusalem, Israel.
a. 18 mo period.
b. 37 children with 55 intruded primary incisors.
c. age: 8 to 63 mo.
d. 56% were partially intruded and 44% completely disappeared in to tissue.
e. 29 pts (w/ 44 teeth) checked within 2 days
f. 60% w/ only 1 intruded tooth. Rest had 2 or more.
g. 93 total 3-step evaluations were available.
2. Teeth intruded more than 7 days are not included in the study.
3. Three steps for root relationship assessment.
a. Clinical exam: Inspection of tooth, and soft/hard tissue surrounding the intruded tooth.
b. PA evaluation: (and sometimes repeating step 1)
c. Lateral extraoral radiograph evaluation:
4. Clinical signs include:
a. hematoma presence
b. projection of labial bone plate
c. relative elongating or shortening of teeth.
d. “unable to assess”
5. Assessments are made independently
6. LATERAL RADIOGRAPH WAS CONSIDERED “CONTRIBUTORY” IF A FINAL DECISION COULD NOT BE MADE WITHOUT STEP 3, OR IF IT DIFFERED FROM THAT MADE FOLLOWING THE 1ST AND 2ND STEPS.
7. Ability to assess the tooth alignment following steps 2 and 3 was statistically analyzed using the McNemar test.
B. Results
1. Assessment was possible in 86% of step 1; 62% of step 2; 42% of step 3. All others were “unable to assess.”
2. In only 5 (5%) of evaluations was step #3 found “contributory.”
3. DIFFERENCE IN EVAUATORS ABILITY TO ASSESS POSITION AFTER STEP 3 VS AFTER STEP 2 WAS NOT STATISTICALLY SIGNIFICANT.
4. Separate evaluations made for:
a. Intrusion of single vs multiple teeth, central vs lateral, partially vs completely intruded, less than vs more than 20mo.,
b. no statistically significant differences in any of these parameters existed.
5. When useful, lateral radiographs were MORE useful when assessing single-tooth intrusions and central intrusions.
6. Also, lateral radiographs were more useful in pt’s under 20 mo.
a. this may be due to the overall difficulty in assessing the position as well as the low radiodensity of permanent succesors.
7. In the case of any evaluator disagreement, 5 of the 6 disagreements occurred in step 3.
Summary of conclusions: In the case of intrusion of maxillary primary incisors, the contribution of the lateral extraoral radiograph in determining the alignment of the root of intruded teeth is LOW.
A. Possible explanations:
1. Overlap, errors in aligning the cone correctly.
2. When evaluating the lateral radiograph alone, one can only clearly Dx when the root of the intruded tooth has been significantly displaced labially. OTHERWISE NO CONCLUSION CAN BE MADE.
3. Should still attempt to Dx based on PA radiograph and not clinical exam alone.
a. gap between intruded tooth and permanent successor.
b. shortened, more opaque image of intruded incisor
c. lack of rotation of the permanent successor
B. Finally:
1. Lateral extraoral radiographs should not be used routinely in cases of intrusion of primary incisors. Lateral radiographs should only be taken when it’s expected contribution can be confirmed by other methods.
Assessment of article: Applicable and well organized. This topic has the potential to be controversial as it seems we have all been instructed at some point in our education to use these lateral radiographs as a diagnostic tool.
Date: 21AUG09
Region: Providence
Article title: The diagnostic value of lateral extraoral radiography for intruded maxillary primary incisors.
Author(s): Holan, Gideon DMD et al.
Journal: Pediatric Dentistry
Volume #; Number; Page #s: Volume 24:1 pp: 38-42
Year: 2002
Major topic: Diagnostic radiographs for intruded maxillary primary incisors.
Minor topic(s): None
Type of Article: Comparative diagnostic study.
Main Purpose: Assess the contribution of a lateral extraoral radiograph for diagnosing the relation between the root of intruded maxillary primary incisors and their permanent successors.
Overview of method of research: Quantitative, clinically diagnostic study.
Findings: N/A
Key points in the article discussion: Intrusive luxation has been found by some authors to be the most common type of injury to the primary incisor region. The proximity of the primary incisor to the labial surface of the permanent successor increases the risk of damage to the developing bud from trauma. It is therefore very important to determine the relation between the root of the intruded primary root and the permanent successor.
A. Methods
1. Study group: all children with intruded primary incisors who presented to XC clinic of the Dept of Ped Dent at the Hadassah School of Dental Medicine in Jerusalem, Israel.
a. 18 mo period.
b. 37 children with 55 intruded primary incisors.
c. age: 8 to 63 mo.
d. 56% were partially intruded and 44% completely disappeared in to tissue.
e. 29 pts (w/ 44 teeth) checked within 2 days
f. 60% w/ only 1 intruded tooth. Rest had 2 or more.
g. 93 total 3-step evaluations were available.
2. Teeth intruded more than 7 days are not included in the study.
3. Three steps for root relationship assessment.
a. Clinical exam: Inspection of tooth, and soft/hard tissue surrounding the intruded tooth.
b. PA evaluation: (and sometimes repeating step 1)
c. Lateral extraoral radiograph evaluation:
4. Clinical signs include:
a. hematoma presence
b. projection of labial bone plate
c. relative elongating or shortening of teeth.
d. “unable to assess”
5. Assessments are made independently
6. LATERAL RADIOGRAPH WAS CONSIDERED “CONTRIBUTORY” IF A FINAL DECISION COULD NOT BE MADE WITHOUT STEP 3, OR IF IT DIFFERED FROM THAT MADE FOLLOWING THE 1ST AND 2ND STEPS.
7. Ability to assess the tooth alignment following steps 2 and 3 was statistically analyzed using the McNemar test.
B. Results
1. Assessment was possible in 86% of step 1; 62% of step 2; 42% of step 3. All others were “unable to assess.”
2. In only 5 (5%) of evaluations was step #3 found “contributory.”
3. DIFFERENCE IN EVAUATORS ABILITY TO ASSESS POSITION AFTER STEP 3 VS AFTER STEP 2 WAS NOT STATISTICALLY SIGNIFICANT.
4. Separate evaluations made for:
a. Intrusion of single vs multiple teeth, central vs lateral, partially vs completely intruded, less than vs more than 20mo.,
b. no statistically significant differences in any of these parameters existed.
5. When useful, lateral radiographs were MORE useful when assessing single-tooth intrusions and central intrusions.
6. Also, lateral radiographs were more useful in pt’s under 20 mo.
a. this may be due to the overall difficulty in assessing the position as well as the low radiodensity of permanent succesors.
7. In the case of any evaluator disagreement, 5 of the 6 disagreements occurred in step 3.
Summary of conclusions: In the case of intrusion of maxillary primary incisors, the contribution of the lateral extraoral radiograph in determining the alignment of the root of intruded teeth is LOW.
A. Possible explanations:
1. Overlap, errors in aligning the cone correctly.
2. When evaluating the lateral radiograph alone, one can only clearly Dx when the root of the intruded tooth has been significantly displaced labially. OTHERWISE NO CONCLUSION CAN BE MADE.
3. Should still attempt to Dx based on PA radiograph and not clinical exam alone.
a. gap between intruded tooth and permanent successor.
b. shortened, more opaque image of intruded incisor
c. lack of rotation of the permanent successor
B. Finally:
1. Lateral extraoral radiographs should not be used routinely in cases of intrusion of primary incisors. Lateral radiographs should only be taken when it’s expected contribution can be confirmed by other methods.
Assessment of article: Applicable and well organized. This topic has the potential to be controversial as it seems we have all been instructed at some point in our education to use these lateral radiographs as a diagnostic tool.
Anterior tooth trauma primary dentition
Dan Boboia
8/14/09
Anterior tooth trauma in the primary dentition: Incidence, classification, treatment methods, and sequelae: a review of literature
Authors: Irwin Fried, DDS, MS: Pamela Erickson, DDS PhD
Volume: 62:256-61
Month, Year: 1995
Major topic: Pediatric Dental Trauma
Main Purpose:
Overview primary tooth trauma, including incidence, classifications, treatment methods, follow-up, and possible sequlae
Methods: Lit Review
Findings:
There are recognized protocols for different types of primary anterior dental trauma: subluxation, concussion, luxation, avulsion, and fracture.
Key points / Summary:
71% of all primary tooth trauma involves the maxillary central. Most dental injuries occur in younger patients due to level of coordination and judgement. Case documentation should include elapsed time since the accident, care given immediately after trauma, indications for meds, and determination to transfer the case to a specialist. Evaluate for jaw fracture and TMD if patient is symptomatic. Check for avulsions, fractures, displacement, alveolar fracture / displacement, and mobility. Radiographs should be taken for initial diagnosis, follow-up, and insurance/liability.
Concusions – no tx.
Subluxations – no tx unless teeth very mobile
Intrusive luxations – allow re-eruption unless there is contact with permanent tooth bud or apex pierces labial bone plate
Alveolar fractures – reduction and splinting (preferably rigid); healing time 7-10 wks
Elis fxs: 1 – nothing, 2 – resin / base, 3 pulpotomy / pulpectomy (artice does not recommend Sveck)
Ext root fx; leave root tip if high risk of damaging permanent tooth bud trying to remove it.
Follow-up trauma: 7-10 days, 3 weeks, 3 months, 6 months. Percussion palpation, temp tests, and electric pulp tests not reliable in most pediatric patients and should only be used as an adjunct. Color change should not be used as the sole diagnostic criteria in need for extraction-many studies show that discolored teeth (yellow and grey) do not develop any radiographic or clinical signs of infection.
Assessment: Very nice review: should be included in orientation to peds dental trauma for dental students and new residents
8/14/09
Anterior tooth trauma in the primary dentition: Incidence, classification, treatment methods, and sequelae: a review of literature
Authors: Irwin Fried, DDS, MS: Pamela Erickson, DDS PhD
Volume: 62:256-61
Month, Year: 1995
Major topic: Pediatric Dental Trauma
Main Purpose:
Overview primary tooth trauma, including incidence, classifications, treatment methods, follow-up, and possible sequlae
Methods: Lit Review
Findings:
There are recognized protocols for different types of primary anterior dental trauma: subluxation, concussion, luxation, avulsion, and fracture.
Key points / Summary:
71% of all primary tooth trauma involves the maxillary central. Most dental injuries occur in younger patients due to level of coordination and judgement. Case documentation should include elapsed time since the accident, care given immediately after trauma, indications for meds, and determination to transfer the case to a specialist. Evaluate for jaw fracture and TMD if patient is symptomatic. Check for avulsions, fractures, displacement, alveolar fracture / displacement, and mobility. Radiographs should be taken for initial diagnosis, follow-up, and insurance/liability.
Concusions – no tx.
Subluxations – no tx unless teeth very mobile
Intrusive luxations – allow re-eruption unless there is contact with permanent tooth bud or apex pierces labial bone plate
Alveolar fractures – reduction and splinting (preferably rigid); healing time 7-10 wks
Elis fxs: 1 – nothing, 2 – resin / base, 3 pulpotomy / pulpectomy (artice does not recommend Sveck)
Ext root fx; leave root tip if high risk of damaging permanent tooth bud trying to remove it.
Follow-up trauma: 7-10 days, 3 weeks, 3 months, 6 months. Percussion palpation, temp tests, and electric pulp tests not reliable in most pediatric patients and should only be used as an adjunct. Color change should not be used as the sole diagnostic criteria in need for extraction-many studies show that discolored teeth (yellow and grey) do not develop any radiographic or clinical signs of infection.
Assessment: Very nice review: should be included in orientation to peds dental trauma for dental students and new residents
Wednesday, August 19, 2009
Treatment of Crown Fractures With Pulp Exposure in Primary Incisors 8/21/09
LUTHERAN MEDICAL CENTER
Dental Residency Program
Literature Review Form
Resident: Murphy Date: 8/21/09 Region: Providence
Article title: Treatment of Crown Fractures With Pulp Exposure in Primary Incisors
Author(s): Holan, Gideon, Kupietzky, Ari.
Journal: Pediatric Dentistry
Volume #; Number; Page #s): 25:3, 241-247
Year: 2003
Major topic: Treatment modalities of Primary incisor crown fracture
Type of Article: Comparative Treatment Study
Main Purpose: To present indications and contraindications of the various treatment modalities for primary incisors w/ complicated crown fractures, and to suggest that partial pulpotomy(PP) is the best treatment option, if indicated.
Overview of method of research: Discussed the four treatment options for fractured teeth w/ a pulp exposure, referencing a case for each option.
Findings: A complicated crown fracture is defined as a fracture involving enamel and dentin w/ pulp exposure. 3% of all injured primary teeth have complicated fractures. Treatment options include direct pulp capping, pulpotomy, pulpectomy, and extraction. Most clinical guides suggest that formocresol pulpotomy or pulpectomy are the best options, even in cases of minor exposures, with extraction being a possibility. While this article discusses all treatment options, it focuses on partial pulpotomies, or Cvek pulpotomies, which are usually used in permanent teeth.
Partial Pulpotomy
A small pulp exposure of up to 14 days old in a non-carious tooth is an indication for a PP. While some clinicians prefer a direct pulp cap, a PP is preferred. There must be sufficient tooth structure remaining to ensure a seal of the exposure site. PP’s are highly indicated in “young” teeth with an open apex and thin root walls. The tooth should be asymptomatic and non-inflamed. The procedure for a PP includes normal prep. For a pulpotomy, however pulpal amputation should not exceed more than 2mm. Good hemostasis should be attained. Follow up at 1 month, 3 months, and 6 months. Dentin bridge formation should be visible at 6-8 weeks. The main advantage of a PP is that after removal of the infected tissue, the remaining tissue is capable of healing, and the tooth can continue normal development/maturation. In capping, the infected tissue is left, possibly hindering complete healing. Also, with PP’s, there is no change in color of the tooth. Contraindications of PP’s are if the exposure is large, more than 2 weeks old, and if the infection is more than 2-3mm into the tissue. If this occurs, a full cervical pulpotomy is indicated.
Cervical Pulpotomy
Indications include a large exposure, with inflamed pulp not extending into the canals, and no excessive bleeding. The big question regarding pulpotomies is what agent to use, FC, CH, ferric sulfate, glutaraldehyde, and bone morphogenetic protein, with FC and CH being most common. CH is usually not used in primary teeth because it has been known to cause internal root resorption. However in this article, it stated that this was true in primary molars, but not necessarily primary incisors. A difference of primary incisors and molars is that incisors have larger canals, which could help fight against the resorption when using CH. FC is the most commonly used agent. While its mechanism is not fully understood, its use results in decreased inflammation, bleeding, and retreatment. However, the pulp may become necrotic when using FC, although staying asymptomatic. Cervical pulpotomy technique includes removal of all coronal portions of the pulpal tissue, good hemostasis, and a tight seal/coronal restoration.
Pulpectomy
If bleeding cannot be controlled, or if the inflammation extends into the canals, a pulpectomy should be performed. Pulpectomy treated primary teeth should resorb at the same rate that a normal tooth physiologically resorbs. Materials used in pulpectomies include, ZOE, iodoform pastes (vitapex), and CH. A good material should be antiseptic, radiopaque, not discolor the tooth, and should be absorbed if any is expelled beyond the apex. The most frustrating aspect of pulpectomies is that discoloration of the tooth often occurs, which parents do not like. The color can range from grey to dark brown. Parents must be told of this possibility before the treatment is started, and that it may occur many months after treatment. Some parents would rather extract the tooth rather than save a discolored tooth. Another option would be a Nu-Smile crown. Contraindications for pulpectomies include insufficient coronal tooth structure remaining, esthetic(parental) concern, and infection possibly involving the succedaneous tooth. The tooth should be accessed in via a conservative exposure, cleaned of all tissue with files, and filled w/ one of the previously mentioned materials.
Extraction
When all else fails, or when you just don’t have a good feeling about postoperative cooperation/success, extract. While space maintenance is a big concern in the primary dentition, the incisor region is extremely stable from canine to canine, even with early loss of teeth. There may be some rearrangement of space, however a space maintainer is rarely necessary. An esthetic appliance may be placed if warranted/requested. The timeline of permanent teeth erupting early/later than expected should be discussed with the parents.
Summary of conclusions: This article drove home the point that a PP is the best treatment with the most advantages, if indicated. It’s quick, easy, and the tooth is expected to maintain its vitality and continue its root development. Successful PP is expressed by a dentinal bridge forming w/I a few months, apex closure, and the root wall thickening. The drawback of PP’s is a lack of reporting on its successful use.
Assessment of article: Overall a good article. I think it was a bit idealistic. Off course we would all love it if a tooth had minimal to no caries, with a tiny, needlepoint pulp exposure. If this were the norm, PP’s would be great and used almost all of the time. Unfortunately, this isn’t the norm, and we see teeth with huge cavities and large exposures. A good clinical application for use of a PP would be a trauma case, as listed in the article. A good review on how to treat a tooth with various levels of trauma, and why to do it.
Dental Residency Program
Literature Review Form
Resident: Murphy Date: 8/21/09 Region: Providence
Article title: Treatment of Crown Fractures With Pulp Exposure in Primary Incisors
Author(s): Holan, Gideon, Kupietzky, Ari.
Journal: Pediatric Dentistry
Volume #; Number; Page #s): 25:3, 241-247
Year: 2003
Major topic: Treatment modalities of Primary incisor crown fracture
Type of Article: Comparative Treatment Study
Main Purpose: To present indications and contraindications of the various treatment modalities for primary incisors w/ complicated crown fractures, and to suggest that partial pulpotomy(PP) is the best treatment option, if indicated.
Overview of method of research: Discussed the four treatment options for fractured teeth w/ a pulp exposure, referencing a case for each option.
Findings: A complicated crown fracture is defined as a fracture involving enamel and dentin w/ pulp exposure. 3% of all injured primary teeth have complicated fractures. Treatment options include direct pulp capping, pulpotomy, pulpectomy, and extraction. Most clinical guides suggest that formocresol pulpotomy or pulpectomy are the best options, even in cases of minor exposures, with extraction being a possibility. While this article discusses all treatment options, it focuses on partial pulpotomies, or Cvek pulpotomies, which are usually used in permanent teeth.
Partial Pulpotomy
A small pulp exposure of up to 14 days old in a non-carious tooth is an indication for a PP. While some clinicians prefer a direct pulp cap, a PP is preferred. There must be sufficient tooth structure remaining to ensure a seal of the exposure site. PP’s are highly indicated in “young” teeth with an open apex and thin root walls. The tooth should be asymptomatic and non-inflamed. The procedure for a PP includes normal prep. For a pulpotomy, however pulpal amputation should not exceed more than 2mm. Good hemostasis should be attained. Follow up at 1 month, 3 months, and 6 months. Dentin bridge formation should be visible at 6-8 weeks. The main advantage of a PP is that after removal of the infected tissue, the remaining tissue is capable of healing, and the tooth can continue normal development/maturation. In capping, the infected tissue is left, possibly hindering complete healing. Also, with PP’s, there is no change in color of the tooth. Contraindications of PP’s are if the exposure is large, more than 2 weeks old, and if the infection is more than 2-3mm into the tissue. If this occurs, a full cervical pulpotomy is indicated.
Cervical Pulpotomy
Indications include a large exposure, with inflamed pulp not extending into the canals, and no excessive bleeding. The big question regarding pulpotomies is what agent to use, FC, CH, ferric sulfate, glutaraldehyde, and bone morphogenetic protein, with FC and CH being most common. CH is usually not used in primary teeth because it has been known to cause internal root resorption. However in this article, it stated that this was true in primary molars, but not necessarily primary incisors. A difference of primary incisors and molars is that incisors have larger canals, which could help fight against the resorption when using CH. FC is the most commonly used agent. While its mechanism is not fully understood, its use results in decreased inflammation, bleeding, and retreatment. However, the pulp may become necrotic when using FC, although staying asymptomatic. Cervical pulpotomy technique includes removal of all coronal portions of the pulpal tissue, good hemostasis, and a tight seal/coronal restoration.
Pulpectomy
If bleeding cannot be controlled, or if the inflammation extends into the canals, a pulpectomy should be performed. Pulpectomy treated primary teeth should resorb at the same rate that a normal tooth physiologically resorbs. Materials used in pulpectomies include, ZOE, iodoform pastes (vitapex), and CH. A good material should be antiseptic, radiopaque, not discolor the tooth, and should be absorbed if any is expelled beyond the apex. The most frustrating aspect of pulpectomies is that discoloration of the tooth often occurs, which parents do not like. The color can range from grey to dark brown. Parents must be told of this possibility before the treatment is started, and that it may occur many months after treatment. Some parents would rather extract the tooth rather than save a discolored tooth. Another option would be a Nu-Smile crown. Contraindications for pulpectomies include insufficient coronal tooth structure remaining, esthetic(parental) concern, and infection possibly involving the succedaneous tooth. The tooth should be accessed in via a conservative exposure, cleaned of all tissue with files, and filled w/ one of the previously mentioned materials.
Extraction
When all else fails, or when you just don’t have a good feeling about postoperative cooperation/success, extract. While space maintenance is a big concern in the primary dentition, the incisor region is extremely stable from canine to canine, even with early loss of teeth. There may be some rearrangement of space, however a space maintainer is rarely necessary. An esthetic appliance may be placed if warranted/requested. The timeline of permanent teeth erupting early/later than expected should be discussed with the parents.
Summary of conclusions: This article drove home the point that a PP is the best treatment with the most advantages, if indicated. It’s quick, easy, and the tooth is expected to maintain its vitality and continue its root development. Successful PP is expressed by a dentinal bridge forming w/I a few months, apex closure, and the root wall thickening. The drawback of PP’s is a lack of reporting on its successful use.
Assessment of article: Overall a good article. I think it was a bit idealistic. Off course we would all love it if a tooth had minimal to no caries, with a tiny, needlepoint pulp exposure. If this were the norm, PP’s would be great and used almost all of the time. Unfortunately, this isn’t the norm, and we see teeth with huge cavities and large exposures. A good clinical application for use of a PP would be a trauma case, as listed in the article. A good review on how to treat a tooth with various levels of trauma, and why to do it.
Intrusion injuries of primary incisors. Part II: Sequelae affecting the intruded incisors
LUTHERAN MEDICAL CENTER
Dental Residency Program
Literature Review Form
Resident: Boboia Date: 8/21/09
Article title: Intrusion injuries of primary incisors: Part II: Sequlae affecting the intruded primary incisors
Author(s): Diab, Mai et al.
Journal: Quintessence International
Volume #; Number; Page #s): 31; 5; 335-340
Month / Year: Nov. 2000
Major topic: Sequelae and management of intruded primary incisors
Type of Article: Review
Summary of Article:
-Intrusion injuries to primary incisors are common (4.4-22%)
-Radiographic exam will often show widened PDL / alveolar bone fx.
-Must assess condition of developing tooth bud with regard to intruded incisor
-Intrusion injuries of this kind may result in: coronal discoloration, pulpal obliteration, pulpal necrosis, root resorption, and ankylosis
Coronal Discoloration:
-Happens to 35%-40% of intrusion injuries; Gray color means damage to pulpal tissue (reddish gray at first then turns gray in 1-2 weeks), reversible, if debris is not absorbed through dentin tooth will remain discolored. Disagreement regarding prognosis among dentists; some believe color change of this kind indicates irreversible pulpitis while others don’t thin it’s enough to confirm pulpal necrosis. If no treatment is provided. Should be followed.
Yellow Discoloration:
-Indicates calcification or accelerated deposition of secondary dentin resulting in pulpal obliteration; monitor teeth for overretention
Pulpal Necrosis:
-22-35% of intruded primary incisors
-Difficult to dx.; clinical signs include discoloration, spontaneous pain, increased mobility 6-8 wks after injury; radiographic changes widening of PDL space, PA radiolucency, internal / external root resorption
-2-5 year olds have lower chance of pulpal necrosis
-Intitiate tx quickly to avoid damage to developing tooth bud
-Some authors believe that pulpal therapy is an option, others believe extraction should be done to avoid damage to developing tooth from overinstrumentation and overfilling the canal.
Pathological external root resorption: Incidence is 14%, usually managed with extraction
Abcess or cellulitis formation: requires immediate extraction of intruded incisor, may require antibiotic therapy depending on severity of infection
Failure of re-eruption and ankylosis: 20-22% of intruded incisors fail to re-erupt completely or into alignment (especially with alveolar fxs.), ankylosis occurs in 2-6% of intrusion injuries to primary incisors-presents with dull sound on percussion; manage by extracting to prevent ectopic eruption
Assessment of article: Good review
Dental Residency Program
Literature Review Form
Resident: Boboia Date: 8/21/09
Article title: Intrusion injuries of primary incisors: Part II: Sequlae affecting the intruded primary incisors
Author(s): Diab, Mai et al.
Journal: Quintessence International
Volume #; Number; Page #s): 31; 5; 335-340
Month / Year: Nov. 2000
Major topic: Sequelae and management of intruded primary incisors
Type of Article: Review
Summary of Article:
-Intrusion injuries to primary incisors are common (4.4-22%)
-Radiographic exam will often show widened PDL / alveolar bone fx.
-Must assess condition of developing tooth bud with regard to intruded incisor
-Intrusion injuries of this kind may result in: coronal discoloration, pulpal obliteration, pulpal necrosis, root resorption, and ankylosis
Coronal Discoloration:
-Happens to 35%-40% of intrusion injuries; Gray color means damage to pulpal tissue (reddish gray at first then turns gray in 1-2 weeks), reversible, if debris is not absorbed through dentin tooth will remain discolored. Disagreement regarding prognosis among dentists; some believe color change of this kind indicates irreversible pulpitis while others don’t thin it’s enough to confirm pulpal necrosis. If no treatment is provided. Should be followed.
Yellow Discoloration:
-Indicates calcification or accelerated deposition of secondary dentin resulting in pulpal obliteration; monitor teeth for overretention
Pulpal Necrosis:
-22-35% of intruded primary incisors
-Difficult to dx.; clinical signs include discoloration, spontaneous pain, increased mobility 6-8 wks after injury; radiographic changes widening of PDL space, PA radiolucency, internal / external root resorption
-2-5 year olds have lower chance of pulpal necrosis
-Intitiate tx quickly to avoid damage to developing tooth bud
-Some authors believe that pulpal therapy is an option, others believe extraction should be done to avoid damage to developing tooth from overinstrumentation and overfilling the canal.
Pathological external root resorption: Incidence is 14%, usually managed with extraction
Abcess or cellulitis formation: requires immediate extraction of intruded incisor, may require antibiotic therapy depending on severity of infection
Failure of re-eruption and ankylosis: 20-22% of intruded incisors fail to re-erupt completely or into alignment (especially with alveolar fxs.), ankylosis occurs in 2-6% of intrusion injuries to primary incisors-presents with dull sound on percussion; manage by extracting to prevent ectopic eruption
Assessment of article: Good review
Sunday, August 16, 2009
Subluxation injuries of maxillary primary anterior teeth:epidemiology and prognosis of 207 traumatized teeth
Resident: Jason Hencler
Date: 8/21/09
Article title: Subluxation injuries of maxillary primary anterior teeth: epidemiology and prognosis of 207 traumatized teeth
Author(s): Irwin Fried, DDS; Pamela Erickson, DDS, PhD; Stephane Schwartz, DDS, MsD; Kathleen Keenan, PhD
Journal: Pediatric Dentistry
Volume #18 ; Number 2; Page 145-151 Year: 1996
Major topic: Subluxation
Type of Article: Retrospective case study
Main Purpose: Investigate the epidemiology, sequelae, and prognosis of injuries to the maxillary primary anterior dentition.
Overview of method of research: Retrospective chart audit to identify patients who sustained subluxation injuries to the maxillary primary anterior dentition between 1982 and 1993. Information was gathered pertaining to the child and all aspects of the trauma. All post-traumatic sequelae, treatment or administration of antibiotics were also evaluated. Data were distributed into the following six time intervals of examination post-trauma: 0-10, 11-30, 31-91, 92-183, 184-365, and 366-730 days. A total of 207 teeth were evaluated in 134 patients (81 male, 53 female) sustaining subluxation injuries to the maxillary primary anterior dentition.
Findings: Central incisors involved 66.2%, lateral incisors involved 33.3%, and only one case involved a canine. Age of patients ranged from 0.8 -7.5 years with trauma more common in males. Physiologic root reorption was found in 38.0% and only 6.8% of the study teeth demonstrated pathologic root resorption. Crown fractures were noted in only 5.8% of the study teeth and 91.5% of patients sustained no alveolar fractures. Patient discomfort was not a common complaint at follow-up examinations. Discoloration, however, increased with time. Periapical radiolucencies were uncommon, while pulpal calcification increased with time.
Key points in the article discussion: Trauma to the maxillary primary anterior dentition is very common. Central Incisors were affected most of the time. Mean age of study patients sustaining subluxations was 3.5 years. Most common etiology of traumatic injuries in this study group was simple falls indoors (52%). The high incidence of traumatic falls is consistent with the developing motor coordination in young children. Subluxations are often not the only tooth injury sustained in a particular accident. Avulsions and/or luxations were found 58.2% of the time along with subluxation injuries. Crown and root fractures were found 5.8% and were infrequent probably due to the relative plasticity of bone in young children which absorbs most of the force during an impact. The treatment of subluxated teeth varies and this study found that 80.2% of the time teeth required no dental treatment. Antibiotics were administered only in cases were a potential for systemic infection such as avulsion or luxation where there is an increased likelihood that the gingiva was lacerated. Discoloration has frequently been reported following traumatic injuries to teeth. This study showed an increase of discoloration over time. A yellow discoloration is thought to be due to partial pulp canal obliteration. A pink tooth is due to blood pigments entering the dentinal tubules at the time of trauma. A gray discoloration is generally thought to be significant of pulpal necrosis. Discoloration should be used as an adjunct in diagnosis, but not as the sole predictor of prognosis and in determining the need for EXT. Other studies found discolored primary teeth failed to develop any radiographic and/or clinical pathology. This study found that incidence and severity of pulpal calcification increases with time. Other studies have found that prognosis following pulp obliteration was favorable and normal root resorption usually occurred.
Summary of conclusions:
Highest incidence of trauma occurred in males 3-4 yo. and females 1-3 yo. Central incisors were most commonly affected typically the result of falls.
More than half the patients were seen within 3hrs of the trauma.
The majority of teeth had a mobility ranging between 1.6 and 2.5mm following trauma.
Treatment included occlusal reduction, splinting, and EXT, but most teeth received no treatment.
Tooth discoloration increased with time after trauma.
Mobility improved with time, with the majority of teeth returning to a normal physiological range.
Pulpal calcification increased in incidence and severity with time.
Low patient return was noted on follow-up, indicating low morbidity of subluxation injuries.
Assessment of article: Great article, an easy read. There is a lot of interesting epidemiological information like patient demographics that wouldn’t be particularly useful for clinical treatment of trauma. Conversely, I thought that the prognosis conclusions made by this study would be helpful when considering treatment options in the clinical setting while managing a patient with subluxation trauma.
Date: 8/21/09
Article title: Subluxation injuries of maxillary primary anterior teeth: epidemiology and prognosis of 207 traumatized teeth
Author(s): Irwin Fried, DDS; Pamela Erickson, DDS, PhD; Stephane Schwartz, DDS, MsD; Kathleen Keenan, PhD
Journal: Pediatric Dentistry
Volume #18 ; Number 2; Page 145-151 Year: 1996
Major topic: Subluxation
Type of Article: Retrospective case study
Main Purpose: Investigate the epidemiology, sequelae, and prognosis of injuries to the maxillary primary anterior dentition.
Overview of method of research: Retrospective chart audit to identify patients who sustained subluxation injuries to the maxillary primary anterior dentition between 1982 and 1993. Information was gathered pertaining to the child and all aspects of the trauma. All post-traumatic sequelae, treatment or administration of antibiotics were also evaluated. Data were distributed into the following six time intervals of examination post-trauma: 0-10, 11-30, 31-91, 92-183, 184-365, and 366-730 days. A total of 207 teeth were evaluated in 134 patients (81 male, 53 female) sustaining subluxation injuries to the maxillary primary anterior dentition.
Findings: Central incisors involved 66.2%, lateral incisors involved 33.3%, and only one case involved a canine. Age of patients ranged from 0.8 -7.5 years with trauma more common in males. Physiologic root reorption was found in 38.0% and only 6.8% of the study teeth demonstrated pathologic root resorption. Crown fractures were noted in only 5.8% of the study teeth and 91.5% of patients sustained no alveolar fractures. Patient discomfort was not a common complaint at follow-up examinations. Discoloration, however, increased with time. Periapical radiolucencies were uncommon, while pulpal calcification increased with time.
Key points in the article discussion: Trauma to the maxillary primary anterior dentition is very common. Central Incisors were affected most of the time. Mean age of study patients sustaining subluxations was 3.5 years. Most common etiology of traumatic injuries in this study group was simple falls indoors (52%). The high incidence of traumatic falls is consistent with the developing motor coordination in young children. Subluxations are often not the only tooth injury sustained in a particular accident. Avulsions and/or luxations were found 58.2% of the time along with subluxation injuries. Crown and root fractures were found 5.8% and were infrequent probably due to the relative plasticity of bone in young children which absorbs most of the force during an impact. The treatment of subluxated teeth varies and this study found that 80.2% of the time teeth required no dental treatment. Antibiotics were administered only in cases were a potential for systemic infection such as avulsion or luxation where there is an increased likelihood that the gingiva was lacerated. Discoloration has frequently been reported following traumatic injuries to teeth. This study showed an increase of discoloration over time. A yellow discoloration is thought to be due to partial pulp canal obliteration. A pink tooth is due to blood pigments entering the dentinal tubules at the time of trauma. A gray discoloration is generally thought to be significant of pulpal necrosis. Discoloration should be used as an adjunct in diagnosis, but not as the sole predictor of prognosis and in determining the need for EXT. Other studies found discolored primary teeth failed to develop any radiographic and/or clinical pathology. This study found that incidence and severity of pulpal calcification increases with time. Other studies have found that prognosis following pulp obliteration was favorable and normal root resorption usually occurred.
Summary of conclusions:
Highest incidence of trauma occurred in males 3-4 yo. and females 1-3 yo. Central incisors were most commonly affected typically the result of falls.
More than half the patients were seen within 3hrs of the trauma.
The majority of teeth had a mobility ranging between 1.6 and 2.5mm following trauma.
Treatment included occlusal reduction, splinting, and EXT, but most teeth received no treatment.
Tooth discoloration increased with time after trauma.
Mobility improved with time, with the majority of teeth returning to a normal physiological range.
Pulpal calcification increased in incidence and severity with time.
Low patient return was noted on follow-up, indicating low morbidity of subluxation injuries.
Assessment of article: Great article, an easy read. There is a lot of interesting epidemiological information like patient demographics that wouldn’t be particularly useful for clinical treatment of trauma. Conversely, I thought that the prognosis conclusions made by this study would be helpful when considering treatment options in the clinical setting while managing a patient with subluxation trauma.
Friday, August 14, 2009
Guideline on Management of Acute Dental Trauma
Resident’s Name: Joanne Lewis Date: August 14, 2009
Article title: Guideline on Management of Acute Dental Trauma (focused on primary dentition for this lit review)
Originating Council: AAPD Council on Clinical Affairs
Journal: AAPD Reference Manual 29
Adopted: 2001 (revised 2004, 2007)
Major topic: dental trauma
Main Purpose: to define, describe appearances, and set forth objectives for general management of acute traumatic dental injuries.
Overview of method of research: The guideline is based on a review of current dental and medical literature related to dental trauma.
Findings: Greatest incidence of trauma to the primary dentition occurs at 2-3 years of age, when motor coordination is developing. Rapid and thorough assessment of the nature and extent of the patient’s injuries is essential to delivering appropriate treatment. After a primary tooth has been injured, the treatment strategy is dictated by the concern for the safety of the permanent dentition. It is important to inform parents about possible pulpal complications, such as the development of an abscess or sinus tract or color change of the crown, as well as potential sequelae to permanent teeth, such as enamel hypoplasia, hypocalcification, crown/root dilacerations, or disruptions in eruption. Specific recommendations are as follows:
- Infraction – no treatment indicated
- Uncomplicated crown fracture – for small fractures, rough margins and edges can be smoothed; for larger fractures, lost tooth structure can be restored.
- Complicated crown fracture – decisions are based on life expectancy of the primary tooth and vitality of the pulpal tissue. Treatment alternatives are pulpotomy, pulpectomy, and extraction.
- Crown/root fracture – extract the entire tooth, unless the retrieval of apical fragments may result in damage to the succedaneous tooth.
- Root fracture – extract the coronal segment with or without the removal of the apical fragment.
- Concussion – unless an associated infection exists, no pulpal therapy is indicated.
- Subluxation – no immediate treatment needed, tooth should be followed for pathology – should return to normal within 2 weeks.
- Lateral luxation – allow passive repositioning or actively reposition and splint for 1-2 weeks as indicated, except when the injury is severe or the tooth is near exfoliation.
- Intrusion – allow spontaneous reeruption except when displaced into the developing successor. If the apex is displaced toward the permanent tooth germ, extraction is indicated. 90% will reerupt spontaneously within 2-6 months. Ankylosis may occur.
- Extrusion – reposition and stabilize with a splint for 1-2 weeks or extract.
- Avulsion – do not reimplant primary teeth.
Assessment of article: Concise reference – recommendations are very general.
Article title: Guideline on Management of Acute Dental Trauma (focused on primary dentition for this lit review)
Originating Council: AAPD Council on Clinical Affairs
Journal: AAPD Reference Manual 29
Adopted: 2001 (revised 2004, 2007)
Major topic: dental trauma
Main Purpose: to define, describe appearances, and set forth objectives for general management of acute traumatic dental injuries.
Overview of method of research: The guideline is based on a review of current dental and medical literature related to dental trauma.
Findings: Greatest incidence of trauma to the primary dentition occurs at 2-3 years of age, when motor coordination is developing. Rapid and thorough assessment of the nature and extent of the patient’s injuries is essential to delivering appropriate treatment. After a primary tooth has been injured, the treatment strategy is dictated by the concern for the safety of the permanent dentition. It is important to inform parents about possible pulpal complications, such as the development of an abscess or sinus tract or color change of the crown, as well as potential sequelae to permanent teeth, such as enamel hypoplasia, hypocalcification, crown/root dilacerations, or disruptions in eruption. Specific recommendations are as follows:
- Infraction – no treatment indicated
- Uncomplicated crown fracture – for small fractures, rough margins and edges can be smoothed; for larger fractures, lost tooth structure can be restored.
- Complicated crown fracture – decisions are based on life expectancy of the primary tooth and vitality of the pulpal tissue. Treatment alternatives are pulpotomy, pulpectomy, and extraction.
- Crown/root fracture – extract the entire tooth, unless the retrieval of apical fragments may result in damage to the succedaneous tooth.
- Root fracture – extract the coronal segment with or without the removal of the apical fragment.
- Concussion – unless an associated infection exists, no pulpal therapy is indicated.
- Subluxation – no immediate treatment needed, tooth should be followed for pathology – should return to normal within 2 weeks.
- Lateral luxation – allow passive repositioning or actively reposition and splint for 1-2 weeks as indicated, except when the injury is severe or the tooth is near exfoliation.
- Intrusion – allow spontaneous reeruption except when displaced into the developing successor. If the apex is displaced toward the permanent tooth germ, extraction is indicated. 90% will reerupt spontaneously within 2-6 months. Ankylosis may occur.
- Extrusion – reposition and stabilize with a splint for 1-2 weeks or extract.
- Avulsion – do not reimplant primary teeth.
Assessment of article: Concise reference – recommendations are very general.
Thursday, August 13, 2009
Sequelae of trauma to primary maxillary incisors and complications in the primary dentition
Resident: Jason Hencler
Date: 8/14/09
Article title: Sequelae of trauma to primary maxillary incisors and complications in the primary dentition
Author(s): M. K. Borum, J. O. Andreasen
Journal: Endodontics and Dental traumatology
Volume #14; Page 31-44
Year: 1998
Major topic: Trauma and primary maxillary incisors
Type of Article: Clinical case study
Main Purpose: Investigate the immediate and long term consequences of trauma to the primary maxillary incisors.
Overview of method of research:
Study group was 287 children who sustained trauma to maxillary primary central and lateral incisors. Patients exhibited 545 traumatized maxillary primary incisors; 428 central and 117 lateral incisors. Parameters of the study included color changes, pulp necrosis (PN), pulp canal obliteration (PCO), gingival retraction, permanent displacement after luxation, pathological root resorption, and premature loss of the traumatized tooth. After initial trauma evaluation, follow-up visits were planned at 4wk, 8wk, and 1 yr as well as when the child was 6 and 10yo. All visits included radiographs and clinical exam.
Findings:
Color changes-Transient gray discoloration (TGD) was seen in 15.2% and 78% of the teeth later turned yellow. The relationship between TGD and later PCO as well as the relationship between TGD and the absence of PN are highly significant. Permanent gray discoloration (PGD) was seen in 18.1%. PCO was seen in 8.6% of the PGD teeth and 65.7% developed PN. Yellow discoloration was seen in 31% in which PCO was seen in 81.5%.
Pulp necrosis-Type of luxation seemed to be an important factor in the development of PN. Age at time of injury seemed to be a significant factor for developing PN, as younger children showed a lower frequency of PN than older children. Pulp Canal Obliteration-None of the teeth with PCO developed PN. The type of luxation also was an important factor in developing PCO. Frequency of PCO in older children was very low. Gingival retraction-The only variable found to be significant for the development of gingival retraction was the presence of gingival injury associated with the trauma. Pathological root resorption: Inflammatory root resorption was found to be associated with PN. Physiological root resorption-PN was significantly related to both accelerated and delayed physiological root resorption. No connection was found between PCO and changes in physiological resorption rates. Premature loss of traumatized Primary teeth-Of the 287 children, 167 experienced premature loss of 1 or more teeth.
Key points in the article discussion:
More than half of the traumatized teeth developed transient or permanent color changes. Transient color changes were associated with PCO while permanent color changes were associated with PN. Yellow discoloration was strongly associated with pulpal obliteraton. Although these findings are significant, color changes alone are not a reliable predictor of pulpal health. The age of the child at the time of injury seems to be very important in the development of PN. A very young child has a high vascular supply to the wide open and very short pulp along with resilient alveolar bone, the pulp is able to survive severe injury. Physiologic resorption in older children can be advanced to a point where the pulp becomes degenerated and vulnerable to even minor injuries. PCO in the primary dentition was highly associated with concussion, subluxation, and intrusion but less associated with lateral luxation. Conversely, PN is highly associated with lateral luxation. Gingival retraction was most often found after gingival trauma associated with tooth trauma. For laterally luxated teeth primary teeth, spontaneous repositioning with in the first days or weeks of trauma can be expected. A tooth that fails to realign within the first weeks of trauma is less likely to regain a healthy pulp, as ingrowth of new pulp tissue is blocked by clot formation between the most apical part of the original socket and the apical foramen of the tooth. Delayed physiologic root resorption may be associated with PN because resorption also takes place from the pulpal side of the root, which may be affected if the pulp is necrotic. PCO was not found to be associated with delayed resorption.
Summary of conclusions: Effects of premature loss of traumatized primary teeth on eruption and alignment of the permanent successors should be considered against the possible damage to the development of the successors by treatments aimed at preserving traumatized teeth. Increase in awareness and research on these problems has been essential in the development of treatment guidelines for the traumatized primary dentition.
Assessment of article: I did think this article was quite long with confusing statistics and tables. But once you’ve picked out the important points and read through the tables and pie charts, this article presented some very relevant information that could easily be useful in clinical situations when seeing patients with trauma.
Date: 8/14/09
Article title: Sequelae of trauma to primary maxillary incisors and complications in the primary dentition
Author(s): M. K. Borum, J. O. Andreasen
Journal: Endodontics and Dental traumatology
Volume #14; Page 31-44
Year: 1998
Major topic: Trauma and primary maxillary incisors
Type of Article: Clinical case study
Main Purpose: Investigate the immediate and long term consequences of trauma to the primary maxillary incisors.
Overview of method of research:
Study group was 287 children who sustained trauma to maxillary primary central and lateral incisors. Patients exhibited 545 traumatized maxillary primary incisors; 428 central and 117 lateral incisors. Parameters of the study included color changes, pulp necrosis (PN), pulp canal obliteration (PCO), gingival retraction, permanent displacement after luxation, pathological root resorption, and premature loss of the traumatized tooth. After initial trauma evaluation, follow-up visits were planned at 4wk, 8wk, and 1 yr as well as when the child was 6 and 10yo. All visits included radiographs and clinical exam.
Findings:
Color changes-Transient gray discoloration (TGD) was seen in 15.2% and 78% of the teeth later turned yellow. The relationship between TGD and later PCO as well as the relationship between TGD and the absence of PN are highly significant. Permanent gray discoloration (PGD) was seen in 18.1%. PCO was seen in 8.6% of the PGD teeth and 65.7% developed PN. Yellow discoloration was seen in 31% in which PCO was seen in 81.5%.
Pulp necrosis-Type of luxation seemed to be an important factor in the development of PN. Age at time of injury seemed to be a significant factor for developing PN, as younger children showed a lower frequency of PN than older children. Pulp Canal Obliteration-None of the teeth with PCO developed PN. The type of luxation also was an important factor in developing PCO. Frequency of PCO in older children was very low. Gingival retraction-The only variable found to be significant for the development of gingival retraction was the presence of gingival injury associated with the trauma. Pathological root resorption: Inflammatory root resorption was found to be associated with PN. Physiological root resorption-PN was significantly related to both accelerated and delayed physiological root resorption. No connection was found between PCO and changes in physiological resorption rates. Premature loss of traumatized Primary teeth-Of the 287 children, 167 experienced premature loss of 1 or more teeth.
Key points in the article discussion:
More than half of the traumatized teeth developed transient or permanent color changes. Transient color changes were associated with PCO while permanent color changes were associated with PN. Yellow discoloration was strongly associated with pulpal obliteraton. Although these findings are significant, color changes alone are not a reliable predictor of pulpal health. The age of the child at the time of injury seems to be very important in the development of PN. A very young child has a high vascular supply to the wide open and very short pulp along with resilient alveolar bone, the pulp is able to survive severe injury. Physiologic resorption in older children can be advanced to a point where the pulp becomes degenerated and vulnerable to even minor injuries. PCO in the primary dentition was highly associated with concussion, subluxation, and intrusion but less associated with lateral luxation. Conversely, PN is highly associated with lateral luxation. Gingival retraction was most often found after gingival trauma associated with tooth trauma. For laterally luxated teeth primary teeth, spontaneous repositioning with in the first days or weeks of trauma can be expected. A tooth that fails to realign within the first weeks of trauma is less likely to regain a healthy pulp, as ingrowth of new pulp tissue is blocked by clot formation between the most apical part of the original socket and the apical foramen of the tooth. Delayed physiologic root resorption may be associated with PN because resorption also takes place from the pulpal side of the root, which may be affected if the pulp is necrotic. PCO was not found to be associated with delayed resorption.
Summary of conclusions: Effects of premature loss of traumatized primary teeth on eruption and alignment of the permanent successors should be considered against the possible damage to the development of the successors by treatments aimed at preserving traumatized teeth. Increase in awareness and research on these problems has been essential in the development of treatment guidelines for the traumatized primary dentition.
Assessment of article: I did think this article was quite long with confusing statistics and tables. But once you’ve picked out the important points and read through the tables and pie charts, this article presented some very relevant information that could easily be useful in clinical situations when seeing patients with trauma.
Department of Pediatric Dentistry
Lutheran Medical Center
Date: 08/14/2009
Article title: Traumatic injuries in the primary dentition
Author(s): Flores MT
Journal: Dental Traumatology
Volume (number): Vol 18
Month, Year: 2002
Major topic: Trauma to primary teeth
Minor topics: epidemiology, preschool, primary dentition
Type of Article: Review of Literature
Main Purpose: Review types of injuries to the primary dentition and present evidence based treatments
Overview of method of research: Review of Literature from 1984 to 2001, including 75 articles.
Findings:
Most luxation injuries heal spontaneously and conservative treatment for preschool aged kids is suggested. Good pain control, ability to cope with the child's anxiety and good hygiene can help save many injured teeth.
Key points/Summary :
- Epidemiology: Many children will experience trauma to their teeth, especially between 18 and 30 months. Some studies show incidences as high as 30%.
- Classification: The WHO has classified traumas based on work from Andreasen & Andreasen which can be seen in the article.
- Treatment: Luxation is the most common injury and there are few long-term studies to base treatment protocols on. The best decisions are going to be guided by evidence, biological and conservative, damage limiting principles.
- Emergency Management: Soft tissue injuries can often obscure tooth damage. Clean the soft tissue first and suture starting with the skin first moving towards mucosa lastly.
- Non-complicated crown fracture: Simple to fix with composite or ionomer. Take a PA to rule out any other pathology and to have as a baseline.
- Complicated crown fracture: Take a baseline PA and then treatment is partial pulpotomy if the apex is not closed. If the primary tooth has not yet started the root resorption process pulpotomy is an option, root canal treatment with ZOE fill, or finally extraction.
- Crown-root fracture: PA xray as a baseline, extract mobile portions and if it is not easily removed, leave root tip to avoid damage to tooth germ.
- Root fracture: PA xray, wire splint if coronal portion is still in place. The crown may be lost in the future. Also, if the crown is very mobile it is acceptable to remove it and leave the remaining root.
- Alveolar fracture: Xray, splint to adjacent teeth for up to 4 weeks. If it is not stable, splint for 2-3 more weeks or extract.
- Concussion: (tooth is tender to the touch only) Keep under observation and do not perform root treatment even if discoloration exists unless infection develops.
- Subluxation: (tooth is mobile without displacement, sulcar bleeding may be present) Good hygiene and infection control will usually lead to normal healing.
- Lateral luxation: (displaced tooth, usually with the crown palatal) Take 2 PAs. If there is no occlusal interference, leave the tooth to heal spontaneously. If occlusal interference was present you can reposition and splint for 2-3 weeks, but that has a higher incidence of pulpal necrosis.
- Intrusion: Take a PA, no need for extra-oral radiographs. If the tooth is displaced with the apex toward the labial bone plate, leave it. If the tooth is displaced with the apex toward the succedaneous tooth germ, extract with the forcep mesio-distally.
- Extrusion: No clinical studies of conservative treatment, reposition and splint or extract.
- Avulsion: Take a PA to rule out intrusion. Do not re-implant.
- Instructions for parents: Excellent hygiene is a must for proper healing. Soft diet for 2 weeks, chlorhexidine rinse, etc.
- Follow-up: the type of follow-up and frequency depends on the type of injury. For crown fractures it is 6-8 weeks; alveolar fracture 3-4 weeks, 6-8 weeks, 6 months, 1 year; Root fracture 2-3 weeks, 6-8 weeks, 1 year (assumes incomplete or no extraction); Lateral Luxation 2-3 weeks, 6-8 weeks, 6 months, 1 year; Intrusion once a week for the first 3 weeks, 6-8 weeks, then as needed.
Assessment of article: A good review that is essential to being able to treat the emergencies that we see. I found this one very useful when I started covering call and also very helpful in our clinic. The follow-up schedule is good to know and follow, especially in cases of litigation I would imagine.
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