1. CLINICAL PEDIATRIC DENTISTRY I DSV 441 CHAPTER 21 MANAGEMENT OF TRAUMA TO THE TEETH AND SUPPORTING TISSUES, 453-503 History And Examination (pages 455-460) 16 Tuesday 3\2\2015 1:00 pm-2:00 pm OTHMAN AL-AJLOUNI 1

2. Lecture outline HISTORY OF THE INJURY CLINICAL EXAMINATION RADIOGRAPHIC EXAMINATION 2

3. H I S T O R Y A N D E X A M I N A T I O N Routine use of a CLINICAL EVALUATION SHEET for injured anterior teeth is helpful during initial examination and subsequent examinations of an injured tooth. The FORM, which becomes a part of the patient's record, serves as a CHECKLIST of important questions that must be asked and observations that must be made by dentist and auxiliary personnel during examination of child. 3

4. H I S T O R Y O F T H E I N J U R Y TIME of injury should first be established. Unfortunately, many patients do not seek professional advice and treatment immediately after an injury. Neurologic assessment, and make appropriate medical referral when indicated without delay. Patient should be assessed for nausea, vomiting, drowsiness, or possible cerebral spinal fluid leakage from nose and ears. Patient should be evaluated for lacerations and facial bone fractures, temperature, pulse, blood pressure, and respiratory rate. Prognosis of an injured tooth depends logically on TIME that has elapsed between occurrence of accident and initiation of emergency treatment. Prognosis of injured teeth maintaining pulpal vitality diminished when treatment was DELAYED. REPEATED injuries to teeth are common in children with protruding anterior teeth and in those who are active in athletics. 4

5. H I S T O R Y O F T H E I N J U R Y 1)Patient's name, age, sex, address, and telephone number 2)When did injury occur? 3)Where did injury occur? 4)How did injury occur? 5)Treatment elsewhere 6)History of previous dental injuries 7)General health 8)Did trauma cause amnesia, unconsciousness, drowsiness, vomiting, or headache? 9)Is there spontaneous pain from teeth? 10)Do teeth react to thermal changes, sweet or sour food? 11)Are teeth painful to touch or during eating? 12)Is there in any disturbance in bite? 5

6. CLINICAL EXAMINATION Clinical examination after teeth carefully CLEANED of debris. Observe amount of tooth structure that has been LOST and should look for evidence of a pulp EXPOSURE. With aid of a good light, clinical crown examined carefully for cracks and craze lines. With light transmitted through teeth in area, color of injured tooth should be carefully compared with that of adjacent uninjured teeth. Severely traumatized teeth often appear darker and reddish, although not actually discolored, which indicates pulpal hyperemia. 6

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9. CLASSIFICATION OF CROWN FRACTURES The Ellis and Davey classification of crown fractures is useful in recording extent of damage to crown. Following is a modification of their classification : I.Class I—Simple fracture of crown involving little or no dentin II.Class II—Extensive fracture of crown involving considerable dentin but not dental pulp III.Class III—Extensive fracture of crown with an exposure of dental pulp IV.Class IV—Loss of entire crown 9

10. Enamel Fx Dentin Fx Pulp Exposure Ellis Class I Ellis Class II Ellis Class III

11. CLINICAL EXAMINATION A vitality test of injured tooth, and teeth in immediate area, as well as opposing arch. The best prediction of continued vitality of pulp is vital response to electric pulp testing at time of initial examination. A negative response is not reliable evidence of pulp death because some teeth that give such a response soon after injury may recover vitality after a time. Electrical stimulus produce negligible additional pulpal irritation, its use is not contraindicated on this basis. Electric pulp test is unreliable even on normal teeth when apices are incompletely formed. 11

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13. CLINICAL EXAMINATION Thermal test is helpful in determining degree of pulpal damage after trauma. It is probably more reliable in testing primary incisors in young children than electric pulp test. Failure of a tooth to respond to heat is indicative of pulpal necrosis. Response to a lower degree of heat is an indication of inflammation. Pain occurring when ice is applied to a normal tooth will subside when ice is removed. A more painful to cold indicates a pathologic change within pulp, the nature of which can be determined when reaction is correlated with other clinical observations. 13

14. CLINICAL EXAMINATION Failure of a pulp to respond immediately after an accident is not an indication for endodontic therapy. Instead, emergency treatment should be completed, and tooth should be retested at next follow-up visit. Laser Doppler flowmetry has been reported to be a significant aid in determining vascular vitality of traumatized teeth. (Very Expensive) 14

15. CLINICAL EXAMINATION 1.Recording of extraoral wounds and palpation of facial skeleton 2.Recording of injuries to oral mucosa or gingiva 3.Examination of crowns of teeth for presence and extent of fractures, pulp exposures, or changes in color 4.Recording of displacement of teeth 5.Disturbances in occlusion 6.Abnormal mobility of teeth or alveolar fragments 7.Palpation of alveolar process 8.Tenderness of teeth to percussion and change in percussion tone 9.Reaction of teeth to pulpal sensibility testing 15

16. Reaction of teeth to sensibility tests 1)Mechanical stimulation 2)Heated gutta-percha 3)Ice 4)Ethyl chloride 5)Carbon dioxide snow 6)Dichlor-difluormethane 7)Electric pulp testers (EPT) 8)Laser Doppler flowmetry (LDF) 16

17. RADIOGRAPHIC EXAMINATION Examination of traumatized teeth cannot be considered complete without a radiograph. It may necessary to obtain a radiograph of soft tissue surrounding injury site. Size of pulp chamber and canal should be carefully examined. Irregularities or an inconsistency compared with of adjacent teeth. In young patients stage of apical development often indicates type of treatment Size of coronal pulp and its proximity to area of fracture influence type of restoration. A root fracture, two or three radiographs of area at different angles may be needed to define defect and aid in deciding on a course of treatment. It provides a record of tooth immediately after injury. Frequent, periodic radiographs reveal evidence of continued pulp vitality or adverse changes that take place within the pulp or the supporting tissues. In more complex facial injuries have occurred or jaw fractures are suspected, extraoral films may also be necessary to help identify extent and location of all injury sequelae. Oblique lateral jaw radiographs and panoramic films are often useful adjuncts to this diagnostic process. 17

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19. EMERGENCY TREATMENT OF SOFT TISSUE INJURY Injury to the teeth of children is often accompanied by open wounds of the oral tissues, abrasion of the facial tissues, or even puncture wounds. The dentist must recognize the possibility of the development of tetanus after the injury and must carry out adequate first-aid measures. Children with up-to-date active immunization are protected by the level of antibodies in their circulation produced by a series of injections of tetanus toxoid. Primary immunization is usually a part of medical care during the first 2 years of life. However, primary immunization cannot be assumed but must be confirmed by examining the child's medical record. When the child who has had the primary immunization receives an injury from an object that is likely to have been contaminated, the antibody-forming mechanism may be activated with a booster injection of toxoid. An unimmunized child can be protected through passive immunization or serotherapy with tetanus antitoxin (tetanus immune globulin, or TIG). The dentist examining the child after an injury should determine the child's immunization status, carry out adequate debridement of the wound, and, when indicated, refer the child to the family physician. Tetanus is often fatal, and preventive measures must be taken if there is a possibility that an injured child is not adequately immunized. Debridement, suturing, and/or hemorrhage control of open soft tissue wounds should be carried out as indicated. Working with an oral and maxillofacial surgeon or a plastic surgeon may also be indicated. 19

20. TETANUS PROPHYLAXIS Tetanus is uncommon, infectious but non-communicable disease, caused by bacteria (clostridium tetani) lives in soil and dust especially in agricultural land produces a type of neurotoxin called tetanospamin affects muscles causes spasm of the muscles. Immunisation is usually received at young age (2-2 ½) years. We need a booster every 10 years. Tetanus prophylaxis should always be considered in case of contaminated wounds. In a previously immunised patient (longer than 10 years previous to injury), a dose of 0.5 ml tetanus toxoid should be given (booster injection). In unimmunised patients, passive immunization should be provided. A 'booster' injection is indicated if the child has not received one in the last 5 years. 20

21. TETANUS PROPHYLAXIS Immunisation completed plus booster within 5 years-----No treatment. Greater than 10 years since immunisation-----toxoid. Between 5&10 years since immunisation and dirty wound---- toxoid. No history of immunisation and dirty wound----- toxoid and antitoxin (tetanus immune human globulin). 21

22. THANKS FOR YOUR KIND ATTENTION