Dental trauma : examination & treatment planning

, Hey lovely dentists

in this lecture I will introduce you to the aspects of examination , how to

examine a patient who has had a traumatic accident and how to diagnose &
plan the treatment for that patient . but
 before talking about those interesting
… subjects , I will talk a little bit about
:Main topics will be discussed

. principles of trauma management -1

principles of trauma
: diagnosis -2 : management
. history -

.clinical examination - : triage & stabilize . 1

Means you have to asses everything
. radiographic examination - around you & have everything under
: control and it includes
.vitality testing -
A - assessing the level of
.treatment planning -3 consciousness of the patient , it's a
kind of neurological
 assessment ,so the question you
?should ask yourself is : is he conscious or unconscious after the trauma
: After that the question will be
? How do you know if the patient is conscious or not
look at the patient, notice if you can see -
. signs of disorientation -
. he can't stand up -
amnesia; which means forgetting. you can check it by -
asking the patient : what is your name? if he can't answer
it , then there is some sort of loss of consciousness , or by
asking where do you live ? or what happened ? some
of them can probably talk but they can't remember or tell you exactly what
.happened
vomiting , nausea , drowsiness ; which is your logic signs of loss of -
. consciousness
.signs of some sort of head injury -

the reasonable man adapts himself to the world ; the unreasonable one persists in trying to adapts "
the world to him self . therefore , all the progress depends on the unreasonable man "
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 Dental trauma : examination & treatment planning

B - paresthesia of lips or anywhere else ; means one of the nerves has been
.hit or the blow was very hard
C - battle sign ; redness on the mastoid process. when the patient got a hit on
one of the sides, then the mastoid process will look red because of hematoma , it
.seems like an ecchymosis behind ear
. D - raccoon sign ; black eye result from an orbital fracture in the bone
E - skull fractures : in this case you may see CSF ( cerebrospinal fluid )
.seeping out of the ear or nose ( nasal or auditory discharge )
F - subjective assessment ; do you think there will be child abuse involved
in the case or the scenario? , or it's just a trauma by accident or by just a
fell . of course there are other ways to assess child abuse ( not into
.discussion right now )

treat the injury as soon as possible; avoid any delay , especially in .2

. severe injuries

you have to be calm & professional , when a child come to your . 3

clinic due to a trauma the parents will be with him in addition to other
family members or relatives , everybody will be in panic and they will
be alarmed , may be they will be screaming , shouting ,crying , accusing each
other or feeling guilty , so you as a dentist you have to be calm you have
to be the person who relaxes everyone , doesn't mean that you forget
everything and you start relaxing the patient's relatives, but what I
mean is to be professional , you have to reassure them , tell them
what is happening, tell them that this is not helping me plz step outside
. calmly & let me do my work , so you have to have a say in this
thorough documentation ; means everything you see, have to be .4
documented such as medical history ,clinical & radiographic findings .
don't lose your x-rays . if you did vitality testing record the results .
photographs , study models so by this way no one will accuse you later on .
if the tooth lose vitality & the parents say it's because of your poor
management , so you can say no I did my pulp testing & it says so & so, the
radiograph I took shows this & tenderness to percussion shows this , so you
. have evidences
Dentists , now you will find a slide containing 2 pictures , the doctor doesn't
know what happened with the child in the picture and she don't know why

the reasonable man adapts himself to the world ; the unreasonable one persists in trying to adapts "
the world to him self . therefore , all the progress depends on the unreasonable man "
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 Dental trauma : examination & treatment planning

does she put that picture , but she thinks that it's just a blow luxation ( that's
.what I heard) injury on the teeth

Now after we talked a little about the principles of trauma management , of

. course everyone of us wanna reach diagnosis
Dental injury should always be considered as emergency & treated
immediately , and a dental injury means any blow to the teeth , especially if it
exposing the pulp or causing mobilization of teeth . We treat the patient to
improve the prognosis, so we provide the best treatment so we can reach the
. best prognosis
the first priority while giving treatment is to relief pain, sometimes you
have to delay pulp therapy because the patient is in pain , the second thing we
should take care of during treatment is to enhance functions ; which means
using the tooth for mastication , speech & so on . the third thing is aesthetics
,although it has a high sequence among teenagers & all of us but this is the
!.sequence of priorities

: Diagnosis include
- . History, that will also include medical history
clinical examination , that will include extra & intra oral examination , soft & -
.hard tissue examination
. radiographic examination -
. vitality testing -

History : means the questions that you are going to ask in order to reach
your diagnosis & build your treatment plan . in the case of trauma there are
specific questions differ from the history you take for any patient. You have to
include the name , age , sex, address & telephone number to contact your
patient , apart from the necessity of those informations , the ability of the
patient to provide those gives you a clue about consciousness ; if he can
remember his name , his address & his telephone number that means he is
.conscious & the head injury is not severe

Medical history : it reviews the disorders that can influence your

: management . you go through the
. systemic review -
. bleeding disorders are very important to know -
the reasonable man adapts himself to the world ; the unreasonable one persists in trying to adapts "
the world to him self . therefore , all the progress depends on the unreasonable man "
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 Dental trauma : examination & treatment planning

. heart conditions especially congenital one -

diabetes specially if it's uncontrolled or the patient hasn't taken his insulin -
. or his drug
epilepsy sometimes as a result of trauma an epileptic seizures might result -
. or the other way around epileptic seizures might cause the trauma
. allergies if the patient has any sort of allergy to anything -
. medications that are being taken , you have to record it -

today someone on the clinic had an epileptic patient taking a drug so what
? you have to do in this case
You write down the name of the drug & the dosage that the patient is taking &
. how many times a day. for example topamax so & so mg , twice daily

at first dentists ask about the basic things beside the medical history & now
: dentists should ask a couple of questions and I will list them below

? when did the injury occur

we care about the time of the injury because it affects our treatment & the
prognosis . if a tooth has a complicated tooth fracture & the pulp is exposed ; if
the exposure was from 2 – 3 hours ago , it will be much more different from a
patient came after 2 days , the prognosis will be different & your approach for
the treatment will be different ; if it's 2 hours you can do direct pulp cap for
example , but if it's 2 days you may do (-------- )pulpotomy( it's one type of
pulpotomy done when there is a partial or superficial necrosis ). So it implies a
. time factor which is critical when considering avulsed teeth or pulp exposure

? Where did the injury occur

This is especially important in the case of contamination and legal issue;
like if it happens in school ; somebody pushed him or because of abuse by a
teacher ( which happened few times ), in home because of abuse or during
playing or in the playground while children are playing , and every case has a
.legal aspects

?How did the injury occur

It shows the possible zones of injury , for example if the child fell off the
steps it means there might be a crown fracture or crown root fracture , if the
blow is very hard or it came from the side it means that this side of the bone

the reasonable man adapts himself to the world ; the unreasonable one persists in trying to adapts "
the world to him self . therefore , all the progress depends on the unreasonable man "
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 Dental trauma : examination & treatment planning

might be fractured , or if the patient fell on his chin it means the condyles could
. be affected & you may find a condylar neck fracture

? Was there a period of unconsciousness

We talked about this , it will tell us about neurological involvement , if so
you have to ask : how long did this occur ? is there a headache , amnesia ,
vomiting , nausea ? and if there is any obvious sign you have to transfer the
. patient to the emergency department ,in the hospital straight away

? Have there been previous injuries to the teeth

Does the patient get those kind of injuries every now & then .? if so , this
may indicate a self injurious behavior which is kind of a syndrome , child abuse
, attention hyperactivity or the child is from the type that always gets himself in
! trouble & gets injuries

? Is there a disturbance in the bite

If yes , most probably there will be bone fracture , especially the step
deformity which occur in the lower anterior teeth, when the alveolar bone is
fractured below the anterior teeth area, anterior teeth area will go back , so a
. step can be noticed between anterior teeth & the canine

? Is there any reaction of the teeth to cold ,heat, sweet or sour food
If there is extreme sensitivity , it means that the pulp is probably exposed or
. the dentine is severely exposed

? Is there a spontaneous pain

If yes it is usually indicate periodontal ligament injury, injury to the bone or
. bone fracture

? Are the teeth tender due to touch or due to eating

If the teeth tender to percussion , this usually indicates luxating injury ,
. luxating to the periodontal ligament

After you take history ,you do your analysis, According to what you find ;
if there is pain ,disturbance to the bite , nausea or vomiting , you analyse then
. you come up with a diagnosis

the reasonable man adapts himself to the world ; the unreasonable one persists in trying to adapts "
the world to him self . therefore , all the progress depends on the unreasonable man "
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 Dental trauma : examination & treatment planning

Now in your clinical examination you have to look at some specific issues
in order to finalize your diagnosis , when the patient attends for treatment of
dental trauma, the oral region is usually heavily contaminated , usually have
dust ,dirt & soil. The first step is to wash the patient's face ;there may be blood
some times . if there are soft tissue wounds a mild detergent should be used .
thorough examination of the injured area should include soft tissue & hard
tissue examination , always use a standardized examination form it will help
. you remember everything
We have a form in the dental teaching center, the good thing about this
form that it has everything you need to examine the patient , so you won't
. forget anything
The steps are , first you clean the patient . record your clinical findings extra
orally , intra orally , soft tissue wounds, hard tissue wounds , any fractures of
the bone or tissue , mobility testing, , percussion, sensibility testing &
radiographic examination , you have to know these by heart for the
.. examination of any tooth

:The extra oral examination

you record the extra oral wounds , if you find any wound present on the
face you should record it . Palpation of the facial skeleton will tell you if there
is any bone which has been fractured . check the mandible from all excursions
up , down , right , left , ask the patient to open widely & then close his mouth ;
this will tell you , if there is any condylar fracture whether in the neck or joint ,
even those movements can tell you If there is something in the symphesis or in
the body . in addition palpate the TMJ ( Temporo Mandibular Joint) , look for
. any swellings or clicking

: soft tissue examination

the doc put a picture showing laceration of the lips ,and it includes bleeding
( the doc points to a picture I don't have , because she doesn't provide us with
.her slides )

:Intraoral examination
You look at all the soft tissues such as the gingiva ,mucosa , tongue & cheeks
. you look if there is any tooth fragments , any cuts or any bruises , then you
take radiograph ; you can take soft tissue radiograph . after that you record
all of these . beside that you can put if there is hematoma present or if an
. artery has been hit or has been cut
the reasonable man adapts himself to the world ; the unreasonable one persists in trying to adapts "
the world to him self . therefore , all the progress depends on the unreasonable man "
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 Dental trauma : examination & treatment planning

: Hard tissue exam

Hard tissue examination is usually done By looking at all teeth ,but before
that, you have to clean the teeth , dry them well , then examine all the crowns
for the presence of cuts , fractures, exposures, changes in color , mobility or
displacement. So examine all the teeth , don’t just look at the tooth which looks
like it's fractured or the one that has bleeding around , ignoring the rest of
.teeth , examine all the teeth , look at everything together
Examine the alveolus for any mobility or any displacement ,a typical sign of
alveolar fracture is the movement of adjacent teeth ,when mobility of single
tooth is tested ; so if there is alveolar fracture in the lower anterior area & you
check the mobility of the central incisor, and the four anteriors moving together
. , it means the whole bone has been fractured
Then the doc showed us a history & examination form , not the one that we
use in our clinics , then she showed us the one we use & I attached it in the end
of the lecture please follow the explanation I will out here on the examination
.sheet
in it you write the patient's name , date of birth , file number , dental history
, medical history , address , telephone number . where the patient came from?
if he was referred by somebody like school, general ( medical ) practitioner "
GP" , general dental practitioner "GDP" , ministry of health "MOH" , specialist ,
.others
Now history section : it includes day of the examination & time , day of
injury & time , where the injury occurred , how the injury occurred ,history of
any previous injury & what was done to the patient , number of any previous
injuries sustained by the same tooth & if it was injured before , is tetanus
needed ? yes or no , when was it last taken ? ( details about tetanus will be at
.the end of the lec)

: Clinical examination section

-. extra oral examination : the head , neck & lips
intra oral examination : examine the mucosa for any swellings , examine the -
gum for any inflammation , check the oral hygiene ; we care about oral hygiene
because it can affect your prognosis , treatment plan & the outcome ; if you did
. a pulp therapy or splinting for the teeth, it will be affected by oral hygiene

the reasonable man adapts himself to the world ; the unreasonable one persists in trying to adapts "
the world to him self . therefore , all the progress depends on the unreasonable man "
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 Dental trauma : examination & treatment planning

occlusal analysis: you record everything ( read them in the form attached ) -
. beside any oral habits
you document the tooth which have been injured , for example if you took -
: " 11 " tooth
Then the clinical injury is a complicated crown fracture , the shade of --
.…the tooth A2 , B1
check if there is mobility ; 0: for no mobility , 1: barely distinguishable , --
. 2: less than 1 mm, 3: more than 1 mm in any direction

check Transillumination : and that's by putting the light directly on the --

. tooth which is dry & looking for any cracks . so it's either normal or cracked
check Tenderness to percussion : there is either no tenderness to --
percussion which is " 0" , "+"
for severe , "ank" for
ankylosed; means

Here the doc gave us an important note as an answer for a student's question: you
.have to do ALL those tests , then give anesthesia & do your work

. stuck to the bone

do Sensibility test --
:using ethyl chloride , the cold
test or EPT ( Electric Pulp Testing ) ; "-" for no response , "+" for hyper
response , " N " for normal response; patient feels something but it's
. not exaggerated
Sinuses : check if there are sinuses next to the tooth, if the patient had --
an injury 2 days ago , and there is a sinus tract , then this sinus tract
most probably is chronic , it had happened months before , meaning
. this tooth is necrotic before the trauma occur
the root development status : you record it from the x-ray; if it is less --
than 2\3 or more than 2\3 or it's complete , the completed root can be
.with open apex or closed

: Avulsion --
Is another trauma entity , if avulsion has occurred
then you document the extra oral period and the
. storage media , this is what we will talk more about later
the reasonable man adapts himself to the world ; the unreasonable one persists in trying to adapts "
the world to him self . therefore , all the progress depends on the unreasonable man "
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 Dental trauma : examination & treatment planning

Here the doc told us that last year there wasn't a component called
radiographic diagnosis in the examination sheet , and most students were
weak in diagnosing caries on x-rays and in deciding treatment plans .
until now 5th year students come to the doc holding the bitewing & they
don't know what to do with the carious molars ; if it needs pulpatomy or
not. But the doc is proud of us " 4th year" , because we are getting better ,
at the same time you should know it for 5th year and you will be asked
about it …. So keep it up 4th year 

There will be a graph on the avulsion section for you to Try to

draw what kind of trauma occurred , and where is it exactly .
There is enamel , dentine & pulp , if the pulp is involved then make a
big circle around the tooth , to show that the pulp is involved then draw the line
. of fracture

radiographic examination section : the same way in our radiographic

. diagnosis in the clinic
So you take a look at the x-ray & you write down your report , if there is
any root fracture , any internal or external root resorption . check the
periodontal ligament & periapical area if there is infection , or any other
.findings

Finally you reach a diagnosis & treatment plan, for example the " 11 " tooth
with the complicated crown fracture , your treatment plan will include the
: following points
restorative treatment : composite resin, build up , "-----" crown( type of -
crown I couldn't hear it, because she is extra fast, but may be it " resin strip " ) ,
.composite filling if it is small fracture
pulp therapy ; you may do direct pulp capping , indirect pulp capping , -
. pulpotomy, none if the pulp is not exposed or for example RCT
splinting : you need to splint the tooth if it's mobile , and then you indicate a -
.period for 1 week or two weeks
follow up the plan , see the patient after two weeks for example or every six -
. months depending on the type of the injury

the reasonable man adapts himself to the world ; the unreasonable one persists in trying to adapts "
the world to him self . therefore , all the progress depends on the unreasonable man "
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 Dental trauma : examination & treatment planning

Here the doctor explained some tests in general , I didn't put it previously
because I think it will disturb the sequence of examination , diagnosis &
.treatment plan and this is the sequence of the doctor lecture

:mobility test
you have to know the degrees of mobility ( from perio ), and it's done by
using the tip of your mirror with your finger , push the mirror gently at the
same time your finger should be stable , if the tooth moves in that direction
then it's mobile , if it moves in any direction then it's grade " 2 ", If it moves up
." & down ( axial movement ) then it's grade " 3

: Percussion test
percussion means tapping the tooth gently , it doesn't mean that you hold
the mirror & start knocking the tooth out , like if you are holding hammer !!
because anyone with no injury or with no caries ,if you tap his tooth, he will feel
something , so imagine if the patient already in real pain & has extreme
sensitivity, it will be exaggerated . sometimes you can do it just by your finger
. & check if the patient's traumatic tooth is sensitive
You also have to know the percussion tone ; the sound that you hear . try to
hear the sound of normal tooth , get use to it , even if you are in cons clinic try
to hear the sounds of normal teeth ! because if the tooth is ankylosed it will
really sounds different , it will have that metallic sound like if two metals
. hitting each other

: Sensibility testing
It gives information about the sensibility or the vitality of the pulp. Vitality ,
what does it mean? It means the presence of blood vessels . sometimes there is
a response but there is no blood vessels ,that doesn't mean that the pulp is
. vital
You need to do the pulp sensibility testing from the beginning , because you
want to have a background or a starting point . so you can say last week or two
weeks ago the pulp was responding , today it's not responding , so it gives you
a reference point . or you can say last week or last month the pulp was not
responding and now it's responding , probably it heals itself . this is one of the
basic things you do as soon as the patient comes into the clinic . the techniques
can be mechanical test, thermal test , electrical test , laser doplar flowmetre .
- mechanical testing ; when you have a tooth structure & the dentine is
exposed , so you can touch the exposed surface using the probe & move
the reasonable man adapts himself to the world ; the unreasonable one persists in trying to adapts "
the world to him self . therefore , all the progress depends on the unreasonable man "
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 Dental trauma : examination & treatment planning

it , if the patient feels something , then the pulp is vital . but when the
pulp is exposed & you want to test it mechanically , you can apply a cotton
pellet which is soaked in saline & put it on the pulp , if the patient feels
something, then it's vital , don't use a probe in this case , a probe can be used
. only in dentine
Thermal test : using heated gutta perch ,ethyl chloride which is the one -
. that we are concerned about

: radiographic examination
do your x-rays , and that can be either intra orally or extra orally; depending
. on the injury that you have
we have the -- maxillary occlusal film : useful for alveolar fractures , for lateral
luxations ( when the tooth go bucally or palataly ), or extrusive
.luxations ( when the tooth can comes out )
lateral maxillary radiograph ; put it laterally to see how the --
tooth came out , or is moving buccally or palatally , it's like
. taking an x-ray from another plane
Paediatric maxillary radiograph : by using the periapical --
radiograph & use it as a maxillary occlusal , we use it for the very young patient
.
Bisecting angle : especially if the patient cannot bite on the --
. periapical radiograph
. OPG : can be used especially for fractures --
Sub mental vertex : to look at zygomatic fractures --
the postero - antero cephalogram : comes with a different --
. angle to show any problems with the ramus
. lateral cephalogram is also useful sometimes --
. chest x-ray : if you are not sure where the tooth has gone --
soft tissue x-ray : if you feel like something is pushed into the --
lip or into the cheeks , something like tooth fragments, stone ,
sand , glass or metal ; like in a car accident, in this case you can
take a soft tissue x-ray. It can be taken with a normal film , but
the exposure is less ; it's 25% less exposure than hard tissue .
here the doc showed us a soft tissue radiograph , she pointed to
.the particles that have been impeded into the lip

the reasonable man adapts himself to the world ; the unreasonable one persists in trying to adapts "
the world to him self . therefore , all the progress depends on the unreasonable man "
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 Dental trauma : examination & treatment planning

Dentists , look at everything in the x-ray , any fracture , foreign body ,

displaced teeth , the periodontal ligament widening , any periapical infection ,
the size of the pulp chamber , the root development , everything is important in
.this case , everything will give you a decision on what to do

:Photos
at the end photos offer exact documentation of the extent of injury & can be
used for treatment planning , legal claims and very important in clinical
research . here In Jordan , they care about photos & radiographs . sometimes
you have to write a report for the court in order to solve the dispute between
. the two sides

Finally , after you formalize your treatment plan talk to your patient about
it , talk about what you are going to do . the treatment plan has a restorative
component , ENDO component ( pulp therapy ), splinting if we need it , follow
up plan . you tell the parents I'm going to do ,for example endo , I'm going to
do this restoration , I might splint this tooth & I will have to see your child after
two weeks, if everything goes positive , then I will see him in a month , if the
treatment is not positive then I will see him every week for example . so you
. explain everything in detail to the patient

Dentists you also have to know the priorities of dental trauma, what to
. treat and what can be postponed to later
the acute thing that you have to treat straight away are the avulsions ( if the
tooth has been lost ),then alveolar fractures , then extrusions , then lateral
.luxation ,and finally root fracture
The sub acute approach : the things that can be postponed for few days like
intrusion , concussion , (----)luxation, crown fracture with pulp exposure ,
. primary teeth injury
Delayed treatment : those can be leaven for a one week or more , like crown
. fracture without pulp exposure
Dentists , Follow up every case of trauma or most of the cases , you will
need to see the patient after 1 week ; the patient has a trauma accident & he
came straight a way to your clinic , you want to see him one week after , then 3
weeks after , then six week after. Then 1 ,2, 3 & 6 months after , then every year
for the next 5 years , this is the general protocol for follow up's in trauma . even

the reasonable man adapts himself to the world ; the unreasonable one persists in trying to adapts "
the world to him self . therefore , all the progress depends on the unreasonable man "
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 Dental trauma : examination & treatment planning

a simple trauma should be followed up long enough , because sometimes

. complications might arise later
Now the final part of the lecture will be about tetanus immunization , you
need to know about this because we are talking about trauma. the doc
mentioned it as interrupting for the lecture , but I think it's better to put it at the
. end so your thoughts will stay connected

:Tetanus immunization
Immunization for tetanus is usually received between 2 – 2.5 years, a
booster is required every ten years to enhance the immunity that you have
against tetanus . tetanus injections are indicated after trauma if the site is
contaminated ; mostly occurs in soft tissue injuries such as lips , cheeks or
gingiva . then you have to ask about tetanus if the patient didn't have it in the 5
previous years ; means the patient should have the booster every ten years but
in the past 5 years was this booster taken or not ? if not then you give the
.tetanus injection
As an infection tetanus is uncommon, it's infectious but non communicable
disease . if people got their immunization , then it's not a big issue . it's caused
by a microorganism called clostridium tetani, it lives in the soil & dust , it
produces a tetanospasm ; neurotoxin , a kind of toxin that affects nerves , leads
to a severe muscle spasm . tetanus is dangerous with a mortality rate of 10-60 %
.
Here the doctor told us about salma hayek and her organization that
support tetanus in Africa , every four minutes a child die due to tetanus ;
because the mothers didn't take the shot in their lives & the children they didn't
take it also , and you can support those poor children by buying pampers !
Signs of tetanus infection include :
- massetric spasm; especially in the face there will be clear signs like
sarcodonic smile because the muscles is very spastic .
- facial spasm.
- spasm of the spinal muscles leading to arched back .
- laryngeal spasm; the dangerous sign because it leads to asphyxiation,
affects any muscle of the body specially the diaphragm .
- autonomic dysfunction; affects the nerves of the heart leading to cardiac
dysarrhythmias & problems in the heart rate or in the beating of the heart.
- death after 10 days due to asphyxia or bronchopneumonia or autonomic
dysfunction.
End of the lecture 
Here I wanna put my regards for my best friends ( you know your selves), and
everyone I know , wish you all the best.

the reasonable man adapts himself to the world ; the unreasonable one persists in trying to adapts "
the world to him self . therefore , all the progress depends on the unreasonable man "
george bernard show

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 Dental trauma : examination & treatment planning

And I wanna thank m . nazirul for revising the lecture after me , and ithar for
trying to help in the final design .

the reasonable man adapts himself to the world ; the unreasonable one persists in trying to adapts "
the world to him self . therefore , all the progress depends on the unreasonable man "
george bernard show

14