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ePaper created 2016-11-22, 09:52:12 | version 1.38.0
traumatic dental injuries CE article | 17 roots 4 2016 itssocket,oneshouldimmediatelyplacethetoothina physiological solution of specialized media (such as Hank’sBalancedSaltSolution)ormilk,orsalineifthose arenotavailable.Onlyafterthetoothissecuredinsolu- tionshouldoneobtainthepatient’sinformation.Once the patient is seated in the dental chair, it is necessary to do a quick central nervous system (CNS) evaluation beforeproceedingwithfurtherassessments. Often,thedentististhefirsthealth-careproviderto see the patient after a head injury (any dental trauma is,bydefinition,aheadinjury)andmustassesstherisk ofconcussionorhemorrhage.Ithasbeenestimatedby a meta-analysis that the prevalence of intracranial hemorrhage after a mild head injury is 8 percent, and the onset of symptoms can be delayed for minutes to hours.4 The most common signs of serious cerebral concussion or hemorrhage are loss of consciousness or post-traumatic amnesia. Nausea/vomiting, fluids from the ear/nose, situational confusion, blurred vi- sion or uneven pupils, and difficulty of speech and/or slurred speech may also indicate serious injury.5 OncethepatienthasbeenclearedofanyCNSissues, thedentaltraumashouldbeassessed.Thekeyistoob- taincomprehensiveinformationabouttheinjuryand, to do so, one must conduct thorough extra-oral and intraoral clinical exams as well as appropriate radio- graphic evaluations. ThenewAAEguidelinesrecommendtakingoneoc- clusal and two periapical radiographs with different lateral angulations for all dental injuries, including crown fractures. If cone-beam computed tomogra- phy is available, it should be considered for more se- rious injuries, such as crown/root, root and alveolar fractures, as well as all luxation injuries. Additionally, sensibility tests should be conducted on all teeth involved as well as opposing teeth. Cold testing is recommended over electric pulp testing in young individuals.6 Both testing methods should be considered, however, especially when there is no re- sponse to one of the two. The pulp might be non-re- sponsiveforseveralweeksafteratraumaticinjury,so a pulp test should be done at every follow-up ap- pointment until a normal response is obtained.7 Once the diagnosis is confirmed and more serious complications such as CNS and jaw or other facial bone fractures have been ruled out, the emergency phase of the treatment needs to be initiated. The aim oftreatingdentaltraumashouldbetoeithermaintain or regain pulpal vitality in traumatized teeth. This is becausedentaltraumamostfrequentlyoccursinpre- 1 1/2 to 2 mm high-speed diamond bur with copious water cooling Pulp capping agent Glass-ionomer Fig.2a: Schematic diagram of minimal pulpotomy,where an approximately 2-mm reservoir is cut with a high-speed diamond bur and copious water cooling and calcium hydroxide mixed with sterile water placed.(Schematic drawings/Provided by Dr Sigurdsson) Fig.2b: Glass ionomer or a protective liner is placed over the pulp capping agent to ensure it stays in place during etching and bonding. Fig.2c: Clinical pictures of the minimal pulpotomy. Fig.3a: Schematic drawing of a common situation after root fracture: The crown portion is displaced inward toward the palate and the fractured piece is stuck to the facial cortical plate. Figs.3b & c: It is impossible to move the coronal portion back to its original location without releasing it from the cortical plate.This is accomplished by pulling the coronal portion down and then repositioning it. Fig.3a Fig.2a Fig.2b Fig.2c Fig.3b Fig.3c 42016 11/2 to 2 mm high-speed