Treating Trauma

Cases involving traumatic movement or damage to teeth often present as an emergency and may require quick thinking and treatment that is not used on a daily basis. Most of us realize that a tooth that is knocked out should be replanted as soon as possible or that a displaced tooth should be repositioned as best as possible. In the absence of an alveolar fracture, most of these cases should be stabilized with physiologic movement allowed. That is, a non-rigid splint such as flexible wire or even dental floss bonded to the teeth should be employed. Be certain to check around the mouth for soft tissue damage that may be overlooked but require attention and radiographs will help determine the presence of root fractures.

Inflammation around the tooth should be controlled with NSAID medications and the use of narrow spectrum steroids such as Dexamethasone are probably effective in reducing the chances of resorption. Further invasive treatment should be delayed for approximately 2 weeks to allow the damage from the initial trauma to heal. After that time, endodontic treatment is often necessary depending on the extent of damage. At minimum, vitality tests should be run to determine the pulpal response. Vitality tests at the time of the initial trauma are unreliable but may be used as a base line in cases where the damage or displacement is not too extensive. A non-responsive pulp immediately after trauma does not always mean endodontic treatment is needed.

If after the first couple weeks it is determined that endodontics is necessary, calcium hydroxide medication of the canal for anywhere from a few weeks to months is recommended. This is especially true with an immature root end as an apexification procedure in an attempt to obtain a root end barrier. If the barrier is not obtained, modern endodontic procedures can create a barrier for the endodontic tilling that follows. In any event, calcium hydroxide modifies the surrounding environment of the tooth to minimize the inflammatory resorptive effect that often follows trauma. This response may follow no matter how quickly or thoroughly we treat a case and must be told to the parent or patient so that the subsequent loss of the tooth is not a total surprise.

One situation that requires an exercise in restraint is a traumatic pulp exposure on a young patient with an immature root. The goal should be to maintain pulpal vitality as long as possible to aid in root maturation. In the absence of caries and with a minimal exposure, any bleeding should be controlled with light pressure followed by protecting the pulp with a hard setting calcium hydroxide material. The fracture should then be restored by an acid etched bonding procedure. Endodontics in these cases is difficult and many times condemns the tooth to a short life due to minimal root strength and retention. Any further development of the root that could be obtained by restraint will aid in the long-term prognosis.

The treatment of traumatic cases requires quick thinking and sometimes improvisation. This is a short summary of the more common situations that may be encountered in practice. If you have further questions or situations you would like to discuss in more depth please feel free to contact our office.