08a ***TRAUMA 1 &2

Compare MTA vs Calcium Hydroxide in treating trauma

- Main point is that MTA sets and seal whereas CaOH will never set. - Both release Ca, OH- o Bakland 2012 [LRS] - CaOH leads to high pH causing zone of liquefactive necrosis *BAD* and a zone of coagulation necrosis. MTA leads to only a narrow band of coagulation necrosis, dentin bridge forms faster, and with fewer vascular inclusions. MTA can be used for vital pulp therapy instead of CaOH, but requires multiple appts. Biocompatible, smaller zone of necrosis, but more staining. Bleeding is not a contraindication. o (MAC: Tronstad's papers on zone of liquefactive necrosis were done with pure CaOH powder. Papers by Fuks and Cvek were done with buffered CaOH (Calxyl and Calasept, the latter is buffered with methylcellulose). Fuks and Cvek had a very high success rate; this success rate may also be high for Fuks and Cvek because these traumatized teeth have not undergone years of insult from caries or restorative)

avulsed primary tooth

Andreason 78 - at 6wk f/u amelo/odonto genesis of perm tooth germes from induced periapical inflammation of primary teeth in monkey does not appear to be affected HOLAN-2013- replantation should be avoided - damages permanent successors

What is incidence of alveolar process fx? Where is most common site to fx in max vs man? What are outcomes for teeth near a fx? Does Immature vs Mature matter when it comes to necrosis/resorption?

Andreason/Lauridson -2% of injuries have alvoelar fx - Max arch - midline suture - Man arch - PDL along mesial of K9 Immature Teeth PCO repair common Repair related resorption frequent but not many other complications Mature Teeth Necrosis 56% of time / resorption and marginal bone loss rare Sig Incr risk for necrosis - fx next to tooth - displacement >2mm - incomplete reposition

What factors affect the prognosis and type of healing that occurs in horizontal root fracture? Should you splint a horizontal root fracture? How often do they undergo necrosis?

Andreason/Mejare/Cvek 2004 - Young age, immature root formation and positive pulp sensibility at the time of injury were found to be significantly and positively related to both pulpal healing and hard tissue repair of the fracture. - Healing was progressively worsened with increased millimeter diastasis between fragments. (*>1mm diastasis between fragments*) Optimal repositioning favors healing (esp when initial displacement <1mm). Flexible splints better prognosis than other splints, but NSD b/w splints and no splints. A few days of treatment delay does not seem to affect healing. Using antibiotics is questionable. o Zachrisson 1975 - necrosis in 20% of root fractures. Overall prognosis 77%. (with repositioning, fixation, and relief from occlusion)

Divide dental injuries by Priority Acute vs Subacute vs Delayed Priority

Bakland and Andreason Acute - tx within hours Root fracture, alveolar fx, lateral lux, extrusive lux, avulsion Subacute - tx several hours Complicated crown fx, concussion, subluxation, intrusion Delayed - can be delayed beyond 24 hrs Uncomplicated crown fx

Is CaOH beneficial in treatment of Trauma?

Barnett 2002 - CaOH beneficial for long term retention after trauma. Arrests external inflammatory resorption, eliminates microorganisms, induces hard tissue formation at apex.

What test should be used in trauma?

Cold = gold standard / EPT is secondary - peters states ept is good to confirm necrosis because of high Pos Pred value

• WHO classification of fracture injuries Crown Infraction and Uncomplicated Crown Fracture - Prognosis of each? How to treat each?

Crown Infraction o Incomplete fracture or crack of enamel without loss of tooth structure. Transillumination helpful. Treatment involves establishing a baseline pulp status with routine follow-up. Prognosis Pulpal complications are extremely rare (0.1%). Uncomplicated Crown Fracture o Fracture of the enamel only or enamel and dentin without pulp exposure. Very common. 1/3 of dental injuries. Treatment Establish baseline pulpal status with routine. 3 angulations of PAs. Determine if concomitant mobility/tenderness to percussion Prognosis o Ravn 1981 [LRS] - In cases involving only enamel-dentin fractures without loosening or tenderness, only 3.2% lose their vitality, while the rate rises to 5.8% with enamel-dentin fracture and tenderness, and 30.1% with enamel-dentin fracture and tenderness + loosening. o Cavalleri 1995 [LRS] - In a 5 year follow- up of children with fractures the rates of necrosis are as follows: Enamel only (0%), enamel and dentin without pulp exposures (6%) and enamel and dentin with pulp exposures (57%).

• Discuss Lateral/Extrusive luxation. AAE Guidelines for Tx (Endo), Repositioning? Immature vs Mature? Testing?

Extrusive - Necrosis 26% Andreason 100% Dumsha, Resorption (Herman) 16% o Displacement in a coronal direction - no bony fx Lateral Necrosis 58% Andreason 75% Dumsha, Resorption (Herman) 30% - Displacement labially,lingually, distally, incisally often involved fx of alveolar plate Treatment Same except splinting time o Obtain profound local anesthesia. Reposition the tooth with digital pressure - it should pop into place. Compress the bony plates. Then place splint (Extrusion 2 weeks / Lateral 4 weeks) If breakdown of marginal bone occurs, a longer interval of 6-8 weeks may be necessary. o Reevaluate with vitality tests, with an observation period of up to 12 months. Sensibility may not return even past 12 months. If necrosis or infection, or radiographic breakdown is noted, initiate endodontic therapy immediately Immature/Open apex - Montor closely - GER/Apexification if necrosis occurs

What is the difference between Ankylosis and Replacement Resorption?

INTERVENING INFLAMMATORY CONNECTIVE TISSUE Andreason Ankylosis represents a fusion of the alveolar bone and the root surface. Can happen 2 wks after replantation. Etiology related to the absence of a vital PDL. Progressive ankylosis is elicited when the entire PDL is removed before replantation or after extensive drying of the tooth before replantation.. o On the other hand, Ne & Witherspoon Ankylosis occurs after necrosis of the periodontal ligament with formation of bone on the denuded area of the root surface. Ankylosis is a union of tooth and bone, with no intervening CT, following external inflammatory resorption. External replacement resorption is a continuous process whereby the tooth is gradually resorbed and subsequently replaced by bone. It differs from ankylosis because of the presence of intervening inflamed CT. Teeth that have ankylosis have a union between bone and root substance without intervening CT.f

• 7. What are the common complications associated with traumatic luxation of permanent teeth? (Be sure to discuss ____, ____, ____, and ____.)

Ischemic infarction, necrosis, resorption and calcific metamorphosis o Ischemic Necrosis - The result of sudden loss of vascular supply. The death of the pulp is not due to bacterial invasion. However, once necrosis occurs, bacteria are able to penetrate into the chamber via exposed dental tubules due to the loss of the innate immunity of the pulpal tissue. Bergenholtz 1974 [LRS] - can become infected after ischemic necrosis. o Andreasen 2015 - JOE review. competition takes place between ingrowth of a new neurovascular system into the traumatized tissue versus bacterial invasion. If there is intact neurovascular supply, immune defenses can stop infection. If this is disturbed, resorption, PCO, or necrosis will occur. Intermediary stations in pulpal response (ie, transient apical breakdown) mimicked the cardinal signs of pulp necrosis, which could be reversible and lead to pulpal healing. o Tronstad 1988: Review of resorption related to trauma

When can you do orthodonitc movement following trauma?

Kindelan - range between 3 months for minor injuries and up to a year following severe injuries.

What factors make it more likely that a tooth will necrose in association with an alveolar fracture?

Lauridsen/Andreason 2016 - fx line next to tooth apex - fx displacement greater than 2mm -Incomplete repositioning of displaced bone/teeth

How do you perform Decoronation? Can you decoronate an ankylosed tooth?

Malmgren 2006 - remove 2mm below bone, remove any GP, allow blood to fill canal then cover like an implant healing cap, can use collagen over top if you want (epithelium will migrate over) Yes, it will slowly be replaced by bone, this process increases at younger ages

What are the types and percentage of avulsed teeth that undergo resorptoin

Souza - If it occurs Replacement 51% Inflammatory 23% Surface 13% Internal 1.2%

• WHO classification of fracture injuries Crown/Root Fracture - Prognosis of each? How to treat each?

Treatment o Andreason in traumatic injuries textbook: o If no pulpal involvement, remove coronal fragment and restore. o If pulp is exposed and extension of fracture is minimal, treat as a crown fracture with pulpectomy and restore. o If fracture extends to a level making restoration impossible, consider fragment removal with one of the following methods to allow restoration: Gingivectomy and possible ostectomy. Orthodontic extrusion. Surgical extrusion: this allows rotation of the remaining tooth. If tooth cannot be converted to a crown-fracture type of state, extraction is warranted.

Review how trauma can lead to resorption of the tooth? What are the most common types of resorption after trauma? What can cause internal resorption to progress?

Tronstad (1988) o mineralized tissue of the permanent teeth are not normally resorbed due to the protective layers of predentin and precementum (Wedenberg). If this layer becomes damaged, multinucleated cells can colonize and cause resorption. In the case of damage to these layers, the term inflammatory resorption is applied. If this occurs on the canal wall it is further classified into internal resorption. o Damage to the external root surface is external resorption or cervical resorption. Any resorption can be transient or progressive. Transient resorption can become progressive if there is an additional long-lasting stimulation of the resorbing cells (such as a necrotic pulp). Progressive internal resorption is due to necrotic tissue in the root canal coronal to vital tissue where the resorption takes place. Replacement resorption results in ankylosis and is an irreversible process if more that 20% of the root surface is involved.

Define Replacement resorption after trauma

Tronstad - osteoblastic repopulation of resorptive lacunae causing the defect to fill in with bone rather than cementum or PDL tissues Tronstad says that process cannot be stopped- AAE says to decoronated once infrapositioned 1mm to adjacent tooth AAE guidelines - says inevitable in avulsed teeth with extraoral dry time longer than 60 mins

• Studies on intrusive luxation and resorption

o Al Badri 2002 [LRS] - If intrusion was greater than 5mm, there is an increase in the incidence, time of onset, and severity of resorption. Resorption occurs 59%. More resorption found in mature roots versus immature roots. There is no additional risk of resorption in surgical repositioning (surgical repositioning isn't all Badri) o Cunha 2002 [LRS] - Immediate repositioning of intruded dog incisors did not harm the repair process nor did it cause additional damage o Tsilingaridis 2012 [LRS], 2016 - 1st study 60 teeth. 2nd study 230 teeth. Degree of intrusion and root development sig correlated to healing, while tx was not. Immature, intruded teeth have better healing outcomes with no tx (allow spontaneous repositioning). 75% necrosis of permanent intruded teeth. 25 % infection related resorption, 22% replacement resorption.

• 3. What are the preventive measures? Are they effective?

o Amy 2005 - Mouthguards should be worn during high risk activities (boxing, basketball, tae-kwon-do, karate, soccer, hockey, judo, wrestling) o Bourguignon 2009 - DCNA review. Mouthguards reduce occurrence of dental injuries by 90%. Also support mandible and absorb condylar stress, helping to prevent cerebral injuries. Pts usu prefer custom made. 3 types -stock -mouth formed -custom <4mm thickness most comfy and extend 2mm into vestibule

• To chew or not to chew after avulsions?

o Andersson 1985 - Monkey study. Chewing hard pelleted food reduced ankylosis compared to soft food diet after avulsion/replantation.

• Storage of teeth in Saliva/Saline?

o Andreasen 1981 [LRS] - monkeys. extraoral storage time and conditions had significant effects on resorption. Dry storage resulted in significantly more resorption. Replacement resorption was rarely seen in teeth stored in saline or saliva. Tap water also less favorable effect. 0,15,30 up to 90 mins. o Oswald, Harrington 1980 [LRS] CLASSIC STUDY- All 90 minute extraoral dried monkey teeth led to ankylosis and replacement resorption. All saliva-stored teeth retained normal mobility, no ankylosis, and displayed healing PDL space. Maintaining vitality of PDL is an important risk factor in the outcomes of avulsed teeth

2 main Factors that influence pulp necrosis after luxation injury.

o Andreasen 1985 [LRS] - Two major factors influencing development of pulp necrosis after luxation injuries: extent of the initial injury to the pulp & periodontium (ie type of luxation) AND the repair potential of the injured tooth, (ie stage of root development).

• What about Rehydrating avulsed teeth?

o Andreasen 1986 - Monkey study. After 30 min dry time, the use of 30 min soak in saline did not impact the rate of pulpal and periodontal healing o Doyle DL 1998 -rehydrating dry teeth will not increase PDL viability after 30 or 60 min. NSD in cell viability after 30 or 60 min either. Although rehydration did not have negative consequences, it did not improve cell viability.

Necrosis and PCO post Trauma - when does it occur - sig studies - 5 factors that influence PCO will occur What is PCO

o Andreasen 1987 -looked at 637 concussed, subluxated, extruded, laterally luxated and intruded permanent incisors were analyzed Holcomb 67 - 3/41 cases of PCO dev necrosis (7%) - Same as adreason/pedersen Robertson/Andreason 96 - PCO after trauma leads to necrosis 16% of time. 84% maintained PCO for 20 yrs. McCabe and Dummer 4-24% PCO 1) PCO was dependent upon type/severity of injury - severe injury = necrosis; moderate = PCO; extrusion, lateral luxation and intrusion more frequent PCO than concussion or subluxation. 2) PCO was dependent upon the stage of root development at the time of injury - significantly more often in teeth with open apices. 3) Type of Fixation PCO was seen more frequently in relation to rigid fixation, than with other forms of fixation. 4) Time PCO generally seen after 1yr of observation, in contrast to 3 months for pulp necrosis. 5) Pulp necrosis subsequent to PCO was uncommon, affecting only 1% of teeth with PCO. PCO tissue (CVEK) as osteoid with little inflammation or bacterial contamination

• Transient apical breakdown (TAB)

o Andreasen 1994 (trauma textbook), Andreasen 1986 [LRS], and Cohenca 2003 [LRS] case report describe how over the course of a year in luxation injuries there might appear to be a periapical radiolucency in a tooth that is not responsive to cold. However, there may be resolution with osseous healing, usually associated with surface resorption and/or PCO. Incidence is about 4% with trauma cases, and 12% with luxation injuries

• 5. Discuss factors which influence the healing response and the prognosis for the avulsed tooth.

o Andreasen 1995 (Part 4) - The following 4 factors had an impact upon PDL healing: stage of root development; length of the dry storage period; immediate replantation; and length of the wet period. PDL healing requires survival of the PDL cells on root surface. Immediate replantation is recommended irrespective of stage of root development. Ankylosis in 61% of teeth

• 9. Discuss splinting/stabilization of the avulsed tooth. • Rigid vs non rigid

o Andreasen 2000 textbook: (1) repositioning [confirm with radiographs], (2) etch, (3) apply splint material, (4) remove splint after 7-10 days o temporary bridge material, Ribbond, or orthodontic wire = semi-rigid splint. Composite = rigid splinting. Semi-rigid splinting = optimal environment for healing of tooth and pulp. Wire diameter not to exceed .016 Von arx - PDL damage and replacement resorption were noted with rigid splints in primates o Berude 1988 [LRS] - NSD in PDL healing or tissue responses in replanted monkey teeth w/ physiologic or rigid splints. (MAC: let clinical situation dictate type of splint. If alveolar fracture involved, OK to use rigid splint)

• Overall predictors for necrosis, resorption, marginal bone loss, disturbed root development, tooth loss.

o Andreasen 2006 [LRS] - Predictors for necrosis: diameter of apical foramen, pulp length, age, intrusion, external contaminants, pulp exposure, exactness of reposition Predictors for root resorption: compression of PDL, drying injury of PDL, unphysiologic storage, age, root development stage, bacteria Predictors for marginal bone loss: compression of bone, exposure of bone, adjacent tooth/bone injury, age Predictors for disturbed root development: luxation with displacement, avulsion and replantation, incomplete repositioning, alveolar fractures, intruded primary predecessors, jaw fractures Predictors for tooth loss: when avulsion replantation is not indicated, complications with avulsion replantation, intrusion complications, crown-root fracture, cervical root fracture

• 4. Describe the periodontal reactions to avulsion and ways it can heal? Discuss the clinical and radiographic appearance of three types of resorption and how these resorptions are treated.

o Andreasen Text - 1994. 4 types of periodontal healing have been described o 1. Healing with a normal periodontal ligament. complete regeneration of PDL, usu takes about 2 - 4 wks. Will only occur if the innermost cell layers along the root surface are vital. Clinically - tooth is in normal position and a normal percussion. Radiographically - normal periodontal ligament space without signs of root resorption. o 2. Healing with surface resorption. Histologically -localized areas along the root surface w/ superficial resorption lacunae required by new cementum, which is called surface resorption. represents localized areas of damage to the PDL or cementum which have been healed by PDL-derived cells. Surface resorption is self-limiting and shows repair with new cementum. Radiographically - usu not visible. However, with proper angulations of the beam, it is possible to recognize small excavations of the root surface with an adjacent periodontal ligament space of normal width. Clinically -normal position & normal percussion tone. Treatment - No treatment indicated b/c self- limiting . o 3. Healing with Ankylosis - (Replacement Resorption) Ankylosis represents a fusion of the alveolar bone and the root surface. Can happen 2 wks after replantation. Etiology related to the absence of a vital PDL. Progressive ankylosis is elicited when the entire PDL is removed before replantation or after extensive drying of the tooth before replantation. Transient replacement resorption is possibly related to areas of minor damage to the root surface, in these cases the ankylosis is formed initially and later resorbed by adjacent areas of vital PDL cells. Radiographically - characterized by disappearance of the normal periodontal space and continuous replacement of root substance with bone. This can be recognized within 2 months post-replantation. Clinically - ankylosed teeth immobile and in kids often in infraocclusion. The percussion tone is high. Treatment - either extraction or luxation with subsequent orthodontic luxation. If extraction is planned, it is important not to remove the entire root surgically as it would leave a marked reduction of the alveolar process. o 4. Healing with Inflammatory Resorption. Histologically -bowl-shaped resorption cavities in cementum and dentin assoc w/ inflammatory changes in the adjacent periodontal tissues (granulation tissue with numerous lymphocytes, plasma cells, and PMNs. Adjacent to these areas the root surface undergoes intense resorption with numerous Howship's lacunae and osteoclasts. Inflammatory resorption is especially frequent and aggressive after replantation in patients from 6 to 10 years of age. Radiographically -characterized by radiolucent bowl shaped cavitations (ragged and irregular) along the root surface with corresponding excavations in the adjacent bone. First signs can be demonstrated as early as 2 weeks after replantation and first recognized in the cervical third. Clinically - replanted tooth is loose and extruded. The tooth is dull and sensitive to percussion and the percussion tone is dull. Treatment - Because inflammatory root resorption is due to an infected pulp, the inflammatory resorptive process can be arrested by appropriate endodontic treatment or extraction.

• 11. When should the pulp be extirpated in an avulsed tooth?

o Andreasen's Text, AAE, IADT - 7 to 10 days. o Andreasen 1981 [LRS] - RCT prior to replantation enhances resorption. Replantation should be done immediately and RCT postponed. Inflammatory root resorption cannot be controlled by pulp extirpation prior to reimplantation. The location of replacement resorption sits close to the apical foramen in the GP root filled group indicates that the root filling procedure itself or the root filling material has injured the PDL in the apical zone. o Kinirons 1999 [LRS] - A delay in pulpal extirpation does not lead to more replacement resorption provided it occurs within 20 days of reimplantation. Ankylosis and replacement resorption might be minimized by limiting splinting to 10 days or less o Hinckfuss, Messer 2009 - pulp extirpation 14 days and later following avulsion/reimplantation, increased risk of inflammatory resorption

• 15. What are the four categories of horizontal root fracture healing described by________?

o Andreasen, Hjorting-Hansen 1967 [LRS] - 4 types of fracture healing: Type I calcified tissue (30%), Type II connective tissue (43%) -PCO normal w this healing Type III CT within Bone (5%) Type IV granulation tissue (22%) (granulomatous tissue) = nonhealing - NSD between coronal, middle, and apical third fractures with respect to final result. - Immediate repositioning and fixation enhanced prognosis. - Overall healing rate was 54%. (MAC: important paper.) o (MAC) Meld of Andreason & Hjorting-Hansen and Pathways 11th ed. Terminology: (1) Healing with calcified tissue. (2) Healing with interposition of connective tissue. (3) Healing with interposition of bone and connective tissue. (4) Interposition of inflammatory tissue without healing. MAC: The 4th one is not healing. Used to be callous formation, but not anymore, because it's only used for bone.

• Three different types of vital pulp therapy:

o Pulp Capping - for very recent exposures <24 hours, immature teeth and possibly mature teeth with simple treatment plans. o Partial Pulpotomy - 'Cvek Pulpotomy' - (94-96% prognosis for success) o Cervical Pulpotomy - Used if inflammation is suspected to extend beyond 2 mm, but not into the canals themselves - high potential for treatment of inflamed pulps (75% prognosis)

• 14. What role does the periodontal ligament play in the repair of root fractures? Where do most horizontal fx occur? Is the pulp necessary for the repair of root fractures? What tissues have been described as being associated with the healing of root fractures? (List investigators, dates and tissues found).

o Andreasen, Hjorting-Hansen 1967 [LRS] - Found dentin and cementoid tissue forming the hard barrier in a type 1 healing. In the group with type 4 reactions, granulation filled the fracture site, the coronal segment was necrotic and the apical vital. In the absence of a vital pulp, hard tissue healing never occurred. The PDL dominance of healing leads to connective tissue and necrotic pulps in the coronal segments. Most fractures in middle third of root. o Herweijer 1992 [LRS] - fractures induced in monkeys. They found that a vital pulp and healthy periodontium are essential for healing by dense connective tissue or hard tissue. Hard tissue originates from the PDL and resembles cementum-not tubular. In the necrotic case, the fracture site was filled with inflammatory cells. Healing is initiated at the pulpal and periodontal level. The absence of pulp will lead to connective tissue healing or non-healing.

• Tooth complications related to alveolar fractures - What are the most common location for fractures on max and man?

o Andreasen, Lauridsen 2015 - analyzed 229 cases alveolar fractures. Mean age 29. Violence and falls most common cause. Most frequent maxillary fracture location was at midline or sagittal suture. Most frequent location of mandibular fracture was along PDL on mesial of canine. Alveolar process fractures are rare. o Lauridsen, Andreasen 2016 - Analyzed healing complication in teeth treated in patients with alveolar fractures. In immature teeth, PCO & repair-related resorption occurred frequently. In mature teeth, pulp necrosis occurred frequently. o Rahimi-Nedjat 2014 [LRS] - Most commonly traumatized teeth in conjunction with maxillofacial fractures are maxillary incisors and mandibular wisdom teeth. Assaults and traffic related accidents are most common (especially bike and motorcycle accidents). Luxations and avulsions were the most common type of injury.

• 12. How does the location of the fracture influence treatment and prognosis in horizontal root fractures? What is long term survival rate for teeth with horizontal root fractures? • Describe different treatments for different locations of horizontal root fractures? Zones of treatment?

o Andreasen, Tsilingaridis 2012 [LRS] - 492 horizontal root fractures. Apical fractures have best prognosis and cervical fractures have worst prognosis. 8 year survival rate of apical, mid-root, and cervical-mid root fractures was all >80%. 8 yr survival of cervical fractures was 25%. Hard tissue formation highest survival. Healing with connective tissue or granulation tissue had lower survival. o Cvek, Andreasen 2002 [LRS] - long-term prognosis oblique fractures (involving cervical & middle third or root) significantly better than for those with transverse fractures (restricted to cervical third). NSD b/w healing and splinting or its duration. Healing noted in 84% of FXs. Cervical fractures had a lower prognosis o Cvek, Andreasen 2008 - 534 teeth. NSD found b/w prevalence of positions in the root of the fractures. 70% of teeth with cervical root fractures were lost. Excluding these teeth, survival rate 88% for horizontal root fractures. o Feiglin 1995 - Prognosis depends on position of the fracture, extent of displacement of the coronal fragment, degree of mobility, and pulpal status. Zone 2 (alveolar margin to 5mm from the crest) are the hardest to treat. Zone 1 - Apical third: watch. Zone 2 - Middle third: splinting is mandatory. RCT may be necessary of coronal segment. If it must be removed, treatment options of radicular portion include periodontal adjustment, orthodontic extrusion, and surgical extrusion. Zone 3 - If the fracture is above the alveolar crest the crown will have to be sacrificed.

• 10. What radiographic technique is recommended as an aid in the identification of suspected root fractures?

o Andreasen: +/- 15-degree radiographs. It is restated by Camp in his DCNA article. Most root fractures are oblique and only visible if the central beam is directed within 15-20 degrees of the plane of fracture. A steep occlusal angle is good for viewing a fracture in the apical 1/3.

What is the biologic basis for splinting after trauma? What characteristics should physiologic vs rigid splint be?

o Antrim 1982 - article on splinting traumatized teeth. 20-30 lb test monofilament. (Navy endodontists) , can double thickness to add strength, add 1-2 teeth on either side o Oikarinen 1990 - biologic basis for splinting o Hassan 2016 - use fishing line, power chain, or titanium splint to fulfill "flexible splint" per IADT Colleagues for excellence 2014 for traumatized teeth o Andersson 1985 - Monkey study. Chewing hard pelleted food reduced ankylosis compared to soft food diet after avulsion/replantation.

How would you treat a traumatized tooth that has gone necrotic but has an open apex?

o Apexification - used in immature teeth with open apices in which standard instrumentation techniques cannot create an apical stop (79-96% success rate) - Apical Barrier??? look up stats

How should you conduct your clinical exam after tooth trauma?

o Bakland in Endodontics Extraoral exam for wounds, palpate facial skeleton Intraoral soft tissue exam Intra oral hard tissue exam. Evaluate teeth for fractures, pulp exposures, color and displacement. Occlusal abnormalities might indicate fractures of the jaw or alveolar process Radiographic exam. Soft tissue injuries. Different vertical and horizontal angulations. Straight on/+15 degrees/-15 degrees Unaccounted for teeth or prosthetic appliances might have been aspirated or swallowed Baseline testing of teeth, especially mobility and percussion. Cold/EPT unreliable - Bastos 2014 [LRS] o Andreasen 2015 - review. Updated original Andreasen article standardizing diagnosis of luxation. Few changes. CBCT is a diagnostic aid, but not standard of care.

• Sensibility testing of teeth after trauma

o Bastos 2014 [LRS] - Retrospective 1200 pts. A positive reaction to pulp sensibility tests during the period immediately after trauma represented a good prediction of vitality (82%); however, the lack of response could not be associated with the later development of pulp necrosis (only converted 38% of time). Electrical tests provided the best support for pulpal diagnosis in the final visit, demonstrating a high PPV.

• CBCT for trauma?

o Radiography in trauma need not only evaluate the involvement of teeth, but may also need to evaluate soft tissues and supporting tissues. o Andreasen 2015 - review. Updated original Andreasen article standardizing diagnosis of luxation. Few changes. CBCT is a diagnostic aid, but not standard of care. conventional PA radiology is the standard of care. That includes multiple angulation to evaluate for root fractures because in order for a root fracture to appear the beam must be parallel the fracture o Tsukiboshi 2006, Palomo 2009, Cohenca 2007, Patel 2018 - discuss the utility of CBCT in the diagnosis of traumatic dental injuries

Does trauma predispose tooth to becoming necrotic? Does negative sensibility mean necrosis? Are there bacteria in a tooth after trauma?

o Bergenholtz 1974 [LRS] - necrotic pulps secondary to trauma were positive for microorganisms 64% of the time. Infections were typically mixed, w/ anaerobic bacteria predominating (78%) and an average of 4.3 species. Claimed that microcracks in teeth might allow progression of bacteria into necrotic pulps of traumatized teeth without direct exposure o Wittgow 1975 - Pulp chambers of necrotic teeth as a result of trauma were infected 80% of the time, and 50% of the samples had 3 or more species involved. o Bhaskar (1973) - 25 traumatized teeth - responded "non vital" to EPT, hot GP, CO2. All these teeth were vital upon access. Therefore it is possible to damage innervation but maintain blood supply through coiled vasculature. Don't do endo unless overt signs of IRP or necrosis

• Storage of teeth in milk? Compare different types of milk. Gatorade?

o Blomlof 1983 [LRS] - successful healing of the PDM (periodontal membrane) of replanted teeth is possible after as long as six hours of storage in milk but only 2 in saliva. o Harkacz 1997 [LRS] - Gatorade is not suitable. Milk is good, but skim and 1% maintained higher PDL cell viability compared to 2% or whole. (PDL cells) o Marino 2000 - Long shelf-life and regular pasteurized milk performed similarly and outperformed, Save-a-Tooth™, Eagle's Minimum Essential Medium, and tap water at all time points up to 8 hrs with regards to PDL cell viability. (PDL cells) (MAC: army study)

• 13. Discuss the current AAE Guidelines for management of dental alveolar injuries and the avulsed tooth in closed apex and open apex teeth? Dry time >60 min vs <60m

o CLOSED APEX: o Tooth has been replanted: leave tooth o Tooth in phys medium for <60 min: hold tooth by crown and clean root with saline. LA. Irrigate socket with saline. Replant slowly and lightly. Verify position with 2 radiographs or CBCT. o Extra-oral dry time >60 min: Carefully remove necrotic PDL w/ gauze; treat root surface with 2% NaF for 20 min. LA. Irrigate socket with saline. Replant slowly and lightly. Verify position with 2 radiographs or CBCT. (can do NSRCT extraoral). o All cases: flexible splint for 1-2 wks. Abx 7 days (amox if <12; doxy >12). NSRCT 7-10 days after incident (leave splint on when initiating). CaOH for 4 weeks. o OPEN APEX: o Tooth has been replanted: leave tooth. Flexible splint for 2 wks. o Tooth in phys medium for <60 min: hold tooth by crown and clean root with saline. Soak tooth in doxy or minocycline (1mg/20ml saline) for 5 min if available (CVEK) LA. Irrigate socket with saline. Replant slowly and lightly. Flexible splint. Verify position with 2 radiographs or CBCT. Goal is revasc. Kling - 18% incidence of revasc following avulsion injury in immature teeth w apical diameter greater than 1mm o Extra-oral dry time >60 min: Carefully remove necrotic PDL w/ gauze. LA. Irrigate socket with saline. Preferable to do RCT prior to replant/ MTA barrier. Replant slowly and lightly. Flexible splint for 2 wks. Verify position with 2 radiographs or CBCT. Decoronation when infraposition >1mm. o All cases: Abx 7 days (amox if <12; doxy >12). NSRCT 7-10 days after incident (leave splint on when initiating). CaOH for 4 weeks. o RECALL: splint removal and exam at 2 wks, 4 wks, 3 months, 6 months, 1 yr, annually for 5 yrs.

How can you preserve bone in a hopeless tooth for a young person?

o Cohenca 2007 [LRS] - case report of decoronation o Malmgren 2006 [LRS] - decoronation can maintain or re-establish normal alveolar conditions. Predictable - after 60 min or greater of extraoral dry time resorption is predictable so decoronation is good ptoin- age is critical! o Mohadeb 2016 - systematic review. within an average of 2-3 years following decoronation of an ankylosed tooth, not only bone was preserved but also a mean of 1mm coronal bone increase was reported. Treatment in patients who have surpassed pubertal growth peaks may not yield maximum treatment outcomes. o (surg 2: Schropp 2003 - regular extraction. Width of alveolar ridge reduced by 50%. Most reduction in first 3 months. A separate study of his from the same year show that placed immediate implant can hold bone or cause new bone)

• 5. What are the recommendations for rapid neurological assessment of patients with traumatic dental injuries?

o Croll 1980 - JADA: Evaluation of the Glasgow coma scale, evaluate for unusual motor activity, and observe communication Assess the airway Replant avulsed teeth if necessary Obtain a medical history and accident information Vital signs Evaluate for signs of rhinorrhea or otorrhea (CSF discharge through eyes or ears may be signs of craniofacial fractures.) Cranial Nerve Testing - Full assessment of 12 CN can be completed by quick evaluation of head and neck region Neurologic impairment needs to be ruled out prior to administration of analgesics Follow-up and provide written instructions

• WHO classification of fracture injuries Complicated Crown Fracture - Prognosis of each? How to treat each?

o Crown fractures involving enamel, dentin and pulp. Treatment: o Sensibility testing not usu needed because pulp can be visualized. 3 radiographs at different angulations. In young patients, try to maintain pulp vitality. In older patients, RCT can be treatment of choice. o Cvek 1978 [LRS] - 7-16 y/o - diff root dev stages. Success rate of Cvek pulpotomy was 96% demonstrated by clinical hard tissue formation with lack of symptoms and radiographic pathology. Barrier formation was found after 3-6 months. Traumatically exposed dental pulps may be resistant to bacterial progression. Sterile saline for irrigation. o Fuks 1987 [LRS] - Cvek pulpotomy is 94% successful in immature permanent incisors. Time appears not to be a significant factor because the pulp can maintain an immune response. o Bakland 2000 [LRS] - no liquefactive necrosis w MTA vs CaOH Fuks and Cvek had a very high success rate; this success rate may also be high for Fuks and Cvek because these traumatized teeth have not undergone years of insult from caries or restorative)

• Discuss intrusive luxation. AAE Guidelines for Tx (Endo), Repositioning? Immature vs Mature?

o Displacement in an apical direction into the alveolus.The most damaging of injuries. Immature/Open Apex <7mm intrusion - spontaneous eruption possible - If no movement in 3 weeks, recommend rapid orthodontic repositioning >7mm ortho or surgical extrusion req'd - Splint 4 weeks Endo Initiate GER or Apexification/Apical Barrier if signs of necrosis occur o Mature Tooth - Up to 3mm - may spont erupt - 3-7mm - ortho/surgical eruption indicated >7mm - surgical repositioning rec. Splint 4 weeks -Endo Prophylactic endodontic therapy is indicated necrosis 100% at 2 weeks after injury - place CaOH for 4 weeks (trope says it reduced ext inflamm resorpt) o Due to extensive injury to the PDL, external replacement root resorption (ankylosis) may occur. o Al Badri 2002 [LRS] Resorption occurs 59%. More resorption found in mature roots versus immature roots. - no diff in resorption if surgical or orthodontic Primary tooth - Displaced labially - spont erupt ok - Displaced into tooth germ - rec ext .

• Studies on extrusive luxation and lateral luxation. What type of luxation and what stage of root end development are most frequently associated with each of these complications?

o Dumsha 1982 [LRS] - teeth with fully mature root development that have been forcefully separated from their blood supply are not expected to recover when replanted in their previous position. 51/52 (98%) teeth disclosed pulpal necrosis-verified by lack of hemorrhage during pulp/pulp remnant removal (during period ranging from 4 weeks to 1.5 years). 86% of pts were asymptomatic at time of access. o Hermann, Lauridsen 2012 [LRS] - risk of severe periodontal healing complications after extrusive or lateral luxation injuries is low. Marginal bone loss and surface resorption occurred significantly more often in teeth with mature rather than immature root development. o Lauridsen, Hermann 2012 [LRS] - concomitant crown fracture without a pulp exposure significantly increased the risk of pulp necrosis in both immature and mature teeth with lateral luxation. A crown fracture in extrusion injuries did not add risk of necrosis, but this is likely due to the small sample size

• Reattaching fractured crown in uncomplicated fracture

o Farik 1998, 1999, 1999. Fracture strength of bonded sheep teeth were not significantly different than intact teeth. Sheep crown fragments had decreased bond strength if dehydrated. Rewet for 24 hours to increase bond strength. o Pagliarini 2000 [LRS] - 5th generation adhesive was less effective than 4th generation and therefore not suitable for fragment reattachment technique. Bonding of coronal fragments that were re-attached with different adhesives of devitalized teeth may be half as effective as that in vital teeth.

• Describe different treatments for different locations of horizontal root fractures? Zones of treatment?

o Feiglin 1995 - Prognosis depends on position of the fracture, extent of displacement of the coronal fragment, degree of mobility, and pulpal status. Zone 2 (alveolar margin to 5mm from the crest) are the hardest to treat. Zone 1 - Apical third: watch. Zone 2 - Middle third: splinting is mandatory. RCT may be necessary of coronal segment. If it must be removed, treatment options of radicular portion include periodontal adjustment, orthodontic extrusion, and surgical extrusion. Zone 3 - If the fracture is above the alveolar crest the crown will have to be sacrificed.

• 2. What are the predisposing factors associated with trauma? Does a correlation exist?

o Gutmann 1995 - DCNA review. Causes and incidence: 1) domestic violence, 2) sporting activities, 3) falls or collisions, 4) car/bike accidents, 5) assaults or altercations, 6) other (cerebral palsy, anesthesia) Predisposing factors: 1) abnormal occlusion, 2) overjet exceeding 4mm, 3) short upper lip, 4) incompetent lips, 5) mouth breathing o Nicolau 2003 [LRS] - Adolescents who experienced adverse psychosocial environments along the life course had more traumatic dental injuries than their counterparts. Stewart- 22k dental injuries annually <18 years old <7 - steps, beds, furniture #1 Cause 7-12 - bikes, outdoor rec 13-17 - sports, basketball, baseball Wasmer - Twin Study - No genetic risk factors - trauma usually result of environment

• Compare histological damage to PDL in avulsions vs luxations

o Haas 2008 [LRS] - Avulsion and severe intrusions produce similar catastrophic damage to root surfaces and the amount of remaining PDL. Severely intruded incisors showed less PDL loss at the cervical third and avulsions showed less PDL loss in the apical third.

• Should you use systemic antibiotics in patients who have undergone tooth trauma? 8. Discuss the use of antibiotics in the avulsed tooth.

o Hammarstrom 1986 [LRS] - in an 8 week avulsion monkey study, antibiotics can be effective in reducing the incidence of inflammatory root resorption - important study!!!! - bacterial contamination in a wound may arrest healing o Sae-Lim 1998 [LRS] - NSD btwn systemic Amoxicillin vs Tetracycline (about 55-65% healing rate). Sig less resorption in Abx group vs non Abx group in avulsions o Andreasen 2006 - review. Abx's w/ root fractures and luxation actually results in more infections. Abx's recommended in avulsion. Abx's in mandibular fractures with oral communication decreases infection risk.

Is CaOH recommended after an avulsed tooth? Are there any potential complications to using CaOH?

o Hammarstrom 1986 [LRS] -calcium hydroxide caused necrosis of cells and induced bone formation in the PDL causing a transient ankylosis after 1 week in the non-infected teeth and no ankylosis was established in the inflamed PDL. o Lengheden 1990 [LRS] - 82% of teeth with immediate CaOH exhibited ankylosis without resorption, while only 9% in obturated group. o Gregoriou 1994 - in dogs, delayed Ca(OH)2 pulpectomy for 7-14 days will decrease the chances for ankylosis without increasing the amount of inflammatory root resorption. o Dumsha 1995 [LRS] - No therapeutic advantage to preventing inflammatory resorption with calcium hydroxide medicament (vs one step w/ GP) when there is delayed pulpal extirpation TROPE 2002 delay pulp extirpation 7-10 days delay CaOH at emergency visit as it can delay healing potential of PDL fibroblasts!!! o MAC: we delay immediate treatment to give fibroblasts a chance to recover o Trope 1995 [LRS] - dog teeth NSRCT (elimination of bacteria) prevents inflammatory root resorption. Root canal infection in the presence of cemental damage will predictably result in root resorption. Long-term Ca(OH)2 is more effective than short-term tx in teeth w/ established inflammatory root resorption.

• Ideal Dry time for avulsed tooth. Also, how to prevent resorption or ankylosis What effect does age of socket have on healing?

o Hammarstrom, Blomlof 1989 - emphasized short (< 15 min) extraoral time and a suitable storage medium. A "very short" rinse to remove foreign bodies. Abx's can help decrease, but not prevent, the inflammatory reaction. Based on the present results it is suggested that root resorption associated with dentoalveolar ankylosis is initiated by endosteal osteoblasts and is a hormonally regulated process. This is in contrast to inflammatory root resorption, which seems to be triggered by inflammatory cells. o Trope 1997 [LRS] - dog study. As socket age increased, incidence of complete healing decreased (also more resorption). The socket is a component of the PDL and plays a role in healing of teeth o Barbizam 2015 - Dog teeth. 20 min of extraoral dry time is as detrimental to the PDL cells as 60 or 90 min of extraoral dry time, even when replanted w/ EMD.

How long can it take for a tooth to regain sensibility after trauma, particularly crown fracture alone? When should you consider tooth necrotic?

o Rauschenberger 1995 - DCNA review. Review of clinical management of crown fractures. Change from vital to non-vital usu occurs w/in first 2 months. A tooth non-responsive to sensibility testing might take 2 wks to 10 months to respond. Can reattach piece if possible. AAE guidelines - lack of response to pulp sensitivity 3 months post trauma =necrosis Advise pulpal test should be diagnosied by at least two signs/symptoms

How to conduct CN assessment?

o I. Olfactory = Smell (Vanilla, Cinnamon) o II. Optic = Visual Acuity & Visual field (Ocular Pursuit / Peripheral Vision) o III. Oculomotor = Accommodation (Pupillary light reflex) o IV. Trochlear = Eye Movement (Superior Oblique Muscle) o V. Trigeminal = Sensory to face -Motor to Muscles of Mastication P.E.R.L.A. (Pupils, Equal, Reactive to Light & Accommodation) o VI. Abducens = Lateral eye Movements (Lateral Rectus Muscle) o VII. Facial = Facial Muscles (Whistle / Pucker, Wrinkle Forehead, Close Eyes) -Taste at the tip of tongue o VIII. Vestibulo-cochlear = Auditory Acuity (Tuning fork, Pill Rolling) -Balance (Rhomberg Test) o IX. Glossopharyngeal = Taste on back of tongue - Phonation -Articulation of words, Swallowing (Say Ah) o X. Vagus = Gag reflex (Use a tongue depressor (TD) o XI. Spinal Accessory = Trapezius & Steroncleidomastoid (SCM) Shrug Shoulders o XII. Hypoglossal = Muscles of tongue (Resistance with TD) Tongue Protrusion

What is a technique for managing/obturating horizontal fractures if the coronal portion goes necrotic?

o Kim 2015 - 89.5% of horizontal root fractures exhibited healing after treatment with MTA

• Surface treatment before replanting an avulsed tooth?

o Lindskog 1985 [LRS] - recommended removing necrotic PDL cells prior to replantation. o Tsilingaridis 2015 - NSD whether replanted teeth are stored in doxycycline or not (Doxy decreases risk of resorption) o Iqbal 2001 - Replanted beagle teeth, EMDOGAIN® sig increased % of healed PDL and decreased replacement resorption compared to controls at 8 & 12 wks. NSD was noted with regards to surface or inflammatory resorption o Lam 2004 - EMDOGAIN did not sig reduce replacement NAJEEB 2017 - Surface application of bisphosphonates reduces root resorptoin of replanted teeth in animal models Doxy exrapolated from Sae-lim study report that tetracycline antiresorptive propertis due to reduced osterclast motility and collagenase function

• Process of dentin resorption molecularly

o Lindskog 1988 -monkeys. 3-stage spreading model was proposed. Stage 1 (>30 hr): dentinoclasts were characterized by an abundance of filopoda projecting towards the dentin surfaces. Stage 2(40 hr): cell size increased accompanied by a progressive disappearance of the peripheral filopod fringe. Stage 3 (> 4 days): the active resorption of the dentin surface.

• What is the most commonly reported dental injury?

o Luxation. 30-44% of all traumatic dental injuries

• What if you see discoloration in the crown of the tooth after a horizontal root fracture?

o Malmgren 2012 - Transient discoloration in intra-alveolar fractures is relatively common and most of these teeth still have a good prognosis for healing. Sensibility normally returns once discoloration has disappeared.

What is subluxation injury? How does it differ from concussion? Risk of Necrosis/Resorption?

o No displacement, increased mobility, sensitivity to percussion. Bleeding from gingival crevice may be noted. - more extensive PDL trauma Vascular supply remains intact. o Radiographic appearance is usually normal. o Treatment and re-evaluation is identical to concussion injury. o A flexible splint can be used for up to two weeks (remove splint at 2 wks) Necrosis 6% o Lauridsen, Herman 2012 [LRS] - No response to EPT at the initial examination or a concomitant crown fracture significantly increased the risk of pulp necrosis in mature teeth with subluxation injuries. Risk of pulp necrosis still low though Andreason 6% Resorption 3% Lauridsen, Herman 2012 [LRS] - Subluxation: Immature teeth risk of 1.7% for infection-related resorption and occurred more if there was a concomitant crown fracture. For mature teeth, after 3 years the risk of surface resorption was 3.6%, for inflammatory resorption was 0.6% and for replacement resorption was 0.6%

What study established that prolonged extraoral dry time affects the PDL viability and increases the rates of resorption? • 2. Discuss transport medium for the avulsed tooth. (overall) • 7. Discuss the effect of transport medium on prognosis. What are the options?

o Oswald, Harrington 1980 [LRS] CLASSIC STUDY- All 90 minute extraoral dried monkey teeth led to ankylosis and replacement resorption. All saliva-stored teeth retained normal mobility, no ankylosis, and displayed healing PDL space. Maintaining vitality of PDL is an important risk factor in the outcomes of avulsed teeth o Several transport media have been purposed as ideal for the avulsed tooth. It is important to use a media that has similar osmolarity as the cells, otherwise either a hypotonic or a hypertonic solution will cause increased inflammation on replantation. Several media have been purposed including: Hank's Balanced Salt Solution, Milk, Saliva, and physiologic saline. Plain tap water or Gatorade is NOT an acceptable medium because it is hypotonic and will cause cell lysis. HBSS = Viaspan = milk at 2-6hrs (HIltz/TROPE) - Saliva ok for up to 2 hrs (Blomlof)

· Overall incidence of trauma and factors associated with increased incidence

o Overall Prevalence (23-25% from Shulman and Kaste studies): o Kaste 1996 - 25% of people age 6-50 had hx of tooth trauma. ½ of people had one tooth injured. Trauma more prevalent in males than females. o Shulman 2004 [LRS] - NHANES. 23.45% individuals had trauma. 4x more prevalent on max than on man incisors. Trauma to max incisors assoc w/ overjet, males, race-ethnicity, and age while trauma to man incisors is associated with gender, age, and overbite. Nicolau - found young boys, obese, divorce, lower grades, higher paternal punishment - Class II Div I o Petti 2018 - Overall TDI prevalence worldwide = 15% with incidence rate of 2.82 of every 100 people a year. Males 1.43 to females. TDI would rank fifth if it was included in world's most frequent diseases and injuries.

• 1. What role does the periodontal ligament play in avulsion injuries?

o PDL is crucial. If replantation occurs quickly, then the viable cells of the PDL will be able to repair and cause a minimal area of resorption on the root. If cells of PDL dry out, the damaged PDL cells will elicit a severe inflammatory response. The two complications to be concerned with are replacement resorption and inflammatory resorption o Van Hassel 1980 [LRS] - monkeys. found that 9/21 teeth with an intact PDL resisted or reversed resorption and were retained, while 1/21 without PDL resisted resorption. The duration of time is not itself a risk factor, but only insofar as it affects PDL vitality. Therefore the vitality of the PDL is established as an important factor in deterring resorption of replanted teeth. o Lindskog 1985 [LRS] - monkeys. recommended removing necrotic PDL cells prior to replantation. 93% of root surfaces showed an intact cementum layer in close contact with bone after removal of the non-vital periodontal membrane= denuding of the root surface prior to replantation may result in slower destruction of tooth structure.

• How to achieve greatest CaOH penetration into dentin. (also mention how to get Roth's to the outer surface)

o Saif, McClanahan 2008 - final irrigation with 3 mL of 17% EDTA and 10 mL 6% NaOCl prior to placement of Ca(OH)2 allowed the greatest hydroxyl ion diffusion to the root surface. o (side note from obturation): Stevens, Strother, McClanahan 2006 - final rinse of 95% EtOH increases Roth's 801 sealer penetration and decreases leakage

• Trauma in primary teeth vs permanent teeth

o Schatz 1994 - retrospective study. 300 pts. 198 boys. 102 girls. 94.6% were max incisors. Luxation most often recorded in primary teeth. High % of crown & crown/root fractures in permanent teeth. Multitooth injuries usu >14yo.

• Glasgow coma scale

o The scale comprises three tests: eye, verbal and motor responses. The three values separately as well as their sum are considered. Score goes 3-15. The lowest possible GCS (the sum) is 3 (deep coma or death), Severe/Coma, with GCS ≤ 8; while the highest is 15 (fully awake person). o Interpretation: individual elements as well as the sum of the score are important. o Generally, brain injury is classified as: Severe/Coma, with GCS ≤ 8; Moderate, GCS 9 - 12; Minor, GCS ≥ 13. o The GCS has limited applicability to children, especially below the age of 36 months (where the verbal performance of even a healthy child would be expected to be poor). Use Pediatric Glasgow Coma Scale instead

Vital Pulp Therapy for Complicated Crown Fracture • Basic critical three elements necessary for vital pulp therapy. Also describe pulpal reactions to complicated crown fractures

o The three most critical elements for the success of vital therapy are: a non-inflamed pulp, bacteria-tight seal, and pulp dressing. o Vital pulp tissue - changes within 24 hours are mainly proliferative with inflammation extending less than 2 mm into the pulp. o Cvek 1982 [LRS] - Monkeys. Fractured teeth. Not more than 2mm of pulp beneath exposure needs to be removed. CaOH was put on top.

• 1. What are the incidences of traumatic injuries to teeth by geographic locations? • 4. Are the results from the various studies consistent in their findings relative to *city or rural settings*?

o There doesn't appear to be a difference based on geographic location when you compare the prevalence between American studies by Schulman (25%) and Kaste (23%) compared to De Oliveira Filho in Brazil (26%) o Soriano has the only implication into rural vs urban settings by using socio-economic status. He showed that boys of the lower socio-economic class are more likely to have a TDI.

• Describe concussion injuries. What is the risk of necrosis/resorption with concussion injuries?

o This injury usually results in limited trauma to the tooth and the supporting periodontium. o Treatment consists of baseline vitality testing, adjusting the occlusion, and soft diet. Tooth is tender to touch or tapping. Radiographic appearance is normal. o Refrain from endodontic therapy at this point as false-negative is likely. o Recall and re-evaluate pulp vitality at 2wks, 4wk, 3m, 6m and 12 months. Necrosis o Lauridsen, Herman 2012 [LRS] - Risk of necrosis is very low with concussion. It is 1% in immature teeth and 3.5% in adult teeth. No response to EPT at initial exam or concomitant crown fracture increases risk of necrosis. Andreason 3% Resorption - 3% o Herman, Lauridsen 2012 [LRS] - Concussion injuries: immature teeth had no healing complications; For mature teeth, the risk of surface resorption (repair related resorption only) was 3.2% after 3 years; Infection-related resorption and replacement resorption were not seen in teeth with concussions

• 9. Discuss splinting/stabilization of the avulsed tooth. • Duration of splint wearing - When should NSRCT be completed?

o Trauma guide: up to two weeks o Nasjleti 1982 [LRS] - Avulsed monkey teeth replanted within 30 minutes healed uneventfully when non-rigidly splinted for 7 days, whereas those splinted for 30 days showed increased areas of root resorption o Kinirons 1999 [LRS] - A delay in pulpal extirpation does not lead to more replacement resorption provided it occurs within 20 days of reimplantation. Ankylosis and replacement resorption might be minimized by limiting splinting to 10 days or less o Hinckfuss 2009 - systematic review. The likelihood of successful periodontal healing after replantation is unaffected by splinting duration.

· 1. What are the incidences of traumatic injuries to teeth by age? · 4. Are the results from the various studies consistent in their findings relative to *age of occurrence*?

o Trope, Barnett (Pathways) - 7-12 yr old (max anteriors -automobile accidents) o Bauss (early ortho study) 2004 - 10.3% of pts presenting for ortho tx had a hx of dental trauma. most frequently in *11-15* y.o. age group, with males having more injuries than females, and falls being the primary cause. o Kaste 1996 - 25% of people age 6-50 had hx of tooth trauma. ½ of people had one tooth injured. Trauma more prevalent in *males than females*.

• Classification of luxation injuries. 6. Describe the types of luxation injuries. What are the recommended follow up intervals for each injury by the AAE Guideline?

o WHO CLASSIFICATION Concussion; Subluxation; Intrusive luxation; Extrusive luxation; Lateral luxation 2,4, 6-8, 6mo, 1yr, 2-5yrs

• What type of cells are important in repairing PDL?

o Wallace 1990 - dog study. Avulsed teeth. No resorption in areas where there were rests of Malassez. o Lekic 1996 - fibroblasts are "the architect, builder, and caretaker" of the PDL

• Does CaOH or other materials weaken dentin?

o YES: White 2002 (arm 2 packet) - bovine teeth. Root dentin is significantly weakened after 5 weeks of exposure to CaOH, MTA, or NaOCl o YES: Andreasen 2002 (Trauma 2 packet) - Sheep study. Long term use of Ca(OH)2 in teeth with immature root formation may decrease the fracture strength of the root. o NO: Hawkins 2015 (arm 2 packet) - Sheep/lamb. No effect of CaOH on dentin fracture resistance over a 6 month time period

• 3. List the pulpal response to avulsion?

o necrosis after avulsion is nearly 100%, except in cases of an immature avulsed tooth. Although a necrotic pulp itself is not a consequence, the necrotic tissue is highly susceptible to bacterial contamination. o Kling 1986 [LRS] - For avulsed incisors, revascularization did not occur with mature teeth, but 18% of immature teeth maintained vitality. Less than 45 minutes of dry time is correlated with success. For those that did not maintain vitality they exhibited PARL or inflammatory resorption o Abd-Elmeguid 2015 - Systematic review. Immature replanted teeth: revascularized 33%, necrosis 67%. PCO observed within 9.5 months.

• 6. What is the short/long term prognosis for the avulsed tooth? What 4 factors impact if PDL will heal? How long after does necrosis typically happen?

• Andreasen's 1995 4 part article series on avulsions o 400 avulsed teeth. Followed 5-20 yrs o Part 1: 8% replanted teeth had pulpal healing. 34% had pulpal healing when incomplete root development. PDL healing 34%. Eventual extraction 30% o Part 2: necrosis usu happens after 3 wks. If PCO, usu after 6 months. Wet storage (saline/saliva) for >5 min decreased chances of pulpal healing. Immediate replantation with brief saline rinse recommended. o Part 3: 28 teeth showed further root development. More common in revascularized teeth and <45 min dry time. o Part 4: The following 4 factors had an impact upon PDL healing: stage of root development; length of the dry storage period; immediate replantation; and length of the wet period. PDL healing requires survival of the PDL cells on root surface. Immediate replantation is recommended irrespective of stage of root development. Ankylosis in 61% of teeth

• Social issues with trauma • Piercings and trauma? • Cerebral palsy and trauma • Trauma and general anesthesia • Drugs and trauma?

• Social issues with trauma o Katner 2012 - Rule out suspected child abuse/neglect o Nicolau 2003 [LRS] - Adolescents who experienced adverse psychosocial environments along the life course had more traumatic dental injuries than their counterparts. • Piercings and trauma? o Levin 2005 [LRS] - oral piercings can cause dental injury • Cerebral palsy and trauma? o Holan 2005 - prevalence of dental injuries in pts with CP much higher than general population. • Trauma and general anesthesia o Gaudio 2010 - most common claim against anesthesiologist. Incidence 1.38/1000 GAs. Damage to teeth can occur in absence of negligence. • Drugs and trauma? o De Oliveira Filho 2014 - Brazilian adolescents. Prevalence of trauma 26% overall. 2.5 times more prevalent in adolescents who had tried marijuana or cocaine. No association of trauma with social class.