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Endodontics | Traumatic Injuries | INBDE, ADAT — Transcript

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0:01hey everyone Ryan here and welcome back
0:03to our series on Endodontics like all my
0:06videos I'm going to focus only on the
0:08highest yield topics and now that we've
0:11covered the basics of endodontic
0:13treatment and procedural complications
0:16let's talk a little bit about traumatic
0:18injuries and the anodic treatment that
0:20can accompany this
0:23trauma so first I wanted to come up with
0:26an easy acronym to remember the basic
0:28protocol following traumatic accident so
0:31if a patient calls you and tells you
0:34their kid fell and knocked a tooth or if
0:37you yourself had such an injury you'd
0:39know what to
0:40do so my acronym is trauma although
0:45trauma is spelled a little bit
0:47interestingly with a V instead of a u
0:49but otherwise I think it works really
0:52really well so our T is for tetus
0:56booster and this is true for evulsion
0:59only and we'll talk more about this but
1:01an evulsion is where a tooth is knocked
1:04completely out of the socket and so in
1:08this situation you'd want a tetanus
1:10booster within the first 48 hours if
1:13that tooth had fallen in the dirt and
1:16got contaminated and the plan was to
1:19have it replanted in the
1:21socket our R is stands for radiographs
1:26and so for trauma you'd want at least
1:28one periapical radi Raph and we'll talk
1:31about situations where you actually want
1:33more than this for example for jaw
1:36trauma or suspected fracture a Panoramic
1:39X-Ray would be
1:42recommended our a stands for antibiotics
1:46and again this is for avulsions only in
1:49that um contaminated tooth situation you
1:52want to replant it want to prevent
1:54infection and take some
1:57antibiotics our U or I should say our v
2:01stands for Vitality
2:03testing and so this involves the
2:05electric pulp testing and coal test we
2:08talked about in a previous video and
2:10remember we talked about how they don't
2:13actually test for True vitality and
2:16that's important here because false
2:18negative results where it says the tooth
2:21is actually dead when it's actually not
2:24dead are rather common following trauma
2:28because the sensory ner nerves in the
2:30tooth may be disrupted for at least 2 to
2:348 weeks uh following the traumatic event
2:38but vascular Supply may still be intact
2:41which is the true measure of
2:44Vitality so it's important to have
2:46follow-up visits which is our M and our
2:49a more appointments and follow-ups are
2:52recommended 3 weeks 3 months 6 months
2:57and 12 months after the traumatic injury
3:01y so I actually already have a video
3:05that looks in depth at the ls
3:06classification system so if you want
3:08more information on this go check out
3:10that video but this system is often
3:13tested on the national board exam so I
3:15thought to mention it here just briefly
3:18and memorizing it is important and it's
3:20kind of nice because it basically goes
3:22in order from least serious to most
3:25serious traumatic incident just to give
3:28you a quick glance of what I talk about
3:32uh some of these are nice to uh nice to
3:34memorize because class one involves one
3:37layer of the tooth class two involves
3:40two layers of the tooth and class three
3:42involves all three layers class four
3:45kills the tooth class 5 Moves the tooth
3:47and class six kicks the tooth out of the
3:50socket so those are all the Ellis
3:53classes again check out my video on it
3:56if you want to see more in-depth
3:58information
4:00all right so we're going to go through a
4:02couple examples of different traumatic
4:04injuries and what you do to treat them
4:08so an uncomplicated fracture refers to
4:11all fractures of teeth without pulp
4:14involvement so they involve just the
4:16enamel layer or the enamel and Denton
4:19layer like in this picture here if only
4:23the enamel is involved smoothing the
4:25edges rounding those edges off to
4:28prevent any further soft tissue damage
4:31lacerations with the sharp edges of a
4:33fracture line that would be our
4:35treatment of choice if a Nel and Dentin
4:38are involved then we would elect to
4:42restore that tooth uh with let's say a
4:44composite resin or something to again
4:47restore uh the tooth to its function and
4:50to olude those dentinal tubules to
4:53prevent sensitivity issues carries and
4:55things like
4:57that next we have a complic ated
5:00fracture and so the uncomplicated
5:02fractures don't involve pulp whereas
5:05complicated fracture by definition does
5:08involve the pulp layer so um these
5:12little things DPC spec pulp uh PPT y all
5:16of these things I'll explain in my next
5:18video on adjunctive and adonic treatment
5:21so definitely go check that out but here
5:24it's very important that the timing is
5:28considered so um all these treatments
5:32involve treating the pulp tissue to some
5:34degree because the fracture involves the
5:36pulp and which one you do depends on how
5:40long after the fracture has occurred
5:42that that patient presents to the clinic
5:44so if it's less than 24 hours we can get
5:47away with a direct pulp cap if it's more
5:49than or equal to 24 hours we'd have to
5:52do a spec pulpotomy where we remove a
5:55part of the coronal pulp tissue it's a
5:58partial pulpotomy is another name for it
6:01and if it's been more than or equal to
6:0372 hours we do a pulpotomy where we
6:05remove the entire coronal
6:10pulp all right so horizontal root
6:13fracture is our next one and this one's
6:15a little bit tricky but I'll try to
6:17break it down to make it a little bit
6:18easier to understand so this is where
6:21the coronal segment has been displaced
6:24and the apical segment is not displaced
6:26it's uh still lodged in the socket this
6:29coronal SE segment might be a little bit
6:31mobile because it's fractured off of the
6:35rest so in this one um as I alluded to
6:38before this is a scenario where you'd
6:41want to take more than just one
6:42periapical in fact you want to take
6:45three periapical and one accusal radaph
6:49at a minimum and this is because a
6:52fracture like this occurs along one
6:56plane of space and if the radaph has
6:58captured along a similar plane you won't
7:01be able to see the fracture line in the
7:03image because an xray is a 2D image of a
7:073D object and so this is why it's super
7:10important to take several radioraps at
7:13different angulations all three of these
7:15PA should be taken at different uh
7:17vertical angulations as the accusal is a
7:21different angulation 90° to the um long
7:24axis of the tooth approximately and
7:28hopefully with all all those radioraps
7:30you'd be able to see where that fracture
7:33is so ideal healing of this fracture is
7:37calcific healing otherwise known as
7:39calcific
7:41metamorphosis which involves reattaching
7:43these two fragments together in close
7:46proximity via calcification so it's
7:48basically a callus that holds these
7:50fractured pieces together by hardening
7:53along the fracture line and we'll talk
7:55more about this when we talk about
7:58responses to trauma
8:00like natural responses of trauma by the
8:02tooth at the end of this
8:05video so next I can get caught in the
8:07weeds a little bit here so I'm going to
8:10keep it pretty simple and say that if
8:12the tooth is vital this coronal segment
8:15is vital we'd want to splint that tooth
8:19as soon as possible because it's
8:21probably quite a bit mobile and we want
8:23to keep it relatively in place so that
8:27we can allow some sort of healing
8:28response
8:30and so if the fracture is in the coronal
8:34third of the root we'd have to use a
8:35rigid splint unfortunately which is not
8:37our first choice generally because it
8:39can lead to the side effect of
8:42ankis and if the fracture line occurs
8:46more towards the apical third of the
8:47root that's better and we can use a
8:50flexible splint for a less amount of
8:52time and that's because we want to avoid
8:56ankis if possible so the flexible splint
8:59and the less amount of time you can use
9:01it you can get away using it that's
9:03better for these potential avoiding
9:06these potential side
9:07effects and as you can see here the
9:10coronal fracture is much worse than the
9:12apical fracture and involves a much more
9:15complicated involved treatment procedure
9:17so apical fractures are better than
9:20coronal fractures which is also true if
9:23you recall from our last video um
9:26perforations proced one of those
9:28procedural complications are better if
9:30they Cur occur apically as opposed to
9:33coronally so just another example of
9:36kind of those trends that you can
9:37remember apical is better than
9:41coronal also an oblique fracture is
9:44better than a transverse fracture that
9:46goes straight across so that's another
9:48thing you can uh keep in your memory
9:51banks now if the tooth is necrotic as in
9:56you know most situations where the tooth
9:58is necrotic we'd want to do a root canal
10:00therapy so that makes
10:03sense now there's a 25% chance of
10:06necrosis of the coronal segment of the
10:08teeth and necrosis of the apical segment
10:12is very very rare so it's a rare
10:16situation where you'd have this segment
10:18that was not dislocated not displaced
10:21become necrotic so the root canal
10:23therapy would be involving uh sealing
10:26off the wide Lumen of the pulp in the
10:28coronal segment and leaving this segment
10:31alone if the apical segment does happen
10:34to be necrotic we can extract it or
10:36surgically treat
10:39it okay so next we have concussion which
10:42is where you bumped your tooth like you
10:45you know bumped your head and so there's
10:47no displacement no Mobility the PDL may
10:50be a little bit sore like you know you
10:52stub your toe on the door frame yes your
10:55PDL will be sore as well and for a
10:58concussion our treatment as you may have
11:01noticed all of the treatments I have are
11:03listed in red because they're extremely
11:06important because those are the things
11:07you'll most likely be tested on the
11:09national board exam you want to let the
11:11tooth rest for a concussion so this
11:14involves avoid biting on it for a few
11:16days and stick to a soft diet if you
11:21can next up is
11:23sublation which involves the tooth being
11:27loosened in the socket
11:29so there's no displacement like
11:32concussion but now we have some
11:34increased
11:35mobility and also the PDL rips and
11:39bleeds as a result so if a patient
11:42presented in your office and said you
11:44know they bumped their tooth it's really
11:46sore and you saw some bleeding around
11:49the sulcus of that tooth that should
11:51clue you in this is not a concussion
11:53we're definitely at least at some
11:57subluxation so subluxation should be
11:59best treated with a flexible splint for
12:02that ideal short period of Time 1 to 2
12:05weeks there is a 6% chance of necrosis
12:09with closed apes and it's more favorable
12:12prognosis with open
12:14apes and so what I mean by this is an
12:17open Apex means that it's an immature
12:20tooth where the root is still developing
12:23and that's a better situation and a
12:25closed Apex means it's a mature tooth
12:28where the root has complet needed
12:29development about 2 to 3 years after the
12:32tooth has fully
12:35erupted next we have Extrusion where the
12:39tooth is partially extruded in a coronal
12:42Direction out of the
12:44socket again open Apex a little bit more
12:47favorable we would reposition that tooth
12:49in its socket use that flexible splint
12:52for about 1 to two weeks and monitor it
12:55as needed again stick to our follow-up
12:57recall of the um those couple weeks the
13:00months and the year and all of that
13:03closed Apex a little bit less favorable
13:05still we would want to reposition it
13:07place a flexible splint and root canal
13:09therapy if needed if that tooth becomes
13:12necrotic because yikes there's a 65
13:15chance per chance of necrosis with
13:17closed
13:19Apes so as you may notice um as I'm
13:22going through this
13:24presentation the traumatic injuries are
13:26getting more and more serious with a a
13:29worse and worse prognosis in terms of
13:32necrosis of that
13:35tooth all right next we have lateral
13:38luxation and this is where we have
13:40displacement of the tooth in any
13:43direction except axially hence the
13:47lateral part of the name so usually this
13:49means the crown is displaced palatally
13:51and the root Apex is displaced lab as in
13:56um this image here so if I got my pen
13:58out
13:59this Crown is dislocated palatally and
14:03the root tip is dislocated laally and
14:07here unfortunately we have alv fracture
14:11which is definitely more serious and
14:13would involve a more extensive um
14:15splinting option if we were trying to
14:18repair that fracture but this is
14:20certainly more
14:22Sinister now we'd have the same
14:24treatment options as Extrusion as I just
14:27alluded to so that's reposition
14:29flexible splint and monitor with root
14:33canal therapy as needed so if the tooth
14:35become symptomatic if there's
14:37irreversible pulpitis or necrosis we'd
14:40have to step in with rot Canal therapy
14:43and here we have 80% chance of necrosis
14:46with closed apices so definitely not a
14:49great prognosis
14:52here all right next we have intrusion
14:56and this is apical displacement of the
14:58tooth
14:59so this tooth is displaced in this
15:04direction and I'm going to jump ahead
15:07there's a 96% chance of necrosis with
15:10closed apases that's really really bad
15:13and that's because as the tooth is
15:16displaced in an apical Direction it
15:19literally sever the vessels that supply
15:23that tooth it you know pushes on these
15:25vessels that supply it at the apical
15:28portion
15:29and that's the life supply of the tooth
15:32so intrusion is just cutting that off
15:35and so necrosis is super super likely in
15:37this situation
15:40unfortunately now there's two very
15:42different treatment options depending on
15:45the nature of the Apex if it's an
15:47immature tooth we allow it to re erupt
15:51and this is this is really really really
15:53important I've definitely seen a quite a
15:55few questions on the board exam about
15:58this exact time topc so if it's
16:00intrusion an open Apex you actually do
16:03nothing other than monitor it and allow
16:05it to re erupt on its own because the
16:07route is still developing and there's a
16:09chance that it pushes that tooth and
16:11continues eruption with a couple of
16:14hiccups but continues that eruption
16:16otherwise as normal closed Apex we go to
16:20our classic repo flexible splint and
16:22root
16:25canal all right and lastly we have
16:29evoltion which I alluded to before
16:31otherwise called X
16:33articulation and this is complete
16:35separation of the tooth from its Alvis
16:38or from its socket so the tooth has just
16:40completely been knocked out like my
16:42example um I may have said in another
16:44video where I got hit in the face with a
16:46baseball as a kid couple teeth got
16:48knocked out that's an example of
16:50evulsion very very traumatic uh trust me
16:54so um important concept here is extra
16:57alveolar dry time E A DT for short and
17:01this refers to the amount of time a
17:03tooth has been out of the mouth while
17:06dry hence extra alveolar outside the
17:10socket dry
17:12time and this is a really really
17:14critical concept because the more time
17:16you wait while the tooth is out of the
17:18socket the worse and worse and worse the
17:21prognosis of saving that tooth
17:24becomes kind of true for all the things
17:26we've talked about the amount of time
17:28between the incident of trauma and
17:31seeing a dentist same thing
17:35here so evulsion our treatment is
17:39basically this is kind of generalized we
17:42want to reimplant as soon as possible
17:45meaning put the tooth back in the socket
17:48with some exceptions and flexible splint
17:51for one to two weeks this is a little
17:54bit of a um over generalization but just
17:58maybe for test purposes remember
18:00reimplant and flexible
18:03splint now for a little bit more detail
18:07like I said it very much depends on this
18:10closed Apex versus open Apex concept
18:13we've been talking about most of this
18:14video and the amount of time that tooth
18:17has been out of the mouth while
18:20dry so um you can read through these on
18:23your own it's
18:24basically uh again worse as you get over
18:2860 minutes
18:29prognosis of the tooth goes way down and
18:31the sooner you can get into the dentist
18:33the better result and less than 30
18:35minutes is
18:37ideal and it may be worth noting um
18:40these Protocols are for permanent teeth
18:43as it's not usually recommended or
18:45necessary to be reimplanting primary
18:48teeth that are knocked out but in the
18:50case of primary tooth trauma our trauma
18:54acronym um that we started with is still
18:56by and large critical that the young
18:59patient follows and should absolutely
19:01see a dentist right
19:04away staying on the topic of evulsion
19:06just for a few more minutes here we have
19:10different storage media so when that
19:11teeth is knocked out instead of keeping
19:14it dry we have some options on how to
19:17save it as best we can for the time
19:19being while we're driving frantically to
19:22the dentist
19:24office so um our best optimal solution
19:28is is called Hanks balanced salt
19:31solution um or here's save a tooth is I
19:34guess one of the um names out there of
19:37the product and we also have uh milk is
19:41not a bad option saline uh saliva if the
19:45patient is um not a child and can maybe
19:49hold the tooth in their mouth for the
19:52time being without swallowing it that's
19:54another option and actually water is the
19:57least desirable solution out there it
20:00might not be what you think but yeah
20:02water is actually very uh not great for
20:05trying to save the tooth because it's
20:07hypotonic it doesn't have the correct
20:09balance of ions to be helping the tooth
20:11survive for that uh little amount of
20:16time so finally we'll talk about
20:18different long-term responses to trauma
20:22so these are like natural responses what
20:24can happen to the tooth um after a while
20:28after this traumatic incident has
20:31happened so our first big one is
20:33external resorption and this initiates
20:36in the periodontium and this is due to
20:39damage to the cemento blasts the cemento
20:42blastic layer of the PDL which comes up
20:45right to the tooth and so we have a
20:48couple different uh subcategories of
20:50external
20:52resorption the first one is replacement
20:54resorption which I talked about before
20:56is a bad side effect of having the those
20:58splints that are too rigid or left on
21:01too long and it's otherwise known as
21:04ankis where your body replaces PDL with
21:08bone hence replacement
21:12resorption there's also cervical
21:15resorption which is subepithelial
21:18sulcular infection resulting from trauma
21:22or uh evidence is still a little bit
21:24shaky on this but potentially nonvital
21:27bleaching so so subepithelial meaning
21:30under the epithelium in the sulcus
21:33basically means it's initiating at the
21:36CJ of the tooth and it's say often
21:40ragged moth eaten appearance uh in the
21:43radiograph this one's actually a little
21:44bit more clear maybe up here it's a
21:46little bit mothy in um and you could
21:49spot a pink uh spot in the tooth
21:55clinically next we have inflammatory
21:57root resorption
21:59and this is where bacteria and
22:00byproducts from the necrotic pulp travel
22:03through dentinal tubules to affect the
22:06parodontium so they go from in the pulp
22:09to outside and impact that PDL to get
22:12another kind of external resorption
22:14effect on the
22:16tooth so margins of external resorption
22:19are ragged poorly defined and if you
22:22take several different angles of
22:24radioraps of
22:26periapical the leion appears to move
22:28with those different
22:31angles now that'll be important when we
22:33compare it to the next one internal
22:37resorption so as opposed to external
22:40this one initiates within the tooth in
22:42the root canal system due to damage to
22:45the odont
22:46blasts so inflammation is due again to
22:50necrotic pulp from carries or trauma but
22:52this time causes resorption from within
22:55rather than from uh the outside from the
22:58PD l so internal resorption has a bit
23:01better prognosis is a little bit easier
23:04or much easier to treat than external
23:07resorption and you actually treat this
23:09with root canal therapy and you can use
23:11a liquefied or flowable obturating
23:14material to flow into this area of
23:17resorption and seal the canal
23:20effectively um as long as it's not too
23:22too
23:23involved the margins as opposed to
23:25external resorption are sharp and wellde
23:28find as you can see here and it does not
23:31move with angled radioraps because it's
23:33located in the center of the tooth so
23:36it's going to stay in the center of the
23:38tooth no matter what angle you take the
23:40radiograph
23:42at and lastly we have our ideal natural
23:46response to trauma which is calcific
23:50metamorphosis and this is where trauma
23:52induces o danta blasts to rapidly form
23:56extensive amounts of reparative Dentin
23:58remember that's one of our tertiary
24:00Dentin within the pulp space and this is
24:04more likely with open Apes intrusions
24:07and severe Crown fractures as a result
24:11of this calcific metamorphosis you get
24:13kind of like a yellow orange color of
24:15the tooth and again it's a sort of
24:18callus that forms that causes this
24:20coloration and it's actually the ideal
24:23response to trauma it also results in
24:26this uh phenomenon as Canal
24:29obliteration where the canal the pulp
24:32Canal shrinks to the point where you
24:34wouldn't even be able to see it on a
24:36radiograph because of this deposition of
24:38reparative Dentin where the tooth
24:41basically um prepares itself it it lays
24:45down more to structure to protect uh to
24:48protect itself and that's again the
24:50natural ideal response to a traumatic
24:53entry like luxation or
24:57intrusion all right so I know that was a
24:59lot of information uh feel free to
25:02rewind and rewatch some of those things
25:04because there's a lot there and um this
25:08is all important stuff because as I as I
25:10said before some of the sections of the
25:13test particularly that ask about case
25:16scenarios um they could reference some
25:19sort of trauma and they would ask you
25:22you know what would be your ideal
25:23treatment modality what you would do
25:25what's the prognosis what's the rate of
25:27a necr prois maybe not exact percentages
25:31but maybe rating what the worst tra
25:34traumatic injury would be what's the
25:36best prognosis things like that so all
25:39that stuff is rather important and
25:42hopefully I was able to uh deliver it in
25:44a way that helps you remember it and can
25:47help you study for the national board
25:50exam so again thanks so much for
25:52watching guys I really appreciate all
25:53the support I'll have the next video in
25:56this series up pretty shortly and then
25:58after that I'll make some practice
26:00questions like I did for the oral
26:02pathology section so you can get a taste
26:04of what some of those board questions
26:06will look like thanks again for watching
26:08and I'll see you all in the next video

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