Dental Trauma in Primary and Permanent teeth

DENTAL TRAUMA
Its include animated video
contact - [email protected]

1. DENTAL TRAUMA PART-1 DR ABHIGYAN SHANKAR DEPT OF PEDIATRIC AND PREVENTIVE PG FINAL YEAR

2. CONTENT INTRODUCTION ETIOLOGY & EPIDEMOLOGY CLASSIFICATION DIAGNOSIS 2

3. INTRODUCTION

4. Trauma to the primary dentition and oral cavity are common occurrences in children and young people. A recent international epidemiological study on traumatic dental injuries (TDIs) involving primary teeth revealed a worldwide prevalence of 22.7 % .They frequently occur in young children as they learn to crawl, walk, run and embrace their physical environment. These injuries often represent painful, distressing events and may result in adverse long-term physical, aesthetic and psychological consequences for the child. 4

5. 5 The majority of dental injuries in the primary and permanent dentitions involve the anterior teeth, especially the maxillary central incisors. Concussion, subluxation, and luxation are the commonest injuries in the primary dentition , while uncomplicated crown fractures are commonest in the permanent dentition . Prognosis of traumatic injuries has improved significantly in the last 20 years. This has been largely due to a greater understanding and knowledge of pulpal procedures.

6. ET I OLOGY & EPI D EMI OLOGI

7. 7 🌍 Worldwide (Global) Global prevalence of TDI ranges from 6 % to 59 % , depending on region and age; nearly 50 % of children experience a dental injury before age 18. Overall, more than 1 billion people worldwide have suffered TDI. In children aged 0 to 6, about 17 out of every 100 injuries happen to the mouth. And one-third of preschoolers have experienced trauma to primary teeth. Males are affected more than females in global data 6% to 59 %

8. 8 In India (National level) A systematic review from India found that about 12 out of every 100 people older than 6 years have experienced it — Prevalance around 12 %.“ Among central India children aged 8‑12 years: prevalence of TDI was 16.7 % , with 67.2 % cases in boys , 32.9 % in girls ; higher prevalence as age increases (from 8 to 12 years)

9. 9 Madhya Pradesh – Bhopal (Local data) Study 1: Bhopal city, age 6–12 years Among 1,204 children , traumatic dental injury prevalence was 20.9 % , Study 2: Urban & rural schoolchildren aged 12 & 15 years in Bhopal district It focused on anterior teeth TDI among 12‑ and 15‑year‑olds, Prevalence was 24%

10. 10 Location / Study Year / Type Age Group TDI Prevalence India (pooled meta‑analysis) 2020 ≤6 yr: ~15% / >6 yr: ~12% ~13% overall Mahbubnagar , Telangana 2022 cross‑sectional 8–15 yr (~6,600 kids) 9.3% Bhopal-specific studies (older) 2013–2017 6–15 yr ~12.8% (older study)

11. 11 Gender-wise Globally and India‑wide: Male have higher incidence than females (ratios from about 2:1 to 2.4:1 ) Central India (Bhopal region among 8–12 yrs): 67.2  % boys vs. 32.9 % girls with TDI . In primary dentition studies (ages ~2–6): about 62 % males , 38 % females in dental trauma cases

12. 12 Age-wise Trends Worldwide : Highest TDI in age groups: 0–6 yrs : oral injuries account for 17 % of total bodily injuries; peak at 2–3 years in primary dentition . Primary dentition TDI: ~77 % occur in first 4 years, India : Among 8–12 yrs: prevalence rises with age — e.g. highest at 12 years (39 % of TDI cases) , lowest at 8 years (8 %)

13. 13 Primary Dentition (Deciduous Teeth) – Etiological Factors Fall from own height Slipping on smooth surfaces (tiles, wet floors) Collisions with furniture or objects Uncoordinated motor skills (toddlers 2–3 years) Inadequate supervision at home Sibling-related injuries (push, throw) Child abuse / non-accidental injury Walking with objects in mouth Playing on beds/sofas without barriers Lack of protective environment at home

14. 14 Age Group Common Injuries Key Cause 1–2 yrs Minor luxation, subluxation Crawling/walking 2–3 yrs Intrusion , lateral luxation Running, 3–4 yrs Luxation, extrusion, concussion Playing at home 4–6 yrs Crown fractures (rare), concussion Falls, sibling play, minor sports 🔹 Most common injury: Luxation (displacement), 🔹 Most common age: 2–3 years (peak incidence)

15. 15 Permanent Dentition – Etiological Factors Falls (school, playground, stairs) Sports injuries (football, cricket, basketball) Road traffic accidents (RTAs) Bicycle/skateboard accidents Physical fights / interpersonal violence Collisions with objects/persons Playing-related trauma Assault Increased overjet (>3 mm) Incompetent lip closure Malocclusion (especially Class II Div 1) Use of sharp tools or hard objects near mouth Poor awareness/protective measures (no mouthguards)

16. 16 Age Group Common Injuries Key Cause 6–9 yrs Uncomplicated crown fractures , luxation Falls at school/home 9–12 yrs Enamel-dentin fractures , avulsion Sports injury, overjet problems 12–15 yrs Crown-root fractures, subluxation Cycling, fighting, school accidents 15+ yrs Root fractures, complicated fractures RTA, violence, sports without guards 🔹 Most common injury: Crown fracture 🔹 High-risk age group: 9–15 years (active outdoor involvement, sports, biking)

17. Component of Trauma

18. 18 Factor Low Velocity, High Mass High Velocity, Low Mass Example Tooth hitting the ground Gunshot, ball strike Speed Slow Fast Weight (Mass) Heavy object Light object Main Effect Deep damage to supporting structures (PDL, bone) Surface-level fracture of crown Fracture Type Minimal / mild crown fracture Clear crown fracture (enamel/dentin) Root/Bone Involvement Often severely damaged Mostly unaffected Energy Distribution Energy absorbed by root and bone Energy used up in breaking the crown Clinical Implication Needs evaluation of periodontal & bone health Focus on crown restoration

19. 19 Impact Type Resilient Object (Soft) Non-Resilient Object (Hard) Example Elbow during play, soft ball, Metal rod, wall,edge of furniture Effect on Crown (Fracture) 🟢 Less likely – fracture reduced 🔴 More likely – sharp fracture Effect on Root / Periodontal area 🔴 More likely – luxation, root movement, bone fracture 🟢 Less likely – damage localized to crown Type of Injury Seen Luxation, subluxation, alveolar bone fracture Crown fracture (enamel/dentin), chipping Energy Transfer Absorbed by soft tissue → transmitted to root Absorbed at impact site → damages enamel/crown Clinical Management Focus Check mobility, bone integrity, root health Restore crown structure, check for pulp exposure

20. 20 Direction of Impact Force Angle Common Injury Facial (Perpendicular) 90° to root axis Crown fracture (clean cut) Oblique (Tilted) 30°–60° angle Crown fracture (oblique), pulp involvement Lateral (Side) From mesial/distal Luxation, root fracture Apical (From below) Upward into socket Extrusion, alveolar fracture

21. Classification of Traumatic Dental Injuries

22. 22 Accurate classification of traumatic dental injuries (TDIs) is essential for proper record-keeping and international comparison. TDIs often occur with facial injuries, making clear classification clinically important. There are two main types of systems: Numeric systems – use codes for easy data collection and registry. Descriptive systems – offer detailed clinical descriptions of the injuries. Different systems may not apply to both primary and permanent teeth. Complex trauma involving both teeth and surrounding structures may not fit into one category, so detailed reporting is needed for better diagnosis, treatment, and data use.

23. 23 International Association of Dental Traumatology (IADT) Founded in 1989 by Dr. JO Andreasen and team. Aims to promote prevention and treatment of traumatic dental injuries (TDI). Engages with dental professionals, colleges, public, industry , and government bodies . Publishes the journal “ Dental Traumatology” , a key resource on TDI. Provides updated, globally accepted guidelines for managing trauma in primary and permanent dentition .

24. 24 Indian Society of Dental Traumatology (ISDT) Formed in 2017 in India to improve awareness and management of dental trauma. Focuses on education and training of teachers, students, parents, sports coaches, and medical professionals. Promotes a multi-sector strategy to spread awareness. Collaborates with IADT and other organizations to enhance Indian participation in research and clinical trauma care

25. 25 Clinical Decision Support Tools Widely used in modern medicine, including dental traumatology . Dental Trauma Guide (DTG) developed in Copenhagen by Dr. Andreasen and team. Offers evidence-based treatment guidelines , animations, and graphics. Covers diagnosis and management of TDI in both primary and permanent teeth . Provides prognosis tools based on user-entered data. “ Tooth SOS ” app launched by IADT in 2017 for easy access to information, especially for emergencies .

26. 26

27. 27 ToothSOS Mobile App

28. 28

29. INJURED TOOTH (Mobile application) 29

30. 30

31. Classification of Dental Fractures 31

32. 32 Ellis and Davey’s Classification of Dental Fractures

33. 33 Class Description Structures Involved Class I Simple fracture involving enamel only . Enamel Class II Fracture involving enamel and dentin , without pulp exposure. Enamel + Dentin Class III Fracture involving enamel, dentin, and pulp . Enamel + Dentin + Pulp Class IV Non-vital tooth with or without crown loss. Pulp necrosis / Dead tooth Class V Tooth avulsion – complete loss of tooth due to trauma. Tooth displaced entirely Class VI Root fracture , may or may not involve crown fracture. Root (and possibly crown) Class VII Tooth displacement without fracture (e.g., luxation, intrusion, extrusion). Periodontal ligament Class VIII Fracture of the crown en masse – total crown separated from root. Entire crown detached Class IX Injuries to primary (deciduous) teeth . Primary dentition

34. 34

35. 35

36. 36

37. 37

38. Cohen’s Class IX:"Traumatic injuries to primary teeth” 38

39. Subtype Description Class IX A Fracture of crown without pulp exposure (uncomplicated crown fracture) Class IX B Fracture of crown with pulp exposure (complicated crown fracture) Class IX C Root fracture Class IX D Luxation (displacement of tooth from socket) Class IX E Avulsion (complete loss of tooth from socket) Class IX F Intrusion (tooth driven into alveolar bone) Class IX G Extrusion (tooth partially displaced out of socket) Class IX H Lateral luxation (tooth displaced laterally, usually with alveolar fracture) Class IX I Concussion or subluxation (injury to supporting structures without displacement) 39

40. 40 Modification of Ellis Classification by McDonald, Avery, and Lynch (1983 ) For Primary Teeth

41. 41 Class Description Class 1 Simple fracture of the crown involving little or no dentin . Class 2 Extensive fracture of the crown involving considerable dentin , but no pulp exposure . Class 3 Extensive fracture of the crown with exposure of the dental pulp . Class 4 Loss of the entire crown due to trauma.

42. 42 Class 1 Simple fracture of the crown involving little or no dentin .

43. 43 Class 2 Extensive fracture of the crown involving considerable dentin , but no pulp exposure .

44. 44 Class 3 Extensive fracture of the crown with exposure of the dental pulp .

45. 45 Class 4 Loss of the entire crown due to trauma.

46. 46 Classification of Dental Trauma of Primary Teeth by Fried and Erickson (1995)

47. 47 Classification of hard tissue fractures : Class I: Simple fracture of enamel only Class II: Fracture involving enamel and dentin Class III: Fracture extends farther into the tooth, with a small pulpal exposure Class IV: Fracture involves significant amount of pulpal exposure Class V: Complete loss of the tooth Class VI: Fracture of the root Trauma affecting the periodontium : Concussion: Sensitivity of the tooth to trauma without abnormal loosening or mobility Subluxation: Loosening of the tooth without mobility Luxation: Displacement of the traumatized teeth

48. 48

49. 49 Andreasen classification adopted by World Health Organization (Primary)

50. 50 1. Injuries to the hard dental tissues and the pulp: 1.1 Enamel fracture 1.2 Enamel-dentin fracture 1.3 Complicated crown fracture 2.Injuries to the hard dental tissues, the pulp, and the alveolar process : 2.1 Crown-root fracture 2.2 Root fracture 2.3 Alveolar fracture 3.Injuries to the periodontal tissues : 3.1 Concussion 3.2Subluxation 3.3 Luxation injuries: 3.3.1 Lateral luxation 3.3.2Intrusive luxation 3.3.3 Extrusive luxation 3.3.4 Avulsion

51. 51 Andreasen’s Classification (1981)

52. 52 Type of Injury Description Enamel Infraction Incomplete crack in enamel without loss of tooth substance . Enamel Fracture (Uncomplicated Crown) Fracture involving loss of enamel only , no dentin or pulp involvement. Enamel–Dentin Fracture (Uncomplicated Crown) Fracture involving enamel and dentin , but no pulp exposure . Complicated Crown Fracture Fracture involving enamel and dentin with pulp exposure . Uncomplicated Crown–Root Fracture Fracture involving enamel, coronal and radicular dentin, and cementum , no pulp exposure . Complicated Crown–Root Fracture Fracture involving enamel, dentin (coronal & radicular), and cementum with pulp exposure . Root Fracture Fracture involving radicular dentin, cementum, and the pulp .

53. 53

54. 54

55. 55

56. 56

57. 57 Type of Injury Description Concussion Injury to tooth-supporting structures without abnormal loosening or displacement , but percussion sensitive . Subluxation (Loosening) Injury causing abnormal loosening of the tooth, without displacement . Extrusive Luxation (Partial Avulsion) Partial displacement of the tooth out of its socket . Lateral Luxation Displacement of the tooth in a non-axial direction , often with fracture of the alveolar socket . Intrusive Luxation (Central Dislocation) Tooth is pushed into the alveolar bone ; often with socket fracture or comminution . Avulsion ( Exarticulation ) Complete displacement of the tooth out of its socket . Andreasen’s Classification (1981) – Injuries to Periodontal Tissues

58. 58

59. 59

60. 60

61. 61 Type of Injury Description Contusion of gingival or oral mucosa A bruise from blunt trauma; may not break the mucosa but causes submucosal hemorrhage . Abrasion of gingival or oral mucosa A superficial wound caused by rubbing or scraping; leaves a raw, bleeding surface . Laceration of gingival or oral mucosa (Not fully shown but implied) A tear or cut in the mucosa, usually from sharp trauma or tooth fracture (common in TDI). Andreasen’s Classification (1981) Injuries to Gingiva or Oral Mucosa

62. 62 Type of Injury Description Comminution of alveolar socket wall Crushing/compression injury of the socket wall (facial or lingual), often seen in intrusive/lateral luxation . Fracture of alveolar socket wall A fracture limited to the facial or lingual socket wall of the alveolus. Fracture of alveolar process Involves the alveolar bone (with or without the socket); may include several teeth moving together. Fracture of the mandible or maxilla A jaw fracture involving the base of the mandible or maxilla ; often extends to the alveolar process. Andreasen’s Classification (1981) - Injuries to Supporting Bone

63. 63

64. 64 Explanation of "N 502 . 50 " " N " – Represents the category (likely dental trauma). " 502 " – Indicates the type of injury , such as crown fractures . ". 50 " – Refers to the specific condition , like: Enamel infraction (crack without loss), or Enamel fracture (loss confined to enamel). It's used in dental trauma classifications , often in ICD-DA or academic references. Helps in documentation , diagnosis , and treatment planning . Let me know if you want a visual chart too! Code De-Code

65. 65

66. 66

67. 67

68. 68

69. 69

70. 70

71. End of part 1 71

72. DENTAL TRAUMA PART-2

73. Diagnosis

74. CONTENT HISTORY CLINICAL EXAMINATION SENSIBILITY TESTS 74

75. 75

76. 76

77. 77

78. 78

79. 79

80. 80

81. 81 Recording of extraoral wounds and palpation of the facial skeleton Recording of injuries to oral mucosa or gingiva Examination of the tooth crowns for the presence and extent of fractures, pulp exposures, or changes in tooth color Recording of displacement of teeth (i.e. intrusion, extrusion, lateral displacement, or avulsion ) Abnormalities in occlusion Abnormal mobility of teeth or alveolar fragments Palpation of the alveolar process Reaction and sound of teeth to percussion

82. 82 Clinical Examination Recording of extraoral wounds and palpation of the facial skeleton Assess and document any extraoral injuries such as lacerations, hematomas, or swelling; palpate the facial skeleton to check for jaw fractures or tenderness. Injuries like wounds under the chin may suggest mandibular fractures or posterior tooth trauma.(ex -Battle sign)

83. 83 2. Inspect the oral mucosa and gingiva for signs of trauma or lacerations Inspect the oral mucosa and gingiva for lacerations, hematomas, or foreign bodies. Gingival bleeding without laceration suggests periodontal ligament damage. Lip wounds should be evaluated for embedded tooth fragments or debris via radiographs.

84. 84 3. Examine tooth crowns for fractures, pulp exposure, or discoloration. Examine tooth crowns for fractures. Clean the crowns of blood and debris before evaluation. Identify whether fractures involve enamel, dentin, or pulp. Use transillumination or shadowing to detect enamel infractions and translucency changes. Look for color changes (often pinkish or dark at the cingulum), which may indicate pulp pathology

85. 85 4. Identify and record any displacement of teeth, such as intrusion, extrusion, lateral displacement, or avulsion. Identify and record any displacement of teeth , such as intrusion, extrusion, lateral luxation, or avulsion. Record the direction and extent (in mm) of displacement. In primary teeth, check if displaced apices are near the permanent successor. Also consider the possibility of aspirated or swallowed teeth — obtain chest or abdominal X-rays if needed

86. 86 5.Evaluate the occlusion for any abnormalities or changes . Evaluate the occlusion for abnormalities. Sudden changes can suggest luxation, alveolar, or jaw fractures. Carefully check posterior occlusion and look for step deformities.

87. 87 6.Check for abnormal tooth mobility or movement of alveolar bone segments. Check for abnormal tooth mobility both horizontally and vertically. Increased mobility may indicate luxation, root fracture, or alveolar fracture (if adjacent teeth move together). Keep in mind that erupting or physiologically resorbing primary teeth may also be mobile. Grade Miller’s Classification Lindhe and Nyman’s Classification Grade 0 Normal physiologic mobility ( ≤0.2 mm horizontally) Normal tooth mobility Grade 1 Slight mobility: >0.2 mm but ≤1 mm horizontal movement Mobility greater than normal , but <1 mm horizontally Grade 2 Moderate mobility: >1 mm but <2 mm horizontal movement Horizontal mobility >1 mm Grade 3 Severe mobility: >2 mm horizontally and/or vertical (apicocoronal) movement Severe mobility with vertical displacement (tooth is depressible in socket)

88. 88 7. Palpate the alveolar process to detect tenderness, step deformities, or mobility. Palpate the alveolar process to detect any tenderness , step deformities , or abnormal mobility of the bone. These findings may suggest an alveolar bone fracture or underlying maxillofacial trauma. Tenderness may indicate underlying inflammation or fracture. Step deformity (a sudden change in the contour of the bone) can be felt along the alveolar ridge and is a classic sign of bone discontinuity due to fracture.

89. 89 8.Perform percussion tests on teeth, noting any unusual sounds or pain response. Perform percussion tests on affected and control teeth. Pain on percussion indicates periodontal ligament trauma. A metallic (high) sound suggests ankylosis or intrusion, while a dull sound may indicate subluxation or luxation. In children, a fingertip may be used for gentler percussion

90. 90 To assess pulpal vitality and response, the following sensibility testing methods can be used: Mechanical stimulation – gentle pressure or tapping to elicit pain response. Thermal tests : Heated gutta-percha Cold tests using: Ice Ethyl chloride Carbon dioxide snow (CO₂ snow) Dichlorodifluoromethane Electric pulp testing (EPT) – measures the tooth's sensory response to electric stimulation. Laser Doppler flowmetry (LDF) – a non-invasive method to assess pulpal blood flow and vitality. Andreasen JO, Andreasen FM, Andersson L, editors. Textbook and color atlas of traumatic injuries to the teeth. John Wiley & Sons; 2018 Dec 17.

91. Timeframe PDL Healing Reliable Pulp Testing 0–2 Days Acute inflammation, provisional matrix ❌ EPT / Cold / Heat unreliable ✅ Laser Doppler Flowmetry (LDF) ✅ Pulse Oximetry 1–2 Weeks Fibroblasts, early collagen, revascularization begins ❌EPT / Cold / Heat unreliable ✅ LDF ✅ Pulse Oximetry 2–3 Weeks Angiogenesis, immature capillaries ❌ EPT / Cold / Heat unreliable ✅ LDF ✅ Pulse Oximetry 4–6 Weeks Functional PDL repair + nerve sprouting ⚠️ EPT / Thermal: partial recovery ✅ LDF ✅ Pulse Oximetry 2–3 Months Organized fibers, pulp reinnervation ✅ Sensibility tests (EPT / Thermal) ~80–90% reliable ✅ LDF ✅ Pulse Oximetry 3–6+ Months Long-term stable healing ✅ All tests reliable ⭐ Pulse Oximetry = most consistent ⭐ LDF = necrosis vs vitality 91

92. 92

93. 93 Test Type < 4 Weeks Post-Trauma 4–6 Weeks Post-Trauma 2–3+ Months / 6 Months EPT / Cold / Heat ❌ Usually false negative ✅ Begin accurate results ✅ Sensibility often returns; sensitivity ~89% Laser Doppler Flowmetry ✅ Detects blood flow early ✅ Sensitive indicator ✅ Predicts necrosis vs. revascularization with high accuracy Pulse Oximetry ✅ Stable reading (0–6 mo ) ✅ Consistent detection ✅ Highly reliable test across timeframe

94. 94 Sensitivity and Specificity – Core Concepts Sensitivity: This is the ability of a test to correctly identify disease (e.g., pulp necrosis). A sensitivity of 1.0 (100%) means all diseased cases are detected (no false negatives). Specificity : This is the ability of a test to correctly identify healthy conditions (e.g., healthy pulp). A specificity of 1.0 (100%) means no healthy cases are wrongly diagnosed as diseased (no false positives). Ideal Scenario: An ideal test would have 100% sensitivity and 100% specificity , meaning it's perfect at identifying both diseased and healthy conditions — but such a perfect test does not currently exist . Clinical Implication : A test with high sensitivity but low specificity may over-diagnose disease (i.e., treat healthy teeth unnecessarily). A test with high specificity but low sensitivity may miss actual disease , which is dangerous, especially in pulp-related issues like pulpal necrosis leading to root resorption .

95. 95 In crown fractures with exposed dentin, sensibility can be tested by scraping with a probe. Some have suggested drilling a test cavity to check for pain (deep dentin-pulp junction), but this is invasive and painful. In pulp-exposed teeth, use a saline-soaked cotton pellet to test; avoid probing as it may worsen trauma or cause severe pain. Andreasen JO, Andreasen FM, Andersson L, editors. Textbook and color atlas of traumatic injuries to the teeth. John Wiley & Sons; 2018 Dec 17.

96. 96 Common thermal test methods: Heated gutta-percha Ethyl chloride Ice Carbon dioxide (CO₂) snow Dichlorodifluoromethane Limitations: Results are not reproducible; responses vary and don't correlate with exact pulp condition. A positive response usually means vital pulp, but sometimes even non-vital (gangrenous) pulp may respond due to pressure from expanding gases.

97. 97

98. 98 Procedure (as per Mumford): Heat ~5 mm of gutta-percha in a flame for 2 seconds, then apply it to the middle third of the facial surface of the tooth. Limitations: Response is not consistent or reproducible. Even healthy (non-injured) teeth may sometimes fail to respond. Sensitivity: 0.86 Specificity: 0.41 Rubber roll Create friction by moving the roll on the tooth by this heat generate that may use for heat test Heated Gutta-Percha Andreasen JO, Andreasen FM, Andersson L, editors. Textbook and color atlas of traumatic injuries to the teeth. John Wiley & Sons; 2018 Dec 17.

99. 99 Procedure: A cone of ice is applied to the facial surface of the tooth. Effectiveness: The response depends on duration; 5–8 s econds improves sensitivity. Like gutta-percha, even non-injured teeth may not respond, reducing reliability. How to Make Ice Pencil Ice( Ice Pencil ) Andreasen JO, Andreasen FM, Andersson L, editors. Textbook and color atlas of traumatic injuries to the teeth. John Wiley & Sons; 2018 Dec 17.

100. 100

101. 101 Procedure: Soak a cotton pledget in ethyl chloride and apply it to the facial surface of the tooth. ⚠️ Flammable – handle with care. Limitations: Shares similar issues with heated gutta-percha (response inconsistency). However, gives more consistent results than gutta-percha. Sensitivity: 0.83 Specificity: 0.93 💨 Ethyl Chloride

102. 102

103. 103 Temperature: –78°C (–108°F) → gives very reliable and consistent results. Effective even in: Immature teeth and teeth with temporary crowns or splints. Advantage: Penetrates well and gives strong cold stimulus. Concern: May cause enamel infraction lines due to extreme cold (not confirmed in later studies). Pulp safety: No permanent pulp damage observed in animal studies. Only risk: Prolonged exposure (−80°C for 1–3 mins) may cause temporary pulpal changes (like secondary dentin). Carbon Dioxide Snow – Cold Test (Dry Ice) Andreasen JO, Andreasen FM, Andersson L, editors. Textbook and color atlas of traumatic injuries to the teeth. John Wiley & Sons; 2018 Dec 17.

104. 104 Temperature: −28°C (−18°F) Applied as a cold aerosol spray on the enamel surface. Advantages: Gives a reliable and consistent response in both mature and immature teeth. Drawbacks: May also cause enamel infraction lines due to thermal shock, though less than CO₂ snow. (e.g. Frigen ®, Provotest ® ) Dichlor-difluormethane Andreasen JO, Andreasen FM, Andersson L, editors. Textbook and color atlas of traumatic injuries to the teeth. John Wiley & Sons; 2018 Dec 17.

105. 105 Electric Pulp Testing (EPT) is a diagnostic method used to check whether the pulp inside a tooth is alive or not — meaning, whether the sensory nerve fibers in the pulp are functioning properly. It uses a small electric current to stimulate these nerves. ⚡

106. 106

107. Pathway of Current Flow Electrode (probe tip) of EPT contacts the dried tooth surface (with conductive medium like toothpaste). Electrical current passes through: Enamel (high resistance) Dentin (lower resistance, fluid conduction in tubules) Pulp tissue The A-delta nerve fibers in the odontoblastic layer/pulp-dentin border are stimulated. This causes rapid depolarization of the nerve membrane → generates action potential → interpreted by patient as a “tingling/sharp sensation. 107

108. Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ K- K- K- K- K- K- K- K- K- K- K- K- K- K- K- K- K- K- K- K- K- K- Na+ Na+ Na+ Na+ Na+ Na+ Na+ K- K- K- K- K- 108

109. 109

110. Response Type EPT Reading / Threshold Clinical Meaning References Fast / Early Reaction <20 µA (≈ 1–3 units) Inflamed pulp, hypersensitivity Petersson et al. 1999 [1], Cohen’s 11th ed. [3] Normal Reaction 20–40 µA (≈ 3–6 units) Healthy, vital pulp Petersson et al. 1999 [1] Late / Delayed Reaction >40 µA (≈ 6–10 units) Aged pulp, secondary dentin, calcified canal, trauma Chen & Abbott 2009 [2], Cohen’s 11th ed. [3] No Response Max value (~80 µA / full scale) Non-vital (necrotic) pulp Petersson et al. 1999 [1], Cohen’s 11th ed. [3] Primary / Immature Teeth Often unreliable or absent Due to incomplete plexus of Raschkow Mejàre & Axelsson 1996 [4] 110

111. 111

112. 112 1️⃣ Inform the Patient Tell the patient about the purpose of the test and ask them to raise a hand or signal as soon as they feel a sensation (like tingling, shock, or vibration). 2️⃣ Isolate and Dry the Tooth Isolate the tooth with cotton rolls and air-dry it . Saliva must be avoided , as it may redirect current to the gums or adjacent teeth , causing false results. However, do not over-dry the tooth either — enamel can lose moisture, increasing resistance and altering the reading. Electrode Placement Place the electrode as far from the gum as possible , preferably on the incisal edge or fracture line , where the response is strongest. Use toothpaste or saline between the electrode and tooth as a conductor. The neutral electrode is held by the patient, or the dentist completes the circuit using a finger or metal tool (like a mirror or probe). Rubber gloves can interfere with the current. Some devices now come with a lip clip to allow testing even with gloves o Steps in Performing EPT

113. 113 4️⃣ Apply the Current Gradually increase the current using the rheostat (control knob) until the patient signals a sensation. If current is increased too slowly , the patient may adapt and no longer feel the sensation — leading to a false high threshold . If increased too fast , it may be painful . The ideal way: steady, moderate increase until sensation is felt. Record the reading for future comparison. 5️⃣ Special Considerations Devices like metal crowns, splints, or arch bars may divert current away from the tooth and give incorrect results . Always place the electrode on enamel , and isolate the tooth from adjacent vital teeth to avoid current bypass.

114. 114 It concluded that combining EPT with Endo‐Ice (cold test) improves accuracy in determining pulp vitality Another clinical analysis reported comparable predictive values for EPT and cold thermal test: Cold test: sensitivity ~0.89, specificity ~0.91 EPT:sensitivity~0.88,specificity~0.90 Combining them provides a better cross-check than either alone A cross‑sectional study at a teaching hospital found both cold and electric tests had similar sensitivity (~82–84%) and specificity (~88%). The overall accuracy was also nearly the same (~84–85%). Authors recommended using both tests together to verify findings

115. 115 🧠 Clinical Application & Protocol Start with Cold Test (e.g. Endo‑Ice on a cotton pellet). Then perform EPT on the same tooth, following proper technique. Compare to a contralateral control tooth for baseline. Interpret combinations: Both positive → tooth likely vital. Both negative → high chance of necrosis. Mixed → consider patient history, clinical signs, repeat testing later (especially post-trauma), and radiographs before deciding.

116. 116 Reason Details Sparse Plexus of Raschkow Primary teeth have fewer A‑delta fibers; reduced density limits electrical stimulation response. ( Deep Blue , ResearchGate ) Incomplete A‑delta network in early roots Plexus formation is immature until later in root development. ( MDPI ) C-fiber dominance & deeper innervation More unmyelinated (C-fibers), which don’t respond to EPT. ( JSciMed Central , Canadian Dental Association ) Root resorption over time Innervation degenerates with normal exfoliation, further reducing responsiveness. ( ResearchGate ) Why EPT Works Poorly on Primary Teeth

117. 117 ✅ 1. Only in Cooperative Children with Good Understanding Studies (e.g. by Hori et al.) show that if a child understands instructions and cooperates, EPT can provide fair diagnostic value in primary teeth, with sensitivity around ~80% and diagnostic accuracy around ~76%

118. 118 Laser Doppler Flowmetry (LDF) Laser Doppler Flowmetry (LDF) is a highly sensitive and specific method for detecting true pulp vitality , especially after dental trauma , and outperforms EPT and cold tests in such cases. But due to cost, time, and equipment limitations, it is not yet widely used in general practice . 🔬 How it works: A laser beam is pointed at the crown (top part) of the tooth. The laser light goes through the tooth and reaches the blood vessels in the pulp. When the light hits moving red blood cells, it gets scattered and undergoes a Doppler shift (change in frequency due to motion). The reflected light is collected by a detector. This signal is processed by a computer to measure the amount of blood flow in the pulp.

119. 119 Feature LDF EPT / Cold Test Tests actual vitality (blood flow) ✅ Yes ❌ No (tests only nerve response) Early detection after trauma ✅ Yes, detects vitality in 3 months ❌ Often takes 6 months Reliable in immature teeth ✅ Yes ❌ No Used in luxated/replanted teeth ✅ Recommended ❌ Often fails

120. Consistency : Vital teeth → 80–90% SpO ₂ Non-vital teeth → 0% or negligible Comparison with traditional tests : Cold/EPT = nerve response → risk of false positives/negatives. Pulse oximetry = measures blood supply → true vitality . Clinical significance : Especially useful in immature permanent teeth, traumatized teeth, children . Painless, objective, non-invasive. Limitations : Lack of standardized dental probes. Factors like enamel/dentin thickness, restorations, or discoloration may affect readings 120

121. 121 Test Primary Teeth 🧒 Permanent Teeth 🧑‍⚕️ Notes 🔵 Pulse Oximetry (PO) ✅ Recommended ✅ Highly reliable Best objective method; measures oxygen saturation of pulpal blood. Excellent for trauma/immature teeth. 🔴 Electric Pulp Test (EPT) ❌ Not reliable ✅ Reliable (in mature teeth) Works via A-delta fibers. Fails in primary/immature/traumatized teeth. High specificity but low sensitivity. 🟡 Cold Test (CO₂ Snow) ⚠️ Sometimes usable ✅ Reliable May be used in older, cooperative children. Cold test is effective in mature teeth, especially anteriors. 🔴 Heat Test (HPT) ❌ Not used ⚠️ Occasionally used Poor patient tolerance; low accuracy in both dentitions. Rarely used clinically. 🔵 Laser Doppler Flowmetry (LDF) 🔄 Accurate but limited use ✅ Highly accurate Measures pulpal blood flow. Gold standard in research. Costly and time-consuming; not routine yet. ⚪ Clinical Signs + Radiograph ✅ Always needed ✅ Always needed Pain, swelling, mobility, sinus tract, radiolucency—important in both dentitions for diagnosis.

122. 122 Test Type < 4 Weeks Post-Trauma 4–6 Weeks Post-Trauma 2–3+ Months / 6 Months EPT / Cold / Heat ❌ Usually false negative ✅ Begin accurate results ✅ Sensibility often returns; sensitivity ~89% Laser Doppler Flowmetry ✅ Detects blood flow early ✅ Sensitive indicator ✅ Predicts necrosis vs. revascularization with high accuracy Pulse Oximetry ✅ Stable reading (0–6 mo ) ✅ Consistent detection ✅ Highly reliable test across timeframe

123. 123 Injury Type Treatment Timing Follow-Up & Action Concussion/Subluxation No immediate treatment needed Exams at 2 weeks, 4 weeks, 6–8 weeks, 6 months, 1 year Extrusive / Lateral Luxation Reposition and splint immediately (same visit) Splint 2–4 weeks; monitor sensibility; RCT if necrosis at ~3 months Intrusive Luxation Within 2–3 weeks : align, splint for ~4 weeks If closed apex → RCT within 2–3 weeks post-repositioning Avulsion (Permanent Tooth) Replant within ≤15 minutes (≤60 min in storage) Splint 1–2 weeks; RCT begins within 1–2 weeks

124. 124