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The prognosis of traumatized permanent anterior teeth with fracture of the enamel and dentin
endodontics
The prognosis of traumatized permanent anterior teeth with fracture of the enamel and dentin Dun Z&k, D.M.D., M.P.H., Auhrey Chosack, B.D.S., M.S.D.. tutd ElicJc,erEicieltnart, Dr. Odonr.. M.S.D., Jerusalem, Israel DEPARTMENT
OF PEDODONTICS,
~IEDICINI-. (FOUNDED
THE HEBREW UNIVERSITY-HADASSAH
SCHOOL OF DENT.41
BY THE ALPHA OMEGA FRATERNITY)
The purpose of this study was to examine, in the light of a 2-year follow-up, the diagnostic and prognostic value of vitality tests in teeth which had suffered fracture of the enamel and dentin without pulp exposure, to assess the period in which late pathologic changes may occur, and to determine the recommended time intervals for follow-up examinations. Eighty-four children, 6 to 14 years of age, with 123 traumatized teeth were included in the study. Of these teeth, 87 percent were “vital” at the initial examination, and most of these remained vital throughout the 2 years. Most pathologic changes occur within 6 months after trauma. It is recommended that follow-up examinations be performed 3 and 6 months after the trauma. Root canal treatment is usually necessary in teeth which have no vital response by the 3- and 6-month examinations.
T
he diagnostic and prognostic value of vitality tests in teeth that suffered fractures of the enamel and dentin without pulp exposure was discussed previously in a preliminary report after a &month follow-up period.] The findings at that stage seemed to indicate that: 1. In cases of fractures of the enamel and dentin without pulp exposure a negative response to ethyl chloride application and electric pulp-tester due to “shock” was rare (3.5 percent). 2. A positive response to vitality tests soon after the trauma is of good prognostic value. 3. The first follow-up examination after the trauma should be performed 3 months after the initial visit; only if there are other signs and symptoms are more frequent examinations indicated. 4. The electric pulp tester was a better diagnostic aid than thermal tests involving ethyl chloride application. Thi\ investigation wa Hebrew Unlcerslt),
supported by the central Research Fund of the
The objectives of the present study, after a follow-up period of up to 2 years, were to assess(1) the diagnostic and prognostic value of vitality tests and the influence of the stage of root development at the initial examination and (2) the over-all period in which late pathologic changes may occur with an eye to determining the recommended time intervals for follow-up examinations after fractures of the enamel and dentin without pulp exposure. MATERIALS
AND METHODS
One hundred twenty-three fractured anterior teeth of eighty-four children, 6 to 14 years of age at the time of trauma, were included in the study. Only teeth with fractures of the enamel and dentin without pulp exposure were considered. The initial examination and treatment took place within 10 days after the trauma. This examination included vitality tests by means of ethyl chloride applications and electric pulp tester, percussion, and periapical radiographs. A tooth was con173
Table I. Time canal
and reason
treatment
response
for performance
in teeth that gave
to stimuli
at the initial
of root
a negative examination
2 bears other
becau~c
01’ penapical
underwent
root
canal
after
the traLmla
(Table
I)
months
In comparing ethyl sidered
vital
chloride
response
or electric
any level tive.
when
The
week
pulp tester.
of the pulp tester detailed
previously during
the first
for
2 years.
During
was
performed
clinical
signs
pulp
damage
in only that
These
pain.
swelling,
tract.
increased
of a sinus
diographic
evidence
of further
root
period, those
the desired
?-year
Some
to
symptoms
mobility.
raor lack
children
failed
to
response
to vitalit)
109 (X7.8 percent) tests at the initial
tion and 14 teeth did not respond
to either
or pulp
109 teeth.
tester
stimuli.
mained
vital
another
7 I were vital
during
Another
gave ‘I
examina-
ethyl
chloride
31 have
follow-up
after 2 years.
period
rcand
Of the other 6 teeth.
canal therapy at 12. months and because of evidence of per&pica1
tooth
after 1 years because degeneration
Of those a 1Z-month
one underwent root another at 14 months disease.
to cold
poaiti\,e
p~ilp stimuli.
underwent
of radiologic
and obliteration
root
canal
evidence
therap)
of calcified
of the pulp chamber.
One
tooth
response at 12 months did no1 cgiving a positive respond to vitality tests at 2 bears. and another 2 teeth (in one patient) with positive responses at .i months ‘rave negative response throughout the 2 years withou1 G? any other signs indicative of p~dpal teeth are still being followed, Fourteen teeth did not respond stimuli at the initial examination.
disease.
sho\ved
Houcvcr
not respond
apices
positive
trauma.
neither
The last 3
positive vitality responses within 3 months and 1-t‘ mained positive throughout the 2 qcars. Another 2 teeth (of the same child) underwent root canal treatment after
to the pLilp te\ter.
OnI!
to cold and negati\c
(Table II,
was
found
between
with
closed
apices
in the response
tcc[h
with
open
at the lime
immcdiatcl>
01. the
after
the
noi in lhc prognosi\
DISCUSSION over-all
follow-up
period
ot teeth
interval
between
i mportancc
in the
The
In the prcscnt
lapse
positive
t3xaniination.
Lvhich
will
therap!
small
\hOLlld
.? \cars
numhcr tbe\tt
a\ they
changes
appear.
without
too
frequent
i’ollo~L~p
it was responses
period
tirnc
ill
f’ound
have
that
withoUt
then
to pulp stimuli
6 months
withIn
almost 3 month\.
This
at the
of root
canal
Howcvcr.
rhc
that follow-LIP
after
ttic
he cuamincd
30 percent
141th
conditions
the traunla.
should
teeth
patholoyc
of‘ such teeth suggest\
teeth
chamination.
mmt
pulp expo-
the rccomn~cntkcl h-month periodic roLltint’ csaminarion\ Of the teeth that gave negati\c pulp rcsponsex imtial
shoLiId
which
the pcrformsnce after
bC ldotli~ al -3 and
and that
should
pathologic
Llnneccs\ar! of
clinical
rccommcnded
and dentin
ma\
necc\sitatc
c\‘cn
as the tinle
ma> occL]r. stud!
initial
\er>
o\er-all
of’ the enamel
sLIre. that gr\c
to
posttraumatlc
i\ of qeat
that
a\ eon
changes
fracture\
view
children
reasonable
pathologic
tar as \\cll
the examinations.
the
;i
trauma.
’ ’ The time interkals
c\aminationh. cover
necessary,
after
be detected
rcspon\c\ to cold or electric Of these, tivc gave
to electric
of the teeth that did
response\
to the pulp tcstcr
and those
respon\c\
10.3 percent
to cold did respond
three teeth ga\c
subjecting
Of the 113 teeth examined, positive
it
response\
\hoLild
RESULTS
and
in the fir-\! c\amination. of the teeth that ?a\~’ positive
be considered
follou-Lip.
pL11p tcstcr
4
that 97 percent
The
discoloration.
l‘hc
v,ithln
was found
trauma
response and
of tooth or bone resorption.
development.
in
irrc\crsibIc
rarctai~tion. therap!
to electric
application
No difference
roo1
teeth
response<
chloride
responses
c\‘eq
at .i-month
the negative signs
spontaneous
the presence
has been
indicated
additional
at
posi-
examined
the study
supplemented
tests.
examination and then
other
complete
of
3 months
therapy
cth! I
A response
were
which
were severe
or to both.
The teeth
canal
Litalit!
to either
scale was considered
method
described.’
intervals
was positive
hone
7 teeth
showed
\~~pport\
trauma during dental at the positivt,
the “\hock.
theor! ” In 50 ~xrccnt of the teeth that had negative response\ ;II the initial examination. there KXS indication for I-OC~(canal treatment \\:\:ithin 4 months after the traLun;t. In the light of all these finding\. it IS suggested that foliou-Lip l\\;lminations of teeth with fractures 01
the enamel and dentin without pulp exposure should be made at frequent intervals up to 6 months after the trauma. so as to ensure early diagnosis of pathosis. The role of root development which, in the preliminary study. was found to be unassociated with the prognosis was tested again in this study in the light of the longer period of the follow-up (2 years against the 6 months of the preliminary study) and the greater number of teeth examined. Similar results were found in this stud) with regard to this factor.
examination, the prognosis is rather unfavorable. All teeth that suffered “shock” usually give a positive response within 3 months. Most pathologic changes in teeth in this group occurred during the first 4 months. Therefore, more frequent examinations than in teeth with initial vital responses are indicated up to 6 months after trauma. Root canal therapy is indicated in teeth that do not regain positive vitality responses within 6 months. REFERENCES
CONCLUSIONS
I. Mo\t teeth with fractures of the enamel and dentin which were vital immediately after the trauma remained so throughout the ensuing 2 years. This finding suggests that a positive pulp response at the initial examination is of good prognostic value. 2. Several teeth that gave positive pulp responses at the initial examination developed pathologic changes. This suggests that follow-up should continue at 3 and 6 months after the trauma and then at 6-month intervals, which is the generally accepted period for routine dental exami nations. 3. When pulp response is negative at the initial
I. Teitler, D.. Zadik. D.. Eidelman. E.. and Chosack. A.: A Clinical Evaluation of Vitality Tests in Anterior Teeth Following Fracture of Enamel and Dentin. ORAL SL.RG. 34: 649-657. 1972. 2. Andrcasen. J. 0.: Traumatic Injuries of the Teeth, cd. I, Copenhagen, lY72. Ejnar Munksgaard Farlag, pp. J7-57. 3. Barkin, P. R.: Time as a Factor in Predicting the Vitality of Traumatized Teeth. .I. Dent. Child. 40: 188-197, lcj7.1. 1. Ravn, J. J.: Dental Injuries in Copenhagen School Children. School Years 1967-1972. Community Dent. Oral Epidemiol. 2: ‘31-235. 1973.
Rqwim r-eqw\r,\ to: Dr. D. Zadik P. 0. Box 499 Jerusalem. Israel
The prognosis of traumatized permanent anterior teeth with fracture of the enamel and dentin Dun Z&k, D.M.D., M.P.H., Auhrey Chosack, B.D.S., M.S.D.. tutd ElicJc,erEicieltnart, Dr. Odonr.. M.S.D., Jerusalem, Israel DEPARTMENT
OF PEDODONTICS,
~IEDICINI-. (FOUNDED
THE HEBREW UNIVERSITY-HADASSAH
SCHOOL OF DENT.41
BY THE ALPHA OMEGA FRATERNITY)
The purpose of this study was to examine, in the light of a 2-year follow-up, the diagnostic and prognostic value of vitality tests in teeth which had suffered fracture of the enamel and dentin without pulp exposure, to assess the period in which late pathologic changes may occur, and to determine the recommended time intervals for follow-up examinations. Eighty-four children, 6 to 14 years of age, with 123 traumatized teeth were included in the study. Of these teeth, 87 percent were “vital” at the initial examination, and most of these remained vital throughout the 2 years. Most pathologic changes occur within 6 months after trauma. It is recommended that follow-up examinations be performed 3 and 6 months after the trauma. Root canal treatment is usually necessary in teeth which have no vital response by the 3- and 6-month examinations.
T
he diagnostic and prognostic value of vitality tests in teeth that suffered fractures of the enamel and dentin without pulp exposure was discussed previously in a preliminary report after a &month follow-up period.] The findings at that stage seemed to indicate that: 1. In cases of fractures of the enamel and dentin without pulp exposure a negative response to ethyl chloride application and electric pulp-tester due to “shock” was rare (3.5 percent). 2. A positive response to vitality tests soon after the trauma is of good prognostic value. 3. The first follow-up examination after the trauma should be performed 3 months after the initial visit; only if there are other signs and symptoms are more frequent examinations indicated. 4. The electric pulp tester was a better diagnostic aid than thermal tests involving ethyl chloride application. Thi\ investigation wa Hebrew Unlcerslt),
supported by the central Research Fund of the
The objectives of the present study, after a follow-up period of up to 2 years, were to assess(1) the diagnostic and prognostic value of vitality tests and the influence of the stage of root development at the initial examination and (2) the over-all period in which late pathologic changes may occur with an eye to determining the recommended time intervals for follow-up examinations after fractures of the enamel and dentin without pulp exposure. MATERIALS
AND METHODS
One hundred twenty-three fractured anterior teeth of eighty-four children, 6 to 14 years of age at the time of trauma, were included in the study. Only teeth with fractures of the enamel and dentin without pulp exposure were considered. The initial examination and treatment took place within 10 days after the trauma. This examination included vitality tests by means of ethyl chloride applications and electric pulp tester, percussion, and periapical radiographs. A tooth was con173
Table I. Time canal
and reason
treatment
response
for performance
in teeth that gave
to stimuli
at the initial
of root
a negative examination
2 bears other
becau~c
01’ penapical
underwent
root
canal
after
the traLmla
(Table
I)
months
In comparing ethyl sidered
vital
chloride
response
or electric
any level tive.
when
The
week
pulp tester.
of the pulp tester detailed
previously during
the first
for
2 years.
During
was
performed
clinical
signs
pulp
damage
in only that
These
pain.
swelling,
tract.
increased
of a sinus
diographic
evidence
of further
root
period, those
the desired
?-year
Some
to
symptoms
mobility.
raor lack
children
failed
to
response
to vitalit)
109 (X7.8 percent) tests at the initial
tion and 14 teeth did not respond
to either
or pulp
109 teeth.
tester
stimuli.
mained
vital
another
7 I were vital
during
Another
gave ‘I
examina-
ethyl
chloride
31 have
follow-up
after 2 years.
period
rcand
Of the other 6 teeth.
canal therapy at 12. months and because of evidence of per&pica1
tooth
after 1 years because degeneration
Of those a 1Z-month
one underwent root another at 14 months disease.
to cold
poaiti\,e
p~ilp stimuli.
underwent
of radiologic
and obliteration
root
canal
evidence
therap)
of calcified
of the pulp chamber.
One
tooth
response at 12 months did no1 cgiving a positive respond to vitality tests at 2 bears. and another 2 teeth (in one patient) with positive responses at .i months ‘rave negative response throughout the 2 years withou1 G? any other signs indicative of p~dpal teeth are still being followed, Fourteen teeth did not respond stimuli at the initial examination.
disease.
sho\ved
Houcvcr
not respond
apices
positive
trauma.
neither
The last 3
positive vitality responses within 3 months and 1-t‘ mained positive throughout the 2 qcars. Another 2 teeth (of the same child) underwent root canal treatment after
to the pLilp te\ter.
OnI!
to cold and negati\c
(Table II,
was
found
between
with
closed
apices
in the response
tcc[h
with
open
at the lime
immcdiatcl>
01. the
after
the
noi in lhc prognosi\
DISCUSSION over-all
follow-up
period
ot teeth
interval
between
i mportancc
in the
The
In the prcscnt
lapse
positive
t3xaniination.
Lvhich
will
therap!
small
\hOLlld
.? \cars
numhcr tbe\tt
a\ they
changes
appear.
without
too
frequent
i’ollo~L~p
it was responses
period
tirnc
ill
f’ound
have
that
withoUt
then
to pulp stimuli
6 months
withIn
almost 3 month\.
This
at the
of root
canal
Howcvcr.
rhc
that follow-LIP
after
ttic
he cuamincd
30 percent
141th
conditions
the traunla.
should
teeth
patholoyc
of‘ such teeth suggest\
teeth
chamination.
mmt
pulp expo-
the rccomn~cntkcl h-month periodic roLltint’ csaminarion\ Of the teeth that gave negati\c pulp rcsponsex imtial
shoLiId
which
the pcrformsnce after
bC ldotli~ al -3 and
and that
should
pathologic
Llnneccs\ar! of
clinical
rccommcnded
and dentin
ma\
necc\sitatc
c\‘cn
as the tinle
ma> occL]r. stud!
initial
\er>
o\er-all
of’ the enamel
sLIre. that gr\c
to
posttraumatlc
i\ of qeat
that
a\ eon
changes
fracture\
view
children
reasonable
pathologic
tar as \\cll
the examinations.
the
;i
trauma.
’ ’ The time interkals
c\aminationh. cover
necessary,
after
be detected
rcspon\c\ to cold or electric Of these, tivc gave
to electric
of the teeth that did
response\
to the pulp tcstcr
and those
respon\c\
10.3 percent
to cold did respond
three teeth ga\c
subjecting
Of the 113 teeth examined, positive
it
response\
\hoLild
RESULTS
and
in the fir-\! c\amination. of the teeth that ?a\~’ positive
be considered
follou-Lip.
pL11p tcstcr
4
that 97 percent
The
discoloration.
l‘hc
v,ithln
was found
trauma
response and
of tooth or bone resorption.
development.
in
irrc\crsibIc
rarctai~tion. therap!
to electric
application
No difference
roo1
teeth
response<
chloride
responses
c\‘eq
at .i-month
the negative signs
spontaneous
the presence
has been
indicated
additional
at
posi-
examined
the study
supplemented
tests.
examination and then
other
complete
of
3 months
therapy
cth! I
A response
were
which
were severe
or to both.
The teeth
canal
Litalit!
to either
scale was considered
method
described.’
intervals
was positive
hone
7 teeth
showed
\~~pport\
trauma during dental at the positivt,
the “\hock.
theor! ” In 50 ~xrccnt of the teeth that had negative response\ ;II the initial examination. there KXS indication for I-OC~(canal treatment \\:\:ithin 4 months after the traLun;t. In the light of all these finding\. it IS suggested that foliou-Lip l\\;lminations of teeth with fractures 01
the enamel and dentin without pulp exposure should be made at frequent intervals up to 6 months after the trauma. so as to ensure early diagnosis of pathosis. The role of root development which, in the preliminary study. was found to be unassociated with the prognosis was tested again in this study in the light of the longer period of the follow-up (2 years against the 6 months of the preliminary study) and the greater number of teeth examined. Similar results were found in this stud) with regard to this factor.
examination, the prognosis is rather unfavorable. All teeth that suffered “shock” usually give a positive response within 3 months. Most pathologic changes in teeth in this group occurred during the first 4 months. Therefore, more frequent examinations than in teeth with initial vital responses are indicated up to 6 months after trauma. Root canal therapy is indicated in teeth that do not regain positive vitality responses within 6 months. REFERENCES
CONCLUSIONS
I. Mo\t teeth with fractures of the enamel and dentin which were vital immediately after the trauma remained so throughout the ensuing 2 years. This finding suggests that a positive pulp response at the initial examination is of good prognostic value. 2. Several teeth that gave positive pulp responses at the initial examination developed pathologic changes. This suggests that follow-up should continue at 3 and 6 months after the trauma and then at 6-month intervals, which is the generally accepted period for routine dental exami nations. 3. When pulp response is negative at the initial
I. Teitler, D.. Zadik. D.. Eidelman. E.. and Chosack. A.: A Clinical Evaluation of Vitality Tests in Anterior Teeth Following Fracture of Enamel and Dentin. ORAL SL.RG. 34: 649-657. 1972. 2. Andrcasen. J. 0.: Traumatic Injuries of the Teeth, cd. I, Copenhagen, lY72. Ejnar Munksgaard Farlag, pp. J7-57. 3. Barkin, P. R.: Time as a Factor in Predicting the Vitality of Traumatized Teeth. .I. Dent. Child. 40: 188-197, lcj7.1. 1. Ravn, J. J.: Dental Injuries in Copenhagen School Children. School Years 1967-1972. Community Dent. Oral Epidemiol. 2: ‘31-235. 1973.
Rqwim r-eqw\r,\ to: Dr. D. Zadik P. 0. Box 499 Jerusalem. Israel