Avulsion: Findings, Treatment & Trauma Assessment Example

Clinical Note: Dental Trauma Assessment Avulsion Example

Chief Complaint: ______________________________

‍History of Trauma

• Date and Time: ______________________________
• Location of Injury: ___________________________
• Mechanism of Injury: (e.g., fall, sports, accident): ____________________________
• Initial Care Provided: Tooth was placed back in the socket / stored in (milk, saline, or dry for X time) before visiting.

Medical History

• Allergies: _________________________________
• Medications: ______________________________
• Tetanus Status: ___________________________
• Relevant Medical History: ______________________

Dental History

• Previous Dental Injuries: ___________________________

Intraoral Findings

Soft Tissues:

• Lacerations: Yes (labial and gingival lacerations near the avulsion site).
• Bleeding: Moderate localized bleeding from the empty socket.
• Swelling: Mild swelling observed around the labial gingiva.

Tooth Findings:

• Tooth #8:
  • The tooth was re-implanted at the time of arrival / not re-implanted (state condition of the tooth).
  • Socket Condition: Gingiva appeared swollen, but the alveolar bone and socket structure were intact.
  • Sensitivity Testing: Not applicable (avulsed tooth).

Radiograph

• Periapical Radiograph:
  • Confirmed correct positioning of the re-implanted tooth (if already placed).
  • No visible root fractures or significant alveolar bone damage observed.
  • Radiograph showed intact socket and no additional luxation or fractures to adjacent teeth.

Plan

Immediate Management:

1. Reimplantation (if not yet performed):
   • Tooth #8 was cleaned with saline to remove debris and gently re-implanted into the socket.
2. Stabilization:
   • A flexible splint was applied to stabilize tooth #8 and adjacent teeth.
   • Splint duration: 2 weeks (extended to 4 weeks if alveolar fractures are present).
3. Pulp Therapy:
   • Scheduled root canal therapy within 7-10 days for mature teeth to prevent infection and resorption.
4. Medications:
   • Antibiotics: Prescribed systemic antibiotics (e.g., doxycycline for adults or amoxicillin for children) to minimize infection risk.
   • Tetanus: Confirmed tetanus prophylaxis status; administered booster if required.
   • Analgesics: Recommended ibuprofen 400-600 mg every 6-8 hours as needed for pain relief.
5. Oral Hygiene:
   • Recommended chlorhexidine rinse (0.12%) twice daily for 1 week to aid healing and prevent infection.
   • Advised a soft diet and gentle brushing around the splint.

Follow-Up Schedule:

• 2 Weeks: Reassess splint stability and soft tissue healing; remove splint.
• 4 Weeks: Radiographic evaluation of pulp vitality and root status.
• 6-8 Weeks: Continued monitoring for healing complications, including resorption or infection.
• 6 Months, 1 Year, 5 Years: Long-term periodic monitoring for pulp necrosis, ankylosis, or external resorption.

Warning About Risks Associated with Dental Trauma

Dental avulsion carries significant risks, including pulp necrosis, root resorption, infection, and ankylosis. Adhering to follow-up schedules and reporting symptoms such as swelling, pain, or discoloration promptly is critical to ensure successful recovery.

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