Concussion: Findings, Treatment & Trauma Assessment Example

Clinical Note: Dental Trauma Assessment Concussion Example

Chief Complaint: ______________________________

‍History of Trauma

• Date and Time: ______________________________
• Location of Injury: ___________________________
• Mechanism of Injury: (e.g., fall, sports, accident): ____________________________
• Initial Care Provided: ________________________

Medical History

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

Dental History

• Previous Dental Injuries: ___________________________

Intraoral Findings

Soft Tissues:

• Lacerations: No visible gingival lacerations.
• Bleeding: No bleeding observed in the surrounding soft tissues.
• Swelling: No significant swelling noted.

Tooth Findings:

• Tooth #8:
  • Mobility: No mobility detected.
  • Displacement: Tooth appeared in its correct anatomical position.
  • Percussion: Tender to percussion but no metallic sound detected.
  • Sensitivity Testing (cold, electric pulp test): Normal response, indicating pulp vitality.

Radiograph

• Periapical Radiograph:
  • Periodontal ligament space appeared normal.
  • No signs of root or alveolar bone fracture.

Plan

Immediate Management:

1. Dietary Modifications:
   • Advised the patient to avoid biting or chewing with tooth #8 for 1-2 weeks to allow healing.
2. Pain Management:
   • Recommended over-the-counter analgesics (e.g., ibuprofen 400-600 mg every 6-8 hours as needed) for tenderness.
3. Oral Hygiene:
   • Encouraged gentle brushing and rinsing with a chlorhexidine rinse (0.12%) twice daily to maintain oral hygiene and prevent gingival irritation.

Follow-Up Schedule:

• 4 Weeks: Clinical and radiographic reassessment to confirm healing and rule out delayed pulp necrosis or periodontal changes.
• 1 Year: Long-term follow-up to monitor for signs of complications, such as resorption or loss of vitality.

Warning About Risks Associated with Dental Trauma

Even in mild injuries like concussion, delayed complications such as pulp necrosis or root resorption may occur. Regular follow-up and prompt reporting of any changes, such as increased tenderness, discoloration, or mobility, are essential for ensuring successful recovery.

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