Extrusion: Findings, Treatment & Trauma Assessment Example

Clinical Note: Dental Trauma Assessment Extrusion 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: Yes (localized gingival lacerations around tooth #8).
• Bleeding: Yes (minor gingival bleeding near the displaced tooth).
• Swelling: Mild localized swelling in the labial gingiva adjacent to tooth #8.

Tooth Findings:

• Tooth #8:
  • Displacement: Extruded by approximately 2 mm along its long axis.
  • Mobility: Increased mobility with moderate tenderness upon touch.
  • Percussion: Tender to percussion.
  • Sensitivity Testing (cold, electric pulp test): Negative, suggesting potential pulpal injury.

Radiograph

• Periapical Radiograph:
  • Widened periodontal ligament space, especially apically.
  • Intact root structure with no signs of fracture.
  • No apparent alveolar bone fracture.

Plan

Immediate Management:

1. Repositioning:
   • Gently repositioned tooth #8 into its original position using manual digital pressure.
2. Splinting:
   • Applied a flexible splint to stabilize tooth #8 and adjacent teeth.
   • Splint duration: 2 weeks.
3. Pulp Monitoring:
   • Advised monitoring pulp vitality during follow-ups, with root canal therapy to be initiated if necrosis develops.
4. Oral Hygiene:
   • Advised soft diet for 2 weeks and use of chlorhexidine rinse (0.12%) twice daily.
5. Medications:
   • Prescribed analgesics for pain management (e.g., ibuprofen 400-600 mg every 6-8 hours as needed).
   • Antibiotics not indicated unless signs of infection develop.

Follow-Up Schedule:

• 2 Weeks: Assess splint stability and healing progress; remove splint.
• 4 Weeks: Clinical and radiographic reassessment of pulp vitality and periodontal healing.
• 6-8 Weeks: Radiographic evaluation for signs of root resorption or other complications.
• 6 Months, 1 Year, 5 Years: Periodic monitoring for long-term complications, including pulp necrosis or ankylosis.

Warning About Risks Associated with Dental Trauma

Dental trauma can lead to complications such as pulp necrosis, root resorption, infection, or ankylosis. Regular follow-up and immediate reporting of symptoms like pain, swelling, or discoloration are crucial for a favorable outcome.

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