Enamel-Dentine Fracture: Findings, Treatment & Trauma Assessment Example

Clinical Note: Dental Trauma Assessment (Enamel-Dentine Fracture 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: Minor lacerations noted on the labial gingiva adjacent to tooth #8.
• Bleeding: No active bleeding observed.
• Swelling: No significant swelling detected.

Tooth Findings:

• Tooth #8:
  • Fracture: Involves enamel and dentin without pulp exposure. The fracture line is visible, with yellowish dentin exposed.
  • Mobility: No abnormal mobility detected.
  • Displacement: The tooth is in its correct anatomical position.
  • Percussion: Mild tenderness noted upon percussion.
  • Sensitivity Testing (cold, electric pulp test): Positive response, indicating pulp vitality.

Radiograph

• Periapical Radiograph:
  • No signs of root or apical involvement.
  • Fracture line confined to the crown, with no evidence of pulp exposure.
  • Periodontal ligament space appeared intact.

Plan

Immediate Management:

1. Temporary Protection:
   • Applied a glass ionomer dressing to seal the exposed dentin and protect it from thermal and bacterial irritation.
2. Definitive Restoration Plan:
   • Planned restoration with composite resin or veneer to restore aesthetics and function.
3. Oral Hygiene:
   • Advised meticulous oral hygiene to prevent bacterial contamination.
   • Recommended using a soft toothbrush and avoiding aggressive brushing near the affected area.
4. Dietary Modifications:
   • Suggested avoiding hard or sticky foods to prevent further damage to the fractured tooth.
5. Medications:
   • Recommended ibuprofen 400-600 mg every 6-8 hours as needed for any discomfort.

Follow-Up Schedule:

• 2 Weeks: Evaluate soft tissue healing and stability of the temporary dressing.
• 4-6 Weeks: Plan and perform definitive restoration (e.g., composite or veneer).
• 6-8 Weeks: Monitor restoration and check for continued pulp vitality.
• 1 Year: Long-term follow-up to assess the restoration’s stability and confirm no delayed complications.

Warning About Risks Associated with Dental Trauma

Even with enamel-dentin fractures, there is a risk of pulp inflammation or necrosis over time. Regular follow-ups and prompt reporting of symptoms such as discoloration, pain, or sensitivity changes are essential for ensuring a successful outcome.

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