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

Clinical Note: Dental Trauma Assessment (Enamel-Dentine-Pulp 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: Mild bleeding observed from the pulp exposure site.
• Swelling: No significant swelling detected.

Tooth Findings:

• Tooth #8:
  • Fracture: Involves enamel, dentin, and pulp with visible pulp exposure. The fracture line extends obliquely across the crown.
  • Mobility: No abnormal mobility detected.
  • Displacement: The tooth is in its correct anatomical position.
  • Percussion: Tender to percussion.
  • Sensitivity Testing (cold, electric pulp test): Negative response, indicating pulpal necrosis or severe trauma.

Radiograph

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

Plan

Immediate Management:

1. Pulp Therapy:
   • For immature tooth (open apex): Performed partial pulpotomy using calcium hydroxide or MTA to preserve pulp vitality and encourage apexogenesis.
   • For mature tooth (closed apex): Initiated root canal therapy due to likely pulp necrosis.
2. Temporary Restoration:
   • Applied a glass ionomer restoration over the pulp and exposed dentin to seal the area and prevent further bacterial contamination.
3. Definitive Restoration Plan:
   • Planned definitive restoration with composite resin or crown after pulp therapy and soft tissue healing.
4. Oral Hygiene:
   • Advised meticulous oral hygiene to avoid bacterial contamination.
   • Recommended chlorhexidine rinse (0.12%) twice daily for 1 week.
5. Dietary Modifications:
   • Suggested avoiding hard or sticky foods to prevent further damage to the fractured tooth.
6. Medications:
   • Recommended ibuprofen 400-600 mg every 6-8 hours as needed for pain relief.
   • Antibiotics prescribed if signs of soft tissue infection or severe injury are present.

Follow-Up Schedule:

• 2 Weeks: Evaluate healing and stability of the temporary dressing and progress of pulp therapy.
• 4-6 Weeks: Complete definitive restoration.
• 6-8 Weeks: Radiographic monitoring to ensure continued healing and check for resorption or further complications.
• 1 Year: Long-term follow-up to monitor restoration stability and confirm no delayed complications such as resorption or ankylosis.

Warning About Risks Associated with Dental Trauma

Complicated enamel-dentin-pulp fractures carry risks such as pulp necrosis, root resorption, and secondary infection. Adhering to follow-ups and reporting symptoms such as pain, swelling, or discoloration is essential for successful treatment and long-term outcomes.

‍