Enamel Fracture: Findings, Treatment & Trauma Assessment Example

Clinical Note: Dental Trauma Assessment (Enamel 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: No lacerations noted on the surrounding soft tissues.
• Bleeding: No bleeding observed.
• Swelling: No significant swelling detected.

Tooth Findings:

• Tooth #8:
  • Fracture: Involves only the enamel with no dentin or pulp exposure.
  • Mobility: No abnormal mobility detected.
  • Displacement: The tooth is in its correct anatomical position.
  • Percussion: No tenderness noted upon percussion.
  • Sensitivity Testing (cold, electric pulp test): Normal response, indicating pulp vitality.

Radiograph

• Periapical Radiograph:
  • No signs of root or apical involvement.
  • No evidence of further damage or fractures extending into the dentin or pulp.
  • Periodontal ligament space appeared intact.

Plan

Immediate Management:

1. Smoothing or Bonding:
   • Smoothed the sharp edges of the fracture to improve aesthetics and prevent irritation.
   • Recommended composite bonding to restore the natural tooth contour if the patient desired aesthetic improvement.
2. Oral Hygiene:
   • Advised meticulous oral hygiene to prevent plaque accumulation on the fractured area.
3. Dietary Modifications:
   • Suggested avoiding hard or sticky foods to prevent further chipping or damage to the affected tooth.

Follow-Up Schedule:

• 6-8 Weeks: Clinical and radiographic evaluation to confirm pulp vitality and ensure no delayed complications.
• 1 Year: Long-term follow-up to monitor restoration integrity and confirm no further issues.

Warning About Risks Associated with Dental Trauma

Even with minor enamel fractures, there is a slight risk of delayed complications such as sensitivity or cracks extending deeper. Regular follow-ups and reporting any discomfort or sensitivity are essential for optimal management.

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