Infarction: Findings, Treatment & Trauma Assessment Example

Clinical Note: Dental Trauma Assessment (Infarction 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: Fine cracks (infractions) visible within the enamel, detected under transillumination.
  • 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 visible fracture lines detected radiographically.
  • Periodontal ligament space appeared intact.

Plan

Immediate Management:

1. Observation and Monitoring:
   • No immediate treatment required as the infractions were superficial and asymptomatic.
   • Advised monitoring for any signs of sensitivity or discoloration over time.
2. Optional Treatment (If Aesthetic Concern):
   • Recommended application of a resin sealant over the infraction lines to prevent staining or bacterial infiltration, if requested by the patient.
3. Oral Hygiene:
   • Advised meticulous oral hygiene to prevent plaque accumulation that could exacerbate the infraction lines.

Follow-Up Schedule:

• 6 Months: Clinical and radiographic evaluation to confirm no progression or secondary complications.
• 1 Year: Long-term follow-up to ensure the tooth remains asymptomatic and structurally stable.

Warning About Risks Associated with Dental Trauma

Although enamel infractions are typically superficial, there is a slight risk of cracks deepening or causing sensitivity over time. Regular follow-ups and prompt reporting of symptoms such as discoloration, sensitivity, or pain are essential for monitoring and management.

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