Lateral Luxation: Findings, Treatment & Trauma Assessment Example

Clinical Note Template: Dental Trauma Assessment Lateral Luxation 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 (e.g., clotting disorders): ______________________

Dental History:
Previous dental injuries: ___________________________

Intraoral Findings

Soft Tissues:

• Lacerations: Yes (Gingival tissue adjacent to tooth #8 shows minor lacerations).
• Bleeding: Yes (Localized gingival bleeding around tooth #8).
• Swelling: Mild localized swelling near the labial gingiva.

Tooth Findings:‍

Tooth #8:

• Displacement: Displaced laterally in the labial direction.
• Mobility: Firmly locked into its displaced position; no significant mobility.
• Percussion: Metallic sound on percussion, indicating ankylosis-like rigidity.
• Sensitivity Testing (e.g., cold, electric pulp test): Negative response to vitality testing (likely indicative of pulp necrosis or transient neural disruption).

Radiograph:

Periapical Radiograph taken of #8, To assess for bone/root/crown fracture.

Findings:

• Widened periodontal ligament space on the side opposite the displacement.
• Compressed periodontal ligament space and possible slight bone fracture near the apex.
• Intact root structure with no evidence of root fracture.

Plan

Immediate Management:

• Reposition:
  • Gentle digital pressure applied to reposition tooth #8 into its correct anatomical position.
• Splinting:
  • Flexible splint for stabilization applied to tooth #8 and adjacent teeth on either side using composite.
  • Splint duration: 4 weeks.
• Pulp Monitoring:
  • Monitor pulp vitality over time (warned patient likely requires root canal therapy if necrosis develops).
• Oral Hygiene:
  • Instructions for soft diet and meticulous oral hygiene with chlorhexidine rinses.
• Medications:
  • Advised analgesics for pain management (e.g., paracetamol 1g every 6-8 hours as needed).
  • No antibiotics are indicated unless there are signs of infection or soft tissue trauma requiring prophylaxis.

Follow-Up Schedule:

• 2 Weeks: Clinical evaluation of splint and soft tissue healing.
• 4 Weeks: Clinical and radiographic assessemnt.
• 6-8 Weeks: Radiographic evaluation for resorption or healing complications.
• 6 Months, 1 Year, 5 Years: Periodic monitoring for signs of root resorption, ankylosis, or healing anomalies.

Warning About Risks Associated with Dental Trauma

Dental trauma can lead to long-term complications such as pulp death, root resorption, infection, ankylosis, or delayed healing. It is essential to follow treatment recommendations, attend follow-up appointments, and report any changes like pain, swelling, or discoloration promptly to ensure the best possible outcome.

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