Subluxation: Findings, Treatment & Trauma Assessment Example

Clinical Note: Dental Trauma Assessment Subluxation 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 visible gingival lacerations noted.
• Bleeding: Mild bleeding observed at the gingival margin of tooth #8.
• Swelling: No significant swelling detected.

Tooth Findings:

• Tooth #8:
  • Mobility: Increased mobility without displacement.
  • Percussion: Tender to percussion.
  • Displacement: No visible displacement or misalignment.
  • Sensitivity Testing (cold, electric pulp test): Normal response indicating pulp vitality.

Radiograph

• Periapical Radiograph:
  • Slightly widened periodontal ligament space around the apex of tooth #8.
  • Intact root structure with no signs of fracture.
  • Alveolar bone appeared intact.

Plan

Immediate Management:

1. Stabilization:
   • Splinting was not required as the tooth showed no displacement.
2. Soft Diet:
   • Advised the patient to follow a soft diet and avoid biting with tooth #8 for 2 weeks to minimize further trauma.
3. Pain Management:
   • Recommended over-the-counter analgesics (e.g., ibuprofen 400-600 mg every 6-8 hours as needed) to manage discomfort.
4. Oral Hygiene:
   • Advised meticulous oral hygiene with gentle brushing around the affected area.
   • Recommended chlorhexidine rinse (0.12%) twice daily for 1 week to aid gingival healing.

Follow-Up Schedule:

• 2 Weeks: Clinical examination to reassess mobility and gingival healing.
• 4 Weeks: Clinical and radiographic evaluation to monitor periodontal health and pulp vitality.
• 6-8 Weeks: Continued monitoring for pulp vitality and potential complications.
• 1 Year: Long-term follow-up to ensure no signs of resorption, pulp necrosis, or delayed healing.

Warning About Risks Associated with Dental Trauma

Even with minor injuries like subluxation, there is a risk of delayed complications such as pulp necrosis or root resorption. Regular follow-up and reporting any changes, such as increased pain, mobility, or discoloration, are essential for optimal healing and long-term success.

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