Guideline on Management of Acute Dental Trauma

Resident’s Name: Joanne Lewis Date: August 14, 2009
Article title: Guideline on Management of Acute Dental Trauma (focused on primary dentition for this lit review)
Originating Council: AAPD Council on Clinical Affairs
Journal: AAPD Reference Manual 29
Adopted: 2001 (revised 2004, 2007)
Major topic: dental trauma
Main Purpose: to define, describe appearances, and set forth objectives for general management of acute traumatic dental injuries.
Overview of method of research: The guideline is based on a review of current dental and medical literature related to dental trauma.
Findings: Greatest incidence of trauma to the primary dentition occurs at 2-3 years of age, when motor coordination is developing. Rapid and thorough assessment of the nature and extent of the patient’s injuries is essential to delivering appropriate treatment. After a primary tooth has been injured, the treatment strategy is dictated by the concern for the safety of the permanent dentition. It is important to inform parents about possible pulpal complications, such as the development of an abscess or sinus tract or color change of the crown, as well as potential sequelae to permanent teeth, such as enamel hypoplasia, hypocalcification, crown/root dilacerations, or disruptions in eruption. Specific recommendations are as follows:
- Infraction – no treatment indicated
- Uncomplicated crown fracture – for small fractures, rough margins and edges can be smoothed; for larger fractures, lost tooth structure can be restored.
- Complicated crown fracture – decisions are based on life expectancy of the primary tooth and vitality of the pulpal tissue. Treatment alternatives are pulpotomy, pulpectomy, and extraction.
- Crown/root fracture – extract the entire tooth, unless the retrieval of apical fragments may result in damage to the succedaneous tooth.
- Root fracture – extract the coronal segment with or without the removal of the apical fragment.
- Concussion – unless an associated infection exists, no pulpal therapy is indicated.
- Subluxation – no immediate treatment needed, tooth should be followed for pathology – should return to normal within 2 weeks.
- Lateral luxation – allow passive repositioning or actively reposition and splint for 1-2 weeks as indicated, except when the injury is severe or the tooth is near exfoliation.
- Intrusion – allow spontaneous reeruption except when displaced into the developing successor. If the apex is displaced toward the permanent tooth germ, extraction is indicated. 90% will reerupt spontaneously within 2-6 months. Ankylosis may occur.
- Extrusion – reposition and stabilize with a splint for 1-2 weeks or extract.
- Avulsion – do not reimplant primary teeth.
Assessment of article: Concise reference – recommendations are very general.

Rapid neurologic assessment and initial management for the patient with traumatic dental injuries.

Resident: Adam J. Bottrill
Region: Providence
Author(s): Croll, Theodore P. et al.
Journal: JADA
Volume #; Page #s: Volume 100 pp: 530-534
Year: 1980
Major topic: Rapid neurological assessment
Minor topic(s): None
Type of Article: Topic review and summary

Main Purpose: Suggested technique for dentists to assess neurological status.
Overview of method of research: Topical summary
Findings: N/A

Key points in the article discussion: The family dentist may be the first health professional to treat a pt who has sustained head trauma. Despite urgent dental needs, overall medical welfare of the patient should always be the primary concern. This paper proposes a protocol to aid the dental practitioner in an effective, yet rapid, neurologic evaluation. DENTAL TREATMENT SHOULD ONLY BEGIN AFTER A SATISFACTORY NEUROLOGIC STATE IS EVIDENT.

A. Sequelae to head trauma
1. Lacerations,
2. Linear/depressed skull fractures (with possible dural laceration and arachnoid herniation)
3. Hematoma (sub or extradural, intraventricula)
4. Brain stem injury
5. Vertebral fracture (with or without spinal cord injury)

B. Facts and figures (1975) 1. 10 mill people in US required med attention due to head injury.
2. 10% of school age children will suffer significant head injury
a. 33% of these children will require hospitalization.
3. NOTHING can be done to avoid the effects of the primary injury… (unless you want to wear a helmet all the time)
a. Therefore, neurosurgeons and neurologists can only direct their course of management towards preventing and treating the secondary injuries associated with trauma.
4. Dx tools include CAT scan, continuous ICP monitoring, MRI etc.
5. The tx of pediatric pt’s vs. adult pt’s varies significantly.

C. Categories and criteria: 1. Jennet and Bond (Long-term sequelae)
a. Good recovery (normal life)
b. Moderately disabled (independent but impaired)
c. Severely disabled (totally dependent on others)
d. Vegetative survival
e. Death
2. Meltzner and Frew (five diagnostic criteria)
a. Airway
b. State of consciousness
c. Vital signs
d. Reflexes (Oppenheim, Gordon, Gonda, Babinski, Chaddock)
e. Pupils
3. Taesdale and Jennet (Glasgow coma scale)



a. Recommend immediate referral for a pt who does not score optimally in any category.
4. Tyler (???)
a. Recommends cranial nerve exam by all dentists.

D. Recommendations: The authors don not believe a prolonged exam is either practical or required. HOWEVER, the dentist should be able to determine whether a pt should be immediately referred for neurological reasons.
1. Look for unusual motor activity or difficulties in communicating (Glasgow coma scale).
2. Assure pt’s airway
3. Hx of the injury
a. Updated tetanus? Cardiac Hx? Etc…
4. Vital signs
5. Observe for rhinorrhea or otorrhea
6. Cranial nerve exam



7. Neurologic impairment must be ruled out before analgesics are prescribed or inhalation sedation is commenced.
8. Follow-up and discharge recommendations

(Croll, Theodore P. et al., JADA, Volume 100 pp: 534 )

Summary of conclusions: If approached systematically and logically, the neurological assessment of head-trauma pt’s can be effective and rapid. If neurological impairment is suspected, immediate medical referral is indicated as impending neurological crisis of secondary injury may be prevented with early Dx and treatment.

Assessment of article: Applicable and well organized.

Guidelines for the management of traumatic dental injuries. III. Primary teeth.

Resident’s Name: Brian Schmid DMD Date: 8/14/09
Article title: Guidelines for the management of traumatic dental injuries. III. Primary teeth.
Author(s): Flores, Malmgren, Andersson et al.
Journal: Dental Traumatology
Month, Year: 2007
Major topic: management of trauma to the primary dentition
Type of Article: Review
Findings: Five percent of all injuries for which people seek treatment is due to oral problems; head injuries comprise 40% of preschool injuries an among facial injuries, dental are the most common. Recommendations for the parent concerning care of the child: keep calm and concentrate on the well-being of the child, wash the wound carefully and compress the area with clean gauze or cotton for 5 minutes to stop any bleeding, seek emergency treatment with a pediatric dentist. Damage to the lips, tongue, teeth, cheek or palate in a child under 5 y.o. should be examined, including considering the possibility of abuse. Care for primary teeth requires the additional consideration that the root of primary teeth are very close to developing permanent teeth. Tooth malformation, impacted teeth and eruption disturbances in the permanent dentition are all sequelae to trauma in the primary dentition. For trauma to an anterior tooth and depending on the childs ability to cooperate, it is recommended that a standard PA, occlusal film and a film at an obtuse angle are taken to rule out root fractures as well as possible. Post treatment, recommend to the parent soft brushing after every meal, twice daily topical treatment with chlorhexidine and to rinse regularly. See charts below for clinical care and followup for a variety of primary tooth injuries.
Assessment of article: Mostly information geared toward parents. But a useful guideline when performing phone consultations or giving info to parents.