International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 3. Injuries in the primary dentition
Correspondence to: Barbro Malmgren, DDS, PhD, DrMed, Karolinska Institutet, Department of Dental Medicine, Division of Pediatric Dentistry, POB 4064, SE-14104 Huddinge, Sweden
Tel.: +46 739851788
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Traumatic injuries to the primary dentition present special problems and the management is often different as compared with the permanent dentition. The International Association of Dental Traumatology (IADT) has developed a consensus statement after a review of the dental literature and group discussions. Experienced researchers and clinicians from various specialities were included in the task group. In cases where the data did not appear conclusive, recommendations were based on the consensus opinion or majority decision of the task group. Finally, the IADT board members were giving their opinion and approval. The primary goal of these guidelines is to delineate an approach for the immediate or urgent care for management of primary teeth injuries. The IADT cannot and does not guarantee favorable outcomes from strict adherence to the guidelines, but believe that their application can maximize the chances of a positive outcome.
Trauma to the oral region occurs frequently and comprises 5% of all injuries for which people seek treatment [1-3]. In preschool children, head and facial non-oral injuries make up as much as 40% of all somatic injuries [1-3]. In the age group 0–6 years, oral injuries are ranked as the second most common injury covering 18% of all somatic injuries [1-3]. Of the oral injuries, dental injuries are the most frequent, followed by oral soft-tissue injuries. Luxation injuries affecting both multiple teeth and surrounding soft tissues are mainly reported in children 1–3 years of age and are typically as a result of falls [2, 4-11]. Emergency situations therefore present a challenge to clinicians worldwide. It is now recognized that child injuries are a major threat to child health and that they are a neglected public health problem . A healthcare professional′s decision on how to treat combined with parental consent and patient assent  is the preferred scenario encountered when facing pediatric emergencies .
Guidelines for the management of primary teeth injuries should assist dentists, other healthcare professionals, and parents or carers in decision making. They should be credible, readily understandable, and practical with the aim of delivering the best care possible in an efficient manner.
The International Association of Dental Traumatology (IADT) has developed an updated set of guidelines based on a review of the current dental literature utilizing EMBASE, MEDLINE, and PubMed searches from 1996 to 2011 as well as a search of the Journal of Dental Traumatology from 2000 to 2011. Search words included primary dentition, deciduous dentition, crown fracture, primary incisor fracture, tooth fractures, root fractures, tooth luxation, lateral luxation and primary teeth, intruded primary teeth, luxated primary teeth, tooth avulsion, and tooth/crown injuries. Additionally, some relevant articles prior to 1996, which have served as the basis for further research in the field of dental traumatology, as well as recent policy statements regarding holistic care and management of the injured child, were also included.
The IADT published its first set of guidelines in 2001  and updated them in 2007 . As with the previous guidelines, the working group included experienced researchers and clinicians in pediatric dentistry and oral and maxillofacial surgery. This revision represents the best evidence from the available literature and expert professional judgement. In cases where the data did not appear conclusive, recommendations were based on the consensus opinion of the working group followed by review by the members of the IADT Board of Directors. It is understood that guidelines are to be applied with judgement of the specific clinical circumstances, clinicians′ prudence, and patients’ characteristics, including but not limited to compliance, finances and understanding of the immediate and long-term outcomes of treatment alternatives versus non-treatment. The IADT cannot and does not guarantee favorable outcomes from strict adherence to the Guidelines, but believe that their application can maximize the chances of a positive outcome. Guidelines undergo periodic updates. These 2012 Guidelines in the journal Dental Traumatology appear in three parts.
- Part I: Fractures and luxations of permanent teeth (Dent Traumatol 2012;28:issue 1)
- Part II: Avulsion of permanent teeth (Dent Traumatol 2012;28:issue 2)
- Part III: Injuries in the primary dentition (Dent Traumatol 2012;28:issue 3)
Guidelines offer recommendations for diagnosis and treatment of specific traumatic dental injuries (TDIs); however, they cannot provide comprehensive nor detailed information found in textbooks, scientific literature, and most recently the dental trauma guide (DTG).
The latter can be accessed on http://www.dentaltraumaguide.org. Additionally, the DTG is also available on the IADT web page (http://www.iadt-dentaltrauma.org) and provides a visual and animated documentation of treatment procedures as well as estimates of prognosis for the various TDIs.
Because the management of permanent and primary traumatized dentitions differs significantly, separate guidelines have been developed (Tables 1 and 2).
Special considerations for trauma to primary teeth
A young child is often difficult to examine and treat because of the lack of cooperation and because of fear. The situation is distressing for both the child and parents or carers .
Furthermore, there are varying conditions in different countries concerning economic and social aspects as well as treatment philosophies [7, 17, 18]. However, child and family-centered pediatric practices and institutions should consider the best interests of children and prepare clinicians to ensure the fulfillment of children′s rights when treatment decisions are made .
It is important to keep in mind that there is a close relationship between the apex of the root of the injured primary tooth and the underlying permanent tooth germ. Tooth malformation, impacted teeth, and eruption disturbances in the developing permanent dentition are some of the consequences that can occur following severe injuries to primary teeth and/or alveolar bone [5, 20-23]. White or yellow-brown discoloration of crown and hypoplasia of permanent incisors are, however, the most common sequelae following intrusion and avulsion of primary teeth in children during the ages of 1–3 years [21-27]. Because of these potential sequelae, treatment selections should be aimed at minimizing any additional risks of further damage to the permanent successors. It is therefore not recommended, for instance, to replant an avulsed primary incisor [16, 28, 29].
Treatment guidelines for fractures of teeth and alveolar bone
A child′s maturity and ability to cope with the emergency situation, the time for shedding of the injured tooth, and the occlusion, are all important factors that influence treatment selection.
Repeated trauma episodes are frequent in children. It should be taken into consideration if planning root canal treatment in an injured primary tooth because trauma recurrence will shorten the survival time for the primary tooth .
Treatment guidelines for luxation injuries
There is no consensus in the literature about best treatment for the traumatized primary dentition. Furthermore, children with dental injuries are not always brought in for treatment immediately, which may be due the to lack of access to dental care [31, 32]. While some reports advocate routine tooth extraction, others stress the importance of a more conservative approach by saving primary teeth whenever possible [29, 33]. Traumatic pulp exposures of primary incisors are rare but can be treated with partial pulpotomy . Pulpectomy with zinc oxide eugenol or calcium hydroxide/iodoform paste is recommended in some countries [30, 35, 36]. However, if full cooperation of the child can not be achieved, extraction is usually the alternative option.
It has been demonstrated that most luxation injuries heal spontaneously [37, 38], avoiding the traumatic experience of a tooth extraction. The clinician′s skills and experience with pediatric patients is of outmost importance for managing the patient′s and the parents′ or carers′ behavior in the emergency situation . After an accurate diagnosis and explanation of various treatment options to the parents or carers, the clinician and parents or carers must decide the treatment planning for the child′s own benefit.
Guidelines for the clinician
These Guidelines contain recommendations for diagnosis and treatment of traumatic injuries in the primary dentition, for caries-free, healthy primary teeth, using proper examination procedures.
Information about the examination of traumatic injuries in the primary dentition can be found in a number of current textbooks [4, 39]. The possibility of child abuse should be considered when assessing children under the age of 5 years who present with intra-oral trauma affecting the lips, gums, tongue, palate, and severe tooth injuries [40-46].
A detailed radiographic examination is essential to establish the extent of the injury to the supporting tissues, the stage of root development, and the relation to the permanent successors. Depending on the child's ability to cope with the procedure and the type of injury suspected, the clinician should decide which radiograph is required for confirming diagnosis. Always consider minimizing the risk of radiation to the child. Several angles are recommended. Select the appropriate radiographic examination:
- 90° horizontal angle with central beam through the tooth in question (size 2 film, horizontal view)
- Occlusal view (size 2 film, horizontal view)
- Extra-oral lateral view of the tooth in question may reveal the relationship between the apex of the displaced tooth and the permanent tooth germ as well as the direction of dislocation (size 2 film, vertical view), but is seldom indicated as it rarely adds extra information.
Splinting is used only for alveolar bone fractures and possibly for intra-alveolar root fractures.
Use of antibiotics
There is no evidence for the use of systemic antibiotics in the management of luxation injuries in the primary dentition. Antibiotic use remains at the discretion of the clinician as TDIs are often accompanied by soft tissue and other associated injuries that may require significant surgical intervention. In addition, the child′s medical status may warrant antibiotic coverage. Whenever possible, contact the pediatrician who may give recommendations for a specific medical condition.
Sensibility and percussion tests
Sensibility and percussion tests are not reliable in primary teeth because of the inconsistent results.
Although these Guidelines recommendations focus on the management of acute dental injuries, crown discoloration may be considered as it is a frequently asked question by the parents or carers, mainly for esthetic reasons. Discoloration is a common complication after luxation injuries [47-50]. Such discoloration may fade, and the tooth may regain its original shade [8, 47, 50, 51]. Teeth with persisting dark discoloration may remain asymptomatic clinically and radiographically or they may develop apical periodontitis [52, 53]. There is an association between crown discoloration and pulp necrosis in traumatized primary teeth [48, 54]. Unless associated infection exists, root canal treatment is not indicated .
Pulp canal obliteration
Pulp canal obliteration is common sequela to luxation injuries. It has been found to occur in 35–50% [48, 50, 53] and indicates ongoing pulp vitality [48, 56]. A yellowish hue can be noted.
Good healing following an injury to the teeth and oral tissues depends, in part, on good oral hygiene. To optimize healing, parents and carers should be advised regarding care of the injured tooth/teeth and the prevention of further injury by supervising potentially hazardous activities. Brushing with a soft brush and use of alcohol-free 0.1% chlorhexidine gluconate topically on the affected area with cotton swabs twice a day for 1 week are recommended to prevent accumulation of plaque and debris. A soft diet for 10 days and restriction in the use of an intra-oral pacifier are also recommended.
Parents or carers should be further advised about possible complications that may occur, like swelling, increased mobility, or sinus tracts. Children may not complain about pain; however, infection may be present, and parents or carers should watch for signs such as swelling of the gums; if present they should bring the children in for treatment.
Documentation that the parents and carers have been informed about possible complications in the development of the permanent teeth, especially following intrusion, avulsion, and alveolar fracture injuries, is very important.
IADT is grateful to the team of Dental Trauma guide www.dentaltraumaguide.org for kindly providing pictures to the article.