Guidelines for the management of traumatic dental injuries. I. Fractures and luxations of permanent teeth

Dental Traumatology 2007; doi: 10.1111/j.1600-9657.2007.00592.x DENTAL TRAUMATOLOGY Guidelines Guidelines for the management of traumatic dental injuries. I. Fractures and luxations of permanent teeth Flores MT, Andersson L, Andreasen JO, Bakland LK, Malmgren B, Barnett F, Bourguignon C, DiAngelis A, Hicks L, Sigurdsson A, Trope M, Tsukiboshi M, von Arx T. Guidelines for the management of traumatic dental injuries. I. Fractures and luxations of permanent teeth. Abstract Crown fractures and luxations occur most frequently of all dental injuries. An appropriate treatment plan after an injury is important for a good prognosis. Guidelines are useful for delivering the best care possible in an efficient manner. 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 specialties were included in the group. In cases where the data did not appear conclusive, recommendations were based on the consensus opinion of the IADT board members. The guidelines represent the current best evidence, based on literature research and professional opinion. In this first article of three, the IADT Guidelines for management of fractures and luxations of permanent teeth will be presented. Marie Therese Flores 1, Lars Andersson 2, Jens Ove Andreasen 3, Leif K. Bakland 4, Barbro Malmgren 5, Frederick Barnett 6, Cecilia Bourguignon 7, Anthony DiAngelis 8, Lamar Hicks 9, Asgeir Sigurdsson 10, Martin Trope 11, Mitsuhiro Tsukiboshi 12, Thomas von Arx 13 1 Pediatric Dentistry, University of Valparaiso, Valparaiso, Chile; 2 Oral and Maxillofacial Surgery, Faculty of Dentistry, Kuwait University, Kuwait; 3 University Hospital, Copenhagen, Denmark; 4 Endodontics, School of Dentistry, Loma Linda University, Loma Linda, CA, USA; 5 Department of Pediatrics, Karolinska Institute, Huddinge, Sweden; 6 Albert Einstein Medical Center, Philadelphia, PA, USA; 7 Private Practice, Paris, France; 8 Hennepin County Medical Center, Minneapolis, MN, USA; 9 Endodontics, University of Maryland, Baltimore, MD, USA; 10 Private Practice, Reykjavik, Iceland; 11 Endodontics, University of North Carolina, Chapel Hill, NC, USA; 12 Private Practice, Nagoya, Japan; 13 Oral Surgery and Stomatology, University of Berne, Berne, Switzerland Key words: trauma; tooth; bone; injury; periodontal; hard tissue; emergency; consensus; review MT Flores, The International Association of Dental Traumatology, PO Box 1057, Loma Linda, CA 92354, USA http://www.iadt-dentaltrauma.org e-mail: mariateresa.flores@uv.cl Trauma to the oral region occurs frequently and comprises 5% of all injuries for which people seek treatment (1, 2). In preschool children the figure is as high as 18% of all injuries (1, 2). Amongst all facial injuries, dental injuries are the most common (1, 2) of which crown fractures and luxations occur most frequently (1, 3). An appropriate treatment plan after an injury is important for a good prognosis. Guidelines are useful for dentists and other health care professionals in delivering the best care possible in an efficient manner. The International Association of Dental Traumatology (IADT) has developed a consensus statement after a review of the dental literature and group discussions. The first set of guidelines was published by IADT in 2001 (4). Experienced researchers and clinicians from various specialties were included in the group. In cases where the data did not appear conclusive, recommendations were based on the consensus opinion of the IADT board members. The guidelines represent the current best evidence, based on literature research and professional opinion. As is true for all guidelines, the health care provider must apply clinical judgment dictated by the conditions present in the given traumatic situation. The IADT does not guarantee favorable outcomes from following the Guidelines, 66 Dental Traumatology 2007; 23: 66 71 Ó 2007 The International Association for Dental Traumatology

Guidelines for fractured and luxated permanent teeth (a) (b) Fig. 1. (a) A 9-year-old girl visiting the emergency dental clinic 30 min after falling from a bicycle. (b) (close up view of Fig. 1a) Clinical examination showing lateral luxation of the left central incisor with fracture of the alveolar process. The incisor is luxated to a superior and labial position. Fig. 3. Intrusive luxation of right lateral and central incisors. Crown fractures are seen on both intruded incisors and the adjacent left central incisor. on this web page and a possibility to download information material for professionals and the public. The publication of the IADT guidelines in the journal Dental Traumatology will be divided into three parts. Part I: Fractures and luxations of permanent teeth in the present issue. Part II: Avulsion of permanent teeth will be published in Dental Traumatology issue 3; 2007. Part III: Guidelines for injuries in the primary dentition will be published in Dental Traumatology issue 4; 2007. Guidelines contain recommendations for diagnosis and treatment of specific traumatic dental injuries using proper examination procedures. Below are some general recommendations: Clinical examination Detailed description of procedures such as clinical examination in the emergency situation (Figs. 1 3) and classification of injuries can be found in current textbooks (1, 5). Fig. 2. Crown fracture of right central incisor and crown-root fracture of left central incisor. but using the recommended procedures can maximize the chances of success. Because management of permanent and primary dentition differs significantly, separate guidelines for management of permanent and primary teeth have been developed. Updating the Guidelines is an ongoing process, and the Guidelines are available on the IADT web page http://www.iadt-dentaltrauma.org. In addition to the clinical guidelines there is also a forum for discussion Radiographic examination As a routine, several projections and angles are recommended: 90 horizontal angle, with central beam through the tooth in question. Occlusal view. Lateral view from the mesial or distal aspect of the tooth in question. For more detailed information see current textbooks (1, 5). Sensibility tests Sensibility testing refers to tests (electric pulp test or cold test) to determine the condition of the tooth pulp. Initial tests following an injury frequently give negative results, but such results may only indicate a Dental Traumatology 2007; 23: 66 71 Ó 2007 The International Association for Dental Traumatology 67

Flores et al. transient lack of pulpal response. Follow-up controls are needed to make a definitive pulpal diagnosis. Patient instructions Good healing following an injury to the teeth and oral tissues depends, in part, on good oral hygiene. Patients should be advised on how best to care for teeth that have received treatment after an injury. Brushing with a soft brush and rinsing with chlorhexidine 0.1% is beneficial to prevent accumulation of plaque and debris. For further reading we recommend some recent good review articles and original papers on treatment delay (6) fractures (7 11), intrusive luxations (12 14), and splinting (15 17). All relevant new and old references can be found in the recent textbook and atlas by Andreasen et al. (1). Treatment guidelines for fractures of teeth and alveolar bone Clinical findings Radiographic findings Treatment Uncomplicated crown fracture Fracture involves enamel or dentin and enamel; the pulp is not exposed. Sensibility testing may be negative initially indicating transient pulpal damage; monitor pulpal response until a definitive pulpal diagnosis can be made Complicated crown fracture Fracture involves enamel and dentin and the pulp is exposed. Sensibility testing is usually not indicated initially since vitality of the pulp can be visualized. Follow-up control visits after initial treatment includes sensibility testing to monitor pulpal status Crown-root fracture Fracture involves enamel, dentin and root structure; the pulp may or may not be exposed. Additional findings may include loose, but still attached, segments of the tooth (Fig. 2). Sensibility testing is usually positive Root fracture The coronal segment may be mobile and may be displaced. The tooth may be tender to percussion. Sensibility testing may give negative results initially, indicating transient or permanent pulpal damage; monitoring the status of the pulp is recommended. Transient crown discoloration (red or grey) may occur The 3 angulations described in radiographic examination to rule out displacement or fracture of the root. Radiograph of lip or cheek lacerations is recommended to search for tooth fragments or foreign material The 3 angulations described in radiographic examination to rule out displacement or fracture of the root. Radiograph of lip or cheek lacerations is recommended to search for tooth fragments or foreign material. The stage of root development can be determined from the radiographs As in root fractures, more than one radiographic angle may be necessary to detect fracture lines in the root (see radiographic examination) The fracture involves the root of the tooth and is in a horizontal or diagonal plane. Fractures that are in the horizontal plane can usually be detected in the regular 90 angle film with the central beam through the tooth. This is usually the case with fractures in the cervical third of the root. If the plane of fracture is more diagonal, which is common with apical third fractures, an occlusal view is more likely to demonstrate the fracture including those located in the middle third If tooth fragment is available, it can be bonded to the tooth. Urgent care option is to cover the exposed dentin with a material such as glass ionomer or a permanent restoration using a bonding agent and composite resin. Definitive treatment for the fractured crown may be restoration with accepted dental restorative materials In young patients with immature, still developing teeth, it is advantageous to preserve pulp vitality by pulp capping or partial pulpotomy. This treatment is also the choice in young patients with completely formed teeth. Calcium hydroxide and MTA (white) are suitable materials for such procedures. In older patients, root canal treatment can be the treatment of choice, although pulp capping or partial pulpotomy may also be selected. If too much time elapses between accident and treatment and the pulp becomes necrotic, root canal treatment is indicated to preserve the tooth. In extensive crown fractures a decision must be made whether treatment other than extraction is feasible Treatment recommendations are the same as for complicated crown fractures (see above). In addition, attempts at stabilizing loose segments of the tooth by bonding may be advantageous, at least as a temporary measure, until a definitive treatment plan can be formulated Reposition, if displaced, the coronal segment of the tooth as soon as possible. Check position radiographically. Stabilize the tooth with a flexible splint for 4 weeks. If the root fracture is near the cervical area of the tooth, stabilization is beneficial for a longer period of time (up to 4 months). It is advisable to monitor healing for at least 1 year to determine pulpal status. If pulp necrosis develops, root canal treatment of the coronal tooth segment to the fracture line is indicated to preserve the tooth 68 Dental Traumatology 2007; 23: 66 71 Ó 2007 The International Association for Dental Traumatology

Guidelines for fractured and luxated permanent teeth Clinical findings Radiographic findings Treatment Alveolar bone fracture The fracture involves the alveolar bone and may extend to adjacent bone. Segment mobility and dislocation are common findings. An occlusal change due to misalignment of the fractured alveolar segment is often noted. Sensibility testing may or may not be positive Fractures lines may be located at any level, from the marginal bone to the root apex. The panoramic technique is of great help in determining the course and position of fracture lines Reposition any displaced segment and then splint. Stabilize the segment for 4 weeks Follow-up procedures for fractured permanent teeth and alveolar fractures Time 4 weeks 6 8 weeks 4 months 6 months 1 year 5 years Uncomplicated crown fracture C(1) C(1) Complicated crown fracture C(1) C(1) Crown-root fracture C(1) C(1) Root fracture S + C(2) C(2) S(*) + C(2) C(2) C(2) C(2) Alveolar fracture S + C(3) C(3) C(3) C(3) C(3) C(3) S, splint removal. S (*), splint removal in cervical third fractures. C, clinical and radiographic examination. Favorable and unfavorable outcomes include some, but not necessarily all of the following Favorable outcome 1 Asymptomatic; positive response to pulp testing; continuing root development in immature teeth. Continue to next evaluation 2 Positive response to pulp testing (false negative possible up to 3 months). Signs of repair between fractured segments. Continue to next evaluation 3 Positive response to pulp testing (false negative possible up to 3 months). No signs of apical periodontitis. Continue to next evaluation Unfavorable outcome Symptomatic; negative response to pulp testing; signs of apical periodontitis; no continuing root development in immature teeth. Root canal treatment is indicated Negative response to pulp testing (false negative possible up to 3 months). Clinical signs of periodontitis. Radiolucency adjacent to fracture line. Root canal treatment is indicated only to the line of fracture Negative response to pulp testing (false negative possible up to 3 months). Signs of apical periodontitis or external inflammatory resorption. Root canal treatment is indicated Treatment guidelines for luxation injuries Clinical findings Radiographic findings Treatment Concussion The tooth is tender to touch or tapping; it has not been displaced and does not have increased mobility. Sensibility tests are likely to give positive results Subluxation The tooth is tender to touch or tapping and has increased mobility; it has not been displaced. Bleeding from gingival crevice may be noted. Sensibility testing may be negative initially indicating transient pulpal damage. Monitor pulpal response until a definitive pulpal diagnosis can be made No radiographic abnormalities Radiographic abnormalities are usually not found No treatment is needed. Monitor pulpal condition for at least 1 year A flexible splint to stabilize the tooth for patient comfort can be used for up to 2 weeks Dental Traumatology 2007; 23: 66 71 Ó 2007 The International Association for Dental Traumatology 69

Flores et al. Clinical findings Radiographic findings Treatment Extrusive luxation The tooth appears elongated and is excessively mobile. Sensibility tests will likely give negative results. In mature teeth, pulp revascularization some times occurs. In immature, not fully developed teeth, pulpal revascularization usually occurs Lateral luxation The tooth is displaced, usually in a palatal/lingual or labial direction (Fig. 1a, b). It will be immobile and percussion usually gives a high, metallic (ankylotic) sound. Sensibility tests will likely give negative results. In immature, not fully developed teeth, pulpal revascularization usually occurs Intrusive luxation The tooth is displaced axially into the alveolar bone. It is immobile and percussion may give a high, metallic (ankylotic) sound (Fig. 3). Sensibility tests will likely give negative results. In immature, not fully developed teeth, pulpal revascularization may occur Increased periodontal ligament space apically The widened periodontal ligament space is best seen on eccentric or occlusal exposures The periodontal ligament space may be absent from all or part of the root Reposition the tooth by gently re-inserting it into the tooth socket. Stabilize the tooth for 2 weeks using a flexible splint. Monitoring the pulpal condition is essential to diagnose root resorption. In immature developing teeth, revascularization can be confirmed radiographically by evidence of continued root formation and pulp canal obliteration and usually return to response to sensibility testing. In fully formed teeth, a continued lack of response to sensibility testing should be taken as evidence of pulp necrosis together with periapical rarification and sometimes crown discoloration Reposition the tooth with forceps to disengage it from its bony lock and gently reposition it into its original location. Stabilize the tooth for 4 weeks using a flexible splint. Monitor the pulpal condition. If the pulp becomes necrotic, root canal treatment is indicated to prevent root resorption. In immature, developing teeth, revascularization can be confirmed radiographically by evidence of continued root formation and possibly by positive sensibility testing. In fully formed teeth, a continued lack of response to sensibility testing indicates pulp necrosis, along with periapical rarification and sometimes crown discoloration 1. Teeth with incomplete root formation: Allow spontaneous repositioning to take place. If no movement is noted within 3 weeks, recommend rapid orthodontic repositioning. 2. Teeth with complete root formation: The tooth should be repositioned either orthodontically or surgically as soon as possible. The pulp will likely be necrotic and root canal treatment using a temporary filling with calcium hydroxide is recommended to retain the tooth Avulsion (will be covered in the next issue of Dental Traumatology). Follow-up procedures for luxated permanent teeth Time Up to 2 weeks 4 weeks 6 8 weeks 6 months 1 year Yearly for 5 years Concussion/subluxation C(1) C(1) C(1) NA Extrusive luxation S+C (2) C(3) C(3) C(3) C(3) C3) Lateral luxation C(3) S C(3) C(3) C(3) C(3) Intrusive luxation C(4) C(4) C(4) C(4) C(4) S, splint removal. C, clinical and radiographic examination. NA, not applicable. Favorable and unfavorable outcomes include some, but not necessarily all of the following Favorable outcome 1 Asymptomatic; positive response to pulp testing (false negative possible up to 3 months); continuing root development in immature teeth; intact lamina dura Unfavorable outcome Symptomatic; negative response to pulp testing (false negative possible up to 3 months); no continuing root development in immature teeth, periradicular radiolucencies 70 Dental Traumatology 2007; 23: 66 71 Ó 2007 The International Association for Dental Traumatology

Guidelines for fractured and luxated permanent teeth Favorable outcome 2 Minimal symptoms; slight mobility; no excessive radiolucency periradicularly 3 Asymptomatic; clinical and radiographic signs of normal or healed periodontium; positive response to pulp testing (false negative possible up to 3 months). Marginal bone height corresponds to that seen radiographically after repositioning 4 Tooth in place or erupting; intact lamina dura; no signs of resorption. In mature teeth, start the root canal treatment within the first 3 weeks Unfavorable outcome Severe symptoms; excessive mobility; clinical and radiographic signs of periodontitis. Root canal treatment is indicated in a closed apex tooth. In immature teeth, apexification procedures are indicated Symptoms and radiographic sign consistent with periodontitis; negative response to pulp testing (false negative possible up to 3 months); breakdown of marginal bone. Splint for additional 3- to 4- week period; root canal treatment is indicated if not previously initiated; chlorhexidine mouth rinse Tooth locked in place/ankylotic tone; radiographic signs of apical periodontitis; external inflammatory resorption or replacement resorption Splinting guidelines for tooth/bone fractures and luxated/avulsed teeth Splinting times Type of injury Subluxation Extrusive luxation Avulsion Lateral luxation Root fracture (middle third) Alveolar fracture Root fracture (cervical third) Splinting time 2 weeks 2 weeks 2 weeks 4 weeks 4 weeks 4 weeks 4 months Type of splints Acid-etch bonded composite splints are recommended, e.g. wire-composite splints and TTS (titanium trauma splint). For detailed description of splinting see current textbooks and articles (1, 5, 15 17). References 1. Andreasen JO, Andreasen F, Andersson L. Textbook and color atlas of traumatic injuries to the teeth, 4th edn. Oxford: Blackwell Munksgaard; 2007. 2. Petersson EE, Andersson L, Sorensen S. Traumatic oral vs non-oral injuries. Swed Dent J 1997;21:55 68. 3. Glendor U, Halling A, Andersson L, Eilert-Petersson E. Incidence of traumatic tooth injuries in children and adolescents in the county of Vastmanland, Sweden. Swed Dent J 1996;20:15 28. 4. Flores MT, Andreasen JO, Bakland LK et al.. International Association of Dental Traumatology. Guidelines for the evaluation and management of traumatic dental injuries. Dent Traumatol 2001;17:1 4. 5. Andreasen JO, Andreasen F, Bakland L, Flores MT. Traumatic dental injuries. A manual, 2nd edn. Oxford: Blackwell Munksgaard; 2003. 6. Andreasen JO, Andreasen FM, Skeie A, Hjorting-Hansen E, Schwartz O. Effect of treatment delay upon pulp and periodontal healing of traumatic dental injuries - a review article. Dent Traumatol 2002;18:116 28. 7. Andreasen JO, Andreasen FM, Mejare I, Cvek M. Healing of 400 intra-alveolar root fractures. 1. Effect of pre-injury and injury factors such as sex, age, stage of root development, fracture type, location of fracture and severity of dislocation. Dent Traumatol 2004;20:192 202. 8. Cvek M, Mejàre I, Andreasen JO. Conservative endodontic treatment of teeth fractured in the middle or apical part of the root. Dent Traumatol 2004;20:261 269. 9. Cvek M, Andreasen JO, Borum MK. Healing of 208 intraalveolar root fractures in patients aged 7 17 years. Dent Traumatol 2001;17:53 62. 10. Jackson NG, Waterhouse PJ, Maguire A. Factors affecting treatment outcomes following complicated crown fractures managed in primary and secondary care. Dent Traumatol 2006;22:179 85. 11. Rafter M. Apexification: a review. Dent Traumatol 2005;21:1 8. Review. 12. Andreasen JO, Bakland LK, Andreasen FM. Traumatic intrusion of permanent teeth. Part 3. A clinical study of the effect of treatment variables such as treatment delay, method of repositioning, type of splint, length of splinting and antibiotics on 140 teeth. Dent Traumatol 2006;22:99 111. 13. Andreasen JO, Bakland LK, Andreasen FM. Traumatic intrusion of permanent teeth. Part 2. A clinical study of the effect of preinjury and injury factors, such as sex, age, stage of root development, tooth location, and extent of injury including number of intruded teeth on 140 intruded permanent teeth. Dent Traumatol 2006;22:90 8. 14. Andreasen JO, Bakland LK, Matras RC, Andreasen FM. Traumatic intrusion of permanent teeth. Part 1. An epidemiological study of 216 intruded permanent teeth. Dent Traumatol 2006;22:83 9. 15. Filippi A, von Arx T, Lussi A. Comfort and discomfort of dental trauma splints - a comparison of a new device (TTS) with three commonly used splinting techniques. Dent Traumatol 2002;18:275 80. 16. Von Arx T, Filippi A, Lussi A. Comparison of a new dental trauma splint device (TTS) with three commonly used splinting techniques. Dent Traumatol 2001;17:266 74. 17. Von Arx T, Filippi A, Buser D. Splinting of traumatized teeth with a new device: TTS (Titanium Trauma Splint). Dent Traumatol 2001;17:180 4. Dental Traumatology 2007; 23: 66 71 Ó 2007 The International Association for Dental Traumatology 71

Dental Traumatology 2007; doi: 10.1111/j.1600-9657.2007.00605.x DENTAL TRAUMATOLOGY Guidelines Guidelines for the management of traumatic dental injuries. II. Avulsion of permanent teeth Flores MT, Andersson L, Andreasen JO, Bakland LK, Malmgren B, Barnett F, Bourguignon C, DiAngelis A, Hicks L, Sigurdsson A, Trope M, Tsukiboshi M, von Arx T. Guidelines for the management of traumatic dental injuries. II. Avulsion of Permanent Teeth. Abstract Avulsion of permanent teeth is the most serious of all dental injuries. The prognosis depends on the measures taken at the place of accident or the time immediately after the avulsion. Replantation is the treatment of choice, but cannot always be carried out immediately. An appropriate emergency management and treatment plan is important for a good prognosis. Guidelines are useful for delivering the best care possible in an efficient manner. 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 specialties were included in the group. In cases in which the data did not appear conclusive, recommendations were based on the consensus opinion of the IADT board members. The guidelines represent the current best evidence based on literature research and professional opinion. In this second article of three, the IADT Guidelines for management of avulsed permanent teeth are presented. Marie Therese Flores 1, Lars Andersson 2, Jens Ove Andreasen 3, Leif K. Bakland 4, Barbro Malmgren 5, Frederick Barnett 6, Cecilia Bourguignon 7, Anthony DiAngelis 8, Lamar Hicks 9, Asgeir Sigurdsson 10, Martin Trope 11, Mitsuhiro Tsukiboshi 12, Thomas von Arx 13 1 Pediatric Dentistry, Faculty of Dentistry, University of Valparaiso, Valparaiso, Chile; 2 Oral & Maxillofacial Surgery, Faculty of Dentistry, Kuwait University, Safat, Kuwait; 3 Department of Oral and Maxillofacial Surgery, University Hospital, Copenhagen, Denmark; 4 Endodontics, School of Dentistry, Loma Linda University, Loma Linda, CA, USA; 5 Department of Pediatrics, Karolinska Institute, Huddinge, Sweden; 6 Albert Einstein Medical Center, Philadelphia, PA, USA; 7 Private Practice, Paris, France; 8 Hennepin County Medical Center, Minneapolis, MN, USA; 9 Endodontics, University of Maryland, Baltimore, MD, USA; 10 Private Practice, Reykjavik, Iceland; 11 Endodontics, University of North Carolina, Chapel Hill, NC, USA; 12 Private Practice, Nagoya, Japan; 13 Oral Surgery and Stomatology, University of Berne, Berne, Switzerland Key words: trauma; tooth; avulsion; injury; periodontal; emergency; consensus; review MT Flores, The International Association of Dental Traumatology, PO Box 1057, Loma Linda, CA 92354, USA Tel.: +56 32 250 8690 http://www.iadt-dentaltrauma.org e-mail: mariateresa.flores@uv.cl Trauma to the oral region occurs frequently and comprise 5% of all injuries for which people seek treatment (1, 2). In preschool children the figure is as high as 18% of all injuries (1, 2). Among all facial injuries, dental injuries are the most common (2) of which avulsions occur in 1 16% of all dental injuries (1, 3). Avulsion of permanent teeth is the most serious of all dental injuries. The prognosis depends on the measures taken at the place of accident or the time immediately after the avulsion. Replantation is the treatment of choice, but cannot always be carried out immediately. Furthermore, replantation should not be performed when primary teeth have been avulsed because of the risk of injury to the underlying permanent tooth germ (1). An appropriate treatment plan after an injury is important for a good prognosis. Guidelines are useful for dentists and other healthcare professionals in delivering the best care possible in an efficient manner. The International Association of Dental Traumatology (IADT) has developed a consensus statement after a review of the dental literature and group discussions. The first set of 130 Dental Traumatology 2007; 23: 130 136 Ó 2007 The International Association for Dental Traumatology

Guidelines for avulsed permanent teeth guidelines for the management of the avulsed tooth was published by IADT in 2001 (4). Experienced researchers and clinicians from various specialties were included in the group. In cases in which the data did not appear conclusive, recommendations were based on the consensus opinion of the IADT board members. The guidelines represent the current best evidence based on literature research and professional opinion. As is true for all guidelines, the healthcare provider must apply clinical judgment dictated by the conditions present in the given traumatic situation. The IADT does not guarantee favorable outcomes from following the guidelines, but using the recommended procedures can maximize the chances of success. Because management of permanent and primary dentition differs significantly, separate guidelines for management of permanent and primary teeth have been developed. Updating the guidelines is an ongoing process, and the guidelines are available on the IADT web page (http://www.iadt-dentaltrauma.org). In addition to the clinical guidelines, there is also a forum for discussion on this web page and a possibility to download information material for professionals and the public. The publication of the IADT guidelines in the journal Dental Traumatology has been divided into three parts: Part I: Crown fractures and luxations of permanent teeth in Dental Traumatology issue 2, 2007; Part II: Avulsion of permanent teeth in the present issue; Part III: Guidelines for injuries in the primary dentition will be published in Dental Traumatology issue 4, 2007. If this is not possible, place the tooth in a suitable storage medium, e.g. a glass of milk or in saline. The tooth can also be transported in the mouth, keeping it between the molars and the inside of the cheek. Avoid storage in water. Seek emergency dental treatment immediately. The poster Save a Tooth is written for the public and is available in several languages: Spanish, English, Portuguese, French, Icelandic, Italian, and can be obtained at the IADT website: http:// www.iadt-dentaltrauma.org. Guidelines for the clinician Guidelines contain recommendations for diagnosis and treatment of specific traumatic dental injuries using proper examination procedures. Some general recommendations are as follows: A. Clinical examination. Detailed description of procedures such as clinical examination and classification of injuries can be found in current textbooks and manuals (1, 5) (Figs 1 and 2). B. Radiographic examination. As a routine, several projections and angles are recommended: 90 horizontal angle, with central beam through the tooth in question; occlusal view; lateral view from the mesial or distal aspect of the tooth in question. First aid for avulsed teeth Dentists should always be prepared to give appropriate advice to the public about first aid for avulsed teeth. An avulsed permanent tooth is one of the few real emergency situations in dentistry. In addition to increasing the public awareness by, e.g. mass media campaigns, healthcare professionals, parents and teachers should receive information on how to proceed following these severe unexpected injuries. Also, instructions may be given by telephone to parents at the emergency site. If a tooth is avulsed, make sure it is a permanent tooth (primary teeth should not be replanted) Keep the patient calm. Find the tooth and pick it up by the crown (the white part). Avoid touching the root. If the tooth is dirty, wash it briefly (10 seconds) under cold running water and reposition it. Try to encourage the patient/parent to replant the tooth. Bite on a handkerchief to hold it in position. Fig. 1. Four permanent teeth avulsed in a 15-year-old boy coming to the clinic 30 min after the accident. There is bleeding from empty alveolar sockets. There is also a laceration injury in the lip. Dental Traumatology 2007; 23: 130 136 Ó 2007 The International Association for Dental Traumatology 131

Flores et al. a b c d e f g h Fig. 2. Replantation of an immature permanent tooth after 1 h of avulsion. A 7-year-old boy fell from the stairs at school. The avulsed tooth was found in the hand and stored in water before replanting at the Emergency Room. No splint was placed. (a,b) Extruded position of tooth 11 following replantation. (c) The X-ray reveals an immature tooth with one-third of root formation. (d) The tooth was repositioned and stabilized with a flexible wire-composite splint. The splint is extended to the primary canines because of the absence of adjacent teeth during early mixed dentition. (e,f) Clinical and radiographic appearance at 1 year follow-up control and arrest of root formation is seen. No root canal treatment is indicated. (g,h) Control after 6 years shows normal color of the crown and normal position of the tooth. Pulp canal obliteration of tooth 11 is seen at the radiographic examination. For more detailed information see current textbooks (1, 5). C. Sensibility tests. Sensibility testing refers to tests (electric pulp test or cold test) to determine the condition of the tooth pulp. Initial tests following an injury frequently give negative results, but such results may only indicate a transient lack of pulpal response. Follow-up controls are needed to make a definitive pulpal diagnosis. D. Patient instructions. Good healing following an injury to the teeth and oral tissues depends, in part, on good oral hygiene. Patients should be advised on how best to care for teeth that have received treatment after an injury. Brushing with a soft brush and rinsing with chlorhexidine 0.1% is beneficial to prevent accumulation of plaque and debris. For further reading we recommend some review articles and original papers (6 20). All relevant new and old references can be found in the recent textbook and color atlas by Andreasen et al. (1). 132 Dental Traumatology 2007; 23: 130 136 Ó 2007 The International Association for Dental Traumatology

Guidelines for avulsed permanent teeth Treatment guidelines for avulsed permanent teeth 1. Tooth with a closed apex. a. The tooth has already been replanted. b. The tooth has been kept in special storage media (Hank s Balanced Salt Solution), milk, saline, or saliva. The extra-oral dry time is less than 60 min. c. Extra-oral dry time longer than 60 min. 2. Tooth with open apex. a. The tooth has already been replanted. b. The tooth has been kept in special storage media (Hank s Balanced Salt Solution), milk, saline, or saliva. The extra-oral dry time is less than 60 min. c. Extra-oral dry time longer than 60 min. Treatment guidelines for avulsed permanent teeth with closed apex Clinical situation (1a) The tooth has been replanted prior to the patient arriving at the dental office or clinic (1b) The tooth has been kept in special storage media (Hank s Balanced Salt Solution), milk, saline, or saliva. The extraoral dry time is less than 60 min (1c) Extra-oral dry time longer than 60 min Treatment Clean the area with water spray, saline, or chlorhexidine. Do not extract the tooth. Suture gingival lacerations if present. Verify normal position of the replanted tooth both clinically and radiographically. Apply a flexible splint for up to 2 weeks. Administer systemic antibiotics. Tetracycline is the first choice (Doxycycline 2x per day for 7 days at appropriate dose for patient age and weight). The risk of discoloration of permanent teeth must be considered before systemic administration of tetracycline in young patients. (In many countries tetracycline is not recommended for patients under 12 years of age). In young patients Phenoxymethyl Penicillin (Pen V), in an appropriate dose for age and weight, can be given as alternative to tetracycline. If the avulsed tooth has contacted soil, and if tetanus coverage is uncertain, refer to physician for evaluation and need for a tetanus booster. Initiate root canal treatment 7 10 days after replantation and before splint removal. Place calcium hydroxide as an intra-canal medicament until filling of the root canal. Patient instructions Soft diet for up to 2 weeks. Brush teeth with a soft toothbrush after each meal. Use a chlorhexidine (0.1%) mouth rinse twice a day for 1 week. Follow-up See Follow-up procedures for avulsed permanent teeth. If contaminated, clean the root surface and apical foramen with a stream of saline and place the tooth in saline. Remove the coagulum from the socket with a stream of saline. Examine the alveolar socket. If there is a fracture of the socket wall, reposition it with a suitable instrument. Replant the tooth slowly with slight digital pressure. Suture gingival lacerations. Verify normal position of the replanted tooth both clinically and radiographically. Apply a flexible splint for up to 2 weeks. Administer systemic antibiotics. Tetracycline is the first choice (Doxycycline 2x per day for 7 days at appropriate dose for patient age and weight). The risk of discoloration of permanent teeth must be considered before systemic administration of tetracycline in young patients. (In many countries tetracycline is not recommended for patients under 12 years of age). In young patients Phenoxymethyl Penicillin (Pen V), at appropriate dose for age and weight, can be given as alternative to tetracycline. If the avulsed tooth has contacted soil, and if tetanus coverage is uncertain, refer the patient to a physician for evaluation and need for a tetanus booster. Initiate root canal treatment 7 10 days after replantation and before splint removal. Place calcium hydroxide as an intra-canal medicament until filling of the root canal. Patient instructions Soft diet for up to 2 weeks. Brush teeth with a soft toothbrush after each meal. Use a chlorhexidine (0.1%) mouth rinse twice a day for 1 week. Follow-up See Follow-up procedures for avulsed permanent teeth. Delayed replantation has a poor long-term prognosis. The periodontal ligament will be necrotic and not expected to heal. The goal in doing delayed replantation is to promote alveolar bone growth to encapsulate the replanted tooth. The expected eventual outcome is ankylosis and resorption of the root. In children below the age of 15, if ankylosis occurs, and when the infraposition of the tooth crown is more than 1 mm, it is recommended to perform decoronation to preserve the contour of the alveolar ridge. The technique for delayed replantation is: Remove attached necrotic soft tissue with gauze. Root canal treatment can be done on the tooth prior to replantation, or it can be done 7 10 days later as for other replantations. Dental Traumatology 2007; 23: 130 136 Ó 2007 The International Association for Dental Traumatology 133

Flores et al. Clinical situation Treatment Remove the coagulum from the socket with a stream of saline. Examine the alveolar socket. If there is a fracture of the socket wall, reposition it with a suitable instrument. Immerse the tooth in a 2% sodium fluoride solution for 20 min Replant the tooth slowly with slight digital pressure. Suture gingival laceration. Verify normal position of the replanted tooth clinically and radiographically. Stabilize the tooth for 4 weeks using a flexible splint. Administration of systemic antibiotics, see (1a). Refer to physician for evaluation of need for a tetanus booster if the avulsed tooth has contacted soil or tetanus coverage is uncertain. Patient instructions Soft diet for up to 2 weeks. Brush teeth with a soft toothbrush after each meal. Use a chlorhexidine (0.1%) mouth rinse twice a day for 1 week. Follow-up See Follow-up procedures for avulsed permanent teeth. Treatment guidelines for avulsed permanent teeth with open apex (2a) The tooth has already been replanted prior to the patient arriving in the dental office or clinic. (2b) The tooth has been kept in special storage media (Hank s Balanced Salt Solution), milk, saline, or saliva. The extraoral dry time is less than 60 min Clean the area with water spray, saline or chlorhexidine. Do not extract the tooth. Suture gingival lacerations if present. Verify normal position of the replanted tooth both clinically and radiographically. Apply a flexible splint for up to 2 weeks. Administer systemic antibiotics. For children 12 years and younger: Penicillin V at an appropriate dose for patient age and weight. Refer the patient to a physician for evaluation of need for a tetanus booster if avulsed tooth has contacted soil or tetanus coverage is uncertain. The goal for replanting still-developing (immature) teeth in children is to allow for possible revascularization of the tooth pulp. If that does not occur, root canal treatment may be recommended see Follow-up procedures for avulsed permanent teeth. Patient instructions Soft diet for up to 2 weeks. Brush teeth with a soft toothbrush after each meal. Use a chlorhexidine (0.1%) mouth rinse twice a day for 1 week. Follow-up See Follow-up procedures for avulsed permanent teeth. If contaminated, clean the root surface and apical foramen with a stream of saline. Remove the coagulum from the socket with a stream of saline and then replant the tooth. If available, cover the root surface with minocycline hydrochloride microspheres (Arestin TM, OraPharma Inc, Warminster, PA, USA) before replanting the tooth. Examine the alveolar socket. If there is a fracture of the socket wall, reposition it with a suitable instrument. Replant the tooth slowly with slight digital pressure. Suture gingival lacerations, especially in the cervical area. Verify normal position of the replanted tooth clinically and radiographically. Apply a flexible splint for up to 2 weeks. Administer systemic antibiotics. For children 12 years and younger: Penicillin V at appropriate dose for patient age and weight. Refer to physician for evaluation of need for a tetanus booster if avulsed tooth has contacted soil or tetanus coverage is uncertain. The goal for replanting still-developing (immature) teeth in children is to allow for possible revascularization of the tooth pulp. If that does not occur, root canal treatment may be recommended see Follow-up procedures for avulsed permanent teeth. Patient instructions Soft diet for up to 2 weeks. Brush teeth with a soft toothbrush after each meal. Use a chlorhexidine (0.1%) mouth rinse twice a day for 1 week. Follow-up See Follow-up procedures for avulsed permanent teeth. 134 Dental Traumatology 2007; 23: 130 136 Ó 2007 The International Association for Dental Traumatology

Guidelines for avulsed permanent teeth (2c) Extra-oral dry time longer than 60 min Delayed replantation has a poor long-term prognosis. The periodontal ligament will be necrotic and not expected to heal. The goal in doing delayed replantation of immature teeth in children is to maintain alveolar ridge contour. The eventual outcome is expected to be ankylosis and resorption of the root. It is important to recognize that if delayed replantation is done in a child, future treatment planning must be done to take into account the occurrence of tooth ankylosis and the effect of ankylosis on the alveolar ridge development. If ankylosis occurs, and when the infraposition of the tooth crown is more than 1 mm, it is recommended to perform decoronation to preserve the contour of the alveolar ridge. The technique for delayed replantation is: Remove attached necrotic soft tissue with gauze. Root canal treatment can be done on the tooth prior to replantation through the open apex. Remove the coagulum from the socket with a stream of saline. Examine the alveolar socket. If there is a fracture of the socket wall, reposition it with a suitable instrument. Immerse the tooth in a 2% sodium fluoride solution for 20 min Replant the tooth slowly with slight digital pressure. Suture gingival laceration. Verify normal position of the replanted tooth clinically and radiographically. Stabilize the tooth for 4 weeks using a flexible splint. Administration of systemic antibiotics, see (2a). Refer the patient to a physician for evaluation of need for a tetanus booster if the avulsed tooth has contacted soil or tetanus coverage is uncertain. Patient instructions Soft diet for up to 2 weeks. Brush teeth with a soft toothbrush after each meal. Use a chlorhexidine (0.1%) mouth rinse twice a day for 1 week. Follow-up See Follow-up procedures for avulsed permanent teeth. Follow-up procedures for avulsed permanent teeth Root canal treatment If root canal treatment is indicated (teeth with closed apex), the ideal time to begin treatment is 7 10 days postreplantation. Calcium hydroxide is recommended for intra-canal medication for up to 1 month followed by root canal filling with an acceptable material. An exception is a tooth that has been dry for more than 60 min before replantation in such cases the root canal treatment may be done prior to replantation. In teeth with open apexes, that have been replanted immediately or kept in appropriate storage media, pulp revascularization is possible. Root canal treatment should be avoided unless there is clinical and radiographic evidence of pulp necrosis. Clinical control Replanted teeth should be monitored by frequent controls during the first year (once a week during the months 1, 3, 6, and 12) and then yearly thereafter. Clinical and radiographic examination will provide information to determine outcome. Evaluation may include the findings described as follows. Favorable outcome (1) Closed apex. Asymptomatic, normal mobility, normal percussion sound. No radiographic evidence of resorption or periradicular osteitis; the lamina dura should appear normal. (2) Open apex. Asymptomatic, normal mobility, normal percussion sound. Radiographic evidence of arrested or continued root formation and eruption. Pulp canal obliteration is the rule. Unfavorable outcome (1) Closed apex. Symptomatic, excessive mobility or no mobility (ankylosis) with high-pitched percussion sound. Radiographic evidence of resorption (inflammatory, infection-related resorption, or ankylosis-related replacement resorption). (2) Open apex. Symptomatic, excessive mobility or no mobility (ankylosis) with high-pitched percussion sound. In the case of ankylosis, the crown of the tooth will appear to be in an infra-occlusal position. Radiographic evidence of resorption (inflammatory, infection-related resorption, or ankylosis-related replacement resorption). Splinting guidelines for avulsed teeth Replanted permanent teeth should be splinted up to 2 weeks. Wire-composite splint has been widely used to stabilize avulsed teeth because it allows good oral hygiene and are well tolerated by the patients (Fig 2). For a detailed description of new splints and splinting times, see recent textbooks and articles (1, 5, 16 20). Dental Traumatology 2007; 23: 130 136 Ó 2007 The International Association for Dental Traumatology 135

Flores et al. References 1. Andreasen JO, Andreasen FM, Andersson L. Textbook and color atlas of traumatic injuries to the teeth, 4th edn. Oxford: Blackwell Munksgaard; 2007. 2. Petersson EE, Andersson L, Sorensen S. Traumatic oral vs non-oral injuries. Swed Dent J 1997;21:55 68. 3. Glendor U, Halling A, Andersson L, Eilert-Petersson E. Incidence of traumatic tooth injuries in children and adolescents in the county of Vastmanland, Sweden. Swed Dent J 1996;20:15 28. 4. Flores MT, Andreasen JO, Bakland LK, Feiglin B, Gutmann JL, Oikarinen K et al. International Association of Dental Traumatology Guidelines for the evaluation and management of traumatic dental injuries. Dent Traumatol 2001;17:193 8. 5. Andreasen JO, Andreasen FM, Bakland LK, Flores MT. Traumatic Dental Injuries. A Manual, 2nd edn. Oxford: Blackwell Munksgaard, 2003. 6. Andreasen JO, Andreasen FM, Skeie A, Hjorting-Hansen E, Schwartz O. Effect of treatment delay upon pulp and periodontal healing of traumatic dental injuries a review article. Dent Traumatol 2002;18:116 28. 7. Andersson L, Malmgren B. The problem of dentoalveolar ankylosis and subsequent replacement resorption in the growing patient. Aust Endod J 1999;25:57 61. 8. Schjott M, Andreasen JO. Emdogain does not prevent progressive root resorption after replantation of avulsed teeth: a clinical study. Dent Traumatol 2005;21:46 50. 9. Barrett EJ, Kenny DJ. Avulsed permanent teeth: a review of the literature and treatment guidelines. Endod Dent Traumatol 1997;13:153 63. 10. Chappuis V, von Arx T. Replantation of 45 avulsed permanent teeth: a 1-year follow-up study. Dent Traumatol 2005;21:289 96. 11. Ma KM, Sae-Lim V. The effect of topical minocycline on replacement resorption of replanted monkeys teeth. Dent Traumatol 2003;19:96 102. 12. Bryson EC, Levin L, Banchs F, Trope M. Effect of minocycline on healing of replanted dog teeth after extended dry times. Dent Traumatol 2003;19:90 5. 13. Schwartz O, Andreasen FM, Andreasen JO. Effects of temperature, storage time and media on periodontal and pulpal healing after replantation of incisors in monkeys. Dent Traumatol 2002;18:190 5. 14. Trope M. Clinical management of the avulsed tooth: present strategies and future directions. Dent Traumatol 2002;18:1 11. 15. Ritter AL, Ritter AV, Murrah V, Sigurdsson A, Trope M. Pulp revascularization of replanted immature dog teeth after treatment with minocycline and doxycycline assessed by laser Doppler flowmetry, radiography, and histology. Dent Traumatol 2004;20:75 84. 16. Oikarinen K, Andreasen JO, Andreasen FM. Rigidity of various fixation methods used as dental splints. Endod Dent Traumatol 1992;8:113 9. 17. Filippi A, von Arx T, Lussi A. Comfort and discomfort of dental trauma splints a comparison of a new device (TTS) with three commonly used splinting techniques. Dent Traumatol 2002;18:275 80. 18. Von Arx T, Filippi A, Lussi A. Comparison of a new dental trauma splint device (TTS) with three commonly used splinting techniques. Dent Traumatol 2001;17:266 74. 19. Von Arx T, Filippi A, Buser D. Splinting of traumatized teeth with a new device: TTS (Titanium Trauma Splint). Dent Traumatol 2001;17:180 4. 20. Oikarinen K. Splinting of traumatized teeth. In: Andreasen JO, Andreasen FM, Andersson L, editors. Textbook and color atlas of traumatic injuries to the teeth, 4th edn. Oxford: Blackwell Munksgaard; 2007. 136 Dental Traumatology 2007; 23: 130 136 Ó 2007 The International Association for Dental Traumatology

Dental Traumatology 2007; doi: 10.1111/j.1600-9657.2007.00627.x DENTAL TRAUMATOLOGY Guidelines Guidelines for the management of traumatic dental injuries. III. Primary teeth Flores MT, Malmgren B, Andersson L, Andreasen JO, Bakland LK, Barnett F, Bourguignon C, DiAngelis A, Hicks L, Sigurdsson A, Trope M, Tsukiboshi M, von Arx T. Guidelines for the management of traumatic dental injuries. III. Primary teeth. Dent Traumatol 2007. Ó Blackwell Munksgaard, 2007 Abstract Trauma to the primary dentition present special problems and the management is often different as compared with permanent teeth. An appropriate emergency treatment plan is important for a good prognosis. Guidelines are useful for delivering the best care possible in an efficient manner. 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 specialties were included in the group. In cases in which the data did not appear conclusive, recommendations were based on the consensus opinion of the IADT board members. The guidelines represent the current best evidence based on literature research and professional opinion. In this third article out of three, the IADT Guidelines for the management of traumatic injuries in the primary dentition, are presented. Marie Therese Flores 1, Barbro Malmgren 2, Lars Andersson 3, Jens Ove Andreasen 4, Leif K. Bakland 5, Frederick Barnett 6, Cecilia Bourguignon 7, Anthony DiAngelis 8, Lamar Hicks 9, Asgeir Sigurdsson 10, Martin Trope 11, Mitsuhiro Tsukiboshi 12, Thomas von Arx 13 1 Pediatric Dentistry, Faculty of Dentistry, University of Valparaiso, Valparaiso, Chile; 2 Department of Pediatrics, Karolinska Institute, Huddinge, Sweden; 3 Oral & Maxillofacial Surgery, Faculty of Dentistry, Kuwait University, Safat, Kuwait; 4 Department of Oral and Maxillofacial surgery, University Hospital, Copenhagen, Denmark; 5 Endodontics, School of Dentistry, Loma Linda University, Loma Linda, CA, USA; 6 Albert Einstein Medical Center, Philadelphia, PA, USA; 7 Private Practice, Paris, France; 8 Hennepin County Medical Center, Minneapolis, MN, USA; 9 Endodontics, University of Maryland, Baltimore, MD, USA; 10 Private Practice, Reykjavik, Iceland; 11 Endodontics, University of North Carolina, Chapel Hill, NC, USA; 12 Private Practice, Nagoya, Japan; 13 Oral Surgery and Stomatology, University of Berne, Berne, Switzerland Key words: trauma; tooth; deciduous; preschool children; injury; periodontal; emergency; consensus; review Marie Therese Flores, The International Association of Dental Traumatology, PO Box 1057, Loma Linda, CA 92354, USA Tel.: +56 32 250 8690 http.//www.iadt dentaltrauma.org e-mail: mariateresa.flores@uv.cl Trauma to the oral region occurs frequently and comprises 5% of all injuries for which people seek treatment (1 4). In preschool injuries, head injuries make up as much as 40% of all somatic injuries (1 4). Among all facial injuries, dental injuries are the most common (1 4). As much as 18% of all somatic injuries are seen in the oral region in children 0 6 years old (1 4). An appropriate treatment plan after an injury is important for a good prognosis. Guidelines are useful for dentists and other healthcare professionals in delivering the best care possible in an efficient manner. 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 196 Dental Traumatology 2007; 23: 196 202 Ó 2007 The International Association for Dental Traumatology

Guidelines for primary teeth clinicians from various specialties were included in the group. In cases in which the data did not appear conclusive, recommendations were based on the consensus opinion of the IADT board members. The guidelines represent the current best evidence based on literature research and professional opinion. As is true for all guidelines, the healthcare provider must apply clinical judgment dictated by the conditions present in the given traumatic situation. The IADT does not guarantee favorable outcomes from following the Guidelines, but using the recommended procedures can maximize the chances of success. Because management of permanent and primary dentition differs significantly, separate guidelines for management of permanent and primary teeth have been developed. Updating the Guidelines is an ongoing process, and the Guidelines are available on the IADT web page http://www.iadt-dentaltrauma.org. In addition to the clinical guidelines, there is also a forum for discussion on this web page and a possibility to download information material for professionals and the public. The publication of the IADT guidelines in the journal Dental Traumatology has been divided into three parts Part I: Crown fractures and luxations of permanent teeth in Dental Traumatology issue 2; 2007 Part II. Avulsion of permanent teeth in issue 3; 2007 Part III. Guidelines for the management of traumatic injuries in the primary dentition published in this issue. First aid and treatment of trauma to the primary dentition Depending on the severity of injuries, usually, the parents will seek treatment at the Emergency Room or will call the pediatrician. Dentists should be willing to give appropriate advice to healthcare professionals and those who closely work or supervise children, about first aid for injuries affecting the primary dentition.(5, 6) The following recommendations will help for the best care of the child: Keep calm and concentrate in the child wellbeing. Wash the wound carefully with plenty of running water. Generally, dental trauma includes injuries to the adjacent soft tissue (Fig 1). Stop bleeding by compressing the injured area with gauze or cotton for 5 min. Seek emergency treatment from a pediatric dentist. Guidelines for the Emergency Room In more severe injuries, especially, when there is bleeding of the lips and intra-oral soft tissue, the Fig. 1. Soft tissue injuries of the upper lip and torn frenum. parents will seek treatment at the Emergency Room where physicians will give the first treatment (Fig 2). After suture of soft tissue lacerations, the child should be referred to a pediatric dentist or a general dentist who treats children for a general evaluation of teeth injuries. Intra-oral trauma affecting the lips, gums, tongue, palate, and severe tooth injuries in children <5 years old, should be examined and suspect of child abuse (7 9). In such cases, the patient should also be examined by a pediatric dentist on call or oral surgeon who will give the diagnosis of primary teeth injuries and prognosis for the developing permanent dentition. The child should be referred for follow-up controls to a pediatric dentist. It is important to explain the parents that the permanent dentition may have long-term consequences that may be seen many years later, at the time of eruption of the permanent incisors. Special considerations for trauma to primary teeth The management of traumatic injuries to primary teeth differs from that used for permanent. It is important to keep in mind that there is 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 (Fig 3). Because of these potential sequelae, treatment selection should such as to avoid any additional risks of further damaging the permanent successors. Dental Traumatology 2007; 23: 196 202 Ó 2007 The International Association for Dental Traumatology 197

Flores et al. a a b b c c Fig. 2. Acute trauma to oral soft tissues and primary teeth. A 2-year-old girl fell on the floor. Suture of the lower lip laceration was the immediate treatment carried out at the Emergency Room and antibiotics were prescribed. The patient was referred to a pediatric dentist. (a) Bleeding from gingival and frenum laceration is seen. Tooth 51 has been laterally luxated in a mesial position and is mobile. The parents were instructed to follow a careful tooth brushing technique. (b) The X-ray shows the displaced position of tooth. (c) Clinical appearance 9 days after trauma. The tooth is almost in its original position, has slight mobility and good oral hygiene is observed. Fig. 3. Injuries to the developing teeth. An 8-year-old girl sought treatment because of delayed eruption of tooth 21. The history revealed that she fell three steps from the stairs while using the baby walker. Recommendations on oral hygiene and followup controls were given at the Emergency Room. Teeth 51 and 61 apparently were not affected and had normal resorption at the time of shedding. (a) Hypoplasia of tooth 11 affecting the incisal third of the crown. Crown dilacerations is seen in tooth 21. (b) Clinical appearance of tooth malformation affecting both central incisors: hypoplasia with loss of tooth structure in tooth 11 and delayed eruption is observed in tooth 21. (c) After completion eruption, crown dilaceration is seen in tooth 21. 198 Dental Traumatology 2007; 23: 196 202 Ó 2007 The International Association for Dental Traumatology

Guidelines for primary teeth Good healing following an injury to the teeth and oral tissues depends, in part, on good oral hygiene. Parents should be advised on how best to care for their children s primary teeth after an injury. (Fig 4). Brushing with a soft brush after each meal and applying chlorhexidine (0.1%) topically to the affected area(s) with cotton swabs twice a day for one week, is beneficial to prevent accumulation of plaque and debris. Along with recommending a soft diet for 10 14 days, restrict the use of pacifier. If there are associated lip injuries, use of lip balm during the healing period will avoid dryness. Parents should be further advised about possible complications that may occur, like swelling, increased mobility or fistula. Children may not complain about pain; however, infection may be present and parents should watch for signs such as swelling of the gums and bring the children in for treatment. Document in the chart that the parent has been informed about possible complications in the devela injured tooth and the occlusion, are important factors that influence treatment selection. Guidelines for the clinician The Guidelines contain recommendations for diagnosis and treatment of traumatic injuries in the primary dentition for caries-free or sound primary teeth using proper examination procedures: b c Fig. 4. (a) A 2 year and 6 month-old boy fell while he was jumping on the bed. The mother noticed that the left central incisor was displaced and sought emergency treatment immediately. Instructions on oral hygiene, including topical use of chlorhexidine gel using cotton swabs for one week, were given to the mother. Also, it was recommended a soft diet for 2 weeks along with restricting the use of pacifier. (b) An occlusal view at the time of injury shows an overlapping of the primary roots and the developing permanent incisors; however, it is possible to observe an apical increased periodontal ligament space. (c) Spontaneous reposition of tooth 61 at two and a half months follow-up control. The child s maturity and ability to cope with the emergency situation, the time for shedding of the A. Clinical examination. Information about examination of traumatic injuries in the primary dentition can be found in a number of current textbooks (1, 5, 10). B. Radiographic examination Depending on the child s ability to cope with the procedure and the type of injury suspected, several angles are recommended: 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, which is useful to 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). C. Patient instructions Dental Traumatology 2007; 23: 196 202 Ó 2007 The International Association for Dental Traumatology 199

Flores et al. opment of the permanent teeth, especially following intrusion, avulsion and alveolar fracture injuries sustained in children under 3 years of age. For further reading we recommend some recent good review articles and original papers on child abuse (7 9), epidemiology (11 13), pulp therapy (14 17), intrusive luxation (18, 19) and tooth abnormalities (20 22). All relevant new and old references can be found in the recent textbook and atlas by Andreasen et al. (1). Treatment guidelines for fractures of teeth and alveolar bone in the primary dentition Clinical findings Radiographic findings Treatment Uncomplicated crown fracture Fracture involves enamel or dentin and enamel; the pulp is not exposed. Complicated crown fracture Fracture involves enamel and dentin and the pulp is exposed. Crown-root fracture Fracture involves enamel, dentin and root structure; the pulp may or may not be exposed. Additional findings may include loose, but still attached, fragments of the tooth. There is minimal to moderate tooth displacement. Root fracture The coronal fragment is mobile and may be displaced. Alveolar fracture The fracture involves the alveolar bone. The tooth-containing segment is mobile. and usually displaced. Occlusal interference is often noted. The relation between the fracture and the pulp chamber will be disclosed. One exposure is useful to rule out the extent of fracture and stage of root development. In laterally positioned fractures, the extent in relation to the gingival margin can be seen. The fracture is usually located mid-root or in the apical third. The horizontal fracture line to the apices of the primary teeth and their permanent successors will be disclosed. A lateral radiograph may also give information about the relation between the two dentitions and if the segment is displaced in labial direction. Smooth sharp edges. If possible the tooth can be restored with glass ionomer filling material or composite. In very young children with immature, still developing roots, it is advantageous to preserve pulp vitality by pulp capping or partial pulpotomy. This treatment is also the choice in young patients with completely formed roots. Calcium hydroxide is a suitable material for such procedures. Both treatments should be considered whenever possible, otherwise extraction is indicated. Treatment recommendation is tooth extraction. Care must be taken to prevent trauma to the subjacent tooth bud. If the coronal fragment is displaced, extract only that fragment. The apical fragment should be left to be resorbed. Reposition any displaced segment and then splint. General anesthesia is often indicated. Monitor teeth in fracture line. Treatment guidelines for luxation injuries in the primary dentition Clinical findings Radiographic findings Treatment Concussion The tooth is tender to touch; it has no increased mobility or sulcular bleeding. Subluxation The tooth has increased mobility but has not been displaced. Bleeding from gingival crevice may be noted. No radiographic abnormalities. Normal periodontal space. Radiographic abnormalities are usually not found. Normal periodontal space. No treatment is needed. Observation. No treatment is needed. Observation. 200 Dental Traumatology 2007; 23: 196 202 Ó 2007 The International Association for Dental Traumatology

Guidelines for primary teeth Clinical findings Radiographic findings Treatment Extrusive luxation The tooth appears elongated and is excessively mobile. Lateral luxation The tooth is displaced, usually in a palatal/lingual direction. It will be often immobile. Intrusive luxation The tooth is usually displaced through the labial bone plate, or can be impinging upon the succedaneous tooth bud. Avulsion The tooth is completely out of the socket. Increased periodontal ligament space apically. Increased periodontal ligament space apically is best seen on the occlusal exposure. When the apex is displaced toward or through the labial bone plate, the apical tip can be visualized and appears shorter than the contra lateral tooth. When the apex is displaced towards the permanent tooth germ, the apical tip cannot be visualized and the tooth appears elongated. A radiographic examination is essential to ensure that the missing tooth is not intruded. Treatment decisions are based on the degree of displacement, mobility, root formation and the ability of the child to cope with the emergency situation. For minor extrusion (<3 mm) in an immature developing tooth, careful repositioning or leaving the tooth for spontaneous alignment are acceptable treatment options. Extraction is the treatment of choice for severe extrusion In a fully formed primary tooth. If there is no occlusal interference, as is often the case in anterior open bite, the tooth is allowed to reposition spontaneously. When there is occlusal interference, with the use of local anesthesia, the tooth can be gently repositioned by combined labial and palatal pressure. In severe displacement, when the crown is dislocated in a labial direction, extraction is the treatment of choice. If minor occlusal interference, slight grinding is indicated. If the apex is displaced toward or through the labial bone plate, the tooth is left for spontaneous repositioning. If the apex is displaced into the developing tooth germ, extract. It is not recommended to replant avulsed primary teeth. Follow-up procedures for traumatized primary teeth Time 1 week 2 3 weeks 3 4 weeks 6 8 weeks 6 months 1 year Uncomplicated crown fracture C Complicated crown fracture C C + R C + R Alveolar fracture C S + C + R C + R C + R (*) Root fracture No Displacement C C + R C + R C(*) Extraction C(*) Concussion/ Subluxation C C Lateral luxation Extrusion Spontaneous repositioning C C + R C + R Intrusion C C + R C C + R C + R C(*) Avulsion C C + R C + R C(*) S = Splint removal; C = Clinical exam R = Radiographic exam. (*) = Radiographic monitoring until eruption of the permanent successor Each subsequent year until exfoliation References 1. Andreasen JO, Andreasen FM, Andersson L. Textbook and color atlas of traumatic injuries to the teeth, 4th edn. Oxford: Blackwell Munksgaard; 2007. 2. Petersson EE, Andersson L, Sorensen S. Traumatic oral vs non-oral injuries. Swed Dent J 1997;21:55 68. 3. Glendor U, Andersson L. Public health aspects of oral diseases and disorders: dental trauma. In: Pine C, Harris R, editors. Community oral health. London: Quintessence Publishing; 2007. p. 203 14. 4. Glendor U, Halling A, Andersson L, Eilert-Petersson E. Incidence of traumatic tooth injuries in children and adolescents in the county of Vastmanland, Sweden. Swed Dent J 1996;20:15 28. 5. Andreasen JO, Andreasen FM, Bakland LK, Flores MT. Traumatic dental injuries. A manual, 2nd edn. Oxford: Blackwell Munksgaard; 2003. 6. Flores MT. Traumatic injuries in the primary dentition. Review. Dent Traumatol 2002;18:287 98. Dental Traumatology 2007; 23: 196 202 Ó 2007 The International Association for Dental Traumatology 201

Flores et al. 7. Maguire SA, Hunter B, Hunter LM, Sibert J, Mann MK, Kemp AM. Diagnosing abuse: a systematic review of torn frenum and intra-oral injuries. Arch Dis Child 2007 [Epub ahead of print]. 8. Cairns AM, Mok JY, Welbury RR. Injuries to the head, face, mouth and neck in physically abused children in a community setting. Int J Paediatr Dent 2005;15:310 8. 9. Serrano García MI, Tolosa Benedicto E, Forner Navarro L. Oral lesions due to child abuse. Identification of the problem and role of the professional. Med Oral 2001;6:276 89 (Article in English, Spanish). 10. Kramer PF, Feldens CA. Traumatismos na deintição decídua. Prevenção, Diagnóstico e Tratamento. Sao Paulo: Santos Editora Ltda; 2005. 11. Skaare AB, Jacobsen I. Primary tooth injuries in Norwegian children (1 8 years). Dent Traumatol 2005;21:315 9. 12. Borum MK, Andreasen JO. Therapeutic and economic implications of traumatic dental injuries in Denmark: an estimate based on 7549 patients terated at a major trauma centre. Int J Paediatr Dent 2001;11:249 58. 13. Kramer PF, Zembruski C, Ferreira SH, Feldens CA. Traumatic dental injuries in Brazilian preschool children. Dent Traumatol 2003;19:299 303. 14. Holan G. Long-term effect of different modalities for traumatized primary incisors presenting dark discoloration with no other signs of injury. Dent Traumatol 2006;22:14 7. 15. Raslan N, Wetzel WE. Exposed human pulp caused by trauma and/or caries in primary dentition: a histological evaluation. Dent Traumatol 2006;22:145 53. 16. Kupietzki A, Holan G. Treatment of crown fractures with pulp exposure in primary incisors. Pediatr Dent 2003;25:241 7. 17. Fuks AB. Current concepts in vital primary pulp therapy. Eur J Paediatr Dent 2002;3:115 20. 18. Spinas E, Melis A, Savasta A. Therapeutic approach to intrusive luxation injuries in primary dentition. A clinical follow-up study. Eur J Paediatr Dent 2006;7:179 86. 19. Gondim JO, Moreira Neto JJ. Evaluation of intruded primary incisors. Dent Traumatol 2005;21:131 3. 20. Sennhenn-Kirchner S, Jacobs HG. Traumatic injuries to the primary dentition and effects on the permanent successors a clinical follow-up study. Dent Traumatol 2006;22:237 41. 21. Christophersen P, Freund M, Harild L. Avulsion of primary teeth and sequelae on the permanent successors. Dent Traumatol 2005;21:320 3. 22. Sleiter R, von AT. Developmental disorders of permanent teeth after injuries of their primary predecessors. A retrospective study. Schweiz Monatsschr Zahnmed 2002;112:214 9. 202 Dental Traumatology 2007; 23: 196 202 Ó 2007 The International Association for Dental Traumatology