By: Prof. Dr. Anne O’Connell

Children and adolescents with traumatic dental injuries (TDI) regularly present to dental practices on an emergency basis or for continued care following the traumatic injury. It is also likely that evidence of a previous TDI may be discovered during a routine examination. Th ere is no gold standard for management of dental injuries due to the huge variety of possible injuries and healing responses across all age groups. Th e International Association of Dental Traumatology (IADT) updates guidelines regularly to assist in the transfer of new evidence-based knowledge into practical actions. Th e most recent guidelines were published in 2020 and are available in several languages on their website (www.iadt-dentaltrauma.org). These guidelines are written to be used by all members of the dental team. In addition, IADT has published a series of short guidelines on dental trauma prevention that can support the dental team in educating parents, teachers, and sport coaches on the importance of preventing a dental injury and how to manage any dental injury in an emergency.

Th e options for pulp therapy and tooth repair and replacement are easy to understand when the injured tooth and the individual are mature. Most dentists however report a lack of confidence in managing acute trauma in younger age groups. Injuries in the primary dentition peaks between two to five years and again in permanent dentition between seven and ten years. Th e priority is to try to restore the injured teeth to normal function where possible. However, especially in immature permanent teeth there are complex issues, and advanced care is frequently required to improve outcomes following the injury. Several clinical issues arise after the initial traumatic event so understanding and managing these complications is an essential skill for the dental team. Understanding the biological basis of healing is critical to good clinical decision making. It is important to think about the injured tissues in the oral cavity: soft tissue (lip, gingiva, tongue) and hard tissue (tooth and bone). Th e goal is to maximize healing in each of these tissue types as soon as possible after the injury. When multiple teeth and tissues are involved, the clinician should prioritize critical healing. Parents and patients must understand the need to cooperate and engage with the management plan following injury. Parents should continue to provide tooth brushing for the non-injured teeth and supervise tooth cleaning or mouth rinsing for the first few days.

BASIC PRINCIPLES FOR THE DENTAL TEAM:

1. Clean the wound and prevent infection.
   a. In an emergency, cleaning the wound and stopping bleeding will allow better evaluation of the injury.
2. Diagnose and document the injury to each tooth. Examine adjacent and opposing teeth as well as the soft tissue.
   a. Photographs are an excellent record.
   b. Radiographs may be required, but make every exposure count (ALARA principle).
   c. List a diagnosis for each tooth as this will guide appropriate management and recall.
3. Look at the IADT guidelines ( www.iadt-dentaltrauma.org).
4. Stabilize the injury.
   a. Soft tissue injuries are commonly contusions or abrasions which will heal within seven to ten days. Lacerations may require apposition of the damaged tissue with sutures (resorbable).
   b. The use of splints to stabilize the injury will also encourage healing of the bone and periodontal ligament. Splinting types and duration are outlined in the IADT Guidelines.
   c. Where dentine has been exposed, cover the tubules by reattaching the fragment, placing a temporary/complete restoration.
   d. When pulp has been exposed, preventing bacterial ingress is essential by creating a barrier between the oral fluids and the damaged tissue. The sooner the better for the comfort of the child, but Cvek has shown that a pulpotomy can be successful up to seven days after the initial injury.
5. Consider what treatment must be completed on the day of emergency and what can be deferred or referred to a more appropriate setting. Preservation of pulp is advantageous in immature permanent teeth as further root development is promoted.
6. Endodontic intervention may be appropriate, and current protocols maximize the success of treatment.
7. Follow up is required for all dental injuries as complications are anticipated and outcomes can be mitigated with correct interventions.
8. Children and their parents need to be involved in the plan, so communication is essential.
9. Professional colleagues such as pediatric dentists, endodontists, restorative dentists and orthodontists are invaluable resources when planning long-term management of injuries in children.

The current knowledge on the management of traumatic dental injuries, both in acute situations and in the long-term follow-on care for the child has been changing over the past few years. Each dental team should keep abreast of the changes so their confidence in managing dental trauma improves and better outcomes are achieved for the patients.

Decision time – What will you do?

Dr. Anne O’Connell is a board-certified pediatric dentist. Previously on faculty in Eastman Dental Center, the University of Maryland and the National Institute of Dental and Craniofacial Research, Dr. O’Connell is currently Head of Pediatric Dentistry at Trinity College, Dublin, and runs the only Pediatric Dentistry PG training course in Ireland.