A Dental Student’s Guide to… dental trauma updates

In this month’s Dental Student’s Guide, Hannah Hook discusses the most recent updates to the guidelines for managing dental trauma.

Dental trauma most commonly occurs in children and young adults under the age of 19.

Approximately 33% of adults have had trauma to their permanent teeth. In addition, 25% of all school children have encountered some form of dental trauma.

The most common type of dental injury in the primary dentition is a luxation injury, compared to the permanent dentition which is most commonly a crown fracture.

The International Association of Dental Traumatology (IADT) first published a set of guidelines for the assessment, diagnosis and management of dental injuries in 2001. These guidelines give a very comprehensive guide to the various types of dental trauma, clinical findings, radiographic findings, treatment, follow-up and outcomes in both the primary and permanent dentition.

Guidance is based on the current available literature and expert professional judgement. It represents the best evidence regarding dental trauma. These guidelines were further updated in 2007, 2012 and most recently 2020.

The most recent guidelines have seen some key updates in the management of the various types of dental trauma, these are discussed below:


Replantation considerations

  • Patients are no longer advised to rinse the avulsed tooth with water prior to replantation – only milk or saline should be used
  • If the surface of the root is visibly contaminated, it should be cleaned by gentle agitation in storage medium or under a stream of saline
  • The best outcome is if the avulsed tooth is replanted within 15 minutes of avulsion
  • If the tooth is kept in storage medium and extra oral dry time is less than 60 minutes, the periodontal ligament cells are classed as ‘viable but compromised’
  • If the extra oral dry time is greater than 60 minutes, the periodontal ligament cells are likely to be ‘non-viable’, regardless of the storage medium
  • Whilst there is little evidence surrounding this, it is preferred that local anaesthetic without a vasoconstrictor is used. This is because the blood flow will not be restricted
  • All avulsed permanent teeth should be replanted as soon as possible regardless of extra oral dry time.

Splinting considerations

  • All avulsed teeth should be splinted for two weeks (it was previously four weeks if extra oral dry time was greater than 60 minutes)
  • If the avulsed tooth is associated with an alveolar fracture, a flexible splint should be used for four weeks
  • A passive and flexible wire should be used to splint the avulsed tooth – the thickness should be up to 0.016” or 0.4mm
  • A fishing line is also suggested as an alternative to wire for splinting.

Endodontic considerations

  • Teeth with an extra oral dry time of 60 minutes should no longer be root treated outside of the mouth
  • Endodontic treatment within two weeks is advised for all teeth with a closed apex
  • Choice of material for initial root treatment is non-setting calcium hydroxide (for four weeks), or a corticosteroid/antibiotic paste (for six weeks).

Fractures and Luxations

Permanent teeth

  • Teeth with a complicated crown fracture (pulp exposure) should undergo a pulp cap or pulpotomy. Extirpation is no longer the first line of treatment for these teeth (unless the tooth requires restoration with a post)
  • Teeth which have been traumatised can be expected to have a negative response to sensibility testing for several months (previously three months)
  • Endodontic treatment should not be started based on a negative sensibility result alone, even if this is three months post injury.

Primary teeth

  • If an intrusive injury has been sustained, teeth should be left in sit and reviewed. Advice is no longer to extract the tooth
  • Emphasis is placed on conservative management of the traumatised tooth, unless the child is at risk of inhalation of the tooth or pain.

Root resorption considerations 

  • Inflammatory root resorption is now termed ‘Infection related inflammatory root resorption’ (IRIRR)
  • If radiographs display any evidence of IRIRR, root canal treatment should be started immediately with non-setting calcium hydroxide (for four weeks) or a corticosteroid/antibiotic medicament (for six weeks).

Key points

  • All avulsed permanent teeth should be replanted as soon as possible, regardless of extra oral dry time
  • All avulsed permanent teeth with a closed apex should undergo root canal treatment within two weeks of replantation
  • Unless associated with an alveolar fracture, all avulsed permanent teeth should be splinted for two weeks
  • Extirpation of teeth with an exposed pulp should no longer be considered unless a post is required. These teeth should instead undergo a pulp cap or partial pulpotomy
  • A negative response to sensibility testing of a traumatised tooth can be expected for several months.

Email [email protected] for references.

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