Injuries to Permanent Dentition Symposium
Dental Trauma Guidelines
Leif K. Bakland, DDS
Abstract
Guidelines have been developed for management of
numerous medical and dental conditions. If carefully
developed and based on best available evidence,
they serve a very useful purpose in giving information
in dealing with health problems to health care
providers as well as patients. The history of trauma
guidelines is quite limited, but the American Associa-
tion of Endodontists has been involved since the
1980s. In recent years, the International Association
of Dental Traumatology has developed guidelines for
management of traumatic dental injuries, with input
from specialists in all relevant disciplines of dentistry.
These guidelines, first developed and published in
2001 and updated twice since then, have been
accepted as reliable recommendations for the urgent
care of traumatic dental injuries; the most recent
trauma guidelines were completed by the International
Association of Dental Traumatology and published in
2012. The application of these guidelines is to provide
both patients and practitioners with the best available
information about management of such injuries. As
with most guidelines, there are limitations that are
primarily related to the level of evidence available,
which is low. However, they are useful and, when fol-
lowed, can lead to better outcomes than when no
guidelines are used. (J Endod 2013;39:S6–S8)
Key Words
Dental trauma, guidelines, replantation, tooth avulsion,
trauma guidelines
From School of Dentistry, Loma Linda University, Loma
Linda, California.
This article is being published concurrently in Pediatric
Dentistry 2013;35(2). The articles are identical. Either citation
can be used when citing this article.
Address requests for reprints to Dr Leif K. Bakland, 11092
Anderson Street, School of Dentistry, Loma Linda University,
Loma Linda, CA 92350. E-mail address: lbakland@llu.edu
0099-2399/$ - see front matter
Copyright ª 2013 American Academy of Pediatric Dentistry
and American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2012.10.021
S6 Bakland
G uidelines are extensively used in medicine and dentistry and are recognized as
important components for both diagnosis and treatment; the United States Depart-
ment of Health and Human Services provides a website (http://guideline.gov) contain-
ing a number of guidelines. In terms of traumatic dental injuries, various disciplines
have published guidelines, including the American Association of Endodontists
(AAE), the American Academy of Pediatric Dentistry (AAPD), and the American Asso-
ciation of Oral and Maxillofacial Surgery (AAOMS).
The AAE began developing guidelines for avulsed teeth in the 1980s and has pub-
lished several trauma guidelines since then, as will be described later.
The AAPD (1) has recently addressed management of acute dental trauma in chil-
dren on the basis of a literature search and expert consensus resulting in new recom-
mendations. Although the introduction states that they are congruent with the 2007
International Association of Dental Traumatology (IADT) guidelines, one major differ-
ence with the IADT guidelines is the AAPD’s concern for replanting avulsed teeth in chil-
dren because of the possible future chance of ankylosis. This was a concern for Barrett
and Kenny (2) as well, and it will be addressed later.
The AAOMS provides recommendations through their website (http://www.
aaoms.org/facial_injury.php). One recommendation is for the use of mouth guards
(3). Otherwise, specific recommendations for various dental injuries are primarily
related to prevention of injuries and the role of surgeons in treating facial trauma.
Guidelines are of global interest. For example, in the United Kingdom, national
clinical guidelines for treatment of traumatically injured teeth have been developed
(4). They are quite similar to the IADT guidelines, with some minor variations such
as recommending against replantation of teeth in young patients if ankylosis is expected.
There is worldwide interest in good information about the best treatment for such
injuries, which demands that the best available evidence be used in the development
of guidelines.
The IADT has been very actively involved in developing and updating guidelines for
the management of traumatic dental injuries for many years. Recently, the guidelines,
first published in 2001 (5) and subsequently updated in 2007 (6), have been updated
again with incorporation of current information from the literature. They have been
published both online (www.iadt-dentaltrauma.org) as well as in Dental Traumatol-
ogy (7–9). The updating of these IADT dental trauma guidelines (IADT-DTGs) was
completed by 3 multidisciplinary international committees (Fractures and Luxations,
Avulsions, and Primary Teeth), with practitioners from pediatric dentistry,
endodontics, oral and maxillofacial surgery, and general dentistry participating in
the committees. The global representation and broad range of expertise ensured
a comprehensive approach to the problem of traumatic dental injuries. The IADT-
DTGs are readily available online at no cost and are a great source of information
for both professionals and patients. The usefulness and application of the guidelines
are quite evident and will be emphasized in this presentation.
History of Dental Trauma Guidelines
The earliest trauma guidelines produced by the AAE go back to 1982 when
a committee appointed by Dr Noah Chivian, then AAE president, developed a set of
guidelines for the treatment of avulsed teeth (10). It was subsequently submitted as
a letter to the editor of the Journal of the American Dental Association by the
committee chair, Dr Joe Camp (11). It is interesting to note that the committee members
agreed that the guidelines would be a ‘‘working document’’ that would be modified as
new information became available. Milk was already recognized as a suitable transport
medium, and attempts to ‘‘revitalize the pulp’’ in teeth with open apexes were
JOE — Volume 39, Number 3S, March 2013
 Injuries to Permanent Dentition Symposium
recommended. Another interesting aspect of these guidelines was that
antibiotics were not recommended ‘‘unless medically indicated or in
cases of contaminated avulsion.’’
In the 1990s another ad hoc committee was appointed by then AAE
President Dick Burns to revise the guidelines for the avulsed tooth. A
controversial issue arose concerning the length of time that calcium
hydroxide (CH) should remain in the root canal system before canal
obturation. Initially, it was suggested that the canal could be filled after
7–14 days of CH. Later, a recommendation was made to leave it in for 6–
24 months before obturation. The basis for the revision was the then
current literature and expert opinion; the latter may be the reason
that the committee initially recommended that root canals of replanted
teeth could be obturated after 7–14 days of CH treatment rather than the
longer time period recommended before. The committee consisted of
American members only, and in their experience, short periods of CH
treatment appeared to work satisfactorily (12). The short CH treatment
time was questioned by a number of members on the basis of their expe-
rience. A subcommittee of the original ad hoc committee was appointed
and asked to evaluate the Scandinavian claim and to modify, if appro-
priate, the guidelines for avulsed teeth. The 1995 revised version con-
tained the Scandinavian suggestion to treat with CH for 6–12 months
before obturation (13).
In 2002, another AAE ad hoc committee was appointed and
charged with the task of developing a set of guidelines for all traumatic
dental injuries and not just avulsions. The AAE committee recognized
that the IADT had already produced a set of such guidelines (5). The
IADT committee that had produced these guidelines consisted of inter-
national specialists from several disciplines including endodontics. The
AAE ad hoc committee studied the IADT guidelines and came to the
conclusion that they would serve the AAE well, so in February 2003
the committee recommended that the AAE adopt the IADT guidelines
as published in the Journal of Dental Traumatology (5). They were
adopted by the AAE in 2004 (14) and are the currently available trauma
guidelines on the AAE website.
Application of Guidelines
The purpose of guidelines is to give health care providers conve-
nient access to current recommendations for treatment that are based
on the best evidence available. The recently published (7–9) IADT-
DTGs meet the criteria for being based on the best evidence. In addition,
the broad-based background of the committee members ensures that
the various experts’ points of view were considered and extensively dis-
cussed before adopting guidelines consensus.
Guidelines may be focused narrowly, as the IADT-DTGs are, to
stress the urgent care approach of managing traumatic dental injuries.
The purpose for that is to avoid confusion and reduce the amount of
information needed to stabilize trauma situations. Properly focused
initial treatment allows subsequent follow-up and evaluation of teeth
that may be lost if not initially managed optimally. Andreasen et al
(15) addressed concerns about initial treatment delay and its effect
on the pulpal and periodontal ligament recovery. Stewart et al (16)
pointed out that following guidelines with respect to pulp management
favored a better outcome. This was further supported by Hinckfuss and
Messer (17), who reported that the timing of pulp extirpation after
replantation (recommended to be done within 10–14 days) was impor-
tant in the reduction of the incidence of infection-related (inflamma-
tory) root resorption.
A recent report by B€ucher et al (18) further illustrates the value of
using the IADT-DTGs in the management of dental trauma. The authors
reported that when trauma patients were treated according to the IADT-
DTGs that were valid at the time (the ones published in 2001 [5] and
JOE — Volume 39, Number 3S, March 2013
2007 [6]), they had lower rates of post-trauma complications than
those in patients who were managed without the use of the guidelines.
The authors emphasized the importance of regular follow-ups to treat
complications in a timely manner. Endodontists are specifically trained
to manage many of the complications such as pulpal problems and root
resorption. It is troubling that currently best evidence, as exemplified by
updated guidelines, is not routinely applied by all dentists managing
patients with traumatic dental injuries.
The IADT-DTGs recommend a biological approach to the urgent
care of dental injuries:
1. Stabilize the injury by carefully repositioning displaced entities and
suturing soft tissue lacerations.
2. Eliminate or reduce the complications from bacterial contamination
by rinsing and flushing with available liquids and use of chlorhexi-
dine when possible.
3. Promote the opportunity for healing by replanting avulsed teeth and
repositioning displaced teeth.
4. Make every effort to allow continued development of alveolar ridges
in children.
The latter issue became a concern for pediatric dentists and others
and led to the recommendation to avoid replantation if there is a risk of
ankylosis preventing continued alveolar ridge development (1, 2).
However, the introduction of decoronation, a procedure to be used
early when ankylosis is observed in a developing child, allows
replantation, even when ankylosis is expected. This procedure has
been shown to provide improved long-term treatment options in cases
of ankylosis of replanted teeth (19, 20).
Expanding the guidelines can be accomplished by interested
dental disciplines; for instance, the AAOMS includes in its recom-
mendations information about protective mouth guards (3), and
the pediatric dentistry guidelines (1) provide information about
orthodontic movement of teeth after trauma. Possibly the AAE
may want to broaden the focus of the guidelines by including
recommendations for the management of young, developing teeth
with necrotic pulps with description of procedures for pulp replace-
ment. Furthermore, orthodontists could recommend techniques for
closing dental spaces after traumatic tooth loss in young children.
However, it seems reasonable to keep the focus for general guide-
lines narrowly focused on the urgent care management of traumatic
dental injuries.
A companion website to the IADT-DTGs has been the Andreasen
Dental Trauma Guide, www.dentaltraumaguide.org. This interactive
guide parallels the IADT-DTGs in its trauma description and recom-
mendations but provides more extensive information and description
of procedures. Dr Jens Ove Andreasen has been the primary force
behind the development of the Guide. The basis for the information
is, first, from the increasing amount of dental literature devoted to
dental traumatology and, second, from the extensive clinical data
and records from thousands of patients with all types of dental
injuries treated at the University Hospital in Copenhagen, Denmark.
The combination of the IADT-DTGs and the Andreasen Dental
Trauma Guide provides both dentists and patients with up-to-date
and readily accessible information.
Limitations
Although it has been shown that following published guidelines
for dental trauma management has resulted in better outcomes than
when guidelines are not followed (15–18), one should probably
not assume that guidelines are established standards of care; the
judgment of the clinician in each individual clinical situation is
Dental Trauma Guidelines S7
Injuries to Permanent Dentition Symposium
an essential component of treatment recommendations. The
following disclaimer is prudently included in the publication of
the IADT-DTG:
Disclaimer: These guidelines are intended to provide infor-
mation for health care providers caring for patients with
dental injuries. They 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, but
using the recommended procedures can maximize the chan-
ces of success. (7–9)
Following guidelines where applicable, however, would lend
support for having performed recommended procedures if a legal
complication should arise. As pointed out by Niederman et al (21)
with regard to evidence-based dentistry, adhering to evidence-based
dentistry may protect one from unjust criticism from peers and patients,
but it is no guarantee against possible legal complaints.
Recommendations
The current IADT Guidelines are readily available to anyone,
dentists and patients alike, online (www.iadt-dentaltrauma.org) and
in print (7–9). Many patients are aware of the Guidelines, and
endodontists, who are frequently the specialist involved in dental
trauma management, will benefit from being able to discuss specific
treatment with patients and/or their parents. The value of following
guidelines that are based on best evidence is clearly evident in terms
of convenience in finding specific procedures to follow as well as
expectations of a reliable outcome.
Summary
Guidelines have been developed for management of numerous
medical and dental conditions. The AAE recognized the need for devel-
oping guidelines for avulsed teeth in the early 1980s and updated these
guidelines in the 1990s. When subsequently it was recognized that such
guidelines needed to be expanded to include additional dental injuries,
the AAE adopted guidelines developed by the IADT in 2001. The IADT
committee that worked on the expanded guidelines included endodon-
tists as well as specialists from other dental disciplines. These guidelines
are used by both patients and health care providers to manage traumatic
dental injuries, and they have become available worldwide through the
Internet. As with most guidelines, there are limitations that are primarily
related to the level of evidence available, which is low. However, they are
useful, and when followed, they can lead to better outcomes than when
no guidelines are used.
Acknowledgments
The author denies any conflicts of interest related to this study.
S8 Bakland
References
1. American Academy of Pediatric Dentistry (AAPD). Guidelines on Management
of Acute Dental Trauma. Chicago, IL: American Academy of Pediatric Dentistry;
2011.
2. Barrett EJ, Kenny DJ. Survival of avulsed permanent maxillary incisors in
children following delayed replantation. Endod Dent Traumatol 1997;13:
269–75.
3. American Association of Oral and Maxillofacial Surgeons. Treating and preventing
facial injury. Available at: http://www.aaoms.org/facial_injury.php. Accessed
November 27, 2012.
4. Paediatric Dentistry–UK. National clinical guidelines and policy documents
1999. Available at: http://www.nhsbsa.nhs.uk/documents/archivepdf/paediatric_
dentistry_uk1999.pdf. Accessed November 27, 2012.
5. Flores MT, Andreasen JO, Bakland LK. Guidelines for the evaluation and manage-
ment of traumatic dental injuries. Dent Traumatol 2001;17:1–4. 49–52, 97–102,
145–8, 193–6.
6. Flores MT, Andersson L, Andreasen JO, et al. Guidelines for the management of trau-
matic dental injuries: I—fractures and luxations of permanent teeth. Dent Trauma-
tol 2007;23:66–71. 130–6, 196–202.
7. DiAngelis AJ, Andreasen JO, Ebeleseder KA, et al. International Association of
Dental Traumatology guidelines for the management of traumatic dental
injuries: 1—fractures and luxations of permanent teeth. Dent Traumatol
2012;28:2–12.
8. Andersson L, Andreasen JO, Day P, et al. International Association of Dental Trau-
matology guidelines for the management of traumatic dental injuries: 2—avulsion
of permanent teeth. Dent Traumatol 2012;28:88–96.
9. Malmgren B, Andreasen JO, Flores MT, et al. International Association of
Dental Traumatology guidelines for the management of traumatic dental
injuries: 3—injuries in the primary dentition. Dent Traumatol 2012;28:
174–82.
10. American Association of Endodontists. Recommended Guidelines for Treatment
of the Avulsed Tooth. Chicago, IL: American Association of Endodontists; 1982.
11. Camp J. Treatment of the avulsed tooth [letter to the editor]. J Am Dent Assoc
1983;107:706.
12. American Association of Endodontists. Recommended Guidelines for Treat-
ment of the Avulsed Tooth. Chicago, IL: American Association of Endodon-
tists; 1994.
13. American Association of Endodontists. Recommended Guidelines for Treat-
ment of the Avulsed Tooth. Chicago, IL: American Association of Endodon-
tists; 1995.
14. American Association of Endodontists. Recommended Guidelines of the American
Association of Endodontists for the Treatment of Dental Injuries. Chicago, IL:
American Association of Endodontists; 2004.
15. Andreasen JO, Andreasen FM, Skeie A, et al. Effect of treatment delay upon pulp and
periodontal healing of traumatic dental injuries: a review article. Dent Traumatol
2002;18:116–28.
16. Stewart CJ, Elledge RO, Kinirons MJ, Welbury RR. Factors affecting the timing of pulp
extirpation in a sample of 66 replanted avulsed teeth in children and adolescents.
Dent Traumatol 2008;24:625–7.
17. Hinckfuss SE, Messer LB. An evidence-based assessment of the clinical guidelines
for replanted avulsed teeth, part I: timing of pulp extirpation. Dent Traumatol
2009;25:32–42.
18. B€ucher K, Neuman C, Hickel R, K€uhnisch J. Complications and survival of teeth after
trauma over a 5-year-period. Clin Oral Invest 11 August 2012. DOI 10.1007/
s00784-012-0817-y.
19. Andreasen JO, Malmgren B, Bakland LK. Tooth avulsion in children: to replant or
not. Endod Topics 2006;14:28–34.
20. Cohenca N, Stabholz A. Decoronation: a conservative method to treat ankylosed
teeth for preservation of alveolar ridge prior to permanent prosthetic
reconstruction—literature review and case presentation. Dent Traumatol 2006;
23:87–94.
21. Niederman R, Richards D, Brands W. The changing standards of care: guest edito-
rial. J Am Dent Assoc 2012;143:434–7.
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