2018 MEETING OF THE WORLD CONGRESS ON DENTAL

TRAUMATOLOGY Garry L. Myers, DDS

Evaluation and Diagnosis

of the Traumatized Dentition

ABSTRACT
SIGNIFICANCE
Traumatic dental injuries comprise a number of the dental emergency patients who are often
seen after hours or on an unscheduled basis in a dental practice environment. Although there Treatment errors when
are a variety of traumatic dental injuries that can occur, each with their own recommended managing traumatic dental
treatment protocols, the initial evaluation and diagnosis of the traumatized dentition make up a injuries are often a result of
critical aspect of the management of these cases. This article will highlight the key improper initial assessment.
components of a thorough and efficient examination process of the traumatized dentition to Obtaining a history, clinical and
include (1) documenting an accurate history of the events causing the injury, (2) performing a radiographic examinations,
systematic clinical examination to include the use of clinical photographs and pulp sensibility and diagnostic testing must be
tests, (3) obtaining appropriate radiographic images and scans, (4) understanding some thorough, yet quick and
considerations unique to evaluating young patients with traumatic injuries, and (5) recognizing efficient. Once this information
the importance of having accurate and thorough documentation of these types of cases. has been obtained, it needs to
Once the evaluation and diagnosis phase has been completed, the necessary treatment be properly interpreted and
protocols can be initiated in an appropriate manner. (J Endod 2019;-:1–6.) documented to facilitate future
follow-up examinations. This
KEY WORDS article aims to provide an
Clinical examination; diagnosis; pulp sensibility testing; radiographs; traumatic dental injuries overview of the steps required
for a good diagnosis and
evaluation of traumatic dental
In both medicine and dentistry, a thorough evaluation and diagnosis of the patient’s presenting condition injuries.
are imperative because this initial assessment sets the table on what is to be recommended regarding
treatment, follow-up examinations, and long-term outcomes. In dentistry, and even more importantly
dental traumatology, evaluation and diagnosis can often be the most challenging aspect of a case from
start to finish. When a patient presents with dental injuries from a traumatic blow to the teeth and
surrounding soft tissues, not only is an initial examination important in these cases, but this process
needs to be thorough and efficient so that the immediate treatment needs can be addressed.
Evaluation and diagnosis of the traumatized dentition can present challenges to the provider that
differ from a routine scheduled examination. Although traumatic dental injuries are infrequent in
occurrence in the daily routine of the general dental practice, it has been estimated that one third of the
population has suffered a dental injury at some point in their lives. The initial emergency treatment of the
traumatized dentition can and will have lifelong effects for not only the tooth/teeth involved but also for the
individual patient. It has been recognized that treatment mistakes made in the management of traumatic
dental injuries are often a result of an improper initial assessment. It should be noted that before evaluating From the Virginia Commonwealth
the traumatized dentition, one needs to have a sound knowledge base of the various types of traumatic University School of Dentistry, Richmond,
Virginia
injuries that can occur. These dental injuries can range from various types of crown fractures
(uncomplicated, complicated, and crown-root fractures), luxation injuries (concussion, subluxation, Address requests for reprints to Dr Garry
extrusion, intrusion, lateral luxation, and avulsion), and root fractures (horizontal, oblique, and vertical root L. Myers, Virginia Commonwealth
University School of Dentistry, Lyons
fractures)1. Recognition of jaw fractures and head and neck injuries is also a critical part of the initial Dental Building, 520 North 12th Street,
evaluation process. Early recognition of the type of dental injury that has occurred is a key step in the Box 980566, Richmond, VA, 23298.
evaluation of the traumatized dentition. This article will focus on the process of the evaluation and E-mail address: gmyers3@vcu.edu
diagnosis of the traumatized dentition. 0099-2399/$ - see front matter
Copyright © 2019 John Wiley & Sons A/S
and American Association of
Obtaining a History Endodontists. This article is being
Obtaining a thorough and accurate account of the events that led to the traumatic injury is a must; published concurrently in Dental
however, this information gathering needs to be done expeditiously. Of some immediate concern is Traumatology. The articles are identical.
Either citation can be used when citing this
recognizing whether there are more serious injuries present other than just the dental injuries. Was there article.
any loss of consciousness by the victim at the time of the traumatic episode? Were there any significant https://doi.org/10.1016/
head and neck or neurologic injuries that may have occurred? The Glasgow Coma Scale is one rapid way j.joen.2019.05.015

JOE  Volume -, Number -, - 2019 Evaluation and Diagnosis of Traumatized Dentition 1

of assessing the patient for any severe brain
injuries2. This is a quick but simple method of
scoring potential head injuries on the basis of 3
response types:
1. opening of the eyes,
2. verbal responses, and
3. motor responses (Table 1).
If no obvious brain injuries have
occurred, a quick assessment for potential jaw
fractures should be performed whether they
involve the maxilla, the body of the mandible,
or the mandibular condyles. This can be done
by looking at any malocclusions present and/
or getting a panoramic image or a cone-beam
computed tomography (CBCT) scan early in
the evaluation process.
Once a serious head, neck, or brain
injury has been ruled out, obtaining more
details of the traumatic event leading to the
dental injuries is important. When, where, and
how did the injury occur? Was the dental injury
a result of the dentition coming into contact
with a solid immovable object (such as the
ground or a wall), or was it a result of being hit
by a moving object (such as a baseball or an
elbow)? Knowing this can help provide some
understanding of how and where the force of
the impact was dissipated at the time of the
injury. It has been well-documented that dental
injuries occur as a result of many scenarios—
contact sports, falls, motor vehicular
accidents, and careless childhood behavior3.
What is probably much less documented (and
possibly less recognized) are injuries sustained
from domestic abuse and/or criminal activities.
This continues to illustrate the importance of
obtaining a thorough history, documenting it,
and ultimately determining whether the present
injuries are consistent with the given cause. Be
TABLE 1 - The Glasgow Coma Scale
Category Grade
Opening of the eyes 4–spontaneous
3–to speech
2–to pain
1–none
Best verbal response 5–oriented
4–confused
3–inappropriate
2–incomprehensible
1–none
Best motor response 6–obeys commands
5–localizes pain
4–withdraws
3–flexion to pain
2–extension to pain
1–none
A Glasgow Coma Score cumulative score of 3–8 indicates
a severe brain injury, a score of 9–12 a moderate head
injury, and a score of 13–15 a mild closed head injury.
2 Myers
thorough, be systematic, be accurate, and be
efficient in documenting the details of the
traumatic event in an organized manner.
The Clinical Examination
Documenting the initial presentation of the
traumatized dentition is very important
because there is only one opportunity to
accomplish this task. Be systematic in your
approach! With the more serious injuries either
ruled out or already managed, one of the best
steps to begin with is to take clinical
photographs of the teeth and soft tissue
injuries. Clinical photographs provide excellent
documentation of the injuries and just as
importantly provide a baseline for comparing
future clinical photographs of the healing areas
over time. Although one does not need to be a
professional photographer in these situations,
developing your dental photography skills will
enhance your abilities as a great diagnostician
and treatment provider.
Making observations of the soft tissues
is the first step. Are there facial or lip
contusions or lacerations? Are there gingival
tears or abrasions present? Has the tongue
sustained any injuries from being caught
between teeth or other foreign objects? These
soft tissues can be examined quickly, and
when bleeding or hemorrhaging has occurred,
these injuries should be gently cleaned,
debrided, and repaired as needed. Clearing
the site of injury from any bleeding and/or dried
blood remnants will enhance the ability to
examine the teeth and record the dental
injuries that have occurred. Additional clinical
photographs may be desirable or useful after
the initial cleaning and hemorrhage control of
the area has been completed.
One of the first observations seen as a
result of a traumatic dental injury could be a
disturbance in the occlusion or bite of the
patient. Disturbances of the bite may often
indicate the presence of 1 of 2 types of injuries,
either a bone fracture or teeth that have been
displaced from their original position (luxation
injuries). Once the etiology of the bite
displacement has been determined, then the
course of subsequent emergency treatment
protocols can start to be planned. Next the
teeth should be examined for any evidence of
crown fractures. When a crown fracture has
occurred, has the pulp been exposed? Does
the fracture line extend down onto the root?
Establish the extent of any crown fractures
because this will help prioritize the treatment
sequence. There was a time when the thought
process was that if a dental pulp was exposed,
the pulp should then be removed. However,
Cvek et al4 showed in 1982 that in cases of
traumatic pulp exposures, inflammatory
changes and bacterial penetration into the pulp
tissues differed significantly from scenarios
related to carious pulp exposures. Their
recommendation of doing partial pulpotomies
in these cases provided a predictable
treatment modality of managing the
traumatically exposed pulp while also
preserving a viable pulp in developing teeth.
On careful evaluation in these situations, pulp
capping, partial pulpotomies, full pulpotomies,
or full root canal therapy of the tooth may
present the best course of action as
emergency treatment5.
Color changes in the traumatized tooth
can also be a notable clinical finding, although
these changes often occur after a period of
time has passed since the injury. These
changes are easily noted when compared
with clinical photographs taken before or after
the time of the injury. Color changes of the
crown of the tooth can provide some
additional insight regarding the pulp status of
traumatized teeth over time. These changes
can be a result of the pulp undergoing pulp
necrosis, or they might reflect a response by
the pulp where tertiary dentin is being formed
as the pulp tissues undergo calcific
metamorphosis, or they might be an
indication of an internal or external resorptive
process developing. Although color changes
of the traumatized tooth can be observed
after injuries, it should be noted that there are
wide variations in the relationship between
color changes of teeth and traumatic dental
injuries.
In the event that there are missing teeth
or tooth fragments, it is imperative that the
emergency provider make an effort to account
for the whereabouts of the missing structures.
Are these embedded in the lip or cheek? Were
they swallowed? Or were they left at the site of
the injury? Use of radiographs may help
answer these questions, but digital palpation
of any soft tissues where lacerations have
occurred will also help address these
concerns. It is important that none of these
missing fragments or teeth are left behind in
the surrounding soft tissues after the initial
treatment.
Pulp Sensibility Testing
The dental pulp has a remarkable capacity to
heal after insults or injury, especially dental
pulps in young, immature teeth. Although
pulp sensibility and periapical testing is an
important aspect of any evaluation of the
dental pulp tissues, it should be noted that
pulp responses in the traumatized dentition
should not be the primary finding that
influences either a pulp diagnosis or a
treatment plan. These early diagnostic tests
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TABLE 2 - Percentage of Dental Pulps Remaining
Viable after Luxation Injuries
Concussions 97%
Subluxations 94%
Extrusive luxations 74%
Lateral luxations 42%
Intrusive luxations 15%
should simply establish some baseline
information and be interpreted as one part of
the overall evaluation process of the
traumatized dentition. As far back as 1973,
Bhaskar and Rappaport6 reported that “pulps
in traumatized teeth can be in shock for a
week”. Their report described observations
where live pulps were found upon their
removal from 25 teeth that were
nonresponsive to cold testing after traumatic
injuries. That same year Barkin7 reported that
pulp testing results can be inconclusive for up
to 3 months after a traumatic dental injury.
Twenty-three years later, Feiglin8 reported
that the pulp status of traumatized teeth
should be monitored for up to 5 years, with
treatment only being initiated following the
development of clinical signs/symptoms or
radiographic changes consistent with
developing apical pathosis. When pulps are
nonresponsive to thermal pulp testing, there
are 2 radiographic changes that would
indicate the presence of a viable pulp in the
tooth; one is the development of calcific
changes in the pulp space, and the other is
evidence of continued root maturation and
apical closure in immature roots. Establishing
baseline pulp sensibility information is critical
for future follow-up assessments of these
teeth. What is the likelihood of dental pulps
remaining viable after traumatic dental
injuries? Andreasen and Pedersen9 reported
findings related to luxation injuries, and they
found a wide variation of responses
dependent on the type of luxation injury
incurred (Table 2). In horizontal root fracture
cases, pulps have been found to survive in
the coronal segment for at least 75% of
cases and in the apical segment for almost
every case10,11. These findings reinforce the
necessity for recognizing and identifying the
presenting traumatic dental injury and
understanding the resiliency that the pulp
tissues have in surviving these injuries when
doing the initial evaluation of the traumatized
dentition. Most traditional pulp sensibility
testing methods have centered around the
stimulation of and the recording of neural
responses of the pulp, when in fact it is an
intact vascular supply that most clinicians
accept as being the key factor. Alternative
pulp testing methods have been considered
and studied that focus on assessing the
JOE  Volume -, Number -, - 2019
pulp’s vascular supply within a tooth. Pulse
oximetry12 and ultrasonic or laser Doppler
flowmetry13 are a few examples of pulp
testing modalities that have been looked at,
and future studies are needed in these areas
to see how they can improve on the
assessment of the pulp tissues after traumatic
dental injuries.
The Radiographic Examination
Radiographic images have always been a key
element in any thorough dental examination,
whether it is a routine examination or an
emergency examination such as seen in
scenarios involving traumatic dental injuries.
Similar to pulp sensibility testing, radiographic
images are important in establishing and
documenting baseline information at the time
of the initial examination for comparison with
future follow-up evaluations and images.
Although taken for granted by many clinicians
and technicians, it is imperative that
reproducible images be taken over time to
accurately assess the healing responses of the
injured structures. Before CBCT, the
recommended radiographic standard for
evaluating traumatic dental injuries included
taking periapical images from different angles,
occlusal images of anterior segments, and a
panoramic image14. Each of these views
provide a different perspective of the injuries,
ranging from a general overview (panoramic
image) down to specific details seen in various
angled periapical images. With the introduction
of CBCT, the details of these injuries have been
more accurately illustrated and in a three-
dimensional format15. Radiographic images
and CBCT scans are essential to help show
fractures of bone and roots of the teeth. In
situations where teeth appear to be missing,
these images help assess whether a tooth was
intruded or avulsed when the victim presents
without a tooth in its place. If tooth fragments
are missing, radiographic images allow the
clinician to examine whether these missing
fragments may have been imbedded into the
cheek, lip, or surrounding soft tissues.
Radiographic images taken at follow-up
examinations will often provide the first
evidence of developing root resorption
subsequent to traumatic injuries. Identifying
the type of root resorption and providing the
best early management of these processes will
go a long way toward improving the outcomes
of these teeth. In cases involving teeth with
incompletely developed roots and open apices
at the time of trauma, it is imperative that
reproducible and diagnostic images are taken
over time. Monitoring of any further
development of the root maturation process
can be noted showing evidence of the
Evaluation and Diagnosis of Traumatized Dentition
presence of viable pulp tissue. The as low as
reasonably achievable principles of radiation
exposure of patients need to be kept in mind;
however, the value of diagnostic and
reproducible images of the traumatized
dentition is a key element of management of
these injuries.
Other Factors to Consider
Gathering information on the history of the
traumatic injury and performing thorough
clinical and radiographic examinations are
critical when first evaluating a patient with a
traumatic dental injury. However, one should
also be aware of other factors that cannot be
overlooked at this initial patient visit. Many
times, these types of traumatic dental injuries
involve children, and often both the child and
their parents will be emotionally traumatized
with the recent sequence of events. After the
initial evaluation, explaining treatment
alternatives can be a delicate situation with the
emotional mindset of both the patient and
parents. If it is someone other than a legal
guardian who brings a minor in with an injury
(such as a youth sports coach), gaining
consent for treatment may create an
unanticipated obstacle. In cases of injuries
resulting from any type of traumatic episode,
interested third parties may get involved (such
as private insurance carriers or lawyers). Once
third-party involvement enters the picture,
treatment records can be requested and/or
subpoenaed. Examination methods and
treatment decisions could be scrutinized. This
brings up one final aspect of the diagnosis and
evaluation of the traumatized dentition, and
that is good recordkeeping. Accurate,
organized, and concise recordkeeping is
imperative in any case involving the
traumatized dentition and surrounding
structures. Documentation should be legible,
and radiographic images should be of
diagnostic quality. Clinical photographs will
always strengthen documentation records.
Although there is no single established way to
document traumatic dental injury cases, many
providers have created their own standardized
form to help ensure that their records are
complete and thorough. An example has been
provided illustrating the degree of accuracy
and detail that should document a traumatic
dental injury (Fig. 1). Dental records should
provide areas for the evaluation, treatment,
and follow-up care for virtually any kind of
traumatic injury.
FINAL THOUGHTS
Evaluation and diagnosis of the traumatized
dentition are simply the first steps in the care
and professional management of a patient who
3
 Trauma c Injury Form

Date_____________ Name_________________________________ Tooth/Teeth #’s_______________

Referring office ______________________________________

Trauma history Radiographic examina on

Age at me of injury__________________ Images taken____________________________
Cause of injury_______________________ Horiz rt fx: {} none {} apical {} mid {} cerv
Date/ me of injury___________________ Bone fx: Y N ________________________
Place of injury_______________________ Apical pathology: Y N
Loss of consciousness? ________________ Apical foramen: {} open {} narrow {} closed
Previous injury? _____________________

Clinical Examina on Treatment provided

So ssues: {} abrasion {} lacera on {} puncture
Crown fx’s: {} simple {} complicated {} crn/rt
Mobility: {} WNL {} I {} II {} III
Luxa ons: {} concussion {} lateral {} intrusive
{} extrusive {} avulsion
Discolored: Y N ____________________
Pressure sensi vity: {} bi ng {} percussion
Temperature sensi vity: {} air {} cold {} heat
{} none {} reposi oned {} splinted
{} pulp cap {} pulpotomy {} pulpectomy
medicaments: __________________________
restora on: ____________________________
other: _________________________________
Photographs ____________________________________
_______________________________________

Diagnos c tests

Tooth#

Cold

Heat

Percussion

Bi ng

Palpa on

Transillumin.

Pulpal diagnosis __________________________________________________ Draw in injury above

Periapical diagnosis _______________________________________________
Prognosis _______________________________________________________

Addi onal comments ______________________________________________________________________________________

________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________

FIGURE 1 – Documentation of evaluations, diagnoses, treatments, and follow-up evaluations of traumatic injury cases must be organized and thorough. This is one example of a form
developed to document such information. (Dental Trauma Form used in the office of Dr Garry Myers while in practice in Olympia, Washington.)

4 Myers JOE  Volume -, Number -, - 2019

 Treatment Details
Appointment 1
Date ________ Tooth # ______ Assistant ________
Pre-med: Amox ____ Clinda ____ Valium _______
Local anesthesia: ___________________________
_________________________________________
Splint placement: {} none {} yes ________________
__________________________________________
Access – pulp status: {} hyperemic {} fibro c {} vital
{} pr-necrosis {} necro c {} purulence
Treatment: {} comp/pr pulpectomy {} pulpotomy
C & S: {} gates {} ultrasonics {} microscope
Irriga on used: {} NaOCl {} CHX {} EDTA {} H2O
Rotaries: _______________________________
Appointment 2
Date ________ Tooth # ______ Assistant _________
Pre-med: Amox ____ Clinda ____ Valium ________
Local anesthesia: ____________________________
__________________________________________
Splint placement: {} none {} yes _________________
__________________________________________
Access – pulp status: {} hyperemic {} fibro c {} vital
{} pr-necrosis {} necro c {} purulence
Treatment: {} comp/pr pulpectomy {} pulpotomy
C & S: {} gates {} ultrasonics {} microscope
Irriga on used: {} NaOCl {} CHX {} EDTA {} H2O
Rotaries: _______________________________

Canal Apex locater Actual lngth File size Canal Apex locater Actual lngth File size
_____ _______ _______ ______ _____ _______ _______ ______
_____ _______ _______ ______ _____ _______ _______ ______
_____ _______ _______ ______ _____ _______ _______ ______
_____ _______ _______ ______ _____ _______ _______ ______
_____ _______ _______ ______ _____ _______ _______ ______

Obtura on: {} CaOH {} GP & sealer {} nothing Obtura on: {} CaOH {} GP & sealer {} nothing
{} lat cond {} warm vert {} single cone {} lat cond {} warm vert {} single cone
{} post space {} bleach paste RD clamp_______ {} post space {} bleach paste RD clamp_______

Access closure: {} co on {} IRM {} cavit {} GI Access closure: {} co on {} IRM {} cavit {} GI

{} composite resin {} amalg {} temp crn {} composite resin {} amalg {} temp crn
{} other __________________________ {} other __________________________

Rx: ____________________________________ Rx: ____________________________________

{} pain med declined by pa ent
{} Pa ent advised of need for follow-up tx
{} Post-opera ve instruc ons given – Oral Written
Next appt: ________________________________
Addi onal notes: _______________________________
_____________________________________________
_____________________________________________
{} pain med declined by pa ent
{} Pa ent advised of need for follow-up tx
{} Post-opera ve instruc ons given – Oral Written
Next appt: ________________________________
Addi onal notes: _______________________________
_____________________________________________
_____________________________________________

Recall 1: Recall 2:
Date _____________ Splint removal: Y N n/a Date ____________ Splint removal: Y N n/a

Diagnos c tests: Diagnos c tests:

Tooth# Tooth#
Cold Cold
Heat Heat
Perc Perc
Bi ng Bi ng
Palp Palp

Radiographs ______________________________________ Radiographs _____________________________________

Notes ___________________________________________ Notes __________________________________________
________________________________________________ _______________________________________________
________________________________________________ _______________________________________________
________________________________________________ _______________________________________________

FIGURE 1 – Continued

JOE  Volume -, Number -, - 2019 Evaluation and Diagnosis of Traumatized Dentition 5

has suffered a traumatic dental injury. On the
initial presentation of these patients, be
systematic in your assessment! Are there more
serious injuries present than simply the teeth
and associated soft tissues? Get a good
history of the circumstances surrounding the
injury. Both the clinical and radiographic
examinations should be thorough, yet succinct
and concise. Clinical photographs provide
great documentation! Know your traumatic
injuries because early and accurate recognition
is important in the evaluation process.
Understand that multiple injuries to a tooth can
decrease the prognosis. Remember that
young pulps have a great capacity to heal and
that every traumatic injury is its own individual
injury. Document every case thoroughly.
Getting complete and accurate diagnostic
information in traumatic dental injury cases will
set the stage for the subsequent treatment that
will be provided. Achieving the best treatment
outcomes will ultimately result in a very happy
patient and a professionally satisfying
experience for the dental care provider.
ACKNOWLEDGMENTS
The author denies any conflicts of interest
related to this study.

REFERENCES
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for the patient with traumatic dental injuries. J Am Dent Assoc 1980;100:530–4.
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Andreasen FM, Andersson L, editors. Textbook and Color Atlas of Traumatic Injuries to the
Teeth. 5th ed. Hoboken, NJ: John Wiley & Sons, Ltd; 2018. p. 266–73.
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experimental crown fractures or grinding in adult monkeys. J Endod 1982;8:391–7.

5. Cvek M, Abbott PV, Bakland LK, Heithersay GS. Management of trauma-related pulp disease
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6. Bhaskar SN, Rappaport HM. Dental vitality tests and pulp status. J Am Dent Assoc
1973;86:409–11.

7. Barkin PR. Time as a factor in predicting the vitality of traumatized teeth. J Dent Child
1973;40:188–92.
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12. Caldeira CL, Barletta FB, Ilha MC, et al. Pulse oximetry: a useful test for evaluating pulp vitality in
traumatized teeth. Dent Traumatol 2016;32:385–9.

13. Olgart L, Gazelius B, Lindh-Stromberg U. Laser doppler flowmetry in assessing vitality in luxated
permanent teeth. Int Endod J 1988;21:300–6.
14. Andreasen FM, Andreasen JO. Diagnosis of luxation injuries: the importance of standardized
clinical, radiographic and photographic techniques in clinical investigation. Endod Dent
Traumatol 1985;1:160–9.
15. Cohenca N, Silberman A. Contemporary imaging for the diagnosis and treatment of traumatic
dental injuries: a review. Dent Traumatol 2017;33:321–8.

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