IADT guidelines for injuries in the primary dentition (2020): observe first, let intruded and displaced baby teeth reposition, never replant an avulsed one

What it says#

The document is part 3 of the four-part IADT guidelines published in Dental Traumatology in 2020, written by a 17-author working group and approved by the IADT Board of Directors. It calls itself a consensus statement: where the published data did not appear conclusive, recommendations were based on the consensus opinions or majority decisions of the working group, and the IADT says it cannot guarantee favorable outcomes from strict adherence. The guideline assumes a medically healthy child with a sound, caries-free primary dentition, and says management may change when several teeth are injured. Its framing numbers: for children aged 0 to 6, oral injuries are 18% of all physical injuries; a meta-analysis it cites puts the world prevalence of traumatic injuries to primary teeth at 22.7%; injuries peak between 2 and 6 years of age, and luxations are the most frequent type.

On assessment, the guideline asks for a structured history, a head, neck and intra-oral examination, and extra-oral and intra-oral photographs, which are strongly recommended. Pulp sensibility tests are unreliable in primary teeth and are not recommended; mobility, color, tenderness to pressure and displacement are recorded instead, with color noted at every visit because discoloration is a common complication of luxation that may fade over weeks or months. Root canal treatment is not indicated for a discolored tooth without clinical or radiographic signs of infection. Radiographs are minimized under the ALARA principle, with a thyroid collar, a lead apron for a parent holding the child, and CBCT rarely indicated. A baseline film, where called for, is a periapical with a size 0 sensor and the paralleling technique or an occlusal with a size 2; none is recommended for an enamel fracture or a concussion, and a soft-tissue film is taken when a fragment may be embedded in the lip, cheek or tongue.

The management principle is conservative. Observation is often the most appropriate option in the emergency situation unless there is a risk of aspiration, ingestion or interference with the occlusion. Earlier guidelines recommended immediate extraction of an intruded or laterally luxated primary tooth when the root was displaced toward the permanent germ; the 2020 document says this is no longer advised, for three reasons: evidence of spontaneous re-eruption of intruded primary teeth, concern that extraction itself may damage the germ, and no evidence that immediate extraction limits damage to the germ. Intrusion and avulsion are the injuries most often associated with anomalies in the successor, and the guideline says it is very important to document that parents were told about possible complications to the permanent teeth, especially after intrusion, avulsion and alveolar fractures.

The twelve tables, condensed. Enamel fracture: smooth sharp edges, no follow-up. Enamel-dentin fracture: cover the dentin with glass ionomer or composite, review at 6 to 8 weeks. Complicated crown fracture: partial pulpotomy under local anesthesia with non-setting calcium hydroxide, glass ionomer and composite (cervical pulpotomy for large exposures), or no emergency treatment when referral within several days is possible; review at 1 week, 6 to 8 weeks and 1 year, with a radiograph at 1 year after pulp treatment. Crown-root fracture: often no treatment with rapid referral; otherwise remove the loose fragment and restore, with pulpotomy or root canal treatment if the pulp is exposed, or extract if unrestorable. Root fracture: nothing if the coronal fragment is not displaced; a displaced but not excessively mobile fragment is left to reposition; an excessively mobile, interfering fragment is extracted, leaving the apical piece to resorb, or repositioned and splinted for 4 weeks. Alveolar fracture: reposition under local anesthesia, flexible splint for 4 weeks, radiographs at 4 weeks and 1 year, review to age 6. Concussion and subluxation: observation, review at 1 week and 6 to 8 weeks, a baseline film for subluxation only. Extrusive luxation: let the tooth reposition unless it is excessively mobile or extruded more than 3 mm, then extract under local anesthesia. Lateral luxation: with minimal or no occlusal interference, let the tooth reposition, usually within 6 months; with severe displacement, extract when there is a risk of ingestion or aspiration, or reposition and splint for 4 weeks. Intrusive luxation: allow the tooth to reposition itself irrespective of the direction of displacement, usually within 6 months and up to 1 year, with referral within a couple of days; review at 1 week, 6 to 8 weeks, 6 months, 1 year and, for severe intrusion, at age 6. Avulsion: do not replant; if the tooth was not brought in, a radiograph is essential to be sure it was not intruded, and a child whose tooth is not found is referred to an emergency room, especially with respiratory symptoms; review at 6 to 8 weeks and at age 6.

Around the tables: ibuprofen and/or acetaminophen when pain is anticipated; no evidence for systemic antibiotics in luxation injuries, though they stay at the clinician's discretion with soft-tissue injuries, significant surgery or a medical indication; a tetanus booster may be needed for a contaminated wound, with referral to a physician within 48 hours if in doubt. Home care is a soft brush or cotton swab plus an alcohol-free chlorhexidine gluconate rinse twice a day for one week (0.12% in the text, 0.1 to 0.2% in the tables), with parents watching for swelling, mobility or a sinus tract. The guideline prefers to avoid extractions at the acute visit because of their role in dental anxiety, and says rapid referral within several days to a child-oriented team is essential for pulp-involving fractures, root fractures and luxations.

Who it applies to#

Any clinician a child with a primary-tooth injury reaches first: general dental practitioners, emergency medical services, pharmacists, community dental clinics and specialist services are all named. The tables are written for the emergency visit; follow-up of complex injuries is assigned to teams with specialist training and access to sedation and general anesthesia. The assumption of a healthy child with a caries-free dentition matters: a carious or medically complex child, or several injured teeth, may call for a different plan. Permanent teeth are parts 1 and 2 of the 2020 guidelines, and treatment of an unfavorable outcome is outside this document's scope.

What changed#

The guideline names the change itself: previous IADT guidelines advised immediate extraction of an intruded or laterally luxated primary tooth whose root pointed toward the permanent germ, and the 2020 document withdraws that advice in favor of spontaneous repositioning with early referral. It also spells out favorable and unfavorable outcomes for every injury, drawing on the IADT core outcome set published in 2018. The AAPD endorsed the guideline in 2020 and reprints it in full in its Reference Manual, so for a US general dentist it doubles as the pediatric academy's own position.

Where the source is#

The document is Day and colleagues, International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 3. Injuries in the primary dentition, Dental Traumatology 2020;36(4):343-359, published by Wiley for the IADT under a CC BY-NC-ND 4.0 license according to the Crossref record. The link under the title is the DOI, which resolves to Wiley Online Library; when this entry was written Wiley refused automated access, so the text was read from the AAPD's free reprint (which carries the tables as page images) and from the accepted author manuscript in the University of Leeds White Rose repository, and the two were compared. The IADT's guidelines page links all four 2020 parts and translations.