Dental Trauma: Clinical Guidelines

List of Abbreviations

ICD-10 – International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, of the World Health Organization.

UHF – ultra-high-frequency therapy

UHF – ultra-high frequency

NSAIDs – nonsteroidal anti-inflammatory drugs

UWS and DU – universal workstation and dental unit

AIDS – acquired immunodeficiency syndrome

OPG – orthopantomogram

TDI – traumatic dental injury

CT – computed tomography

CBCT – cone-beam computed tomography

EPT – electric pulp testing

Terms and Definitions

Evidence-based medicine – an approach to medical practice that aims to optimize decision-making by emphasizing the use of evidence from well-designed and well-conducted research on the efficacy and safety of preventive, diagnostic, and therapeutic interventions, which is searched for, compared, summarized, and widely disseminated for patient care.

Disease – a disorder of bodily function, working capacity, or the ability to adapt to changing environmental conditions (internal and external) arising from the action of pathogenic factors, accompanied by a simultaneous alteration of the body's protective-compensatory and protective-adaptive reactions and mechanisms.

Instrumental diagnostics – diagnostics performed by examining a patient using various devices, apparatuses and instruments.

Laboratory diagnostics – a set of methods aimed at analyzing the test material using various specialized equipment.

Medical intervention – a set of medical examinations and/or medical manipulations, as well as artificial termination of pregnancy, aimed at prevention, diagnosis, treatment, rehabilitation, or research, performed by a healthcare professional or other person authorized to carry out medical activities in relation to a patient, affecting their physical or mental state.

Level of evidence certainty – reflects the degree of certainty that the found effect of a medical intervention is true.

Grade of recommendation – reflects not only the certainty in the reliability of the intervention's effect, but also the certainty that following the recommendations will bring more benefit than harm in a specific situation.

Surgical treatment – a method of treating diseases through the division and joining of tissues during a surgical operation.

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Dental trauma – a disruption of the anatomical integrity of the teeth and surrounding tissues, leading to the reversible or irreversible loss of their functional properties.

Dental injuries – a generalized term combining various mechanisms of damage to tooth structures and surrounding tissues. The incidence of dental injuries within the structure of dental pathology is steadily increasing, driven by the overall rise in trauma rates. Dental injuries occur 1.5–2 times more frequently in males than in females. Dental injuries are often combined with jaw trauma, and their management therefore requires collaboration between dental and trauma specialists.

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

Regarding the possible causes of dental trauma, we distinguish the following—the etiological classification of dental trauma: domestic or household dental trauma; traffic or vehicular dental trauma; sports dental trauma; occupational trauma.

Domestic (household) trauma occurs in 60% of patients who present with complaints of dental trauma. Of these 60%, more than half involve trauma to the maxillary central incisors. Furthermore, men seek treatment for dental injuries more often than women.

Classification of dental trauma by time of onset:

Acute dental trauma.

Chronic dental trauma.

Acute dental trauma

Acute dental trauma most commonly results from a single, high-intensity impact. Causes of acute dental trauma include blows, falls face-down, falls on the back, chin impacts, and many others.

Chronic dental trauma

Chronic dental trauma is caused by continuous mechanical stress, resulting in the progressive thinning of the tooth enamel. The most frequent causes of chronic dental trauma include: harmful habits, such as biting thread, nail-biting, cracking seeds and nuts, etc.; improper intraradicular post placement; orthodontic treatment; occlusal trauma as a complication of fluorosis, enamel hypoplasia, cysts, and jaw tumors.

1.3 Epidemiology of the Disease or Condition

Among traumatic (mechanical) injuries to the human skeleton, facial bone fractures account for 3.2% to 8%. Their average incidence is 0.6 per 1,000 population.

Tooth luxations and fractures account for 3% of maxillofacial trauma.

Injuries to maxillary teeth occur 3 times more frequently than injuries to mandibular teeth [2].

1.4 Features of Coding the Disease or Condition

ICD-10 code:

S02.5 Fracture of tooth,

S03.2 Dislocation of tooth.

1.5 Classification of the disease or condition

Classification according to WHO 1987

Class I. Tooth contusion with minor structural damage (enamel cracks)

Class II. Uncomplicated crown fracture

Class III. Complicated crown fracture

Class IV. Crown-root fracture

Class V. Crown-root fracture

Class VI. Root fracture

Class VII. Tooth dislocation (subluxation)

Class VIII. Complete tooth dislocation (avulsion)

1.6 Clinical presentation of the disease or condition

Tooth concussion. Corresponds to ICD-10 code S02.5. Belongs to the first class of injuries according to ICD-10. Tissue structure is minimally disturbed; cracks or chips in the enamel are identified, generally without pulp exposure, while the integrity of the periodontal ligament is preserved. Despite being classified as a closed injury, if the neurovascular bundle is ruptured, blood enters the pulp chamber and disrupts its blood supply. After 5–6 months, the traumatized tooth acquires a dark shade and, in the absence of necessary treatment, may cause inflammation. During a concussion, the patient typically experiences a constant dull toothache, which may become sharp upon biting.

Tooth fracture. Corresponds to ICD-10 code S02.5. — a type of injury involving fractures of the roots, the crown of the tooth within the dentin or enamel, and chipping of the crown. There are two main types: coronal fractures and root fractures. Coronal fractures manifest as alterations in tooth shape, aesthetic defects, and pain; the tooth is immobile. Sharp edges injure the mucosa; acute pulpitis or periodontitis is possible. Root fractures, in turn, are classified into: transverse; comminuted; longitudinal; oblique; in the apical/middle/coronal third; with/without displacement. Symptoms: pain on biting/percussion, crown mobility.

Acute dental injuries are typically the result of sudden, extremely forceful impacts: falls, blows to the jaw during accidents, fights, sports activities, etc. Chronic dental injuries arise from prolonged trauma and may be associated with the habit of holding foreign objects in the mouth, nail-biting, biting thread, and other causes. As a result of prolonged mechanical action on the tooth, enamel thinning and chipping occur, leading to tooth destruction. In such cases, dental trauma may occur with a normal level of force applied to the tooth, such as during chewing [1].

Additionally, dental injuries can occur due to breaches in dental treatment technique. For example, a tooth crack may form as a result of placing an improperly sized intraradicular post, and a tooth luxation may occur due to careless extraction of neighboring teeth using an elevator. Dental injury is also possible via incorrectly selected and fitted orthodontic appliances, overextended fillings, etc. Complicated dental injuries resulting from cervical caries, fluorosis, enamel hypoplasia, radicular cysts, jaw tumors, and other odontogenic diseases are not uncommon.

Thus, depending on the duration of exposure to causative factors, dental injuries can be acute or chronic. Among permanent tooth injuries, crown fractures are the most frequent.

A more complex injury is tooth luxation. The tooth partially dislodges from its socket, becomes mobile, and changes its position relative to other teeth. There are three types of luxation: partial (subluxation), complete (avulsion), and intrusive.

Partial luxation (subluxation/extrusion). Corresponds to ICD-10 code S03.2. Tearing of periodontal fibers is observed. The alveolar wall is damaged. Following trauma, the tooth is mobile, and the coronal and root parts are often displaced in opposite directions. Deep periodontal pockets form and may bleed. Severe pain upon pressure and chewing; tenderness to palpation/percussion, edema, hyperemia, reduced pulp electrical excitability. X-ray: widened/uneven periodontal ligament space. Complications: granulomas, radicular cysts, chronic periodontitis, root resorption.

Complete luxation (Avulsion). Corresponds to ICD-10 code S03.2. Complete rupture of connective tissues, resulting in the tooth falling out of its socket (most commonly maxillary central incisors). Profuse bleeding, severe pain. In some cases, severe damage to soft tissues and blood vessels is observed.

Intrusive dislocation (intrusion). Corresponds to ICD-10 code S03.2. The essence of this injury is reflected in its name. As a result of mechanical impact, the tooth is driven deep into the socket: the root penetrates the bone, and the crown sinks into the socket (becomes shorter). Visually, the tooth appears shorter. Symptoms: pain, rare bleeding, gingival edema/hyperemia. The crown is shortened/absent, immobile, percussion is mildly painful, rotation/displacement is possible. X-ray: periodontal ligament space is narrowed/disrupted, the root appears longer; in deep intrusion, the tooth is located within the jaw or sinus (2–3 projections are required).

2. Diagnostics, medical indications and contraindications for diagnostic methods

Diagnosis of dental trauma is performed by collecting complaints and anamnesis, clinical examination, and additional diagnostic methods.

The main objective in diagnosis is to determine the pattern, extent, severity, and clinical course of the dental trauma, as well as to identify endogenous and exogenous factors. A thorough diagnosis is carried out by a dental surgeon and a maxillofacial surgeon, with the involvement of other dental specialists and an otorhinolaryngologist if necessary. A comprehensive patient treatment plan is drawn up depending on the established diagnosis.

Good Clinical Practice (GCP)

Criteria for establishing a diagnosis in acute dental trauma:

Nosological form: tooth fracture within the enamel, tooth fracture within the enamel and dentin.

Phase: any.

Complication: uncomplicated.

ICD-10 code: S02.5.

Adult patients

– Traumatic defect of the dental crown within the enamel without dental pulp damage.

– Absence of pathological changes in the periodontal tissues in the area of the injured tooth.

– Absence of pathological changes in the root area and periodontal tissues according to X-ray examination data.

Nosological form: dental crown fracture with pulp involvement.

Phase: any.

Complication: uncomplicated.

ICD-10 code: S02.5.

Adult patients

– Traumatic defect of hard dental tissues within the enamel and dentin with pulp involvement.

– According to the fracture line direction: oblique, transverse fracture.

– Absence of pathological changes in the periodontal tissues in the area of the injured tooth.

– Absence of pathological changes in the root area and periodontal tissues according to X-ray examination data.

Nosological form: root fracture.

Phase: any.

Complication: uncomplicated.

ICD-10 code: S02.5.

Adult patients

– Pathological tooth mobility.

– Damage to periodontal tissues in the area of the injured tooth.

– Root fracture line is identified by X-ray examination data.

According to the fracture line direction: oblique, transverse, and longitudinal root fracture;

in the presence of multiple lines: comminuted;

according to the fracture level: in the apical, middle, or cervical third of the root.

Nosological form: crown-root fracture.

Phase: any.

Complication: uncomplicated.

ICD-10 code: S02.5.

Adult patients

– Pathological tooth mobility.

– Damage to periodontal tissues in the area of the injured tooth.

– Traumatic defect of hard dental tissues within the enamel and dentin with pulp involvement.

– Root fracture line is identified by X-ray examination data.

Nosological form: tooth dislocation.

Phase: subluxation (tooth luxation).

Complication: uncomplicated.

ICD-10 code: S03.2.

Adult patients

– Change in tooth position in the dental arch.

– Pathological tooth mobility.

– Damage to periodontal tissues in the area of the injured tooth.

– Displacement of the tooth relative to the dental socket according to X-ray examination data.

– Absence of pathological changes in the alveolar bone tissues of the jaw bones.

Nosological form: tooth dislocation.

Phase: intrusive dislocation (intrusion).

Complication: uncomplicated.

ICD-10 code: S03.2.

Adult patients

– Change in tooth position in the dental arch.

– Driving of the tooth toward the socket.

– Damage to periodontal tissues in the area of the injured tooth.

– Displacement of the tooth toward the socket due to the intrusion of the tooth into the bone tissue according to X-ray examination data.

– Absence of pathological changes in the alveolar bone tissues of the jaw bones.

Nosological form: tooth dislocation.

Phase: complete dislocation (exarticulation).

Complication: uncomplicated.

ICD-10 code: S03.2.

Adult patients

– Empty dental socket filled with a blood clot.

– Damage to periodontal tissues in the area of the injured tooth.

– Absence of the tooth in the socket according to X-ray examination data.

• All patients with acute dental trauma are recommended to undergo case history taking, examination of the oral cavity and teeth, and other necessary examinations to establish a diagnosis and prescribe appropriate treatment, with the results recorded in the dental patient's medical record (see Appendix A3, Table 1) [4, 5].

GCP CLoE 5Grading of Recommendations Assessment, Development and Evaluation (GRADE) – C (Level of Evidence – 5)

Comments: rational therapy depends on a correct diagnosis, which can be made using various patient examination methods. Since dental trauma is a complex injury, information obtained from different examination methods will help determine the components of the injury and prioritize treatment.

Diagnosis of acute dental trauma includes medical history taking, clinical examination, and additional diagnostic methods.

2.1 Complaints and Anamnesis

When taking the anamnesis, one should ascertain the presence or absence of complaints, the nature and time of the injury, allergic history, and the presence of acute and chronic somatic diseases.

• All adult patients with acute dental trauma are recommended to determine whether the patient maintains proper oral hygiene care (for determination of oral hygiene indices, see Appendix A3.4. Hygiene Index), identify complaints (Collection of anamnesis and complaints in oral pathology), as well as the nature of pain and discomfort in the injured segment (Appendix A3.2. Patient Questionnaire), possible malocclusion or bite alteration (Determination of bite), and determine the duration of changes and previous treatment or lack thereof [1, 2, 5, 14].

Level of Recommendation CLevel of Evidence 5Level of recommendation validity – C (level of evidentiary reliability – 5)

Complaints in various types of traumatic injuries

In root fracture:

– pain from mechanical stimuli (when biting, pressing on the tooth);

– tooth mobility (may be absent in fractures passing through the apical third).

In crown-root fracture:

– cosmetic defect;

– pain from mechanical and thermal stimuli;

– tooth mobility.

If there is exposure of the dental pulp cavity, pain symptoms characteristic of pulpitis are noted.

In dental concussion:

– pain when biting food, pressing on the tooth;

– discoloration of the tooth (in case of pulp concussion or disruption of vessel wall integrity).

More often, the coronal part of the tooth remains intact, and patients seek medical attention only when complications arise as a result of pulp necrosis with symptoms of acute exacerbation of chronic periodontitis, detection of a fistulous tract on the mucous membrane projected at the root apex, or tooth discoloration.

In tooth subluxation (luxation):

– tooth displacement;

– tooth mobility;

– pain from mechanical stimuli;

– bleeding of the mucosa due to periodontal tissue damage;

– occlusal contact disturbance up to the inability to close the mouth (with significant tooth displacement).

In tooth exarticulation:

– shortening of the dental crown or its complete absence;

– pain;

– gingival bleeding.

In complete luxation:

– absence or loss of the tooth;

– pain;

– gingival bleeding in the area of the socket;

– cosmetic defect;

– discomfort during eating;

– speech defect [4, 5].

• When taking an anamnesis in adult patients with acute dental trauma (Anamnesis and complaint collection in oral pathology) for the purpose of disease diagnosis, treatment planning, and addressing the need to refer the patient to other specialists, it is recommended to ascertain and document in the medical history:

– circumstances of the incident (where, when, how, against what, and as a result of what the injury occurred);

– whether the patient lost consciousness or had other signs of traumatic brain injury (vomiting, nausea, dizziness, headache, and other neurological symptoms);

– exact time of the injury;

– whether medical assistance was provided to the patient at the scene of the injury or in another medical facility;

– whether tetanus vaccination was administered (in case of wound contamination and foreign body penetration);

– presence of concomitant pathology, allergic reactions, and medication use;

– whether there was a previous injury to the maxillofacial region and teeth;

– patient's complaints are taken into account or clarified with their legal representatives (pain and discomfort in the area of a specific tooth, change in the appearance of the tooth, time of onset of complaints);

– whether a malocclusion has occurred [11, 12].

GCP CLEL 5Grade of Recommendation – C (Level of Evidence – 5)

2.2 Physical Examination

Comments.

1. External examination of the maxillofacial region:

– possible alteration of facial configuration due to soft tissue edema in the injury area or due to fracture and displacement of facial bones;

– assessment of the color and condition of the skin;

– upon palpation of lymph nodes, enlargement of regional lymph nodes associated with acute dental trauma is practically not observed;

– palpation of the masticatory muscles, salivary glands, and temporomandibular joint;

– assessment of the degree of mouth opening and pain;

– determination of occurred bite changes;

– presence of traumatic skin and lip injuries (abrasions, hematomas, wounds);

– presence of signs of wound contamination and foreign body penetration.

2. Intraoral examination:

– examination of the mucosa in the area of the injured tooth;

– detection of hyperemia, edema, submucosal hematoma, tenderness upon palpation, mucosal tears, ulcers, erosions, and other pathological processes on the mucosa, foreign body penetration, and tooth fragments;

– change in the coronal part of the tooth;

– change in tooth color, presence of a crown defect, cracks in hard tissues, change in tooth position in the dental arch;

– assessment of the periodontal condition;

– presence of edema, hyperemia, bleeding from the gingival sulcus;

– assessment of the condition of all existing teeth, especially adjacent teeth;

– assessment of the periodontium and periodontium condition;

– performance of vertical and horizontal percussion;

– palpatory determination of infiltrate presence;

– determination of tooth mobility and its degree;

– determination of the hygiene index and periodontal need index.

3. Palpation.

Palpation is used to assess the presence of:

– pain;

– local hyperthermia;

– infiltration (localization, dimensions);

– hematoma (density, consistency, displaceability relative to surrounding tissues, fluctuation, and softening);

– edema.

4. Percussion.

Allows assessment of tenderness associated with damage to periodontal and periapical tissues. Yields a positive result in concussion, dislocation, crown-root fracture, and root fracture. Most pronounced in the first days after traumatic injury.

During the physical examination, targeted identification is made of:

– inadequate psychoemotional state of the patient prior to treatment;

– acute lesions of the oral mucosa and the red border of the lips;

– acute inflammatory diseases of oral organs and tissues;

– periodontal tissue diseases;

– unsatisfactory oral hygiene;

– refusal of treatment [1, 13].

When examining a patient with dental trauma, additional diagnostic methods should also be performed:

– X-ray examination (OPG, CT, CBCT): allows visualization of periodontal ligament widening and ruling out tooth root fracture; in tooth luxation, it reflects the direction and degree of displacement of the injured tooth; if the tooth is absent from the socket, X-ray examination must be performed with particular care (in case of deep impaction, the tooth may be located in the jaw body, maxillary sinus, and other areas).

– functional tests: for pulp state assessment – electric pulp testing and other examination methods [2, 14] (see Appendix A3, table 1).

2.3 Laboratory Diagnostics

Comments.

Cytological diagnostics aims to study the structural features of cellular elements and their conglomerates by examining touch smears, imprint smears, scrape smears from the surface of the mucosa, erosion, ulcer, fistulas, periodontal pockets, as well as oral lavage sediment and punctate from deeply situated tissue areas.

Absolute indications for a complete blood count (CBC) and general-medical biochemical blood test are the presence of a mucosal necrosis area in the oral cavity, long-standing non-healing ulcers, as well as all cases where hematopoietic disease is suspected.

During biochemical blood analysis, special attention is paid to indicators: total protein, urea, residual nitrogen, glucose, total bilirubin, cholesterol, uric acid, trace elements, and others. Glucose testing is performed when diabetes mellitus is clinically suspected (dry mouth, chronic recurrent candidiasis, periodontal disease) [13, 14].

2.4 Instrumental Diagnostics

2.4.1 Diagnostic Imaging

Comments. Radiological examination makes it possible to detect:

– bone tissue condition;

– periodontal tissue condition;

– integrity of the compact lamina surrounding the tooth germ zone and the alveolar bone wall;

– presence of the fracture line, its direction, localization, and the relation of bone fragments;

– position of the tooth root relative to the socket, symmetrical and adjacent teeth, and neighboring anatomical regions;

– width of the periodontal ligament space in various areas;

– relation of the crown fracture line to the pulp cavity.

Tooth root fracture. Radiological diagnosis allows identifying the fracture line (appearing as a dark band (radiolucent line) crossing the root). In doubtful cases, radiological examination in other projections is recommended. More precise information can be obtained via computed tomography.

In dental concussion, no pathological changes are detected.

Subluxation. On the radiograph, when the crown is displaced toward the occlusal plane, the periodontal ligament space is uniformly widened, and the crown is positioned lower than adjacent teeth. With mesial or distal crown displacement, the periodontal ligament space is widened on one side and narrowed or completely unnoticeable on the other.

Tooth intrusion. Radiographic examination reveals displacement of the tooth towards the socket; the periodontal ligament space is most often absent. The incisal edge and the enamel-dentin junction are positioned higher than those of adjacent teeth, and the tooth root appears longer. In cases of deep impaction, the radiograph may show the tooth located within the jaw body, the maxillary sinus, the nasal cavity, etc. Therefore, if the tooth is absent from the socket, a radiographic examination in 2–3 projections is recommended [4, 5].

To obtain more accurate information about the position of the intruded tooth, the presence of a fracture of the alveolar process, the maxillary sinus wall, the tooth root, and other pathological changes, cone-beam computed tomography (A06.07.013) is recommended [24, 25].

Complete dislocation (avulsion). The radiograph reveals an empty tooth socket; disruption of the integrity of both the compact and spongy bone on either side may be noted, indicating the direction of the applied force [4, 5].

2.4.2 Electric Pulp Testing (EPT) of the Tooth

• To assess pulp condition in adult patients with acute dental trauma, it is recommended to perform electric pulp testing (EPT) of the tooth in case of traumatic injury to permanent teeth [4, 5]. In subluxation, EPT values range from 2–4 µA if the neurovascular bundle is preserved, up to 40–60 µA upon rupture of the neurovascular bundle. In complete dislocation — over 100 µA, and in intrusion, pulp sensitivity is sharply reduced to 80–100 µA [2, 3, 4].

GCP CLoE 5Grading of Recommendations Assessment, Development and Evaluation (GRADE) – C (Level of Evidence – 5)

Comments: during EPT in the first days after trauma, the electrical excitability of the pulp decreases due to damage to the neurovascular bundle, compression by a hematoma or exudate (often reversible). Dynamic monitoring is recommended.

Norm: 2–6 µA; in caries — up to 12–15 µA. Compare with intact teeth, taking into account device calibration. Sensitivity may decrease in lateral luxations.

In concussion, crown fractures (with/without pulp involvement), subluxation, electrical excitability decreases; a persistent increase > 100 µA after 10–15 days indicates pulp necrosis.

In intrusive luxation — irreversible pulp necrosis, electrical excitability > 100 µA.

2.5 Other Procedures

For other diagnostic procedures, adult patients with dental trauma should consult related specialists: a maxillofacial surgeon, a general practitioner (dentist), and an infectious disease specialist [5, 14].

2.5.1 Thermometry (Dental Thermal Diagnostics)

• Patients with acute dental trauma are recommended to undergo thermometry (thermal pulp testing) to determine the sensitivity of the neurovascular bundle of the permanent tooth [4, 5].

GCP CLEL 5Grade of Recommendation – C (Level of Evidence – 5)

Comments.

Temperature tests (heated gutta-percha, dry ice, carbon dioxide) allow evaluation of the reaction of the injured and adjacent teeth. Severe pain that persists after the stimulus is removed indicates pulp inflammation. The absence of a reaction usually indicates necrosis of the neurovascular bundle, but in the first days after trauma, it may be associated with reversible nerve conduction impairment due to hematoma or edema, so sensitivity should be evaluated dynamically [18, 19].

The method has limitations, as traumatic neuritis increases pain sensitivity, and sharp pain may occur. The absence of a reaction during repeated tests, crown discoloration, and bone destruction at the root apex on the radiograph suggest pulp necrosis and the need for appropriate treatment [18, 19].

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

General approaches to the treatment of dental trauma

The principles of treatment for patients with dental trauma involve the simultaneous resolution of several tasks:

- elimination of the traumatic cause that triggered the pathological changes;

- prevention of the further development of the pathological process;

- preservation and restoration of the functional capacity of the tooth or teeth and the entire dentognathic system;

- elimination of emerging complications of the pathological process;

- improvement of the patients' quality of life.

Therapeutic measures are predominantly carried out in an outpatient setting. The severity of the injury, its extent, and the presence of inflammatory phenomena, the general and local clinical picture, as well as radiographic data are taken into account.

3.1 Conservative Treatment

Non-pharmacological care for acute trauma involves emergency measures aimed at eliminating the causes and reducing inflammatory reactions. Further treatment is scheduled on a planned basis.

3.1.1 Drug therapy

Comments.

For the treatment of dental contusion and tooth fracture, patients with dental trauma are prescribed drugs from the following groups:

– antihistamines for systemic use;

– analgesics;

– calcium preparations;

– vitamins (multivitamins, ascorbic acid, including combinations with other agents).

Antibacterial therapy is prescribed individually, based on the patient's general somatic condition. Antibiotic therapy is mandatory for patients with comorbid conditions (cardiovascular system, immune system, oncological diseases, elderly patients, etc.). See Section A3.1 Table 1. Requirements for drug therapy in outpatient and polyclinic treatment.

• For patients with dental contusion and tooth fracture, along with systemic antibacterial drugs, it is recommended to prescribe antidiarrheal drugs, including agents containing lactic acid-producing microorganisms in combination with other drugs, for the prevention of antibiotic-associated diarrhea and pseudomembranous colitis, as well as other ecologically undesirable effects [10, 15].

GCP CLoE 5Grading of Recommendations Assessment, Development and Evaluation (GRADE) – C (Level of Evidence – 5)

• For the treatment of dental trauma in adult patients, it is recommended to use antiseptics and disinfectants active against protozoa, Gram-positive and Gram-negative bacteria, and viruses, in the form of mouthwashes (used for up to 14 days) [10, 15].

GCP CLoE 5Grading of Recommendations Assessment, Development and Evaluation (GRADE) – C (Level of Evidence – 5)

• For local anesthesia during the treatment of dental trauma in adult patients, it is recommended to use local anesthetics in combination with alpha- and beta-adrenomimetics, as well as previously widespread substituted amide drugs (antiarrhythmic drugs, class IB C01BB), and less commonly esters (aminobenzoic acid esters N01BA) to provide effective pain relief, increase the duration of anesthesia, reduce bleeding, and ensure metabolic stability at the inflamed injury sites [21, 22, 23].

GCP CLEL 5Grade of Recommendation – C (Level of Evidence – 5)

• In adult patients with dental trauma, in order to minimize risks and ensure the safety of each surgical intervention, it is recommended to choose the anesthetic indicated for the patient in terms of the functional state of their body, allergic history, presence of comorbidities and the degree of their compensation, and the nature of the upcoming intervention [24].

GCP CLEL 5Grade of Recommendation – C (Level of Evidence – 5)

• In adult patients with dental trauma, upon the development of an inflammatory process and symptoms of general intoxication, it is recommended to prescribe antimicrobial agents and antiseptics for the local treatment of oral cavity diseases in order to prevent complications (acute purulent periostitis, spread of purulent exudate into the bone, and development of acute osteomyelitis of the jaw or perimaxillary soft tissues with the formation of an abscess or phlegmon) [10, 15].

GCP CLEL 5Grade of Recommendation – C (Level of Evidence – 5)

• In adult patients with dental trauma, on the first day after surgical intervention, it is recommended to prescribe nonsteroidal anti-inflammatory drugs to relieve pain and the inflammatory process [25].

GCR BLEL 2Grade of Recommendation – B (Level of Evidence – 2)

Comments.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are mostly derivatives of weak organic acids. The main pharmacodynamic effects of NSAIDs include anti-inflammatory, analgesic, antipyretic, and antiplatelet actions.

3.1.2 Smoothing of sharp tooth edges

– crown fracture within the superficial layers of the tooth enamel;

– in cases where restoration of the coronal part of the tooth is impossible [17, 18].

GCP CLEL 5Grade of Recommendation – C (Level of Evidence – 5)

Comments: performed using rotary instruments with water cooling. The main task is the prevention or elimination of trauma to the lip mucosa caused by sharp edges of the hard dental tissue defect resulting from the injury.

After grinding the hard dental tissues, remineralizing agents (A11.07.012 Deep fluoridation of tooth enamel) are applied to the treated surface [26].

3.1.3 Restoration of the coronal part of the tooth

Comments. In the vast majority of cases, this is performed during the patient's initial visit for acute dental trauma.

To restore the resulting defects, the following materials are used: glass ionomer cements, compomer and composite filling materials.

The temporary restoration method is recommended during the patient's initial visit for a crown fracture within the enamel and dentin without pulp exposure in cases where permanent restoration of the hard tissue defect is not feasible. The technique involves medicamentous treatment of the fracture line with weak antiseptic solutions, application of a calcium-containing preparation projected onto the pulp horn, and sealing the fracture line with a glass ionomer cement dressing to prevent pulp infection.

3.1.4 Extirpation method

1. when the crown fracture line extends through the enamel and dentin with pulp exposure;

2. when there are signs of an inflammatory process in the dental pulp [18, 27].

GCP CLEL 5Grade of Recommendation – C (Level of Evidence – 5)

Comments.

Algorithm and features of the tooth extirpation method:

1. preliminary X-ray examination (A06.07.001 Panoramic radiography of the upper jaw; A06.07.002 Panoramic radiography of the lower jaw, A06.07.003 Targeted intraoral contact radiography, A06.07.004 Orthopantomography, A06.07.007 Intraoral bite-wing radiography, A06.07.008 Radiography of the upper jaw in an oblique projection, A06.07.009 Radiography of the lower jaw in a lateral projection, A06.07.013 Computed tomography of the maxillofacial region);

2. administration of local anesthesia;

3. isolation of the operational field;

4. preparation of endodontic access;

5. thorough removal of root canal contents;

6. determination of the root canal working length;

7. mechanical preparation;

8. instrumental and medicamentous treatment of root canals (minimal mechanical preparation; irrigation is performed using chlorhexidine**, hydrogen peroxide**, sodium hypochlorite (diluted with distilled water to a concentration of less than 1%));

9. drying is carried out using sterile paper points;

10. X-ray control (A06.07.001 Panoramic radiography of the upper jaw; A06.07.002 Panoramic radiography of the lower jaw, A06.07.003 Targeted intraoral contact radiography, A06.07.004 Orthopantomography, A06.07.007 Intraoral bite-wing radiography, A06.07.008 Radiography of the upper jaw in an oblique projection, A06.07.009 Radiography of the lower jaw in a lateral projection, A06.07.013 Computed tomography of the maxillofacial region): performed after root canal obturation and during follow-up dispensary observation stages (Dispensary appointment (examination, consultation) of a dentist B04.065.005);

11. restoration of the anatomical shape of the tooth: recommended to be performed at the next visit after root canal filling;

12. glass ionomer cements, compomer and composite filling materials are used to restore the coronal part of the tooth, and tooth restoration using standard protective crowns is also possible;

13. dynamic monitoring;

14. mandatory examination and X-ray imaging (A06.07.001 Panoramic radiography of the upper jaw; A06.07.002 Panoramic radiography of the lower jaw, A06.07.003 Targeted intraoral contact radiography, A06.07.004 Orthopantomography, A06.07.007 Intraoral bite-wing radiography, A06.07.008 Radiography of the upper jaw in an oblique projection, A06.07.009 Radiography of the lower jaw in a lateral projection, A06.07.013 Computed tomography of the maxillofacial region) after 3 months, then 2 times a year [26].

During temporary root canal filling, the operating field is isolated (use of a rubber dam system is preferred), the pulp chamber is widely opened to ensure optimal access to the root canals. After thorough removal of the root canal contents and determination of the working length, multiple irrigations of the root canal with antiseptic solutions are performed. Next, the root canal is dried and medications containing aqueous- or oil-based calcium hydroxide are introduced to provide an anti-inflammatory effect on the periapical tissue lesion and an antimicrobial effect on the root canal system.

The pulp cavity is hermetically sealed with a glass ionomer cement filling, a temporary crown, or a temporary composite restoration is performed.

3.1.5 Selective grinding

Comments: selective grinding of the antagonist is performed using a bur, checking occlusal contacts. Next, fluoride-containing preparations (A11.07.012 Deep fluoridation of tooth enamel) are applied to the treated surfaces.

3.1.6 Splinting

Comments: in case of a tooth root fracture at the initial visit, reposition of the tooth fragments with precise alignment of the coronal and root fragments (in case of displacement) and immobilization by splinting are performed. The optimal duration of splinting is from 2 to 4 months. Mechanical load on the tooth must be limited. For this purpose, the tooth is taken out of occlusion by selective grinding (A16.07.025 Selective grinding of hard dental tissues).

Several outcomes of root fracture treatment are distinguished:

1. formation of calcified tissue consisting of dentin or cementum;

2. healing involving connective tissue from periodontal fibers;

3. healing with the formation of bone-like tissue and areas of connective tissue between the fragments;

4. ingrowth of granulation tissue into the fracture line.

The latter type is the most unfavorable, as it is accompanied by fragment mobility and damage to the neurovascular bundle, and a fistulous tract can be detected on the oral mucosa corresponding to the fracture projection. Such a clinical situation requires endodontic intervention with X-ray control of the root canal filling quality and follow-up monitoring to ensure the absence of inflammatory changes in the periapical tissues of the tooth.

3.2 Surgical Treatment

3.2.1 Surgical reposition

1. with significant displacement of the tooth during luxation relative to the alveolus, when digital reduction is insufficient;

2. with intrusive luxation of the tooth;

3. to align fragments in displaced root fractures, which ensures better healing [18, 31].

GCP CLoE 5Grading of Recommendations Assessment, Development and Evaluation (GRADE) – C (Level of Evidence – 5)

Comments: tooth repositioning is performed using surgical forceps or fingers, followed by splinting and radiographic examination (Orthopantomography A06.07.004, Target intraoral periapical radiography A06.07.003, Intraoral bite-wing radiography A06.07.007, Panoramic radiography of the maxilla A06.07.001, Panoramic radiography of the mandible A06.07.002, Oblique projection radiography of the maxilla A06.07.008, Lateral projection radiography of the mandible A06.07.009) to confirm the correct position of the tooth root in the alveolus or to align fragments in case of a root fracture.

3.2.2 Replantation

Comments.

The procedural algorithm depends on the time elapsed since the trauma occurred and the method of tooth transportation.

General recommendations include:

1. minimize the time the tooth spends outside a liquid medium (do not allow it to dry out);

2. rinse the tooth with an isotonic solution;

3. examine the socket and, if necessary, perform revision, flush, and reposition the alveolar wall;

4. perform tooth replantation without excessive pressure (if complete insertion of the tooth root into the socket is not possible, temporary occlusal pads made of glass ionomer cement are formed on the lower molars (for up to 1 month) to disclude the replanted tooth from traumatic occlusion);

5. suture any gingival lacerations;

6. perform splinting (on the vestibular surface, with an open gingival margin for hygiene access);

7. check the occlusal relationship;

8. perform a radiographic examination to ensure the correct position of the tooth relative to the socket.

In cases of delayed presentation and improper tooth transportation, delayed replantation may be considered to preserve the shape of the alveolar ridge. The most favorable prognosis is observed when replantation is performed within the first 30 minutes after trauma (self-replantation is possible), as well as by keeping the root surface moist (saliva, pasteurized milk, or isotonic NaCl are suitable).

3.2.3 Tooth extraction

1. in cases of intrusive luxation of the tooth;

2. in cases of crown and root fracture (coronal-radicular fracture) of the tooth;

3. significant mobility, trauma to the oral mucosa, or malocclusion [4, 5].

GCP CLoE 5Grading of Recommendations Assessment, Development and Evaluation (GRADE) – C (Level of Evidence – 5)

3.2.4 Periosteotomy

Comments.

If a secondary infection develops, the inflammatory process spreads due to hematoma suppuration, or pain intensifies, surgical intervention is performed (periostotomy and possibly extraction of the traumatized tooth). The wound is drained.

Schedule a follow-up visit for the next day to assess the condition of the postoperative wound. If pain decreases and there is no purulent discharge from the wound, remove the drain and rinse the wound with antiseptics and disinfectants [10, 15, 16].

3.3 Other Treatment

In dental trauma, to accelerate the resolution of inflammation, physical therapy methods should be prescribed on the 2nd–3rd day after treatment: ultra-high-frequency electric field therapy A17.30.017 (UHF therapy), super-high-frequency electromagnetic field therapy A17.30.020, fluctuotherapy A17.30.033, laser physiotherapy of the maxillofacial region A22.07.003, low-level laser therapy targeting the gingival area A22.07.008, and magnetotherapy for oral cavity and dental pathology A17.07.005 [4, 5, 32].

3.3.1 Physiotherapeutic treatment

• To increase the efficacy of treatment for acute dental trauma, including root fractures, it is recommended that patients with acute dental trauma undergo laser physiotherapy (A22.07.003) [18, 32].

GCP CLoE 5Grading of Recommendations Assessment, Development and Evaluation (GRADE) – C (Level of Evidence – 5)

• Physiotherapeutic treatment is recommended for patients with acute trauma after diagnosis and local treatment of the oral cavity in the trauma zone to improve local blood supply and prevent inflammation [18].

GCP CLoE 5Grading of Recommendations Assessment, Development and Evaluation (GRADE) – C (Level of Evidence – 5)

Comments: the combined effect of low-level laser radiation and a constant magnetic field provides anti-inflammatory, anti-edematous, and analgesic effects, improves microcirculation, and stimulates reparative processes in the area of injury.

Contraindications include:

presence of signs of concussion,

presence of a cardiac pacemaker.

4. Medical Rehabilitation and Sanatorium-Resort Treatment

Comments.

A favorable outcome following dental trauma includes the following signs: absence of pathological symptoms, preservation of physiological tooth mobility, painless tooth percussion and alveolar ridge palpation, and absence of radiographic signs of pathological changes in the periodontal region.

5. Prevention and Dispensary Observation

Requirements for work, rest, treatment, and rehabilitation regimens

Patient care and auxiliary procedure requirements

The patient should return the next day for an examination visit (subsequent dentist consultation/examination B01.065.008) following the therapeutic procedures; thereafter, depending on the need for dressings or the next treatment stage, the visit schedule is determined individually based on the course of the inflammatory process.

Comments.

Possible in the following conditions:

1. subluxation of the tooth without displacement, with physiological or grade I mobility;

During dynamic observation of a dental subluxation in the absence of complaints, crown discoloration, tooth mobility, and radiographic signs of a pathological process, recovery can be stated. If the dental crown acquires a gray shade, tooth mobility, signs of root resorption, or bone tissue resorption on radiographs are detected, this indicates the development of chronic periodontitis. In such cases, tooth extraction is indicated.

In case of pulp necrosis or inflammatory root resorption, endodontic intervention is performed [4, 5].

• After completion of the surgical and therapeutic procedure, patients with dental trauma are recommended not to eat for two hours to ensure physiological rest of the tooth. On the day of surgery, rough and hot food should be avoided, chewing on the operated side should be refrained from, and thermal applications should not be used [4].

GCP CLEL 5Grade of Recommendation – C (Level of Evidence – 5)

6. Organization of Medical Care

Therapeutic measures for dental trauma are carried out in outpatient settings after diagnosis clarification by dentists, general dentists, and dental surgeons, with the involvement of prosthodontists if necessary.

Type of medical care: primary health care.

Form of medical care: emergency.

Conditions for providing medical care: outpatient.

7. Additional Information

For a disease to develop, a combination of risk factors and immediate causes of the disease is necessary. It is often difficult to isolate the cause of a disease, as there may be multiple causes, and they are interrelated. The immediate cause of the disease (etiological factors) directly affects the body, causing pathological changes in it. Etiological factors can be bacterial, physical, chemical, etc.

Disease risk factors are factors that negatively affect health. They favor the onset and development of diseases and cause pathological changes in the body. The World Health Organization has identified more than 200 factors that have the most significant impact on modern humans. Among them are physical, chemical, biological, social, psychological, and genetic factors. Risk factors are distinguished into primary and secondary.

Primary: unhealthy lifestyle (smoking, alcohol consumption, unbalanced diet, stressful situations, constant psycho-emotional stress, physical inactivity, poor living conditions, drug use, unfavorable moral climate in the family, low cultural and educational level); unfavorable heredity (hereditary predisposition to various diseases, genetic risk — predisposition to hereditary diseases); unfavorable environmental state (air pollution with carcinogens and other harmful substances, water pollution, soil pollution, sharp changes in atmospheric parameters, increased radiation, magnetic, and other emissions); unsatisfactory performance of healthcare services (low quality of medical care, untimely provision of medical care, poor accessibility of medical care).

Secondary: diseases that burden the course of other diseases (diabetes mellitus, atherosclerosis, arterial hypertension, etc.).

In addition to the prevalence of the process, morphological, and molecular-genetic characteristics, the course of the disease and the effectiveness of its treatment are significantly influenced by concomitant pathologies, adequacy of supportive therapy, social adaptation of the patient, and the presence or absence of daily physical activity [13, 14].

Criteria for Evaluating the Quality of Medical Care

References

Appendix A1. Working Group Composition

1. Working Group Members:

Bazikyan Ernest Aramovich. Head of the Department of Dental Surgery and Implantology, Yushchuk Research and Educational Institute of Medical Education, Russian University of Medicine of the Russian Ministry of Health. Honored Doctor of the Russian Federation, Professor, Doctor of Medical Sciences.

Chunikhin Andrey Anatolyevich. Professor of the Department of Dental Surgery and Implantology, Yushchuk Research and Educational Institute of Medical Education, Russian University of Medicine of the Russian Ministry of Health, Professor, Doctor of Medical Sciences.

Klinovskaya Anna Sergeevna. Associate Professor of the Department of Dental Surgery and Implantology, Yushchuk Research and Educational Institute of Medical Education, Russian University of Medicine of the Russian Ministry of Health, Candidate of Medical Sciences.

No conflict of interest.

Appendix A2. Methodology for Developing Clinical Guidelines

Target audience for these clinical guidelines:

1. dentist;

2. prosthodontist;

3. general dentist;

4. oral and maxillofacial surgeon;

5. maxillofacial surgeon.

Table 1. Scale for assessing levels of evidence (LE) for diagnostic methods (diagnostic interventions)

Table 2. Scale for assessing the levels of evidence (LE) for prevention, treatment, and medical rehabilitation methods, including those based on natural therapeutic factors (preventive, therapeutic, and rehabilitation interventions)

Table 3. Scale for evaluating the levels of убедительности рекомендаций (LoR) for prevention, diagnostic, treatment, and medical rehabilitation methods, including those based on natural therapeutic factors (preventive, therapeutic, and rehabilitative interventions)

Procedure for updating clinical guidelines.

The mechanism for updating clinical guidelines provides for their systematic revision — at least once every three years, as well as upon the emergence of new evidence-based medicine data regarding the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.

comments to previously approved clinical guidelines, but no more than once every 6 months.

Appendix A3. Reference Materials

Regulatory References

1. - Federal Law No. 323-FZ "On the Fundamentals of Protecting the Health of Citizens in the Russian Federation" dated November 21, 2011 [11].

2. - Decree of the Government of the Russian Federation No. 1387 dated November 5, 1997 "On Measures to Stabilize and Develop Healthcare and Medical Science in the Russian Federation" (including the "Concept of Healthcare and Medical Science Development in the Russian Federation").

3. - Order of the Russian Ministry of Health No. 786n dated July 31, 2020 (as amended on February 18, 2021) "On Approval of the Procedure for Providing Medical Care to the Adult Population for Dental Diseases".

4. - Order of the Russian Ministry of Health No. 804n dated October 13, 2017 (as amended on September 24, 2020, with rev. dated October 26, 2022) "On Approval of the Nomenclature of Medical Services".

5. - Order of the Moscow Healthcare Department No. 1300 dated November 16, 2020 (as amended on March 17, 2025) "On the Implementation of Measures for Organizing Internal Quality Control and Safety of Medical Activities in Medical Organizations of the State Healthcare System of the City of Moscow".

6. - National Standard of the Russian Federation GOST R 56034-2014 "Clinical Guidelines (Treatment Protocols)". General Provisions (approved by Order of the Federal Agency for Technical Regulation and Metrology of the Russian Federation No. 503-st dated June 4, 2014.

Appendix A3.1

Table 1 Requirements for drug therapy in outpatient and polyclinic settings

Appendix A3.2

Patient Questionnaire

Full Name __________________________________________ Date of completion

How do you rate your overall well-being today?

Please mark the value corresponding to your health state on the scale.

Appendix A3.3

Periodontal index: (PI) (Russell A., 1956), allows for assessing the presence of both gingivitis and other signs of periodontal pathology: tooth mobility, clinical pocket depth, etc. [35].

The following scores are used:

0 - no changes or inflammation;

1 - mild gingivitis (gingival inflammation does not involve the entire tooth);

2 - gingivitis without damage to the attached epithelium (clinical pocket is not detected);

4 - disappearance of the closing cortical plates at the alveolar crest peaks on the radiograph;

6 - gingivitis with clinical pocket formation, no functional impairment, tooth is not mobile;

8 - pronounced destruction of all periodontal tissues, tooth is mobile, may be displaced.

Appendix A3.4

Hygiene index

Fedorov-Volodkina Index (1968) until recently was widely used in our country [35].

The hygiene index is determined by the staining intensity of the labial surface of the six lower anterior teeth with iodine-potassium iodide solution, evaluated on a five-point scale and calculated using the formula:

where K_av. – general cleaning hygiene index; K_u – cleaning hygiene index of a single tooth; n – number of teeth.

Staining of the entire crown surface means 5 points; 3/4 – 4 points; 1/2 – 3 points; 1/4 – 2 points; absence of staining – 1 point.

Normally, the hygiene index should not exceed 1.

Green-Vermillion Index (Green, Vermillion, 1964). The Simplified Oral Hygiene Index (OHI-S) evaluates the tooth surface area covered with plaque and/or calculus, and does not require special dyes. To determine OHI-S, examine the buccal surface of 16 and 26, the labial surface of 11 and 31, and the lingual surface of 36 and 46, moving the probe tip from the incisal edge toward the gingiva.

Absence of dental plaque is designated as 0, plaque covering up to 1/3 of the tooth surface as 1, plaque covering from 1/3 to 2/3 as 2, plaque covering more than 2/3 of the enamel surface as 3. Dental calculus is then determined using the same principle.

Formula for index calculation.

where n is the number of teeth, ЗН is dental plaque, and ЗК is dental calculus.

Appendix B. Physician Action Algorithms

Appendix C. Patient Information

On the day of the surgical intervention (after the treatment), you should refrain from eating for 2–3 hours, avoid overheating, limit physical activity, and apply an ice pack to the skin in the area of the procedure for 10–20 minutes with 1-hour breaks during the first 24 hours after surgery. Avoid thermal procedures (sauna, hot baths, etc.) and physical exertion. If pain occurs or inflammatory symptoms increase in the surgical area, you must consult your dentist immediately.

The following day, you are advised to attend a follow-up appointment for an examination after the therapeutic procedures and a postoperative dressing change.

To evaluate the treatment efficacy, you should also visit the dentist for a follow-up examination in 7 days. During the follow-up visit, you may be advised to undergo diagnostic X-ray imaging of the surgical area.

If the treatment involved tooth splinting, you must visit the dentist in 6 months to evaluate the treatment efficacy and remove the splint.

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

Not applicable.