Management of Acute Dental Trauma in Pediatric Patients: Clinical Guidelines

List of Abbreviations

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

TDI – traumatic dental injury

EPT – electric pulp testing

WHO – World Health Organization

GIC – glass ionomer cement

MTA – mineral trioxide aggregate

Terms and Definitions

• Fracture – complete or partial disruption of the integrity of hard tissues under a load exceeding the strength of the injured area

• Contusion (lat. contusio) – closed injury to tissues and organs without significant disruption of their structure

• Complete dislocation (avulsion) – complete rupture of the circular and periodontal ligament and extrusion of the tooth from the alveolus under the action of a significant force directed toward the occlusal plane

• Subluxation – an injury involving partial damage to the periodontal ligament, leading to tooth displacement, the degree and direction of which depend on the characteristics of the acting force

• Apexogenesis – continuation of root formation with partially preserved viable pulp

• Apexification – the process of final formation of the root apex after the death of the germinative zone

• Tooth intrusion – a dental dislocation in which the tooth is displaced toward the socket due to the impaction of the tooth root into the bone tissue

• Hypoesthesia – complete or partial loss of sensitivity in a specific part of the body

• Obliteration – a pathological process in which a hollow organ – a cavity or root canal of a tooth – narrows or becomes overgrown

• Resorption – the process of destruction (breakdown, degradation) of bone tissue or the tooth root by osteoclasts.

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Acute dental trauma is the result of a single damaging factor leading to the disruption of the anatomical integrity and function of the tooth.

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

Acute dental injuries (TDIs) in children occur as a result of short-term mechanical force, which may compromise the integrity of the crown, root, or periodontium of the affected tooth individually. Most frequently, however, the tooth is injured along with its surrounding tissues. In young children, TDIs most commonly coincide with the onset of active mobility at the age of 1–3 years, which is combined with a decrease in protective reflexes, the toddler's curiosity, and instability of neuromuscular reflexes. The next period of increased traumatism occurs at the age of 7–10 years. This is associated with children's mobility and the beginning of active physical education and sports without necessary adult supervision. The high prevalence of traumatic injuries in childhood results in only 15–20% of patients receiving qualified medical care. Therefore, pediatric dentists who are familiar with the clinical presentation, diagnosis, and rehabilitation methods for such children are of particular importance today [1, 2].

1.3 Epidemiology of the Disease or Condition

According to both domestic and foreign researchers, every 3rd to 4th child is subject to acute dental trauma (TDI) to some degree. In a study conducted in 2011, the prevalence of dental trauma was 9.75%, making it the second most frequent condition after dental caries and its complications (69.02%). Thus, on average, every 10th child encounters a clinically significant dental injury. Acute dental trauma is the second leading cause of tooth loss in children after caries [3, 4, 5].

In children aged 0 to 6 years, oral injuries account for 18% of all injuries, and the oral cavity is the second most common site of injury.

A meta-analysis of Traumatic Dental Injuries (TDIs) showed that the global prevalence of primary teeth involvement is 22.7% [6, 7].

1.4 Features of Coding the Disease or Condition

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

The clinical presentation of acute dental trauma in children is characterized by diversity and depends on the severity of the lesion, the time elapsed since the injury, and the child's age.

Features of traumatic injuries in children include a combination of damage to the hard dental tissues, periapical tissues, neurovascular bundle of the tooth, and surrounding bone structures [8]. They are also often combined with soft tissue facial injuries (abrasions, contusions, lacerations) [9, 10, 11].

Traumatic injuries of the maxillofacial region are in some cases combined with cerebral concussion and other neurological disorders.

Crown fracture within the enamel zone. Corresponds to ICD-10 code S02.5 and is characterized by a defect in the crown part of the tooth within the enamel, most commonly in the area of the mesial angles of the central incisors. Damage to the oral mucosa by the sharp edges of the defect is possible.

Crown fracture without pulp exposure. Corresponds to ICD-10 code S02.5. Depending on the direction, oblique, transverse, and longitudinal fractures are distinguished. In crown fractures of both primary and permanent teeth within the enamel and dentin without pulp exposure, children complain of pain when biting hard food and when touching the tooth. The tooth responds to thermal and chemical stimuli. Objectively, a partial crown defect is noted; in deep fractures, the pulp may show through, but the pulp chamber is not opened.

Crown fracture with pulp exposure. Corresponds to ICD-10 code S02.5 and is characterized by a significant crown defect combined with the opening of the pulp chamber and exposure of the pulp. Pain appears from mechanical stimuli when eating hard food, and from temperature stimuli as a result of pulp exposure. Infection of the pulp occurs through the formed communication.

Root fracture. Corresponds to ICD-10 code S02.5. Depending on the direction of the fracture line, oblique, transverse, and longitudinal root fractures are distinguished, or comminuted fractures if there are multiple lines. In trauma to a primary or permanent tooth, the main symptom is mobility, as well as pain when biting and chewing food, and when touching the tooth. When the fracture line is located in the coronal third or runs obliquely, pronounced crown mobility is observed, whereas in a fracture passing through the apical third of the tooth root, mobility may be insignificant. A change in the position of the tooth due to displacement of the coronal fragment is possible.

Crown-root fracture. Corresponds to ICD-10 code S02.5. This type of fracture passes through all hard dental tissues – enamel, dentin, and cementum, and periodontal tissues may also be affected. Since the dental pulp communicates with the oral cavity through the fracture line, its infection occurs. The fracture of a particular part of the crown and root depends on the direction of the fracture line (frontal, sagittal, less commonly longitudinal along the tooth root). The clinical presentation will depend on many factors and is therefore varied. Pain sensations when eating, from thermal stimuli, and tooth mobility are possible. Due to the communication with the pulp chamber, pain characteristic of an inflammatory process in the pulp is noted.

Tooth contusion. In this type of acute trauma, minor damage to the periodontal tissues occurs without tooth displacement, and its mobility remains within physiological limits. Visually, the tooth crown appears intact. Also, changes in the pulp associated with its concussion and disruption of the vessel wall integrity may be observed during a contusion, leading to hemorrhage and hematoma formation, which can outwardly manifest as a change in the color of the tooth crown (from pink to purple).

Tooth dislocation. Corresponds to ICD-10 code S03.2. Due to significant damage to the ligamentous apparatus, the tooth becomes mobile and shifts in one direction or another (vestibularly, orally, toward the occlusal surface, medially, distally). Bleeding of the mucosa and often its rupture are also noted. With significant displacement of the tooth toward the occlusal plane, closing the teeth is impossible.

Tooth intrusion. Corresponds to ICD-10 code S03.2. Due to the displacement of the tooth into the socket and bone tissue, the clinical crown is shortened and sometimes not visible in the socket, depending on the impact force. The crown of the tooth is immobile. The intrusion is often accompanied by its displacement in vestibular or oral directions. In some cases, rotation of the tooth around its axis is observed. With deep impaction, the tooth may be located within the jaw body or displaced toward the maxillary sinus or nasal cavity.

Complete dislocation (exarticulation, avulsion) corresponds to ICD-10 code S03.22. Since this type of injury is accompanied by a complete rupture of the periodontal ligament, the tooth falls out of the alveolus. In most cases, the child and their legal representatives bring the avulsed tooth with them. Aspiration or swallowing of the tooth by the patient is possible.

2. Diagnostics, medical indications and contraindications for diagnostic methods

The examination aims to establish a diagnosis corresponding to the patient model, rule out complications, and determine the feasibility of initiating treatment without additional diagnostic and therapeutic-prophylactic measures.

The main objective in diagnosis is to identify clinical and radiological signs of acute dental trauma, determine the clinical form and severity of the pathological process, and select the appropriate treatment method. Diagnosis is performed for each tooth individually.

Criteria for establishing a diagnosis in acute dental trauma:

Nosological form: enamel fracture, enamel-dentin fracture

Phase: any

Complication: uncomplicated

ICD-10 code: S02.5

Pediatric patients with primary or permanent teeth with incomplete or complete root formation

• Traumatic defect of the tooth crown within the enamel without pulp involvement

• Absence of pathological changes in 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: crown fracture with pulp involvement

Phase: any

Complication: uncomplicated

ICD-10 code: S02.5

Pediatric patients with primary or permanent teeth with incomplete or complete root formation

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

  According to the fracture line direction, the following are distinguished: oblique, transverse fracture

• Absence of pathological changes in 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

Pediatric patients with primary or permanent teeth with incomplete or complete root formation

• Pathological tooth mobility

• Damage to periodontal tissues in the area of the injured tooth

• The root fracture line is identified via X-ray examination.

  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

Pediatric patients with primary or permanent teeth with incomplete or complete root formation

• 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

• The root fracture line is identified via X-ray examination

Nosological form: Tooth dislocation

Phase: subluxation (tooth luxation)

Complication: uncomplicated

ICD-10 code: S03.2

Pediatric patients with primary or permanent teeth with incomplete or complete root formation

• Change of 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 tooth socket according to X-ray examination data

• Absence of pathological changes in the tissues of the alveolar process of the jaw bones

Nosological form: Tooth dislocation

Phase: intrusive luxation (intrusion)

Complication: uncomplicated

ICD-10 code: S03.2

Pediatric patients with primary or permanent teeth with incomplete or complete root formation

• Change of tooth position in the dental arch

• Displacement 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 impaction into the bone tissue according to X-ray examination data

• Absence of pathological changes in the tissues of the alveolar process of the jaw bones

Nosological form: Tooth dislocation

Phase: complete dislocation (exarticulation)

Complication: uncomplicated

ICD-10 code: S03.2

Pediatric patients with primary or permanent teeth with incomplete or complete root formation. Absence of the tooth in the dental arch

• Empty tooth 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

2.1 Complaints and Anamnesis

• All pediatric patients with acute dental trauma are recommended to undergo medical history taking, oral cavity and dental examination, and other necessary examinations to establish a diagnosis and prescribe the required treatment, with the results recorded in the dental patient's medical chart (Table 1) [1, 12, 13, 14].

GCR CLEL 5Grade of Recommendation 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 helps determine the components of the trauma and prioritize treatment.

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

The specific features of diagnostic procedures in children should be considered:

• varying levels of objectivity of information obtained from questioning the child and third parties (parents interpret complaints and history differently);

• subjectivity of the child's sensations during diagnostic tests;

• varying levels of interaction between the physician, patient, and parents;

• inability to perform complex diagnostic manipulations due to the age and psycho-emotional characteristics of the child;

• limitations in performing certain examinations (electric pulp testing of primary and permanent immature teeth, radiographic examination is difficult in young children) [1].

Table 1 Requirements for the diagnosis of acute dental trauma in outpatient settings

• When taking a medical history in pediatric patients with acute dental trauma for the purpose of diagnosis, treatment planning, and deciding on 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 consciousness was lost or there were other signs of traumatic brain injury (vomiting, nausea, dizziness, headache, and other neurological symptoms);

- exact time of injury;

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

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

- presence of comorbidities, allergic reactions, and current medications;

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

- patient's complaints or clarification from their legal representatives (pain and discomfort in the area of a specific tooth, change in the tooth's appearance, onset of complaints);

- whether a malocclusion has occurred [15, 16, 17].

GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)

Comments.

Complaints for various types of traumatic injuries:

In case of enamel crown fracture:

- cosmetic defect

- discomfort due to mucosal trauma from sharp edges of the defect

In case of uncomplicated crown fracture

- cosmetic defect

- reaction to thermal and chemical stimuli (pain is more pronounced if the dental pulp is located closer to the fracture line)

In case of complicated crown fracture with pulp involvement

- cosmetic defect

- discomfort from mechanical and thermal stimuli (the intensity of pain depends on the time elapsed since the injury, individual characteristics of the nervous system, and the depth of the defect)

In some cases, pain is absent due to impaired nerve impulse conduction when the neurovascular bundle of the pulp is ruptured or compressed in periapical tissues as a result of edema or hematoma formation

In root fracture

- pain from mechanical stimuli (when biting or applying pressure to the tooth)

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

In crown-root fracture of the tooth

- cosmetic defect

- pain from mechanical and thermal stimuli

- tooth mobility

If there is a communication with the pulp cavity, pain characteristic of pulpitis is observed.

In tooth concussion

- pain when biting food or applying pressure to the tooth

- tooth discoloration (due to pulp concussion or disruption of the vascular 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, the presence of a fistulous tract on the mucosa near the root apex, or tooth discoloration

In subluxation of the tooth

- tooth displacement

- tooth mobility

- pain from mechanical stimuli

- bleeding of the mucosa due to periodontal tissue damage

- disruption of occlusal contacts up to the inability to close the mouth (with significant tooth displacement)

In tooth exarticulation

- shortening of the tooth crown or its complete absence

- pain

- gingival bleeding

In complete dislocation (avulsion)

- absence or loss of the tooth

- pain

- gingival bleeding in the socket area

- cosmetic defect

- discomfort when eating

- speech defect. [1, 12, 13].

2.2 Physical Examination

Comments.

1. External examination of the maxillofacial region:

- possible distortion of facial contours due to soft tissue edema in the injury area or due to fracture and displacement of facial bones;

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

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

- presence of signs of wound contamination and foreign body ingress.

2. Intraoral examination:

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

- identification of hyperemia, edema, submucosal hematoma, tenderness on palpation, presence of mucosal tears, embedded foreign bodies, or tooth fragments;

- alteration of the tooth crown;

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

- assessment of the periodontal status;

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

- assessment of the condition of all existing teeth, especially adjacent teeth

- assessment of the condition of the periodontium and periapical tissues;

- performance of vertical and horizontal percussion;

- palpation-determined presence of an infiltrate;

- determination of tooth mobility and its degree.

3. Palpation.

Palpation is used to assess the presence of:

- tenderness;

- local hyperthermia;

- infiltration (localization, size);

- hematoma (density, consistency, mobility 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 psycho-emotional state of the patient before 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;

- poor oral hygiene;

- refusal of treatment [1; 13].

When examining a child with acute dental trauma, attention should also be paid to the following aspects:

- extraoral injuries in the chin area indicate potential indirect trauma to the temporomandibular joints; functional and radiological examinations must be performed (A06.07.004, A06.07.003, A06.07.007, A06.07.001, A06.07.002, A06.07.008, A06.07.009, A06.07.013);

- bleeding or discharge of clear fluid (cerebrospinal fluid) from the nose may indicate potential damage to the nasal floor, for instance, due to an intrusive tooth luxation, although epistaxis may also occur;

- bleeding or fluid discharge from the ears may indicate damage to the ear canals, e.g., by the articular heads (in doubtful cases, an additional consultation with an otorhinolaryngologist is required);

- the intraoral examination should not be limited only to the area of visible damage, but should also cover the region of antagonist teeth;

- palpation (finger pressure) in children provides more reliable data (pain on pressure) than percussion;

- soft tissue examination must be supplemented by a radiological examination (A06.07.004, A06.07.003, A06.07.007, A06.07.001, A06.07.002, A06.07.008, A06.07.009, A06.07.013) if foreign bodies (tooth fragments, pebbles, etc.) are suspected to be present.

Determination of tooth mobility grade.

Mobility grade is recorded on a scale from 0 to 3 to identify the type of tooth luxation:

0 – no mobility

1 – horizontal mobility up to 1 mm

2 – horizontal mobility greater than 1 mm

3 – mobility along the tooth axis [11].

2.3 Laboratory Diagnostics

Not performed in children with acute dental trauma.

2.4 Instrumental Diagnostics

2.4.1 Diagnostic Imaging

Comments. Radiological examination makes it possible to detect:

- stage of tooth development and root formation;

- root length, wall thickness, presence of a flaring root canal, growth zone, size and clarity of the lamina dura line surrounding it along the entire perimeter;

- pathological root resorption, intracanal, inflammatory, replacement resorption (ankylosis), and severity of the process;

- state of the bone tissue;

- changes in bone density, pattern, presence of destruction foci or signs of a productive process, bone radiolucency focus, its size, contour sharpness, spread towards adjacent teeth, presence of a cyst, its size, position;

- state of the periodontal tissues;

- integrity of the lamina dura surrounding the tooth growth zone and the alveolar bone wall;

- position of the deciduous tooth root relative to the permanent tooth germ;

- presence of a fracture line, its direction, localization, and fragment alignment;

- 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;

- relationship between the crown fracture line and the pulp cavity.

In enamel-dentin crown fractures without pulp exposure, or crown fractures with pulp exposure, no pathological changes are detected; a hard tissue defect is identified along with the spatial relationship between the crown fracture line and the borders of the pulp cavity. Furthermore, radiological examination rules out root and alveolar process fractures.

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. Radiological examination reveals tooth displacement toward the socket; the periodontal ligament space is most often absent. The incisal edge and the dentinoenamel junction are positioned higher than in neighboring teeth, and the root appears longer. In cases of severe intrusion, the radiograph may show the tooth located within the jaw body, the maxillary sinus, the nasal cavity, etc. [10, 18, 19].

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 [19, 20].

Complete luxation (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. [1, 10, 12, 13]

2.4.2 Electric Pulp Testing (EPT) of the Tooth

• Pediatric patients with acute dental trauma are recommended to undergo electric pulp testing (EPT) in case of traumatic injury to permanent teeth [1, 12, 13, 22, 29-34].

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

Comments: this diagnostic method is not performed in deciduous teeth. When testing electric pulp sensitivity in teeth with unformed roots, comparative diagnostics is performed with values from teeth at the same stage of development. During electric pulp testing in the first days after trauma, a decrease in pulp electrical excitability in injured teeth is noted, as dental trauma damages the neurovascular bundle and nerve fiber conduction is impaired or completely absent. Such changes may be associated not only with the rupture of the neurovascular bundle, but also with compression of the pulp tissue by a hematoma or exudate, which in most cases is a reversible phenomenon. Therefore, dynamic monitoring of the electrical excitability of the neurovascular bundle is recommended.

Normally, pulp threshold excitation values range from 2 to 6 µA. Threshold current values in caries do not exceed 12-15 µA. However, different device calibrations should be taken into account; comparative measurements with adjacent or symmetrical intact teeth must be performed during diagnosis. Interpretation of the EPT test is complicated by the fact that pulp sensitivity may be temporarily or permanently reduced, especially in lateral luxations [13; 24, 25].

In types of trauma such as dental concussion, enamel crown fracture, crown fracture without pulp exposure, crown fracture with pulp exposure, and tooth subluxation, a decrease in pulp electrical excitability is observed in the first days following trauma. Therefore, for these types of acute trauma, dynamic monitoring of the pulp state is recommended, and only with a persistent decrease in electrical excitability exceeding 100 µA after 10-15 days can potential pulp necrosis be diagnosed [26, 27, 28].

As a result of intrusive luxation, irreversible pulp damage occurs in most cases; therefore, according to EPT data, pulp sensitivity is significantly reduced and exceeds 100 µA. [1, 12, 13, 29-34].

2.5 Other Procedures

2.5.1 Thermometry (Dental Thermal Diagnostics)

• Pediatric patients with acute dental trauma are recommended to undergo thermometry (thermal pulp testing) to determine the sensitivity of the permanent tooth neurovascular bundle [1, 26, 27, 28, 29, 30, 31].

GDR CLE 5Grade of recommendation C (level of evidence – 5)

Comments: using thermal stimuli (heated gutta-percha, dry ice, carbon dioxide), the reaction of not only the injured tooth, but also neighboring teeth is determined. Marked pain from the stimulus that persists even after its removal indicates an inflammatory process in the pulp. The absence of a reaction to thermal tests indicates necrosis of the tooth neurovascular bundle; however, in the first days after dental trauma, the lack of sensitivity may be due to impaired conduction resulting from nerve fiber compression by an emerging hematoma or the development of post-traumatic edema. Since this condition is reversible, studying sensitivity to thermal stimuli dynamically is recommended.

However, this method has limited indications for use in children, as exposure to high or low temperatures may cause a sharp pain reaction, since traumatic neuritis can be accompanied by increased pain sensitivity. If during dynamic monitoring temperature tests show no response to temperature changes, the color of the tooth crown changes, and radiographic examination reveals bone tissue destruction at the root apex, pulp necrosis can be suspected, which requires appropriate treatment [1, 29, 30, 31].

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

3.1 Conservative Treatment

General Principles

The principles of treatment for children with acute dental trauma of primary and permanent teeth provide for the simultaneous achievement of several objectives:

- tooth preservation;

- elimination of factors causing the development of an inflammatory process in the pulp and periodontal tissues;

- creation of conditions for the continuation of root apexogenesis;

- prevention of the further spread of the process to the surrounding bone tissue and adjacent anatomical regions;

- preservation of the integrity and viability of the developing permanent tooth germ in trauma to primary teeth;

- restoration of the anatomical shape of the tooth, dental arch, and the morphofunctional integrity of the dentofacial system;

- prevention of the development of dentofacial anomalies associated with early tooth loss;

- improvement of the patients' quality of life [1, 12, 13, 35].

Treatment of acute dental trauma in most cases includes:

- in order to reduce the occlusal load on the traumatized tooth, grinding of the antagonist is performed, followed by the application of remineralizing agents;

- recommendations for the patient/their legal representatives (see Appendix B);

- dynamic monitoring of the condition of the neurovascular bundle of the tooth, periapical tissues, bone structures surrounding the tooth, and the continuation of root formation in incomplete apexogenesis [1, 10, 11, 12, 13, 23, 35].

Treatment of acute dental trauma in some cases includes:

- referral of the child to a pediatrician for tetanus vaccination for prophylactic purposes if there are signs of wound contamination;

- in young children, procedures may be performed under anesthesia [37];

- referral for consultation with other specialists: a neurologist, orthodontist, pediatrician, medical psychologist, etc.;

- application of modern conservative endodontic treatment methods (partial pulpotomy, pulpotomy, deep pulpotomy) in case of pulp infection in teeth with unformed roots, which contributes to the continuation of apexogenesis and tooth preservation [21, 36, 38, 39, 40];

- prescription of medications is carried out according to medical indications, taking into account the age and weight of the child. Analgesics are most commonly prescribed shortly after dental trauma. The prescription of systemic antibiotics during replantation is not mandatory, as there are no studies reliably confirming an increase in treatment outcomes (including) of replantation when they are prescribed [42, 43].

3.1.1. Smoothing of sharp tooth edges

Comments: performed using rotary instruments with water cooling. The main objective is the prevention or elimination of trauma to the labial mucosa caused by sharp edges of the hard dental tissue defect resulting from trauma [1, 12, 13].

After grinding the hard dental tissues, remineralizing agents (ATC code: A12AA) are applied to the treated surface [1, 12, 13].

3.1.2. Temporary restoration of the tooth crown

• The method of temporary restoration is recommended for pediatric patients with acute dental trauma upon initial presentation with a crown fracture within the enamel and dentin without pulp exposure in cases where permanent restoration of the hard tissue defect is impossible (A16.07.002.003, A16.07.002.005) [1, 12, 13].

GDR CLE 5Grade of recommendation C (level of evidence – 5)

Comments: the technique consists of disinfecting the fracture line with mild antiseptic solutions, applying a calcium-containing preparation in the projection of the pulp horn, and sealing the fracture line with a glass ionomer cement dressing to prevent pulp infection

3.1.3. Restoration of the tooth crown

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

In childhood, glass ionomer cements, compomer, and composite filling materials are used to restore the resulting defects.

The choice of treatment method for teeth with unformed roots and the materials used depends on the stage of root formation and the severity of the damage.

- regardless of the stage of tooth development, when the fracture line passes through the deep layers of dentin, placing a calcium hydroxide-based therapeutic lining in the pulp projection;

- fabrication and fixation of a crown if a significant part of the tooth crown is missing as a result of the fracture;

- using the direct veneer fabrication technique using compomer and composite filling materials;

- at the stage of root formation, when it has already reached normal length but the apex is missing, it is recommended to use a glass ionomer cement insulating base covering the dentin along the fracture line, along with a compomer or composite filling material during restoration;

- at the final stages of tooth root development, to restore the anatomical shape, it is possible to use a glass ionomer cement base and composite filling materials [1, 12, 13].

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

Comments: the temporary restoration method is recommended upon the patient's initial presentation with a crown fracture within the enamel and dentin without pulp exposure in cases where permanent restoration of the hard dental tissue defect is impossible. The technique involves disinfecting the fracture line with mild antiseptic solutions, applying a calcium-containing preparation in the projection of the pulp horn, and sealing the fracture line with a glass ionomer cement dressing to prevent pulp infection [1, 12, 13]

3.1.4. Restoration of the tooth crown using own fragment

Comments: fixation is possible using modern adhesive systems and composite filling materials.

Method for restoring the coronal part of the tooth using its own fragment:

- matching the fragment to the tooth along the fracture line to assess the preservation of hard tissues and the feasibility of this method

- if the tooth fragment was delivered "dry", it is recommended to leave it in saline for at least 20 minutes before restoration

- local anesthesia

- thorough cleaning of all tooth surfaces (air-abrasive methods may be used)

- antiseptic treatment of the tooth, especially the fracture line

- application of phosphoric acid to the tooth enamel and the separated fragment

- thorough rinsing with water

- application of the adhesive system to the hard dental tissues along the fracture line, adjacent enamel areas, and the entire separated fragment, thorough drying, and polymerization

- application of a small amount of flowable composite along the fracture line, alignment with the fragment, removal of excess composite, and polymerization

- covering the fracture line with composite filling material

- grinding and polishing

- recommendations for the patient/parent (see Appendix B).

3.1.5. Biological method (direct pulp capping)

Comments: this procedure is performed by direct pulp capping using calcium-containing medications (ATC code: A12AA).

Procedure technique:

- local anesthesia;

- isolation;

- cleaning;

- antiseptic treatment with a solution (chlorhexidine**);

- application of a thin layer of a calcium-based therapeutic dressing on the pulp;

- base/lining (glass ionomer cement);

- X-ray imaging (A06.07.004, A06.07.003, A06.07.007, A06.07.001, A06.07.002);

- restoration of the coronal part of the tooth;

- follow-up observation (see Appendix B).

3.1.6. Partial pulpotomy

Comments.

Procedure for partial pulpotomy:

- local anesthesia;

- isolation;

- antiseptic treatment of all tooth surfaces and the fracture line;

- removal of pulp tissue to a depth of 1–2 mm using a sterile diamond bur;

- irrigation with antiseptic solutions (0.05% chlorhexidine solution – ATC code: D08AC02), stopping bleeding if necessary;

- application of a therapeutic dressing (calcium preparations, MTA) to the pulp surface in the created cavity;

- base/lining (glass ionomer cements are most commonly used);

- restoration of the coronal part of the tooth (can be delayed – after 2–3 weeks);

- if there are no signs of inflammation, restoration is performed;

- follow-up observation

- radiological control (A06.07.004, A06.07.003, A06.07.007, A06.07.001, A06.07.002, A06.07.008, A06.07.009, A06.07.013).

3.1.7. Pulpotomy (vital amputation)

Comments:

Pulpotomy procedure:

- local anesthesia;

- isolation;

- antiseptic treatment of all tooth surfaces and the fracture line;

- removal of the coronal pulp;

- hemostasis with a sterile cotton pellet soaked in saline for 1 minute;

- irrigation with antiseptic solutions (0.05% chlorhexidine solution – ATC code: D08AC02);

- application of a therapeutic dressing (calcium preparations, MTA) to the pulp stump;

- base/lining (glass ionomer cements are most commonly used);

- restoration of the coronal part of the tooth (can be delayed – restoration is performed after 2–3 weeks in the absence of signs of inflammation);

- follow-up observation

- radiological control (A06.07.004, A06.07.003, A06.07.007, A06.07.001, A06.07.002, A06.07.008, A06.07.009, A06.07.013).

3.1.8. Extirpation method

Comments:

Algorithm and features of the extirpation treatment method for primary teeth in children:

- preliminary X-ray imaging (A06.07.004, A06.07.003, A06.07.007, A06.07.001, A06.07.002, A06.07.008, A06.07.009, A06.07.013);

- administration of local anesthesia;

- isolation of the operating field;

- creation of endodontic access;

- a specific feature is the possibility of creating access in primary incisors from the vestibular surface with widening toward the incisal edge to ensure the most straightforward access to the root canal;

- thorough removal of the root canal contents;

- determination of the root canal working length;

- minimal mechanical preparation

- medication treatment of the root canals (minimal mechanical preparation; irrigation is performed using chlorhexidine** (2%), hydrogen peroxide** (3%), sodium hypochlorite (diluted with distilled water to a concentration of less than 1%);

- drying is performed using sterile paper points;

- root canal filling: resorbable filling materials (zinc oxide-eugenol paste, iodoform- or calcium hydroxide-based paste) are used as filling materials [1, 12, 42];

it is desirable to avoid extruding filling material beyond the apical foramen;

- radiological control (A06.07.004, A06.07.003, A06.07.007, A06.07.001, A06.07.002, A06.07.008, A06.07.009, A06.07.013): performed after root canal obturation and during follow-up stages;

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

- glass ionomer cements, compomer and composite filling materials are used to restore the coronal part of the tooth, and restoration with standard stainless steel crowns is also possible;

- follow-up observation:

- mandatory examination and X-ray imaging (A06.07.004, A06.07.003, A06.07.007, A06.07.001, A06.07.002, A06.07.008, A06.07.009) after 3 months, then 2 times a year [1, 12, 13, 43].

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, repeated irrigation of the root canal with antiseptic solutions is performed. Next, the root canal is dried, and medicaments containing calcium hydroxide on an aqueous or oily base are introduced to provide an anti-inflammatory effect on the periapical lesion and an antimicrobial effect on the root canal system [42, 43].

The pulp chamber is hermetically sealed with a glass ionomer cement filling, a temporary crown, or a temporary composite restoration [1, 12].

3.1.9. Selective grinding

Comments: selective grinding of the opposing tooth is performed with a bur, checking occlusal contacts. Next, fluoride-containing preparations (ATC code: A01AA) are applied to the treated surfaces [1, 12, 13].

3.1.10. Splinting

Comments: in case of a root fracture of a permanent tooth at the initial visit, reposition of the tooth fragments with exact alignment of the coronal and root fragments (in case of displacement) and immobilization via splinting are recommended. The recommended duration of splinting is from 2 to 4 months. Mechanical load on the tooth must be restricted. For this purpose, taking the tooth out of occlusion via selective grinding is recommended, and patients are advised to avoid biting food with their front teeth. Since there is a possibility of preserving pulp vitality, endodontic treatment is not recommended until signs of pronounced inflammatory process or pulp necrosis are detected based on electric pulp testing (EPT) and X-ray data.

Several outcomes of root fracture treatment are distinguished:

• formation of calcified tissue consisting of dentin or cementum;

• healing involving connective tissue from periodontal fibers;

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

• 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.

In case of pulp necrosis, endodontic treatment is recommended followed by root canal filling with a calcium hydroxide-based dental material to relieve inflammation and stimulate osteoplastic processes. Final root canal filling is recommended upon confirmation by X-ray examinations of fracture healing signs according to the first three types and the absence of inflammatory changes in periapical tissues.

In the case of a transverse root fracture in the apex region of a permanent fully formed tooth complicated by pulp necrosis, root-end resection is recommended on a planned basis after endodontic treatment [56].

In case of complete avulsion of a permanent tooth, replantation is advisable in pediatric patients to restore the anatomical and physiological integrity of the dental arch [41-44, 53, 54].

Replantation of primary teeth is ineffective and therefore not recommended [1, 10, 12, 13].

The algorithm for the procedure depends on the time elapsed from the injury until the patient seeks care, the method of tooth transportation, and the stage of root formation.

General recommendations include:

- minimizing the time the tooth spends outside a fluid medium (avoiding drying out);

- rinsing the tooth with an isotonic solution;

- inspecting the socket and, if necessary, performing revision, rinsing, and repositioning the alveolar wall;

- performing tooth replantation without excessive pressure;

- suturing in the presence of gingival tears;

- performing splinting;

- checking the occlusal relationship;

- X-ray 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 performed. The purpose of this method is to preserve the shape of the alveolar process of the jawbones.

The success of treatment for permanent teeth depends mainly on the time elapsed from the injury to seeking medical care, the stage of root formation, the condition of the root and the socket of the avulsed tooth, as well as the method of tooth transportation. The most favorable prognosis is when tooth replantation is performed within the first 30 minutes after injury. The optimal condition for healing processes is transporting the tooth while keeping the root surface moist. The patient's own saliva, pasteurized milk, or isotonic sodium chloride solution are most suitable for this purpose.

Avulsed teeth must be replanted into the socket as soon as possible. If the tooth is not contaminated, the doctor may advise parents by phone on how to independently replant the tooth within the first 30 minutes after injury before seeing a doctor. In other cases, the tooth is transported in a moist environment to provide immediate medical assistance. One of the recommended ways is transporting the avulsed tooth in the vestibule of the patient's oral cavity, as saliva is the most favorable biological medium. However, this method is not suitable for all patients, as the possibility of swallowing or aspiration cannot be ruled out.

Before performing replantation, the condition of the root and the integrity of the periodontal fibers on its surface are assessed, which is an important factor for subsequent regeneration. Visible contaminants are carefully removed, and rinsing with a physiological saline solution is performed.

Manipulation of the root should be avoided so as not to damage the remnants of periodontal tissues on its surface. Pulp extirpation as part of emergency first aid in children is almost never indicated, especially with an unformed root apex when there is a possibility of revascularization. If there are indications for endodontic treatment immediately after injury or later, it should be performed approximately one week after the injury. For root canal filling, the use of calcium hydroxide-based preparations is preferred.

Before replantation, foreign bodies are removed from the socket, and the alveolar process is examined to rule out a fracture. If complete placement of the tooth root into the socket is impossible because a displaced crown interferes with tooth closure, occlusal overlays should be fabricated in the area of the lower first permanent molars using glass ionomer cement for a short period (up to 1 month). This will disclude the replanted tooth from traumatic contact and create conditions for normal regeneration at the initial stage. After replantation, the alveolar mucosa is sutured if its integrity is compromised, and a flexible splint is applied for 2 to 4 weeks. The splint should leave the gingival margin free to ensure adequate oral hygiene. A key requirement for splinting in dental trauma in children is its ability to fix teeth in the correct position while maintaining their physiological mobility, which is a critical condition for preventing the development of dental ankylosis. It is recommended to use splinting on the vestibular surface of the teeth [1, 12, 13].

3.2 Operative (surgical) treatment

3.2.1. Tooth extraction

• Tooth extraction (A16.07.001, A16.07.002) is recommended for pediatric patients with acute dental trauma in the following cases:

- in case of intrusion of a primary tooth when it is located far from its normal position (in soft tissues, deep within the jaw body, in the maxillary sinus, etc.), and also when root displacement occurred toward the permanent tooth germ;

- upon detection of signs of pathological root resorption of a primary tooth or bone tissue destruction on X-ray examination;

- in case of a primary tooth root fracture;

- in case of a crown and root fracture (crown-root fracture) of a primary and permanent tooth;

- in case of a primary tooth crown fracture with pulp exposure shortly before tooth exfoliation;

- significant mobility, trauma to the oral mucosa, or inability to fully close the mouth and impaired occlusion resulting from pronounced displacement of a primary tooth due to incomplete luxation [53, 54].

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

3.3 Other Treatment

3.3.1 Physiotherapeutic treatment

• To increase the effectiveness of treatment for acute dental trauma, including root fracture, it is recommended that pediatric patients with acute dental trauma undergo laser physiotherapy (A22.07.003) [1, 12, 56].

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

Comments: Physiotherapy is recommended for pediatric patients with acute trauma after diagnosis and local treatment of the oral cavity in the trauma zone in order to preserve pulp vitality by improving microcirculation and stimulating reparative processes in the injury area.

The combined effect of low-level laser radiation and a constant magnetic field provides an anti-inflammatory, anti-edematous, and analgesic effect, helps improve microcirculation, and stimulates reparative processes in the injury area.

Contraindications include:

presence of signs of concussion,

presence of a cardiac pacemaker.

4. Medical Rehabilitation and Sanatorium-Resort Treatment

The large number and variety of complications arising from acute dental trauma require mandatory follow-up monitoring of both the injury area and the developing child's body as a whole.

Regardless of the type of traumatic injury, a comprehensive diagnostic assessment is performed, including basic and additional examination methods. X-ray control and pulp electric vitality testing of permanent teeth are mandatory.

Adherence to follow-up monitoring schedules is required. The optimal schedule is a visit 3 months after the end of the active treatment period, and subsequently every six months with mandatory detailed recording of the examination data in the patient's medical history. The purpose of this follow-up monitoring is the prevention, timely detection, and treatment of complications of acute dental trauma, and creating conditions for the normal development of the dentition and maxillofacial system in children.

When acute trauma occurs during a period when apexogenesis is not yet complete, particularly careful monitoring of the root formation process of the permanent tooth is required. The completion of the root and periodontal tissue development process will be one of the main criteria for the effectiveness of the treatment performed [1, 12, 13].

A favorable outcome following dental trauma includes the following signs: absence of pathological symptoms, preservation of physiological tooth mobility, painless tooth percussion and alveolar process palpation, absence of radiographic signs of pathological changes in the periodontal area, and continued growth and formation of the tooth root.

5. Prevention and Dispensary Observation

• As preventive measures for acute dental trauma, it is recommended for preschool-aged children to eliminate traumatic factors in the home environment (covering sharp corners, smoothing out uneven flooring, etc.) and to supervise the child during games and active movement.

• For school-aged children, it is recommended: teaching street safety rules, adult supervision during sports activities and physical education classes, using protective mouthguards, and normalizing occlusion to prevent acute dental trauma [43].

Level of Evidence CGrade of Recommendation 5Level of Clinical Effectiveness C (level of evidence – 5)

Active surveillance

Comments.

Possible in the following conditions:

- incomplete luxation of a primary tooth with physiological or grade I mobility; without root displacement toward the permanent tooth germ;

- incomplete luxation of a permanent tooth without displacement, with physiological or grade I mobility;

- intrusion (intrusive luxation) of a primary tooth with incomplete apexogenesis without root displacement toward the permanent tooth germ (first 3–4 weeks after acute dental trauma);

- intrusion (intrusive luxation) of a permanent tooth with incomplete apexogenesis (first 3–4 weeks after acute dental trauma) [50].

During follow-up monitoring of an incomplete luxation of a primary tooth, in the absence of complaints, changes in crown color, tooth mobility, and absence of radiographic signs of a pathological process, recovery can be concluded. If the coronal part of the tooth acquires a gray tint, tooth mobility is detected, or signs of root or bone resorption appear on the radiograph, this indicates the development of chronic periodontitis. In such cases, extraction of the primary tooth is indicated. Subsequently, an orthodontic appliance is fabricated to replace the dental arch defect and prevent the formation of dentofacial anomalies.

In cases of intrusion (intrusive luxation) of a primary tooth, treatment most often comes down to tooth extraction, especially if the root has a palatal direction, as there is a risk of damaging the permanent tooth germ in this situation. If the roots of the primary teeth are not formed, with a less significant and more favorable direction of displacement, observation of spontaneous "eruption"—extrusion of the injured tooth toward the occlusal plane—is performed.

In the case of intrusion of a permanent tooth with incomplete apexogenesis, an expectant management approach is recommended, as there is a high probability of spontaneous tooth extrusion toward the occlusal plane. This process can take up to 9–12 months. If there are no signs of tooth extrusion within 3–4 weeks, orthodontic extrusion or surgical repositioning is performed. In case of pulp necrosis or inflammatory root resorption, endodontic intervention is performed [43].

6. Organization of Medical Care

Type of medical care: primary health care.

Conditions for providing medical care: outpatient.

7. Additional Information

7.1 Emergency care provided

Correct and timely emergency care has a critical impact on treatment outcomes in certain types of dental trauma. For example, in the case of a complete avulsion of a permanent tooth in a child, the probability of its engraftment (periodontal type of healing) depends on the type of transport medium and the time spent outside the socket (drying). This information must be gathered during the interview with persons accompanying the child and recorded in the medical history. [12, 45]

Optimal transport media for the temporary storage of avulsed teeth are pasteurized milk, saline solution, or the patient's saliva. The avulsed tooth should be reinserted into the socket as soon as possible. The critical time is one hour, after which necrotic processes begin to predominate on the root surface, significantly reducing the likelihood of a successful replantation outcome. As drying time increases, complications frequently develop in the form of surface, ankylosis-associated (replacement), or infectious-inflammatory root resorption [1, 42, 43].

7.2 Past and comorbid conditions

Certain somatic and infectious diseases, as well as dental diseases and conditions, can significantly affect treatment outcomes in dental trauma, particularly the likelihood of successful engraftment during tooth replantation. [1, 12].

Multiple caries, aggressive periodontal diseases, severe malocclusion, and uncompensated somatic pathology (immunosuppression, diabetes mellitus, cardiovascular diseases) negatively affect the regeneration process and may be contraindications for tooth replantation in complete avulsion. Extensive alveolar bone damage resulting from trauma also greatly reduces the likelihood of successful engraftment of injured teeth [10; 46].

7.3 Patient and Parental Cooperation, Avoidance of Re-injury

Cooperation of the patient and their parents (guardians) during the monitoring and treatment of children with dental injuries is a prerequisite for achieving the optimal therapeutic outcome [1, 12, 13, 43].

Parents (guardians) must be informed of the need to discontinue contact sports for at least 1 month after the trauma and to have a protective mouthguard fabricated thereafter. A soft diet must be followed for 2 weeks to 1 month, hard foods should not be bitten with the injured teeth, teeth should be cleaned with a soft toothbrush after each meal, and antiseptic and disinfectant agents (0.05% chlorhexidine solution) should be used for oral cavity rinsing twice a day for one week following the trauma [1, 12, 13, 43].

Criteria for Evaluating the Quality of Medical Care

Group of diseases or conditions: Dental trauma

ICD-10 codes: S02.5, S03.2

Nosological forms: Tooth fracture, tooth luxation

Type of medical care: Primary health care

Conditions for providing medical care: Outpatient

References

Appendix A1. Working Group Composition

1. Larisa P. Kiselnikova, Doctor of Medical Sciences, Professor, Head of the Department of Pediatric Dentistry, Russian University of Medicine of the Russian Ministry of Health

2. Gennady A. Osipov, Candidate of Medical Sciences, Associate Professor of the Department of Pediatric Dentistry, Russian University of Medicine of the Russian Ministry of Health

3. Natalia Yu. Vasilyeva, Candidate of Medical Sciences, Associate Professor of the Department of Pediatric Dentistry, Russian University of Medicine of the Russian Ministry of Health

4. Tatyana E. Zueva, PhD, Associate Professor at the Department of Paediatric Dentistry, Russian University of Medicine of the Russian Ministry of Health

5. Elena E. Maslak, Doctor of Medical Sciences, Professor, Professor of the Department of Pediatric Dentistry, Volgograd State Medical University of the Russian Ministry of Health.

6. Taras V. Zakirov, Candidate of Medical Sciences, Associate Professor of the Department of Pediatric Dentistry and Orthodontics, Ural State Medical University of the Russian Ministry of Health.

7. Lyudmila I. Vorozhtsova, Chief Physician, Branch No. 4 of the Association «Stomatology» ANO, Yekaterinburg.

8. Anna D. Dakhnova, Pediatric Dentist, Department of Pediatric Dentistry, Clinic of the Center of Dentistry and Maxillofacial Surgery, A.I. Evdokimov Scientific and Educational Institute of Dentistry, Russian University of Medicine of the Russian Ministry of Health

Conflict of interest: none.

Appendix A2. Methodology for Developing Clinical Guidelines

Target audience for these clinical guidelines:

1. Paediatric dentists

2. Dentists

Table 1. Levels of Evidence (LoE) grading scale for diagnostic methods (diagnostic interventions)

Table 2. Scale for assessing levels of evidence (LE) for prevention, treatment and rehabilitation methods (preventive, therapeutic, rehabilitation interventions)

Table 3. Levels of evidence (LE) grading scale for prevention, treatment, and rehabilitation methods (preventive, therapeutic, rehabilitation 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

Appendix A3. Reference Materials

1. Order of the Ministry of Health of the Russian Federation dated December 30, 2003, No. 620 «On the approval of protocols for the management of children suffering from dental diseases».

2. Order of the Ministry of Health of the Russian Federation dated November 13, 2012, No. 910n «On the approval of the Procedure for providing medical care to children with dental diseases».

Appendix A3.1. List of medical services for the diagnosis and treatment of acute dental trauma

(from the Order of the Ministry of Health of the Russian Federation dated October 13, 2017, No. 804n «On the approval of the nomenclature of medical services»)

Table 1. History taking, anamnesis, physical examination

Table 2. Instrumental diagnostics

Table 3. Other diagnostics

Table 4. Conservative treatment

Table 5. Surgical treatment

Table 6. Other treatment

Appendix B. Physician Action Algorithms

1. Tooth crown fracture

Nosological form: tooth crown fracture without pulp involvement

ICD-10 code: S02.5

1.1. Diagnostic procedures:

1.1.1. Collection of complaints and anamnesis

1.1.2. External examination of the maxillofacial region

1.1.3. Dental examination using instruments

1.1.4. Thermal pulp testing

1.1.5. Tooth percussion

1.1.6. Fluorescent stomatoscopy

1.1.7. Occlusion evaluation

1.1.8. Diagnosis of the condition of the dentognathic system using radiation imaging methods and means

1.1.9. Intraoral periapical radiography

1.2. Treatment

1.2.1. Dynamic monitoring of the vitality of the neurovascular bundle for 10-15 days

1.2.2. If pulp vitality is preserved – restoration of the coronal part of the tooth with filling material depending on the stage of root formation

1.2.3. Professional oral hygiene

1.2.4. Prescription of remineralizing therapy.

1.2.5. Fluoridation of hard dental tissues

1.3. Recommendations

1.3.1. Patients with tooth crown fracture without pulp involvement should visit a specialist once every 3 months, and then once every 6 months for monitoring, preventive examinations, and hygienic procedures.

1.3.2. During the period of dynamic monitoring of neurovascular bundle vitality, it is recommended to avoid hard foods, restrict participation in contact sports, or use protective mouthguards during athletic activities.

Nosological form: tooth crown fracture with pulp involvement

Stage: unformed root stage

ICD-10 code: S02.5

1.4. Diagnostic procedures:

1.4.1. Taking complaints and anamnesis

1.4.2. External examination of the maxillofacial region

1.4.3. Examination of the oral cavity using instruments

1.4.4. Thermal pulp testing

1.4.5. Tooth percussion

1.4.6. Fluorescent stomatoscopy

1.4.7. Occlusion evaluation

1.4.8. Diagnosis of the condition of the dentognathic system using radiation imaging methods and means

1.4.9. Intraoral periapical radiography

1.5. Treatment

1.5.1. For patients seeking care within the first 24 hours after trauma – conservative vital pulp therapy (direct pulp capping): application of calcium hydroxide-based preparations to the exposed pulp area under a temporary dressing. Fabrication of a protective metal orthodontic crown is recommended

1.5.2. For patients seeking care from 24 to 72 hours after trauma – partial pulpotomy (coronal pulpotomy) followed by application of calcium hydroxide-based preparations to the radicular pulp. Fabrication of a protective metal orthodontic crown is recommended

1.5.3. In case of pulp necrosis – extirpation of necrotic tissue followed by apexification (root canal filling with calcium hydroxide-based materials or MTA to close the root apex).

1.5.4. After completion of root formation or apexification, endodontic treatment of the tooth is recommended, followed by restoration of the coronal part with filling material or a dental crown

1.6. Recommendations

1.6.1. Patients with tooth crown fracture involving the pulp must visit a specialist once every 3 months, and subsequently once every 6 months to monitor root formation or apexification processes, as well as for preventive examinations and hygienic procedures.

Nosological form: tooth crown fracture with pulp involvement

Stage: formed root stage

ICD-10 code: S02.5

1.7. Diagnostic procedures:

1.7.1 Taking complaints and anamnesis

1.7.2. External examination of the maxillofacial region

1.7.3. Examination of the oral cavity using instruments

1.7.4. Thermal pulp testing

1.7.5. Tooth percussion

1.7.6. Fluorescent stomatoscopy

1.7.7. Bite determination

1.7.8. Diagnostics of the maxillofacial system condition using diagnostic imaging methods and tools

1.7.9. Periapical intraoral contact radiography

1.8. Treatment

1.8.1. Pulp extirpation followed by root canal filling with oil-based pastes or gutta-percha points

1.8.2. Restoration of the tooth crown with a filling material or an artificial crown

1.9. Recommendations

1.9.1. Patients with a crown fracture involving the pulp should visit a specialist every 3 months, and then every 6 months for follow-up examinations and hygiene procedures.

2. Root fracture

Nosological form: tooth root fracture

ICD-10 code: S02.5

2.1 Diagnostic procedures:

2.1.1 Collection of complaints and anamnesis

2.1.2. External examination of the maxillofacial region

2.1.3. Dental examination using instruments

2.1.4. Thermal pulp testing

2.1.5. Tooth percussion

2.1.6. Fluorescent stomatoscopy

2.1.7. Bite determination

2.1.8. Diagnostics of the maxillofacial system condition using diagnostic imaging methods and tools

2.1.9. Periapical intraoral contact radiography

2.2. Treatment

2.2.1. During the initial visit, repositioning with precise alignment of the coronal and root fragments (in case of displacement) and immobilization via splinting are performed. The splinting period is from 2 to 4 months

2.2.2 Disocclusion of the tooth

2.2.2. In case of pulp necrosis, root canal filling in the coronal fragment area is performed using calcium hydroxide-based pastes to reduce inflammation and stimulate osteoplastic processes. The temporary filling material is periodically replaced, and the definitive root canal filling is performed once signs of fracture healing are confirmed

2.3. Recommendations.

2.3.1 Limitation of load on the injured tooth, avoidance of biting food with the injured tooth

2.3.1. Patients with a crown fracture without pulp involvement should visit a specialist once a month, then every 3 months, and then every 6 months to monitor the viability of the neurovascular bundle, fragment consolidation processes, or apexification process, as well as for follow-up examinations and hygiene procedures.

3. Tooth dislocation

Nosological form: tooth luxation

ICD-10 code: S03.2

3.1. Diagnostic procedures:

3.1.1 Collection of complaints and anamnesis

3.1.2. External examination of the maxillofacial region

3.1.3. Dental examination using instruments

3.1.4. Thermal pulp testing

3.1.5. Tooth percussion

3.1.6. Fluorescent stomatoscopy

3.1.7. Bite determination

3.1.8. Diagnostics of the maxillofacial system condition using diagnostic imaging methods and tools

3.1.9. Periapical intraoral contact radiography

3.2. Treatment

3.2.1. During the initial visit, tooth reposition and immobilization via splinting are performed. The splinting period is 3–4 weeks

3.2.2 Follow-up monitoring of the neurovascular bundle viability

3.2.3 In case of neurovascular bundle necrosis, endodontic treatment of the tooth is performed

3.3. Recommendations

3.3.1 Limitation of load on the injured tooth, avoidance of biting food with the injured tooth

3.3.2. Patients with a crown fracture without pulp involvement should visit a specialist once a month, then every 3 months, and then every 6 months to monitor the viability of the neurovascular bundle, as well as for follow-up examinations and hygiene procedures.

Nosological form: extrusion (tooth intrusion)

ICD-10 code: S03.2

3.4 Diagnostic procedures:

3.4.1. Collection of complaints and anamnesis

3.4.2. External examination of the maxillofacial region

3.4.3. Dental examination using instruments

3.4.4. Thermal pulp testing

3.4.5. Tooth percussion

3.4.6. Fluorescent stomatoscopy

3.4.7. Bite determination

3.4.8. Diagnostics of the maxillofacial system condition using diagnostic imaging methods and tools

3.4.9. Periapical intraoral contact radiography

3.5. Treatment

3.5.1. If the tooth root is in a state of incomplete apexogenesis, an expectant management approach is recommended, as there is a high probability of spontaneous eruption of the tooth toward the occlusal plane. This process may take up to 9–12 months.

3.5.2 If the permanent tooth root is already formed, orthodontic movement of the tooth using fixed appliances is necessary. In case of significant impaction of the tooth into the socket, surgical exposure of its crown part is performed beforehand.

3.5.3 If the permanent tooth is located at a significant distance from its natural position and orthodontic treatment is impossible, surgical repositioning of the tooth followed by splinting is performed.

3.5.4 Since intrusion of a tooth is most frequently accompanied by loss of pulp vitality, endodontic intervention is necessary. Root canal filling is preferably performed using calcium hydroxide-based pastes, followed by replacement of the medication every 3–6 months.

3.6. Recommendations

3.6.1 Limitation of load on the injured tooth, avoidance of biting food with the injured tooth.

3.6.2 Patients with a crown fracture without pulp exposure should visit a specialist once a month, then every 3 months, and subsequently every 6 months to monitor the eruption of the tooth with an incomplete root formation, replace the filling material in the root canal, and for preventive examinations and oral hygiene procedures.

Nosological form: exarticulation

ICD-10 code: S03.2

3.7 Diagnostic procedures:

3.7.1 Inquiry (history taking) and examination

3.7.2. External examination of the maxillofacial region

3.7.3. Examination of the oral cavity using instruments

3.7.4. Determination of occlusion

3.7.5. Assessment of the dentition status using diagnostic imaging methods and tools

3.7.6. Targeted intraoral periapical radiography

3.8. Treatment

3.8.1. First 30–60 minutes after injury: tooth reimplantation into the socket followed by splinting for 2–4 months.

3.8.2 In case of a prolonged absence of the tooth in the socket – root apicoectomy followed by retrograde root canal filling with glass ionomer cement. Tooth reimplantation into the socket followed by splinting for 2–4 months.

3.8.3 Taking the tooth out of occlusion

3.9 Recommendations

3.9.1 Limitation of load on the injured tooth, avoidance of biting food with the injured tooth.

3.9.2. Patients with a crown fracture without pulp exposure should visit a specialist once a month, then every 3 months, and subsequently every 6 months to monitor regeneration processes, and for preventive examinations and oral hygiene procedures.

Appendix C. Patient Information

ADDITIONAL INFORMATION FOR THE PATIENT AND THEIR LEGAL REPRESENTATIVES

1. Filled teeth must be brushed with a toothbrush and toothpaste just like natural teeth – twice a day. Rinse your mouth after meals to remove food debris.

2. Dental floss can be used to clean interdental spaces after receiving instruction on its use and upon the recommendation of a dentist.

3. If bleeding occurs while brushing teeth, hygiene procedures must not be discontinued. If bleeding does not stop within 3–4 days, a doctor must be consulted.

4. If, after filling and the wearing off of anesthesia, the filling interferes with dental occlusion, you should consult your attending physician in the near future.

5. If composite material fillings are present, avoid foods containing natural and artificial colorants (e.g., blueberries, tea, coffee, etc.) within the first two days after tooth filling.

6. If sharp pain occurs in the tooth, you should consult your dentist as soon as possible.

7. To prevent chipping of the filling and the hard tooth tissues adjacent to the filling, it is not recommended to eat or chew very hard foods (e.g., nuts, rusks) or bite off large pieces (e.g., from a whole apple).

8. You should visit the dentist every six months for preventive examinations and necessary procedures (for composite fillings – to polish the filling, which will increase its service life).

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

Not applicable.