The Permanent Tooth Dental Trauma Notes Template
A permanent tooth dental trauma notes template captures the IADT-compliant trauma assessment — time and mechanism of injury, extra-oral dry time and storage medium for avulsions, head injury and tetanus screen, intra-oral examination with mobility / percussion / sensibility, radiographic assessment per IADT views, IADT 2020 classification (concussion / subluxation / extrusion / lateral luxation / intrusion / avulsion / fracture), treatment (splinting / replantation / endodontics), and IADT-prescribed follow-up schedule — meeting IADT Guidelines 2020 (4th edition).
Failure to document extra-oral dry time and storage medium for avulsions makes the treatment decision (replantation vs delayed) indefensible if ankylosis or resorption develops. Below is the template UK clinicians paste into their PMS for any permanent tooth dental trauma.
Download the free Permanent Tooth Dental Trauma template — plain text, GDC/FGDP(UK)-aligned.
Why this permanent tooth dental trauma template wins
- Extra-oral dry time + storage medium documented for avulsions — determines treatment protocol AND prognosis.
- Head injury screen built in — defends against missed head injury referral.
- IADT 2020 classification used — universal taxonomy for trauma.
- IADT-prescribed follow-up schedule fully documented at first visit — closes the loop.
- Prognosis discussed honestly with written information — Montgomery defence + IADT recommendation.
Compliance: the medico-legal angle
- IADT Guidelines 2020 (4th edition) — gold-standard reference for dental trauma worldwide. Endorsed by BSPD.
- GDC Principle 4 — trauma records must enable longitudinal follow-up.
- Montgomery — trauma prognosis (especially avulsion) must be discussed honestly.
- IRMER 2017 — multiple radiographs in trauma have specific justification per IADT views.
Common mistakes UK dentists make
- Extra-oral dry time not documented for avulsions — biggest IADT compliance gap.
- No head injury screen for high-energy trauma — risk of missed concussion/intracranial pathology.
- IADT follow-up schedule not booked at first visit — long-term monitoring fails.
- Sensibility test relied upon at acute visit — false negatives common, vitality decision premature.
- Splinting with rigid material — IADT recommends flexible splint to allow physiological movement and pulp revascularisation.
Frequently asked questions
What's the ideal storage medium for an avulsed tooth?
Best to worst: HBSS (Hanks Balanced Salt Solution — purpose-made tooth rescue kits), milk, saliva (in the patient's own mouth between cheek and gum), saline, water. Dry is worst. Parents/teachers/coaches should know: place tooth in milk if no HBSS available, transport to dentist immediately. EO dry time <15 minutes = best prognosis.
How long should I splint after avulsion?
IADT 2020: flexible splint 2 weeks for avulsion (longer for concomitant alveolar fracture — 4 weeks). Avulsion with closed apex needs endodontic treatment started 7-10 days post-replantation to prevent inflammatory resorption.
When do I start RCT post-replantation?
Closed apex avulsion: start endo 7-14 days post-replantation (Ca(OH)2 dressing 1-3 months, then obturation). Open apex avulsion: ATTEMPT REVASCULARISATION (no immediate endo) — monitor for necrosis; if necrosis develops, MTA apexification or pulp regeneration protocol.
What about tetanus?
Open wounds in soil-contaminated trauma raise tetanus risk. Check immunisation status. If unknown or not up to date, refer to GP for tetanus booster. Document the screen.
What signs of resorption should I look for?
Clinical: tooth becoming high-pitched on percussion (ankylosis), gradual mobility decrease then stiffness. Radiographic: external inflammatory resorption (saucer-shaped root surface loss within weeks-months), replacement resorption / ankylosis (bone fusion, no PDL space), internal resorption (rare). Monitor at every follow-up per IADT.
When should I refer to a paediatric dentist or specialist?
Complex trauma (multiple teeth, alveolar fracture, severe displacement), uncertainty about treatment protocol, suspected non-accidental injury (mandatory referral to safeguarding), inability to perform IADT-compliant care. Refer urgently with full documentation.