The Permanent Tooth Dental Trauma Notes Template

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 a template for UK clinicians to paste into their PMS for any permanent tooth dental trauma.

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.

The template (paste into your PMS notes field)

Paste the permanent tooth dental trauma template below into your PMS notes field. Patient demographics are left out because your PMS already holds them.

INJURY HISTORY:
- Time of injury: [Today / __ hours ago / __ days ago]
- Mechanism: [Fall / sports / RTA / fight / sport — specify]
- Extra-oral dry time (for avulsion): __ minutes (CRITICAL — determines protocol)
- Storage medium (for avulsion): [Saliva (cheek) / milk / HBSS / saline / water / dry — affects prognosis]
- Previous trauma to same tooth: [Y/N — relevant to prognosis]

MHx:
- Tetanus status: [Up to date / unknown / need GP referral if penetrating wound]
- Head injury screen: [LOC / vomiting / amnesia / drowsiness — if positive, refer A&E IMMEDIATELY before dental treatment]
- Anticoagulants / bleeding disorder: [Y/N]
- Other relevant: [Allergies, medications]

EXTRA-ORAL EXAMINATION:
- Lacerations: [Lip / chin / cheek — size / depth]
- Bruising / swelling: [Sites]
- Mandible: [Palpation — pain / step deformity / mobility]
- Maxilla: [Mobility — Le Fort fracture screen if RTA]
- Lymphadenopathy: [Y/N]

INTRA-ORAL EXAMINATION:
- Tooth/teeth affected (FDI): [List]
- Soft tissue: [Lacerations / displacement of gingiva]
- Per affected tooth:
  - Mobility (Miller 0-3): __
  - Percussion (vertical/horizontal): [Pain / metallic / dull]
  - Sensibility test (Endo-Ice / EPT): [Response — note: false negatives common in acute phase]
  - Periodontal probing: [If displacement]
  - Visible fracture: [Enamel / dentine / pulp exposure — size of exposure if present]
  - Displacement: [Direction / extent]

RADIOGRAPHIC ASSESSMENT (per IADT views):
- Periapical(s): [Affected tooth + adjacent]
- Occlusal: [Often needed for anterior]
- Lateral (if luxation): [Displacement assessment]
- Pano (if multiple teeth or maxillary fracture): [As indicated]
- Justification + quality + report

IADT 2020 CLASSIFICATION:
- Concussion / subluxation / extrusion / lateral luxation / intrusion / avulsion (with extra-oral time + storage)
- Crown fracture: [Enamel infraction / enamel fracture / enamel-dentine fracture (uncomplicated) / enamel-dentine-pulp fracture (complicated)]
- Crown-root fracture: [Complicated / uncomplicated]
- Root fracture: [Apical 1/3 / middle 1/3 / cervical 1/3]
- Alveolar fracture: [If present]

TREATMENT PROVIDED:
- Replantation (if avulsion): [Storage medium during procedure / technique / position confirmed clinically and radiographically]
- Splint: [None / passive flexible splint — stainless-steel wire up to 0.4mm or nylon line 0.13-0.25mm, bonded with composite, kept off the gingiva]
- Splint duration (IADT 2020): [Subluxation — none, or up to 2 weeks only if excessive mobility or tender on biting / Extrusion — 2 weeks (a further 4 weeks if marginal bone breakdown or fracture) / Lateral luxation — 4 weeks / Intrusion (after repositioning) — 4 weeks / Avulsion — 2 weeks (more rigid splint for about 4 weeks if alveolar or jaw fracture) / Root fracture, apical or middle third — 4 weeks / Root fracture, cervical third — up to 4 months / Alveolar fracture — 4 weeks]
- Endodontic plan (IADT 2020): [Avulsion, closed apex — start RCT within 2 weeks of replantation / Avulsion, open apex — no RCT now: spontaneous revascularisation possible; apexification, revitalisation or RCT only if follow-up shows pulp necrosis and infection / Lateral luxation, closed apex — endodontic assessment at about 2 weeks; pulp likely to become necrotic, start RCT / Intrusion, closed apex — start RCT at 2 weeks or as soon as the tooth's position allows / Other injuries or open apex — monitor the pulp; treat only if necrosis and infection (or inflammatory resorption) develop; do not start RCT on a negative sensibility test alone]
- Restoration (if fracture): [Composite / temporary]
- Splint removal date: [Specified]

PROGNOSIS DISCUSSED with patient/parent:
- Root resorption (external inflammatory / replacement / ankylosis): risk factors discussed
- Pulp necrosis: requires future RCT
- Eventual tooth loss (long-term): possible
- Written information provided

FOLLOW-UP SCHEDULE (IADT 2020 — clinical + radiographic review; S = splint removal):
- Enamel infraction: no follow-up needed
- Enamel fracture / enamel-dentine fracture: 6-8 wk, 1 yr
- Enamel-dentine-pulp fracture: 6-8 wk, 3 mo, 6 mo, 1 yr
- Crown-root fracture: 1 wk, 6-8 wk, 3 mo, 6 mo, 1 yr, then annually for at least 5 years
- Root fracture (apical / middle third): 4 wk (S), 6-8 wk, 4 mo, 6 mo, 1 yr, then annually for at least 5 years
- Root fracture (cervical third): 4 wk, 6-8 wk, 4 mo (S), 6 mo, 1 yr, then annually for at least 5 years
- Alveolar fracture: 4 wk (S), 6-8 wk, 4 mo, 6 mo, 1 yr, then annually for at least 5 years
- Concussion: 4 wk, 1 yr
- Subluxation: 2 wk (S if splinted), 12 wk, 6 mo, 1 yr
- Extrusion: 2 wk (S), 4 wk, 8 wk, 12 wk, 6 mo, 1 yr, then annually for at least 5 years
- Lateral luxation: 2 wk, 4 wk (S), 8 wk, 12 wk, 6 mo, 1 yr, then annually for at least 5 years
- Intrusion: 2 wk, 4 wk (S if splinted), 8 wk, 12 wk, 6 mo, 1 yr, then annually for at least 5 years
- Avulsion, closed apex: 2 wk (S), 4 wk, 3 mo, 6 mo, 1 yr, then annually for at least 5 years
- Avulsion, open apex: 2 wk (S), 1 mo, 2 mo, 3 mo, 6 mo, 1 yr, then annually for at least 5 years

EMERGENCY CONTACT GIVEN: [Y]
PATIENT/PARENT WARNED: [Severe pain / swelling / sinus tract / discolouration → contact urgently]

Try the permanent tooth dental trauma note in the live demo → No account needed.

What good looks like — a worked example

The same permanent tooth dental trauma template, completed for a realistic case.

INJURY HISTORY:
- Time of injury: 90 minutes ago
- Mechanism: Fell off scooter onto concrete pavement, no helmet on face. Witnessed by mum.
- Extra-oral dry time (for avulsion UR1): 5 minutes (mum picked up tooth quickly, transported in milk — confirmed)
- Storage medium: Milk for entire transport time
- Previous trauma to UR1: None.

MHx:
- Tetanus: Up to date (routine childhood immunisations complete for age 9, confirmed with mum).
- Head injury screen: No LOC. No vomiting. Mum reports child mentally clear, normal alertness, no amnesia for the event. Walking normally. No head injury treatment needed. Will safety-net.
- Anticoagulants / bleeding: None.
- Allergies: NKDA.

EXTRA-ORAL EXAMINATION:
- Lacerations: Upper lip 2cm superficial laceration, will close without suture. Chin abrasion.
- Bruising / swelling: Mild upper lip swelling.
- Mandible: Palpation NAD. No step. Normal opening.
- Maxilla: Stable.
- Lymphadenopathy: Not palpable.

INTRA-ORAL EXAMINATION:
- Tooth affected (FDI): UR1 (11) — AVULSED, replanted today by clinician
- Soft tissue: Gingival laceration UR1 site, sutured (Vicryl 6-0, 3 sutures)
- UR1 (post-replantation):
  - Mobility: Grade 1 after splinting (was Grade 3 pre-splint)
  - Percussion: Mildly tender. Baseline recorded for comparison at review (a high metallic note later would suggest ankylosis)
  - Sensibility: No response (expected — acute trauma may show false negative for weeks)
  - Visible: Tooth in approximate normal position post-replantation, splinted
- Adjacent teeth (UL1, UR2): NAD on examination, sensible to cold, no mobility

RADIOGRAPHIC ASSESSMENT:
- PA UR1 + UR2 + UL1: Justification — confirm replantation position, exclude root fracture, baseline for healing. Quality A. Report: UR1 in alveolar socket, slightly extruded (~1mm) from baseline, no root fracture, no alveolar fracture. Adjacent teeth normal. Open apex confirmed (immature root, age 9).
- Occlusal: Confirmed labio-lingual position adequate.

IADT 2020 CLASSIFICATION: Avulsion UR1, replanted within 60 minutes total (5 min EO dry + 55 min in milk + immediate replantation). Open apex. Good prognosis for pulp revascularisation given short EO time + milk storage + open apex.

TREATMENT PROVIDED:
- Replantation: UR1 cleaned with saline (no scrubbing of root surface), positioned in socket with finger pressure, position confirmed radiographically.
- Splint: Passive flexible splint, 0.4mm stainless-steel wire bonded with composite to the labial surfaces of UR2-UR1-UL1, composite kept off the gingiva. 2 weeks per IADT 2020 for avulsion.
- Endodontic plan: Open apex — no root canal treatment now; spontaneous revascularisation possible. Monitor for pulp necrosis and infection at follow-up. If they develop, apexification, revitalisation/revascularisation or root canal treatment.
- Restoration: Not needed (no fracture).
- Splint removal date: 2 weeks from today.

PROGNOSIS DISCUSSED with mum + patient:
- Root resorption (external inflammatory or replacement / ankylosis): possible, despite optimal EO time. Risk discussed.
- Pulp necrosis: possible, will monitor.
- Eventual tooth loss in adulthood: possible if ankylosis develops; long-term retention possible with optimal healing.
- Written information provided (IADT patient information leaflet for avulsion).

FOLLOW-UP SCHEDULE (IADT 2020, avulsion with open apex):
- 2 weeks (splint removal + clinical/radiographic check) — booked
- 1 month
- 2 months
- 3 months
- 6 months
- 12 months
- Then annually for at least 5 years
- Vitality test at each follow-up. Watch for: pulp necrosis (would require endo), root resorption (radiographic monitoring), ankylosis (high-pitched percussion).

EMERGENCY CONTACT GIVEN: Yes — practice number + out-of-hours.
WARNINGS: Mum and patient understand to contact urgently for severe pain, swelling, sinus tract development, or tooth discolouration in coming days.

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.
• IR(ME)R 2017 — multiple radiographs in trauma have specific justification per IADT views.

Common documentation mistakes

• Extra-oral dry time not documented for avulsions — a key 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.

Sources

• GDC Standards for the Dental Team, Principle 4: Maintain and protect patients’ information (accessed 18 October 2026)
• The Ionising Radiation (Medical Exposure) Regulations 2017 (SI 2017/1322) (accessed 18 October 2026)
• Montgomery v Lanarkshire Health Board (UK Supreme Court, 2015, UKSC 11) (accessed 18 October 2026)
• Levin L, et al. IADT guidelines for the management of traumatic dental injuries: General introduction. Dent Traumatol 2020 (accessed 18 October 2026)
• Bourguignon C, et al. IADT guidelines for the management of traumatic dental injuries: 1. Fractures and luxations. Dent Traumatol 2020 (accessed 18 October 2026)
• Fouad AF, et al. IADT guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth. Dent Traumatol 2020 (accessed 18 October 2026)

Frequently asked questions

Guides that cover this

• Antibiotic Prescribing in Dentistry: SDCEP Guide & Doses (UK 2026)

Patient leaflets for this treatment

• Dental Trauma — Knocked Out, Broken, and Loose Teeth

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