The Primary Tooth Trauma Notes Template

Primary tooth trauma carries safeguarding considerations the permanent tooth template doesn't — non-accidental injury must be actively considered at every paediatric trauma visit. Below is a template for UK clinicians to paste into their PMS for primary tooth trauma.

Why this primary tooth dental trauma template wins

• Safeguarding assessment at EVERY paediatric trauma visit — protects child + protects clinician from missing concerns.
• Accompanying adult + PR explicitly recorded — defends consent basis.
• IADT 2020 primary dentition guidance — different from permanent (DON'T REPLANT avulsions of primary teeth).
• Permanent successor documented at every visit — IADT 2020 asks you to record that parents were told about possible effects on the permanent tooth.
• Long-term follow-up of permanent successor — captures delayed effects (Turner's tooth, enamel hypoplasia).

The template (paste into your PMS notes field)

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

INJURY HISTORY:
- Patient age: [years]
- Accompanying adult: [Name / relationship]
- Time of injury: [Hours / days ago]
- Mechanism: [Reported by — fall / running into object / sports / other]
- Witnessed by: [Y/N — accompanying adult / another adult / unwitnessed]

SAFEGUARDING ASSESSMENT (active consideration at every paediatric trauma visit):
- Injury consistent with explanation: [Y / NO — concerns]
- Developmental stage allows injury: [Y / NO]
- Other concerns: [Bruising in different stages / fingerprint marks / inconsistent histories — describe]
- Action: [No concerns — proceed / Concerns — follow the practice child-protection policy; refer the same day to local authority children's social care (police / 999 if the child is in immediate danger); record the referral and outcome. The LADO is only for concerns about a member of staff or another adult working with children]

MHx (from parent):
- Bleeding disorders: [Y/N]
- Tetanus / immunisations: [Up to date / unknown]
- Allergies: [List or NKDA]
- Other relevant: [Conditions affecting healing]

CLINICAL EXAMINATION:
- Behaviour: [Cooperative / distressed / unable to examine]
- Extra-oral: [Lacerations / bruising / facial bones]
- Intra-oral:
  - Tooth affected (primary): [E.g. ULA / URA — primary upper incisors]
  - Mobility: Grade
  - Displacement: [Direction — labial / lingual / intrusion / extrusion]
  - Crown fracture: [Enamel / dentine / pulp exposed]
  - Soft tissue: [Lacerations]

RADIOGRAPHIC ASSESSMENT:
- Indicated for: [Significant displacement / intrusion (CRITICAL to assess permanent successor) / pain / suspected root fracture]
- If indicated: PA or upper anterior occlusal. Quality + report including assessment of permanent successor.
- If NOT indicated: justify in note (e.g. "Mild subluxation, child cooperative, no displacement, asymptomatic on percussion — radiograph not justified per IADT 2020 primary dentition guidance")

IADT 2020 CLASSIFICATION (primary):
- Concussion / subluxation / extrusion / lateral luxation / intrusion / avulsion / crown fracture

MANAGEMENT DECISION (IADT 2020 — primary dentition, Tables 1-12):
- Concussion / mild subluxation: monitor, soft diet, no treatment
- Extrusion: not interfering with the occlusion — allow to reposition spontaneously; excessively mobile or extruded >3mm — extract under LA
- Lateral luxation: minimal or no occlusal interference — allow to reposition spontaneously (usually within 6 months). Severe displacement — (A) extract if there is a risk of ingestion or aspiration, or (B) gently reposition under LA, flexible splint for 4 weeks if unstable
- Intrusion: allow to reposition spontaneously IRRESPECTIVE of the direction of displacement (usually within 6 months, sometimes up to 1 year); arrange rapid referral (within a couple of days) to a child-oriented team
- Avulsion: DO NOT REPLANT (risk to permanent successor)
- Crown fracture: composite restoration if cooperative / smooth sharp edges
- Root fracture: coronal fragment not displaced — no treatment; displaced, excessively mobile and interfering with the occlusion — extract only the loose coronal fragment (apical fragment left to resorb) or reposition and splint
- Immediate extraction because the root is displaced towards the successor is no longer advised (IADT 2020)
- Record that parents were told about possible complications for the permanent successor

CONSENT (parent):
- Management options + risks (including risk to permanent successor) + decision
- Specifically for extraction: risk to permanent successor weighed against risk of leaving in situ

PROCEDURE: [As decided]
- LA: [Agent + volume — paediatric dose-adjusted]
- Extraction technique: [Forceps / elevator — atraumatic, avoid pressure on permanent successor]
- Suture: [None / resorbable if indicated]

POST-OP ADVICE (verbal + written for parent):
- Soft diet
- Pain relief (paracetamol + ibuprofen — paediatric dose, per weight)
- Watch for: swelling / sinus tract / discolouration of remaining primary teeth in coming weeks
- Permanent successor warning: monitor for delayed eruption, abnormal shape (Turner's tooth), enamel hypoplasia

FOLLOW-UP (IADT 2020 — schedule depends on injury type):
- Extrusion: 1 week, 6-8 weeks, 1 year
- Lateral luxation / intrusion: 1 week, 6-8 weeks, 6 months, 1 year; severe intrusion — further review at 6 years of age
- Continue clinical follow-up each year until the permanent successor erupts where an unfavourable outcome is likely
- Long-term: monitor permanent successor eruption (typically age 7-9 for upper incisors)

SAFEGUARDING DOCUMENTATION (if concerns escalated): [Referral to children's social care / police — date, time, who, reference number, outcome, follow-up]

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

What good looks like — a worked example

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

INJURY HISTORY:
- Patient age: 3 years
- Accompanying adult: Mum (Mrs Jones — parental responsibility)
- Time of injury: 1 hour ago
- Mechanism: Reported by mum — child running, tripped on rug, hit face on coffee table corner
- Witnessed by: Mum (witnessed directly)

SAFEGUARDING ASSESSMENT:
- Injury consistent with explanation: YES — mechanism plausible for age and developmental stage
- Developmental stage: YES — 3-year-old running and falling is age-appropriate
- Other concerns: None. No other bruising. Child engaged appropriately with mum, no signs of distress beyond expected from injury. Mum's account consistent throughout.
- Action: No safeguarding concerns. Proceed with dental treatment.

MHx (from mum):
- Bleeding disorders: None
- Immunisations: Up to date per Red Book
- Allergies: NKDA
- Other: None.

CLINICAL EXAMINATION:
- Behaviour: Initially distressed, settled with mum's comfort, cooperative for examination
- Extra-oral: Small abrasion upper lip, slight swelling. No facial bone tenderness. No bruising elsewhere.
- Intra-oral:
  - Tooth affected: ULA (primary upper left central incisor — 61 in FDI)
  - Mobility: Grade 2
  - Displacement: Crown displaced palatally ~2mm (apex displaced labially). No occlusal interference.
  - Crown fracture: None
  - Soft tissue: Small gingival laceration palatal to ULA, will heal without suture

RADIOGRAPHIC ASSESSMENT: Upper anterior occlusal radiograph indicated — baseline for a luxation injury and assessment of root and permanent successor. Justified per IADT 2020 primary dentition. Quality A. Report: ULA apex displaced labially, away from the permanent successor — successor not impinged. No root fracture. Permanent successor developing normally.

IADT 2020 CLASSIFICATION: Lateral luxation of ULA (61), crown palatal / apex labial — apex displaced AWAY from permanent successor.

MANAGEMENT DECISION (IADT 2020 Table 10 — lateral luxation): Minimal displacement, no occlusal interference. Options:
- Conservative: allow spontaneous repositioning (usually within 6 months) — IADT first-line when there is minimal or no occlusal interference
- Repositioning + splint: reserved for severe displacement; not indicated here
- Extraction: only for severe displacement with risk of ingestion or aspiration — not indicated here
- Mum informed of possible complications for the permanent successor (IADT: document this)

CONSENT (mum): Options discussed. Mum elects conservative management (monitor) given low risk to permanent successor and child's anxiety about further procedures.

PROCEDURE:
- No active treatment today beyond cleaning gingival area with saline
- LA not given (no extraction or repositioning)
- Reassurance to mum and child

POST-OP ADVICE (verbal + written for mum):
- Soft diet 2 weeks (no biting with front teeth)
- Pain relief (age 3, SDCEP/BNFC age bands): paracetamol oral suspension 120mg/5ml — 180mg (7.5ml) up to four times daily, maximum 4 doses in 24 hours; ibuprofen oral suspension 100mg/5ml — 100mg (5ml) three times daily after food. Mum aware of dosing.
- Clean the gingiva with a soft brush or cotton swab and alcohol-free chlorhexidine 0.1-0.2% twice daily for one week
- Watch for: increased swelling, sinus tract development, ULA discolouration in coming weeks (may turn grey if pulp necroses — would need extraction at that point), pain on biting
- Permanent successor: We'll monitor when permanent upper central incisor erupts around age 7-8 for any abnormalities (delayed eruption, abnormal shape, enamel changes).

FOLLOW-UP (IADT 2020 — lateral luxation):
- 1 week
- 6-8 weeks
- 6 months
- 1 year
- Then annual clinical review until permanent successor erupts if an unfavourable outcome is likely
- If discolouration or symptoms develop, return urgently

SAFEGUARDING DOCUMENTATION: Not applicable today (no concerns escalated). General safeguarding awareness maintained.

Compliance: the medico-legal angle

• IADT 2020 Part 3 — Primary Dentition (DOI:10.1111/edt.12576) — gold-standard reference.
• GDC Principle 1 — child's best interests + safeguarding.
• Children Act 1989 / Working Together to Safeguard Children 2026 — referral to local authority children's social care when there is a concern about a child's welfare.
• BSPD guidance — paediatric trauma management.
• GDC Principle 4 — comprehensive trauma record including safeguarding consideration.

Common documentation mistakes

• No safeguarding consideration documented — GDC + safeguarding policy breach.
• Replanting avulsed primary tooth — IADT explicit DO NOT REPLANT (risk to permanent successor).
• No permanent successor monitoring scheduled — delayed effects on permanent dentition missed.
• No accompanying adult / PR documented — consent basis undocumented.
• No radiograph for significant displacement — cannot assess permanent successor risk.

Sources

• GDC Standards for the Dental Team, Principle 1: Put patients’ interests first (accessed 18 October 2026)
• GDC Standards for the Dental Team, Principle 4: Maintain and protect patients’ information (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)
• Day PF, et al. IADT guidelines for the management of traumatic dental injuries: 3. Injuries in the primary dentition. Dent Traumatol 2020 (accessed 18 October 2026)

Frequently asked questions

Guides that cover this

• Paediatric Dental Doses (UK): Antibiotics, Analgesics and Local Anaesthetic by Age and Weight

Patient leaflets for this treatment

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

Related dental note templates

Browse the full set of free dental notes templates.