Adherence to Guidelines After Dental Trauma Ensures Positive Outcomes

By Dr. Nestor Cohenca, DDS, FIADT


Dental trauma occurs daily. When protocols aren’t followed, healthy teeth are lost and the patient’s quality of life is compromised. In addition, beyond the patient’s health, first responders may be subject to legal action when protocols aren’t followed and the victims or their insurance companies sue for damages.

A typical example would be when a student-athlete is injured during a high school basketball game, resulting in the loss of a tooth. The team’s trainer or coach takes the injured player to the emergency room (ER), along with the tooth, which was placed in a cup or dry gauze and given to the emergency personnel.

Unfortunately, since proper protocol wasn’t followed, the patient will ultimately lose this tooth.  Treatment if even possible often will be complex, time consuming, and expensive, requiring multidisciplinary approaches. Depending on the age of the patient, the tooth eventually will need to be extracted and replaced.

The loss of a front tooth as a result of an accident is legally defined as a 1% to 3% disability. Thus, the intervention of lawyers and insurance companies is almost always a given. Patients and/or their parents will demand compensation for physical and psychological damages. If treatment guidelines aren’t followed, the legal review will lead to a significant professional liability with all its consequences.

The International Association for Dental Traumatology (IADT) first developed guidelines establishing protocols for the treatment of traumatic dental injuries in 1991. These guidelines are reviewed periodically based on new research or evidence, with updates released typically every 2 to 4 years.

While the American Association of Endodontics (AAE) and American Association of Pediatric Dentistry (AAPD) have initially established their own set of guidelines, today all 3 organizations are using the same guidelines, based on the original IADT recommendations. And, effective January 2017, guidelines will begin to be reviewed quarterly, meaning new guidelines may be released more frequently.

Dental trauma guidelines provide specific recommendations and protocols to ensure the best positive patient outcomes. However, trauma guidelines have not been consistently followed, as most professionals are unaware of their existence or, even worse, decide to ignore them. Along with the IADT, AAE, and AAPD, dental trauma professionals have been working to increase the knowledge of not only the guidelines, but also and equally importantly the prevention of such injuries.

Treatment guidelines provide guidance on what to expect, what the expected outcomes are based on the injury, and the different factors related to that injury, along with a clear recommendation about the immediate treatment specifically to the type of injury. It’s critically important to understand that the immediate care performed by the first responder will determine if the tooth will be saved or not. Simple as that!

Since nondental professionals such as teachers, coaches, trainers, and emergency medical technicians will be the first people to treat these injuries when they happen, their education about the proper immediate treatment will define not only the dental outcome but also the psychological, aesthetic, social well-being, and quality of life of the child.

In the past, education and training for nondental professionals (commonly present at the site of these injuries) was not readily accessible. Unfortunately, colleges and universities do not provide enough education about dental trauma. Yet today, access to guidelines and education is simple.

The IADT, AAE, and AAPD provide free access through their respective websites. Additionally, webinars and online courses are available, meaning professionals, providers, patients, and attorneys all have access to these guidelines. What this means for first-responders, whether a high school coach or an EMT treating an accident victim, is that ignorance about guidelines will no longer be acceptable.

Trauma Guidelines and Litigation

In addition to providing a treatment roadmap, trauma guidelines are used as a legal document by attorneys and insurance companies regarding the proper course of action in the case of trauma. While guidelines are a recommendation, if someone treats a case and does not follow recommended protocols, that person can be liable and at risk for a lawsuit for not following published trauma guidelines. 

In cases where litigation enters the scene, it’s important that proper treatment guidelines are followed. The insurance company representing an accident victim or attorneys representing the victim in, say, a bar fight will seek damages associated with the treatment of injuries. Attorneys or insurance companies typically do not go after dentists, but may seek compensation from the place or person responsible for the accident.

For example, consider first responders treating an auto accident victim or a physical education (PE) teacher treating a student, each of whom has suffered a traumatic dental injury. Legal teams and insurance companies will request all the documentation on the case to evaluate the immediate treatment at the place of injury, at the ER, and at the dental practice. After all, their entire job is to protect their clients and compensate them for the physical and psychological damages for the rest of their life!

All factors are taken into account when you have insurance or legal implications. This also applies to dentists, whether or not litigation is against the dentist. Attorneys and insurers will seek notes, chart notes, x-rays, treatment plans, and the costs associated with the immediate and long-term life of the patient.  

Get Informed: What First Responders Can Do

The challenge for dental professionals is that they are not first on the scene to provide treatment, and they must rely on first responders to follow guidelines to ensure the best chance for a positive patient outcome. The best course of action for dental providers is to educate first responders about the existence of guidelines to ensure patient health and to protect against costly litigation.

Traumatic injuries occur approximately in 30% of the population. Just to put things in perspective, 169 people are exposed to facial or dental injuries every single day in the United States. As such, awareness needs to extend beyond the dental community to first responders. We totally depend on them!

The first step toward improving treatment is awareness. Encourage your network to do research and to seek out information. There are courses and webinars available as a source of information to not only the dental community, but also to coaches, teachers, and others who may be considered first responders.  

The next step is to go to communities: schools, hospitals, and other organizations to talk with people who are where injuries may occur and try to promote the knowledge among these groups. Encourage your community to visit the websites and social media channels of the IADT, AAE, and AAPD for information and updates.

Bottom line: The outcome of traumatic injuries often depends exclusively on the immediate care provided at the site of the injury. Therefore, encourage first responders to take initiative and learn about how to prevent treat traumatic dental injuries, as there are plenty of resources available. For more information, visit

Nestor Cohenca, DDS, FIADT, is an endodontist and a leading expert in dental trauma and pediatric endodontics. He is in private practice at Lakeside Endodontics, Everett, Wash. Also, he is an affiliate professor with the Department of Pediatric Dentistry at the University of Washington School of Dentistry and with Seattle Children’s Hospital. Dr. Cohenca is the upcoming president of the IADT and provides online coursework for dental and non-dental professionals seeking CE hours. Visit for details.

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