Acute Traumatic Injuries: Assessment and Documentation

Board takeaway

• Safety. Start with the child, then the teeth: record possible head, neck, respiratory, and other bodily injuries before concentrating on the dental injury.
• Dental baseline. Account for every missing tooth or fragment, identify primary versus permanent teeth and root maturity, and record baseline findings that later reviews can compare.

The two-page AAPD form links history, examination, treatment, counseling, and disposition. Use the relevant trauma guideline to choose treatment; a checkbox records an action, not its indication.

History and safety screen

Patient and event

• Identify patient, birth date, examination date/time, accompanying person, and referral source.
• Record allergies, medications, relevant medical history, and last tetanus immunization.
• Establish injury time, elapsed interval, witnesses, mechanism/location, and care already provided—including by whom.

Safety and dental symptoms

• Document altered mental status, headache/nausea/vomiting, ear/nose bleeding, loss of consciousness, neck pain, respiratory symptoms, and other bodily injuries.
• Capture jaw-motion or bite pain, spontaneous/thermal dental pain, displacement, looseness, fracture, or avulsion. Record whether missing teeth/fragments were recovered and the tooth transport medium.
• Include prior trauma, appliances, oral habits, and descriptions of positive findings.

Examination map

• Craniofacial: nerve deficits, suspected fracture, TMJ asymmetry/deviation, bleeding/drainage, swelling, bruising, wounds, burns, and foreign bodies.
• Soft tissue: lips, frenum, gingiva, cheeks, tongue, floor of mouth, and palate; describe and diagram injuries.
• Occlusion: bilateral molar/canine relationships, overbite (%), overjet (mm), crossbite, midline deviation, interferences, and appliances.
• Tooth-by-tooth: avulsion dry time/storage medium; infractions/fractures; pulp exposure size/appearance; mobility (mm); luxation direction/extent; percussion, color, electric/thermal testing, and existing disease/restorations.
• Radiographic record: pulp size, root maturity/fractures, periodontal ligament space, periapical findings, alveolar fracture, and foreign bodies.

Treatment, counseling, and disposition

• Summarize whether all missing teeth/fragments are accounted for, appliance damage/loss, photographs, and suspected/confirmed abuse.
• Mark care actually performed: soft-tissue care, anesthesia/medication, repositioning/reimplantation, stabilization, pulp treatment, restoration, extraction, prescriptions, or other care.
• Record discussions of diet, hygiene, pain, swelling, infection, prescriptions, and complications—including developing-tooth injury, abnormal position/ankylosis, tooth loss, and pulp injury to affected or adjacent teeth.
• Document tetanus-booster discussion, prevention/mouthguards, follow-up, and referral destination.

Common board traps

Answer aloud

How would you structure the initial dental-trauma record?

Record medical safety first, then an injury baseline, treatment, instructions, and disposition.

• History: medical conditions, medications/allergies, tetanus history, mechanism, timing, witnesses, and prior care.
• Safety: head/neck symptoms, mental status, respiratory symptoms, and other bodily injuries.
• Findings: extraoral/intraoral examination, soft tissues, occlusion, tooth-by-tooth findings, and indicated imaging/interpretation.
• Plan: diagnosis, treatment performed, counseling, follow-up, and referrals so the next clinician can continue care.

What remains after documenting a fractured tooth?

Complete the injury assessment and account for missing teeth/fragments before closing the record.

• Document recovery status, transport medium and dry time where relevant, soft tissues, occlusion, adjacent teeth/supporting structures, and appliances.
• Assess whether history and findings raise abuse concerns.
• Record counseling, home care, follow-up, and medical/dental referrals.
• The form records actions; injury-specific guidance supplies treatment indications and intervals.