Eligibility Criteria

The sample considered studies conducted in humans, being inclusion criteria: clinical studies (case series, cohorts, cross- sectional, randomized clinical studies) evaluating the approach to dentoalveolar trauma in primary dentition. In addition, studies that compiled available information, such as clinical guidelines and systematic reviews, were considered.

Exclusion criteria were: studies performed in adults or adolescents, not describing post-traumatic indications or not available in their entirety from the database. Those with data older than 5 years were not included.

Search strategy

Although this work is a review of the literature, the search strategy was carried out systematically. The literature search was carried out between the months of August and September of 2021, on the following databases: MEDLINE/PubMed, SCOPUS, BVS, ProQuest and Science Direct. DeCS terms ("Tooth injuries", "Primary tooth"), MeSH terms ("Tooth injuries", "Primary tooth") and keywords related to dentoalveolar trauma and primary dentition were used to search for potential articles. In addition, the reference lists of the selected articles were reviewed by hand to identify potentially relevant studies that might have been overlooked during the initial searches of the electronic databases. No language restriction was applied.

The titles and abstracts of all references were reviewed. Duplicates were eliminated and articles that met the inclusion criteria were selected based on their titles and abstracts.

The search and the analysis of the articles were performed by one reviewer (G.J).

Guidelines for oral hygiene and use of oral antiseptics

Regarding oral hygiene indications, they are not very specific in the education given to tutors, nor does it emphasize the relationship with tissue healing. Only one study by ^{Lessa et al. 2020 6} expresses the need to carry out education related to oral hygiene instruction after the emergency consultation. However, the type of toothbrush, the frequency or the duration of the oral hygiene is not specified. Some authors do agree on the importance of using a soft brush ^2,7,8 traumatic dental injuries.

The prescription of oral antiseptics seems to be a universal topic. From the 7 studies that incorporate guidelines related to oral hygiene, more than half of them refer to the topical use ^2,8-10 and/or as a rinse ^7,10 of the alcohol-free chlorhexidine digluconate. As for its concentrations, they vary between 0.1% and 0.2%. Various studies conclude that the effectiveness in terms of bacterial plaque control is similar to 0.1%-0.12% or 0.2%^11,12. Its use should be recommended topically with cotton swabs and/or gauze instead of indicating its use as a rinse in children under 6 years of age due to the risk of ingestion of the chlorhexidine solution.

Only 2 authors mentioned that the frequency and duration ^7,9 of the use of alcohol-free chlorhexidine digluconate is due to the parents´ discretion. There is an apparent consensus of regimen of 2 times a day for 7^2,8-10 or 14 days¹⁰, estimated time for the repair of the gingival fibers⁹.

Medication prescription

On this topic, the use of medications seems to be a consensus that it should be limited. The use of systemic antibiotics after dental trauma emergency care have limited or insufficient evidence ^8,13. There are some specific indications for its use such as patients with compromised general medical status ^2,13,14, need for surgical intervention², severe tooth dislocations and significant damage to the oral tissues^2,9. However, some authors ^{Holan et al. 2019 9} and ^{Day et al. 2020 2} do not mention the type of dislocation or damage to the oral tissues.

The use of analgesics and anti- inflammatories was reported in a coincident way by ^{Malmgren et al. 2017 8} and ^{Day et al. 2020 2}, indicated for lateral/intrusive dislocations and root fractures which may be associated with severe pain. However, there are no pharmacological guidelines when only soft tissues are involved.

There is a lack of recommendations for the prescription of antibiotics, analgesics and anti-inflammatories regarding the indication, dosage, frequency, and duration of treatment, thus leaving it to the professional criteria. That is why an individualized evaluation of the patient is required, considering the severity of the injuries and the risk of bacterial contamination. It is important to call attention to the fact that the use of antibiotics must be rigorous, due to the growing increase in antibiotic resistance globally¹⁵. As for analgesics, to limit their use for a maximum of 3 days, the period of greatest pain^16,17, re-evaluating the patient if it persists after this period of time so as not to mask another source of pain.

Diet/Feeding instructions

Diet/nutrition is only mentioned in 4 studies, appearing to have no greater relevance in the healing of the tissues involved. All the authors agree on changing the diet towards a “soft diet” ^2,7-9, understood as one that consists of easily digestible foods, low in fiber, cooked, and of a soft consistency¹⁸. The duration of this regimen varies between 10 to 14 days^7-9,14, with no relation to the severity of the associated traumatic dental injuries. No recommendations are given regarding the temperature at which food should be eaten, to promote healing of the affected tissues. These instructions should be considered important due to the fact that the literature has shown that hot or cold stimuli may influence pulpal healing due to the effect of the temperature on cellular metabolism¹⁹.

Restriction of sucking habits and risky activities

Nutritive and non-nutritive sucking habits are only mentioned by ^{Malmgren et al. 2017 8} which restricts the use of pacifiers and bottles for 7 days due to the need for rest of the affected tooth, thus allowing the repair of the periodontal fibers. In addition, the long term sucking habits may be associated with the development of malocclusions^20-22, increasing the risk of suffering dental trauma^23,24. No author refers to the management and/or suspension of digital suction.

Regarding risky activities, only one author indicates the need for parental supervision of potentially dangerous activities². This is noteworthy considering that the main causes of TDI are associated with involuntary falls, collisions, and recreational activities such as crawling, walking, and running^5,25. For this reason, it is necessary to guide parents in the use of mouthguards when performing sports and/or risky activities such as: soccer, hockey, cycling or others. In addition, to avoid bad habits such as biting objects, ice cubes and/or toy, and to reinforce the importance of adult supervision of babies and infants, and the use of a car seat when minors are transferred²⁶.

Complications and sequelae in permanent dentition

Only 45% of the studies declare that it is necessary to explain to the parents the possible sequelae in the permanent dentition. It should be noted that serious alterations can occur as a result of orofacial trauma at an early age²⁷. These sequelae are frequently related to enamel alterations with aesthetic compromise; however some severe sequelae may lead to the loss of the permanent successor^27,28. Alveolar fracture, intrusion and avulsion are mentioned as the types of injuries which may cause sequelae in the permanent successors, mainly if the injury occurs before 3 years of age^28,29. The sequelae observed at the level of the crown and the root of the permanent successor are associated with TDI occurrence at 2 and 4 years of age, respectively²⁷.

Less than half of the authors identify complications that require an observation by the caregiver such as swelling, increased mobility, sinus tract and signs of infection² in the traumatized primary tooth. In a more consensual manner, most authors attach importance to informing the need for follow-up of TDI, due to its relationship with short and long-term prognosis^4,30,31.

However, only half of the authors indicate that controls should be performed until the traumatized primary tooth has exfoliated and the permanent tooth has erupted ^{2,6,8-10,13,14}. The controls should consider the follow-up of possible sequelae in the traumatized primary teeth, to timely perform the adequate treatment to prevent its premature loss. The permanent tooth should also be monitored, both in its eruption process and in the timely intervention of some types of sequelae such as crown or root dilaceration.

Finally, it is necessary to call attention to the way in which this guidance are delivered to parents. The emergency dental consultant is a stressful moment to all the individuals. For this reason, these instructions should be given not only verbally, but also as a written medium such as a brochure to facilitate the understanding by the responsible adult.