Physical Examination and Diagnosis

Abstract

Although there is a sense of urgency when a child presents to the dental office or emergency department with a traumatic dental injury, it is essential that thorough documentation is made of the event, treatment, and follow-up. It is recommended that a trauma assessment form be used to provide consistency and to minimize the risk of missing vital information. Often, the injury may result in litigation at a later date, so having detailed documentation of the accident, the clinical findings, and the treatment recommendations is critical. Whenever possible, clinical photographs and radiographs should be made to aid in the documentation of the injury. Early in the assessment, the dentist must determine if the injuries are serious enough to warrant referral to the emergency department. This is done by completing a neurologic evaluation of each of the cranial nerves. For young children or children with developmental disabilities, the child’s reaction may be difficult to assess.