首次发布：2020年5月30日
关键词：外伤，⽛撕脱伤，⽛齿折断，预防，⽛脱位性损伤
Keywords：Trauma, avulsion, tooth fracture, prevention, luxation
简略标题：IADT⽛外伤治疗指南：总论
Short title：IADT guidelines for management of traumatic dental injuries: General Introduction
DOI：https://doi.org/10.1111/edt.12574
译者：张黎丽、丁谦⽂、张昕、龚怡
摘要 (Abstract)
⽛外伤(TDIs)多好发于⼉童和青少年，在⽼年⼈中的发病率明显低于年轻群体。乳⽛外伤最 常见的类型是⽛脱位性损伤，⽽恒⽛外伤则多见于⽛冠折。 正确的诊断、及时的治疗和随访观察对⽛外伤的良好预后⾄关重要。国际⽛外伤协会(IADT)在全⾯回顾1996-2019年 EMBASE, MEDLINE, PUBMED, Scopus和Cochrane 数据库的⼜腔学科⽂献的基础之上，结合2000⾄2019年《⽛外伤学》杂 志的⽂献，制定了最新的⽛外伤治疗指南。制定指南的⽬的是为⽛外伤的患者能够得到即刻或紧急 的救治提供相关的信息，以便在后续治疗中能够得到经验丰富的⽛外伤专家和⼜腔全科医⽣的进⼀步治疗。
Traumatic dental injuries (TDIs) occur most frequently in children and young adults. Older adults also suffer TDIs but at significantly lower rates than individuals in the younger cohorts. Luxation injuries are the most common TDIs in the primary dentition, whereas crown fractures are more commonly reported for the permanent teeth. Proper diagnosis, treatment planning and follow up are very important to assure a favorable outcome. These updates of the International Association of Dental Traumatology's (IADT) Guidelines include a comprehensive review of the current dental literature using EMBASE, MEDLINE, PUBMED, Scopus, and Cochrane Databases for Systematic Reviews searches from 1996 to 2019 and a search of the journal Dental Traumatology from 2000 to 2019. The goal of these guidelines is to provide information for the immediate or urgent care of TDIs. It is understood that some follow‐up treatment may require secondary and tertiary interventions involving dental and medical specialists with experience in dental trauma.
与以往制定⽛外伤指南的⽅法相同，此次参与制定⽛外伤指南的专家来⾃于⼜腔专业的不同 学科、以及社区的⼜腔全科医⽣，他们具有科学研究的基础和丰富的临床经验。此次修订的⽛外伤 指南是基于现有的⽂献和专家意见，在某些已公布的⽂献数据有争议的情况下，牙外伤指南的提出 得到了专家们的⼀致认可，并由IADT董事会成员审查和批准通过。指南的应⽤要根据病⼈的具体情况⽽定，临床医⽣应对病情进⾏仔细的判断和评估，根据病⼈的依从性、经济状况、在各种治疗⽅案中进⾏优化选择，医⽣应明确判断病⼈的⽛外伤类型和损伤程度、以及远期的预后效果。 虽然 IADT不能保证医⽣遵循⽛外伤治疗指南就⼀定会使病⼈得到良好的预后效果， 但是IADT可以相信，医⽣在临床中应⽤治疗指南可以极⼤提⾼⽛外伤患者良好预后的概率。
As with previous guidelines, the current working group included experienced investigators and clinicians from various dental specialties and general practice. The current revision represents the best evidence based on the available literature and expert opinions. In cases where the published data were not conclusive, recommendations were based on the consensus opinions of the working group. They were then reviewed and approved by the members of the IADT Board of Directors. It is understood that guidelines are to be applied using careful evaluation of the specific clinical circumstances, the clinician's judgment, and the patient's characteristics, including the probability of compliance, finances and a clear understanding of the immediate and long‐term outcomes of the various treatment options vs non‐treatment. The IADT does not, and cannot, guarantee favorable outcomes from adherence to the Guidelines. However, the IADT believes that their application can maximize the probability of favorable outcomes.
1 前言 INTRODUCTION
⽛外伤(TDIs) 多发⽣于⼉童和青少年，占所有外伤的5%。25%的学龄⼉童都曾有过⽛外伤的 经历，33%的成年⼈也曾有过恒⽛外伤的经历，其中⼤多数⽛外伤发⽣在19岁之前。研究显⽰：乳⽛外伤最常见的类型是半脱位，⽽恒⽛外伤则多见于冠折。 我们认为：医⽣对⽛外伤的正确诊断和 选择适宜的治疗计划、以及⽇后的随访观察，对⽛外伤患者的良好预后是⼗分重要的。
Traumatic dental injuries (TDIs) occur frequently in children and young adults, comprising 5% of all injuries. Twenty‐five percent of all school children experience dental trauma and 33% of adults have experienced trauma to the permanent dentition, with the majority of the injuries occurring before age 19. Luxation injuries are the most common TDIs in the primary dentition, whereas crown fractures are more commonly reported for the permanent teeth. Proper diagnosis, treatment planning and follow up are important to assure a favorable outcome.
目前国际⽛外伤协会(IADT)在全⾯回顾1996-2019年 EMBASE、MEDLINE、PUBMED、 Scopes searches 数据库的⼜腔学科⽂献的基础之上，结合2000⾄2019年《⽛外伤学》杂志的⽂献，制 定了最新的⽛外伤治疗指南。
These updates of the International Association of Dental Traumatology's (IADT) Guidelines include a review of the current dental literature using EMBASE, MEDLINE, PUBMED, and Scopus searches from 1996 to 2019 and a search of the journal Dental Traumatology from 2000 to 2019.
⽛外伤治疗指南的⽬的是为⾸诊医⽣提供即刻或紧急救治⽛外伤患者的⽅法，以便在后续治 疗中得到经验丰富的⽛外伤专家和⼜腔全科医⽣的进⼀步治疗。
The goal of these guidelines is to provide information for the immediate and urgent care of TDIs. It is understood that some of the subsequent treatment may require secondary and tertiary interventions involving specialists with experience in dental trauma.
IADT在2001年发布了第⼀版⽛外伤治疗指南，并于2007年进⾏了指南的更新，在2012年的《⽛ 外伤学》杂志上又公布了指南的再⼀次修订更新。根据以前制定指南的要求，此次参与指南制定的 专家团队包括了经验丰富的研究⼈员和从事⼜腔专业不同学科的专家、以及全科医⽣。此次修订的⽛外伤治疗指南是基于现有的⽂献和专家意见，在某些公布的数据没有统⼀结论的情况下，⽛外伤 治疗指南的提出得到了专家们的⼀致认可，并由IADT董事会成员审查和批准通过。
The IADT published its first set of guidelines in 2001 and updated them in 2007. A further update was published in Dental Traumatology in 2012. As with previous guidelines, the current working group included experienced investigators and clinicians from various dental specialties and general practice. The current revision represents the best evidence based on the available literature and expert professional judgment. In cases where the data were not conclusive, recommendations were based on the consensus opinion of the working group, then reviewed and approved by the members of the IADT Board of Directors.
指南的应⽤要根据病⼈的具体情况⽽定，临床医⽣应对病情仔细的判断和评估，根据病⼈的依从性、经济状况、以及各种治疗⽅案的选择，医⽣应明确判断病⼈的⽛外伤类型和损伤程度、以及远期的预后效果。 虽然IADT不能保证医⽣遵循治疗指南操作就⼀定会使病⼈获得良好的预后效果， 但是IADT可以相信，医⽣在临床中应⽤⽛外伤治疗指南，可以⼤⼤增加⽛外伤患者预后良好的概率。
It is understood that guidelines are to be applied with evaluation of the specific clinical circumstances, clinicians' judgment and patients’characteristics, including but not limited to the probability of compliance, finances and an understanding of the immediate and long‐term outcomes of treatment options vs non‐treatment. The IADT does not, and cannot, guarantee favorable outcomes from adherence to the Guidelines, but the IADT believes that their application can maximize the chances of a favorable outcome.
治疗指南为医⽣诊断和治疗⽛外伤（TDIs）提供了建议。然⽽我们要知道，⾼度概括性的治疗指南是⽆法像教科书以及⽂献那样提供全⾯的知识和详细的信息。如果你要了解⽛外伤诊断和治 疗的更多信息，可以在⽛外伤指南的官⽅⽹站 http://www.dentaltraumaguide.org 中去发现⽛外伤指南(Dental Trauma Guide, DTG)。 不仅如此，在国际⽛外伤协会（IADT）的官⽅⽹站 http://www.iadt-dentaltrauma.org 还可以发现《⽛外伤学》杂志的链接，它可以提供详细的⽛外伤科学⽂献和相关信息。
These Guidelines offer recommendations for the diagnosis and treatment of specific TDIs. However, they provide neither the comprehensive nor the detailed information found in textbooks, the scientific literature, or the Dental Trauma Guide (DTG). The DTG can be accessed at http://www.dentaltraumaguide.org. In addition, the IADT website http://www.iadt‐dentaltrauma.org provides connection to the journal Dental Traumatologyand other dental trauma information.
2 概论 GENERAL RECOMMENDATIONS
2.1 乳牙外伤的特殊注意事项
Special considerations for trauma to primary teeth
幼⼉由于恐惧⽽配合性差，医⽣往往难以检查和治疗，这种状况也困扰着孩⼦和他们的⽗母。所以，在幼⼉⽛外伤就诊时，我们要特别注意受伤乳⽛的根尖与继承恒⽛胚之间的关系，因为乳⽛的严重外伤和／或⽛槽⾻损伤往往导致继承恒⽛的畸形、阻⽣和延迟萌出。⼉童的发育程度和应对紧急情况的能⼒，受伤患⽛脱落的时间和咬合关系都是影响治疗效果的重要因素，⼉童⽛外伤还常 常合并多发性损伤，这也会影响⽛外伤的预后。
A young child is often difficult to examine and treat due to lack of cooperation and because of fear. This situation is distressing for both the child and the parents. It is important to keep in mind that there is a close relationship between the root apex of the injured primary tooth and the underlying permanent tooth germ. Tooth malformation, impacted teeth and eruption disturbances in the developing permanent dentition are some of the consequences that can occur following severe injuries to primary teeth and/or alveolar bone. A child's maturity and ability to cope with the emergency situation, the time for shedding of the injured tooth, and the occlusion are all important factors that influence treatment. Multiple traumatic episodes are also common in children and this may affect the outcomes following trauma to a tooth.
2.2 年轻恒⽛与发育成熟的恒⽛
Immature vs mature permanent teeth
年轻恒⽛外伤，⾸选的治疗⽅案是尽量保存其⽛髓，以确保年轻恒⽛⽛根的继续发育。 ⼤多数⽛外伤发⽣在⼉童和青少年时期，失去⽛齿会影响其终⽣。 当年轻恒⽛发⽣折断暴露⽛髓时、或发⽣脱位性损伤或根折时，⽛髓都具有较强的修复能⼒。
Every effort should be made to preserve the pulp in the immature permanent tooth to ensure continued root development. A large majority of TDIs occur in children and teenagers where loss of a tooth has lifetime consequences. The immature permanent tooth has considerable capacity for healing after traumatic pulp exposure, luxation injury, or root fracture.
2.3 恒牙撕脱伤
Avulsion of permanent teeth
撕脱恒⽛的预后在很⼤程度上取决于在事故发⽣地对外伤⽛的即刻处理，我们应⼤⼒提⾼公众 对撕脱⽛紧急救治的意识。对撕脱⽛治疗⽅法的选择和预后的效果，在很⼤程度上取决于撕脱⽛⽛ 周膜(PDL)的损伤状况和根尖孔的发育程度。 可以详见IADT的⽛撕脱伤治疗指南。
The prognosis for avulsed permanent teeth is heavily dependent on the actions taken at the place of accident. Promotion of public awareness of first‐aid treatment for the avulsed tooth is strongly encouraged. Treatment choices and prognosis for the avulsed tooth are largely dependent on the viability of the periodontal ligament (PDL), and the maturity of the root. See the IADT's specific Guidelines for managing avulsed teeth.1
2.4 患者/家长须知
Patient/parent instructions
⽛外伤的良好愈合依赖于患者的定期复诊和良好的⼜腔卫⽣护理，我们应该指导患者和患⼉家 长如何更好地护理受伤的⽛齿，防⽌进⼀步的伤害，以获得最佳的愈合。精⼼的⼜腔护理并使⽤抗 菌剂含漱1-2周（如：0.12%⽆酒精的葡萄糖酸氯⼰定）。对于幼⼉可以使⽤棉签将氯⼰定涂在外伤⽛受损的区域进⾏护理。
Patient compliance with follow‐up visits and home care contributes to better healing following a TDI. Both the patient and the parents of a young patient should be advised regarding care of the injured tooth or teeth for optimal healing, preventing further injury, employing meticulous oral hygiene, and rinsing with an antibacterial agent such as alcohol‐free chlorhexidine gluconate 0.12% for 1‐2 weeks. Alternatively, with a young child, it is desirable to apply the chlorhexidine to the affected area with a cotton swab.
2.5 复诊，夹板固定时间和主要预后结果的汇总表
Summary tables for follow up, splinting duration and core outcomes
针对乳⽛、恒⽛不同类型的外伤复诊时间和夹板固定时间不同，特总结如下。见表1、2和3。
To help summarise activities for the follow‐up appointment and splinting regimes, Tables 1‐3are presented for different injuries in the primary and permanent dentitions. The core outcome variables, explained in the next paragraph, are also included.
表 1. 乳⽛外伤随访⽅式
Primary dentition follow‐up regimes
注 Note
在这些随访中，由Kenny等⼈收集的⼀般性外伤和特异性外伤的核⼼结果共识。《牙外伤学》2018
At these follow‐up visits consider collecting the generic and injury‐specific outcomes as identified by the Core Outcome Set—Kenny et al Dent Traumatol 2018.
* = 临床复诊 clinical review appointment.
S = 拆除夹板 splint removal.
R = 即使没有临床症状或体征，也应⾏x光检查 radiograph advised even if no clinical signs or symptoms.
表 2. 恒牙外伤复诊随访⽅式
Permanent dentition follow‐up regimes
注 Note
在这些随访中，由Kenny等⼈收集的⼀般性外伤和特异性外伤的核⼼结果共识。《⽛外伤学》2018
At these follow‐up visits consider collecting the generic and injury‐specific outcomes as identified by the Core Outcome Set—Kenny et al Dent Traumatol 2018
* = 临床复诊 clinical review appointment.
S = 拆除夹板 splint removal.
R = 即使没有临床症状或体征，也应⾏x光检查 radiograph advised even if no clinical signs or symptoms.
# = 年轻恒⽛⽛髓出现坏死和感染，要考虑以下附加的结果:⽛根长度、宽度和⽛冠折断程度 for immature permanent teeth with necrotic and infected pulps, consider the following additional outcomes: root length, root width, and late stage crown fracture.
表 3. 恒⽛列和乳⽛列的夹板固定时间
Splinting durations for the permanent and primary dentitions
2.6 核⼼结果共识
Core outcome set
哥本哈根的研究中⼼对全世界的外伤相关⽂献进⾏了回顾性研究。 Andreasen博⼠和他的团 队⽆论在⽛外伤的研究深度、还是研究的⼴度都取得了卓越的成就。科学研究关键的重要特征之⼀ 就是可重复性，在⼀个中⼼的⼀组患者群体中发现的结果同样适⽤于其它患者群体，其他中⼼的研 究结果也可以证实以往研究结果的正确性，⽽且这些研究结果的发表也是很有必要的。通过分析数 量不断增加的研究成果，可以提⾼临床医⽣和研究⼈员分析⽐较、对⽐和综合研究的能⼒。
When the worldwide trauma literature is reviewed, it is dominated by one center in Copenhagen. The lifetime work of Dr Andreasen and his research group is remarkable in both its longevity and the prolific publication of their results. One of the key fundamentals of scientific research is replication, where the results found in one center with one group of patients are also consistently seen across other patient groups. It is essential that the results from other centers are published even when they confirm the findings from earlier studies. By increasing the number of studies available for clinicians and researchers to analyze, the ability to compare, contrast and combine studies as appropriate is enhanced.
国际⽛外伤协会（IADT）最近开发了针对⼉童和成⼈⽛外伤(TDI)的核⼼结果共识(COS) 1。这是⾸先在⽛科领域开发的第⼀批COS之⼀，它采⽤了⼀种可靠的共识⽅法论，并对⽛外伤⽂献中使⽤ 的结果进⾏系统性回顾 2。⼀部分研究结果被证明可重复⽤于不同类型的⽛外伤中，并贯穿始终， 这部分研究结果归⼊“通⽤结果”——它与所有的⽛外伤（TDI）类型相关。另⼀部分研究结果被证明 仅仅与⼀种或多种特定的⽛外伤（TDI）类型相关 3——称为“特异性结果”。此外，这些研究结果的 具体内容和因果关系，研究的时间点以及研究的相关⼈员都是衡量的因素。
The IADT recently developed a core outcome set (COS) for traumatic dental injuries (TDI) in children and adults.2 This is one of the first COS developed in dentistry and follows a robust consensus methodology and is underpinned by a systematic review of the outcomes used in the trauma literature.3 A number of outcomes were identified as recurring throughout the different injury types. These outcomes were then included as “generic”—that is relevant to all TDI. Injury‐specific outcomes were also determined as those outcomes related only to one or more particular TDI. Additionally, the study established what, how, when and by whom these outcomes should be measured.
表1和表2显示了不同的⽛外伤类型，随访复查的时间、内容。可以在⽛外伤杂志官⽅⽹站的原 始⽂件1和补充材料中查找到每个结果的详尽信息。
Tables 1 and 2 show the generic and injury‐specific outcomes to be recorded at the follow‐up review appointments for the different traumatic injuries. Further information for each outcome is described in the original paper.2
利益冲突 CONFLICT OF INTEREST
作者确认他们没有利益冲突。
The authors confirm that they have no conflict of interest.
伦理审查 ETHICAL APPROVAL
本文不需要道德上的批准。
No ethic approval was required for this paper.
参考⽂献 References
1. Fouad AF, Abbott PV, Tsilingaridis G, et al. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth [published online ahead of print, 2020 May 27].Dent Traumatol. 2020. https://doi.org/10.1111/edt.12573
2. Kenny KP, Day PF, Sharif MO, Parashos P, Lauridsen E, Feldens CA, et al. What are the important outcomes in traumatic dental injuries? An international approach to the development of a core outcome set. Dent Traumatol. 2018; 34: 4– 11.
3. Sharif MO, Tejani‐Sharif A, Kenny K, Day PF. A systematic review of outcome measures used in clinical trials of treatment interventions following traumatic dental injuries. Dent Traumatol. 2015; 31: 422– 8.
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