International Association of Dental Traumatology Guidelines For The Management of Traumatic Dental Injuries: 3. Injuries in The Primary Dentition

International Association of Dental Traumatology guidelines for the management of
Accepted Article
traumatic dental injuries: 3. Injuries in the Primary Dentition.
Peter Day1, Marie Therese Flores2, Anne O'Connell3, Paul V. Abbott4, Georgios Tsilingaridis5,
Ashraf F. Fouad6, Nestor Cohenca7, Eva Lauridsen8, Cecilia Bourguignon9, Lamar Hicks10, Jens
Ove Andreasen11, Zafer C. Cehreli12, Stephen Harlamb13, Bill Kahler14, Adeleke Oginni15, Marc
Semper16, Liran Levin17.
1School of Dentistry at the University of Leeds and Community Dental Service Bradford District Care NHS Trust.
2Department of Pediatric Dentistry, Faculty of Dentistry, Universidad de Valparaíso, Valparaíso, Chile.
3Paediatric Dentitsry, Dublin Dental University Hospital, Trinity College Dublin, The University of Dublin, Ireland.
4UWA Dental School, University of Western Australia.
5Karolinska Institutet, Department of Dental Medicine, Division of Orthodontics and Pediatric Dentistry, Huddinge &
Center for Pediatric Oral Health Research, Stockholm, Sweden.
6Adams School of Dentistry, University of North Carolina, Chapel Hill, NC, USA.
7Department of Pediatric Dentistry, University of Washington and Seattle Children’s Hospital. Seattle, WA
8Resource Center for Rare Oral Diseases, Copenhagen University Hospital, Denmark.
9Private Practice, Paris, France.
10Division of Endodontics, University of Maryland School of Dentistry, UMB, Baltimore, Maryland, USA.
11Resource Centre for Rare Oral Diseases, Department of Oral and Maxillofacial Surgery, University Hospital in
Copenhagen (Rigshospitalet), Copenhagen, Denmark.
12 Department of Pediatric Dentistry, Faculty of Dentistry, Hacettepe University, Ankara, Turkey.
13Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.
14School of Dentistry, The University of Queensland, Australia.
15Faculty of Dentistry, College of Health Sciences, Obafemi Awolowo University, Ile-Ife, Nigeria.
16Specialist Private Practice, Bremen, Germany.
17Faculty of Medicine and Dentistry, University of Alberta, Canada.
This article has been accepted for publication and undergone full peer review but has not been
through the copyediting, typesetting, pagination and proofreading process, which may lead to
differences between this version and the Version of Record. Please cite this article as doi:
10.1111/edt.12576
This article is protected by copyright. All rights reserved
Keywords: Trauma, avulsion, tooth fracture, prevention, luxation
Accepted Article
Short title: IADT traumatic dental injuries guidelines: Injuries in the Primary Dentition
Correspondence and reprint requests to:

Prof. Liran Levin – Chair of the IADT Guidelines Committee
University of Alberta, Faculty of Medicine & Dentistry
5-468 Edmonton Clinic Health Academy
11405 - 87 Avenue NW, 5th Floor
Edmonton AB T6G 1C9
E-mail: liran@ualberta.ca
Acknowledgement and Competing Interest

The authors declare there are no competing interest for the above manuscript. No funding was
received for the presented work.
Images Courtesy of the Dental Trauma Guide
Ethical Statement – No ethic approval was required for this paper.

Accepted Article
PROFESSOR MARIE THERESE FLORES (Orcid ID : 0000-0003-2412-190X)
PROFESSOR PAUL VINCENT ABBOTT (Orcid ID : 0000-0001-5727-4211)
DR GEORGIOS TSILINGARIDIS (Orcid ID : 0000-0001-5361-5840)
PROFESSOR ASHRAF F. FOUAD (Orcid ID : 0000-0001-6368-1665)
PROFESSOR NESTOR COHENCA (Orcid ID : 0000-0002-0603-5437)
DR EVA LAURIDSEN (Orcid ID : 0000-0003-0859-7262)
DR BILL KAHLER (Orcid ID : 0000-0002-4181-3871)
PROFESSOR LIRAN LEVIN (Orcid ID : 0000-0002-8123-7936)
Article type : Comprehensive Review
International Association of Dental Traumatology guidelines for the management of

traumatic dental injuries: 3. Injuries in the Primary Dentition.
Abstract:
Traumatic injuries to the primary dentition present special problems that often require far
different management when compared to that used for the permanent dentition. The
International Association of Dental Traumatology (IADT) has developed these Guidelines as
a consensus statement after a comprehensive review of the dental literature and working
group discussions. Experienced researchers and clinicians from various specialties and the
general dentistry community were included in the working group. In cases where the
published data did not appear conclusive, recommendations were based on the consensus
opinions or majority decisions of the working group. They were then reviewed and approved
by the members of the IADT Board of Directors.
The primary goal of these Guidelines is to provide clinicians with an approach for the
immediate or urgent care of primary teeth injuries based on the best evidence provided by the
literature and expert opinions. The IADT cannot, and does not, guarantee favorable outcomes
from strict adherence to the Guidelines, However, the IADT believes their application can
maximize the probability of favorable outcomes.

Accepted Article Introduction
Injuries to children are a major threat to their health and they are generally a neglected public
health problem.1 For children, aged 0-6 years, oral injuries account for 18% of all physical
injuries and the mouth is the second most common area of the body to be injured.2 A recent
meta-analysis on traumatic dental injuries (TDIs) reveals a world prevalence of 22.7%
affecting the primary teeth.3 Repeated TDIs are also frequently seen in children.4
Unintentional falls, collisions and leisure activities are the most common reasons for TDIs,
especially as children learn to crawl, walk, run and embrace their physical environment.5
They most commonly occur between 2 to 6 years of age4-7 with injuries to periodontal tissues
occurring most frequently.6, 8
Children with these injuries present to many health care
settings, including general dental practitioners, emergency medical services, pharmacists,
community dental clinics and specialist dental services. Consequently, each service provider
needs to have the appropriate knowledge, skills and training in how to care for children with
TDIs to their primary dentition.
The primary teeth Guidelines contain recommendations for the diagnosis and management of
traumatic injuries to the primary dentition, assuming the child is medically healthy with a
sound and caries-free primary dentition. Management strategies may change where multiple
teeth are injured. Many articles have contributed to the content of these Guidelines and the
treatment Table and these articles are not mentioned elsewhere in this introductory text.9-15
Initial presentation and minimising anxiety to the child and parent:

Management of TDIs in children is distressing for both the child and the parents. It can also
be challenging for the dental team. A TDI in the primary dentition often may be the reason
for the child's first visit to the dentist. Minimising anxiety for the child and parents, or other
caregiver, during the initial visit is essential. At this young age, the child may resist co-
operating for an extensive examination, radiographs and treatment. Knee to knee examination
can be helpful in examining a young child. Information about how to undertake an
examination of a child with a TDI involving their primary dentition can be found in current
textbooks16-18 or can be viewed in the following video

(https://tinyurl.com/kneetokneeexamination). Wherever possible the acute and follow-up
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dental care should be provided by a child-oriented team that has experience and expertise in
the management of paediatric oral injuries. These teams are best placed to access specialist
diagnostic and treatment services, including sedation and general anaesthesia, and pain
management for the prevention or minimization of suffering.19
A structured approach:
It is essential that clinicians adopt a structured approach to managing traumatic dental
injuries. This includes history taking, undertaking the clinical examination, collecting test
results and how this information is recorded. The literature shows that the use of a structured
history at the initial consultation leads to a significant improvement in the quality of the
trauma records involving the permanent dentition5, 20
. There are a variety of structured
6-18
histories available in current textbooks or used at different specialist centres.21, 22 Extra-
oral and intra-oral photographs act as a permanent record of the injuries sustained and are
strongly recommended.
Initial assessment:
Elicit a careful medical, social (including those who attend with the child), dental and
accident history. Thoroughly examine the head and neck and intra-orally for both bony and
soft tissue injuries.17, 18
Be alert to concomitant injuries including head injury, facial
fractures, missing tooth fragments or lacerations. Seek a medical examination if necessary.
Soft tissue injuries:

It is essential to identify, record and diagnose extra-oral and intra-oral soft tissue injuries.18, 23
The lips, oral mucosa, attached and free gingivae, and the frenula should be checked for
lacerations and hematomas. The lips should be examined for possible embedded tooth
fragments. The presence of a soft tissue injury is strongly associated with the pursuit of
immediate care. Such injuries are most commonly found in the 0-3 year age group.24
Management of soft tissues, beyond just first aid, should be provided by a child-oriented team
with experience in paediatric oral injuries. Parental engagement with the homecare for soft

tissue injuries to the gingivae is critical and will influence the outcomes for healing of the
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teeth and soft tissues. Parental homecare instructions for intra-oral soft tissue injuries are
described later in these Guidelines.
Tests, crown discoloration and radiographs:

Extra-oral and intra-oral photographs are strongly recommended.
Pulp sensibility tests are unreliable in primary teeth and are therefore not recommended.
Tooth mobility, color, tenderness to manual pressure and the position or displacement should
be recorded.
The color of injured and un-injured teeth should be recorded at each clinic visit.
Discoloration is a common complication following luxation injuries.8, 25-27
This discoloration
may fade and the tooth may regain its original shade over a period of weeks or months.8, 28-30
Teeth with persistent dark discoloration may remain asymptomatic clinically and
radiographically normal, or they may develop apical periodontitis (with or without
symptoms).31, 32
Root canal treatment is not indicated for discolored teeth unless there are
clinical or radiographic signs of infection of the root canal system.18, 33
Every effort has been made in these Guidelines to reduce the number of radiographs needed
for accurate diagnosis, thus minimising a child’s exposure to radiation. For essential
radiographs, radiation protection includes the use of a thyroid collar where the thyroid is in
the path of the primary x-ray beam34 and a lead apron for when parents are holding the child.
Radiation-associated risks for children are a concern as they are substantially more
susceptible to the effects of radiation exposure for the development of most cancers than
adults. This is due to their longer life expectancy and the acute radiosensitivity of some
developing organs and tissues.35, 36
Therefore, clinicians should question each radiograph they
take and cognitively ask if additional radiographs will positively affect the diagnosis or
treatment provided for the child. Clinicians must work within the ALARA (As Low As
Reasonably Achievable) principles to minimize the radiation dose. The use of CBCT
following TDI in young children is rarely indicated.37
Diagnosis:

A careful and systematic approach to diagnosis is essential. Clinicians should identify all
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injuries to each tooth including both hard tissues injuries (e.g. fractures) and periodontal
injuries (e.g. luxations). When concomitant injuries occur in the primary dentition following
extrusion and lateral luxation injuries, they have a detrimental impact on pulp survival.27 The
accompanying Table and the trauma pathfinder diagram (www.dentaltraumaguide.org) help
clinicians identify all possible injuries for each injured tooth.
Intentional (non-accidental) injuries:

Dental and facial trauma can occur in cases of intentional injuries. Clinicians should check if
the history of the accident and the injuries sustained are consistent or match. In situations
where there is suspicion of abuse, prompt referral for a full physical examination and
investigation of the incident should be arranged. Referral should follow local protocols,
which is beyond the scope of these Guidelines.
Impact of orofacial and primary tooth trauma on the permanent dentition:

There is a close spatial relationship between the apex of the primary tooth root 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 injuries to primary teeth and the alveolar bone.38-44 Intrusion and avulsion
injuries are most commonly associated with the development of anomalies in the permanent
dentition.38-43
For intrusive and lateral luxation injuries, previous Guidelines have recommended the
immediate extraction of the traumatised primary tooth if the direction of displacement of the
root is toward the permanent tooth germ. This action is no longer advised due to 1) evidence
of spontaneous re-eruption for intruded primary teeth,8, 10, 26, 44-46 2) the concern that further
damage may be inflicted on the tooth germ during extraction, and 3) the lack of evidence that
immediate extraction will minimise further damage to the permanent tooth germ.
It is very important to document that parents have been informed about possible
complications to the development of the permanent teeth, especially following intrusion,
avulsion, and alveolar fractures.

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Management strategy for injuries to the primary dentition:
In general, there is limited evidence to support many of the treatment options in the primary
dentition. Observation is often the most appropriate option in the emergency situation unless
there is risk of aspiration, ingestion or interference with the occlusion. This conservative
approach may reduce additional suffering for the child18 and the risk of further damage to the
permanent dentition.18, 47 48
A summary of the management of TDIs in the primary dentition includes the following:
 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.
 It is critical that parents are given appropriate advice on how best to manage the acute
symptoms to avoid further distress.49, 50 Luxation injuries, such as intrusion and lateral
luxation, and root fractures may cause severe pain. The use of analgesics such as
ibuprofen and/or acetaminophen (paracetamol) is recommended when pain is
anticipated.
 Minimising dental anxiety is essential. Provision of dental treatment depends on the
child’s maturity and ability to cope. Various behavioural approaches are available51-53
and have been shown to be effective for managing acute procedures in an emergency
situation..54, 55
TDIs and their treatment have the potential to lead to both post-
traumatic stress disorder and dental anxiety. The development of these conditions in
young children is a complex issue56 57
with little research specifically examining
either condition following TDIs in the primary dentition. However, evidence from the
wider dental literature suggests that the multi- factorial nature of dental anxiety, its
fluctuating nature and the role of dental extractions are exacerbating factors.58-60
Where possible, avoidance of dental extractions. especially at the acute or initial visit
is a reasonable strategy.
 Where appropriate and the child’s cooperation allows, options that maintain the
child’s primary dentition should be the priority,61 Discussions with parents about the
different treatment options should include the potential for further treatment visits and
consideration for how best to minimise the impact of the injury on the developing
permanent dentition,62

 For crown and crown-root fractures involving the pulp, root fractures and luxation
Accepted Article injuries, rapid referral within several days to a child-orientated team that has
experience and expertise in the management of dental injuries in children is essential.
 Splinting is used for alveolar bone fractures41, 63
and occasionally may be needed in
cases of root fractures64 and lateral luxations.64
Avulsed primary teeth:

An avulsed primary tooth should not be replanted. Reasons include a significant treatment
burden (including replantation, splint placement and removal, root canal treatment) for a
young child as well as the potential of causing further damage to the permanent tooth or to its
eruption.41, 42, 65, 66
However, the most important reason is to avoid a medical emergency
resulting from aspiration of the tooth. Careful follow up is required to monitor the
development and eruption of the permanent tooth. Refer to the accompanying Table for
specific guidance.
Antibiotics and Tetanus:

There is no evidence for recommending the use systemic antibiotics in the management of
luxation injuries in the primary dentition. However, antibiotic use does remain at the
discretion of the clinician when TDIs are accompanied by soft tissue and other associated
injuries or significant surgical intervention is required. Finally, the child´s medical status may
warrant antibiotic coverage. The child’s paediatrician should be contacted where questions
arise in these situations.
A tetanus booster may be required if environmental contamination of the injury has occurred.
If in doubt, refer to a medical practitioner within 48 hours.
Parental instructions for homecare:

Successful healing following an injury to the teeth and oral tissues depends on good oral
hygiene. To optimize healing, parents or caregivers should be advised regarding care of the
injured tooth/teeth and the prevention of further injury by supervising potentially hazardous

activities. Clean the affected area with a soft brush or cotton swab and use alcohol-free
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chlorhexidine gluconate 0.12% mouth rinse applied topically twice a day for one week to
prevent accumulation of plaque and debris and to reduce the bacterial load. Care should be
taken when eating not to further traumatize the injured teeth while encouraging a return to
normal function as soon as possible.
Parents or caregivers should be advised about possible complications that may occur, such as
swelling, increased mobility or a sinus tract. Children may not complain about pain, but
infection may be present. Parents or caregivers should watch for signs of infection such as
swelling of the gums. If present, they should take the child to a dentist for treatment.
Examples of unfavorable outcomes are found in the Table for each injury.
Training, skills and experience for teams managing the follow-up care:
During the follow-up phase of treatment, dental teams caring for children with complex
injuries to the primary dentition should have specialist training, experience and skills. These
attributes enable the members of the team to respond appropriately to the medical, physical,
emotional and developmental needs of children and their families. In addition, skills within
the team should also encompass health promotion and access to specialist diagnostic and
treatment services including sedation, general anaesthesia and overall pain management for
the prevention or minimization of suffering.19
Prognosis:
Factors relating to the injury and subsequent treatment may influence pulp and periodontal
outcomes and they should be carefully recorded. These prognostic factors need to be
carefully collected at both the initial consultation and at follow- up visits. This is most likely
achieved using the structured history form described previously. The dental literature and
appropriate websites (e.g. www.dentaltraumaguide.org) provide clinicians with useful
information on the probable pulp and periodontal prognosis. These sources of information
can be invaluable when having conversations with the parents or caregivers and the child.
Core Outcome Set:

The International Association for Dental Traumatology (IADT) recently developed a core
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outcome set (COS) for traumatic dental injuries (TDIs) in children and adults.68 This is one of
the first COS developed in dentistry and is underpinned by a systematic review of the
outcomes used in the trauma literature and follows a robust consensus methodology. 69 Some
outcomes were identified as recurring throughout the different injury types. These outcomes
were then identified as “generic” (i.e, relevant to all TDIs). Injury-specific outcomes were
also determined as those outcomes related only to one or more individual TDIs. Additionally,
the study established what, how, when and by whom these outcomes should be measured.
Table 1 in the General Introduction section of the Guidelines shows the generic and injury
specific outcomes to be recorded at the follow-up review appointments recommended for the
different traumatic injuries. Further information for each outcome is described in the original
article68 with supplementary materials available on the Dental Traumatology journal’s
website.

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Accepted Article
Treatment guidelines for fractures of primary teeth and alveolar bone
Table 1 – Treatment guidelines for enamel fractures in the primary dentition
Favorable and Unfavorable Outcomes include some, but not

necessarily all, of the following:
Radiographic
ENAMEL FRACTURE Treatment Follow-up Favorable Outcomes Unfavorable Outcomes
Recommendations
 No radiographs  Smooth any sharp edges.  No clinical or radiographic  Asymptomatic  Symptomatic

recommended follow-up recommended
 Parent / Patient Education:  Pulp healing with:  Crown discoloration
- Exercise care when eating not to - Normal color of the  Signs of pulp necrosis and
further traumatize the injured tooth remaining crown infection - such as:
while encouraging a return to normal
- No signs of pulp necrosis - Sinus tract, gingival
function as soon as possible.
and infection swelling, abscess or
Clinical findings: - Encourage gingival healing and increased mobility
- Continued root development
prevent plaque accumulation by
Fracture involves enamel in immature teeth - Persistent dark gray
parents cleaning the affected area
only discoloration with one or
with a soft brush or cotton swab
more other signs of
combined with an alcohol-free 0.1 to
infection
0.2% chlorhexidine gluconate
mouthrinse applied topically twice a - Radiographic signs of pulp

Accepted Article
day for one wee necrosis and infection
 No further root development of

immature teeth

Accepted Article
Table 2 – Treatment guidelines for enamel-dentin fractures (with no pulp exposure) in the primary dentition
Favorable and Unfavorable Outcomes include some, but

not necessarily all, of the following:
ENAMEL-DENTIN
Radiographic
FRACTURE Treatment Follow-up Favorable Outcome Unfavorable Outcome
Recommendations
(with no pulp exposure)
 Baseline radiograph  Cover all exposed dentin with glass  Clinical examination after 6-8  Asymptomatic  Symptomatic
optional ionomer or composite weeks
 Pulp healing with:  Crown discoloration
 Take a radiograph of  Lost tooth structure can be restored  Radiographic follow-up
- Normal color of the  Signs of pulp necrosis and
the soft tissues if the using composite immediately or at a indicated only when clinical
remaining crown infection - such as:
fractured fragment is later appointment findings are suggestive of
suspected to be pathosis (e.g. signs of pulp - No signs of pulp necrosis - Sinus tract, gingival
Clinical findings:  Parent / Patient Education:
embedded in the lips, necrosis and infection) and infection swelling, abscess or
Fracture involves enamel - Exercise care when eating not to increased mobility
cheeks or tongue - Continued root
and dentin. The pulp is not further traumatize the injured
development in immature - Persistent dark gray
exposed tooth while encouraging a return  Parents should watch for any
teeth discoloration with one
 The location of missing to normal function as soon as unfavorable outcomes. If
or more other signs of
tooth fragments should possible seen, the child needs to
root canal infection
be explored during the return to the clinic as soon as
- Encourage gingival healing and
possible. When unfavorable - Radiographic signs of
trauma history and prevent plaque accumulation by
outcomes are identified, pulp necrosis and
examination, parents cleaning the affected

Accepted Article
especially when the area with a soft brush or cotton treatment is often required infection
accident was not swab combined with an alcohol-
 The follow-up treatment,  No further root development
witnessed by an adult free 0.1 to 0.2% chlorhexidine
which frequently requires the of immature teeth
or there was a loss of gluconate mouthrinse applied
expertise of a child-oriented
consciousness topically twice a day for one
team, is outside the scope of
week
 Note: while fragments these guidelines
are most often lost out
of the mouth, there is a
risk of that they can be
embedded in the soft
tissues, ingested or
aspirated

Accepted Article
Table 3 – Treatment guidelines for complicated crown fractures (with pulp exposure) in the primary dentition
Favorable and Unfavorable outcomes include some,

but not necessarily all, of the following:
COMPLICATED CROWN
Radiographic
FRACTURE Treatment Follow-up Favorable Outcome Unfavorable Outcome
Recommendations
(i.e. with exposed pulp)
 A periapical radiograph  Preserve the pulp by partial pulpotomy.  Clinical examination after:  Asymptomatic  Symptomatic
(using a size 0 Local anaesthesia will be required. A non-
- 1 week  Pulp healing with:  Crown discoloration
sensor/film and the setting calcium hydroxide paste should be
paralleling technique) applied over the pulp and cover this with a - 6-8 weeks - Normal color of the  Signs of pulp necrosis and
or an occlusal glass ionomer cement and then a composite remaining crown infection - such as:
- 1 year
radiograph (with a size resin. Cervical pulpotomy is indicated for - No signs of pulp - Sinus tract, gingival
 Radiographic follow-up at 1 year
2 sensor/film) should teeth with large pulp exposures. The necrosis and infection swelling, abscess or
following pulpotomy or root canal
be taken at the time of evidence for using other biomaterials such increased mobility
treatment. Other radiographs are - Continued root
initial presentation for as non-staining calcium silicate based
only indicated where clinical development in - Persistent dark gray
Clinical findings: diagnostic purposes cements is emerging. Clinicians should
findings are suggestive of immature teeth discoloration with one
and to establish a focus on appropriate case selection rather
Fracture involves enamel pathosis (e.g. an unfavorable or more signs of root
baseline than the material used
and dentin plus the pulp is outcome) canal infection
exposed.  Take a radiograph of  Treatment depends on the child´s maturity
- Radiographic signs of
the soft tissues if the and ability to tolerate procedures . Therefore,
 The location of missing pulp necrosis and
fractured fragment is discuss different treatment options (including  Parents should watch for any
tooth fragments should be infection
suspected to be pulpotomy) with the parents. Each option is unfavorable outcomes. If seen,
explored during the trauma
embedded in the lips, invasive and has the potential to cause long- the child needs to return to the  No further root
history and examination,
cheeks or tongue term dental anxiety. Treatment is best clinic as soon as possible. Where development of immature
especially when the
performed by a child-oriented team with unfavorable outcomes are teeth
accident was not

Accepted Article
witnessed by an adult or experience and expertise in the identified, treatment is often
there was a loss of management of paediatric dental injuries. required.
consciousness Often no treatment may be the most
 The follow-up treatment, which
appropriate option in the emergency
 Note: while fragments are frequently requires the expertise
situation, but only when there is the potential
most often lost out of the of a child-oriented team, is
for rapid referral (within several days) to the
mouth, there is a risk of outside the scope of these
child-oriented team
that they can be guidelines
embedded in the soft  Parent / Patient Education:
tissues, ingested or
- Exercise care when eating not to
aspirated
further traumatize the injured tooth
- To encourage gingival healing and

prevent plaque accumulation, parents
should clean the affected area with a
soft brush or cotton swab combined
with an alcohol-free 0.1 to 0.2%
chlorhexidine gluconate mouthrinse
applied topically twice a day for one
week

Accepted Article
Table 4 – Treatment guidelines for crown-root fractures in the primary dentition
Favorable and Unfavorable Outcomes include some,

CROWN-ROOT Radiographic
Treatment Follow-Up Favorable Outcome Unfavorable Outcome
FRACTURE Recommendations
 A periapical radiograph  Often no treatment may be the most  Where tooth is retained,  Asymptomatic  Symptomatic
(using a size 0 appropriate option in the emergency clinical examination after:
 Pulp healing with:  Crown discoloration
sensor/film and the situation, but only when there is the
- 1 week
paralleling technique) potential for rapid referral (within several - Normal color of the  Signs of pulp necrosis
or an occlusal days) to a child-oriented team - 6-8 weeks remaining crown and infection - such as:
radiograph (with a size - 1 year - No signs of pulp necrosis - Sinus tract, gingival
 If treatment is considered at the emergency
2 sensor/film) should and infection swelling, abscess or
appointment, local anaesthesia will be  Radiographic follow-up after
be taken at the time of increased mobility
required 1 year following pulpotomy or - Continued root
initial presentation for
 Remove the loose fragment and determine root canal treatment. Other development in immature - Persistent dark gray
diagnostic purposes
if the crown can be restored radiographs only indicated teeth discoloration with
and to establish a
where clinical findings are one or more signs of
baseline  Option A:
suggestive of pathosis (e.g. root canal infection
- If restorable and no pulp exposed, an unfavorable outcome)
- Radiographic signs
cover the exposed dentine with glass
of pulp necrosis and
Clinical findings: ionomer
infection
 Parents should watch for any
Fracture involves - If restorable and the pulp is exposed,
unfavorable outcomes. If  No further root
enamel, dentin and root; perform a pulpotomy (see crown
seen, the child needs to return development of immature
the pulp may or may not fracture with exposed pulp) or root
to the clinic as soon as teeth
be exposed (i.e. canal treatment, depending on the

Accepted Article
complicated or stage of root development and the possible. Where unfavorable
uncomplicated) level of the fracture. outcomes are identified,
treatment is often required.
 Additional findings  Option B:
may include loose,  The follow-up treatment,
- If unrestorable, extract all loose
but still attached, which frequently requires the
fragments taking care not to damage
fragments of tooth expertise of a child-oriented
the permanent successor tooth and
team, is outside the scope of
leave any firm root fragment in situ, or
these guidelines
extract the entire tooth
 Treatment depends on the child´s maturity

and ability to tolerate the procedure.
Therefore, discuss treatment options
(including extraction) with the parents.
Each option is invasive and has the
potential to cause long-term dental
anxiety. Treatment is best performed by a
child-oriented team with experience and
expertise in the management of paediatric
dental injuries
 Parent / Patient Education:

function as soon as possible


Accepted Article
with an alcohol-free 0.1 to 0.2%
week

Accepted Article
Table 5 – Treatment guidelines for root fractures in the primary dentition
Favorable and Unfavorable Outcomes include

some, but not necessarily all, of the following:
Radiographic
ROOT FRACTURE Recommendations Treatment Follow-Up Favorable Outcome Unfavorable Outcome
and Findings
 A periapical (size 0  If the coronal fragment is not displaced, no  Where no displacement of coronal  Asymptomatic  Symptomatic
sensor/film, paralleling treatment is required fragment, clinical examination after:
 Pulp healing with:  Signs of pulp necrosis and
technique) or occlusal
 If the coronal fragment is displaced and is not - 1 week infection - such as:
radiograph (size 2 - Normal color of the
excessively mobile, leave the coronal fragment to
sensor/film) should be - 6-8 weeks crown or transient - Siinus tract, gingival
spontaneously reposition even if there is some
taken at the time of red/gray or yellow swelling, abscess or
occlusal interference - 1 year and where there are
initial presentation for discoloration and increased mobility
clinical concerns that an
diagnostic purposes  If the coronal fragment is displaced, excessively pulp canal
unfavorable outcome is likely. - Persistent dark gray
and to establish a mobile and interfering with occlusion, two options obliteration
discoloration with one
- Then continue clinical follow-up
Clinical findings: baseline (under local anaesthesia) are available, both of
- No signs of pulp or more signs of root
which require local anaesthesia each year until eruption of
Depends on the location  The fracture is usually necrosis and canal infection
permanent teeth
of fracture located mid-root or in  Option A: infection
- Radiographic signs of
 If coronal fragment has been
the apical third - Continued root pulp necrosis and
 The coronal - Extract only the loose coronal fragment. The
repositioned and splinted, clinical
fragment may be apical fragment should be left in place to be development in infection
examination after:
mobile and may be resorbed immature teeth
- Radioraphic signs of
- 1 week
displaced  Realignment of the root- infection-related

Accepted Article
 Occlusal  Option B: - 4 weeks for splint removal fractured tooth (inflammatory)
interference may be resorption
- Gently reposition the loose coronal - 8 weeks  No mobility
present
fragment. If the fragment is unstable in its  No further root
- 1 year  Resorption of the apical
new position, stablize the fragment with a development of immature
fragment
flexible splint attached to the adjacent  Where there are concerns that an teeth
uninjured teeth. Leave the splint in place for unfavorable outcome is likely, then
 No improvement in the
4 weeks continue clinical follow-up each year
position of the root-
until eruption of permanent teeth
 The treatment depends on the child´s maturity and fractured tooth
ability to tolerate the procedure. Therefore,  If coronal fragment has been
discuss treatment options with the parents. Each extracted, clinical examination after:
options is invasive and has the potential to cause - 1 year

long-term dental anxiety. Treatment is best
 Where there are concerns that an
performed by a child-oriented team with
unfavorable outcome is likely, then
experience and expertise in the management of
continue clinical follow-up each year
paediatric dental injuries. Often no treatment may
until eruption of permanent teeth
be the most appropriate option in the emergency
scenario, but only when there is the potential for  Radiographic follow-up only indicated
rapid referral (within several days) to the child- where clinical findings are suggestive
oriented team of pathosis (e.g. an unfavorable
outcome)

- Exercise care when eating not to further  Parents should be informed to
traumatize the injured tooth while watchfor any unfavorable outcomes
encouraging a return to normal function as and the need to return to the clinic as
soon as possible soon as possible. Where unfavorable
outcomes are identified, treatment is
- To encourage gingival healing and prevent
often required.
plaque accumulation, parents should clean
the affected area with a soft brush or cotton

Accepted Article
swab combined with an alcohol-free 0.1 –  The follow-up treatment, which
0.2% chlorhexidine gluconate mouthrinse frequently requires the expertise of a
applied topically twice a day for one week child-oriented team, is outside the
scope of these guidelines

Accepted Article
Table 6 – Treatment guidelines for alveolar fractures in the primary dentition

Radiographic
ALVEOLAR
Recommendations Treatment Follow-Up Favorable Outcome Unfavorable Outcome
FRACTURE
and Findings
 A periapical (size 0  Reposition (under local anesthesia)  Clinical examination after:  Asymptomatic  Symptomatic
sensor/film, paralleling any displaced segment which is
- 1 week  Pulp healing with:  Signs of pulp necrosis
technique) or occlusal mobile and/or causing occlusal
and infection - such as:
radiograph (size 2 interference - 4 weeks for splint removal - Normal crown color or
sensor/film) should be transient red/gray or - Sinus tract, gingival

 Stabilise with a flexible splint to the - 8 weeks
taken at the time of initial yellow discoloration swelling, abscess or
adjacent uninjured teeth for 4 weeks - 1 year
presentation for and pulp canal increased mobility
diagnostic purposes and  Treatment should be performed by a - Further follow-up at 6 years of age is obliteration
- Persistent dark gray
to establish a baseline child-oriented team with experience indicated to monitor eruption of the - No signs of pulp discoloration plus one
Clinical findings:
and expertise in the management of permanent teeth
 A lateral radiograph may necrosis and infection or more signs of root
The fracture involves paediatric dental injuries
give information about  Radiographic follow up at 4 weeks and 1 canal infection
- Continued root
the alveolar bone (labial
the relationship between  Parent / Patient Education: year to assess impact on the primary tooth development in - Radiographic signs of
and palatal/lingual) and
the maxillary and and the permanent tooth germs in the line immature teeth pulp necrosis and
- Exercise care when eating not
may extend to the
mandibular dentitions to further traumatize the injured of the alveolar fracture. This radiograph infection including:
adjacent bone  Periodontal healing
and if the segment is teeth while encouraging a return may indicate a more frequent follow-up infection related
 Mobility and displaced in a labial regimen is needed. Other radiographs are  Realignment of the alveolar (inflammatory)
to normal function as soon as

Accepted Article
dislocation of the direction possible. indicated only where clinical findings are segment with the original resorption
segment with suggestive of pathosis (e.g. an unfavorable occlusion restored
 Fracture lines may be - To encourage gingival healing  No further root
several teeth outcome)
located at any level, from and prevent plaque  No disturbance to the development in immature
moving together are
the marginal bone to the accumulation, parents should  If the fracture line is located at the level of development and/or teeth
common findings
root apex or beyond, and clean the affected area with a the primary root apex, an abscess can eruption of the permanent
 Limited or no
 Occlusal they may involve the soft brush or cotton swab develop. A periapical radiolucency can be successor
improvement in the
interference is primary teeth and/or their combined with an alcohol-free seen on the radiograph.
position of the displaced
usually present permanent successors. 0.1- 0.2% chlorhexidine
segment and the original
gluconate mouthrinse applied
 Further imaging may be occlusion is not re-
topically twice a day for one  Parents should be informed to watch for
needed to visualise the established
week any unfavorable outcomes and the need to
extent of the fracture(s),
return to the clinic as soon as possible.  Negative impact on the
but only where it is likely
Where unfavorable outcomes are development and/or
to change the treatment
identified, treatment is often required. eruption of the
provided.
permanent successor
 The follow-up treatment, which frequently
requires the expertise of a child-oriented
team, is outside the scope of these
guidelines

Accepted Article
Treatment guidelines for luxation injuries of primary teeth
Table 7 – Treatment guidelines for concussion of primary teeth

Radiographic
CONCUSSION Treatment Follow-Up Favorable Outcome Unfavorable Outcome
Recommendations

Accepted Article
 No baseline  No treatment is needed.  Clinical examination after:  Asymptomatic  Symptomatic
radiograph
 Observation. - 1 week  Pulp healing with:  Signs of pulp necrosis and
recommended
infection - such as:
- 6-8 weeks - Normal color of the
crown or transient - Sinus tract, gingival
red/gray or yellow swelling, abscess or
- Exercise caare when eating not to  Radiographic follow up only indicated discoloration and pulp increased mobility
further traumatize the injured tooth where clinical findings are suggestive of canal obliteration
while encouraging a return to normal pathosis (e.g. an unfavorable outcome)
- No signs of pulp discoloration plus one
Clinical findings: necrosis and infection or more other signs of
- To encourage gingival healing and root canal infection
The tooth is tender to  Parents should be informed to watch for  Continued root development
touch but it has not been any unfavorable outcomes and the need in immature teeth  Radiographic signs of pulp
displaced to return to the clinic as soon as necrosis and infection
soft brush or cotton swab combined  No disturbance to the
possible. Where unfavorable outcomes
 It has normal with an alcohol-free 0.1 – 0,2% development and/or eruption  No further root development
are identified, treatment is often required.
mobility and no mouthrinse chlorhexidine gluconate of the permanent successor of immature teeth
sulcular bleeding applied topically twice a day for one  The follow-up treatment, which
 Negative impact on the
week frequently requires the expertise of a
development and/or
child-oriented team, is outside the scope
eruption of the permanent
of these guidelines
successor

Accepted Article
Table 8 – Treatment guidelines for subluxation of primary teeth

Radiographic
SUBLUXATION Recommendations Treatment Follow-Up Favorable Outcome Unfavorable Outcome
and Findings
 A periapical (size 0  No treatment is needed.  Clinical examination after:  Asymptomatic  Symptomatic

sensor/film, paralleling
 Observation - 1 week  Pulp healing with:  Signs of pulp necrosis and
technique) or occlusal
radiograph (size 2 - 6-8 weeks - Normal color of the
sensor/film) should be taken crown or transient - Sinus tract, gingival

 Parent / Patient Education:  Where there are concerns that an
at the time of initial red/gray or yellow swelling, abscess or
unfavorable outcome is likely, then
- Exercise care when eating not to discoloration and pulp increased mobility
presentation for diagnostic continue clinical follow-up each
further traumatize the injured teeth canal obliteration
purposes and to establish a year until eruption of the - Persistent dark gray
while encouraging a return to
baseline permanent teeth - No signs of pulp discoloration plus one or
normal function as soon as
Clinical findings: necrosis and infection more signs of root canal
 Normal to slightly widened possible  Radiographic follow up only
The tooth is tender to periodontal ligament space infection
indicated where clinical findings  Continued root
- To encourage gingival healing.
touch and it has will be visible are suggestive of pathosis (e.g. an development in immature  Radiographic signs of pulp
Parents should clean the affected

Accepted Article
increased mobility, but it area with a soft brush or cotton unfavorable outcome) teeth necrosis and infection
has not been displaced swab combined with an alcohol-
 No disturbance to the  No further root development
free 0.1 – 0.2% chlorhexidine
 Bleeding from development and/or of immature teeth
gluconate mouthrinse applied  Parents should be informed to
gingival crevice eruption of the permanent
topically twice a day for one week watch for any unfavorable  Negative impact on the
may be noted successor
outcomes and the need to return development and/or eruption
to the clinic as soon as possible. of the permanent successor
Where unfavorable outcomes are
identified, treatment is often
required.

frequently requires the expertise of
a child-oriented team, is outside
the scope of these guidelines

Accepted Article
Table 9 – Treatment guidelines for extrusive luxation of primary teeth

Radiographic
EXTRUSIVE
LUXATION
and Findings
 A periapical (size 0  Treatment decisions are based on the  Clinical examination after:  Asymptomatic  Symptomatic
sensor/film, paralleling degree of displacement, mobility,
- 1 week  Pulp healing with:  Signs of pulp necrosis and
technique) or occlusal interference with the occlusion, root
radiograph (size 2 formation and the ability of the child to - 6-8 weeks - Normal color of the
sensor/film) should be tolerate the emergency situation crown or transient - Sinus tract, gingival
- 1 year
taken at the time of initial red/gray or yellow swelling, abscess or
 If the tooth is not interfering with the  Where there are concerns that an
presentation for discoloration and pulp increased mobility
occlusion - let the tooth spontaneously unfavorable outcome is likely, then
diagnostic purposes and canal obliteration
reposition itself - Persistent dark gray
continue clinical follow-up each
to establish a baseline - No signs of pulp discoloration plus one
 If the tooth is excessively mobile or year until eruption of the
 Slight increase to necrosis and infection or more signs of root
Clinical findings: extruded >3mm, then extract under local permanent teeth
substantially widened canal infection
anesthesia  Continued root development
Partial displacement of  Radiographic follow up only
periodontal ligament in immature teeth  Radiographic signs of pulp
the tooth out of its socket indicated where clinical findings
space apically  Treatment should be performed by a child-
necrosis and infection
are suggestive of pathosis (e.g. an  Realignment of the extruded
 The tooth appears oriented team with experience and
 No further root development

Accepted Article
elongated and can expertise in the management of paediatric unfavorable outcome) tooth of immature teeth
be excessively dental injuries. Extractions have the
 No interference with the  No improvement in the
mobile. potential to cause long-term dental anxiety
occlusion position of the extruded
 Parents should be informed to
 Occlusal tooth
watch for any unfavorable  No disturbance to the
interference may  Parent / Patient Education: outcomes and the need to return development and/or eruption  Negative impact on the
be present
to the clinic as soon as possible. of the permanent successor development and/or eruption
Where unfavorable outcomes are of the permanent successor
required
a child-oriented team, is outside
the scope of these guidelines
with an alcohol-free 0.1 – 0.2%
week

Accepted Article
Table 10 – Treatment guidelines for lateral luxation of primary teeth

Radiographic
LATERAL
LUXATION
and Findings
 A periapical (size 0  If there is minimal or no occlusal  Clinical examination after:  Asymptomatic  Symptomatic
sensor/film, paralleling interference, the tooth should be allowed to
- 1 week  Pulp healing with:  Signs of pulp necrosis and
technique) or occlusal spontaneously reposition itself
radiograph (size 2 - 6-8 weeks - Normal color of the
- Spontaneous repositioning usually
sensor/film) should be crown or transient - Sinus tract, gingival
occurs within 6 months - 6 months
taken at the time of red/gray or yellow swelling, abscess or
 In situations of severe displacement, two - 1 year discoloration and pulp increased mobility
initial presentation for
diagnostic purposes options are available, both of which require  If repositioned and splinted, canal obliteration
and to establish a local anesthesia: review after: - No signs of pulp discoloration plus one or
baseline  Option A: necrosis and infection more signs of root canal
- 1 week
 Increased periodontal infection
- Extraction when there is a risk of - 4 weeks for splint removal  Continued root
ligament space apically ingestion or aspiration of the tooth development in immature  Radiographic signs of pulp
(most clearly seen on - 8 weeks
teeth necrosis and infection
 Option B:
an occlusal radiograph, - 6 months
 Periodontal healing  Ankylosis
especially if tooth is - Gently reposition the tooth.
- 1 year
displaced labially)  Realignment of the  No further root development
- If unstable in its new position, splint for
Clinical findings:  Where there are concerns that an laterally luxated tooth of immature teeth
4 weeks using a flexible splint attached
unfavorable outcome is likely then
The tooth is displaced, to the adjacent uninjured teeth  Normal occlusion
continue clinical follow-up each
usually in a  Treatment should be performed by a child- year until eruption of the  No disturbance to the  No improvement in position of
palatal/lingual or labial
oriented team with experience and permanent teeth development and/or the laterally luxated tooth

Accepted Article
direction expertise in the management of paediatric  Radiographic follow up only eruption of the permanent  Negative impact on the
dental injuries. Extractions have the indicated where clinical findings successor development and/or eruption
 The tooth will be
potential to cause long-term dental anxiety. are suggestive of pathosis (e.g. of the permanent successor
immobile
an unfavorable outcome)
 Occlusal
interference may be  Parent / Patient Education:
present  Parents should be informed to

- Exercise care when eating not to further
watch for any unfavorable
traumatize the injured teeth while
outcomes and the need to return
encouraging a return to normal function
to the clinic as soon as possible.
as soon as possible.
- To encourage gingival healing and identified,treatment is often
prevent plaque accumulation, parents required.
soft brush or cotton swab combined with
frequently requires the expertise
an alcohol-free chlorhexidine gluconate
of a child-oriented team, is
0.1 – 0,2% mouthrinse applied topically
outside the scope of these
twice a day for one week
guidelines

Accepted Article
Table 11 – Treatment guidelines for intrusive luxation of primary teeth

Radiographic
INTRUSIVE LUXATION Recommendations Treatment Follow-Up Favorable Outcome Unfavorable Outcome
and Findings
 A periapical (size 0  The tooth should be allowed to  Clinical examination after:  Asymptomatic  Symptomatic
sensor/film, paralleling spontaneously reposition itself,
- 1 week  Pulp healing with:  Signs of pulp necrosis
technique) or occlusal irrespective of the direction of
and infection - such as:
radiograph (size 2 displacement. - 6-8 weeks - Normal color of the
sensor/film) should be taken crown or transient - Sinus tract, gingival

- Spontaneous improvement in - 6 months
at the time of initial red/gray or yellow swelling, abscess or
the position of the intruded - 1 year
presentation for diagnostic discoloration and pulp increased mobility
tooth usually occurs within 6
purposes and to establish a - Further follow-up at 6 years of canal obliteration
months. - Persistent dark gray
baseline age is indicated for severe - No signs of pulp discoloration with one
- In some cases it can take up intrusion to monitor eruption of
 When the apex is displaced necrosis and infection or more signs of
to 1 year the permanent tooth
toward or through the labial infection
 Continued root
bone plate, the apical tip  A rapid referral (within a couple of
development in immature  Radiographic signs of
can be seen and the image days) to a child-oriented team
 Radiographic follow up only teeth pulp necrosis and
of the tooth will appear that has experience and expertise
indicated where clinical findings are infection
in the management of paediatric  Periodontal healing
shorter (foreshortened) than
suggestive of pathosis (e.g. an  No further root
dental injuries should be arranged
the contralateral tooth  Re-eruption/re-alignment
unfavorable outcome)
development of
of the intruded tooth

Accepted Article
 When the apex is displaced  No disturbance to the immature teeth
towards the permanent development and/or
 Parent / Patient Education:  Parents should be informed to  Ankylosis
tooth germ, the apical tip eruption of the permanent
Clinical findings: watch for any unfavorable
cannot be visualized and the - Exercise care with eating not successor  Negative impact on the
outcomes and the need to return to
The tooth is usually image of the tooth will to further traumatize the development and/or
the clinic as soon as possible.
displaced through the labial appear elongated injured tooth while eruption of the
bone plate, or it can impinge encouraging a return to permanent successor
on the permanent tooth bud normal function as soon as
required
possible
 The tooth has almost or
completely disappeared - To encourage gingival healing
into the socket and can and prevent plaque
a child-oriented team, is outside the
be palpated labially accumulation, parents should
scope of these guidelines
clean the affected area with a
soft brush or cotton swab
combined with an alcohol-free
0.1 – 0.2% chlorhexidine
gluconate mouthrinse applied
topically twice a day for one
week

Accepted Article
Table 12 – Treatment guidelines for avulsion of primary teeth

Radiographic
AVULSION Recommendations Treatment Follow-Up Favorable Outcome Unfavorable Outcome
and Findings
 A periapical (size 0  Avulsed primary teeth should  Clinical examination after:  No signs of disturbance to  Negative impact on the
sensor/film, paralleling not be replanted development and/or development and/or
- 6-8 weeks
technique) or occlusal eruption of the permanent eruption of the
radiograph (size 2 - Further follow-up at 6 successor. permanent successor
sensor/film) is essential  Parent / Patient Education: years of age is indicated to
where the primary tooth is monitor eruption of the

- Exercise care when eating
not brought into the clinic permanent tooth
not to further traumatize the
to ensure that the missing injured soft tissues  Radiographic follow up only
tooth has not been indicated where clinical findings
- To encourage gingival
intruded are suggestive of pathosis (e.g.
Clinical findings: healing and prevent plaque
 The radiograph will also an unfavorable outcome)
accumulation, parents
The tooth is completely out of the provide a baseline for should clean the affected
socket assessment of the area with a soft brush or
 Parents should be informed to
 The location of the missing developing permanent cotton swab combined with
watch for any unfavorable
tooth should be explored during tooth andto determine if it an alcohol-free 0.1 – 0.2%
outcomes and the need to
the trauma history and has been displaced chlorhexidine gluconate
return to the clinic as soon as
examination, especially when mouthrinse applied topically
possible. Where unfavorable
the accident was not witnessed

Accepted Article
by an adult or there was a loss twice a day for one week outcomes are identified,
of consciousness. treatment is often required
 While avulsed teeth are most  The follow-up treatment, which

often lost out of the mouth, frequently requires the expertise
there is a risk of that they can of a child-oriented team, is
be embedded in soft tiss ues of outside the scope of these
the lip, cheek or tongue, pushed guidelines
into the nose, ingested or
aspirated.
 If the avulsed tooth is not found,

the child should be referred for
medical evaluation to an
emergency room for further
examination, especially where
there are respiratory symptoms

International Association of Dental Traumatology Guidelines For The Management of Traumatic Dental Injuries: 3. Injuries in The Primary Dentition

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International Association of Dental Traumatology guidelines for the management of

2Department of Pediatric Dentistry, Faculty of Dentistry, Universidad de Valparaíso, Valparaíso, Chile.

4UWA Dental School, University of Western Australia.

Center for Pediatric Oral Health Research, Stockholm, Sweden.

9Private Practice, Paris, France.

Copenhagen (Rigshospitalet), Copenhagen, Denmark.

12 Department of Pediatric Dentistry, Faculty of Dentistry, Hacettepe University, Ankara, Turkey.

14School of Dentistry, The University of Queensland, Australia.

16Specialist Private Practice, Bremen, Germany.

17Faculty of Medicine and Dentistry, University of Alberta, Canada.

Correspondence and reprint requests to:

Acknowledgement and Competing Interest

Ethical Statement – No ethic approval was required for this paper.

This article is protected by copyright. All rights reserved

Article type : Comprehensive Review