首次發(fā)布：2020年5月30日
關(guān)鍵詞：外傷，?撕脫傷，?齒折斷，預(yù)防，?脫位性損傷
Keywords：Trauma, avulsion, tooth fracture, prevention, luxation
簡略標(biāo)題：IADT?外傷治療指南：總論
Short title：IADT guidelines for management of traumatic dental injuries: General Introduction
DOI：https://doi.org/10.1111/edt.12574
譯者：張黎麗、丁謙?、張昕、龔怡
摘要 (Abstract)
?外傷(TDIs)多好發(fā)于?童和青少年，在?年?中的發(fā)病率明顯低于年輕群體。乳?外傷最 常見的類型是?脫位性損傷，?恒?外傷則多見于?冠折。 正確的診斷、及時的治療和隨訪觀察對?外傷的良好預(yù)后?關(guān)重要。國際?外傷協(xié)會(IADT)在全?回顧1996-2019年 EMBASE, MEDLINE, PUBMED, Scopus和Cochrane 數(shù)據(jù)庫的?腔學(xué)科?獻(xiàn)的基礎(chǔ)之上，結(jié)合2000?2019年《?外傷學(xué)》雜 志的?獻(xiàn)，制定了最新的?外傷治療指南。制定指南的?的是為?外傷的患者能夠得到即刻或緊急 的救治提供相關(guān)的信息，以便在后續(xù)治療中能夠得到經(jīng)驗豐富的?外傷專家和?腔全科醫(yī)?的進(jìn)?步治療。
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.
與以往制定?外傷指南的?法相同，此次參與制定?外傷指南的專家來?于?腔專業(yè)的不同 學(xué)科、以及社區(qū)的?腔全科醫(yī)?，他們具有科學(xué)研究的基礎(chǔ)和豐富的臨床經(jīng)驗。此次修訂的?外傷 指南是基于現(xiàn)有的?獻(xiàn)和專家意見，在某些已公布的?獻(xiàn)數(shù)據(jù)有爭議的情況下，牙外傷指南的提出 得到了專家們的?致認(rèn)可，并由IADT董事會成員審查和批準(zhǔn)通過。指南的應(yīng)?要根據(jù)病?的具體情況?定，臨床醫(yī)?應(yīng)對病情進(jìn)?仔細(xì)的判斷和評估，根據(jù)病?的依從性、經(jīng)濟(jì)狀況、在各種治療?案中進(jìn)?優(yōu)化選擇，醫(yī)?應(yīng)明確判斷病?的?外傷類型和損傷程度、以及遠(yuǎn)期的預(yù)后效果。 雖然 IADT不能保證醫(yī)?遵循?外傷治療指南就?定會使病?得到良好的預(yù)后效果， 但是IADT可以相信，醫(yī)?在臨床中應(yīng)?治療指南可以極?提??外傷患者良好預(yù)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
?外傷(TDIs) 多發(fā)?于?童和青少年，占所有外傷的5%。25%的學(xué)齡?童都曾有過?外傷的 經(jīng)歷，33%的成年?也曾有過恒?外傷的經(jīng)歷，其中?多數(shù)?外傷發(fā)?在19歲之前。研究顯?：乳?外傷最常見的類型是半脫位，?恒?外傷則多見于冠折。 我們認(rèn)為：醫(yī)?對?外傷的正確診斷和 選擇適宜的治療計劃、以及?后的隨訪觀察，對?外傷患者的良好預(yù)后是?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.
目前國際?外傷協(xié)會(IADT)在全?回顧1996-2019年 EMBASE、MEDLINE、PUBMED、 Scopes searches 數(shù)據(jù)庫的?腔學(xué)科?獻(xiàn)的基礎(chǔ)之上，結(jié)合2000?2019年《?外傷學(xué)》雜志的?獻(xiàn)，制 定了最新的?外傷治療指南。
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.
?外傷治療指南的?的是為?診醫(yī)?提供即刻或緊急救治?外傷患者的?法，以便在后續(xù)治 療中得到經(jīng)驗豐富的?外傷專家和?腔全科醫(yī)?的進(jìn)?步治療。
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年發(fā)布了第?版?外傷治療指南，并于2007年進(jìn)?了指南的更新，在2012年的《? 外傷學(xué)》雜志上又公布了指南的再?次修訂更新。根據(jù)以前制定指南的要求，此次參與指南制定的 專家團(tuán)隊包括了經(jīng)驗豐富的研究?員和從事?腔專業(yè)不同學(xué)科的專家、以及全科醫(yī)?。此次修訂的?外傷治療指南是基于現(xiàn)有的?獻(xiàn)和專家意見，在某些公布的數(shù)據(jù)沒有統(tǒng)?結(jié)論的情況下，?外傷 治療指南的提出得到了專家們的?致認(rèn)可，并由IADT董事會成員審查和批準(zhǔn)通過。
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.
指南的應(yīng)?要根據(jù)病?的具體情況?定，臨床醫(yī)?應(yīng)對病情仔細(xì)的判斷和評估，根據(jù)病?的依從性、經(jīng)濟(jì)狀況、以及各種治療?案的選擇，醫(yī)?應(yīng)明確判斷病?的?外傷類型和損傷程度、以及遠(yuǎn)期的預(yù)后效果。 雖然IADT不能保證醫(yī)?遵循治療指南操作就?定會使病?獲得良好的預(yù)后效果， 但是IADT可以相信，醫(yī)?在臨床中應(yīng)??外傷治療指南，可以??增加?外傷患者預(yù)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.
治療指南為醫(yī)?診斷和治療?外傷（TDIs）提供了建議。然?我們要知道，?度概括性的治療指南是?法像教科書以及?獻(xiàn)那樣提供全?的知識和詳細(xì)的信息。如果你要了解?外傷診斷和治 療的更多信息，可以在?外傷指南的官??站 http://www.dentaltraumaguide.org 中去發(fā)現(xiàn)?外傷指南(Dental Trauma Guide, DTG)。 不僅如此，在國際?外傷協(xié)會（IADT）的官??站 http://www.iadt-dentaltrauma.org 還可以發(fā)現(xiàn)《?外傷學(xué)》雜志的鏈接，它可以提供詳細(xì)的?外傷科學(xué)?獻(xiàn)和相關(guān)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 概論 GENERAL RECOMMENDATIONS
2.1 乳牙外傷的特殊注意事項
Special considerations for trauma to primary teeth
幼?由于恐懼?配合性差，醫(yī)?往往難以檢查和治療，這種狀況也困擾著孩?和他們的?母。所以，在幼??外傷就診時，我們要特別注意受傷乳?的根尖與繼承恒?胚之間的關(guān)系，因為乳?的嚴(yán)重外傷和／或?槽?損傷往往導(dǎo)致繼承恒?的畸形、阻?和延遲萌出。?童的發(fā)育程度和應(yīng)對緊急情況的能?，受傷患?脫落的時間和咬合關(guān)系都是影響治療效果的重要因素，?童?外傷還常 常合并多發(fā)性損傷，這也會影響?外傷的預(yù)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 年輕恒?與發(fā)育成熟的恒?
Immature vs mature permanent teeth
年輕恒?外傷，?選的治療?案是盡量保存其?髓，以確保年輕恒??根的繼續(xù)發(fā)育。 ?多數(shù)?外傷發(fā)?在?童和青少年時期，失去?齒會影響其終?。 當(dāng)年輕恒?發(fā)?折斷暴露?髓時、或發(fā)?脫位性損傷或根折時，?髓都具有較強的修復(fù)能?。
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 恒牙撕脫傷
Avulsion of permanent teeth
撕脫恒?的預(yù)后在很?程度上取決于在事故發(fā)?地對外傷?的即刻處理，我們應(yīng)??提?公眾 對撕脫?緊急救治的意識。對撕脫?治療?法的選擇和預(yù)后的效果，在很?程度上取決于撕脫?? 周膜(PDL)的損傷狀況和根尖孔的發(fā)育程度。 可以詳見IADT的?撕脫傷治療指南。
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/家長須知
Patient/parent instructions
?外傷的良好愈合依賴于患者的定期復(fù)診和良好的?腔衛(wèi)?護(hù)理，我們應(yīng)該指導(dǎo)患者和患?家 長如何更好地護(hù)理受傷的?齒，防?進(jìn)?步的傷害，以獲得最佳的愈合。精?的?腔護(hù)理并使?抗 菌劑含漱1-2周（如：0.12%?酒精的葡萄糖酸氯?定）。對于幼?可以使?棉簽將氯?定涂在外傷?受損的區(qū)域進(jìn)?護(hù)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 復(fù)診，夾板固定時間和主要預(yù)后結(jié)果的匯總表
Summary tables for follow up, splinting duration and core outcomes
針對乳?、恒?不同類型的外傷復(fù)診時間和夾板固定時間不同，特總結(jié)如下。見表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?外傷隨訪?式
Primary dentition follow‐up regimes
注 Note
在這些隨訪中，由Kenny等?收集的?般性外傷和特異性外傷的核?結(jié)果共識?！堆劳鈧麑W(xué)》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.
* = 臨床復(fù)診 clinical review appointment.
S = 拆除夾板 splint removal.
R = 即使沒有臨床癥狀或體征，也應(yīng)?x光檢查 radiograph advised even if no clinical signs or symptoms.
表 2. 恒牙外傷復(fù)診隨訪?式
Permanent dentition follow‐up regimes
注 Note
在這些隨訪中，由Kenny等?收集的?般性外傷和特異性外傷的核?結(jié)果共識?！?外傷學(xué)》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
* = 臨床復(fù)診 clinical review appointment.
S = 拆除夾板 splint removal.
R = 即使沒有臨床癥狀或體征，也應(yīng)?x光檢查 radiograph advised even if no clinical signs or symptoms.
# = 年輕恒??髓出現(xiàn)壞死和感染，要考慮以下附加的結(jié)果:?根長度、寬度和?冠折斷程度 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?列和乳?列的夾板固定時間
Splinting durations for the permanent and primary dentitions
2.6 核?結(jié)果共識
Core outcome set
哥本哈根的研究中?對全世界的外傷相關(guān)?獻(xiàn)進(jìn)?了回顧性研究。 Andreasen博?和他的團(tuán) 隊?論在?外傷的研究深度、還是研究的?度都取得了卓越的成就?？茖W(xué)研究關(guān)鍵的重要特征之? 就是可重復(fù)性，在?個中?的?組患者群體中發(fā)現(xiàn)的結(jié)果同樣適?于其它患者群體，其他中?的研 究結(jié)果也可以證實以往研究結(jié)果的正確性，?且這些研究結(jié)果的發(fā)表也是很有必要的。通過分析數(shù) 量不斷增加的研究成果，可以提?臨床醫(yī)?和研究?員分析?較、對?和綜合研究的能?。
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.
國際?外傷協(xié)會（IADT）最近開發(fā)了針對?童和成??外傷(TDI)的核?結(jié)果共識(COS) 1。這是?先在?科領(lǐng)域開發(fā)的第?批COS之?，它采?了?種可靠的共識?法論，并對?外傷?獻(xiàn)中使? 的結(jié)果進(jìn)?系統(tǒng)性回顧 2。?部分研究結(jié)果被證明可重復(fù)?于不同類型的?外傷中，并貫穿始終， 這部分研究結(jié)果歸?“通?結(jié)果”——它與所有的?外傷（TDI）類型相關(guān)。另?部分研究結(jié)果被證明 僅僅與?種或多種特定的?外傷（TDI）類型相關(guān) 3——稱為“特異性結(jié)果”。此外，這些研究結(jié)果的 具體內(nèi)容和因果關(guān)系，研究的時間點以及研究的相關(guān)?員都是衡量的因素。
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顯示了不同的?外傷類型，隨訪復(fù)查的時間、內(nèi)容。可以在?外傷雜志官??站的原 始?件1和補充材料中查找到每個結(jié)果的詳盡信息。
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
利益沖突 CONFLICT OF INTEREST
作者確認(rèn)他們沒有利益沖突。
The authors confirm that they have no conflict of interest.
倫理審查 ETHICAL APPROVAL
本文不需要道德上的批準(zhǔn)。
No ethic approval was required for this paper.
參考?獻(xiàn) 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.
