MODIFIED EDEN BAYSAL DENTAL TRAUMA INDEX (MEBDTI) Traumatic dental injuries (TDI) are common in both the primary and permanent dentitions. Using a standardized index to record the entire dental and ST injuries would result in the possibility of more robust data from various centers.

1. MODIFIED EDEN BAYSAL DENTAL
TRAUMA INDEX (MEBDTI)
DR PREM SHANKAR CHAUHAN

2. INTRODUCTION
• Traumatic dental injuries (TDI) are common in both the primary and permanent dentitions.
• In addition to damaging the teeth and supporting structures, injuries to extra-oral and intra-
oral soft tissues can occur.
• Dentists often focus on dental injuries, and trauma to the extra-oral and intra-oral soft
tissues may not be documented in detail.

3. • Frequently the only records of the soft tissue injury (STI) at the time of dental trauma are
photographs.
• The current IADT Guidelines emphasize the need for the excellent recording of all injuries
and they highlight the value of clinical photography for documentation.
• However, the recording and management of STI associated with TDI are beyond the scope
of the IADT guidelines at present.

4. • Soft tissue injuries are described as abrasion, laceration, contusion, or avulsion, both extra-orally
and intra-orally(Table 1).
• Despite these standardized categories, much of the literature on facial and dental trauma is
deficient in reporting STI, especially when the damage is not related to specific dental injuries.

5. • In addition, details such as the type, site, and extent of any injury are rarely documented.
• There is also variation in how the STI is reported in the literature.
• Much of the existing data on soft tissue injuries are based on retrospective reviews of
orofacial injuries presenting to an emergency center or by referral to a trauma center.

6. STUDY
DONE BY
PURPOSE OF STUDY FINDINGS OF STUDY
Soares et
al
Examined prevalence of STI in
Children
Prevalence rate-56.23%, but did not mention reason
for excluded studies- whether STI was absent or not
adequately reported
Rego et al Examined prevalence of STI in
children and adolescents
Facial STI was very prevalent and noted that only 5.6%
of children attending had an associated (unspecified)
dental trauma.
Sae- Lim et
al
Prevalence of STI in all age groups 45.3% of individuals presenting with a TDI had a
concomitant soft tissue injury
Ozgur et al
(2021)
Prevalence of STI in younger
children
High prevalence of STI-62.3%
Skaricic et
al (2016)
Prevalence of STI in younger
children
High prevalence of STI- 45.4%
Eyuboglu
et al
Prevalence of STI in broader age
group
21% of children (mean age 9.1 + 3.6 yrs) with dental
trauma also had STI and further that 50% of
traumatized primary teeth and 32% of permanent
teeth were related to a STI.

7. • Incomplete information within the literature highlights the need for the standardized
recording of oral hard and soft tissue injuries in both medical and dental urgent care
settings.
• Interestingly, individuals with an associated STI were more likely to attend emergency services
sooner than those who did not have an STI.
• Clinically, standardized registration of dental injuries is essential to overcome dental record
deficiencies and ideally should also include associated soft tissue injuries.
• There is a need for a rapid and straightforward method to record the entire injury in a format
compatible with electronic records.

8. • Clinicians dealing with traumatic dental injuries seek to be accurate in their diagnosis and
management of these injuries.
• Reliable and consistent data on TDI will facilitate the development of comparable
databases internationally.
• The merging of databases can allow a larger research base to enhance evidence in
traumatology in the future.

9. • The recently introduced Eden Baysal Dental Trauma Index (EBDTI) records tooth-specific
dental injuries in detail.
• The encoded descriptions of the index allow concise storage of clinical information regarding
the entire dental injury, such as the type and extent of the injury and maturity of the root.
• This index only records specific tooth injuries without registering STI.

10. • This shortcoming was acknowledged in the previous paper pointing out that ST damage
reported is not necessarily related to an injured tooth/teeth; therefore, STI may only be recorded
on a whole patient basis.
• In addition to one or multiple traumatized teeth, any intra-oral soft tissues, lips, or skin injury
together or separately, should be recorded at the emergency visit.

11. • This paper extends the information recorded by EBDTI to include soft tissues, enabling the
diagnosis of the entire injury to be recorded in a code format using a modification of the index.
• Using a standardized index to record the entire dental and ST injuries would result in the
possibility of more robust data from various centers.
• It would improve the information available worldwide to advance dental traumatology science.
• The aim of the study was to extend the EBDTI index to record soft tissue injuries in dental
trauma patients in a concise format and to approve the face and content validity of this
version as the modified EBDTI (MEBDTI).

12. MATERIALS AND METHODS
• The recently developed EBDTI was assessed independently by a panel of 15 experienced dental
trauma experts worldwide.
• The face and content validation of the index was completed after two online rounds using the
RAND e-Delphi method and published, where the information on the expert panel and consensus
method was described in detail.
• The EBDTI contains all the essential clinical parameters following Andreasen's classification and
also associated injuries for each traumatized tooth (Figure 1).

14. • During the first round of the validation process of EBDTI, some expert panel members
suggested the inclusion of soft tissue injuries.
• The majority of members felt strongly (53.3%), with 33.3% neutral, and only 13.4% did not
support the idea.
• Therefore, an extension of the index was developed and called the Modified Eden Baysal
Dental Trauma Index (MEBDTI).
• The RAND e-Delphi method was used to evaluate this modified version of the index with the
same group of experts.

15. A definition and two statements were sent to the expert panel. (Table 2)

16. • The panel members rated the statements on a 9-point Likert scale where 1 represented
”total disagreement”, and 9 indicated “total agreement”.
• The nine codes were then clustered as 1–3, 4–6, and 7–9, indicating “disagreement”, “in
doubt”, and “agreement”, respectively.
• A remark space was provided below each set of scores, offering each expert an opportunity
to explain their assessments.
• A statement was considered valid after reaching a 75% consensus among panel members

17. • A numerical code was suggested using zero to depict no soft tissue injury, 1–4 to record
extraoral injuries (e.g., skin and lip), and 5–8 to record intraoral injuries (e.g., gingiva,
frenulum, and palate) as illustrated in Figures 2 and 3.
• The MEBTDI records the soft tissue injuries on a patient basis in conjunction with the
information about the injured tooth or teeth and the alveolar process (Figure 2).
• Thus, it can be used for individuals of any age.

19. Clinical cases illustrating the proposed possible soft tissue injuries
Soft tissue codes are used as superscripts in the Modified Eden Baysal Dental Trauma Index - MEBDTI (*)

20. • The index generates a unique patient-specific digital code suitable for computer registration
with information about the dental and associated soft tissue injury or injuries.
• Training of personnel in the use of the index will be required.
• The application of the Modified Eden Baysal Dental Trauma index is demonstrated in several
clinical cases (Figures 4 to 8), highlighting the code generated for each injury.
• In addition, an online code generator is available for easy recording (https://disac
il.ege.edu.tr/tr-12572/ modif ied_eden_baysal_dental_ trauma_index_gener ator.html).

21. RESULTS
• The international expert panel, who rated the original index, also rated the modified version.
• Only one round was necessary to reach a consensus on two statements and the definition within
the panel. The response rate was 100%.
• Minimal wording corrections were suggested, and 86.7% agreement was obtained on the definition
of the modified index.
• The panel reached a consensus on the statements with 86.7% and 93.3% agreement, respectively.

22. DISCUSSION
• The location and extent of soft tissue injuries have rarely been reported within the dental
trauma literature, with most data obtained from a retrospective review of records.
• The reported prevalence of STI associated with trauma to the primary dentition ranges from
50–62.5%.
• The ranges reported in permanent teeth in children and adolescents were 32 −41% and 14.7%
in young adults.

23. • The use of retrospective studies and the lack of standardization in medical/dental records make
the estimation of the prevalence difficult.
• In some reports, swelling, a sign of injury, was used as a diagnostic category, complicating
comparison to other papers.
• It would be ideal if there were an agreement to use the four categories of soft tissue injuries
suggested in Andreasen's Classification (Table 1).
• There is an identified need for a standardized method for collecting and recording STIs
associated with traumatic dental injuries.

24. • For the first time, a new tool for recording soft tissue injuries associated with traumatic dental
injuries was proposed and validated for face and content by international experts in dental
traumatology using an online consensus methodology.
• The RAND e-Delphi consensus method has been recognized as a useful instrument to build
consensus among experts on various health topics with interactive rounds.
• In the present study, each member rated the statements anonymously and commented freely
without the influence of others.
• This proven research technique obtains subjective judgments of an expert group, and the
process was completed in a single round for the present proposal.

25. • This new tool records both hard and soft tissue injuries related to dental trauma in a single code using
an extension for the previously introduced index (EBDTI) that is in a format suitable for electronic
records.
• The ability to generate a multicenter database using the original index EBDTI was reported recently,
where four cities in Turkey collaborated to use web-based forms and the EBDTI in a prospective
study of traumatic dental injuries in children.
• Within six months, the database had detailed information on 252 patients with 280 traumatized teeth,
including 19 avulsed teeth and additional data on root maturity and/or accompanying injuries that help
in treatment planning.
• Thus, the generation of new standardized databases both nationally and internationally is now
possible.

26. • Using this extension of the EBTDI tool that records the entire injury should empower researchers
to further explore critical issues in healing after injuries to the face, mouth, and teeth.
• The Dental Trauma Guide, is an Internet-based knowledge platform consisting of 4,000 dental
trauma cases with long-term follow-up to guide the public and the professions on the best
treatment approach online. It has suggested the use of the recently introduced EBDTI to register
dental trauma cases on the site to facilitate comparison of data and outcomes worldwide.
• The use of MEBDTI will simplify recording of the entire injury on a whole patient basis.
• Furthermore, the validated extension of the index allows a simple, efficient, and clinical-friendly
method to record a total injury diagnosis, including the extra-oral and intra-oral soft tissues in
individuals of all ages in an emergency setting.

27. Case 1 : A four- year- old boy fell over a stone fence while playing. The injuries sustained were avulsion of
52, intrusion of 51 and 61, and subluxation of 62. He sustained extra- oral abrasions and lip contusion with
gingival and lip abrasions intra- orally.
[(51) 00Im- , (52) 00Am- , (61) 00Im- , (62) 00Sm- ]1,3,5

28. Case 2: This 5.5- year- old boy fell from a zipline onto a concrete container. He had a skin laceration on the
chin plus a laceration and contusion of the lower lip. Intra- orally, there was a gingival laceration, intrusion
of 52, 51, 61, and palatal luxation of 62. A soft tissue radiograph of the lower lip was taken to determine if
any tooth fragment/foreign body was embedded in the lip
[(51)00Im- , (52)00Im- , (61) 00Im- , (62) 00Lm- ].2,3,6,7

29. Case 3: An 11- year- old boy lost balance while tying his shoelaces and fell unprotected against the floor.
There was upper lip contusion with avulsion of 11 and uncomplicated crown fractures of 11 and 21
[(11) 20Am- , (21) 20Nm- ]3

30. Case 4: This 9- year- old boy fell from his bicycle and presented with extensive facial abrasions and upper
lip contusion. The dental injuries were concussion of 12, apical root fracture of 11, and uncomplicated
crown fracture of 21
[(11)01Nm- , (12)00Cm- , (21)20Nm- ]1

31. Case 5: This 16- year- old boy fell from his bicycle and presented with chin lacerations and upper and
lower lip abrasions. The dental injuries were uncomplicated crown fracture of 11, extrusion and
uncomplicated crown fracture of 21 and lateral luxation and uncomplicated crown fracture of 22
[(11)20Nm - , (21)20Em - , (22)20Lm - ]1,2

32. Advantages of using MEBDTI
1. The code generated is compatible with all computer systems and can be produced quickly with
the help of the online code generator and entered into any electronic medical record.
2. It can be captured within the emergency clinical setting and verified across multiple sites in an
epidemiological exercise.
3. Such data could provide essential information on the interrelationship between dental and soft
tissue injuries.
4. A systematic approach to data collection on the emergency visit improves useful data quality,
both for the clinician and in standardizing data collection for future prospective studies.
5. Adopting this extended version of EBTDI would encourage consistent data collection using
examination, radiographs, and photographs.

33. 6. Prospective studies using the MEBDTI will allow the true prevalence of STI associated with
TDI to be reported.
7. This could facilitate the creation of an expanded information platform and the potential
development of guidelines for STI management associated with dental injuries.
8. The widespread use of MEBDTI could allow for national databases to be developed as well as
integration of multiple databases internationally to generate robust evidence and allow
significant research questions in traumatology to be answered.

34. • The use of intra-oral photography to document the original injury and at review appointments is
highly recommended.
• It has become the standard of care in many institutions with patient consent.
• The 2020 IADT guidelines emphasize the importance of clinical photography and establishing
an accurate record of the injury.
• The photography of additional soft tissue involvement must now be encouraged and should
record all intra-oral and peri-oral injuries.

35. • The extra-oral image must include the area between the orbit and the chin (lower ⅔ facial height)
as a minimum.
• Photographs capture the extent and exact location of injuries, and subsequent duration and
success of healing, providing a permanent record of soft tissue damage and healing.
• These additional records will allow further investigation into any association between dental and
soft tissue injuries and the possible impact on the outcome of healing.

36. • The association between STI and dental injuries on the overall tooth survival following dental
trauma has not been reported.
• The use of the MEBDTI to record baseline whole patient injury and standardized records can
address this unknown association.
• The 2020 IADT guidelines emphasize the importance of hygiene in the immediate aftermath
of an oral injury to encourage a favorable healing response.
• Appropriate STI management at the emergency visit often requires cleaning the wound,
which usually heals quickly due to the rich vasculature in the oral area.

37. • It is anticipated that soft tissue injuries heal favorably with a return to normal appearance or
unfavorably with scar formation, recession, or loss of attachment.
• Contamination of a soft tissue wound has been identified as an unfavorable healing response.
• Approximation of the wound edges extra-orally or intra-orally increases the healing speed by
regaining ST integrity, maximizing healing with primary intention.

38. • It is accepted that delayed or inappropriate STI management may have a lasting esthetic effect
on the individual.
• There is a need for accurate baseline data and meticulous records following dental trauma due
to the variety of injuries and their complexity.
• It is recognized that the MEBDTI index does not identify the extent or severity of the STI and
cannot be used to propose any type of soft tissue management.
• However, the use of photographs and continued accurate clinical records may help to predict
the impact of STI on overall tooth survival following dental trauma.

39. • The MEBTDI is a powerful diagnostic tool that can be used clinically and for research data
collection to answer critical questions within dental trauma.
• For example, with accurate baseline documentation of soft tissue injuries, it will be possible to
gather data that may be included in future IADT dental trauma guidelines.
• In addition, a collaboration between various trauma clinics using MEBDTI for baseline records
will generate large databases that can be explored to improve data quality and answer crucial
questions.

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42. International Association of Dental Traumatology has recently
included Eden Baysal Dental Trauma Index for recording dental
injuries in ‘Dental Trauma Guide’ which is an evidence based
treatment guide .

43. Who should use the index?
• The index can be used in routine clinical patient recordings as well as epidemiological
studies.
• The information obtained may be used in treatment planning by dental professionals and for
future health care planning by stakeholders and governments for the community

44. Important Considerations
• The index can be included on computer or as a form that can be filled manually.
• Training of the personal is necessary before collecting data on recording trauma cases in
dental clinics.
• A training program is necessary for the study team and inter and intra- examiner reliability
should be calculated.

45. • If one is uncertain about the codes to select, the severe code that will affect the treatment
plan should be chosen.
For example, if you are unsure about the location of the root fracture, since the fracture line
close to the gingival margin has a lower success rate and the patient will need an intense
treatment protocol with longer splinting time, it is advised to choose the severe code.
• If there is more than one code at the same digit, always record the most severe code that
will affect the treatment.
For example, if there is enamel fracture (code 1) on the mesial incisal edge of a permanent
first incisor and complicated crown-root fracture (code 5) on the distal part of the tooth, one
must record 5 as the first digit.

46. • Third digit that records the luxation injuries only include bodily movement of the tooth
in the socket, not the movement of the tooth fragment.
For example, extrusion of the broken tooth fragment is probable finding of the dislocation
and is not coded as the 3rd digit but if preferred the index has the potential to record that
data as well.
• But a study may plan to include luxation injuries related to root fragments and this should be
clearly stated in the study protocol.