Introduction.

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Traumatic dental injuries to the permanent dentition are estimated to have a global prevalence of 15.2%.1 This equates to potentially over one billion people living today having experienced dental trauma.

The immediate management of dental trauma impacts the prognosis of the affected structures, and therefore the outcome. This is of particular note when the periodontal ligament and pulp sustain severe injuries, more likely to have long-term sequelae and complicating management.

Given the unplanned nature associated with immediate trauma management, it is crucial that clinicians are well versed in appropriate management strategies and/or can quickly access current best practice guidance.

This article aims to provide key tips for the successful management of trauma affecting permanent teeth.

  1. 1.

    Be informed

There are several relevant resources for trauma management, and up-to-date best practice guidance is free to access in the public domain. Online resources are frequently updated, and it is recommended clinicians likely to manage dental trauma consider incorporating regular guidance review into personal development plans.

The Dental Trauma Guide website2 contains links to the 2020 International Association of Dental Traumatology (IADT) guidelines3 and detailed management steps for all types of dental trauma.4,5,6 ToothSOS7 is a mobile application and Dental Trauma UK8 another site providing guidance for both clinicians and patients.

The immediate management of dental trauma impacts the prognosis of the affected structures, and therefore the outcome.

As the pulp is often affected in dental trauma, it is recommended that clinicians be familiar with both the American Association of Endodontists' consensus statement from 2008 (regarding diagnostic terms used in endodontics)9 and the 2021 European Society of Endodontology position statement on the endodontic management of traumatised teeth.10

Traumatic injuries can result in teeth remaining in aberrant positions. For example, an intruded tooth may fail to spontaneously re-erupt, or a displaced tooth may cause an occlusal interference. Orthodontic colleagues may be called upon to reposition and realign traumatised teeth in which case the 2020 'Guidelines for the orthodontic management of the traumatised tooth'11 are of value.

Not only is information available, but online videos, such as those provided by Dundee School YouTube page,12 guide clinicians on practical skills (eg placing a dental splint).

For gathering the key information needed during emergency trauma management, developing and using a pro forma has been shown to aid in data capture when used for referrals.13 The use of pro formas can enhance the reliability and standardisation of dental trauma patient assessment. In designing a pro forma, it is important General Dental Council14 and medicolegal requirements are met.

  1. 2.

    Screen for medical injuries and safeguarding concerns

If medical injuries are suspected, an urgent referral to Accident & Emergency (A&E) or oral and maxillofacial surgeons (OMFS) is recommended. It is advisable to have awareness of the local A&E department location, contact details and urgent referral pathways.

Injuries which are not life-threatening/severe can potentially wait until initial dental trauma has been stabilised as this is likely to enhance the treatment outcome. Stabilisation is often best done by the patient's registered dentist in accordance with IADT guidelines, prior to referring for a second opinion and/or management in a specialist dental centre (to a paediatric, restorative or endodontic specialist), if this is needed. Severe dental trauma may require referral; less serious injuries rarely do.

In screening for urgent medical injuries, the 'ABCDE approach' as per Resuscitation guidelines15 can be used. Key injuries to screen for and rationalisation are summarised in Table 1.

Table 1 Relevant non-dental injuries
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Unfortunately, some dental trauma injuries are associated with non-accidental injury (NAI) and/or intimate partner violence (IPV), defined as 'any behaviour within an intimate relationship that causes physical, psychological, or sexual harm to those in the relationship'.18 A recent review of IPV found twice as many women were identified as victims when healthcare professionals enquired regarding abuse.19 Figures from England and Wales estimate 2 million adults aged between 16-59 experienced domestic abuse in the year ending March 2018.20

Be aware of injuries which appear suspicious - for example, perhaps the injury history and the injury itself do not sensibly align; the person or their accompanying persons behave outwith the norm (eg a particularly overbearing partner). It can be helpful to see the patient unaccompanied which is sometimes difficult to achieve; however, when taking radiographs, accompanying persons must leave the room and this opportunity may be used to ask safeguarding questions.

The National Institute for Health and Care Excellence recommend frontline staff know the signs to look for and are prepared to have a brief intervention with patients if there are fears abuse may have occurred. A helpful tool to use is 'Ask Validate Document Refer'21 as summarised below:

  • Ask: If concerning signs are noted or suspicion raised, ask the patient. This opens up the floor, inviting the patient to talk

  • Validate: If patients reveal abuse, acknowledge the wrong that has been done to them, let them know it is not their fault

  • Document: Records must be complete and contemporaneous, and may be used later in court. If consented to, photographs can be useful

  • Refer: Referral to local social services, appropriate shelters, or police, if necessary, may be required.

Abuse and IPV is a very serious concern. This article cannot cover it in its entirety; seeking relevant safeguarding CPD for the benefit and welfare of all patients, and colleagues, is recommended.

If there are immediate concerns regarding the patient's safety, police may need to be involved. If there is reason to believe a person is in immediate danger, or that person is a danger to the public, it is recommended the police be called, dialling 999, if necessary. The General Dental Council Standard 4.3.1 acknowledges this.14

  1. 3.

    Be prepared clinically: consider a 'trauma tool kit'

For clinicians likely to manage immediate trauma cases, it can be helpful to have a 'trauma tool kit', enabling appropriate equipment to be quickly available chairside. Such tool kits can be developed with reference to guidelines.

As dental trauma cases can involve prosecution, taking photographic records is advised and many patients can supply pre-injury and injury photographs from their mobile phones, if the dental clinic does not have photographic facilities.

  1. 4.

    Aim to stabilise, preserve and protect tissues

Stabilising injured tissues involves prioritising the health and healing of the pulp and periodontal supporting apparatus. Favourable outcomes are when repair (ie scar tissue) or regeneration of tissues occurs, ideally the latter.

If the pulp is exposed, encourage healing by placing a material likely to stimulate this. Today, calcium silicate cements (CSCs) are recommended and available in pre-mixed formulations such as Biodentine. Use of biocompatible and bioactive CSCs and prevention of microbial contamination increase the likelihood of successful pulpal recovery. Use of a dental dam (if the pulp is exposed) is important to reduce the risk of microbial ingress and facilitate the use of sodium hypochlorite irrigation. Following placement of a CSC, an adhesive restoration should be placed. In some cases of pulpal exposure, partial pulpotomies are indicated (detailed in IADT guidelines) and are associated with high success rates.

Teeth which have been moved in position need the periodontal supporting apparatus stabilised. This will involve repositioning and retaining the tooth or teeth in their pre-injury position with a splint. Stabilisation in a harmonious static and functional occlusal relationship is key.

Root fractures must be stabilised in this way also, via splinting, to encourage the fracture site to heal. Splints should be placed so as not to interfere with periodontal tissue healing, the occlusion or oral hygiene practices.

In considering protection, it is of note that the use of custom-made mouth guards for contact sports appear to significantly decrease the risk of orofacial trauma, as does early orthodontic correction of overjets of >6 mm in 6-13-year-old children.22 Each of these prevention strategies are recommended for routine use, where appropriate.

  1. 5.

    Splinting and maintaining aesthetics

Splinting aims to stabilise the tooth in the pre-injury position and be easy to place and remove.23 In some cases, ascertaining the pre-injury tooth position is challenging; radiographs and recent 'selfies' may be of help. Mixed dentition cases can be more complex to splint and if needed, advice sought from specialist centres; however, teeth sufficiently loose to be an aspiration risk must be managed as a matter of urgency.

Once in place, a splint must reliably stay in situ, avoiding undue stress on the tooth or periodontal ligament and allow for functional tooth movement. To achieve this, evidence supports the use of flexible composite and wire splints (wire diameter less than 0.4 mm).24,25

Where teeth have been avulsed and lost, it is important to maintain aesthetics and the edentulous area (preventing drifting and tilting of neighbouring teeth), until definitive restoration. A 'Flipper' (partial denture replacing one or more teeth and clasping molars) or Essix retainer with pontic can be quickly made and effectively maintains the space and aesthetics.

  1. 6.

    Recognise more serious dental trauma injuries

Those injuries most damaging to the pulp and periodontal tissues are luxations, particularly lateral and intrusion, and avulsions. These injuries are most likely to develop challenging long-term sequelae which must be monitored for (discussed later).

Those teeth which have been avulsed or intruded and have complications, and teeth with cervical or crown root fractures, are those most likely to be lost.

  1. 7.

    Follow-up and further planning

Having dealt with immediate trauma stabilisation, longer-term planning must take a more holistic approach, including discussing patient expectations. The IADT guidelines provide follow-up schedule advice and possible complications arising from the trauma itself.

In the longer term, the general oral condition must be considered and in particular aesthetics, function and prognosis of traumatised teeth. If teeth have a guarded or poor outlook, whether from trauma, caries or periodontal disease, factors in relation to tooth replacement must be assessed. This will include consideration of patient age, caries and periodontal status and risk, smile line, gingival phenotype, occlusal factors, the chances of further trauma, and the position and number of teeth likely to be lost. Specialist input may be of help if loss of several teeth is anticipated.

  1. 8.

    Shared decision-making and consent

To maximise the trauma outcome, accurate diagnoses, effective management and prediction of prognosis is needed. These must be discussed with the patient in an understandable manner. Any treatment must be with the informed consent of the patient, or where necessary, the patient's advocate. Medicolegally, advice on the diagnosis, reasonable treatment options and associated risks/benefits must be discussed and documented, along with referral arrangements, if relevant.

The Scottish initiative Realistic Medicine26 is a useful resource regarding shared decision-making. This aims to help clinicians and patients communicate effectively about options. Patients may find the simple questions about treatment options particularly useful.

Following healthcare consultations, patients' retention of information is known to be low;27,28 this, coupled with a stressful trauma event, means that patients may not be receptive to information. It is therefore sensible to reiterate prognosis and long-term sequelae advice at follow-up appointments and consider sending summary letters or producing relevant patient information leaflets.

  1. 9.

    Sequelae

Ongoing clinical and radiographic monitoring is advisable because complications can arise more than ten years after injury. Teeth with closed apices are more likely to have complications (Tables 2 and 3).

Table 2 Sequelae of traumatic dental injuries
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Table 3 Radiographically identified complications
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  1. 10.

    Summary

Many clinicians work in dental settings where patients sustaining trauma can present; however, this may be infrequent, heightening stress when dealing with trauma.

To support trauma management, consider displaying trauma management pathways in the clinic. For example, a flowchart with web links to best practice guidance; warning signs indicative of more serious medical injuries; contact numbers for local A&E, OMFS and other dental specialist services.

The use of a pro forma can encourage robust and thorough trauma assessment, as well as be an educational tool. Having a 'trauma tool kit' either physically set up or as a laminated aide-mémoire list can facilitate speedy management when unscheduled emergency trauma patients attend. To support good quality patient communication, summary letters or information leaflets highlighting the timescales for follow-up, possible sequelae and prognosis are helpful.

Trauma cases can highlight interesting clinical conundrums in their immediate and longer-term management. Peer discussion activities and sharing learning from cases is valuable, along with CPD activities. Many specialist societies have annual conferences of relevance to trauma management, which together with the points raised in this article aim to equip clinicians with the knowledge and skills of ways in which to provide high-quality care when trauma is sustained to permanent teeth.