Evidence based dental trauma treatment
The Dental Trauma Guide
A source of evidence based treatment guidelines for dental trauma
Dental traumatology, the evidence problem
Dental trauma cases often result in a treatment sequence that involves both general dentists and many specialists. Optimal treatment relies upon the expertise of a broad spectrum of dental specialists such as oral and maxillofacial surgeons, pediatric dentists, endodontists, orthodontists, prosthodontists and periodontists. The primary urgent care is frequently provided by the oral and maxillofacial surgeon or the pediatric dentist in a hospital emergency department setting. Subsequently the patient may be referred to a general dentist or an endodontist for secondary level care such as endodontic and restorative management. Alternatively, a general dentist is seeing the patient first and refers the patient to the specialists. Later the orthodontist and prosthodontists and periodontist may become involved with additional treatment. The long chain of referrals that are frequently seen in dental trauma cases means that control of the overall quality of treatment is often lost. The research activity in clinical traumatology has been extremely low and, in some sense, dental traumatology has become an orphan in dentistry. Dental traumatology relies on knowledge from research in many different specialties. For this reason, inter-disciplinary communication over the specialty borders is very important.
At the end of the last century there was a growing interest among all dental disciplines in analyzing the validity of existing treatment principles which lead to the recognition that evidence-based dentistry (EBD) with the randomized clinical trial (RCT) as the gold standard was the path for the future. In the famous pyramid “Mount evidence” most studies in dental traumatology belong at very low levels in the evidence pyramid. Only a couple of clinical RCTs have yet been published, and the prospect for future RCTs appears slim.
What is the cause of this problem?
First of all, the shared responsibility among several dental specialties makes research in dental traumatology complicated to organize and evaluate. Secondly, the ethical problems associated with getting informed consent from an injured child or adult to participate in an RCT are unavoidable. Reasonable arguments for carrying out the experiments despite these problems are rarely present. This obstacle is almost prohibitive for most RCTs dealing with treatment of acute traumatic dental injuries.
What are the alternatives?
Often animal models are the best alternative. They allow the researchers to control the parameters that may influence the outcome of the experiment in a fashion not attainable in human studies as the injuries can be inflicted by the examiner under controlled conditions. The current treatment guidelines give testimony to the value of animal experiments as they rely heavily on information obtained from animal studies.
Are animal experiments reliable?
This question has been examined carefully and monkey experiments seem to have a high degree of reliability, whereas the use of dogs often seem to give too optimistic results in relation to pulp healing. Rat studies appear to show a significant variance in periodontal ligament (PDL) healing with a likelihood of transient ankylosis, which makes this model unreliable in dental trauma studies affecting the PDL. For this reason, the principal findings from experimental studies should ideally be verified in clinical studies.
Are human clinical non-randomised studies a valid approach to assess the effect of dental trauma treatments?
If the correct statistical models are used, and groups with similar preinjury and injury characteristics can be isolated and compared, then it is possible to reduce the amount of interference caused by confounding factors. The results must however be evaluated with a certain amount of reservation as the risk of interference by confounding factors can never be eliminated with certainty. This type of analysis has so far offered useful information about the effect of various treatment procedures such as repositioning, type and length of splinting times and the use of antibiotics, RCT is not always possible to arrange in traumatology, especially not in the emergency situation, However in later treatment situations when different drugs or treatments can be applied randomization may be possible.
How big is the knowledge gap before we can have the necessary scientific foundation for offering evidence based treatment for all dental trauma types?
To answer that question one must start by focusing on the strongest predictor for successful/unsuccessful trauma healing, namely the trauma type. Dental trauma can be divided into 9 fracture and 6 luxation entities. Combination injuries in which both luxation and fracture have occurred are unfortunately frequent, causing 54 combinations which must be seen as 54 distinct healing scenarios. The complexity is further increased by the fact that trauma to the primary and the permanent teeth must be treated as separate entities. This results in 108 distinct trauma events! One single word may characterize treatment of traumatic dental injuries around the world: CHAOS.
Several predictors for pulp and periodontal healing have been identified for the individual trauma entities, some reflect the severity and nature of the trauma inflicted, some describe patient characteristics, and some reflect the influence of the choice of treatment. The strongest predictor appears to be the trauma type. The stage of root development appears to be a strong outcomes predictor for all types of dental trauma, and it affects both pulpal and periodontal healing. This is not surprising since a good blood supply is essential for pulpal healing and thus the size of the apical foramen is directly related to the revascularization potential of the affected tooth.
The choice of treatment offered has a direct effect on the healing outcome for luxation injuries where several treatment options frequently are available such as ± repositioning, ± splinting and ± antibiotics . For treatment of crown fractures with exposed dentin and/or the pulp the amount of research needed before reliable answers to all treatment possibilities have been covered seems formidable. For crown-root fractures there are several treatment options and extensive research is needed before reliable answers can be established as to which treatment option offers the best possible treatment.
The multitude of possible trauma scenarios and the broad variety of treatment options make it very difficult for lay people and practitioners to provide evidence-based treatment and recommend the best possible treatment choice for the patient. Keeping this in mind, it is not surprising that much dental trauma treatment worldwide is far from ideal. Surveys in many countries worldwide such as England, Australia, New Zealand, Tanzania, Brazil, Switzerland, Sweden, Turkey, Kuwait, Malaysia, Turkey India, Japan, China, Nigeria and Chile have shown that knowledge of adequate treatment of traumatized teeth is deficient, implying that up to half of all treatments offered are either not necessary or directly harmful to the patient.
The Dental Trauma Guide is an attempt to elevate this unfortunate situation by making the current knowledge in dental traumatology easily available on the internet. For 40 years, patient records have been collected at the University Hospital in Copenhagen, creating the information contained in the extensive database used in developing the Dental Trauma Guide for treatment selection and prognosis estimation. Since 1965 standardized documentation of long-term effects of trauma treatments have been collected and this material (4000 cases) together with the results of 80 clinical studies and 65 experimental animal studies using monkeys now forms the scientific basis for the Dental Trauma Guide.
An effort has been made to make the information available in a structured and user friendly fashion allowing the practitioner to develop a correct diagnosis, a treatment plan, and a follow-up plan along with identifying a risk estimate for healing complications.
Arriving at the correct diagnosis
As previously mentioned, a traumatized tooth may suffer one of 108 distinct trauma conditions. The correct choice of treatment is obviously dependent on the ability of the practitioner to make the correct diagnosis. In this respect the Dental Trauma Guide will follow the international WHO classification. To help the newcomers in dental traumatology a Trauma Pathfinder will be incorporated in the website to guide the practitioner via a series of ‘yes’ and ‘no’ questions to a correct diagnosis.
It is very important to register the injuries in a standardized way. The classification by Andreasen is recommended because it is closely related to the treatment. The dental trauma guide will enable the clinician to find all information to be able to diagnose and classify TDI.
Recently, an index based on 5 digits will comprise all important information that can be easily computerized. Using this together with a schematic picture illustrating the injuries will simplify for clinicians worldwide, even clinicians with little experience in trauma, to accurately register TDI in the emergency situation. This index enables combination injuries to be registered at the same time (Eden Baysal index). Standardized registration will enable comparison of data and outcome between different centers worldwide enabling larger materials.
Examples of use of the index:
Left central incisor with extrusive luxation can be described with the 5-digit code: (21)00Ei-
Right lateral incisor with crown root fracture with pulp exposure and immature root development: (12)5Ni-
Left central incisor with crown facture with pulp exposure and lateral luxation with alveolar process fracture will get the code: (11)30Lm+
Lateral incisor with crown fracture in dentin without pulp exposure and root fracture in apical third of the root with mature apex (12)21Ni-
Selecting treatments which may optimize pulp and periodontal healing
A paradox in dental traumatology is that almost all treatment procedures impose an element of new trauma when applied, i.e. being traumatogenic. To mention a few, repositioning of a displaced tooth manually or by forceps will damage or destroy thousands or millions of PDL cells. Application of many types of splints, especially arch bars, in which loosened teeth are fastened to an arch bar with wires will create large compression zones in the PDL due to tightening of the steel wires and establish invasion paths for bacteria along subgingivally placed wires. Insufficient coverage of exposed dentin and pulp may lead to microleakage with formation of anaerobic bacterial colonies, which may seriously damage the pulp. Proper treatment selection, which sometimes means minimal or no treatment, is therefore crucial.
In the Dental Trauma Guide treatment approaches is presented according to the present guidelines from the International Association of Dental Traumatology. These guidelines are developed by international specialists in Dental Traumatology based on available evidence and best clinical practice.
Follow-up regimens for dental trauma patients
An optimal follow-up plan should aim at selecting points in time where the chances of diagnosing healing complications are most effective. For obvious reasons, cost and the convenience of the patient and practitioner have to be taken into consideration when construction a good and cost-effective control system. The suggested follow-up plan for a given trauma entity are proposed based on a series of clinical studies where survival analysis has documented the most optimal time for diagnosis of pulp and periodontal healing complications.
Description and diagnosis of healing complications.
In the Dental Trauma Guide the terminology of healing complications has been based on the 2020 edition of the Textbook and Color Atlas of Traumatic Dental Injuries by Andreasen et al. In relation to pulpal healing the following outcome descriptions are used:
- Pulp necrosis (sterile or infected)
- Pulp canal obliteration (partial or total)
In relation to PDL healing the following healing complications are described:
- Repair-related root surface resorption
- Infection-related root surface (inflammatory) resorption
- Progressive osseous root surface ankylosis-related (replacement) resorption
Concerning the marginal periodontium the following two entities are recognized:
- Permanent marginal bone loss
Finally, and probably the most essential complication is tooth loss usually caused by the abovementioned healing complications.
Prediction of healing complications
Several clinical studies have been done to identify healing/non healing predictors for the various trauma entities. These studies have so far identified 15 predictors, which have been significantly linked to the occurrence of healing complications. Some of these factors have been shown to be very strong (type and extent of injury and stage of root development) whereas others only have a minor influence (treatment). The identification of these factors is usually based on a multivariate statistical analysis with regression analysis being the primary tool. To some extent the influence these predictors has on pulp and periodontal healing can be verified by the result found from the monkey experiments.
One of the goals for the Dental Trauma Guide is to give the dental practitioner a tool whereby a risk profile based on the most important predictors can be developed for an individual patient with a given trauma entity.
Presently the trauma archives at the University Hospital contains 40.000 patient trauma records, all having standardized clinical, radiographic and photographic documentation of the type and extent of the injury including associated soft tissue injuries as well as information about the treatment offered. Approximately 10 %, or 4000 patients, have had long-term follow-up of 1-10 years and these patients constitute the core of the trauma database. These traumas are to a large extent representative for the 104 different trauma scenarios (see earlier). The database is constantly expanded by new trauma cases evaluated in the Dental Trauma Guide trauma clinic.
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