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Relevance

Following initial stabilisation of traumatic dental injuries (TDIs) to permanent teeth, follow-up is likely to be required. This is often best carried out in general dental practice, easing barriers to accessing dental care, particularly in rural and isolated communities, and potentially enhancing the cost-effectiveness and sustainability of dental care. It is important that general dental practitioners (GDPs) are aware of which TDIs are the more serious, and most likely to develop problematic consequences, requiring follow-up and potentially further dental intervention.

In a previous article, the immediate management of TDIs was discussed.1 An accurate diagnosis will inform initial management, treatment required and the follow-up regime. For follow-up to be effective, it is helpful if the clinician is aware of the original trauma diagnosis and follow-up be in accordance with recognised guidelines.2,3 Follow-up aims to facilitate early diagnosis, treatment and/or referral of deleterious problems occurring as a result of the trauma, particularly because many problematic sequelae are asymptomatic and develop many months, or years, after the TDI.4,5,6

This article and the second part, guide and inform TDI follow-up, the investigations and special tests recommended, the reliability of these, and TDI sequelae to monitor for.

  1. 1.

    Confirm TDI diagnosis

Trauma is seldom an anticipated or predictable event, with a range of case severity occurring, often with concurrent medical injuries, and potentially out-of-hours. This can lead to challenging circumstances identifying, diagnosing and stabilising TDIs, particularly when patient co-operation may be limited due to patient age and/or distress. In medical A&E services, access to take periapical and other intra-oral radiographs can be limited and impact the accurate diagnoses of injuries. For example, without a periapical, root fractures may not be identified and the injury insufficiently stabilised.7

It is therefore important when examining a historical trauma case for the first time, that the history and examination be carried out thoroughly and an open mind kept until the diagnosis is clarified. Be aware of potential misdiagnoses when initial management has been undertaken by a different clinician. If correspondence and/or dental records are available, reviewing these together with previous and current radiographs is sensible. Once the diagnosis is confirmed, or an informed best guess made, the International Association of Dental Traumatology (IADT)2 guidance should be referred to for recommended follow-up regimes and likely complications. The various relevant current guidelines in relation to TDIs have previously been discussed and readers are directed to this.1 Pre-existing guidelines8 have recently been reviewed and changes to recommended dental materials, follow-up timings and diagnostic imaging regimes made.

  1. 2.

    Patient education

Patients and, in the case of minors, their advocates, must be made aware of potential TDI sequelae, the need for follow-up and problematic signs/symptoms to look out for. Figure 1 illustrates a case example where the patient failed to return for review and at four months post injury, a hopeless outlook for the previously traumatised tooth evident. Although earlier attendance may not have changed the outlook in this case, it is essential patients understand the importance of TDI follow-up as early intervention can improve some outcomes.

Fig. 1
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Tooth 31 was replanted following avulsion. The patient re-attended some four months later, having missed intervening appointments. Replacement resorption is seen and the outlook for 31 hopeless

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Providing patients with the right information is therefore crucial and integral to shared decision making and informed, valid consent.9,10,11 Highlighting what patients should self-monitor for can be incorporated into a wider discussion regarding prognosis, expected outcome(s) and long-term treatment planning. There are evidence-based resources developed specifically for the public to refer to.12,13,14,15 Patient information leaflets can be useful16,17 provided they are appropriately designed.18,19 Today, patients have unlimited access to online resources, of which content may not be quality assured. Therefore, providing accurate, comprehensive information directly to patients during dental visits may better guide realistic expectations and inform a self-monitoring toolkit of what to look out for and act on. Asking patients to make a dental appointment should they notice signs or symptoms such as pain, swelling, sinus tract and tooth discolouration may enhance outcomes.

  1. 3.

    Be aware of potential TDI sequelae

Table 1summarises potential dental sequelae commonly encountered following a traumatic dental injury. The pulpal and periradicular diagnosis referred to are those used in the American Association of Endodontists 2008 Diagnostic Guidelines.20 The impact of these injuries on tooth survival has been colour coded: green (*) indicates sequelae unlikely to reduce tooth survival, amber (†) highlights those which may reduce tooth survival, and red (§) are sequelae likely to reduce tooth survival.

Table 1 TDI sequelae, significance, and management
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A consequence of TDI can be the premature loss of a tooth, such as an avulsed tooth not recovered at the time of injury, or a tooth subsequently becoming unrestorable, such as that seen in Figure 1. Premature tooth loss must be factored into treatment planning. The patient age, tooth eruption stage and occlusion will require consideration, along with potential specialist referral. In most cases, retaining teeth or a poor outlook and maintaining the space of teeth already lost due to TDI is recommended whilst treatment planning takes place.

  1. 4.

    Review and document TDI follow-up systematically

At each follow-up appointment, the aim is to identify if there has been deterioration of the injured tooth or teeth and whether aesthetics and function are satisfactory. A patient history should be gathered and clinical examination of the TDI affected teeth (including neighbouring and opposing teeth), surrounding tissues and a check of static and functional occlusion of TDI affected teeth made. IADT guidelines2 signpost review periods and when to sensibility test and radiograph TDI affected teeth, depending on the injury previously sustained.

Comprehensive documentation is crucial for clinical notes.32 A standardised method of recording a trauma review, such as using a pro forma, may help to mitigate human factors regarding information collection and enhance information gain.33,34 These can be designed to include information signposting appropriate review intervals in relation to the injury sustained.

At TDI review appointment, ensuring a clear, accurate trauma diagnosis has previously been established and recorded. Enquiries should be made as to the development of signs or symptoms of pulpal, periodontal or periradicular disease. Using a pain recognised pain scale or pain assessment tool35 can aid in capturing a pain history if problems are reported. The patient's view on the aesthetics of the TDI affected teeth should be explored, together with asking about changes in tooth position and/or occlusion.

Sensibility tests are an important element of trauma review, but these do always reveal true pulpal status.36,37 Combining several tests and correlating these with signs and symptoms to determine pulpal diagnosis is the most robust approach, although still not 100% accurate.38 Pulse oximetry is reportedly the most diagnostically accurate test,39 however this, together with laser doppler flowmetry are not commonly available or undertaken in dental clinics.

Figure 2 summarises the clinical examination, investigations and special tests frequently undertaken at TDI follow-up. Videos demonstrating how to undertake these tests are available on the Dundee School of Dentistry YouTube Channel.40

Fig. 2
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Follow-up examination, special tests and investigation summary2,37,41,42,43,44

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Conclusion

This article has discussed the importance of TDI diagnosis, the communication of TDI injury sequelae with patients and in the case of minors, their guardians; the potential sequelae of TDIs and how these might impact tooth survival. The second part of this article expands on this and considers late trauma presentation, when to retain or extract teeth and the role of dental implants in TDI affected individuals.

All images, figures and tables produced by the Dundee Dental Hospital and Research School with full permissions given for publication.

The authors have no conflicts of interest to declare.