Clinical audit of children with permanent tooth injuries treated at a dental hospital in Ireland.
Traumatic dental injuries represent prevalent and a complex injury and estimates of prevalence vary depending on cultural and social conditions. Access to dental services, differing thresholds for attendance, differences in parental or patient attitudes to dentistry and the lack of uniformity in recording of traumatic dental injuries all confound such estimates. In addition many studies, including the present study, are confined to particular age groups or subgroups based on other factors such as those attending a particular service. Hence direct comparison often cannot be made [Glendor, 2009a]. A summary report on Children's Dental Health in the United Kingdom (UK), [Lader et al., 2003] found that the incidence of accidental damage to anterior teeth had declined in recent years. O'Brien  had previously found that one in five school aged children in the UK had experienced trauma to their anterior permanent teeth. A recent review of the literature, [Glendor, 2009a], cites USA studies and concludes that almost one third of children with primary teeth and a quarter of adults exhibit evidence of previous dental trauma.
Records of consecutive dental trauma cases referred to the Paediatric Dentistry department at Cork University Dental School and Hospital were analysed. The objective was to examine the pattern of presentation and treatment of injuries to the permanent teeth. The aim of the study was to examine the treatment of these children at the hospital in terms of the following aspects:
* To review key demographic factors pertaining to patients presenting with dental traumatic injuries to the permanent dentition; age, gender and distance travelled,
* To establish the prevalence of and type of injuries to permanent teeth,
* To review the treatment provided with regard to splinting of mobilisation injuries and the prevalence of pulp extirpation and to compare treatment with recommendations in guidelines.
Materials and methods
This audit was conducted in 2008 using consecutive computerised attendance records accessed to identify clinical records for children attending for treatment of trauma to the permanent dentition at the Cork University Dental School and Hospital. Treatment records were examined for the 94 available patients. Findings were entered to a Microsoft excel database, the data was made anonymous and an NCSS statistical package was used to complete the analysis.
Data was reviewed with regard to demographic factors including the age of the child at the time of the injury, gender and distance the patient had travelled for access to services based on their address. The aetiology of dental injury sustained and distribution of principal type of injury were examined in respect of each tooth. The number of teeth involved per patient was recorded as an indication of the severity of dental injury. Key clinical aspects of the management of cases of dental trauma were audited. The stage of apical maturation was determined from standard radiographs and recorded. Root canals whose walls were divergent or parallel were deemed to be immature and those whose walls were convergent were classed as mature.
The prevalence of splint placement and the duration of splinting were calculated from clinical records. The prevalence of pulpal extirpation was also determined and the data recorded in the database. Splinting times in the present audit were compared with those recommended in the International Association for Dental Trauma (IADT) established guidelines [Flores et al., 2007a, Flores et al., 2007b]. For the purposes of this audit the standard set also incorporated a 7-day period to allow for contingencies, parental availability and scheduling. Comparisons were made between the audit findings for pulpal extirpation and recommendations of published data [Andreasen et al,. 2003].
Records of treatment for dental trauma were available in respect of 94 children with a total of 168 traumatised teeth for the period reviewed. The sample comprised 29 females and 65 males. The mean age at which injury occurred was 10.1 years (SD [+ or -] 2.64). Ages ranged from 5.3-17.1 years.
With reference to the distances travelled by child patients to receive treatment in respect of dental injuries, the majority of children (81.7%) presenting with dental trauma lived within 50 km of the dental hospital while 9 children (9.7%) travelled over 100 km for treatment of dental trauma.
With regard to the cause of the injuries, sports accounted for trauma to 39 (23.2%) of the 168 teeth in this sample. A further 38 (22.6%) were attributed to falls. Bicycles were involved in 26 (15.5%) of the traumatised teeth in these children while another 11 (6.6%) were attributed to other domestic accidents. Assaults accounted for 7 dental injuries; 4 were attributed to a pedestrian accident, 1 as a passenger and 1 while swimming. For 41 (24.4%) of teeth in this study the cause of injury was unclassified. The relative proportions of cause of injury for all the teeth in this study are as represented in Fig 1.
The tooth most frequently involved in traumatic injury in this study was the maxillary central incisor, 131 teeth (77.9%); maxillary lateral incisors accounted for 22 teeth, (13.0%). Injuries to mandibular teeth were less common, comprising 15 teeth, (8.9%). In 106 cases (63.1%) had closed or closing apices and 62 (36.9%) had open apices. In 46% of children sample they had experienced injury to a single tooth. The majority (54%) had experienced injury to 2 or more teeth.
Fig 2. represents the distribution of the type of dental injury sustained. Uncomplicated crown fractures were the most common type of injury in this audit, comprising 39 teeth (23.2%). Complicated crown fractures, involving pulpal exposure, accounted for injuries in 18 (10.7%) of teeth; 37 teeth (22.0%) were subluxated. In 9 teeth (5%) there were root fractures and 10 teeth (6.0%) were extruded; a further 14 (8.3%) were lateral luxations. Intrusions affected 7 (4.2%) and avulsions were seen in 30 teeth in this sample (17.7%).
[FIGURE 1 OMITTED]
[FIGURE 2 OMITTED]
Overall, dental hard tissues injuries accounted for 34% of teeth in this audit while the remaining 64% of teeth had injuries primarily to the periodontal ligament. Of the 39 uncomplicated crown fractures recorded, 24 (61.5%) were in males and 15 (38.5%) in females. Of the 18 complicated crown fractures recorded 17 (94.4%) were seen in male patients. Of those teeth experiencing complicated fracture, 6 (33.3%) had open apices and 12 (66.6%) had closed apices.
Table 1 shows that a large majority of subluxations, extrusions and lateral luxations were seen in males and most of these teeth had closed apices. In the case of subluxation, approximately half were splinted, while almost all extruded and laterally luxated teeth were splinted. The splinting times and pulp extirpation prevalence are summarised.
Table 2 shows that the majority of intruded, avulsed and root fractured teeth were seen in males. Most of the intruded teeth had closed apices but there was nearly equal distribution of open and closed apices seen in the avulsed and root fractured categories. Splinting prevalence and duration along with prevalence of pulp extirpation are summarised for each injury type.
In Table 3 a comparison of the duration of splinting according to IADT guidelines is made. The audit standard set included an additional 7 days to provide for appointment scheduling and other contingencies. The data indicated that, in some instances, there was a tendency to maintain splinting for a longer duration than the guidelines recommend.
The prevalence of pulpal extirpation in this audit compared to the expected prevalence for avulsion, lateral luxation and extrusion injuries is shown in Table 4. The findings show good correlation with the expected outcomes derived using criteria described by Andreasen et al. .
The age profile of children experiencing dental trauma in the present study was in keeping with findings of other hospital based studies [Wright et al., 2007; Diaz et al., 2010]. A recent UK multicentre study of dental trauma in the permanent dentition [Zaitoun et al., 2010] reported a mean age of 11.1 years with a range of 6 -16 years. Previous studies have consistently confirmed the finding that the incidence of dental traumatic injury in males is higher than in females [Lader et al., 2003]. Wright et al.,  indicated that the discrepancy between males and females is greater in the case of more severe injury types. The results of the present study, with a tendency towards a high proportion of teeth in males being involved in the more severe injuries, broadly support that finding.
The Cork University Dental School and Hospital serves a population that includes both urban and rural communities in the south of Ireland. The majority of patients (81.72%) attending for treatment of dental trauma lived within 50 km of the Dental Hospital. The observation that a proportion of patients travelled more than 50 km to access dental treatment would raise some concerns as to the potential time delay between the injury and presentation for initial treatment. The records audited in this study did not include a sufficiently consistent or detailed indication of the time that had elapsed since the injury, to enable meaningful analysis. The importance of early remedial intervention in determining the prognosis of traumatised teeth is well established [Andreasen et al., 2002]. Recent studies have again highlighted this aspect of service provision. Kargul and Welbury  reported that geographical location resulted in significant delays in accessing secondary care and emphasise the importance of prompt treatment in determining prognosis.
In their multi-centre study Zaitoun et al.  identified prolonged transit time as the main reason for delay in receiving emergency treatment for dental trauma. With regard to follow-up treatment for dental trauma [Glendor et al., 2000] considered the implications for patients and their caregivers following dental trauma. In addition to the time required for carrying out treatment, the 'indirect time' (travelling, checking in and waiting) was considered. Lack of access to a clinic close to their home greatly increased the travel aspect of the indirect time. The finding in the present study that patients were prepared to travel to receive treatment for dental trauma is consistent with findings of previous reports. Nguyen et al.,  reported that parents and children were prepared to accept a considerable socio-economic burden in order to maintain replanted avulsed incisors. It has been suggested that improved education in the management and clinical follow-up of dental trauma within primary care would result in improved outcomes for patients [Glendor, 2009b, Kinirons, 2010].
Wright et al.  found that falls were the most frequent cause of injury followed by sports injuries. In the present study sports comprised the largest category of causes classified with falls second most prevalent. Glendor [2009a], reviewing the literature regarding causes and aetiology of traumatic dental injuries, noted that causes of dental injury vary between cultures and countries. Sports and falls feature prominently as causes of dental trauma, as they do in the present study. However it is noted that violence is recorded as the main cause of traumatic dental injury in some studies. Glendor [2009a] suggested that perhaps the existence of a high proportion of 'unknown' causes, as in the present study, might result from individuals concealing violence as the real cause. Furthermore, Glendor advocated that use of a system of universally accepted aetiological factors would improve comparison between studies.
The finding in the current study that 46% of children presenting to the dental hospital had experienced injury to a single tooth is consistent with previous hospital studies. Tham et al.  reporting on 529 dental injuries in a sample that included adult patients, found 25% of injuries involved 2 teeth, 12.5% three teeth and 8% involving 4 or more and that injuries arising in single incidents were often multiple and serious.
Audits of dental trauma conducted in a hospital setting can be expected to show a higher proportion of more severe injuries than that seen in the general population [Batstone et al., 2004]. The prevalence of the different injury types seen in the present study is similar to that seen in other hospital studies [Zaitoun et al., 2010]. The distribution of injury types in such studies is likely to be weighted towards such more complex presentations than observed in studies of general populations. The availability of primary care dental services will also influence pattern of injury type presenting to hospital.
Stockwell  studied dental trauma in a school population of 66,500 children aged between 6 and 12 years of age. That research found that injuries involving enamel and dentine comprised the largest class of trauma amounting to 42.7%. Uncomplicated fractures accounted for 23% of injuries in our study where more than three quarters of all the injuries involved the pulp and /or periodontal injury.
Splinting and prevalence of pulp extirpation, being key aspects of the clinical management of dental traumatic injuries, were the focus the present audit. Splinting times were compared with IADT guidelines [Flores et al., 2007a, Flores et al., 2007b]. A small effect of having incorporated the 7-day contingency period, beyond IADT guideline times, in the audit standard is evident in Table 3, demonstrating a general adherence to splinting guidelines. A tendency to maintain splinting for longer than the guidelines advice, was evident in some cases. It was likely that difficulties attending appointments contributed to this tendency, although this was not studied in the present audit. The effect of the severity of the injuries, with more than half of the cases treated having 2 or more traumatised teeth, may also contribute to the longer splinting times observed in some cases. This could be the subject of future analysis when a greater number of cases becomes available. Placement of composite resin and wire splinting is the standard procedure in treatment traumatic dental injuries in the dental hospital. However, the available records in this study did not include specific recording of the type of splinting used. This further supports the adoption of a standardised system of data recording.
The stage of apical development is a determinant both of prognosis and of the appropriate clinical intervention relating to pulpal vitality. The comparisons of the management of the injury types with that advocated in existing recommendations, took account of apical development. Small numbers of teeth in subcategories of injury type meant that analysis of pulpal extirpation was confined to avulsion, lateral luxation and extrusion. Analysis of these categories showed results indicating good compliance with recommendations.
It is accepted that extended splinting times will increase the risk of ankylosis as shown in replanted teeth in monkeys [Andreasen, 1980]. Nonetheless, it is unlikely that flexible splinting of other types of injuries for periods that are slightly longer than advocated will cause this effect. The available guidelines [Andreasen et al., 2003, Flores et al., 2007a, Flores et al., 2007b] are very valuable assistance to clinicians in clinical decision making management of traumatic dental injuries. Von Arx, , noted that there was agreement that splinting times should be based on clinical and radiographic findings and suggested that as the periodontal ligament heals to its normal strength within 14 days, there are only a small number of situations that merit splinting for longer.
The primary purpose of audit is to inform and hence enhance the management of dental trauma. The audit process itself can also benefit from enhancement as it evolves [RCSE, 2000]. This work represents a retrospective audit of the available data in this unit. As such, the limitations associated with interpretation of the data must be acknowledged. Standardised data recording systems with regard to dental trauma are aspired to frequently in the literature. A further benefit of utilising a standardised recording system would be the facilitation of the clinical audit process. The current audit has yielded worthwhile information regarding the management of dental trauma for these children.
The long distance travelled by some patients raises the issue of lack of rapid access. The proportion of serious injuries was higher than reported in population studies. General adherence to guidelines in respect of splinting and prevalence of pulp extirpation was demonstrated. Utilising standardised recording system would facilitate the clinical audit process and comparison between studies.
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C. Stewart, M. Kinirons, P. Delaney
Paediatric Dentistry Clinic, Cork University Dental School and Hospital, University College Cork, Ireland.
Postal address: Dr C Stewart, Dept. of Paediatric Dentistry, Cork University Dental School and Hospital, University College Cork, Ireland.
Table 1. Audit of data concerning management of subluxation, extrusion and lateral luxation in a population of children in Ireland. Apical Injury type Gender Status Splinted Subluxation Males Open Yes (n = 37) 28 (75.7%) 12 (32.4%) 19 (51.3%) Females Closed No 9 (24.3%) 25 (67.6%) 18 (48.7%) Extruded Males Open Yes (n = 10) 8 (80.0%) 1 (10.0%) 10 (100.0%) Females Closed No 2 (20.0%) 9 (90.0%) 0 (0.0%) Lateral luxation Males Open Yes (n = 14) 11(78.6%) 3 (21.4%) 13(92.9%) Females Closed No 3 (21.4%) 11 (78.6%) 1 (7.1%) Splinting Pulp Injury type Gender times extirpation Subluxation Males 19 days Yes (n = 37) 28 (75.7%) (SD = 13.6) 10 (27.0%) Females No 9 (24.3%) 27 (73.0%) Extruded Males 39 days Yes (n = 10) 8 (80.0%) (SD = 27.3) 6 (60.0%) Females -- No 2 (20.0%) 4(40.0%) Lateral luxation Males 26 days Yes (n = 14) 11(78.6%) (SD = 20.5) 5 (35.7%) Females -- No 3 (21.4%) 9 (64.3%) Table 2. Audit of data concerning management of intrusion, avulsion and root fracture luxation in a population of children in Ireland. Injury type Gender Apical Splinted / Status Actively repositioned * Intruded Males Open * Yes (n = 7) 5 (71.4%%) 1 (14.3%) 6 (85.7%) Females Closed No 2 (28.6%) 6 (85.7%) 1 (14.3%) Avulsed Males Open Yes (n = 30) 17 (56.7%) 15 (50.0%) 22 (73.3%) Females Closed No 13 (43.3%) 15 (50%) 8 (26.7%) Root Fracture Males Open Yes (n =9) 8 (88.9%) 4 (44.4%) 8 (88.9%) Females Closed No 1 (11.1%) 5 (55.6%) 1 (11.1%) Injury type Gender Times Pulp extirpation Intruded Males 32 days Yes (n = 7) 5 (71.4%%) (SD = 19.1) 4 (57.1%) Females -- No 2 (28.6%) 3 (42.9%) Avulsed Males 22 days Yes (n = 30) 17 (56.7%) (SD = 17.6) 20 (66.7%) Females -- No 13 (43.3%) 10 (33.3%) Root Fracture Males 31 days Yes (n = 9) 8 (88.9%) (SD = 21.3) 0 (0.0%) Females -- No 1 (11.1%) 9 (100.0%) Table 3. Relationship between splinting times and IADT guidelines in a population of children in Ireland. Injury type Guideline splinting time IADT * Avulsed n = 30 Up to 2 weeks Lateral Luxation n = 14 4 weeks Subluxated n = 37 2 weeks Extruded n = 10 2 weeks Injury type Number of teeth splinted up to guideline duration Avulsed n = 30 20 ([less than or equal to] 14 days) Lateral Luxation n = 14 11 ([less than or equal to] 28 days) Subluxated n = 37 28 ([less than or equal to] 14 days) Extruded n = 10 4 ([less than or equal to] 14 days) Injury type Number of teeth splinted up to guideline duration + 7 days Avulsed n = 30 22 ([less than or equal to] 21 days) Lateral Luxation n = 14 11 ([less than or equal to] 35 days) Subluxated n = 37 31 ([less than or equal to] 21 days) Extruded n = 10 5 ([less than or equal to] 21 days) Injury type Number of teeth splinted for a longer period Avulsed n = 30 8 Lateral Luxation n = 14 3 Subluxated n = 37 6 Extruded n = 10 5 * IADT [Flores et al., 2007a, Flores et al., 2007b]. For the purposes of this analysis a 7 day period was also included to allow for contingencies. Table 4. Prevalence of pulp extirpations compared with expected prevalence in a population of children in Ireland based on previous studies. * Injury Type Actual number of Expected number of pulp extirpations pulp extirpations * Avulsion 20 21.00 (n =30) Lateral luxation 5 6.54 (n = 14) Extruded 6 5.92 (n = 10) * Using the criteria of Andreasen, .
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|Author:||Stewart, C.; Kinirons, M.; Delaney, P.|
|Publication:||European Archives of Paediatric Dentistry|
|Date:||Feb 1, 2011|
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