Dental trauma - the child patient and parent perspective
A. Wallace, H. D. Rodd, H. Zaitoun
Department of Paediatric Dentistry, Wellesley Road, CharlesCliffordDentalHospital, Sheffield
September2013
Introduction
Children commonly traumatise their permanent front (incisor) teeth, with reported injury in up to 13% of British 15-year-olds. In about 6% of cases the nerve inside the tooth will die following this injury and will require root canal treatment. To ensure success, this root filling needs to be packed against a hard barrier at the end of the root of the tooth. However, in young patients, the roots are not fully formed and the barrier is absent. Hence, before a root filling can be placed in an immature tooth, the roots have to be artificially matured to stimulate the formation of a barrier using a material called calcium hydroxide. This paste is put inside the root canal and sealed into the tooth. On average, this treatment takes 12 months over at least 7 dental visits. Alternatively an artificial barrier can be placed in the canal using newer materials such as mineral trioxide aggregate (MTA), or Biodentine. This material is pushed to the end of the root where it sets hard and forms an artificial barrier against which a root filling can be placed. This requires an average of only 2 visits over a period of 1 to 2 months. To date, only MTA has been evaluated in a randomised controlled clinical trial (RCT), the benefits of which have been reported solely in terms of clinical outcomes rather than patient reported outcomes (Chala et al., 2011).
The benefits of the newer material are yet to be established. The first major advantage of Biodentine over MTA is its significantly reduced cost which has economic benefit for the NHS and it provides a more cost effective option for use in general dental practice or the salaried services.
The second potential advantage of Biodentine is the absence of tooth discolouration following treatment. Tooth discolouration is a common adverse effect of dental trauma which can be potentiated by use of materials including MTA (Roberts et al., 2007). In instances where this has occurred, patients express great concern about the grey appearance of their treated tooth, and frequently require tooth bleaching which largely restores the aesthetics of the tooth. Recently a European Union Council Directive banned the use of bleach in persons under the age of 18 (2011). This will have significant implications for children and young people who have sustained dental trauma as tooth lightening will no longer be available to them. This will undoubtedly compound the negative psychosocial impacts of dental injury in terms of oral health-related quality of life (Porritt et al., 2011).
We aim to determine the efficacy and acceptability of Biodentine, a new material used in root canal treatment, through an RCT comparing it to the current gold standard treatment, calcium hydroxide. Our previous work has highlighted the psychosocial impacts and family burden resulting from dento-alveolar trauma and prolonged courses of treatment (Porrit et al., 2011). It is therefore essential that any future RCT considers patient-driven goals and outcome measures, and not just the more traditional clinical outcomes.
Aim
Establishing the concerns of young patients and their families following dental trauma and its management will help support individuals and improve the standard of care by ensuring the following:
1. Improving patient satisfaction as clinicians will be able to identify patient concerns and outline management strategies that will address these concerns
2. Improving services for other patients by reducing duration of treatment, number of visits and thus increasing capacity of specialist trauma clinics
3. Improving compliance with demanding, complex dental care
4. Ensuring that children and young adults receive high quality and timely treatment to improve not only their oral health, but their overall wellbeing
The aim of our patient involvement initiative was to seek the patients' experiences and perspectives of treatment following a dental injury. The purpose of engaging patients and their families at this stage is to propose meaningful patient-reported outcome measures as part of the evaluative process of the planned RCT.
Method
Thirty children who attended the CharlesCliffordDentalHospital were approached after their appointment to complete a simple speech bubble diagram regarding the treatment of their injured tooth. This was then posted through our special dental mailbox placed on our reception desk, to ensure anonymity.
Children and young people aged 7-16 years who had recently received treatment to manage their injured tooth were informed about the discussion group and given an information pack to take home. This included a child information sheet, a parent information sheet, a reply form and stamped envelope. If after reading the information about the focus group, they wished to take part, they returned the completed reply form with their contact details. The chief investigator then contacted the families who wished to take part and arranged a suitable date for the meeting. A poster was also placed in our clinic waiting room informing all patients about the project.
Children and their parents who were unable to participate in our focus groups were given a questionnaire to complete during their scheduled appointment.
The participants
Thirty children and young people (mixture of boys and girls)were included in asimple participatory activity which involved completion of a simple speech bubble diagram to tell us the three best things and three worst things about their treatment; and also, if they could make a wish about their teeth, what would it be?
Two focus groups and one interview were also held in the school summer holidays and after school. In the first of the focus groups, four children (three boys / one girl), aged between 8-11 years old were involved alongside their parents. In the second focus group, three young people (all male), aged between 12-15 years old and their parents were included. An interview was carried out with one thirteen year old boy and his mother. The conversations were prompted by a topic guide, were audio-taped and transcribed verbatim for further qualitative analysis.
Six children (mixture of boys and girls) and their parents were given a questionnaire to complete after their visit asking their views on dental trauma and the treatment they received.
The contributions
Many children reported that the staff were always very kind and informed them of what was going to happen that visit which reassured them. However, some children had multiple dentists and would have preferred continuity.
Children reported that they adapted their eating habits as a result of the injury. However, the appearance, especially the colour of their injured tooth was a significant concern and many said they tried to prevent others from seeing their teeth when smiling and speaking. This recurring theme highlighted the psychosocialimpacts of dental trauma on children. Some children had received tooth bleaching which they reported had made a significant improvement. However, other children were unable to receive this treatment due to the change in legislation and were left unhappy with their discoloured tooth.
The number and length of visits were also a concern for both patient and parent. When asked what the ‘perfect treatment would be,’ many replied with ‘for it not to take as long.’Other things that the children did not like were, ‘the needle,’ the ‘x-ray,’ and ‘the raincoat.’
The majority of the children’s wishes were: ‘that it never happened.’ Although dental trauma is not completely preventable, the number of dental injuries may be reduced by raising awareness of the importance of wearing mouth guards; as sports related injuries are acommon cause of dental injury.
After the dental injury some patients were referred to multiple hospitals/clinics prior to reaching the Charles Clifford dental hospital. Time is an extremely important factor in the management of dental trauma. Therefore a potential area to explore in the future would be to improve access and awareness of the facilities at the CharlesCliffordDentalHospital to allow seamless referrals of children who have suffered dental trauma.In addition, parents were very concerned about the prognosis of the teeth and future financial costs.
Evaluation
After the focus group a patient and public involvement (PPI) monitoring form was given to the participants to complete for evaluation purposes (one completed PPI form enclosed).
Future plans
We are committed to applying for an NIHR grant through the RfPB programme to fund a feasibility study, for a future RCT, to determine the efficacy and patient acceptability of a new material Biodentine against the gold standard, calcium hydroxide for the management of non-vital immature incisors. We will be requesting funding in the region of £230,000 for a 2-year project. The contributions from our patients and parents in this project have helped us to formulate patient-reported outcome measures which will be part of the evaluative process of the RCT.
Difficulties encountered
Dental trauma often requires specialised treatment. CharlesCliffordDentalHospital has a wide spread catchment area and therefore many of our patients travel a long distance for appointments. This made recruitment more challenging as attendance to the focus group meant an additional visit to Sheffield.
We hoped to sample an equal gender mix, however, dental trauma is twice as common in boys as it is in girls, and this was reflected in our patient recruitment.
Some familiescould not take part in our discussion groups as they were unable to make care arrangements for their other children. In addition, we also received late notice cancellations due to illness and other engagements.
We were successfully awarded funding by the RDSYH of £480.
Appendix: detailed breakdown of how the funding was spent
Travel expenses to SheffieldDentalSchool£79.60
Light refreshments£31.64
£10 gift voucher to each child and adult participant£280
Office and postage costs for information leaflets, poster and evaluation questionnaire £31.74
TOTAL SPENT£422.98
PPI forms, list of participants and signed receipt forms available on request.
Key References
Chala S, Abouqual R, Rida S. Apexification of immature teeth with calcium hydroxide or mineral trioxide aggregate: a systematic review and meta-analysis. Oral surg Oral Med Oral Pathol Radiol Endod 2011;112:36-42.
European Union Council Directive 2011/84/EU. Published September 2011.
Marshman Z, Hall M, Porrit J, Albadri S, Rodd HD, Choosing patient-centred outcome measures for a randomised controlled trial involving non-vital incisors. International Journal of Paediatric Dentistry, 2009; 19, Issue s: 43-45.
Porrit JM, Rodd HD, Baker, SR. Quality of life impacts following dento-alveolar trauma. Dental Traumatology. Dental Traumatology 2011; 27: 2–9.
Roberts HW, Toth JM, Berzins DW, Charlton DG. Mineral trioxide aggregate material use in Endodontic treatment: A review of the literature. Dental Materials 2007; 24:149-168.
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