Improving dental trauma management in primary care: A team‐based approach

Dental trauma has a high prevalence, with one in three preschool children sustaining a traumatic dental injury to the primary dentition and one in four school children to the permanent dentition.1 Primary care provides a first-line contact for paediatric patients accessing emergency care within England. General Dental Practitioners are often the first clinicians to see children after they have sustained dental trauma.2 Initial management can influence the long-term outcome for the teeth involved,3 and dental trauma can have life-long implications on quality of life.1 It is therefore important that the correct clinical care is provided at the first appointment, in a timely manner, with assessment made regarding the need for onward referral to a paediatric specialist. The primary care practice in this service evaluation is situated in Yorkshire, England, and can refer children via an online referral system to either the local Community Dental Service (secondary care) or Leeds Dental Institute (tertiary care) for specialist paediatric dentistry. The practice has a patient base of both National Health Service (NHS) and private patients; children are seen on an NHS basis within the practice. The International Association of Dental Traumatology (IADT) have produced comprehensive guidance for the management of traumatic dental injuries (TDIs), which provide a gold standard for dentists managing dental trauma. Primary care dentists, however, have been shown to have lower confidence levels in dealing with complex dental trauma.2 Anecdotally within the practice, the dentists felt that there was an increase in the number of trauma cases that were presenting. The dentists' experience differed in number of years qualified and experience in dealing with traumatic dental injuries (TDIs). The service evaluation aimed to review the current management of TDI within the practice. To evaluate the management of TDIs within a general dental practice setting. Clinical records were retrospectively evaluated between the period of January 2021 to March 2023. Appointments that had been booked as ‘trauma’ on the practice electronic software were reviewed, and TDIs in primary and permanent dentitions were included. Data collection occurred pertaining to patient age, trauma history diagnosis, treatment provided, radiographs taken, onward referral and whether initial assessment and management of trauma was in line with IADT guidelines. Onward referrals were reviewed as to whether they met current local protocols for referral; the following injuries (in permanent teeth) were taken to be appropriate for referral to specialist care; avulsed teeth, crown–root fractures, luxation injuries and complicated enamel dentine fractures with open apices. Descriptive analysis of the results was undertaken. An anonymous online survey was sent to the four dentists working within the practice. The survey explored the dentists' self-perceived knowledge and confidence in managing dental trauma using Likert scales where a score of 5 indicated a high level of confidence. Free text was collected regarding specific areas of low confidence. Twelve patients presented with TDIs to 15 teeth in the period between January 2021 and March 2023 with eight distinct TDI diagnoses. The majority of TDIs were in permanent teeth (80%, n = 12). All cases were managed in line with IADT guidance at the initial appointment. Note keeping and quality of onward referral, however, were found to be suboptimal (Table 1). Dentists' confidence in managing TDIs was relatively low with mean self-reported confidence score of 2.5 of 5 (range 2–4). Free-text data detailing areas of low confidence related to appropriateness of referrals, use of crown formers to repair enamel dentine fractures, partial pulpotomies and timescales for splinting and review. Following Evaluation 1, a combination of staff training and practice measures were introduced to the practice (Table 2). Dentists: Reception: Dental Nurses: Detailed and set out to lead a clinician through a trauma appointment in a standardised manner and improve record keeping Training on importance of taking photos in initial appointment Prompt added to patient record on practice software detailing IADT recommended dates for clinical and radiographic review Placed on every computer screen next to a phone The service was re-evaluated between 1 September 2023 and 25 November 2023, 6 months after implementation of changes. There was a reduction in the number TDIs seen in this period, with five patients attending and the majority of TDIs (66.67%, n = 5) occurring in primary teeth (Table 1). Subsequently, no children were referred into specialist services in line with local protocols. Mean self-reported confidence in managing TDIs increased to value 3.5 (range 3–4), with free-text responses indicating increased confidence. There was some uptake in the use of the notes proforma, but the use of clinical photographs remained suboptimal. Annual review of TDI management and referral is planned and next due in September 2024. Following the Evaluation 2, a monthly peer review session has been arranged within the practice with case-based discussions. Uptake of the note proforma and clinical photographs will be explored including any potential barriers. New starters will receive trauma training relevant to their role at induction and staff refresher training delivered within staff meetings annually. This project engaged all the staff within the practice and raised their awareness and knowledge of dental trauma management. Additionally, it provides data regarding the presentation of management of TDIs in general dental practice, which contributes to the limited existing literature in this setting.2 A standardised data set approach to recording dental trauma supports quality care and allows for comparison of outcomes following TDI.4 In addition, effective telephone triaging has been shown to improve access to emergency dental care.5 Implementation of these systems within the practice has led to a standardised approach and an increase in confidence levels of the dentists in managing TDIs. Within the second cycle of evaluation, it was noted that no onward referrals were made. The interventions in this project may have led to a reduction in referrals as the dentists felt more comfortable to deal with the cases of trauma in-house, were aware of local protocols regarding appropriate trauma referrals, and had telephone access to specialist advice if required. The reduction in referrals may also be attributed to a smaller number of permanent teeth being affected by trauma in the second cycle. The author was also undertaking further postgraduate training in paediatric dentistry with the Level 2 complexity care programme following the time period of the first evaluation. This program is specifically designed to upskill general dentists and may have had a ripple effect within the practice. The retrospective design of the project was a limitation and the fact that it was undertaken in a single dental practice has led to a small sample size. Using the code ‘trauma’ to search for records will have inevitably missed cases of trauma such as enamel/dentine fractures, which may be recorded as ‘broken tooth’. In addition, the time frame of review is short, and therefore, the sample size is small, but the measures taken appear to demonstrate effective changes have been made to the management of dental trauma within the practice. There was no cost implication to the practice other than the investment in a subscription to the IADT ‘Dental Trauma Guide’ website, all the resources and equipment were all readily available. All staff within the practice were upskilled and the changes simple to implement. These simple changes are reproducible in wider general practice and could be extended to services which have first-line contact with trauma cases to improve the immediate management of TDI in these patients. Thank you to Dr Rachael Nichol and Dr Esther McDerra for their supervision of the project. Thank you to all the team at Outwood Dental Practice for their support and participation.