The Impact of Traumatic Dental Injuries on the Mental and Social Well-Being of Children and Adolescents: Recommendations for Patient Management

Abstract

Traumatic injuries to the oral cavity are frequent during childhood, with a documented rate of more than 30% worldwide. These injuries commonly include the skull and mouth, and thus teeth are frequently impacted. Consequently, the individual ends up in pain accompanied by both esthetic and functional issues. The combination of these factors can have a detrimental impact upon normal functioning of a young individual’s lives if the injury is not efficiently treated or managed. This then impacts on the individual’s mental health and their quality of life. Not being able to function as part of a society that they are accustomed to, can cause people to withdraw from society and lose self-confidence. The negative psychological effect of traumatic dental injuries is specific to an individual, and as such each patient should be treated holistically with all factors taken into account. There is a dearth in literature around the full psycho-social impacts of traumatic dental injuries. Dentistry as a clinical field is advancing in treatment of such injuries, but there is still a lack of knowledge and awareness regarding the individual experience and how this could be managed going forward in terms in-chair strategies and the involvement of a multi-disciplinary team.

1. Introduction

Facial esthetics play an important role in how one perceives one own self and how one is perceived by others. Any detrimental impact caused by trauma that then affects one’s physical appearance can lead to distress and anxiety. This in turn can then affect the quality of life of individuals who are impacted.

Globally, the reported prevalence of traumatic dental injuries (TDI) during childhood or adolescence is a common occurrence with up to 30% [1, 2, 3] of young individuals being impacted. For those affected, these TDIs are painful experiences on a physical level, but they often also influence the emotional and psychosocial well-being of these individuals [4, 5]. Current evidence [6] supports the above notion that children and adolescents who have suffered a traumatic injury to the dentition experience significant negative impacts to their overall well-being.

The psychological, social and emotional impacts of a TDI are unique to each individual which then impacts upon their treatment preferences, coping and eventual recovery. Contemporary dentistry and medicine now recognize the critical prerequisite which is to identify and address these psychosocial aspects as part of a more holistic approach to healthcare. Furthermore, if such traumatic injuries are not effectively and holistically managed, then the affected individuals are shown to be more likely to suffer decreased self-esteem and low feelings of self-worth due to their changed appearance [4]. Quality of life is negatively impacted and often children whose appearance is affected are reluctant to laugh or smile and if there is pain or a fracture then they are also unable to enjoy their food or even brush their teeth properly. This has further consequences for them in terms of their health. This could then impact their lives negatively as they often do not have the coping mechanisms in place to help them navigate these difficult situations. Thus, childhood and adolescence are sensitive developmental periods that may pose complex challenges to the effective management of dental trauma. Dealing with the consequences of childhood trauma is a complex interplay between managing expectations with the hidden impacts of the traumatic event. This eventually influences both patient compliance and cooperation which are key to successful outcomes. Thus, full family collaboration and involvement from the starting point of injury is critical. The emphasis on a team effort being a point of note to be emphasized at all visits. There is also an urgency to engage in consistent monitoring and long-term follow up, especially in the not fully mature patient with a developing dentition. The high probability that there will be psychological impacts stemming from the traumatic event has become a frequent finding with studies [4, 5, 6] showing that effects can be seen in the overall negative well-being of the child.

In this chapter we will consider the possible social and psychological consequences of dental trauma in young individuals whilst simultaneously indicating the various management techniques for approaching these dental traumatic injuries in children and adolescents.

2. Psychological impact of dental trauma on children and adolescents

Tooth loss affects many people and can impact individuals severely in that it often leads to hidden consequences that need to be managed strategically and holistically. These hidden consequences at impact affected individuals in varying degrees include psycho-social and emotional impacts. A recent study [4] also indicated that the mental well-being of children is frequently adversely affected following dental trauma and the consequences of such injuries significantly impact the psychosocial and emotional wellbeing of the affected children. This is because whether a tooth was knocked out due to dental trauma or disease, the result is the same: negatively affected oral health and esthetics.

It is common knowledge amongst oral health professionals that not attending to tooth loss can have detrimental effects for oral health wellbeing in any individual. The long term effects include tooth migration, jawbone loss and even the eventual loss of additional remaining teeth. Thus as noted, dental trauma and the physical effects are usually given priority within the clinical context. However, a critical aspect of dental trauma which is linked to the nature or circumstances of the incident itself, is the potential for affected children to consequently experience negative mental health outcomes. Whilst the physical effects of tooth loss are known and documented widely, distinguishing the deeper level emotional effects of the dental trauma can be more challenging.

Evidence also indicates that previous traumatic injuries to a child’s dentition impacts negatively on their oral-health-related quality of life [7, 8]. No matter the reason, tooth loss or other types of dental trauma for any individual is almost always a negative experience. Children are particularly vulnerable in these circumstances. A child who has been impacted by dental trauma can go on to develop decreased feelings of self-worth and a lowered self-esteem due to their changed appearance. They may often also experience feelings of sadness, anger, hopelessness and loss of confidence. Affected appearances may also predispose these children to teasing, bullying [9] and torment from other children or peers they come into contact with. This is especially the case for those injuries that have not been effectively or holistically managed.

To this effect, literature around general physical injuries on any part of the body of a child indicates that approximately 50% of all injured children can show signs of post-traumatic stress disorder (PTSD) at six weeks and as late as eight months after the physical injury [10, 11]. In terms of facial esthetics, Kaur et al. found that disappointment with one’s own dental esthetics is a strong predictor for negative self-esteem [12]. A myriad of dental issues that include visible tooth loss, visible untreated caries and malaligned teeth influence a person’s perceptions of esthetics as well as psychosocial behavior in young people. This then impacts on self-esteem.

It is now almost a decade since the global medical pediatric emergency fraternity called out for improved psychological evaluations and assessments of children impacted by any type of trauma [11]. This was so that management and support guidelines could be duly effected in order to be able to emotionally support those young individuals who are vulnerable and at high risk of developing Post Traumatic Stress Disorder (PTSD). Consequently, it is crucial that oral health professionals are also conscious of the possibility that some children with a traumatic dental injury may experience negative psychological effects due to the mental trauma associated with the distressing incident. The impacts of negative mental health within the dental context may only become obvious at subsequent dental visits through displays of anxiety and disruptive behavior. These factors also need to be further explored. It should also be noted that the affected children have to deal with both the traumatic incident from their own perspective, as well as the secondary emotions and distress from their parents and/or friends.

3. Impact of traumatic injury on social well-being and Oral health related quality of life (QoL) in children and adolescents

Taking the above factors into consideration, it is indicative that a part of the reason a person loses self-confidence is related to the underlying social stigma attached to tooth loss. Evidence points to social consequences which includes shying away from relationships or socializing with peers [13, 14]. This ultimately leads to patients who had dental trauma having less meaningful social interactions that can affect their overall well-being, as compared to others with no trauma that affects their esthetics.

Evidence [15] shows that essential functional activities that are compromised in children affected by dental trauma include: chewing, speaking, showing their teeth and brushing. Peers also engage in social judgment [16, 17] and tend to judge those with visible facial trauma more negatively than they judge others, with younger age groups being more negatively judgmental than older children. This can also be attributed to a greater degree of mental maturity in older children [18, 19]. Unfortunately, these negative social judgments can then have a lifetime of consequences, impacting career and even relationship success [16, 17].

Due to a lower self-esteem and poor confidence levels stemming from these traumatic events, affected individuals are then prone to neglect their self-care and may even start to lack in basic hygiene. This ultimately leads to poor social interactions and eventually impacts on financial status and income in later years. The lack of social interaction also impacts individuals negatively because this then impairs their ability to form close friendships or engage in romantic relationships later in life. Thus, the long term impacts of poorly managed dental trauma can significantly impact on individuals well-being and be pervasive in all areas of their lives [20].

4. Management guidelines for managing dental trauma amongst children and adolescents

Management guidelines for the holistic treatment of dental trauma amongst young individuals include the following:

4.1 Treatment of immediate pain and full history of complaint

As a first step, the oral health professional should immediately conduct all the necessary steps that entail selection of appropriate trauma treatment as needed. Pain elimination should be a high priority. The clinician should also simultaneously reassure the child and the parents/caregivers in order to alleviate their high levels of anxiety. This stage of treatment is also crucial for building rapport with the child and the parent/caregiver. The element of trust needs to be solidified early in this relationship between clinician and the affected child with parents/caregiver included.

Because there will be pain involved this first step is crucial because all individuals associate new experiences with past experiences and if the past experience was accompanied by pain, then future dental visits may be construed in the same light. Parents/caregivers may also be anxious about long term impacts on the child’s esthetics as well as the added financial burden that this injury now presents with. Thus, by alleviating all these concerns, the oral health professional will help to allay long-term consequences that could significantly impact long-term treatment and care.

During this visit, a full medical, behavioral and social history of the patient should be detailed out in the patients file. All this information can be garnered from the parent who can then be distracted from their anxiety during this information session as well since they will be kept busy, even if for a short period of time. The importance of attending all follow-up visits must also be constantly reiterated with patients and if needed, a financial plan drawn up together with the patient in order to consider all factors that may impact upon long term follow-up visits.

4.2 Strategies to ease anxiety in affected individuals

The entire oral health team will need to work together to ensure that these young individuals are afforded a very low stress environment in order for treatment procedures to be meted out successfully. The following recommended treatment and behavioral strategies can be considered when managing these individuals who will be fearful and anxious due to the uncertainties surrounding the short and long-term consequences of their injuries:

4.2.1 Restoration of esthetics: after the initial clinical examination, radiographic examination and sensibility tests to determine condition of the pulp, recommended treatment strategies for dental traumatic injuries should be followed

According to Flores et al., for an uncomplicated crown fracture the following can be done: if any portion of the broken tooth is available, this can be bonded to the affected tooth. Emergency care involves covering of the exposed dentin with either permanent restoration material or a glass ionomer using a compatible bonding agent. The use of accepted dental restorative materials is recommended in order to restore esthetics to the highest level of suitability as possible [21].

According to Flores et al., for complicated crown fractures the following can be done: for teeth that are still developing, all attempts to preserve pulp vitality by a partial pulpotomy or pulp capping. This treatment procedure can also be used in children with completely formed teeth. Esthetically pleasing materials for such procedures include calcium hydroxide and Mineral Trioxide Aggregate (white). With patients more advanced in age, root canal treatment can be the treatment of choice and factors that also further determine this would include how much time has lapsed between the incident and treatment [21].

Behavioral strategies to ease anxiety in children during their clinical examination and treatment include the following:

4.2.2 Distraction

This technique involves talking to the child in a comforting manner throughout the treatment procedure in order to veer their thoughts away from what you are doing on them currently. All words and terminology used should meet the mental maturity of the individual at all times. Distraction may also include allowing the child to watch cartoons or music videos whilst you are working on them.

4.2.3 Tell-show-do

This technique involves you showing the child the instrument you will be using on them whilst showing them the instrument itself and then only using the instrument on him/her. It thus focuses on using a step-by-step technique to draw the individual into this specific experience. For example, if you are planning on using a probe to start off with, then show the individual the probe whilst you explain the functions of the probe and what you are going to do in the mouth with it. This technique was introduced by Addelston [22] more than half a century ago and has been shown to be highly effective [22].

4.2.4 Behavior shaping

For this technique, you introduce everything that you are doing in small steps and praise the child after each accomplishment. Example, sitting on chair follows with praise, then opening mouth wide follows with praise then allowing you to treat them is followed by praise or even a reward, like a sticker. Ensure that you are always using basic language and terminologies that the individual will easily understand.

4.2.5 Modeling

In the modeling technique, one would show the affected child video clips of other children having dental procedures being done on them. This will hopefully prompt the child to feel that they are also capable of being like the children in the video clips.

4.2.6 Right of choice

In order for the individual to feel a sense of involvement in the procedure, it is important to involve them in some aspects of decision-making around their treatment which are non-impactful. An example of this would be what flavor of topical anesthetic to use or even which glove to put on which of the clinician’s hands [22, 23].

4.2.7 Non-verbal communication

Patients can be informed that they can communicate at any time during the treatment by lifting their hand up or if questioned, they can use a thumbs up for affirmative and thumbs down for negative. The clinician will always stop for the hand up signal or thumbs down signal. This will help in reassuring the patient that they are still able to communicate with the clinician during the procedure and may reduce feelings of powerlessness that young individuals may feel when being treated in a clinical environment.

4.2.8 Management of psychological impacts

Children who experience dental trauma often develop anxiety and fear due to pain associated with the traumatic injury itself. Experiencing pain during such an episode can have lifelong consequences on future and long-term dental treatment. Because research [8] strongly indicates a negative impact on oral health quality of life and levels of anxiety in children, dentists are advised [23] to manage patients whilst taking into consideration the following factors: (a) Removing or minimizing of predisposing factors (example, do not keep extraction forceps within sight or do not have pictures/artwork of individuals in dental chairs having extractions done) in order to create a safe and comfortable environment within the dental setting to avoid further negative experiences; (b) educating children and their caregivers on how to avoid situations leading to dental trauma (example, having seatbelts on at all times or using mouthguards during extreme sports); (c) encouraging use of and providing protective devices for children who are susceptible to dental traumatic injuries (example, mouthguards and head/face protective helmets for those children engaging frequently in high impact and/or contact sports); and (d) immediately treat any signs of traumatic dental injury. Since the occlusion is a predisposing factor for traumatic dental injuries, early orthodontic treatment for such children may be a factor worth considering as a long term preventive strategy. Subjective and objective evaluations of anxious, fearful and phobic patients who display negative psychological behavior in the dental setting are suggested in order to enhance the diagnosis for comfortable and successful patient management.

Psychophysiological patient responses can include the following:

• Muscle tightness

• Restlessness

• Unsteady hands

• Excess sweating

• Constant clearing of throat

• Strong startle response

• Frequent urination

• Holding things very tightly

• Pulsation in the temporal and carotid arteries

• Depth and speed of respiration

Subsequent behavioral and emotional responses can include the following:

• Inattentiveness

• Irritation

• Talking fast

• Hyperactivity

• Getting tongue-tangled

• Outbursts of emotions

• Sitting on the edge of the chair

• Pacing

• Rapidly thumbing through magazines

• Confusion

• Poor memory

• In a hurry

• Nervousness

• Leaning forward whilst sitting

• Excessive worrying

• Outbursts of emotions

Based on the dentist’s experience and expertise, anxiety and phobias can be managed by psychotherapeutic interventions, pharmacologic interventions, or a combination of both.

According to Appukuttan [24], psychotherapeutic interventions can include the following [24]:

• Communication skills: a two-way communication strategy between dentist and patient where both parties are given an opportunity to converse freely. This must start at first visit as it also helps to build rapport and trust between both clinician, the patient and their caregivers/guradians/families.

• Relaxation techniques: deep breathing and muscle relaxation can be encouraged in patients because it is almost impossible to be psychologically upset whilst being simultaneously physically relaxed. It is further suggested that dentists acquire training in this technique and practice it with anxious or phobic patients prior to the commencement of treatment.

• Guided imagery: this technique can be performed by an adequately trained dentist or with the use of audio recordings. It involves teaching patients to create a mental image of a personally comforting experience that consciously navigates their attention toward complete body relaxation, thereby minimizing anxiety.

• Biofeedback: requires trained dentists or therapists to use specific instruments to monitor patients and to then use the information obtained to help patients practice and obtain self-regulation of their emotions.

• Acupuncture: a procedure whereby tiny needles are inserted in specific areas on the body to target healing of ailments, in this case anxiety. It is a procedure used widely but does require special training before it can be introduced into practice.

• Enhancing control: a procedure where patients get to feel like they have a sense of control over the procedure. This includes them giving the dentist a signal to pause treatment when they need a break (and dentist should adhere to this agreement) or giving patient a mirror to watch the procedure beign conducted on them.

• Positive reinforcement: this technique rewards desired behaviors and subsequently encourages the continuation of those behaviors. Such reinforcers include verbal praise, positive facial expressions and/or positive voice modulation.

• Cognitive behavioral therapy (CBT): this technique attempts to redefine the content of negative cognitions and thereby increase the patient’s control over their own negative thoughts by redirecting their thoughts. This technique is a mixture of cognitive and behavioral approaches and includes learning to change negatively distorted thoughts and actions. Basically, new skills are learned to manage anxiety symptoms over s series of visits. However, dentists do need specialized training before this therapy can be instituted by them.

4.3 Multi-disciplinary team approach

Oral health professionals should have a comprehensive referral list on hand where patients can be referred and duly accommodated at the practice being referred to. At one of the initial dental visits, families should be comprehensively informed about all the possible consequences of traumatic dental injuries and who they could see if any issues arise post-treatment if the issue does not have a dental focus. The referral list should then be shared with all families of young individuals experiencing dental trauma—whether they ask to be referred to other healthcare professionals or not. This list should include amongst others: social workers, psychologists, trauma counselors, play therapists, pediatric specialists and maxillofacial surgeons who specialize in treating children. There should also be regular communication amongst these professionals as this is imperative to long-term treatment success for any of these professionals.

5. Conclusion

Traumatic dental injuries that are not effectively and holistically managed are significant in that they have been shown to impact on an individual’s quality of life. In most societies, esthetics is held in high regard, specifically facial esthetics. Trauma to the outer and inner oral structures can leave an individual with dental anomalies or deformities. This can then cause body dysmorphic issues in that a person battles to accept their changed appearance leaving them stressed and anxious. The traumatic event itself can have lasting negative repercussions which when combined with a changed appearance, can cause long term psychological effects for the patient. These negative impacts can be negated by means of a comprehensive emergency care strategy that is accompanied by a comprehensive referral system and multidisciplinary team approach.

Conflict of interest

The author confirms that there are no conflicts of interest related to this piece of work.