Enhancing treatment outcomes in dental traumatology—dental trauma first aid and the implementation of mouthguards

Abstract

Research in dental traumatology plays a crucial role in advancing our understanding of oral injuries and improving treatment outcomes for patients worldwide. There is a lack of qualitative or mixed method studies found in the dental traumatology literature, and thus, opportunities are being missed to gain insights into patients' perspectives of traumatic dental injuries (TDIs).¹ In this Issue, Kenny et al. provided an overview of qualitative research, its key approaches, and how to appraise it, and explored its potential value to dental traumatology research.² This review summarizes the common strategies and methods used and outlines the key factors that guide the appraisal of qualitative studies. Applying qualitative research methods in dental research is important to generate rich and detailed data to provide explanations and insights into people's experiences, beliefs, attitudes, and the complexity of human decision-making and behavior.

The application of finite element analysis (FEA) in dentistry research offers valuable insights into the biomechanics of the oral cavity, facilitating advancements in dental science and clinical practice.^3-8 In this Issue, Atif et al. reviewed FEA applications in dental traumatology research, evaluated their quality and outcomes, and assessed methodological aspects.⁹ Finite Element Analysis is an important tool for understanding dental traumatology biomechanics, aiding diagnosis, preventive measures, treatment planning, and outcome prediction.

Mineral trioxide aggregate (MTA) apexification is an option for treating immature teeth with necrotic pulps as MTA provides scaffolding for the formation of hard tissue and the potential for a biological seal.¹⁰ Tooth apexification results in horizontal calcification in apical areas in most cases with a weaker apical closure trend and thinner dentin wall thickness, with a strong tendency to form a calcific barrier rather than a normal apical constriction.¹¹ In this Issue, Chotvorrarak et al. suggested methods and clinical findings for reinforcing traumatized anterior immature teeth with pulp necrosis treated with MTA apexification.¹² Immature teeth treated using MTA apexification should be appropriately restored to prevent cervical and root fractures.

Inadequate and fragmented education in dental traumatology within undergraduate dental education results in insufficient clinical exposure to TDI in most dental schools.^{13, 14} Dentists often exhibit insufficient knowledge in treating TDIs, highlighting the fact that comprehensive dental trauma education is crucial for adequately preparing dental students to manage cases of oral injuries.^{13, 15-17} In this Issue, Cvijic et al. assessed the knowledge of general dentists on the acute management and follow-up of TDIs and their sociodemographic and attitudinal covariates.¹⁸ Sociodemographic and professional profiles of respondents as well as attitudinal indicators were queried. Clinical case scenarios on emergency treatment and further follow-ups of TDI were used to calculate a dental trauma knowledge score. Continuous education on dentoalveolar trauma will likely improve dentists' knowledge level and consequently their treatment decisions.

Ensuring that emergency paramedics and medical personnel are trained to conduct intraoral examinations to identify trauma-affected teeth is essential, as is educating all stakeholders involved in TDI about preventive measures and appropriate emergency response strategies.^19-21 Understanding dental trauma first aid is crucial, yet it has been reported as lacking among numerous public members.²⁰ Social media, with its accessibility and widespread influence, has emerged as a prevalent platform for health content, likely extending to TDIs given the common reliance on online platforms, including mobile apps like ToothSOS, for accessing health information.^22-24 Pediatricians often demonstrate inadequate knowledge of dental trauma first aid, and their awareness of avulsion treatment and tools like the ToothSOS mobile application remains deficient.²⁵ Moreover, sports coaches, who often play a critical role in the immediate response to orodental injuries, lack awareness of appropriate first aid measures for such incidents.^{26, 27} In this Issue, Alomari et al. evaluated the short- and long-term effects of educational intervention on elementary school teachers' knowledge of traumatic dental injuries.²⁸ The study included elementary school teachers in the United Arab Emirates. The assessments were performed using a four-part validated questionnaire that evaluated demographics, knowledge, attitudes, and self-assessment concerning TDIs and were conducted before and after a lecture presentation featuring various dental trauma scenarios. Educational sessions are pivotal for enhancing treatment outcomes in dental traumatology.

Furthermore, in the present Issue, Wenger et al. assessed the knowledge levels of the management of TDIs among athletic trainers in the Midwest of the United States, and evaluated variables that may influence knowledge levels.²⁹ A survey including background, emergency management of TDIs, and opinion questions was sent to athletic trainers. This study emphasizes the importance of the sports community having adequate education on emergency management of such dental injuries.

The COVID-19 pandemic confronted the global healthcare system with immense challenges, having specific effects on the daily lives of all people and also influencing the patterns, circumstances, and distributions of injuries and trauma.^23-33 In this Issue, Dudde et al. analyzed the impact of the COVID-19 pandemic on mandible fracture patterns and circumstances in a German cranio-maxillofacial trauma center.³⁴ This retrospective study compared the mandible fracture patterns of patients in the pre-COVID era with patients in the intra-COVID era. The number and types, location, circumstances leading to mandible fracture, hospital admissions, and treatments were analyzed. The COVID-19 pandemic had a potential impact on traumatic injuries, such as mandible fractures, underscoring the broader implications of public health crises on traumatic injury patterns.

Due to the proximity of the face and the brain, there is a tendency to relate facial fractures to brain injury; among patients with facial injuries, traumatic brain injuries account for over 40% of cases, and as facial injury severity increases, so does the likelihood of experiencing a traumatic brain injury.³⁵ In this Issue, Mao et al. evaluated the correlation between traumatic brain injuries and maxillofacial fractures, as well as the impact of age, sex, trauma mechanism, and season on traumatic brain injuries.³⁶ Demographic information, cause of injury, maxillofacial fracture type, and traumatic brain injury type were collected. Maxillofacial surgeons and emergency physicians should be aware of the likelihood of traumatic brain injuries in patients with maxillofacial fractures to decrease underdiagnosis of traumatic brain injuries and consequent complications.

Roughly half of all maxillofacial injuries primarily impact the lower third of the face, with a notable emphasis on the condyle region.³⁷ The primary causes of mandibular condylar fractures are falls, road traffic accidents, and assaults.^38-40 In terms of epidemiological distribution, males constitute a larger proportion of mandibular condylar fractures, while the incidence among the pediatric population is relatively lower compared to adults.^{39, 41} In this Issue, Chen et al. investigated the demographics, causes, classifications, clinical manifestations, and treatments of pediatric mandibular condylar fractures, as well as the concomitant injuries in maxillofacial and other body parts.⁴² This retrospective study analyzed the clinical data of 189 pediatric patients with mandibular condylar fractures between 2011 and 2022. Mandibular condylar fractures in pediatric patients may exhibit distinct epidemiological characteristics attributed to their unique growth and development phase, as well as various anatomical, physiological, biomechanical, and behavioral factors that differentiate them from adults.

Sports mouthguards, recommended for various athletic activities, are effective tools for preventing and reducing common orofacial injuries, thus mitigating the heightened risk of dental trauma among people engaged in sports worldwide.^{43, 44} In this Issue, Haddad e Borro et al. assessed the surface characteristics of sports mouthguards under mechanical stresses during cleaning, either by brushing or immersion in disinfectant solutions.⁴⁵ Ethylene-vinyl acetate samples were randomly assigned to cleaning methods: no cleaning, brushing with water, brushing with neutral liquid soap, brushing with toothpaste, immersion in distilled water for 10 min, immersion in 2.25% sodium hypochlorite solution for 10 min, and immersion in sodium bicarbonate solution for 5 min. Surface roughness average and wettability were measured. Besides encouraging the use of the appropriate fitting and designed mouthguards, improvements should be made to their maintenance and guidance on how to clean them so that they last longer.

Moreover, in this Issue, Mat Zainal et al. investigated the effects of sports mouthguards on oral functions and speech over time.⁴⁶ Thirty national rugby players received custom-fitted mouthguards. Their questionnaire responses and speech recordings were collected before mouthguard use and at various intervals after using mouthguards. Mouthguards are crucial for protecting athletes against orofacial injuries, yet concerns persist regarding their potential impact on oral functions. It is important to spread the message that custom-fitted mouthguards do not lead to significant long-term disruptions in oral functions and athletes generally adapt to mouthguard use, reporting improved comfort and greater support for their use.⁴⁶

The mobility of the traumatized tooth can be influenced by factors such as the splinting material, splint extension, the presence or absence of the neighboring intact permanent teeth, and the condition of the periodontal ligament (PDL).^{6, 7} The International Association of Dental Traumatology guidelines recommend the use of 0.25 mm nylon-resin composite splints for stabilizing permanent teeth.^{47, 48} However, less information is available regarding their use in mixed dentitions with missing teeth.^{6, 47, 48} In this Issue, Atif et al. aimed to determine the appropriate dimensions of stainless steel wire and its extent, for achieving the physiologic mobility in primary dentition.⁴⁹ This study was designed as an in vitro experiment using a typodont primary dentition model. Splinting was done using 0.2 mm, 0.3 mm, and 0.4 mm stainless steel wire. These groups were subdivided based on the extent of the splint, pre-splint mobility, and post-splint mobility. Because of the different macroscopic dimensions of primary teeth, and hard tissue variations at the microscopic level for enamel crystals, there may be varied mechanical behavior of the splint in terms of hardness and elastic modulus. Therefore, recommended specifications of splinting in permanent dentition might vary for primary teeth.