What's Next in Dental Trauma? Innovations, Preventive Strategies, and Future Treatment Paths

Abstract

Sport-related traumatic dental injuries (TDIs) are prevalent, particularly in contact sports like football, hockey, and basketball, where athletes face a higher risk of injury [1, 2]. Custom-made sports mouthguards are widely recognized as one of the most effective preventive measures for preventing TDIs, offering superior protection compared to over-the-counter or boil-and-bite alternatives [1]. Despite their proven effectiveness, there is no globally standardized approach to the design, fabrication, or usage of mouthguards, leading to inconsistencies in their protection quality. In this issue, Avgerinos et al. emphasized the need for mouthguards made from FDA-approved materials and offered a position statement for the proper selection, construction, clinical use, and maintenance of mouthguards [3]. These guidelines highlight the importance of educating both dental professionals and athletes about the benefits of mouthguards in reducing the prevalence of TDIs in sports. The lack of a standardized approach to mouthguard fabrication underscores the need for global consistency to ensure that all athletes receive optimal protection against dental injuries.

Dental trauma is a prevalent concern in the field of dentistry, affecting individuals across various age groups, with the anterior teeth being the most commonly injured [4, 5]. The most frequent types of dental trauma include crown fractures, avulsions, and luxations, with varying degrees of severity in pulp and surrounding periodontal tissues [6, 7]. Effective treatment of these injuries is essential to restore both function and aesthetics [7, 8]. Among the available treatment options, dental fragment reattachment has emerged as an ideal solution for rehabilitating fractured teeth. This technique involves reattaching the fractured dental fragment using adhesive materials, offering both aesthetic and functional benefits while maintaining the integrity of the original tooth structure [9]. In this issue, Mulinari et al. conducted a bibliometric and altimetric analysis to explore the evolution of publications on this topic [10]. This analysis provides insights into the scientific trends surrounding dental fragment reattachment, highlighting the growing body of research and its implications for clinical practice.

Traumatic dental injuries to the permanent dentition are a significant health problem with potential life-long consequences [11]. One common and serious complication following dental trauma in children and adolescents is pulp necrosis in immature permanent teeth [12, 13]. The treatment of these injuries can be particularly challenging due to the unique anatomical and physiological characteristics of immature teeth, such as open apex, unfavorable crown-to-root ratio, thin dentinal walls, and a higher risk of root fractures. These factors complicate treatment options and necessitate a careful approach [14, 15]. Although various interventions are available for managing pulp necrosis in immature teeth, including apexification with calcium hydroxide, apexification with calcium silicate-based materials (MTA), and regenerative endodontic treatment (RET) [6, 14, 16, 17], the growing number of publications on these topics has made it difficult to form definitive conclusions. Discrepancies and variations in the reported outcomes of these treatments underscore the need for further comparative evaluation of the existing evidence. In this issue, Tewari et al. conducted an umbrella review to analyze the available scientific evidence on the effectiveness of these three techniques [18]. This evaluation compared the three approaches and assessed the quality of the published evidence, providing insights into the most effective treatment options for pulp necrosis in immature permanent teeth.

Several factors and mechanisms contribute to traumatic dental injuries, including falls, sports injuries, and road traffic accidents [19, 20]. The existing literature extensively documents these common causes of dental trauma. However, additional underlying factors, such as the proclination of anterior teeth, inadequate lip coverage, neuromotor disorders, and impaired postural balance, can also increase the risk of injury [21-23]. Although there is ample literature, there is a noticeable gap in research regarding the role of sensorineural systems, particularly hearing loss and vestibular dysfunction, in the occurrence of TDIs. In this issue, Rajeswary et al. conducted a comparative study examining the prevalence and patterns of TDIs among children and adolescents with severe-to-profound hearing impairments versus those without hearing impairments [24]. This study emphasized the importance of addressing the unique needs of children with hearing loss to reduce the risk of traumatic dental injuries.

Oral and maxillofacial injuries (OMFIs) are among the most frequently affected body regions in cases of urban violence, making them a significant concern for trauma management in high-risk areas [25, 26]. While both men and women face similar risk factors associated with OMFIs in violent urban environments, behavioral, social, and even cultural factors can significantly influence the prevalence, nature, and outcomes of these injuries between the sexes [25, 26]. As a consequence, the etiology, frequency, severity, and anatomic distribution of OMFIs may exhibit differences depending on sex. In this issue, Fernandes et al. assessed the distinct characteristics of OMFIs in women and men admitted to a referral hospital in Brazil, with a specific focus on their correlation with urban violence [27]. By analyzing these injuries, the authors identified significant differences in the underlying causes of OMFIs between the sexes, highlighting the variations in trauma mechanisms. The study also emphasized noteworthy differences in the incidence of dentoalveolar injuries, as well as the frequency of multiple facial fractures.

Dental avulsion is a serious injury where a tooth is completely displaced from the alveolar socket and can lead to functional and psychological issues, especially when maxillary central incisors are involved [28]. Delayed replantation of avulsed teeth is a key issue as it leads to periodontal ligament (PDL) necrosis and worsens the prognosis, increasing the risk of resorption. This is influenced by factors like extra-alveolar storage time, storage medium, and root development stage [6, 29]. In this issue, Sheikholaemeh and Sengul evaluated the long-term PDL healing patterns and the factors influencing the survival of avulsed teeth [30]. By investigating these factors, the study seeks to better understand how root development stages impact the healing and survival of replanted teeth after an avulsion injury.

Facial trauma, often involving maxillofacial skeletal fractures, is a common issue in emergency departments, with about one-third of trauma cases including fractures in the maxillofacial region [11, 31]. These types of trauma can lead to significant functional, aesthetic, and psychological issues, placing a burden on individuals and society [32, 33]. Orbital fractures are frequently associated with complex midface fractures, and about 36.3% of maxillofacial trauma cases involve orbital fractures [34]. Ophthalmic injuries accompanying maxillofacial trauma can range from mild issues like subconjunctival hemorrhage to severe conditions such as corneal lacerations, globe rupture, and retinal detachment. These injuries, particularly those related to orbital fractures, can result in potentially blinding complications [35]. However, these injuries are often not immediately apparent and can be easily overlooked, leading to delayed or inadequate treatment. In this issue, Khan et al. assessed the patterns of ophthalmic injuries in maxillofacial trauma patients over a 12-year period at a Medical College in India [36]. By evaluating these injury patterns, the research aimed to provide valuable insights into regional trauma trends, which could help in formulating preventive strategies and improving treatment planning for ophthalmic injuries in maxillofacial trauma cases.

Iatrogenic factors like endotracheal intubation during general anesthesia might cause TDIs in some cases [37-39]. TDIs associated with general anesthesia are a major cause of malpractice claims against anesthesiologists. Despite being a frequent complication, there is a notable lack of education among anesthesiologists concerning dental anatomy, the risk of TDIs associated with endotracheal intubation, and effective management strategies. In this issue, Al- Shiekh assessed the awareness, knowledge, practices, and attitudes of anesthesiologists regarding TDIs associated with endotracheal intubation during general anesthesia [40]. This research aimed to identify gaps in knowledge and suggest measures to reduce the risk of peri-anesthetic traumatic dental injuries, ultimately improving patient care and minimizing complications during anesthesia procedures.

Tooth loss in the anterior maxilla of young individuals is commonly attributed to TDI or congenital agenesis [32, 41, 42]. This loss can present both functional and aesthetic challenges, complicating the process of tooth replacement [20]. When it comes to addressing these challenges, several treatment options are available, including implant-supported restorations, conventional fixed dental prostheses, resin-bonded bridges, and autotransplantation [43, 44]. While implant-supported restorations offer excellent aesthetic results, they come with limitations, particularly for growing patients. Among the treatment alternatives, autotransplantation of premolars to the anterior maxilla is often overlooked despite showing high survival rates [45]. However, the existing studies on the long-term survival of autotransplanted teeth are limited, and few have addressed the prognostic factors influencing the success of this treatment. Additionally, the aesthetic outcomes and patient-reported outcomes are less studied compared to treatments involving implant-supported restorations, leaving gaps in understanding the full potential of autotransplantation [46]. In this issue, Akhlef et al. reported the long-term survival rate, success rate, aesthetic outcomes, and patient-reported outcomes of premolar autotransplantation to the anterior maxilla in 122 patients [47]. This study evaluated the prognostic factors that could influence both the survival and aesthetic success of the treatment, providing valuable insights for clinicians and patients considering autotransplantation as a viable alternative for tooth replacement.

Dental injuries often occur during childhood, especially when learning to walk, with many incidents taking place at home [32, 48, 49]. While the emergency management of TDIs is critical, public awareness remains insufficient [8, 50-52], prompting many individuals to seek guidance from online platforms. As technology advances, Artificial Intelligence (AI) tools like chatbots have become more popular for accessing health information, especially in emergencies [53, 54]. However, concerns remain about the accuracy and reliability of these tools. For conditions like TDIs, timely and accurate advice is crucial, as misinformation can lead to serious consequences. Despite this, many people turn to online platforms for guidance due to insufficient public awareness of TDI emergency management. In this issue, Guven et al. evaluated the performance of AI chatbots, comparing the readability and reliability of responses to patient queries about TDIs [55]. The evaluation highlighted the strengths and limitations of AI tools like ChatGPT, helping healthcare professionals and patients navigate dental emergencies more effectively.

Vertical root fractures (VRFs) are often caused by excessive occlusal forces in restored teeth, particularly in mandibular molars and premolars, as well as the insertion of retention pins or screws. Early detection of VRFs is vital to prevent damage to surrounding tissues [56, 57]. However, VRFs' diagnoses are challenging because they often present subtle or no symptoms [58]. In clinical practice, intraoral periapical radiographs are the standard imaging technique, but they have limitations in detecting VRFs due to the two-dimensional nature of the images. To address these challenges, AI-based image enhancement techniques are being explored to improve diagnostic accuracy. While Cone-Beam Computed Tomography (CBCT) offers three-dimensional imaging, it is prone to metallic artifacts and is not considered the primary diagnostic tool for VRFs due to its limitations [58-60]. Therefore, there is a significant need for an improved and reliable method to diagnose VRFs without unnecessary radiation exposure. In this issue, Ozsari et al. evaluated the use of AI-based transfer learning techniques to enhance VRF detection from intraoral periapical radiographs [61]. Deep learning models such as DenseNet, ConvNext, Inception, MobileNetV2, and fusion approaches were applied. These AI-based models aim to address the limitations of traditional radiography and provide a cost-effective solution for better VRF detection in clinical practice.

Facial injuries, particularly to the teeth, are common in sports-related accidents. These injuries are particularly prevalent in contact sports, which present a much higher risk than non-contact sports [2, 62]. TDIs can result in serious, long-term damage to teeth and surrounding structures, significantly impacting an athlete's health and performance. Despite the well-known effectiveness of mouthguards in preventing such injuries, a large number of athletes still fail to wear them consistently, and many of those who do use them experience discomfort or inadequate protection due to poor fit or substandard quality [63, 64]. It is well known that sports mouthguards should be designed and custom-fabricated to guarantee an ideal fit and maximum comfort for the athletes. The stock and boil-and-bite mouthguards are commonly available in sports stores; however, they often provide poor adaptation to the unique shape of the mouth and fail to offer sufficient retention, compromising their effectiveness and comfort [65]. This highlights the need for improved sports mouthguards that offer both robust protection and comfort. In this issue, Mizuhashi et al. proposed a design criterion for fabricating sports laminate mouthguards with sufficient thickness to protect orofacial structures [66]. The study emphasized the importance of maintaining appropriate measurements on the labial, buccal, and occlusal surfaces to ensure optimal protection.