Towards a Comprehensive Approach to Dental Trauma: Risks, Responses, and Innovations in Clinical Practice

Abstract

Contact sports are frequently associated with a high risk of orofacial injuries, including dental trauma and facial fractures [1-3]. To reduce these risks, protective devices such as mouthguards and faceguards have been commonly used in sports such as football, boxing, ice hockey, baseball, and rugby [4-7]. Conventional fabrication techniques for these devices are well established in the literature [8]. However, the use of digital workflows for producing custom faceguards has not yet been standardized, and protocols remain limited. In this issue, Rondon et al. presented an overview describing the use and the potential benefits of digital technology in the design and production of faceguards [9], offering new perspectives on its application within dentistry and sports-related care.

Physical activity includes a variety of movements such as running and climbing, and its benefits are well established in the literature [10, 11]. Engaging in regular physical activity during childhood helps prevent obesity, supports physical and cognitive development, and lowers the risk of systemic diseases [11]. However, participation in moderate to vigorous physical activities, particularly when not properly supervised, can increase the risk of injuries, including traumatic dental injuries (TDIs) [1, 5]. Some evidence suggests a possible association between physical activity and TDIs [12, 13], exploring how this activity affects the prevalence and severity of TDIs in preschool children. In this issue, Lopéz et al. presented a study evaluating the association between physical activity and the prevalence and severity of TDIs in a cohort of 4-year-old children from Southern Brazil [14]. The findings of this study highlighted the importance of understanding how early-life physical activity may impact oral health and reinforced the importance of preventive strategies to minimize dental injuries in young children.

TDIs in childhood can be caused by various factors, including lack of motor skill coordination, increased physical activity, lack of supervision, and environmental risks [15-17]. Falls, collisions, and accidents during play are the most frequently reported causes [15]. Globally, the prevalence of TDIs in the deciduous dentition is estimated to be over 20%, with anterior teeth, particularly the maxillary incisors, being the most commonly affected due to their prominent position in the dental arch [18]. These injuries can result in pain, impaired mastication, and functional limitations, as well as esthetic concerns that negatively impact the quality of life of children and their families [19, 20]. Moreover, because of the close anatomical relationship between the apex of a primary tooth and the underlying permanent tooth germ, trauma to the deciduous dentition may result in developmental disturbances in the permanent successors. These sequelae, which include enamel hypoplasia, discoloration, and disturbances in eruption, are often unpredictable and may only become evident after a considerable time period. A long-term follow-up and careful clinical evaluation are essential in cases of TDIs involving primary teeth. In this issue, Fagundes et al. investigated the impact of different treatment approaches, whether conservative or invasive, on the development of sequelae in permanent successor teeth following TDIs to the supporting tissue of anterior primary teeth [21]. The study underscored the need to consider key clinical variables when assessing the risk of long-term consequences and emphasized the importance of selecting the most appropriate treatment strategy to minimize potential adverse effects on the permanent dentition.

TDIs are a global public health problem, with a high prevalence in children. However, it is also notable among adults, with estimates indicating that over 30% have experienced TDIs affecting the permanent dentition [22]. The causes of these injuries are diverse and may include falls, sports-related incidents, and collisions during daily activities [15, 23]. Some occupations are also associated with an increased risk of TDIs. For example, professionals such as animal handlers, veterinarians, zookeepers, wildlife researchers, agricultural workers, and cattle farmers are frequently exposed to situations that may result in dental trauma. Injuries in these settings often occur through direct interactions with animals, including bites, kicks, head-butts, or accidental collisions, each capable of causing varying degrees of dental trauma [24, 25]. Although people working in these environments are at significant risk of TDIs due to occupational hazards, there is a lack of studies exploring the prevalence of TDIs among cattle farmers. In this issue, Kariya et al. [26] presented a study that assessed the prevalence of TDIs in this specific population. The study identified key risk factors associated with TDIs among cattle farmers, examined how injury patterns varied by the type of animal handled and years of professional experience, and emphasized the frequency and severity of dental trauma. The findings reinforce the need for preventive strategies to reduce the risk of TDIs in high-risk occupational groups such as cattle farmers.

Dental trauma in sports is common and can have multiple impacts, including physical, psychological, and economic consequences. These injuries represent the second most common type of accidents following domestic accidents [5, 27]. The injuries during sports activities can have a psychological impact on the performance of athletes, potentially leading to anxiety about re-injury and inhibiting their performance. This phenomenon has been explained through different cognitive models [28-30]. Even though the prevalence in athletes is high [27], there is a lack of validated tools specifically designed to assess re-injury anxiety resulting from orofacial and dental trauma in adolescent athletes. In this issue, Ravi et al. developed and validated a questionnaire to assess the presence of re-injury anxiety following orofacial and dental trauma in 10-to-16-year-old boxers [31]. This study underscores the importance of recognizing and addressing the psychological impact of orofacial injuries in young athletes, particularly in high-risk contact sports like boxing, and contributes to a more holistic understanding of sports-related dental injuries. It highlights the need for attention to patient-centered measures in sports dentistry and for age-appropriate tools to assess psychological readiness and support recovery.

TDIs represent a large proportion of oral-related emergency visits, presenting a clinical challenge [32, 33]. Timely and appropriate care for dental trauma is essential to achieve the best results and reduce the possible long-term effects linked to these injuries [18, 34]. The significance of prompt treatment is highlighted by its ability to enhance the prognosis and overall effectiveness of treating dental trauma. As a large number of TDIs are presented to emergency hospitals, physicians and nurses working at emergency departments are the primary individuals providing initial emergency treatment. However, although there are studies evaluating the knowledge of non-dental professionals about dental trauma [35-37], there are not enough studies evaluating nursing students' knowledge of TDIs. In this issue, Akgül et al. [38] assessed the knowledge and attitudes of nursing students regarding appropriate intervention methods for managing cases of TDIs using a survey modified from a previously published study. The study emphasized the importance of nursing students' knowledge in managing TDIs and highlighted the benefits of incorporating this topic into nursing curricula. It pointed to the value of collaboration with dental professionals in delivering educational programs, supporting nurses who choose to work in emergency departments to feel more confident and prepared in handling dental trauma cases.

Information about medical and dental trauma could directly impact the prognosis of the injured teeth and the healthy development of the dentoalveolar complex [15, 22, 39]. The use of Artificial Intelligence (AI) chatbots has become prevalent in recent years as a potential source to get information about general issues in dentistry, including TDIs [40-42]. However, the accuracy and reliability of online healthcare information for patients when making medical or dental decisions can differ or be questionable compared to what is presented in the literature. In this issue, Öztürk et al. [43] evaluated and compared the quality, reliability, readability, and originality of information provided by the GPT-3.5 and GPT-4.0 versions of ChatGPT for dental students and professionals, using the IADT guidelines as a reference standard. This study emphasized the importance of critically evaluating and using such tools in dental education and practice with caution.

Dental avulsion refers to the complete displacement of a tooth from its alveolar socket due to trauma [19]. This type of dental injury most affects children aged 7 to 9 years, with the maxillary central incisors being the most frequently involved teeth in both primary and permanent dentitions [39]. Prompt and appropriate emergency intervention is essential for favorable outcomes, with immediate replantation being the recommended approach for permanent teeth when it is feasible [44, 45]. Today, AI offers a powerful tool for rapid access to health-related information, including first aid guidance for dental avulsion. However, existing research has been limited, with few studies comparing the performance of different chatbot models in addressing specific dental trauma scenarios [40, 46-48]. In this context, Mustuloğlu and Deniz [49] evaluated and compared the accuracy and consistency of responses from six AI chatbots using an 18-item true/false questionnaire based on IADT guidelines for dental avulsion.

Each chatbot was queried three times per day over 3 days, and responses were compared to expert-validated answers and independently assessed by blinded reviewers to determine accuracy and variability.

Zirconia is a biocompatible ceramic material known for its high strength, fracture resistance, and excellent esthetic properties, making it ideal for dental restorations [50]. In pediatric dentistry, preformed zirconia crowns have become a leading choice for the full-coverage restoration of severely damaged or decayed primary anterior teeth, including those affected by dental trauma [50, 51]. These crowns offer significant advantages over traditional options, such as stainless steel or resin-based crowns, due to their superior esthetics, long-term durability, precise fit, and favorable gingival response, contributing to both functional and esthetic outcomes in young patients [52-55]. Despite the notable advantages of preformed zirconia crowns in restoring primary teeth, there is a lack of research investigating how these restorations respond to TDIs. To address this gap, in this issue, Goyal et al. [56] analyzed and compared the stress distribution patterns induced by trauma in a zirconia-restored primary anterior tooth versus a natural primary tooth, using three-dimensional dynamic finite element analysis. This study addresses a knowledge gap in pediatric dentistry by investigating how zirconia crowns influence the biomechanical response of primary teeth during trauma. Through advanced 3D analysis, it offers clinically relevant insights for improving prevention and treatment strategies.

In pediatric and adolescent patients, traumatic injuries and external cervical resorption can significantly affect the integrity of permanent anterior teeth [57]. Injuries such as avulsion, intrusion, and lateral luxation often result in damage to the periodontal ligament, which can lead to ankylosis due to replacement of the root structure by bone [58, 59]. Managing ankylosed or structurally compromised teeth during growth is complex. Conventional approaches such as composite build-up or extraction can present clinical limitations and variable prognoses in growing patients [59, 60]. Decoronation combined with root submergence has been proposed as a biologically conservative technique to preserve alveolar bone volume and support future prosthetic rehabilitation [61-63]. In this issue, Kaán et al. [64] conducted a long-term observational study to assess the outcomes of decoronation and root submergence in a series of adolescent patients who had decoronation and root submergence performed on a permanent upper incisor, with a follow-up duration of no less than 1.5 years after the procedure. The study evaluated vertical alveolar ridge preservation using both qualitative and quantitative methods to examine the survival of various types of temporary restorations following the procedure.

Root fractures affecting permanent teeth are generally associated with intense mechanical forces, such as those encountered in athletic activities, motor vehicle incidents, or interpersonal trauma [65]. The healing process can involve various tissue responses, including the deposition of mineralized tissue at the fracture line or the integration of fibrous or periodontal structures between the segments [66]. In contrast, when infection arises in the coronal segment, healing is disrupted, leading to inflammatory resorption at the fracture site [66]. While various healing responses of root fractures have been well documented, most literature has focused on fractures without associated displacement or luxation. Marginal bone loss has been observed in luxation injuries such as intrusion and lateral luxation, but no prior studies have documented marginal breakdown in cases involving root-fractured teeth with concomitant luxation of the coronal fragment. In this issue, Heithersay and Alvino presented an example of contrasting responses following transverse root fractures in two maxillary central incisors sustained by a 16-year-old male patient after a serious accident [67]. This report documented the different sequelae, one involving infective marginal breakdown associated with luxation and the other featuring transient internal surface and tunneling resorption. It aimed to detail the long-term management of these distinct conditions over a substantial 35-year period and illustrated the therapeutic approaches required by each case, including extended non-surgical endodontic intervention for one and careful monitoring for the other.

Tooth loss due to trauma presents a clinical challenge, especially in growing patients. When the anterior teeth are affected, the difficulty increases significantly because of esthetic and functional considerations [22, 68]. Traditional management strategies, such as removable prostheses, bonded bridges, and orthodontic space closure, might not meet long-term expectations in young individuals [68]. Tooth autotransplantation is a biologically conservative and promising treatment alternative, particularly when a donor tooth with incomplete root development is available [69, 70]. While conventional autotransplantation techniques have demonstrated high survival rates, especially when using premolars, they often involve direct manipulation of the donor tooth during site preparation [71]. This increases the risk of periodontal ligament damage, which may compromise healing outcomes. Preplanned virtual autotransplantation using 3D-printed donor tooth replicas has been introduced to improve surgical precision and reduce trauma to the donor tooth [68, 72, 73]. In this issue, Barraco et al. presented a case involving the autotransplantation of an immature microdontic third molar to replace a traumatized maxillary central incisor in an 18-year-old patient [74]. The procedure was guided by a digitally designed and 3D-printed replica of the donor tooth, demonstrating the feasibility of this technique in young patients.