Innovations and Evidence-Based Practices in Dental Traumatology

Abstract

Regenerative endodontic treatment (RET) has emerged as a biological alternative for managing traumatized immature permanent teeth with necrotic pulp and apical periodontitis [1]. Unlike traditional methods such as calcium hydroxide or mineral trioxide aggregate apexification, which provide apical closure but may fail to support continued root development, RET aims to regenerate the pulp–dentin complex, enabling further root maturation and increasing the long-term survival of the affected teeth [2-4]. The success of RET depends on effectively removing microorganisms from the root canal [4]. However, eliminating bacterial infection in immature traumatized teeth can be a challenge due to various complicating factors, such as external bacterial invasion, limited mechanical instrumentation, and persistent biofilms. In this issue, Wikström et al. [5] assessed the disinfection efficacy of calcium hydroxide and chlorhexidine gluconate dressing regarding total bacterial load and influence on treatment outcomes of RET. This clinical study highlighted the critical importance of thorough bacterial reduction for the success of RET.

Dental avulsion is the most frequently reported dental injury in children aged 7–9 years. In both primary and permanent dentitions, the maxillary central incisors are the teeth most commonly affected [6, 7]. Avulsion occurs more frequently in primary dentition than in permanent dentition [8]. For permanent teeth, immediate replantation into the socket is the most effective approach, and timely emergency management is crucial for successful treatment and a favorable prognosis [9-11]. Despite the availability of advanced tools and artificial intelligence (AI) for accessing information, knowledge among laypersons about first aid for dental avulsion remains limited and should be widely disseminated. In this issue, Mathew et al. [12] detailed the essential steps laypersons should follow to manage permanent tooth avulsion according to the current IADT recommendations. They presented essential tips as a simple and clear guide for laypersons to manage permanent tooth avulsion emergencies effectively.

The temporomandibular joints (TMJs) play a vital role in mandibular movement and functional stability. Together with the mandible, they form the temporomandibular system, which maintains structural integrity and biomechanical balance during daily activities [13]. However, external forces from sports-related impacts, particularly in contact sports, can disrupt this balance and result in injuries such as TMJs damage, mandibular fractures, and temporomandibular disorders [14]. Despite the clinical significance of these injuries, the mechanisms by which sports-related impacts lead to TMJs injuries are still lacking in the literature. In this issue, Li et al. [15] employed an improved finite element model to analyze the dynamic biomechanical responses of the temporomandibular system under frontal impact conditions. This approach aimed to evaluate the risk of joint and mandibular injuries, providing a foundation for better prevention and management strategies in sports-related orofacial trauma.

Traumatic dental injuries (TDIs) represent a significant health issue, comprising functional, aesthetic, and psychological impacts, particularly in populations exposed to high-risk environments such as the military. These injuries can occur in all age groups but are most common in children and young adults [16-18]. In military contexts, the risk is intensified by factors such as combat operations, blast exposure, vehicular accidents, and training-related incidents, in addition to noncombat activities like falls during training [19, 20]. Tooth fractures remain the most frequent injuries, but soft tissue trauma and luxation injuries are also common [21]. Early diagnosis and multidisciplinary treatment are essential to minimizing long-term complications [22]. The epidemiology, treatment approaches, and outcomes of dental trauma in military populations are limited. In this issue, Arbel et al. [23] conducted a retrospective study that investigated patterns, associated injuries, and complications of dental trauma among soldiers in the Israel Defense Forces (IDF), including prehospital care, hospitalization, and follow-up, with the aim of informing evidence-based strategies for comprehensive management. This study underscores the critical role of multidisciplinary care in the treatment and prognostic assessment of these injuries, with the goal of improving patient outcomes.

Maxillary incisor loss in young patients can occur due to factors such as trauma, agenesis, or iatrogenic causes, presenting a significant clinical challenge for patients and dental professionals [24-26]. Managing this tooth loss requires meeting high aesthetic demands while allowing for continued skeletal and dental development, which limits the suitability of conventional treatments such as implants or fixed prosthetic restorations [24, 27]. Autotransplantation of premolars has emerged as a favorable alternative, as it not only replaces the missing tooth but also maintains a vital periodontal ligament, promoting alveolar bone remodeling, soft tissue preservation, and long-term functional adaptation. Unlike implants, this biologically compatible approach supports normal dentoalveolar development and often provides superior gingival and aesthetic outcomes, with lower costs compared to prosthetic solutions [25, 28-30]. In this issue, Doomen et al. [31] assessed the aesthetic results and patient satisfaction of premolars transplanted to the maxillary incisor region, using both objective clinical criteria and subjective assessments to capture perspectives from both patients and professionals. The study emphasized the relevance of autotransplantation as a promising treatment approach for replacing missing teeth in the maxillary incisor region.

TDIs present a challenge due to their functional, aesthetic, and psychological implications [18]. Maxillary incisors are the most affected teeth, with enamel fractures being the most common clinical presentation [32, 33]. Prompt and adequate management is essential for favorable treatment outcomes and prognosis, as dental trauma can result in long-term complications that are difficult to address [10]. The limited training and clinical exposure in undergraduate dental education often result in a lack of knowledge and confidence among general dentists regarding TDIs management [34-36]. Continuing professional development courses have become a key strategy for addressing these gaps, with webinars offering a flexible and accessible learning format [37-39]. In this issue, Cvijic et al. [40] evaluated the effect of the educational intervention on general dentists' TDIs knowledge in the Public Dental Service of Vestland County, Norway. It demonstrated both the value and the challenges of implementing continuing professional development courses in dental traumatology to enhance dentists' knowledge and clinical practices.

Orthodontists play a crucial role in the management of TDIs, often initiating or continuing treatment to reposition or stabilize teeth affected by trauma [41-43]. A thorough clinical evaluation, including detailed patient history and radiographic monitoring, is essential to guide treatment planning and minimize the risk of complications [42, 44]. Traumatized teeth may respond unpredictably to orthodontic forces, with potential adverse outcomes such as accelerated root resorption and pulp necrosis, necessitating cautious and informed management [43]. Despite most orthodontists having the diagnostic skills for dentoalveolar trauma, some report limited confidence or experience in managing orthodontic treatment following trauma [45, 46]. This underscores the need for standardized guidelines to support clinical decision-making in these complex cases. In this issue, Salgado et al. [47] evaluated the knowledge and experience of Brazilian orthodontists regarding the management of traumatized teeth, aiming to contribute to improving protocols and patient outcomes. This study reinforced the importance of educational background and clinical training in shaping orthodontists' preparedness for managing TDIs. It emphasized the need for standardized protocols and greater integration of trauma management into orthodontic education.

Artificial intelligence is changing health care by improving diagnostic accuracy, treatment planning, and patient care through advanced computational capabilities. Among AI applications, large language models (LLMs), such as ChatGPT, have emerged as powerful tools capable of generating human-like text and assisting with tasks in clinical health decisions, exam preparation, and language translation [48, 49]. In dentistry, the use of LLMs is expanding, particularly in education and patient educational support, where they offer immediate and accessible information [50]. This is especially relevant in managing dental trauma, which often requires urgent intervention and specialized knowledge [50, 51]. With many individuals seeking online advice in emergencies when professional care is unavailable, LLMs have the potential to fill critical knowledge gaps. In this issue, Kuru et al. [52] compared the performance of multiple LLMs on diverse dental trauma questions, aiming to assess the accuracy and reliability of their responses. This study pointed out the need for cautious integration of LLMs into dental education, emphasizing the importance of improving model reliability and ensuring effective human oversight to support meaningful learning outcomes.

Sports activities, particularly contact and high-velocity sports, carry a considerable risk of dental trauma, affecting both professional and amateur athletes [33, 53]. While mouthguards are widely recommended to prevent dental fractures, dislocations, and soft tissue injuries, their protective capacity remains a challenge, even when they meet ideal specifications [54]. To improve protective performance, researchers have explored reinforcement strategies for mouthguards aimed at enhancing their ability to distribute and absorb impact energy [55]. New technologies that combine computer simulations with laboratory testing offer valuable tools for designing and evaluating these reinforced devices, allowing for a precise analysis of how different reinforcements affect stress reduction in oral tissues. In this issue, de Queiroz et al. [56] examined how reinforcing a 4-mm-thick mouthguard with a polyamide mesh, placed at different positions within the guard, influences its ability to absorb impact forces and protect the mouth and surrounding structures from trauma. This study highlights the effectiveness of incorporating reinforcement materials to improve mouthguard protection and the value of combining computational modeling with experimental methods for studying biomechanical trauma.

Awake bruxism is characterized by involuntary clenching or grinding of the teeth and is associated with multiple adverse effects such as temporomandibular disorders, headaches, tooth wear, and fractures of dental restorations [57, 58]. In athletes, particularly those engaged in strength-based sports like powerlifting, jaw clenching can be intensified due to its link with enhanced muscle strength and performance. While this behavior may provide athletic advantages, it also increases the risk of damage to teeth, prosthetic restorations, and soft tissues [58, 59]. The lack of targeted protective strategies for managing awake bruxism during sports practice poses a challenge for both performance and oral health. Mouthguards, which are recommended for preventing TDIs in contact sports, have recently been proposed as a means to protect oral structures during resistance training [53, 54]. Custom-made mouthguards, specifically designed for individuals with awake bruxism, could reduce the harmful effects of clenching while maintaining comfort and athletic performance [60, 61]. By combining protective function with the potential to enhance force generation, these appliances present a promising solution for athletes prone to awake bruxism-related injuries. In this issue, Fiamengui et al. [62] described the fabrication process of a custom-made mouthguard specifically for athletes with awake bruxism during sports activities, providing a discussion of its indications, benefits, constraints, and potential approaches for future research.

Evidence-based practice is essential for advancing dentistry, relying on high-quality systematic reviews to guide clinical decision-making [63-65]. However, the reliability of these reviews depends heavily on transparent and accurate reporting, particularly in abstracts, which often serve as the primary source of information for busy clinicians and researchers [66, 67]. Incomplete or poorly structured abstracts can limit the accessibility, relevance, and credibility of findings, potentially affecting patient care. Despite the introduction of the PRISMA extension for abstracts (PRISMA-A) and its 2020 update, studies across various dental specialties indicate that abstract reporting quality is not satisfactory. The PRISMA-A checklist provides a standardized framework designed to improve the clarity and completeness of systematic review abstracts. Its use aims to ensure that key information, such as objectives, methodology, and results, is consistently reported, enabling stakeholders to evaluate the validity of reviews more effectively [68]. In this issue, Nagendrababu et al. [69] evaluated the reporting quality of abstracts of systematic reviews with meta-analyses in dental traumatology, using the PRISMA-A 2020 checklist and identified the potential factors that could influence the overall quality of abstract reporting. This study highlighted the significance of standardized and comprehensive reporting in abstracts of systematic reviews in dental traumatology.

Crown fractures are the most prevalent TDIs in permanent teeth, with pulp necrosis being the most severe complication, particularly when combined with luxation injuries [70, 71]. The reported incidence of pulp necrosis varies widely due to factors such as tooth maturity, type of fracture, and associated injuries, reflecting the multifactorial nature of these cases [72, 73]. However, there is a lack of histopathologic studies in humans that explore pulp tissue response following crown fractures, limiting understanding of the biological changes involved. A detailed clinical and histological evaluation of human pulp tissue following trauma can provide new insights into the healing potential and pathological responses of teeth subjected to combined injuries. In this issue, Tzanetakis et al. [74] analyzed and described the histological condition of pulp tissue in a young permanent tooth after experiencing an uncomplicated crown fracture accompanied by subluxation, offering new perspectives on pulp response and trauma-related complications.

The authors declare no conflicts of interest.