Emerging Insights in Dental Trauma: Exploring Potential Risk Factors, Innovations, and Preventive Strategies

Abstract

Several factors are associated with dental trauma (DT) occurrence, and these factors are well-established in the literature [1, 2]. However, new studies and hypotheses suggest that a lack of balance is positively associated with falls in children and older individuals [3, 4]. In this issue Lunardelli et al. investigated the relationship between orthostatic balance and the occurrence of DT in 6-year-old school children in Brazil [5]. The study emphasizes the connection between reduced orthostatic balance and an increased risk of falls, identifying it as a factor in the etiology of DT in children. This highlights the need for preventive measures focused on creating safer environments, particularly in schools, and involving a multidisciplinary team to support school-aged children in minimizing the risk of falls and dental trauma.

Traumatic dental injuries (TDI) are highly prevalent during childhood, particularly in the primary dentition [6, 7]. Although TDI is recognized as a common issue, the factors influencing its prevalence in preschool-aged children have been poorly understood [8, 9]. In this issue, Rivera López et al. investigated these factors through a cohort study involving 4-year-old children from South Brazil [10]. Using directed acyclic graphs (DAGs), the researchers developed a theoretical model to explore the complex relationships among potential risk factors, including demographic, behavioral, and environmental variables. This study provides insights into the multifactorial nature of TDI in young children, offering a foundation for targeted prevention and early intervention strategies. By applying advanced analytical techniques, Rivera López et al. contribute to a deeper understanding of dental trauma causes and its broader implications for pediatric oral health.

Autotransplanted teeth have demonstrated a remarkable survival rate of over 95% [11-13]. However, the lack of standardization and precision in quantifying root development results in inconsistent findings and impedes comparisons between studies. Traditional analysis methods based on two-dimensional radiographs shows significant limitations, such as image overlap, patient positioning challenges, and low measurement accuracy. Cone-beam computed tomography (CBCT) might provide a more accurate and detailed analysis, particularly in regions like the periapical areas [14]. In this issue, Beltrame et al. proposed a methodology for assessing root development and measuring root length using CBCT in 12 patients [15]. This study highlighted CBCT's superiority over conventional radiography for evaluating root development after autogenous tooth transplants. This method, as any radiographic tool, should be assessed in terms of radiation risks vs. the suggested benefits.

Advances in CBCT and 3D-printed replicas have demonstrated improvements in the efficiency and precision of dental procedures, including tooth autotransplantation [16-18]. However, most evidence supporting these outcomes comes from observational studies, case reports, and a limited number of case–control studies. Consequently, there is insufficient data from controlled clinical trials evaluating the biological efficacy (i.e., long-term clinical and radiological outcomes), limiting the understanding of the impact of these technologies. In this issue, Lejnieks et al. assessed the efficacy of a combined CBCT and 3D replica protocol in a controlled clinical trial. The goal was to investigate clinical and radiological outcomes after 1 year of follow-up, providing stronger evidence of the benefits of these technologies in molar autotransplantation [19]. The investigation underscores the potential of CBCT and 3D replica protocols to enhance surgical efficiency and serve as valuable training tools, calling for further studies to address current limitations and explore their broader applications in clinical practice.

Artificial Intelligence (AI) has emerged as a valuable resource, providing information for patients and clinicians seeking online healthcare knowledge to support medical and dental decision-making [20, 21]. However, rigorous evaluations of the accuracy and consistency of responses provided by AI tools, such as Google Gemini, in the context of managing traumatized permanent teeth, are still lacking. Although these technologies hold significant potential to transform access to healthcare information, concerns remain regarding their reliability and potential biases. Previous studies suggest that tools like Google Bard, an experimental version of Gemini, provide less consistent information compared to other models, such as ChatGPT, particularly on topics related to endodontics [22]. In this issue, Portilla et al. evaluated the accuracy and consistency of responses about traumatized permanent teeth management provided by Google Gemini compared to those from experienced academic endodontists. Using a set of predefined questions, they conducted a comprehensive comparison [23]. This study suggests that Gemini has the potential to become an accessible support tool for dental professionals. However, improving its database and algorithms is crucial to enhancing its accuracy in traumatized permanent teeth related topics. Advancing training and data refinement is essential to ensure more reliable and robust responses in the future. Furthermore in this issue, Johnson et al. aimed to assess the validity and reliability of AI chatbots, including Bing, ChatGPT 3.5, Google Gemini, and Claude AI, in addressing frequently asked questions related to dental trauma [24]. Ensuring the secure and accurate distribution of medical information, particularly in the field of dental trauma, requires authorities to establish clear guidelines and regulations governing chatbot use. Collaborative efforts are essential to address ethical concerns and ensure the accuracy and reliability of information provided by these AI platforms.

Public knowledge about the management of TDI remains insufficient [25, 26]. However, with advancements in AI, these tools are now able to deliver public health support and information that helps dental professionals and patients deal with issues like tooth avulsions. Large language models (LLMs) offer significant benefits in dental education, however, since these tools are fine-tuned using public human feedback, their data may be biased or incorrect, particularly regarding answers to questions about tooth avulsion [20]. In this issue, Tokgöz Kaplan and Cankar verified the accuracy and comprehensiveness of answers about dental avulsion provided by ChatGPT and Gemini. Four pediatric dentist reviewers evaluated and scored the responses according to the IADT guidelines [27]. This evaluation revealed that although both AI tools have potential, further improvements in training and data quality are necessary to ensure the reliability and accuracy of their answers.

Avulsion of a permanent tooth is one of the most severe types of dental trauma [28]. Treatment requires prompt and correct emergency management, and it depends on the viability of the periodontal ligament (PDL) cells [29]. Avulsion can cause injuries to the PDL, including dehydration and structural damage to periodontal fibers [30]. For this reason, storing an avulsed tooth in an appropriate medium can help preserve the viability of periodontal cells and prevent their dehydration and breakdown [31]. According to the guidelines of the International Association of Dental Traumatology (IADT), saline, saliva, and milk are considered natural or biological solutions that help maintain PDL viability before replantation [32]. In this issue, Lee et al. investigated the effects of six experimental media on the viability of periodontal ligament fibroblasts (PDLF). The media included Hank's Balanced Salt Solution (HBSS), HBSS supplemented with ascorbic acid (Vitamin C), HBSS supplemented with platelet-derived growth factor (PDGF), HBSS supplemented with a combination of PDGF and ascorbic acid, HBSS supplemented with platelet lysate, and Dulbecco's Modified Eagle Medium [33]. The modified HBSS mixtures were evaluated for their ability to support PDLF viability and contribute to the success of replantation procedures. The results of this study could help enhancing our overall understanding and future considerations of proper storage media for avulsed teeth.

Central incisors are frequently affected by dental trauma [34, 35], especially in cases of proclined maxillary anterior teeth [36]. Various preventive measures are available for different activities and age groups [37, 38]. The use of mouthguards is the most common method to prevent dental trauma during sports. Different manufacturing methods exist for mouthguards [39]; However, custom-made mouthguards are more professionally crafted, offering a better fit and, according to some reports, improved cardiopulmonary capacity for athletes. In this issue, Bhadule et al. created a 3D finite element analysis (FEA) model using a CBCT scan of a 12-year-old male patient [40]. They simulated the actual trauma impact on proclined maxillary anterior teeth with and without a mouthguard. The study emphasized the importance of properly fitted mouthguards in protecting against oral and maxillofacial injuries by reducing stress magnitude, particularly in dentitions with proclined maxillary anterior teeth. Mouthguards also play a crucial role in protecting teeth and soft tissues from dental trauma during sports and other high-risk activities [41, 42]. The most commonly used types include stock mouthguards, mouth-formed models, and custom-made options, each offering varying levels of comfort and protection [41, 43]. However, despite their widespread use, some mouthguards are made from materials that may not provide sufficient shock absorption, durability, or user comfort [44, 45]. Therefore, there is a growing need to explore alternative materials to develop mouthguards that enhance performance, improve user experience, and promote broader adoption. In this issue, Nassani et al. evaluated and compared the impact absorption capacities of thermoformed ethylene vinyl acetate (EVA) mouthguards and 3D-printed polyolefin mouthguards for sports dentistry applications [46]. The study emphasized the impact toughness of 3D-printed polyolefin mouthguards in comparison to traditional EVA mouthguards commonly used in sports, highlighting the benefits of each material. Furthermore, the use of mouthguards fabricated with materials that provide adequate and uniform thickness is essential to reduce the effects of stress distribution and strain produced during impact [47, 48]. Some experimental studies have investigated the production processes and quality of mouthguards. The thickness of a mouthguard significantly impacts its ability to protect the teeth and its effectiveness. However, single-layered mouthguards often provide insufficient thickness and less longitudinal dimensional stability, leading athletes to increasingly use double-layered mouthguards [49], which are considered the best option for adequate thickness [50]. In this issue, Uma et al. investigated and compared the final thickness of double-layered sports mouthguards fabricated using different methods, such as a puncturing technique and/or a cooldown period before pressing the second sheet [51]. The study highlighted the significant impact of fabrication techniques on the thickness of double-layered mouthguards.

Fiber splint stabilization play a vital role in minimizing secondary trauma and promoting favorable healing outcomes due to their flexibility and ability to distribute stress effectively [52, 53]. Their performance, particularly during mastication, highlights their advantage over alternative materials [54], making them a key component in the effective management of TDI [55]. While many studies have demonstrated the stress-distributing properties of fiber splints in traumatized teeth, research focusing on their effectiveness during mastication is limited. Specifically, the impact of splint positioning whether in the incisal or cervical region on stress distribution remains unclear. This knowledge gap restricts optimization of treatment approaches and understanding of the biomechanical behavior of splints under dynamic occlusal forces. In this issue, Ding et al. investigated how the positioning of fiber splints, either in the incisal or cervical region, affects stress distribution on traumatized teeth during mastication [56]. Utilizing FEA, the research provided insights into the biomechanical effects of splint placement, contributing to more effective treatment strategies for managing traumatic dental injuries.