Prevention of orofacial trauma in sports and beyond—What can be done further?

Orofacial trauma is considered a public health problem in high-impact sports, imposing a detrimental impact on oral health-related quality of life.^6-8 The main concerns are not only the physical and functional impact but also the esthetic ramifications, psychosocial impairment, and incurred cost.^{9, 10} To reduce the incidence and severity of oral trauma, a custom-made mouthguard is recommended.^11-13 Contact sports-related dental trauma contributes to a significant proportion of sports injuries among school children.^{6, 14} In this issue, Udayamalee et al.¹⁵ conducted a study among 1340 adolescent contact sports players in Sri Lanka. A checklist was administered to obtain demographic information, sports practices, and the use of mouthguards. A proper understanding of dental trauma prevalence makes targeting dental trauma reduction and oral health program plans possible and more effective.

Basketball is characterized by sprinting and jumping, a very aggressive defense system, and body contact among players, making contact injuries likely.^{8, 13} In this issue, Doğan et al.¹⁶ compared basketball players' subjective assessments of different thicknesses of custom-made and boil-and-bite mouthguards. Sixty systematically healthy male professional basketball players evaluated mouthguard comfort and usability, including comfort, fit, stability, tiredness, thirsting, oral dryness, nausea, speaking, breathing, drinking, ease of wear and removal, and inclination to chew. The optimal thickness of mouthguards for basketball players may lead to their consistent use and improved compliance with proper protection against dental trauma.

Oral injuries make up a large portion of the total injuries suffered by ice hockey players.¹⁷ Along with the use of mouthguards, the introduction of face shields and helmets in ice hockey led to a reduction in dental injuries.^{12, 18} In this issue, Opazo-Garcia et al.¹⁹ aimed to determine characteristics and differences regarding mouthguard usage among field hockey players from different countries participating in the XII ODESUR games. A cross-sectional study included 78 voluntary hockey athletes who answered a questionnaire, collecting information on the type and the time of mouthguard use. There is a need for sports dentistry as a discipline to promote and adopt best practices to protect athletes from potential risks of dental trauma. Knowledge about dental trauma first aid is very important but at the same time deficient among many members of the public.²⁰ Essential areas of education that should be addressed include the use and availability of protective devices such as mouthguards, face shields, and helmets.²¹ Better advocacy, regulations, and enforcement are warranted in order to improve the utilization of protective measures.

The mechanical performance of mouthguards in terms of shock absorption is affected by several factors, such as material type, manufacturing process, and thickness.^{22, 23} Ethylene-vinyl acetate is the most popular material utilized to manufacture custom-fit mouthguards.^{23, 24} In this issue, Rondón et al.²⁵ evaluated the effect of different materials for conventional or 3D-printed models on the physical and mechanical properties and surface characteristics of ethylene-vinyl acetate mouthguards. Mouthguards were laminated over four model types: conventional Type IV dental stone model, resin-reinforced Type IV dental stone model, 3D resin-printed model without surface treatment, and 3D-printed model with water-soluble gel coating during the post-curing process. The interaction between the ethylene-vinyl acetate with distinct materials utilized for obtaining dental models can affect the performance of mouthguards and needs to be taken into consideration.

Known associated factors for traumatic dental injuries include socioeconomic aspects, inadequate lip seal, accentuated overjet, and anthropometric characteristics.^26-28 In this issue, Bernardino et al.²⁹ investigated the association of sleep disorders, school jet lag, and anxiety with traumatic dental injuries in school children 8–10 years of age. The study was conducted among 739 pairs of parents/guardians and children enrolled in public and private schools. Sleep disorders and anxiety may have consequences on the occurrence of dental traumatic injuries and might be important aspects when it comes to prevention efforts.

Crown fractures are the most common dental injuries in the permanent dentition.^{3, 30} If left untreated, fractured anterior teeth may compromise tooth function and facial esthetics.^{31, 32} The extent of the fracture, age of the patient, root development, involvement of the pulp and periodontal tissues, esthetic complications, and quantity and quality of the remaining dental structure affect the treatment strategy.³⁰ In this issue, Aharonian et al.³³ investigated the fracture resistance of bovine incisors restored by two different techniques, original tooth fragment reattachment, and direct composite restoration, in three different fracture models. Sixty extracted bovine lower incisors were randomly divided into three groups (angle, oblique, or transverse). Half the teeth in each group were restored by fragment reattachment, and the other half by direct composite restoration. Several techniques are available to treat crown fractures, the most common forms of traumatic dental injuries. A tailor-made treatment plan should be adjusted for each individual patient taking into consideration all aspects related to the long-term success of the treatment.

Post-traumatic choice of treatment is based on a combination of multiple factors, such as the severity of the initial injury, the stage of root development, and time of arrival.⁴ In this issue, Cheng et al.³⁴ evaluated the treatment outcomes of permanent teeth with uncomplicated and complicated crown fractures and investigated potential factors. All complicated crown fractured teeth were treated with pulpotomy, while for teeth with uncomplicated crown fractures, three treatments (restoration, indirect pulp capping, or pulpotomy) were employed. Potential factors associated with pulp survival were analyzed. Accurate diagnosis and identification of micro exposures are important. Dentists should take multiple risk factors into account when selecting optimal treatment strategies.

Violence is a complex phenomenon, with a large number of cases resulting in maxillofacial injuries, including soft tissue injuries and dental trauma.^{35, 36} Management of traumatic dental injuries is challenging for clinicians due to its emergency and abruptness.¹⁰ In this issue, Corral Nunez et al.³⁷ described dental trauma in patients injured by police during the social unrest period in Chile. Clinical records of patients who were affected by the violence of state agents during social mobilizations were collected and reviewed. Information on the sociodemographic characteristics of the patients and the dental trauma diagnoses with their treatment needs were obtained. Since numerous episodes of civil unrest have occurred worldwide, it is interesting to investigate the specific characteristics of these events with relation to traumatic dental injuries.

The management of missing maxillary incisors in growing patients is challenging as a consequence of the extremely demanding esthetic requirements in the front of the mouth.^{38, 39} Tooth autotransplantation is the transplantation of an erupted or unerupted tooth from one site to another within the same patient.^{40, 41} It is a viable option to replace missing anterior teeth in developing patients as it preserves and stimulates continuing bone formation in the area of the missing tooth.^{40, 42} In this issue, Sans et al.⁴³ demonstrated the use of milled polymethyl methacrylate interim veneers for immediate restoration of autotransplanted teeth. The development of a simple, immediate, and atraumatic esthetic interim restoration would be of great benefit to both the clinician and patient and address the concerns caused by immediately preparing the tooth postoperatively and cementing a permanent restoration.

Maxillofacial traumatic injuries are common since the face is one of the most unprotected parts of the body and are associated with considerable functional, psychological, and cosmetic morbidity and disability.^{44, 45} Furthermore, dentoalveolar trauma is a public health problem because it can affect dental structures and their supporting tissues, triggering esthetic, functional, and psychological damage.²⁶ In this issue, Turino et al.⁴⁶ assessed global trends in scientific publications on maxillofacial and dentoalveolar trauma in the elderly. Medical Subjects Headings (MeSH), synonyms, and related terms relevant to maxillofacial and dentoalveolar trauma in the older population were used in the search strategy for PubMed, Embase, Scopus, Web of Science, Cochrane, and LILACS. This strategy gives a nice overview of publications in the field of dental traumatology.

Avulsion of permanent teeth accounts for 0.5%–16% of dental injuries.⁴⁷ Replantation is considered the preferred treatment strategy for avulsed permanent teeth.^{47, 48} Effective management of tooth avulsions necessitates prompt and appropriate intervention to salvage the teeth and mitigate the risk of enduring complications.^{49, 50} External replacement root resorption is the most common periodontal adverse outcome after tooth avulsion.⁵¹ In this issue, Eggmann et al.⁵² presented the dental care given to an adult with simultaneous avulsion of multiple teeth. The external replacement resorption progression rate of affected teeth was also evaluated. Multiple avulsions underscore the importance of immediate and appropriate intervention alongside with imperative for carefully considered long-term management strategies.