1 INTRODUCTION

Traumatic dental injuries (TDI) are common in both the primary and permanent dentitions. In addition to damaging the teeth and supporting structures, injuries to extra-oral and intra-oral soft tissues can occur. Dentists often focus on dental injuries, and trauma to the extra-oral and intra-oral soft tissues may not be documented in detail. Frequently the only records of the soft tissue injury (STI) at the time of dental trauma are photographs. The current IADT Guidelines emphasize the need for the excellent recording of all injuries and they highlight the value of clinical photography for documentation.1-4 However, the recording and management of STI associated with TDI are beyond the scope of the IADT guidelines at present.

Soft tissue injuries are described as abrasion, laceration, contusion, or avulsion, both extra-orally and intra-orally (Table 1).5 Despite these standardized categories, much of the literature on facial and dental trauma is deficient in reporting STI, especially when the damage is not related to specific dental injuries. In addition, details such as the type, site, and extent of any injury are rarely documented. There is also variation in how the STI is reported in the literature.

TABLE 1. Definition of each type of soft tissue injury, according to Andreasen Soft tissue injury Definition Abrasion A superficial wound in which epithelial tissue is rubbed or scratched Laceration A shallow or deep wound in skin/mucosa with tearing of tissue Contusion Hemorrhage of subcutaneous tissue without laceration of epithelial tissue Avulsion Loss of tissue

Much of the existing data on soft tissue injuries are based on retrospective reviews of orofacial injuries presenting to an emergency center or by referral to a trauma center.6-9 Soares et al.9 examined the prevalence of STI in children attending a dental trauma center in Rio de Janeiro by examining their medical records. They reported that 543 records out of a total of 1030 records were included in the study but the report failed to mention if the excluded records did not include soft tissue injuries or did not record them adequately. This would suggest that 56.2% of children with a reported soft tissue injury may underestimate the overall incidence of STI following facial trauma in children. Although the prevalence of STI associated with TDI was not reported, they did mention that most individuals with a TDI had an associated STI. In contrast, Rego et al.6 examined records of children and adolescents attending an emergency hospital where facial STI was very prevalent and noted that only 5.6% of children attending had an associated (unspecified) dental trauma. Incomplete information within the literature highlights the need for the standardized recording of oral hard and soft tissue injuries in both medical and dental urgent care settings.

Sae-Lim et al. reported that 45.3% of individuals presenting with a TDI had a concomitant soft tissue injury when reporting to an out of hours service for all age groups in a hospital.8 Two retrospective studies in younger children have reported a high prevalence of STI accompanying dental injuries: Ozgur et al. in 2021, 62.3%,10 and Skaricic et al. in 2016, 45.4%.11 Eyuboglu et al.12 reported on a broader age group where they noted that 21% of children (mean age 9.1 + 3.6 yrs) with dental trauma also had STI and further that 50% of traumatized primary teeth and 32% of permanent teeth were related to a STI. The reported prevalence of orofacial STI ranges from 12.3% to 56.2% in children8 to 14.7% in Finnish adults.13 Interestingly, individuals with an associated STI were more likely to attend emergency services sooner than those who did not have an STI.7, 9-12

Clinically, standardized registration of dental injuries is essential to overcome dental record deficiencies and ideally should also include associated soft tissue injuries. There is a need for a rapid and straightforward method to record the entire injury in a format compatible with electronic records. Clinicians dealing with traumatic dental injuries seek to be accurate in their diagnosis and management of these injuries. Reliable and consistent data on TDI will facilitate the development of comparable databases internationally. The merging of databases can allow a larger research base to enhance evidence in traumatology in the future. The recently introduced Eden Baysal Dental Trauma Index (EBDTI) records tooth-specific dental injuries in detail.14 The encoded descriptions of the index allow concise storage of clinical information regarding the entire dental injury, such as the type and extent of the injury and maturity of the root. This index only records specific tooth injuries without registering STI. This shortcoming was acknowledged in the previous paper pointing out that ST damage reported is not necessarily related to an injured tooth/teeth; therefore, STI may only be recorded on a whole patient basis.14 In addition to one or multiple traumatized teeth, any intra-oral soft tissues, lips, or skin together or separately, should be recorded at the emergency visit.5

This paper extends the information recorded by EBDTI to include soft tissues, enabling the diagnosis of the entire injury to be recorded in a code format using a modification of the index. Using a standardized index to record the entire dental and ST injuries would result in the possibility of more robust data from various centers. It would improve the information available worldwide to advance dental traumatology science.15

The aim of the study was to extend the EBDTI index to record soft tissue injuries in dental trauma patients in a concise format and to approve the face and content validity of this version as the modified EBDTI (MEBDTI).

2 MATERIALS AND METHODS

The recently developed EBDTI was assessed independently by a panel of 15 experienced dental trauma experts worldwide. The face and content validation of the index was completed after two online rounds using the RAND e-Delphi method and published, where the information on the expert panel and consensus method was described in detail.14, 16, 17 The EBDTI14 contains all the essential clinical parameters following Andreasen's classification and also associated injuries for each traumatized tooth (Figure 1).

Summary of codes used in the “Eden Baysal Dental Trauma Index”14

During the first round of the validation process of EBDTI, some expert panel members suggested the inclusion of soft tissue injuries. The majority of members felt strongly (53.3%), with 33.3% neutral, and only 13.4% did not support the idea.

Therefore, an extension of the index was developed and called the Modified Eden Baysal Dental Trauma Index (MEBDTI). This study follows the tenants of the Declaration of Helsinki.The RAND e-Delphi method was used to evaluate this modified version of the index with the same group of experts. A definition and two statements (Table 2) were sent to the expert panel. The panel members rated the statements on a 9-point Likert scale where 1 represented ”total disagreement”, and 9 indicated “total agreement”. The nine codes were then clustered as 1–3, 4–6, and 7–9, indicating “disagreement”, “in doubt”, and “agreement”, respectively. A remark space was provided below each set of scores, offering each expert an opportunity to explain their assessments. A statement was considered valid after reaching a 75% consensus among panel members.

TABLE 2. Definition of the index and the statements used for consensus by the expert panel Definition of the index: “Modified Eden Baysal Dental Trauma Index records soft tissue injuries affecting gingiva and/or skin by using superscript numbers that follow the five digits of Eden Baysal Dental Trauma Index in brackets for each patient.’’ Statement 1: “Extra-oral, intra-oral and radiographic findings are used to record the cases on patient basis with the modified version of the index. Superscript numbers from 0 to 8 are used to record soft tissue injuries affecting gingiva and/or skin and lip following the five digits of the Eden Baysal Dental Trauma Index in brackets.” Statement 2: “When multiple teeth are affected in a patient, the Eden Baysal Dental Trauma Index of all traumatized teeth will be recorded in brackets separated by commas, and soft tissue codes will be added as a superscript after the bracket. There might be more than one type of soft tissue injury, and if so, superscript numbers should be written in ascending order separated by commas.”

A numerical code was suggested using zero to depict no soft tissue injury, 1–4 to record extraoral injuries (e.g., skin and lip), and 5–8 to record intraoral injuries (e.g., gingiva, frenulum, and palate) as illustrated in Figures 2 and 3.

Visual Structure of the index. Summary of the codes used in the “Modified Eden Baysal Dental Trauma Index”

Soft tissue codes are used as superscripts in the Modified Eden Baysal Dental Trauma Index - MEBDTI (*)

The MEBTDI records the soft tissue injuries on a patient basis in conjunction with the information about the injured tooth or teeth and the alveolar process (Figure 2). Thus, it can be used for individuals of any age. The various soft tissue injuries are classified on a whole patient basis since soft tissue injuries do not necessarily correspond to a particular tooth or site. The individual dental injury/injuries are recorded by the original EBDTI in brackets and separated by commas if more than one tooth is affected. Soft tissue injuries affecting the skin, lip, and/or gingiva are recorded by adding superscript numbers outside the brackets containing codes of EBDTI of injured teeth/tooth. Multiple soft tissue injuries should be written in ascending numerical order separated by commas (Figure 2). Clinical cases illustrating the proposed possible soft tissue injuries are shown in Figure 3.

The index generates a unique patient-specific digital code suitable for computer registration with information about the dental and associated soft tissue injury or injuries. Training of personnel in the use of the index will be required. The application of the Modified Eden Baysal Dental Trauma index is demonstrated in several clinical cases (Figures 4-8), highlighting the code generated for each injury.

Case 1. [(51) 00Im-, (52) 00Am-, (61) 00Im-, (62) 00Sm-].1,3,5A four-year-old boy fell over a stone fence while playing. The injuries sustained were avulsion of 52, intrusion of 51 and 61, and subluxation of 62. He sustained extra-oral abrasions and lip contusion with gingival and lip abrasions intra-orally

Case 2. [(51)00Im-, (52)00Im-, (61) 00Im-, (62) 00Lm-].2,3,6,7This 5.5-year-old boy fell from a zipline onto a concrete container. He had a skin laceration on the chin plus a laceration and contusion of the lower lip. Intra-orally, there was a gingival laceration, intrusion of 52, 51, 61, and palatal luxation of 62. A soft tissue radiograph of the lower lip was taken to determine if any tooth fragment/foreign body was embedded in the lip

Case 3. [(11) 20Am-, (21) 20Nm-].3An 11-year-old boy lost balance while tying his shoelaces and fell unprotected against the floor. There was upper lip contusion with avulsion of 11 and uncomplicated crown fractures of 11 and 21

Case 4. [(11)01Nm-, (12)00Cm-, (21)20Nm-].1This 9-year-old boy fell from his bicycle and presented with extensive facial abrasions and upper lip contusion. The dental injuries were concussion of 12, apical root fracture of 11, and uncomplicated crown fracture of 21

Case 5. [(11)20Nm -, (21)20Em -, (22)20Lm -].1,2This 16-year-old boy fell from his bicycle and presented with chin lacerations and upper and lower lip abrasions. The dental injuries were uncomplicated crown fracture of 11, extrusion and uncomplicated crown fracture of 21 and lateral luxation and uncomplicated crown fracture of 22

In addition, an online code generator is available for easy recording (https://disacil.ege.edu.tr/tr-12572/modified_eden_baysal_dental_trauma_index_generator.html).

3 RESULTS

The international expert panel, who rated the original index,14 also rated the modified version. Only one round was necessary to reach a consensus on two statements and the definition within the panel. The response rate was 100%.

Minimal wording corrections were suggested, and 86.7% agreement was obtained on the definition of the modified index. The panel reached a consensus on the statements with 86.7% and 93.3% agreement, respectively.

4 DISCUSSION

The location and extent of soft tissue injuries have rarely been reported within the dental trauma literature, with most data obtained from a retrospective review of records.6-9

The reported prevalence of STI associated with trauma to the primary dentition ranges from 50–62.5%.10-12 The ranges reported in permanent teeth in children and adolescents were 32 −41%11, 12 and 14.7% in young adults.13 The use of retrospective studies and the lack of standardization in medical/dental records make the estimation of the prevalence difficult. In some reports, swelling, a sign of injury, was used as a diagnostic category, complicating comparison to other papers.11, 12 It would be ideal if there were an agreement to use the four categories of soft tissue injuries suggested in Andreasen's Classification (Table 1).5 There is an identified need for a standardized method for collecting and recording STIs associated with traumatic dental injuries.

For the first time, a new tool for recording soft tissue injuries associated with traumatic dental injuries was proposed and validated for face and content by international experts in dental traumatology using an online consensus methodology. The RAND e-Delphi consensus method has been recognized as a useful instrument to build consensus among experts on various health topics with interactive rounds.17 In the present study, each member rated the statements anonymously and commented freely without the influence of others. This proven research technique obtains subjective judgments of an expert group, and the process was completed in a single round for the present proposal. This new tool records both hard and soft tissue injuries related to dental trauma in a single code using an extension for the previously introduced index (EBDTI) that is in a format suitable for electronic records.14 The ability to generate a multicenter database using the original index EBDTI was reported recently, where four cities in Turkey collaborated to use web-based forms and the EBDTI in a prospective study of traumatic dental injuries in children.15 Within six months, the database had detailed information on 252 patients with 280 traumatized teeth, including 19 avulsed teeth and additional data on root maturity and/or accompanying injuries that help in treatment planning. Thus, the generation of new standardized databases both nationally and internationally is now possible. Using this extension of the EBTDI tool that records the entire injury should empower researchers to further explore critical issues in healing after injuries to the face, mouth, and teeth. The Dental Trauma Guide, which is an Internet-based knowledge platform consisting of 4,000 dental trauma cases with long-term follow-up to guide the public and the professions on the best treatment approach online, has suggested the use of the recently introduced EBDTI to register dental trauma cases on the site to facilitate comparison of data and outcomes worldwide.18

The use of MEBDTI will simplify recording of the entire injury on a whole patient basis. Furthermore, the validated extension of the index allows a simple, efficient, and clinical-friendly method to record a total injury diagnosis, including the extra-oral and intra-oral soft tissues in individuals of all ages in an emergency setting. The MEBDTI may be easily understood by medical and dental colleagues who are likely to attend to individuals with orofacial trauma, facilitating the recording of injuries that align with the IADT guidelines for managing traumatic dental injuries. The modified index summarizes the entire injury recorded in a single entry that clinicians may easily apply.

This index offers the prospect of a standardized record that can be used to summarize the individual trauma experience using a code as illustrated in Figures 4-8. The code generated is compatible with all computer systems and can be produced quickly with the help of the online code generator and entered into any electronic medical record. It can be captured within the emergency clinical setting and verified across multiple sites in an epidemiological exercise. Such data could provide essential information on the interrelationship between dental and soft tissue injuries. A systematic approach to data collection on the emergency visit improves useful data quality, both for the clinician and in standardizing data collection for future prospective studies. Adopting this extended version of EBTDI would encourage consistent data collection using examination, radiographs, and photographs.

The development of a multicenter database on orofacial trauma that accurately documents the combined injuries is an exciting prospect. Prospective studies using the MEBDTI will allow the true prevalence of STI associated with TDI to be reported. In addition, the use of the MEBDTI could lead to extensive data on hard and soft tissue injuries being collected across various networks worldwide. This could facilitate the creation of an expanded information platform and the potential development of guidelines for STI management associated with dental injuries. The widespread use of MEBDTI could allow for national databases to be developed as well as integration of multiple databases internationally to generate robust evidence and allow significant research questions in traumatology to be answered.

The use of intra-oral photography to document the original injury and at review appointments is highly recommended. It has become the standard of care in many institutions with patient consent. The 2020 IADT guidelines emphasize the importance of clinical photography and establishing an accurate record of the injury.1-4 The photography of additional soft tissue involvement must now be encouraged and should record all intra-oral and peri-oral injuries. The extra-oral image must include the area between the orbit and the chin (lower ⅔ facial height) as a minimum (illustrated in the cases shown in Figures 4-8). Photographs capture the extent and exact location of injuries, and subsequent duration and success of healing, providing a permanent record of soft tissue damage and healing. These additional records will allow further investigation into any association between dental and soft tissue injuries and the possible impact on the outcome of healing.

The association between STI and dental injuries on the overall tooth survival following dental trauma has not been reported. The use of the MEBDTI to record baseline whole patient injury and standardized records can address this unknown association. The 2020 IADT guidelines emphasize the importance of hygiene in the immediate aftermath of an oral injury to encourage a favorable healing response.1-4 Appropriate STI management at the emergency visit often requires cleaning the wound, which usually heals quickly due to the rich vasculature in the oral area. It is anticipated that soft tissue injuries heal favorably with a return to normal appearance or unfavorably with scar formation, recession, or loss of attachment.5, 13, 14, 19, 20 Contamination of a soft tissue wound has been identified as an unfavorable healing response. Approximation of the wound edges extra-orally or intra-orally increases the healing speed by regaining ST integrity, maximizing healing with primary intention.

It is accepted that delayed or inappropriate STI management may have a lasting esthetic effect on the individual. There is a need for accurate baseline data and meticulous records following dental trauma due to the variety of injuries and their complexity. It is recognized that the MEBDTI index does not identify the extent or severity of the STI and cannot be used to propose any type of soft tissue management. However, the use of photographs and continued accurate clinical records may help to predict the impact of STI on overall tooth survival following dental trauma.

The MEBTDI is a powerful diagnostic tool that can be used clinically and for research data collection to answer critical questions within dental trauma. For example, with accurate baseline documentation of soft tissue injuries, it will be possible to gather data that may be included in future IADT dental trauma guidelines. In addition, a collaboration between various trauma clinics using MEBDTI for baseline records will generate large databases that can be explored to improve data quality and answer crucial questions.

AUTHOR CONTRIBUTION

The authors wish to thank expert panel group; A Moule (Australia), JV Bastos (Brazil), JE Onetto (Chile), JO Andreasen, E Lauridsen (Denmark), C Bourguignon (France), AC O’Connell (Ireland), K Takimoto (Japan), L Andersson (Sweden), N Altay, Z Çehreli, G Duruk (Turkey), P Day, E Alnuaimi (UK), S Omar (USA) for their valuable time and contributions.

The authors wish to thank Canberk Koparal for his contribution to the development of the “index generator.”

PATIENT CONSENT

The authors verify that all images are obtained with the patients’ consent, and all personal identifiers are omitted from any of the images.

ETHICAL STATEMENT

This study follows the tenants of the Declaration of Helsinki.

REFERENCES

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