Dental Injuries in Sports Dennis N. Ranalli, DDS, MDS

Address University of Pittsburgh School of Dental Medicine, 350 I Terrace Street, 440 Salk Hall, Pittsburgh, PA 15261, USA. E-mail: dnr4@pitt.edu

Current Sports Medicine Reports 2005,4:12-17 Current Science Inc. ISSN 1537 -890x Copyright© 2005 by Current Science Inc.

Introduction Dental injuries occur in contact and noncontact sports, as well as during recreational activities. Sports-related dental injuries in children and adolescents are predictable based on an analysis of a specific set of causal factors [ 1,2]. Most sports-related dental injuries are preventable with the use of properly fitted athletic mouth guards [3], but despite advancements in mouth guard fabrication techniques, compliance by athletes is neither optimal, nor insisted upon by some referees and coaches, even in those sports that mandate mouth guard use [4-6]. Thus, dental injuries continue to occur and are likely to increase as participation in sports continues to rise [7]. It is important for members of the sports medicine team to recognize, triage, and provide emergent management for dental injuries, particularly in those instances in which a team dentist is not available on site. This article reviews some of the more common dental injuries that occur in the arena of sports, including emergent manage­ment and preventive interventions.

Epidemiology of Dental Injuries Primary dentition Dental injuries may occur from traumatic forces directed to the teeth or indirectly as the result of tooth to tooth contact from forces directed to the mandible. Such force vectors may be generated by various sources that often are associ­ated with the age of the individual. For instance, the most frequent injury to the primary dentition in young children involves the intrusive displacement of the anterior teeth as the result offalls [8]. Not only are the affected primary incisors a cause for immediate concern, but the underlying developing permanent successors also may be affected.

Damage to the underlying permanent teeth may only be evident as these teeth erupt into the dental arch with a non esthetic developmental defect such as localized enamel hypoplasia on the surface of the crown. Conversely, these teeth may remain impacted as the result of a nonfunctional dilacerated root. The former would require the placement of an acid-etch composite resin, tooth-colored esthetic restoration; the latter would require surgical exposure and extraction, followed by a prosthesis to replace the missing permanent tooth.

Permanent dentition The most common injury to the permanent anterior teeth of adolescents and adults involves crown fractures that may be limited to the tooth enamel or may extend through the dentin into the dental pulp [9]. Crown fractures to the permanent anterior teeth arise from various causes, but often are associated with vehicular accidents or participation in sports (Fig. 1). One causal factor of note for fractured crowns is the use of oral jewelry in pierced tongues in the general population as well as in the culture of athletes. It should be emphasized that tongue jewelry causes numerous systemic and oral maladies, and the presence of tongue jewelry while participating in sports is banned by most athletic organizations. Despite the dangers associated with this practice, athletes are reluctant to remove the tongue jewelry as the piercing is apt to close in a relatively short amount of time. They often mask the presence of the jewelry in competition by substituting clear see-through plastic for the metallic or multicolored plastic studs [ 10-12].

Data from one national study of dental trauma to the anterior teeth of individuals between the ages of 6 and 50 years reported that 25% of the population of the United States had sustained one or more traumatic injuries to the anterior teeth from all causes. In addition, the study

Figure 1. The most frequent type of traumatic dental injury to a perma­nent tooth is a crown fracture such as the enamel-dentin fracture on the maxillary left permanent central incisor of this patient.

reaffirmed previous reports that the maxillary permanent central incisors are the teeth involved most frequently and that males are at greater risk than females for experiencing dental trauma. The race of the individual was determined not to be a statistically significant factor [13] .

Sport-specific dental trauma In a review article that examined the scientific literature related to dental trauma in specific sports, 104 articles published over the past 20 years were sited [ 14•]. The sports reviewed included basketball, baseball and softball, soccer, ice hockey, field hockey and lacrosse, bicycling, and rugby and football. Other sports with fewer available epidemio­logic studies such as alpine skiing, gymnastics, judo, karate, kendo, wrestling, volleyball, swimming, snowboarding, and skateboarding also were reviewed. Although the authors noted that the injury rate among the various sports and geographic regions was relatively similar based on orofacial injury site studies, they cautioned that dental injury events are likely underreported as there is currently no national or international mechanism to accurately record these injuries. Further, the importance of mouth guards for preventing dental injuries was emphasized.

Predicting sports-related dental trauma The capability to determine the likelihood of sports­related traumatic dental injuries in children and adoles­cents was reported as a Bayesian probabilistic model [ 1]. In developing this predictive index, 14 causal factors were identified and prioritized by a team of experts in the field . The 14 causal factors are delineated under several different categories.

Demographic information: age of the athlete, dental malocclusion, sex of the athlete, history of previous dental injury;

Use of protective equipment: helmets, facemasks, mouth guards;

Dental Injuries in Sports • Ranalli 13

Contact versus noncontact sport: velocity of the sport, intensity of the sport;

Athlete participation: level of activity, exposure time, focus of attention;

Rating of activity: level of coaching, level of the sport. The information derived from this predictive index was

translated into a computer-based program that will enable dentists to perform chair-side risk assessments of their patient-athletes. The clinical application of the index will facilitate early detection of high-risk individuals and, through appropriate protective equipment recommenda­tions, decrease the morbidity associated with dental trauma [ 1]. Subsequent to the introduction of the predic­tive index, preliminary field testing was performed for face validity with 60 subjects: 30 dental faculty members and 30 residents from the same institution. The index was determined to be valid and usable [2]. Further develop­ment and testing of this instrument is ongoing.

Athlete Evaluation When an athlete sustains a sports-related dental injury several factors require consideration prior to the initiation of emergent interventions. These factors include an evalua­tion of the athlete's physical status and an examination of the oral status and extent of the dental injury [15,16•].

Physical status As is the case with all athletic injuries, there is a need to know relevant information about the patient's medical history, including known allergies, current medications, and past illnesses. Frequently, this information already is known by team physicians and trainers from the preseason medical history and physical examination as well as ongoing medical care throughout the season.

At the time of the dental injury, the athlete's physical status needs to be assessed. This may include the evalua­tion of vital signs and cardiopulmonary status, as required. Oral injuries may compromise the airway and must be cleared. Airway obstruction might be precipitated by accumulation of blood as the result of a mucosal lacera­tion, dislodged dental appliances including mouth guards, or fractured tooth fragments [16•] .

Once a patent airway has been established and the athlete is stabilized, attention then can be directed toward the actual intraoral soft or hard tissue damage. In instances of oral mucosal lacerations, a sterile gauze pack should be positioned over the laceration with finger pressure. When blood flow is diminished to a slow oozing, the wound should be examined and cleansed thoroughly. If foreign matter is present, it must be removed and a determination should be made whether or not sutures are indicated. For deep lacerations, the wound should be sutured in layers beginning in the deepest portion of the laceration. In those instances in which

14 Head and Neurologic Conditions

anatomic borders are crossed, as in the region of the vermillion borders of the lips, proper alignment of the tissue borders is essential for an esthetic cosmetic outcome. Antibiotics should be prescribed for most sports-related oral mucosal lacerations, and are recom­mended for through and through lacerations. Tetanus immunization status also should be determined at this time and a booster given as required [15,16•].

Other dental injuries that require antibiotic coverage include teeth that have been avulsed from the alveolar socket, some root fractures, alveolar bone, and maxillary or mandibular fractures. Antibiotic preferences for oral injuries include cephalosporins or amoxicillinfclavanic acid [16•]. In addition, American Heart Association Guide­lines should be followed for patients with a history of rheumatic heart and valvular diseases prior to oral surgical procedures [17].

It is important to note that every orofacial injury has the potential to be associated with a mild traumatic brain injury. Evaluation for possible concussion is warranted for athletes who sustain dental injuries [ 18 .. ].

Oral status Several factors should be kept in mind to enhance both the short- and long-term prognosis for traumatic dental injuries. These factors include, among others, the general health of the patient, the age of the patient (as permanent teeth in younger patients have a better potential of responding favorably), and the time interval between the injury and the initiation of treatment. In general, better outcomes can be expected when appropriate interventions are initiated expeditiously.

For the purposes of this article, traumatic dental injuries to the permanent anterior teeth of athletes are described under the categories of crown fractures, root fractures, and luxation injuries. Regardless of the type of dental injury the athlete has experienced, the goals of treatment are consistent. These goals include retaining the tooth in the dental arch, maintaining the vitality of the dental pulp, preventing internal and external root resorption, and restoring the injured tooth to form, function, and esthetics. An added goal for traumatic dental injuries in athletes is preventing future injuries through recommendations for use of properly fitted mouth guards (Fig. 2) during practice sessions as well as in competition [19].

It should be noted for risk management reasons associated with informed consent that the athlete must be counseled regarding the possibility that even a minor dental injury may result in pulp tissue necrosis or loss of the affected tooth in the near or distant future. Further, intervention for dental injuries to athletes who are minors requires parental consent. This is often included on preseason authorization forms signed by the parent in the event of a future emergency related to participation in sports [20].

Dental Injuries Crown fractures Crown fractures are the most common type of dental injury to the permanent anterior teeth and may, in increasing order of severity and complexity, involve the crown enamel only, the enamel and dentin, or may extend through the enamel and dentin into the dental pulp [ 21].

Enamel fractures In some instances of enamel-only fractures, the athlete may experience roughness from the chipped tooth on the tongue. Most enamel-only fractures can be corrected by smoothing and contouring the rough edge of the tooth. Enamel-only fractures are not considered dental emergencies and often go unnoticed by the athlete. They often are asymptomatic and discovered during routine dental examinations.

Enamel-dentin fractures Enamel-dentin fractures will elicit painful sensations when the exposed dentin is subjected to air, cold drinks, or when touched. These sensations are a positive sign that the dental pulp is vital. In all cases of enamel-dentin fractures, an attempt to locate the fracture fragment is desirable. If the fragment is successfully located, it should be placed in a liquid such as milk or Hank's balanced saline solution and given to the patient to take to the dental office or emergency room. The fragment may be suitable for reattachment with bonding agents and composite resin materials [22,23]. Another approach to on-site manage­ment of enamel-dentin fractures is the use of a pulp­protecting agent such as calcium hydroxide paste or zinc oxide mixed with eugenol. Either of these medicaments may be placed directly over the exposed dentin to reduce sensitivity. It is essential that athletes who experience an enamel-dentin fracture be referred to a dentist as soon as possible for best possible results. The dentist may place a composite resin or glass ionomer bandage over the exposed dentin as an interim restoration until a functional and esthetic restoration can be placed [ 21].

Enamel-dentin-pulp fractures Enamel-dentin-pulp fractures are the most complex of the crown fractures and require differential evaluation prior to the initiation of definitive treatment [24]. The treatment selected is based on the dental pulp status and the dental age of the tooth. For teeth with a vital pulp and a closed root apex, the treatment includes placement of a calcium hydroxide paste over the exposed pulp followed by the placement of an esthetic restoration. For teeth with a vital pulp and an open root apex, the objective is to first induce physiologic root end closure using an apexogenesis procedure. On the other hand, for teeth with a nonvital pulp and a closed root apex, standard root canal treatment can be performed. Finally, for teeth with a nonvital pulp and an open root apex the objective is to first induce a

Figure 2. The most effective intervention for preventing a sports­related dental traumatic injury is the use of a properly fitted, custom­fabricated mouth guard such as the one worn on the maxillary arch of this athlete.

calcific closure of the root end using an apexification procedure. If a dentist is not available on site at the time of the injury, an enamel-dentin-pulp fracture in a vital tooth with either an open or closed root apex will demon­strate seepage of blood from the pulp chamber accompa­nied by heightened sensitivity to stimuli or pain. This is considered a dental emergency that requires immediate attention by a dentist. If an enamel-dentin-pulp fracture is not accompanied by pain or the opening into the pulp chamber is dry or oozes putrescent exudates, then a non­vital situation can be assumed. Nonvital teeth that are not accompanied by heightened sensitivity or pain do not require immediate attention, but should be referred to a dentist for evaluation and treatment as soon as an appoint­ment can be arranged [21-24].

Root fractures Root fractures occur less frequently than do crown fractures, but they also can be grouped into three categories depending on the location of the root fracture [25,26]. Root fractures may occur in the apical third, the middle third, or the cervical third of the root adjacent to the cementoenamel junction of the crown and root. Root fractures in the apical third have a much better prognosis than do fractures in the cervical third.

Apical root fractures Apical-third root fractures have an excellent prognosis for healing of the segments and maintaining pulp vital­ity, particularly in the absence of segmental mobility. Such fractures often go undetected on site and are discovered on evaluating a periapical radiograph of the affected tooth [27].

Middle root fractures Middle-third root fractures have a good prognosis for healing of the segments depending on how quickly after the injury emergent intervention is initiated. Even without

Dental Injuries in Sports • Ranalli 15

a periapical radiograph on site, visual examination will reveal that the coronal segment of the tooth appears longer than the adjacent teeth and is extruded to varying degrees from the alveolar socket. Bleeding will be evident from the gingival sulcus and with gentle finger pressure the segment can be rotated slightly in the socket. On-site emergent management should include repositioning the coronal segment into the alveolar socket with gentle finger pressure then instructing the athlete to bite down gently on sterile gauze [27] . This biting pressure will maintain the position of the tooth during immediate transport to the dental office for radiographic evaluation and splinting of the affected tooth. Similar to successful management for a fracture to a long bone, management of a fractured tooth requires reducing the space between the fractured segments, splinting the tooth for 6 to 8 weeks, and prevent­ing infection with proper oral hygiene and daily rinses of chlorhexidine gluconate. Systemic antibiotics also may be indicated. The tooth should then be monitored periodically for evidence of healing or for signs and symptoms of pulpal necrosis [27]. Root canal treatment may become necessary.

Cervical root fractures The prognoses for cervical-third fractures are decidedly less optimistic. On-site emergent intervention is the same as for middle-third root fractures, but on referral to the dentist a determination will be made if the tooth or coronal segment can be saved and restored; or if the tooth requires extraction and an eventual prosthetic replacement. Single replace­ments of anterior teeth can be restored to form, function, and esthetics with a dental implant [28].

Traumatic displacements Extrusive, intrusive, lateral luxations Similar to crown fractures and root fractures, traumatic displacement of permanent anterior teeth can be classified into three categories: extrusive luxation, intrusive luxation, or lateral luxation. These displacement or luxation injuries are different from both crown and root fractures in that traumatic displacements are not associated with fracture. Instead displacements involve compressing, stretching, or rupturing of the periodontal ligament that attaches the cementum of the root to the surface of the alveolar boney socket. In addition to the general goals for management of tooth injuries described previously, tooth displacements require repositioning the tooth as quickly as possible, maintaining the vitality of the periodontal ligament, and preventing pulp necrosis . On site the tooth should be repositioned for lateral and extrusive luxation injuries and referred immediately to the dental office. Those that are intruded should not be repositioned and also should be referred immediately to the dental office. Following repositioning, a passive semirigid splint should be placed for 7 to 10 days with the area kept clean by proper brushing and daily rinses with E:hlorhexidine gluconate. Systemic

16 Head and Neurologic Conditions

antibiotics also may be indicated. The tooth should then be monitored periodically for healing of the attachment apparatus or any indication of loss of vitality. Root canal treatment can be initiated as needed [29, 30].

Avulsion For situations in which an athlete sustains a total extrusive luxation of a permanent anterior tooth (also referred to as tooth avulsion or tooth exarticulation), immediate intervention is required on-site if the tooth is to have any chance of surviving the accident. The critical time frame is the first 15 minutes following the injury.

The first step in emergent management is to locate the tooth, handling it only by the crown and not the root. If the tooth cannot be located it may not have been avulsed, but rather could be totally intruded into the alveolar socket. This can only be confirmed by a periapical radiograph. On the other hand, if the tooth has been avulsed and located the next step on site is to examine the tooth for the presence of any debris such as turf or cinders, then to wash it off gently with sterile physiologic saline, or milk; the debris should not be scraped off of the root as this will destroy the critical portion of the periodontal ligament that remains attached to the cementum of the root. The tooth can then be repositioned into the alveolar socket [31,32]. It is essential to confirm that the labial and lingual surfaces of the tooth are in proper position by comparison with the adjacent teeth. When the tooth has been implanted into proper position the athlete should be asked to bite on sterile gauze and be transported immediately for dental treatment as described previously in this section.

In the event that no one on site is capable or willing to reposition the avulsed tooth back into the alveolar socket, the athlete along with the avulsed tooth must be transported with all possible haste to the dental office. It should be noted that not all hospital emergency rooms have dentists or oral and maxillofacial surgeons available on staff and some of these facilities do not stock the dental supplies necessary to place an adequate tooth splint.

The avulsed tooth should not be transported dry, wrapped in a paper towel, or in gauze as this will dessicate the remnants of the periodontal ligament remaining attached to the root and will minimize substantially any hope that the tooth will survive. Tooth saver kits are available commercially through dental suppliers at a reason­able cost and are recommended as an item for inclusion in the team physician's and team trainer's medical bag [33]. If tooth saver kits are not available on site, the tooth may be transported in a glass jar, paper cup, or sealable plastic bag containing Hank's balanced saline solution or fresh milk; skim milk is preferable [34].

Conclusions The intent of this article is to provide dental first aid informa­tion to sports medicine professionals regarding appropriate

on-site emergent management protocols for common dental injuries at all levels of athletic participation. Establishment of networks with local dentists is recommended for consulta­tion and as a referral base for definitive treatment of sports­related dental traumatic injuries. Further, sports medicine teams are urged to consider the advantages of appointing a team dentist as a primary dental care provider on-site, as well as for long-term continuity of care following dental trauma. This approach seems desirable for a variety of reasons, including medicolegal issues related to risk management and informed consent.

Recent reports indicate that participation in athletics continues to increase [7]; thus, increasing the probability for all sports injuries, including dental trauma. Not only should a team dentist be available to address emergent needs and long-term continuity of care, but perhaps more importantly, to provide athletes with properly fitted custom mouth guards to prevent many of these sports-related dental injuries from happening in the first place [35].

References and Recommended Reading Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

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3. Academy for Sports Dentistry: Position statement: a properly fitted mouthguard. Academy for Sports Dentistry Newsletter 1998, 15:10.

4. Ranalli DN, Lancaster DM: Attitudes of college football officials regarding NCAA mouthguard regulations and player compliance. J Public Health Dent 1993, 53:96-100.

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7. National Collegiate Athletic Association News Release: NCAA sports participation on the rise. http://www.ncaa.org/releases/ research/199912200lre•htm Accessed September 27, 2004.

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