«Docteur Philippe Poisson - Assistant Hospitalier et Universitaire Pôle d’Odontologie et de Santé Buccale CHU de Bordeaux - Laboratoire Mouvement, ...»
MOUTHGUARDS FOR USE IN SPORTS
Docteur Philippe Poisson
- Assistant Hospitalier et Universitaire
Pôle d’Odontologie et de Santé Buccale
CHU de Bordeaux
- Laboratoire Mouvement, Adaptation, Cognition
Université Victor Segalen Bordeaux 2
Responsable de Pôle d’Odontologie et de Santé
Professeur Georges Dorignac
Responsable d’UMR 5227 :
Professeur Julien Petit Version du 09 mars 2008 2
PART 1 : DENTAL AND OROFACIAL INJURIES IN SPORTS, 5
RISK FACTORS AND PREVENTIVE MEASURES
I DENTAL AND OROFACIAL TRAUMAS 5A/ Sports involved in dental and orofacial traumas 5 1- Basket Ball 5 2- Football 6 3- Ice Hockey 6 4- Handball 6 5- Soccer 6 6- Rugby 6 7- Cycling 7 8- Martial Arts 7 9- Swimming 7 10- Baseball 7 11- Skiing 7 12- Boxing 8 B/ Types of trauma 8 1- Teeth frequently injured 8 2- Number of injured teeth 8 3- Dental injury types 8 C/ Causes of dental and orofacial traumas 8 D/ Underestimation of the number of traumas 9
II PREDISPOSITION FACTORS 9
PART 1 : DENTAL AND OROFACIAL INJURIES IN SPORTS, RISK
FACTORS AND PREVENTIVE MEASURESIn its classification of sports with an oro-dental risk, the International Dental Federation distinguished the high-risk sports such as football and the medium risk sports such as Basketball (1). On the other hand, when the frequency of oro-dental traumas is considered, several studies (1,2) have shown that some sports present a high frequency (Ice Hockey), some a medium frequency (Basketball, Handball and Soccer) and others a low frequency (Football and Volley-ball). In another study on sports practice in Israel, Levin et al. (3) found that for oro-dental traumas the Basketball prevalence was the greatest, followed by that of soccer, cycling, martial arts and swimming. Therefore it seems that a discrepancy exists between the traumas frequency and the traumas risk. A first explanation was proposed by Flanders et al. (4) taking Football and Basketball as an example. A discrepancy should exist for Football and not for Basketball because the use of a mouthguard is compulsory in the former and not in the latter.
To clarify these points this review will firstly present an epidemiological report of the dental traumas encountered in sports, secondly an analysis of the factors involved in these traumas and finally a description of the preventive measures to reduce the traumas frequency.
I DENTAL AND OROFACIAL TRAUMAS
The causes and consequences of oro-dental traumas are analysed in many publications. They all precisely describe the sport traumatology but they use different classifications and different parameters to measure the traumas frequency (5). With such diversity, it seems difficult to compare the data, hence this review only presents the data which corresponded and were precisely defined (5).
Sports traumatology is one of the main causes of dental and orofacial injuries with the falls, the traffic accidents and the fights (6-12).
A/ Sports involved in dental and orofacial traumas:
The risk of oro-dental traumas depends on the sport (1), which is not systematically a contact sport (13). Dental and orofacial traumas are also observed in Skiing (8,9,11,12), Baseball (14,12), Cycling (8,11,15) and Swimming (3,16).
1- Basket Ball:
In Illinois between 1991 August and 1992 May, the cumulative incidence of orofacial traumas was 18.3 injuries for 10000 players (4). In the Finland championship, between 1979 and 1985 this cumulative incidence (calculated from the number of incidental cases and a number of involved players) was 33.4 injuries for 10000 players and the number of incidental cases was 5.8 % of the total number of injuries (2). During the 1989 Canadian games (2 weeks long) the cumulative incidence was very high and had different values for men and women (17): for men, 80 injuries for 10000 players and for women 250 injuries for 10000 players. It should be noted that none of injured players used a mouthguard (17).
Labella et al. (18) emphasised the protective role of a mouthguard during basket ball games:
the cumulative incidence for a one year season was 1.2 dental traumas for 10000 players using a mouthguard whereas it was 6.7 dental traumas for 10000 players not using a mouthguard.
Finally, the dental injuries prevalence was 6.4% for players between 18 and 30 years old (19).
5 2- Football:
The cumulative incidence of orofacial injuries calculated on a 10 months period is 1.4 injuries for 10000 players (4). However, in another study (2) the data allowed to calculate the cumulative incidence on a period of 2 years, which was 67 injuries for 10000 players.
3- Ice Hockey:
A single study (2) gives the cumulative incidence, which was 51.2 dental injuries for 10000 players during a 5.5 years duration. However, another study in Finland (16) indicates that the number of incidental cases for dental traumas in a public dental health centre was 29 injuries during the 1983 season.
Ferrari et al. (19) found that for hockey players between 22 and 30 years old, the dental injuries prevalence was 11.5% which is much lower than the prevalence in handball (37.1%), basket ball (36.4%), martial arts (32.1%) and the football (23.1%). The hockey prevalence is low probably because most of players (91%) use a mouthguard, which is not the case in other sports (19).
The cumulative incidence for dental traumas calculated on a 7 years period is 50.2 injuries for 10000 players (2). Handball as a relatively high-risk sport, is confirmed by a measure of the dental traumas prevalence which was 37.1% (19). However, Lang et al. (20) found a lower prevalence between 6.25% and 15.6%, depending on the player status (professional or not) and on the country (Swiss or Germany).
The cumulative incidence is 19.4 injuries for 10000 players (2,21). Two prevalence measurements are in agreement with this result: the dental traumas prevalence measured in soccer is the lowest (23.1%) among those measured in other sports (19) but Yamada et al.
(22) found a slightly higher prevalence (32.3%).
For orofacial traumas observed during a 2 years period, the percentage of injured soccer players (25%) was the highest just above that of rugby (13) but other studies found different results. Tanaka et al. (12) reported for 17 years period 11 orofacial fractures for soccer, among 98 for all sports (percentage of incidental cases 11.2%) whereas rugby, skiing and baseball had higher numbers of fractures, 23, 23 and 13 respectively. Hill et al. (15), during a 1 year period, reported for orofacial traumas 109 incidental cases among 790 for all sports (percentage of incidental cases 13.8%), number of incidental cases well below those for rugby (206) and for Cycling (189).
For mandibular fractures, the soccer percentage of incidental cases observed in different studies is similar: 12.1% (11), 8.9% (8), 8.5% (12).
This sport is commonly thought to expose to risk (1) and it is not surprising that all studies agree with this idea. In a first study on rugby, Chapman (23) found that in Australia, the orodental traumas prevalence was 15.8% when the whole Australian championship was considered, 25% when the study was restricted to the Queensland team and 41.7% for the Australian national team. In a second study, Chapman and Nasser (24) confirmed the prevalence for the Australian team (42.3%) but found slightly different prevalences for other national teams: Ireland (26.9%), Scotland (50%) and Wales (54.2%). On average, these values are on agreement with that (56.5%) found by Yamada et al. (22). In France, for all championships the prevalence is similar to that found for the Irish team that is between 27% and 33%. (25, 26).
6 For the orofacial traumas, in Japan between 1977 and 1993, the rugby percentage of incidental cases was 23.5% (12). This was confirmed by Delilbasi et al. (14) also in Japan, who found for the 1986-2002 period a 28% rugby percentage of incidental cases which was lower than that of baseball. In France, the rugby is also the second cause of orofacial traumas (15%) but behind Soccer (25%) (13).
More specifically, in Rugby, for the mandibular fractures, the number of incidental cases in Japan was 15 to be compared to a total of 59 fractures (percentage of incidental cases of mandibular fracture 25%) (12). In France between 1992 and 1996, again for the mandibular fractures, the number of incidental cases was 16 to be compared to a total of 33 fractures in all sports (rugby percentage of incidental cases 48.5%) (11).
All these results suggest that the orofacial traumatology depends on the country.
Almost 85 million Americans regularly cycle and, each year, 540,000 of them experience a trauma (27). However, in sports, the incidence is probably high because Levin et al. (3), who studied the prevalence of sports for the oro-dental traumas, found that cycling was in third place after basket ball and football.
For the orofacial traumas, the number of cycling incidental cases during a one year period, was 189 with a 790 total injuries (cycling percentage of incidental cases 24%) (15).
Considering the mandible fractures, two studies give similar cycling percentage of incidental cases: 25.4% (8) and 30.3% (11).
8- Martial Arts:
The prevalence of dental traumas is 32.1% which seems normal for a fighting sport (19).
Among the orofacial traumas the most frequent ones concern the mandible. The number of incidental cases of mandible fracture between 1977 and 1993 was 6 in 59 fractures (percentage of incidental cases of mandible fracture 10.2 %) (12).
For taekwondo, very often, the head is injured with a cumulative incidence of 6.1 injuries for 1000 sportsmen and a cumulative incidence of 4.55 injuries for 1000 sportswomen (28).
For dental traumas during the 1983 year, the number of incidental cases (26) was just below that of Ice Hockey (16).
In a first study it was the first cause of maxillo-facial fractures with a 44% percentage of incidental cases just before the rugby (28%) and the soccer (18%) (14). However in a second study, again in Japan, between 1977 and 1993, for maxillo-facial fractures the number of incidental cases was 13 for 98 injuries (baseball percentage of incidental cases 13%) (12).
Similar results were found for the mandible fractures: 8 incidental cases for 59 fractures (baseball percentage of incidental cases 13.6%) whereas the incidental cases were 14 for skiing and 15 for rugby (12).
As already noted, skiing is the first cause of orofacial traumas, the percentage of incidental cases between 1977 and 1993, being 23.5% (12). In Innsbruck, between, 1991 and 1996, Gassner et al. (29) found a slightly higher percentage (30%).
For mandibular fractures, again in Innsbruck but between 1984 and 1993 the percentage of incidental cases was very high (55.3%) (8). At the contrary Paoli et al. in Toulouse, between 1992 and 1996, found for mandibular fractures due to skiing a very small percentage, 3% of 7 the total of incidental cases (11). These 2 examples illustrate the dependency of the statistics on the studied areas or countries. Obviously mountains are required to practice alpin skiing.
Surprisingly, very few mandibular fractures are encountered in boxing. Tanaka et al. (12), during a 17 years period, observed only 2 incidental cases which correspond to a percentage of 3% of the total of incidental cases for all sports. No maxillary or malar fracture was observed as well as alveolar process fracture Tanaka et al. (12).
These low percentages are due to the use of mouthguard and of protective accessories.
B/ Types of trauma:
1- Teeth frequently injured:
In the whole population, the most frequently injured teeth are the maxillary central incisors (6,30-34). The maxillary central incisors are involved in 50.64% of the dental traumas, the maxillary lateral incisors in 12.1%, the mandibular central incisors in 7.96% and the mandibular lateral incisors in 6.37% (6). Lombardi et al. (31), Martin et al. (32) and Schaltz and Joho (33) also found that the highest proportion of dental traumas was for permanent or primary central maxillary incisors. In addition, Schaltz and Joho (33) observed that 94.6% of dental traumas involve permanent or primary maxillary incisors.
During sport practice (football, ice hockey, basket ball, handball, soccer) 76% of dental traumas involve the maxillary teeth, mostly the central maxillary incisors (2) whereas 6% of dental traumas involve the posterior teeth (24, 26).
2- Number of injured teeth:
For the whole population, in 60% of dental traumas, only one tooth is injured (6,30) and two teeth are injured in 29.1% of dental traumas (6). Surprisingly, the mean number of teeth involved in a dental trauma is two (10,32).
In sport practice the mean number of injured teeth per dental trauma is also two (26).
3-Dental injury types:
As noted by Bastone et al. (5), it is difficult to describe the different injuries because the authors use different terminology.