Effectiveness of Mouthguards for the Prevention of Orofacial Injuries and Concussions in Sports: Systematic Review and Meta-Analysis

Characteristics of Rodeo Injuries and Suggestions for Injury Prevention: A Systematic Review

Background

Rodeo is a globally popular sport, with its athletes prone to various types of injuries. There is no systematic review discussing rodeo injuries across all age groups.

Purpose

To (1) review the published literature on incidence, types of injuries, and factors leading to injuries in rodeo athletes; (2) provide prevention recommendations for health care providers; and (3) identify gaps in the research.

Study Design

Systematic review; Level of evidence, 4.

Methods

A comprehensive search of available literature was electronically performed through MEDLINE, Embase, and SPORTDiscus databases using the key terms "rodeo" and "injury" or "trauma" between 1995 and 2021. A systematic review was performed using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, which identified 116 eligible studies. Outcome data included frequency of injuries, risk factors for injury, and types of injury.

Results

A total of 23 studies met the inclusion criteria (N = 2105 athletes), of which 13 were retrospective studies. In the included studies, the injury rate per competition exposure (CE) ranged from 4.2 to 19.1 injuries per 1000 CE. Sprains and strains accounted for the highest percentage of injury types, ranging from 15% to 34%. The knee was the most common location of injury, making up 11.1% to 17% of injuries. Concussions occurred in up to 15.3% of injuries for all events and up to 77% of injuries in roughstock events. Of all rodeo events reported, bull riding caused the highest percentage of injuries, making up 19.4% to 58.4% of injuries, and bareback had the second highest at 15.3% to 28.8% of injuries.

Conclusion

There was a high prevalence of various injury types and mechanisms in rodeo. Improved injury surveillance and the introduction of a comprehensive standardized injury reporting system would be helpful in the future prevention, diagnosis, and treatment of rodeo injuries.

Mechanisms of dental injuries in basketball, United States, 2003-2022

BACKGROUND/AIM

Oral injuries such as oral soft tissue lacerations and contusions can occur in basketball by mechanisms such as running into other players or falling. Given a high enough impact force, dental injuries such as tooth fractures and avulsions can occur. Previous research has studied the different types of oral injuries as well as the mechanisms that cause them. Yet, the mechanisms resulting in dental injuries have remained unexplored. The aims of this study were to investigate the distribution of different oral injuries within each injury mechanism and evaluate which mechanisms were most likely to lead to a dental injury.

MATERIALS AND METHODS

This is a retrospective cohort study using the National Electronic Injury Surveillance System (NEISS). Subjects who experienced oral injuries from basketball between January 1, 2003 and December 31, 2022 were included in this study. The independent variable was the injury mechanism. The dependent variable was the dental injury outcome (yes/no). Multivariate logistic regression was used to measure the association between the injury mechanism and the dental injury outcome. A p < .05 was considered statistically significant.

RESULTS

This study included 4419 subjects who experienced oral injuries (national estimate, 138,980). Approximately 14.7% of oral injuries were dental injuries. Subjects experiencing collisions with objects such as walls or the basketball hoop (odds ratio (OR), 4.39; p < .001), falls (OR, 3.35; p < .001), or contact with the basketball (OR, 1.77; p = .006) had significantly higher odds of sustaining a dental injury relative to those experiencing contact with another player.

CONCLUSIONS

Basketball players experiencing contact to the mouth have high odds of sustaining a dental injury. An understanding of injury mechanisms is important for medical teams to manage these injuries and for coaches to educate athletes on safe and proper playing styles. Furthermore, healthcare providers and basketball staff should encourage athletes to wear mouthguards to reduce the risk of traumatic dental injuries.

The International Association of Dental Traumatology (IADT) and the Academy for Sports Dentistry (ASD) guidelines for prevention of traumatic dental injuries: Part 3: Mouthguards for the prevention of dental and oral trauma

The Guidelines for Prevention of Traumatic Dental Injuries were reviewed and approved by the Board of Directors of the International Association of Dental Traumatology (IADT) and the Academy for Sports Dentistry (ASD).

Fabrication of sports mouthguards using a semi-digital workflow with 4D-printing technology

Purpose This technical procedure report explains the fabrication protocol for a newly developed 4D-printed sports mouthguard (MG) based on 4D-printing technology.Methods An intraoral scanner was used to scan a maxillary arch model. A two-layer sports MG was designed based on the scanned model using computer-aided design software and output in a standard tessellation language file format. Two types of filament materials were used for the MG material: a thermoplastic shape memory polyurethane elastomer with a unique glass transition temperature for the external layer and a thermoplastic elastomer for the internal layer. Both MGs were printed using a fused deposition modeling 3D printer and assembled using adhesives after trimming the support material. To confirm the shape-memory performance of the fabricated 4D-printed MG, a deviation analysis was performed by superimposing the internal surface data of the fabricated MG and the MG whose shape was recovered. The distance between the data obtained by deviation analysis was calculated, and the root mean square error value (mm) was determined.Conclusions The 4D-printing technology simplifies the complex processes required with conventional methods. It also overcomes the issues of conventional and 3D-printed MGs, such as the reduced fitting accuracy caused by deformation, because this technology employs shape memory materials.

Faculty of sports science students, physical education teachers, and athletes' level of knowledge and attitude about mouthguards

OBJECTIVES

Traumatic dental injury occurs during sports competitions, training, and practice and can be prevented by the use of mouthguards. For this reason, this study aimed to evaluate the knowledge and attitudes of sports science faculty students, physical education teachers, and athletes about mouthguards.

METHODS

Five hundred thirty-two participants were reached via social media. In the questionnaire consisting of 20 questions, questions about the sociodemographic characteristics of the participants were asked in part 1, and questions about their level of knowledge and attitudes about the mouthguards were asked in part 2. Descriptive statistical analysis and a chi-square test were used to evaluate the data.

RESULTS

The number of people who think that mouthguards protect the athlete from traumatic dental injury is 381 (71.6%). The number of people who think that mouthguards affect the performance of the athlete is positively 228 (42.9%). To protect against traumatic dental injury, 51.48% of the participants preferred the custom-made; 39.3% of them preferred the boil-bite; 33.22% of them preferred the standard/stock type mouth guard; and 22.96% of them preferred the helmet, and 18.26% of them preferred the face mask.

CONCLUSIONS

The knowledge and attitude of sports science faculty students, physical education teachers, and athletes are low about mouthguards. Since these people who are engaged in sports have a high exposure to traumatic dental injuries, education should be given to increase their awareness about mouthguards.

Knowledge of traumatic dental injuries and mouthguard behavior among Croatian soccer players

OBJECTIVES/AIM

Sports-related dental injuries occur frequently among athletes due to inadequate knowledge and prevention measures. The aim of the study was to assess knowledge, attitudes, and practices of active soccer players from all leagues in Croatia regarding traumatic dental injuries and the use of mouthguards.

MATERIAL AND METHODS

393 respondents completed a questionnaire-based online survey from March 2022 to April 2022. The questionnaire consisted of 37 questions divided in four sections: demographic characteristics, experience with orofacial injuries, knowledge of emergency therapeutic procedures for dental injuries, and behaviors related to the use of a mouthguard.

RESULTS

Insufficient knowledge was confirmed by a total score of 2.8 ± 2.8 points, with a possible maximum of 11. Respondents' better knowledge can be associated with educational level (p = .002), playing position (p = .046), and personally experienced injuries to the face and jaw (p ≤ .001) and teeth (p = .022). Less than 40% of respondents suffered facial and jaw injuries while playing football and 18.6% suffered dental injuries. Although most respondents (93.9%) were familiar with mouthguards and 68.9% believed that they help prevent injuries while playing football, only 16% used them.

CONCLUSION

The study revealed significant gaps in knowledge regarding dental injuries and the practice of mouthguard usage among Croatian soccer players. Therefore, it is evident that additional education is needed to prevent dental injuries and take proper procedures when taking care of them among the examined population.

Evidence pertaining to modifiable risk factors for oral diseases: an umbrella review to Inform oral health messages for Australia

The aim of this umbrella review was to collate and appraise the evidence base regarding modifiable risk factors for the prevention of oral diseases to inform the update of the Oral Health Messages for Australia. Eleven questions related to modifiable risk factors and dental disease were investigated. Electronic databases (Medline, Embase and PubMed) were searched from January 2010 to October 2022. Systematic reviews evaluating interventions/exposures in healthy subjects from high-income countries, where Westernized practices, oral health promotion and healthcare systems are similar to Australia, were included. Quality appraisal of included systematic reviews was guided by the AMSTAR tool. Of the 3637 articles identified, 29 articles met eligibility criteria. High-quality systematic reviews were identified for questions relating to diet, infant feeding, dental check-ups and oral hygiene. Free sugars consumption above 5% of energy intake, infrequent toothbrushing, smoking/vaping and alcohol intake were consistently associated with poorer oral health outcomes. Breastfeeding up to the age of 24 months was not associated with an increased risk of early childhood caries. The use of interdental cleaning devices and mouthguards during contact sports are likely to be effective in preventing dental disease.

Mouthguards Based on the Shear-Stiffening Effect: Excellent Shock Absorption Ability with Softness Perception

Mouthguards are used to prevent craniomaxillofacial injuries when collisions happen during contact and high-speed sports. However, poor compliance with mouthguard wear in athletes is attributed to discomfort because of its thickness and hardness. These drawbacks significantly restrict their protective performance for oral tissues and applications during contact sports; as a result, the incidence of craniomaxillofacial injuries increases. In this study, non-Newton material is introduced into mouthguard material and then a mouthguard with shear-stiffening behavior is fabricated, which is named the shear-stiffening mouthguard (SSM). Compared with commercial mouthguard materials (Erkoflex and Erkoloc-pro), SSMs show remarkable enhancement of shock absorption ability with an approximately 60% reduction in peak force relative to commercial materials and approximately 3-fold extensive buffer time. Moreover, Young's modulus of SSMs (average 0.48 MPa) is extremely lower compared to commercial materials (22.88 MPa for Erkoflex and 26.71 MPa for Erkoloc-pro). This manifests that SSMs have not only excellent shock absorption ability but also softness perception. Moreover, SSMs show biocompatibility in vitro. In conclusion, this work provides a platform to develop a new type of thin and soft mouthguard with a shear-stiffening effect and broadens the horizon in protecting oral tissues with shear-stiffening materials.

Prevention strategies and modifiable risk factors for sport-related concussions and head impacts: a systematic review and meta-analysis

OBJECTIVES

To evaluate prevention strategies, their unintended consequences and modifiable risk factors for sport-related concussion (SRC) and/or head impact risk.

DESIGN

This systematic review and meta-analysis was registered on PROSPERO (CRD42019152982) and conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

DATA SOURCES

Eight databases (MEDLINE, CINAHL, APA PsycINFO, Cochrane (Systematic Review and Controlled Trails Registry), SPORTDiscus, EMBASE, ERIC0 were searched in October 2019 and updated in March 2022, and references searched from any identified systematic review.

ELIGIBILITY CRITERIA

Study inclusion criteria were as follows: (1) original data human research studies, (2) investigated SRC or head impacts, (3) evaluated an SRC prevention intervention, unintended consequence or modifiable risk factor, (4) participants competing in any sport, (5) analytic study design, (6) systematic reviews and meta-analyses were included to identify original data manuscripts in reference search and (7) peer-reviewed. Exclusion criteria were as follows: (1) review articles, pre-experimental, ecological, case series or case studies and (2) not written in English.

RESULTS

In total, 220 studies were eligible for inclusion and 192 studies were included in the results based on methodological criteria as assessed through the Scottish Intercollegiate Guidelines Network high ('++') or acceptable ('+') quality. Evidence was available examining protective gear (eg, helmets, headgear, mouthguards) (n=39), policy and rule changes (n=38), training strategies (n=34), SRC management strategies (n=12), unintended consequences (n=5) and modifiable risk factors (n=64). Meta-analyses demonstrated a protective effect of mouthguards in collision sports (incidence rate ratio, IRR 0.74; 95% CI 0.64 to 0.89). Policy disallowing bodychecking in child and adolescent ice hockey was associated with a 58% lower concussion rate compared with bodychecking leagues (IRR 0.42; 95% CI 0.33 to 0.53), and evidence supports no unintended injury consequences of policy disallowing bodychecking. In American football, strategies limiting contact in practices were associated with a 64% lower practice-related concussion rate (IRR 0.36; 95% CI 0.16 to 0.80). Some evidence also supports up to 60% lower concussion rates with implementation of a neuromuscular training warm-up programme in rugby. More research examining potentially modifiable risk factors (eg, neck strength, optimal tackle technique) are needed to inform concussion prevention strategies.

CONCLUSIONS

Policy and rule modifications, personal protective equipment, and neuromuscular training strategies may help to prevent SRC.

PROSPERO REGISTRATION NUMBER

CRD42019152982.

Protective equipment in youth ice hockey: are mouthguards and helmet age relevant to concussion risk?

OBJECTIVES

To compare the incidence rates and odds of concussion between youth ice hockey players based on mouthguard use and helmet age.

MATERIALS AND METHODS

Within a 5-year longitudinal cohort (2013/2014 to 2017/2018) of male and female ice hockey players (ages 11-18; n=3330 players) in Alberta (Canada), we analysed the relationship of equipment and concussion in both a prospective cohort and nested case (concussion) control (acute musculoskeletal injury) approach. The prospective cohort included baseline assessments documenting reported mouthguard use (yes/sometimes, no use), helmet age (newer/<2 years old, older/≥2 years old) and important covariables (weight, level of play, position of play, concussion history, body checking policy), with weekly player participation throughout the season. The nested case-control component used injury reports to document equipment (mouthguard use, helmet age) and other information (eg, mechanism and type of injury) for the injury event. Multivariable mixed effects negative binomial regression (prospective cohort, incidence rate ratios (IRRs)) and multivariable mixed effects logistic regression (nested case-control, odds ratios (OR)) examined the association between equipment and concussion.

RESULTS

Players who reported wearing a mouthguard had a 28% lower concussion rate (IRR=0.72, 95% CI 0.56 to 0.93) and 57% lower odds of concussion (OR=0.43, 95% CI 0.27 to 0.70) compared with non-wearers. There were no associations in the concussion rate (IRR=0.94, 95% CI 0.75 to 1.15) and odds (OR=1.16, 95% CI 0.73 to 1.86) between newer and older helmets.

CONCLUSIONS

Wearing a mouthguard was associated with a lower concussion rate and odds. Policy mandating use should be considered in youth ice hockey. More research is needed to identify other helmet characteristics (eg, quality, fit) that could lower concussion risk.

Traumatic dental injuries in high school athletes in the United States of America from 2005 to 2020

BACKGROUND/AIM

Participation in sports activities is a source of dental injury. Despite recommendations for the use of mouthguards, athletes underutilize them. The aim of this study was to provide estimates of dental injuries, the mechanism of injuries and the utilization of mouthguards in high school sports.

MATERIALS AND METHODS

This study was a secondary analysis of an existing dataset of a convenience sample of the National High School Sports-Related Injury Surveillance Study. Data of athletic exposures, dental injuries, mouthguard usage, and mechanism of injury from the 2005/2006 to the 2019/2020 academic years were analyzed.

RESULTS

During the study period, there were 459 dental injuries in 49,987,927 athletic exposures resulting in a dental injury rate of 0.9 per 100,000 athletic exposures (AE). Slightly more than half of the traumatic dental injuries were sustained during competition (n = 256; 55.8%) and the rest (n = 200; 43.6%) were sustained during practice. The rate of dental injury in competition was 3.6 times higher than the rate in practice (RR: 3.6, 95% CI: 3.0-4.4). Dental injuries comprised 0.4% of the total 108,574 injuries sustained by athletes. Among girls' sports, field hockey had the highest rate (3.5 per 100,000 AE) and among boys' sports, basketball (2.4 per 100,000 AE) had the highest rate of dental injury. The most common mechanism of injury was contact with another player (276; 60.4%) followed by contact with apparatus (146; 31.9%). In the majority of dental injuries (308; 75.1%), the athlete was not wearing a mouthguard when the dental injury was sustained.

CONCLUSIONS

Dental injuries were a small proportion of all injuries sustained by high school athletes. The majority of dental injuries were sustained when the athlete was not wearing a mouthguard.

Sports mouthguard overview: Materials, fabrication techniques, existing standards, and future research needs

Sports mouthguards are proven devices that reduce both the probability of and damage to orofacial tissues. While commonly used, clinicians may be unaware of the different sports mouthguard materials, proposed fabrication techniques, design recommendations, and newer digital fabrication methods. An overview of existing sports mouthguard standards is presented. It identifies that identify that the present requirements, while historically chosen in good faith, appear to be arbitrarily selected and not from clinical evidence-based derived data. In addition, identified sports mouthguard heterogeneous testing and data acquisition methods distinguishes that little possibility is afforded for the correlation of results. Furthermore, updated evidence with concussion prevention and/or alleviation is presented with evidence provided by sports mouthguard imbedded technology. The need for continued research is stressed to provide evidence-based data for concussion alleviation/prevention, digital fabrication methods and materials, and clinically based information for the revision of existing standards.

Impacts of educational interventions on the knowledge of prevention and emergency management of traumatic dental injuries in 11-17-year-old martial arts athletes: a randomized controlled trial

PURPOSE

We compared the effect of an educational pamphlet and a mobile application regarding prevention and emergency management of sport-related traumatic dental injuries (TDIs) on knowledge and self-reported preventive practice of 11-17-year-old Karate and Taekwondo athletes.

METHODS

Participants were invited through an online link published by the Public Relations of the corresponding federations. They completed an anonymous questionnaire consisting of demographics, self-reported experience of TDIs, knowledge of emergency management of TDIs, self-reported preventive practice of TDIs, and the reason for not using mouthguard. The respondents were randomly allocated to pamphlet or mobile application group with the same content. Three months after the intervention, the questionnaire was completed by the athletes again. Repeated measures ANOVA and a linear regression model served for statistical analysis.

RESULTS

In pamphlet group, 51 athletes and in mobile application group 57 athletes completed both baseline and follow-up questionnaires. At baseline, the mean score was 1.98 ± 1.20 and 1.82 ± 1.24 (out of 7) for the knowledge and 3.70 ± 1.64 and 3.33 ± 1.95 (out of 7) for practice in the pamphlet and application group, respectively. In 3-month follow-up, the mean score of knowledge and self-reported practice was significantly higher compared to baseline in both groups (p < 0.001) with no statistically significant difference between the two groups (p = 0.83 and p = 0.58, respectively). Most of the athletes were very satisfied or satisfied with both types of the educational intervention.

CONCLUSION

Both pamphlet and mobile application seem to be useful to improve awareness and practice regarding TDI prevention in adolescent athletes.

Musculoskeletal Injury Risk in a Military Cadet Population Participating in an Injury-Prevention Program

Background and Objectives: Musculoskeletal injuries are a major health hazard among military personnel. Previous research has proposed several exercise-based strategies for prevention. The purpose of this study was to investigate the effect of an exercise-based injury-prevention program on the incidence of musculoskeletal injury, motor performance and psychosocial status. Materials and Methods: Thirty-six Estonian Military Academy cadets were randomly assigned into either an intervention or control group. The intervention group followed a neuromuscular exercise-based injury-prevention warm-up program, three times per week for 6 months. The control group continued with the usual warm-up. The main outcome measure was injury incidence during the study period. Additionally, evaluation of isokinetic lower-extremity strength, postural sway, physical fitness and psychosocial status was included pre- and post-intervention. Results: During the 6-month study period, the musculoskeletal injury incidence was 43% in the intervention group and 54% in the control group (RR = 0.8; 95% CI = 0.41 to 1.99). The noted 20% risk reduction was not statistically significant (p = 0.59). Furthermore, there were no statistically significant differences between the intervention and control group in motor performance or psychosocial status measures. Conclusions: In conclusion, no effect of the exercise-based injury-prevention program on injury risk, motor performance or psychosocial status could be detected.

Play Ball: A 10-Year Comparative Analysis of Craniofacial Safety in Baseball and Softball

INTRODUCTION

Within the United States, the number of players participating in baseball increased by nearly 21% to 15.9 million between 2014 and 2019. Additionally, batting helmets with face-masks are encouraged yet optional in youth baseball as well as college baseball and softball. in light of inconsistencies in safety equipment enforcement and usage, this study aims to perform a comparative analysis of the number and frequency of baseball and softball-related craniofacial injuries (CFis).

METHODS

Data regarding baseball and softball-related injuries were gathered from the National Electronic Injury Surveillance System database from 2011 to 2020. Craniofacial injuries were isolated and organized into 5-year age groups beginning with 5 to 9 years and ending with 25 to 29 years of age. Data was further stratified by location and type of injury. Injury types specifically reported in this study included concussion, contusion, fracture, and laceration.

RESULTS

Distribution of injuries across age groups differed significantly between baseball and softball (P < 0.001). When comparing the 10 to 14 year old group to the 15 to 19 year old group, we found that concussions and head contusions comprise a significantly greater proportion of all injuries in softball than in baseball. Conversely, facial fractures, facial lacerations, and mouth lacerations comprise a significantly greater proportion ofinjuries in baseball than in softball.

CONCLUSION

Future prospective studies aiming to better characterize the within-game nature of these reported CFIs would certainly be beneficial in guiding the baseball and softball communities toward consideration of implementing maximally efficacious updates to current safety equipment standards.

A Novel Method for the Mechanical Testing of Sports Mouthguards

Current mouthguard test methods require improvement, as the impact energies during traditional testing do not reflect the higher energy that can be observed in actual use during sport. A new data set of ball speeds experienced during the sport of field hockey was obtained. These ball speeds have then been used to estimate impact energies. This information was used to subsequently develop a new test method consisting of a high-speed camera and drop tower. Observations show an increase in energy experienced by the mouthguard for higher-impact energies. The work carried out showed that current testing methods for sports mouthguards use lower-energy impacts than experienced during the sport of field hockey. The new method that is proposed allows for a more realistic representation of real-world impacts.

Developing the role of the sports dentist

Sports dentistry has traditionally focused on orofacial trauma. There is now increasing evidence that participation in sport, particularly at elite level, may significantly increase the risks to oral health. The negative impact of poor oral health on athlete-reported wellbeing and performance is clear. The risks to athlete oral health can and should be mitigated and the role of the sports dentist is evolving to meet these new challenges. Custom-made mouthguards provide protection against orofacial trauma and potentially, concussion. Oral health screening should be included in athlete pre-season preparation. As integrated members of the athlete support team, dentists and dental care professionals can provide sport-specific oral health advice, encouraging athletes to take ownership of their oral health. The potential for translational health and wellbeing benefits to the wider population is also substantial, particularly with youth groups and recreational athletes. Sports dentistry requires distinctive skills. A UK-wide network of dentists and other oral health professionals with an interest in sport is important, to ensure that both appropriate advice and treatment is evidence-based and to further develop the research and clinical foundations.

Self-reported experience of orofacial injury, preventive practice, and knowledge of Iranian adolescent martial art athletes towards sports-related orofacial injuries

BACKGROUND

Increased engagement of adolescents in martial arts exposes them to a relatively high risk of experiencing orofacial injuries. We evaluated self-reported experience of orofacial injuries, preventive practice, and knowledge of management of sport-related orofacial injuries and related factors in adolescent Karate and Taekwondo athletes in Iran.

METHODS

This cross-sectional study was conducted on Iranian martial arts athletes including Karate and Taekwondo aged 11-17-year-old in 2020 via an online questionnaire. The anonymous self-administrated questionnaire had four parts: background (age, gender, duration of sports activity, training sessions per week, and previous education on orofacial injury); self-reported experience of orofacial injury; preventive practice including mouthguard and helmet use; and knowledge of emergency management of orofacial injuries. Preventive practice and knowledge scores were calculated by summing up the scores of corresponding questions (possibly range 0-7). A linear regression model and the Pearson correlation served for statistical analysis.

RESULTS

Totally, 295 athletes with a mean age of 14.56 ± 1.91 years participated in the study. A quarter (n = 74, 25.1%) of athletes stated that they had received training on prevention of orofacial injuries. Only 3.7% (n = 11) of the participants reported the use of custom-made mouthguards, and 62% (n = 183) reported a positive history of orofacial injuries. A significant relationship existed between self-reported orofacial injury and age (β = - 0.32, p < 0.001), hours of training per week (β = 0.12, p = 0.037), type of sport (β = 0.11, p = 0.049), and previous training on orofacial injuries (β = - 0.14, p = 0.010). No difference existed in the history of orofacial injury between females (n = 114) and males (n = 69) (p = 0.374). The mean score of self-reported preventive practice and knowledge of management of orofacial injuries was 3.53 ± 1.82 (out of 7) and 1.67 ± 1.10 (out of 7), respectively. Age (β = 0.19, p = 0.002) and history of orofacial injury (β = - 0.15, p = 0.010) were associated with the score of self-reported preventive practice. Female athletes (β = 0.11, p = 0.048) and athletes who exercised more per week (β = 0.15, p = 0.012) had significantly more knowledge on management of orofacial injuries.

CONCLUSION

Adolescent athletes had relatively undesirable preventive practices and a distinct lack of knowledge. The high occurrence of self-reported orofacial injuries indicates the importance of more education and stricter rules for the athlete population.

Craniomaxillofacial injuries from the sport of wrestling: a query of the National Electronic Injury Surveillance System (NEISS)

PURPOSE

The purpose of this study was to provide a novel report on the head and neck injuries from the sport of wrestling and their characteristics in the USA.

MATERIALS AND METHODS

This is a 20-year retrospective cross-sectional study conducted using the National Electronic Injury Surveillance System (NEISS). Reports were included in the analysis if the injury stemmed from combat with another person. The predictor variables were obtained from both patient and injury characteristics. The principal outcome variable was admission rate, which was used to proxy the severity of the injury at hand. Bivariate analysis (i.e., chi-square and independent sample tests) was used to determine if an association existed between two variables of interest.

RESULTS

The final sample in our study consisted of 4485 cases of craniomaxillofacial injuries secondary to wrestling. The increase in injuries from the year 2000 to 2019 was significant (P < 0.05). The average age of patients was 15.73 (range: 3 to 59 years old). Virtually all of the injuries occurred in males (95.6%). The majority of patients was under the age of 18 (82.3%). With regard to race, white wrestlers (57.1%) comprised the majority of patients. Insight into race was not available for 1245 patients (27.8%). Most wrestling-related injuries took place during the winter season (60.6%). Concussion was the most common primary diagnosis (29.0%). The head (57.1%) was the most commonly injured craniomaxillofacial region. The most common setting in which the injury took place was a place of recreation/sports (49.9%). Among the mechanisms of injuries, the take-down (26.5%) was the most common. Patients who were thrown/taken down (5.04%) were significantly more likely to get admitted (P < 0.01) relative to patients who were injured otherwise (2.6%). Similarly, patients who fell/tripped (6.6%) were significantly more likely to get admitted (P < 0.05) relative to patients who were injured otherwise (3.1%). While cases of concussion (6.0%) were significantly more likely to get admitted (P < 0.01) relative to other cases, cases of contusions/abrasions (0.6%) were significantly less likely to get admitted (P < 0.01) relative to other cases. Similar to contusions/abrasions (0.2%), lacerations were significantly less likely to get admitted (P < 0.01) relative to other cases. Patients aged 12-18 (P < 0.01) were most likely to suffer concussions, whereas patients aged 19-34 (P < 0.01) were least likely to suffer concussions. In contrast to concussions, patients aged 12-18 (P < 0.01) were least likely to suffer lacerations, whereas patients aged 19-34 (P < 0.01) were most likely to suffer lacerations. Patients aged 6-11 (P < 0.01) were most likely to be thrown/taken-down whereas patients aged 19-34 (P < 0.01) were least likely to be thrown. Patients aged 19-34 (P < 0.01) were most likely to be collided against intentionally, while patients aged 6-11 (P < 0.01) were least likely to be collided against intentionally. Patients aged 34 years or older were most likely to fall/trip, while patients aged 12-18 (P < 0.01) were least likely to fall/trip.

CONCLUSIONS

Certain types of injuries that occur during wrestling are more or less common depending on the age groups involved in the sport. Concussions were the most common injury incurred overall, and the head is the most commonly affected craniomaxillofacial area. Take-downs were the most likely mechanism of injury to lead to hospital admissions. The average number of wrestling injuries increased over 20 years being analyzed in this study. Future studies should investigate methods to lessen concussions in wrestling, decrease the number of illegal moves performed, and look into ways to mitigate harm from take-downs, given the increasing number of injuries acquired from this sport.

Prevalence of orofacial trauma and the attitude towards mouthguard use in handball players: A survey in Lorraine, France

BACKGROUND/AIMS

Contact sports such as handball may lead to orofacial injuries that can often be prevented by the use of a properly fitted mouthguard. Several studies have investigated orofacial injuries during contact sports in different countries, but there is a lack of data that is specific for French handball players. Therefore, the aims of this study were to determine the prevalence of orofacial injuries and the proportion of handball players using a mouthguard in Eastern France.

MATERIAL AND METHODS

Data were collected from handball players aged over 15 years old from five handball clubs in the Lorraine Region (Eastern France). A questionnaire containing 26 questions about the general characteristics of participants, orofacial injury experiences, emergency procedures following tooth avulsion, and use of mouthguards was self-administered.

RESULTS

Two hundred and sixty-three handball players, of which 76.8% (202) were males, aged 23 ± 8 years on average, with a mean playing experience of 11 ± 6 years, participated in the study. Among them, 24.7% (65) reported at least one orofacial injury. A total of 237 orofacial injuries was declared. The main types of orofacial injuries including lip, cheek and tongue injuries were reported by 18.6% of handball players (49); dental injuries were reported by 9.9% (26) and injuries to the temporomandibular joint were reported by 4.9% (13). Most participants knew about mouthguards (97.3%, 254) and considered them efficient for preventing dental injuries in handball (95.3%, 242/254), but only 3.0% (8) used them.

CONCLUSION

The prevalence of orofacial injuries among French handball players was high while mouthguards were very rarely used. Information should be provided to handball teams regarding mouthguard use and the management of dental injuries.

Mouthguards in dentistry: Current recommendations for dentists

Properly fitted mouthguards reduce the risk and severity of orofacial injury, to both hard and soft tissues, preventing thousands of dollars of trauma management. In this review, findings from recent research will be evaluated to discuss the strengths and limitations of the different types of mouthguards, including their indications by sport. Design, ideal dimensions, and other characteristics will also be explored. Additionally, patient education and motivation will be examined, with a focus on the dentist's role in this regard. Finally, in addition to proper oral hygiene, the importance of proper mouthguard maintenance and evaluation will be discussed. This review will therefore be able to act as a guide for dentists looking to provide patients of all ages with personal protective equipment and stay up-to-date on recent developments in this branch of the sports dentistry field.

Sex-Based Differences in Symptoms with Mouthguard Use Following Pediatric Sport-Related Concussion

CONTEXT

Current evidence regarding the protective effect of mouthguard use on symptom severity in children and adolescents who sustain sport-related concussions is insufficient to make clinical recommendations.

OBJECTIVE

To compare the association between mouthguard-use and symptoms stratified by sex in the first 4-weeks after pediatric sport-related concussion. We hypothesized that mouthguard-use would be associated with lower symptoms.

DESIGN

Prospective cohort study.

SETTING

Nine Canadian pediatric emergency departments (EDs).

PATIENTS

Children aged 5-18 years presenting ≤48 hours of concussion sustained during a collision or contact sport.

MAIN OUTCOME MEASURES

Injury characteristics were collected using the Acute Concussion Evaluation. Primary outcome measure was symptom score (0-6), measured using age-appropriate versions (5-7 years; 8-12 years; 13-18 years) of the Post-Concussion Symptom Inventory. Independent variable was time postconcussion (at initial assessment, 1-, 2-, 4, weeks).

RESULTS

Of 1019 children (73% male; median [IQR] age=13.43[11.01,15.27] years), 42% wore a mouthguard at time of injury. There was no significant group by sex by time interaction for symptoms (χ23=0.27; p=.965). Male mouthguard users reported similar symptom scores in the ED (diff=-0.07; 95%CI:-0.23,0.09), at week-1 (diff=-0.02; 95%CI:-0.18,0.14), week-2 (diff=-0.03; 95%CI:-0.19,0.13), and week-4 (diff=-0.13; 95%CI:-0.29,0.04) compared with males who didn't wear a mouthguard. Female mouthguard users reported minimally higher symptom scores at week-1 compared with non-mouthguard users (diff=0.29; 95%CI:0.01,0.56). Symptom scores were not significantly different for females who wore a mouthguard and those who didn't in the ED (diff=0.22; 95%CI:-0.04,0.48), at week-2 (diff=0.22; 95%CI:-0.06,0.51), or week-4 (diff=0.08; 95%CI:-0.20,0.36).

CONCLUSION

Wearing a mouthguard at time of injury is not associated with reduced acute and subacute symptoms after sport-related concussion in either males or females who were treated in the ED compared with those who did not wear a mouthguard. Athletes are still encouraged to wear a mouthguard during sports since overwhelming evidence supports their use in preventing dental injuries.

Prevalence of orofacial injuries in wheeled non-motor sports athletes: A systematic review and meta-analysis

BACKGROUND/AIMS

As the popularity of sports activities grows, so do the number of sport-related injuries. Furthermore, sports that use equipment or vehicles that modify the speed of the player can present more serious injuries. The aim of this systematic review was to identify the overall prevalence of orofacial trauma in wheeled non-motor sports athletes.

METHODS

The search strategy was applied in eight electronic databases (Embase, LILACS, Livivo, PEDro, PubMed, Scopus, SportDiscus, and Web of Science). Additionally, a complementary search of the gray literature (Google Scholar, OpenGrey, and ProQuest Dissertations & Theses Global), reference lists of included articles, and studies indicated by experts on the subject was done. The included articles were observational studies with sufficient data of orofacial trauma (type and anatomical site) in wheeled non-motor sport athletes, regardless of the competition level. Risk of bias was assessed by using the Joanna Briggs Institute Critical Appraisal Checklist for Studies Reporting Prevalence Data. The meta-analysis was performed using R Statistics software, and the strength of cumulative evidence was assessed by The Grading of Recommendations Assessment, Development, and Evaluation.

RESULTS

From 4042 identified studies, after the removal of duplicates and phase one of selection (title and abstracts screening), 251 studies remained for phase two (full-text screening). Five articles were finally included. One study was considered to have a low risk of bias and four had a moderate risk of bias. The cumulative prevalence of orofacial injuries in wheeled non-motor sport athletes was 21.7% (CI: 8.7-34.7; I² :97.6%) and the prevalence of dental injuries in these sports was 7.5% (CI:4.3-10.7; I² :61.9%). The certainty in cumulative evidence was considered to be very low.

CONCLUSION

About 22% of the wheeled non-motor sport athletes have suffered orofacial injuries. The most prevalent type of injury was classified as dental trauma.

Attitudes and opinions towards the prevention of orofacial injuries among water polo coaches in Catalonia: A cross-sectional study

BACKGROUND/AIM

Although orofacial injuries are frequent in water polo, fewer than 10% of players use mouthguards. The aim of this study was to determine the degree to which coaches and sports club managers encourage mouthguard use in water polo and to explore their opinions regarding other strategies designed to reduce the prevalence of orofacial injuries.

MATERIAL AND METHODS

This was a cross-sectional study in which the coaches and sports club managers of 16 water polo clubs in Catalonia were invited to participate. An online questionnaire was administered to the coaches to obtain general data, to determine whether they had recommended mouthguard use to their players and to record their opinions on other strategies designed to reduce the prevalence of orofacial injuries. Sports club managers were interviewed about the facilities offered by their clubs for players to obtain mouthguards and about their attitudes regarding the prevention of orofacial injuries.

RESULTS

The questionnaire was administered to 72 coaches who trained 111 teams during the 2019-2020 season, together with 14 sports club managers. Coaches of only 11 teams (10%) recommended mouthguard use to their players. Two clubs (14%) offered some facilities to their players to obtain mouthguards. Interestingly, only 18% of the coaches believed that mouthguard use should be mandatory, in contrast to 50% of the sports club managers (p = 0.017; Fisher's exact test). Most coaches and sports club managers believe that a video monitoring system should be used to identify dangerous play and that orofacial injuries should be reported under a surveillance programme.

CONCLUSIONS

Few water polo coaches recommend mouthguard use to their players and very few clubs offer facilities to obtain custom-made oral protection. However, most coaches and sports club managers agree that the rules should be modified to protect players from aggressive play.

Sport and Dental Traumatology: Surgical Solutions and Prevention

Trauma is a worldwide cause of millions of deaths and severe injuries every year, all over the world. Despite the limited extension of the oral region compared to the whole body, dental and oral injuries account for a fairly high percentage of all body traumas. Among head and neck traumas, dental and facial injuries are highly correlated to sport activities, and their management can be a real challenge for practitioners of any specialty. In case of trauma directed to periodontal structures, restorative and endodontic solutions may not be sufficient to achieve a definitive and long-lasting treatment. This article aims to illustrate surgical options and appliances to prevent dental injuries that may be available to the clinicians treating dental trauma involving oral soft and hard tissues.

'Injury prevention versus performance': has the time come to mandate the use of mouthguards in all contact sports?

Mouthguard use continues to be a hotly debated issue in the domain of contact sports. Regulations from sports governing bodies on wearing mouthguards and attitudes towards their use from athletes vary significantly across ‘at-risk sports’. We explore how recent advances in sports dentistry have led to the widespread availability of new customisable mouthguards and whether their use may impact athletic performance, reduce orofacial trauma or sport related concussion. We also discuss whether ‘no mouthguard, no play’ policies designed to mandate their use may help to promote a culture of safe participation in contact sport.

ASSOCIATION BETWEEN LEVELS OF SPORTS PARTICIPATION AND ORAL INJURIES AMONG COMBAT ATHLETES

ABSTRACT Introduction Oral injuries are common traumas in combat sports due to the aggressive nature of both offense and defense. Sports mouth guards are made to reduce the risk of traumatic face and jaw injuries and concussions during sports activities. Objective The objective of this study was to determine the prevalence of oral injuries in combat sports and to examine the association between participation levels and percentage of injury occurrence. Methods One hundred and eight participants (mean age: 22.42 ± 2.162 years) who were involved in sparring events were recruited. Data were collected using a questionnaire consisting of 22 questions about the demographic profile of the athletes, their injury experience and type of injuries sustained, awareness and use of mouth guards in sports activities. Descriptive analysis, Chi-square test, and one-way analysis of variance (ANOVA) were applied for data analysis. Results Almost 77% of participants had experienced oral injuries during sports activities and nearly 90% were aware that oral injuries can be reduced by using mouth guards. In addition, 52.7% of participants complained that the mouth guard is not comfortable to use during sports activities. Findings revealed a significant moderate association between levels of participation and number of oral injuries ( p = 0.013). One-way ANOVA showed a significant mean difference in the rate of oral injury for the four levels of participation groups F (3, 104) = 6.21, p = 0.011. Post-hoc comparisons using the Bonferroni test indicated a significant mean difference between university-state levels ( p = 0.033) and university-national levels ( p = 0.028). Conclusion This study revealed that higher levels of participation in sports have a higher risk of injury. It was also found that the discomfort of using a mouth guard can be reduced if the coaches make the athletes wear proper mouth guards that follow the recommended specifications. Level of evidence IIIb; Case control study.

Global status of knowledge for prevention and emergency management of traumatic dental injuries in sports persons and coaches: A systematic review

BACKGROUND/AIMS

Sports-related dental injuries can cause pain, disfigurement, and broken teeth which may affect the athlete's well-being and psychological status. Such injuries may also lead to the fear of re-injury and other problems. Since a delay in adequate emergency treatment can have adverse effects, it is imperative that athletes and coaches have sufficient awareness of emergency treatment options. Hence, the aim of this systematic review was to evaluate the global status of knowledge among athletes and coaches regarding the prevention and emergency management of traumatic dental injuries.

METHODS

The protocol was designed using the PRISMA guidelines and registered in PROSPERO (CRD42020184956). A broad-based search using text words and MeSH terms was performed in established databases according to a predefined strategy without any distinction of language and year of publication. Studies without details of the questionnaire, knowledge score, validity, and reliability were excluded. Data extraction was performed and risk-of-bias assessment was done by means of the Joanna Briggs Institute's critical appraisal tool.

RESULTS

Nine studies published between 2005 and 2020 were included for qualitative synthesis. They were primarily from Asia with none from North America and Australia. Most of them were cross-sectional, used convenience sampling, and were interview-based. Less than 10% of the participants in two studies had adequate knowledge of the immediate emergency management of tooth avulsion, while only 2.4% of basketball players and coaches knew that it was necessary to collect the avulsed tooth or broken tooth fragments. The overall level of knowledge was reported as poor or insufficient in all studies, with moderate or high risk-of-bias in six studies.

CONCLUSION

The knowledge regarding emergency management of TDI was found to be low globally. Along with the choice of the sport, there was a high level of variability in the study design and sampling characteristics.

Evidence mapping and quality assessment of systematic reviews in dental traumatology

BACKGROUND/AIMS

Evidence mapping of systematic reviews (SRs) systematically and comprehensively identifies, organizes, and summarizes the distribution of scientific evidence in a field. The aims of this study were to delineate domains in dental traumatology (DT), evaluate the existing SRs within the domains, and identify the paucity of evidence for future research.

METHODS

Domains and sub-domains of DT were established according to the methods of qualitative research. The protocol for evidence mapping was prepared as per the guidelines of GEM and PRISMA. The search strategy was formulated using words and MeSH terms in eight databases without restriction of languages and year of publication. Gray literature, protocol registries, and references of selected articles were also searched. Duplicates were removed, and the final selection of SRs was completed. Data extraction and quality analysis using the ROBIS tool and the PRISMA checklist were performed.

RESULTS

The overall search resulted in 64 SRs from 1999 to 2020 with 44 published in last six years. The highest number of SRs had been performed in the Prognostic domain (n = 19) followed by the domains of Epidemiology (n = 15), Therapeutics (n = 10), Oral Biology (n = 7), Diagnostics (n = 6), Preventive (n = 5), and Research Methods (n = 2). Within each domain, there were variabilities in the number of reviewers, a priori protocols, search limitations, risk of bias methods, and meta-analysis. Of the SRs, including 4 Cochrane reviews, 28.4% were inconclusive. A low risk of bias was found in 48.4% of the SRs. Among the registered and ongoing SRs, six were from the domain of epidemiology, two in the domain of therapeutics, five from prognostics, and one each in the domains of prevention and research methods.

CONCLUSION

The SRs in DT could be mapped in seven domains with variabilities in the methods. The majority had an a priori registered protocol and a low risk of reporting errors. Within the Epidemiology and Preventive domains, SRs were present in all the sub-domains with the majority demonstrating low-risk of bias (ROB). The domain of prognosis had SRs in most sub-domains but with a high ROB. Insufficient numbers of SRs were present in most sub-domains of the Diagnostics, Therapeutics, Research Methods and Oral Biology domains.

Associations and risk factors for dental trauma: A systematic review of systematic reviews

OBJECTIVE

We sought to revise, qualify and summarize the body of evidence based on current information on the known associations and risk factors for traumatic dental injury (TDI) occurrence with an overview of systematic reviews.

METHODS

Electronic searches were performed with no language nor date restrictions.According to the PECO strategy, systematic reviews that investigated participants (P) with (E) and without (O) the presentation of factors relating to TDI and these factors' association with TDI episodes (O) as primary or secondary outcomes were included. Quality assessment and bias control were carried out according to the AMSTAR 2 checklist. In cases of systematic review results of discordance, the Jadad decision algorithm was applied.

RESULTS

After titles, abstracts and full texts were read, 19 systematic reviews were included in this overview. Four were classified with critically low, eleven with low and four with moderate methodological quality, respectively. In all studies, 249 cross-sectional, 34 epidemiological surveys, 22 cohort, 9 case-control, 4 longitudinal, 3 ecological and 30 unspecified studies were included. Male gender, child age, greater overjet, inadequate lip coverage, anterior open bite, caries in the permanent dentition, overweight, a previous history of TDI, tongue piercing, the use of alcoholic beverages and participation in sports were all associated with a greater chance of suffering TDI.

CONCLUSIONS

Sociodemographic, clinical and environmental factors are associated with a greater chance of TDI occurrence. However, most of the systematic reviews included were of a low quality and may not provide an accurate and comprehensive summary of the available research that addresses the question of interest. Well-designed primary studies on different aspects of TDI are encouraged to provide higher quality scientific evidence.

Present Status in Polymeric Mouthguards. A Future Area for Additive Manufacturing?

Athletes from contact sports are more prone to orofacial injuries because of the exposure to possible shocks and collisions derived from physical proximity. The use of protector polymeric mouthguards proved to be useful in the prevention of the described injuries. There are different types of mouthguards with varying ranges of protection and prices, but they are all made from polymers and share the same propose: to absorb and dissipate the impact energy resulting from the shocks. As they are used inside the mouth, they should not impair breathing and speaking nor compromise the comfort of the athlete. However, the ideal mouthguard is yet to be created. The choice of the most appropriate polymeric material and the standard required properties have not yet been reported. Regardless of the numerous studies in this field, normalized control parameters for both material characterization and mouthguard fabrication are absent. This paper aims to present a review of the current types of available mouthguards and their properties/characteristics. Moreover, a detailed description of the most common polymers for the fabrication of mouthguards, together with the manufacturing techniques, are discussed.

Mouthguard use in youth ice hockey and the risk of concussion: nested case–control study of 315 cases

Background

Concussion is the most common injury in youth ice hockey. Whether mouthguard use lowers the odds of concussion remains an unanswered question.

Objective

To determine the association between concussion and mouthguard use in youth ice hockey.

Methods

Nested case–control design. Cases and controls were identified from two prospective cohort studies using valid injury surveillance methods. Cases were players concussed during a game or practice; controls were players who sustained a non-concussion injury during a game or practice. The primary exposure was mouthguard use at time of injury; mouthguard type (dental custom fit or off the shelf) was a secondary exposure. Physician-diagnosed or therapist-suspected concussion was the primary outcome. Dental injury was a secondary outcome. Multilevel logistic regression with random effect at a team level was used to obtain ORs for the mouthguard effect, adjusted for level of play, age group, position, concussion history, mechanism of injury, cohort, session type and body checking policy.

Results

Among cases, 236/315 (75%) were wearing a mouthguard at time of injury, while 224/270 (83%) controls were wearing a mouthguard at time of injury. Any mouthguard use was associated with an adjusted OR for concussion of 0.36 (95% CI 0.17 to 0.73). Off-the-shelf mouthguards were associated with a 69% lower odds of concussion (adjusted OR: 0.31; 95% CI 0.14 to 0.65). Dental custom-fit mouthguards were associated with a non-significant 49% lower odds of concussion (adjusted OR: 0.51; 95% CI 0.22 to 1.10). No dental injuries were identified in either cohort.

Conclusion

Mouthguard use was associated with lower odds of concussion. Players should be required to wear mouthguards in youth ice hockey.