dental injuries

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Dental Injuries : On-the-spot tips for dealing with the fallout from a kick in the teeth

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Dental injury is a distressing event, often causing psychological as well as physical problems, since it normally involves the highly visible front teeth. And it is particularly common among athletes, with sports-related dental injuries said to account for nearly 40% of the total, writes John Banky ⁽¹⁾.

However, even this statistic probably underestimates the true prevalence of sport-related dental injury, which is often not reported ⁽²⁾, tends to occur outside surgery hours ⁽³⁾ and frequently happens in conjunction with other, more serious injuries, such as concussion, cuts to the scalp and face and fracture of the jaw or other facial bones ^(4-9).

The risk of dental injury is particularly high with collision and contact sports. Sports involving high speeds and high impact (such as alpine skiing, boxing and martial arts) tend to result in more facial bone fractures, while those with low speeds and low impact (such as basketball, rugby and football) are more likely to be associated with dental injuries ⁽¹⁰⁾.

With numbers of contact sport participants on the increase, traumatic accidents resulting in dental injuries are also on the rise ⁽¹¹⁾. And the bad news is that dental injury can still happen to athletes who are behaving responsibly by wearing the recommended mouthguards ^(12-13).

Equally worrying is the fact that, although dental injury has been recognised as an occupational hazard for sportsmen and women for many years, its management ‘in the field’ remains poor ⁽¹⁴⁾, which is not surprising given the lack of appropriate training offered to teachers, first-aid providers and other sport management personnel, and the inadequacy of existing first-aid kits.

Managing dental injury

As dental injury is usually part of a multi-injury presentation it is often not noticed or ignored at the time of presentation. But this type of injury is not minor and requires prompt treatment if it is not to lead to further problems.

It should go without saying that anyone with injured teeth should be seen by a dentist as soon as possible. But meanwhile there is much that can be done at the scene of the accident to provide immediate care and reduce the risk of long-term complications.

The first point to make is that athletes with any injury to the head, face or mouth should not return to the field until the full extent of the damage has been evaluated. The head, face and mouth have a plentiful blood supply, which leads to copious bleeding after injury. And concerns about exposure to blood-borne infections now prohibit athletes from remaining on the sports field with an uncontrolled bleeding wound or blood-stained clothing.

Although injuries to lips and cheeks tend to bleed profusely, they also heal quickly due to the excellent blood supply to the face. However, such injuries are often linked with loosened, chipped or fractured teeth, which need treatment as suggested below:

Loosened teeth

These are teeth that move excessively while remaining in their correct position in the mouth. Appropriate action is to:

Hold the affected tooth in place;
Splint the mobile tooth to a sound neighbouring tooth. Stiff aluminium foil is available but difficult to use. The splinting material supplied in the dental emergency kit Dentist In A Box is easier to use. (See table 1, below, for details about this and other dental emergency kits);
Seek dental assistance.

Table 1: dental emergency kits compared
	Dentist In A Box	Dentanurse	Save-A-Tooth
Website for more information	dentistinabox.com.au/~dentabox	dentanurse.com	save-a-tooth.com
Instructions provided in kit	Yes	Yes	Yes
Can be used to replace lost filling(s)	Yes	Yes	No
Material requires mixing before use	No	Yes	N/A
Provides storage for knocked out teeth	Yes	No	Yes
Can be used to splint loosened teeth	Yes	No	No
Country of origin	Australia	UK	USA

Chipped and fractured teeth

Cover the exposed area of tooth, which may be very sensitive to temperature change or the movement of air across the tooth surface;
Take care to find and collect any chipped off tooth fragments; otherwise a chest X-ray may be needed to exclude the possibility of fragments being lodged in the lungs or windpipe;
Fragments can be reattached temporarily but securely, using the splinting material provided in Dentist In A Box, to cover the exposed area of tooth. If this is not possible, be sure to keep them to pass on to the dentist;
Chipped back teeth can be managed using the no-mix temporary filling material provided in Dentist In A Box.

Dislodged/avulsed teeth

A permanent tooth that has been completely knocked out of the mouth requires prompt and effective management and should ideally be reinserted into its socket. This can be done by anyone: for detailed advice, see table 2, below ^(15,16).

Table 2: how to manage dislodged teeth
Don’t: Panic Disturb the yellow part (root) of the tooth And never rinse the tooth in water!	Do: Remain calm Wear gloves to protect yourself from blood-borne infection Find the tooth as quickly as possible and collect and save all the fragments to show the dentist Handle the tooth only by the white part (crown) at all times Immediately replace the tooth in its socket using the other teeth as guides Immobilise any loosened teeth using splinting material from Dentist In A Box Seek dental help as soon as possible
If you cannot reinsert the tooth immediately into its socket, transport the patient at once to a dentist with the tooth completely submerged in isotonic saline (from Dentist In A Box). For best results, the tooth should be reinserted within 20 minutes of injury.

Research has shown that immediate care after injury offers an 85-97% chance of tooth survival. The chances of success are reduced to 84% five minutes after injury, 8-66% 5-20 minutes post- injury and 3-21% after more than 20 minutes. Clearly, minimal delay between injury and the provision of primary care is essential for the best long-term results.

Rapid care doesn’t just improve the chances of tooth survival, but also reduces the risk of post- injury complications and thus the overall costs of dental treatment.

Concussion

This is often associated with dental injury, and a recent study suggested that when dental injury occurs concussion should be suspected, and vice versa⁽⁹⁾.

Long-term problems

Often the full extent of damage to the teeth and surrounding area after injury is not immediately apparent. For this reason, the International Association of Dental Traumatology recommends that people with dental injuries should be reviewed at regular intervals for up to five years.

Signs and symptoms suggesting a need for further investigation and possible treatment include any of the following:

swollen face;
swollen gum around the teeth;
extreme sensitivity of the teeth to temperature;
a pimple on the gum, giving rise to occasional discharge (the pimple may disappear then reappear again after a time);
change (dulling/darkening) of tooth colour;
pain on chewing and/or biting;
painful or restricted movement of the jaw.

Such symptoms may be caused by:

cracked/split tooth crown;
cracked/split tooth root;
damage to the nerve of the tooth;
temporomandibular joint injury;
fractured jaw or cheek.

Restorative care for dental traumatic injury may be lengthy, complicated, costly and extensive ⁽¹⁷⁾, often undertaken in several stages. And even after it has finished, periodic review is still likely to be needed.

It is important to point out that treatment is not always successful and the affected teeth may still be lost as a result of persistent infection. If the cause of the infection cannot be eliminated, the bony support around the root will be eroded, loosening the affected tooth (and, possibly, its neighbours) and making tooth loss inevitable.

The lifetime maintenance cost for dental injury was estimated by a National US Youth Task Force in 1992 at $10,000-15,000 per injured tooth, including initial treatment, further treatment of complications, provision or replacement of crowns and review visits.

Reducing the risks

Missing front teeth are a highly visible form of disfigurement, which may in some cases be the only legacy of a sporting career. Schools and sporting organisations acknowledge the devastating impact of dental injury and make efforts to reduce the risk by encouraging the use of mouthguards.

However, for these to be effective, they must be worn regularly. And the problem is that there are a number different types of devices to choose from, with variable degrees of comfort and quality of fit, all claiming to provide adequate protection, which has led to widespread confusion among players ^(12,18-23).

Since younger players tend to take their lead on such matters from elite and other more experienced athletes, the fact that some of these don’t wear mouthguards has a predictably discouraging effect ⁽²⁾.

So what makes for an acceptable mouthguard? The following factors are key:

It should be comfortable, well-fitting and not prone to dislodging on impact;
It should provide adequate thickness of material (4mm) over vulnerable areas to reduce impact forces ⁽²⁴⁾;
When biting lightly on the guard, large areas of its biting surface should be in contact with the teeth in the opposing jaw, so minimising the risk of jaw fracture;
Only a custom-fitted mouthguard can accommodate each individual’s unique arrangement and number of teeth, while ensuring adequate thickness of material to protect vulnerable areas.

For a comparison of the main types of mouthguard available, see table 3, below.

Table 3: types of mouthguards compared
Boil & bite	No moulding	Custom-fitted
Relatively inexpensive Available from sports shops / pharmacies Favoured by younger players (at greatest risk of injury), wearing braces or still growing, who need to regularly replace their mouthguard No moulding / moulded in mouth Poor fit so poorly tolerated Interferes with speech, breathing and swallowing Unable to ensure adequate thickness of mouthguard material to cover vulnerable areas		Moderately expensive Provided by dentists / dental technicians Made on model of the mouth Secure fit so well tolerated Minimal interference with speech, breathing and swallowing Reduces the risk of concussion Accurate control of mouthguard material thickness to cover vulnerable areas

Mouthguard use and care

Don’t share your mouthguard. This is a closefitting appliance designed to be worn only by its owner;
Don’t store the mouthguard in places where it may be subject to excessive heat build-up (eg your car) which may lead to distortion;
During use, remove the mouthguard after each quarter/half of play, and rinse it and your mouth with water before reinserting. At the end of play rinse your mouth with water, wash the mouthguard with soap and cold or warm (never hot) water, then rinse with cold water;
Store the mouthguard in its container when not in use. This should have ventilation holes that allow the guard to dry and encourage air circulation, preventing the build-up of unpleasant odours;
Before use, check the dry mouthguard in good light for any visible tears, particularly where the material is thin or worn. Identify any rough areas that may indicate splits or cracks by running your finger along the non-fitting surface of the guard that comes into contact with the opposing teeth. This surface must also be checked for damage following any heavy blow to the mouth or jaw.

Remember that no mouthguard will last forever. With use, the biting surface of any mouthguard may flatten, wear or become dangerously thin over the biting edges of the front teeth, allowing the player to bite through the mouthguard during use.

Damaged or worn mouthguards provide no protection other than a (false) sense of security, so be sure to get yours checked by a dentist before each season of play and at any other time if you have cause for concern.

Finally, remember that it is easier and cheaper to replace a mouthguard than to replace a lost tooth!

John Banky BDSc (Melb), LDS (Vic) is a general dental practitioner with a special interest in dental trauma, working in Melbourne, Australia