Australian Dental Journal
The official journal of the Australian Dental Association
Australian Dental Journal 2014; 59: 473–481 doi: 10.1111/adj.12223
Prevalence of dental trauma and use of mouthguards in rugby union players E Ilia,* K Metcalfe,† M Heffernan‡ *Private Dental Practice, Turramurra, New South Wales. †Westmead Centre for Oral Health, Westmead, New South Wales. ‡Discipline of Endodontics, Faculty of Dentistry, The University of Sydney, Camperdown, New South Wales.
ABSTRACT Background: There is a high prevalence of orofacial trauma in rugby union players. Mouthguards reduce complications following dental injuries, should dental injuries occur. The aim of this study was to investigate the prevalence of oral trauma and the significance of mouthguard use in adult amateur rugby union players in New South Wales, Australia. Methods: Questionnaires were distributed to players in rugby union clubs. It questioned players about their mouthguard use and orofacial trauma experience; the type of injury, complications, if a mouthguard was worn, where treatment was sought and outcome. Results: The prevalence of orofacial trauma in rugby union players is 64.9%. The most common injury was laceration to intraoral and extraoral soft tissues at 44.5%. Of all orofacial injuries reported, 41.9% were to the dentition. Following dental injury, loss of the tooth was the most common complication (34.7%). 76.9% of players wore mouthguards. By wearing a mouthguard, the risk reduction for ongoing complications following dental injuries was 18.5% (p-value = 0.009). Of these, 10.4% (p-value = 0.45) represented loss of the tooth. Conclusions: Rates of orofacial trauma and complications in amateur rugby union players are high in Australia. Use of mouthguards results in significant risk reduction for complications following dental injuries, including loss of tooth. Keywords: Orofacial, trauma, mouthguard, sports injury, epidemiology. (Accepted for publication 25 March 2014.)
INTRODUCTION Dental injuries are challenging, time consuming, costly to treat and can have aesthetic, functional, financial and psychological effects for the patient.1–10 Orofacial and dental trauma can result from falls, assaults, motor vehicle accidents and sporting accidents.11 Injuries consist of simple tooth concussion, fracture, luxation and avulsion, laceration of the gingiva, and jaw fractures.1–3,12 Orofacial and dental injuries commonly occur during sports participation, with as many as 31% of orofacial injuries reported to result from trauma while playing sports.4,12–14 Of 9543 patients treated over 10 years by a maxillofacial surgery department in an Australian hospital, sports injuries (31%) came only second to activities of daily life (38%) as the reason of presentation.11 Other causes of injury included violence (12%), traffic accidents (12%) and work accidents (5%).11 Contact sports are defined as sports in which players interact with each other, trying to prevent the © 2014 Australian Dental Association
opposing team or player from winning.9,15 Players of contact sports are at an increased risk of orofacial and dental trauma because of the high impact contact.1,4–7,12,13,15–18 Of the adults presenting to Australian accident and emergency departments with sports injuries, participants of cycling, hockey and rugby union commonly sustained injuries distributed to the head and upper extremities.19 Rugby union players were likely to injure the head and upper extremities, with 63% of trauma distributed in this region.19 A study of English rugby union players found that 41% of players had experienced dental injuries, of which 37% were fractured teeth.20,21 Another study found a high prevalence of soft tissue injuries, with 40% of Scottish rugby union players reporting injuries to the face or head requiring sutures.4,20 Several published studies have investigated the prevalence of orofacial and dental trauma in participants of contact sports. A high prevalence of dental injuries among schoolboy rugby union players in Australia and England has been reported.20 Additionally, 473
E Ilia et al. a cohort of 99 Scottish first division rugby union players was studied with the aim to identify the nature and severity of orofacial injuries that had been sustained by the participants.4 It was found that rugby union players frequently sustained orofacial injuries and the face was the most commonly injured part of the body.4 Soft tissue injuries were most prevalent but 30% of players had fractured their teeth, 19% had a tooth avulsed and 5% had fractured their mandible.4 Only a small amount of research has assessed the prevalence of orofacial trauma in adult Australian rugby union players. Previous studies have highlighted the high risk of orofacial and dental trauma associated with rugby union and other contact sports. Mouthguards can reduce the extent of injuries to the teeth and surrounding structures, should they occur.1,4,6,8,10,12,14,16,20 There are three types of mouthguards available: type I (stock) are for public sale and used without modification; type II (‘boil and bite’) are made of a thermoplastic material that is softened and then moulded to the dental arch by the user; and type III (custom-made) are made by a dentist using a mould of the patient’s dental arches.13,15,16,22 Custom-made mouthguards offer greater protection and wearers have fewer complaints about difficulty in breathing and speaking.6,7 Because of the high risk of orofacial trauma in contact sports it is important that players are made aware of the preventive role of mouthguards in dental injuries. Several studies have investigated mouthguard use by sports participants and the role of mouthguards in the prevention of orofacial and dental trauma. A survey of 236 basketball players in China assessed their knowledge about the value of mouthguards in the prevention of dental injuries.10 Player knowledge was high (80%) but only one player wore a custom-made mouthguard. These results show a discrepancy between player knowledge about injury prevention and their reported behaviour. A study of 961 Australian Rules football players that investigated player mouthguard use during training and matches found that a large proportion (72%) of players wore a mouthguard during competition, of which 73% were custom-made mouthguards.16 A study of Japanese high school soccer and rugby union players’ awareness of the value of mouthguards found that a greater proportion of rugby players owned a mouthguard compared to soccer players (24.1% vs. 0.8%).5 Almost all rugby union players acknowledged that mouthguards were necessary, with ‘boil and bite’ mouthguards being the most commonly used type of mouthguard (89.3%).5 Rugby union referees were given the power to enforce compulsory mouthguard use in all grades of domestic rugby union in New Zealand. Data on 474
injury compensation claims made before and after this policy was implemented shows the positive effects of compulsory mouthguard use on orofacial injury rates.23 The self-reported rate of mouthguard use increased from 67% to 93% after the introduction of these rules.23 There was a 43% reduction in dental injury claims. Rates of mouthguard use were lower during training than competition even though players often spend more time in training than in competition.23 The findings confirm the preventive value of mouthguards and provide evidence for the introduction of compulsory mouthguard use. There is published research looking at mouthguard use by players of a variety of sports.5,7,10,13,18,21 Questionnaires have commonly been used to gather this data. To date there is no published data evaluating mouthguard use by young adults playing rugby union. The aim of this study was to investigate the prevalence of orofacial trauma and assess mouthguard use and effect in amateur rugby union players in New South Wales, Australia. MATERIALS AND METHODS Ethics and grants Ethics approval was obtained by The University of Sydney Human Ethics Research Committee prior to commencement of the study. Data collection Data were collected for this cross-sectional analytical study between July 2010 and July 2011, by distributing a questionnaire to rugby union players from seven rugby union clubs in suburban Sydney and country New South Wales, Australia. A written participant information sheet was issued and participant consent given before the questionnaires were distributed. Participant confidentiality was maintained with no names recorded on the questionnaire. The researchers were present while the questionnaires were completed to ensure the answers were not discussed or researched. The questionnaire was collected immediately after it was completed by the participant. The questionnaire One questionnaire was used to collect the data. The questionnaire was validated by a pilot survey of 10 males aged 18–35 years. The questions asked in the questionnaire drew influence from questionnaires from previous studies.3,15,17,25 The questionnaire contained 27 multiple choice questions and was divided into four parts. Parts 1, 2 and 4 are relevant to this article © 2014 Australian Dental Association
Dental trauma in rugby union (Fig. 1). Players were asked for a dental injury risk rating for their sport, their orofacial and dental trauma experience and mouthguard use. Inclusion criteria To be included in this study, players had to be over the age of 18 years, fluent in verbal and written English and currently playing rugby union. Rugby clubs were contacted by the researchers and given an information sheet describing the study design and aims, and what would be expected of the players and the club should they decide to participate. Once the club gave consent to participate, a training session or competition day was attended to distribute the questionnaires.
Participants Questionnaires were collected from 240 participants (response rate 100%). Fifteen questionnaires were incomplete and therefore not included in the study. All participants were males aged 18 to 51 years. Data analysis method Data were entered into Microsoft Excel 2007 (Microsoft Corporation) for evaluation. All relevant data were used for analysis unless otherwise noted. Frequency proportions were produced by IBM® SPSS® Statistics Software, Version 19. Statistical significance was generated by the Spearman’s rank correlation, two-sided Pearson’s chi-squared test and two-sided Fisher’s exact test where appropriate. Data for orofa-
Fig. 1 The questionnaire. © 2014 Australian Dental Association
475
476
13 (8.90) 1 (0.68) 4 (2.74) 0 (0.00) 75 (51.37) 1 (0.68) 5 (3.52) 4 (2.74) 2 (1.36) 26 (17.81) 6 (4.10) 9 (6.16) 1 (0.68) 0 (0.00) 28 (19.18) 1 (50.00) 63 (63.34) 1 (50.00) 35 (24.66)
12 (63.16)
-
1 (50.00) 8 (9.09)
0 (0.00) 19 (19.19)
0 (0.00) 9 (8.08)
0 (0.00) 0 (0.00) 1 (0.68) 0 (0.00) 17 (11.46) 2 (8.70) 3 (15.79) 3 (13.04) 4 (21.05) 1 (4.35) 0 (0.00) 17 (73.91)
5 (25.00) 9 (60.00) -
66 (45.44)
9 (75.00) 1 (50.00) 120 (75.47) 4 (40.00) 2 (100.00)
13 (76.47)
5 (23.81) 4 (23.53) 3 (25.00) 1 (50.00) 39 (24.53) 16 (76.19)
80 (55.56) Total players
Dislocated jaw Other
5 (33.33) 6 (60.00) 0
11 (55.00)
20 (7.75) 15 (5.81) 10 (3.88) 2 (0.78) 146 (64.89)
9 (45.00) 10 (66.67)
8 (5.48) 9 (6.16) 2 (1.36) 4 (2.74) 2 (8.33) 22 (91.67) 8 (34.78) 15 (65.22)
7 (17.07) 25 (60.98) 14 (43.75) 9 (25.71) 26 (74.29) 14 (43.75) 32 (12.40)
18 (56.25)
15 (36.59) 41 (15.89)
23 (8.91)
15 (10.27) 13 (8.90) 11 (7.53) 7 (4.79) 13 (8.90) 12 (8.21) 2 (1.36) 0 (0.00) 3 (6.00) 3 (7.32) 15 (30.00)
4 (8.00) 6 (14.63) 28 (56.00) 16 (39.02) 13 (29.55) 31 (70.45)
33 (25.98) 94 (74.02) 52 (45.22) 63 (54.78)
Lacerations to lip, cheeks or tongue Fractured tooth/root Loosened tooth/ come out of place Broken jaw/bones of face Bleeding socket Avulsion
115 (44.57)
26 (63.41)
67 (45.89) 14 (9.59) 22 (15.07) 12 (8.21) -
Dentist & doctor n (%) Dentist n (%) Doctor/ hospital n (%) Lower posterior n (%) Lower anterior n (%) Upper posterior n (%) Upper anterior n (%) Complications n (%) Training n (%) Competition n (%) No mouthguard n (%) Yes mouthguard n (%)
Two hundred and twenty-five questionnaires were completed. Players were aged between 18 and 51 years; the average age was 24.12 5.72. The average length of time participants had played contact sport was 12.8 years, ranging from 1 to 42 years. The mean perceived risk of orofacial trauma reported by players was 6.67 (2.27) on a scale between zero and 10, with 10 indicating the sport carries the highest risk. The player’s assessment of risk was proportional to the length of time they had played contact sports, with each year playing, the perceived risk of receiving an orofacial injury increased by 0.277 (p = 0.13). A previous history of orofacial trauma was reported by 64.9% of players. The most common orofacial injuries experienced were lacerations to lips, cheeks or tongue making up 44.6% of all orofacial traumas. Injuries to the orofacial bones made up 12.8% of all injuries. Around 40% of participants (39.6%) had experienced a concussion while playing rugby union. Of the orofacial injuries reported, 41.9% were injuries to the dentition, i.e. avulsion, luxation, crown or root fracture (Fig. 2). Teeth in the anterior region were most commonly injured (82.8% of teeth injured). Maxillary anterior teeth were the most frequently injured teeth, accounting for 63.6% of teeth injured. Mandibular anterior teeth made up 19.2%, mandibular posterior teeth 9.1% and maxillary posterior teeth 8.1% of teeth injured. Complications following orofacial trauma were reported by 24.7% of players. Following dental injuries only, the need for extraction or loss of the tooth was the most common complication, accounting for 34.8% of all complications (Fig. 3). Of those players that had suffered complications; avulsions, luxations and crown fractures complications occurred in 60.0%, 43.8% and 39.0% of these players respectively. More complications were reported following an injury to maxillary posterior teeth and anterior mandibular teeth.
Total n (%)
RESULTS
Table 1. Orofacial injury types, whether a mouthguard was worn, timing of injury, complications, tooth affected and follow-up management
cial injuries were expressed as a percentage of the participants (Table 1). Calculations for regularity of wear were calculated from the total number of players wearing stock, ‘boil and bite’ and custom-made and mouthguards independently. Each response where the mouthguard was worn (training and/or competition) was given a value of 1 unit. If the participant wore a mouthguard at both training and competition, it was given a value of 2. The values were then divided by the total number of ‘wears’ possible by the player (2) and the ‘wear’ of both types of mouthguards compared.
No treatment n (%)
E Ilia et al.
© 2014 Australian Dental Association
Dental trauma in rugby union Prevalence of orofacial trauma by type 50 44.57
Prevalence (%)
40
30
20
15.89 12.40 8.91
10
7.75
5.81
3.88 0.78
0
Types of trauma
Fig. 2 Prevalence of orofacial trauma by type.
More orofacial injuries occurred during competition than training with 75.5% and 24.5% of players experiencing injuries in competition and training respectively. When the orofacial trauma occurred, 55.6% of players were wearing a mouthguard. When reviewing dental injuries only, i.e. fractured tooth, bleeding socket, avulsion and luxation injuries, 58.3% of players were not wearing a mouthguard. Over 60% of players that suffered avulsion injuries or a fractured tooth were not wearing mouthguards when the injury occurred. Following the injury, 19.2% of players sought treatment from a dentist and 11.5% from a doctor or hospital. Following the trauma, over 50% (51.4%) of respondents did not seek professional treatment. Players were less likely to seek treatment for soft tissue injuries, with 58.3% of players that reported these injuries, not seeking professional treatment. Most participants (97.3%) acknowledged that mouthguards have a role in the prevention of orofacial injury, but only 87.1% of players thought they were necessary (Table 2). Of the 76.9% of players that wore mouthguards, 57.2% wore them during competition only, 41.6% during both training and
Prevalence (%)
30
Table 2. Value of mouthguards Mouthguard use
Total n (% participants)
Mouthguards have a role in the prevention of orofacial injury Mouthguards do not have a role in the prevention of orofacial injury Mouthguards are necessary Mouthguards are not necessary
219 (97.3) 6 (2.7) 196 (87.1) 29 (12.9)
Table 3. Mouthguard use
Complications following orofacial trauma 40
competition and 1.2% during training alone. Some participants (23.1%) never wore a mouthguard (Table 3 and 4). There was no relationship between the age of the player and mouthguard use in players under the age of 31 years. A peak of non-use was noted at 24 years of age. Players over the age of 33 years were excluded from the analysis due to the limited sample size in this age group. The majority of players have been advised to wear a mouthguard (86.2%). Of these, the largest source of advice was from family, friends and parents (62.7%) and second from coaches or managers (50.7%), then dental professionals (48.9%). Only 14.2% had been advised to wear a mouthguard through media (Fig. 4). A large proportion of mouthguard wearers liked their mouthguard (53.2%), 17.9% disliked their mouthguard and 27.2% were indifferent to mouthguard use. Of the players that wore mouthguards, 0.6% wore stock mouthguards, 58.4% ‘boil and bite’ and 41.0% custom-made mouthguards. Players with custom-made mouthguards wore them 1.06 times more often than those with ‘boil and bite’ mouthguards. More wearers of custom-made mouthguards liked them (73.3%) compared with only 38.6% of players who wore ‘boil and bite’ mouthguards. Wearers of ‘boil and bite’ and stock mouthguards had more complaints about their mouthguards than players who wore custom-made mouthguards.
38.10
Mouthguard use
Total n (% participants)
28.57 23.81
Mouthguard wearers Mouthguard non-wearers
20
173 (76.9) 52 (23.1)
9.52
10
Table 4. When mouthguards are worn 0
Mouthguard use
Types of Complications
Fig. 3 Complications following orofacial trauma. © 2014 Australian Dental Association
Competition Competition and training Training only Total
Total n (% of wearers) 72 99 2 173
(57.2) (41.6) (1.2) (100) 477
E Ilia et al. most frequently reported injury in this study. Another study found a high prevalence of soft tissue injuries with 40% of rugby union players in Scotland suffering injuries requiring sutures.4 These findings confirm the high incidence of orofacial injuries associated with rugby union, which is likely to be related to the high contact nature of the sport. A large number of all orofacial injuries were dental injuries (those relating only to the teeth), including tooth fracture and luxation injuries. A high prevalence of crown fractures has also been seen in Scottish and Brazilian sport participants.4,17 Teeth in the maxillary anterior region were the most commonly injured teeth, a trend that correlates with findings from previously published studies.1,3,4,6,13,26 More injuries occurred during competition than training, which is likely to be due to the increased intensity and time playing full contact during games. A quarter of participants in this study who had experienced orofacial trauma suffered complications following the injury. The most common dental complications were loss of the tooth or the need for extraction of the tooth, change in tooth colour, and a need for further treatment. This may be due to a lack of appropriate first aid or professional management, as over one-quarter of players (27.0%) that suffered complications following orofacial injuries did not seek professional treatment. Dental injuries were more common and the complication rate was higher when a player was not wearing a mouthguard, notably for avulsion injuries and tooth fractures. By wearing a mouthguard the risk reduction for ongoing complications following dental injuries was 18.5% (p-value = 0.009). Of these, 10.4% (p-value = 0.45) represented loss of the tooth. This supports the findings published in previous studies that mouthguards can prevent complications if an injury does occur.4,6–8,12,16,20,27–29
Sources of advice to wear a mouthguard Parents/Family/Friends
62.7
Coach/Manager
50.7
Dentists Source
48.9
Media
14.2
Doctor
12.4
Other
0.9 0
20
40
60
80
Response (% of participants)
Fig. 4 Sources of advice for players in wearing a mouthguard.
Difficulty breathing (24.9% of players) and talking (15.1% of players) were the most common complaints reported by both wearers and non-wearers of mouthguards. Other complaints were poor fit and saliva build-up and gagging, which were reported by 10.7% of players (Fig. 5). DISCUSSION This study reports the high prevalence of orofacial trauma in amateur rugby union players in Australia. The majority of players will experience orofacial trauma during their time playing rugby union. Rates of dental injuries and complications following those injuries were increased in players not using mouthguards. As hypothesized, a high proportion of participants (64.9%) reported a past history of orofacial trauma. This trend was mirrored in an English study, with 41% of rugby union players reporting a past history of dental trauma.20,21 Rugby union players commonly sustain soft tissue injuries to the head and face with lacerations to the lips, cheeks or tongue being the
Reasons why mouthguards are disliked or not worn Difficulties Breathing Difficulties Talking
Reasons
Don't Need One
Fit Saliva Build up and Gagging Painful Custom Mouthgaurd
Cost
Boil and Bite Mouthguard, Stock Mouthguard
Other
Do Not Wear a Mouthguard 0
5
10
15
20
25
30
Response (%)
Fig. 5 Complaints by wearers and non-wearers of mouthguards by type of mouthguard worn. 478
© 2014 Australian Dental Association
Dental trauma in rugby union The player-perceived risk of orofacial trauma (6.67 2.27 out of 10) indicates that the majority of players were aware that rugby union is a high-risk sport. Surprisingly, there was no relationship between player perceived risk of injury and player past dental trauma experience, with those players who had and had not experienced orofacial trauma reporting a similar perceived risk of orofacial trauma. Despite this, 60% of players who were not wearing a mouthguard when they suffered an orofacial injury, now wear mouthguards; 40% in both training and competition. This shows experiencing dental or orofacial trauma acts as a motivator to wear a mouthguard, despite these players not admitting an ‘increased perceived risk of injury’. It is unfortunate that a large number of players need to suffer an injury before they start wearing a mouthguard. There was a relationship between length of time playing contact sports and player perceived risk. Players who had played contact sports for longer considered rugby union to carry a higher risk of orofacial injury, with the self-perceived risk of injury increasing 0.277 out of 10 (p = 0.13), each year they played contact sports. Although there was no statistical significance between the number of years played and risk assessment, the trend is important. The pattern may be due to players witnessing other players suffer injuries throughout their playing career, resulting in an increase in their perception of risk with time. The lower rate of mouthguard use during training may suggest a drop in the player’s perceived risk in this environment compared to competition. In this study, 50% of players did not wear mouthguards during training. It has been found that 80% of Australian Rules players wore mouthguards but only 13% wore mouthguards during training.29 Many contact sport participants spend more time in training than in competition, with a portion of training devoted to full contact practice. This emphasizes the lack of player understanding about the risk of injury during training, and the importance of mouthguard use in training and competition. Making mouthguard wear compulsory in both training and competition should be a focus of future legislation aimed at sports participants. ‘Boil and bite’ type mouthguards were the most commonly worn type of mouthguard. This is likely to be due to the reduced cost of ‘boil and bite’ mouthguards compared to custom-made mouthguards and players’ poor understanding of the advantages of custom-made mouthguards. Most mouthguard wearers liked their mouthguard (53%). Common complaints included poor fit and difficulty breathing which supports previous findings in the literature.5,6,16,22 More wearers of custom-made mouthguards liked their mouthguards than wearers of ‘boil and bite’ and stock mouthguards. Due to their specific and individualized © 2014 Australian Dental Association
adaption to the anatomy of the wearer’s oral tissues, custom-made mouthguards have been found to be superior in comfort, adaptability, stability and ability to talk and breathe.6 Custom-made mouthguards offer an individualized design according to the patient’s oral anatomy and an even distribution of material.6,30 The Australian Dental Association has advocated the use of custom mouthguards as the superior choice in the prevention of dental injuries.30,31 Therefore, custommade mouthguards should be recommended by dentists for better comfort, fit, stability and protection and more likely to be worn by the player.4,30 The most common source of advice for players with regard to the value of mouthguards in the prevention of orofacial trauma was family and friends. Importantly, almost half of the players were advised to wear a mouthguard by their dentist, suggesting this professional group has a significant influence. Coaches and managers also played a role in recommending mouthguard use, highlighting the importance of support staff knowledge of the benefits of mouthguard use. Given this, there needs to be a greater focus on educating all influences on the benefit of custom fit mouthguards specifically, in addition to the benefit of wearing mouthguards during both competition and training. Education could also be provided in the form of seminars for coaching staff and management, posters in changing rooms and team clubhouses, and verbal advice and written information sheets in dental surgery. Although the majority of players (86.2%) have been advised to wear a mouthguard, and less than half these numbers wear them during both training and competition. It is clear advice on mouthguard wear will not persuade some players to wear them, despite known and acknowledged benefits. Taking the positive effect of New Zealand’s legislation change as an example, changing laws to ensure compulsory, custom-made mouthguard use during training and competition in rugby union will have the biggest impact on players. Part of the questionnaire required players to recall past orofacial injuries. The retrospective nature of this study may affect the accuracy of the responses.20 Some injuries, particularly minor injuries may be forgotten and not reported in the survey. Additionally, some injuries and complications may be poorly understood by the player, particularly if they have poor knowledge of dental injuries or if the problem was not explained well by the treating medical or dental professional. In addition, self-diagnosis may not be accurate. An example may be the report of concussion, a medical diagnosis which has variability and a scope of grading systems. Diagnostic ambiguity may result in players incorrectly reporting injuries or complications or not identifying injuries or complications that have previously occurred. 479
E Ilia et al. The reasons for the peak of non-use of mouthguards at age 24 are unknown. It could be associated with risk-taking behaviour in this age group. Whereas 18-year-old players are still influenced by their parents and the education they received at school about the value of mouthguards, 24-year-olds may have become complacent and no longer influenced by family members. CONCLUSIONS Rates of orofacial trauma and complications in amateur rugby union players are high in Australia. Crown and root fracture are the most common dental injury, and tooth loss the most common complication following injury. Use of mouthguards results in significant risk reduction for complications following dental injuries, including loss of tooth. Age and previous history of injury does not significantly increase players’ perceived risk of injury. Acknowledging the benefits of mouthguards and advice to wear a mouthguard does not result in all players using a custom-made mouthguard in competition and training. Given players are influenced by family, friends, coaches and club administrators, the education of these people, dental professionals and players on the prevention of injury and subsequent complications by custom-made mouthguards, is essential. Legislation change to ensure compulsory custommade mouthguard wear during training and competition may result in the best outcome. ACKNOWLEDGEMENTS We wish to thank the Australian Dental Research Foundation and The University of Sydney for providing the funding for this study. Recognition to Dr Karen Byth for her assistance in the analysis of the results. Thanks also to Old Ignatians Rugby Union Football Club, Eastwood Rugby Union Football Club, Lindfield Rugby Club, Penrith Rugby Club, Colleagues Rugby Union Club, Hornsby Rugby Club and Bathurst Bulldogs Rugby Club for their contribution to this study. Dr Evanna Ilia and Dr Katie Metcalfe are the authors of this article, and Dr Michelle Heffernan was the research supervisor. REFERENCES 1. Lowe RM, Ponnambalam Y. Dental and maxillofacial skeletal injuries seen at the University of Otago School of Dentistry, New Zealand, 2000–2004. Dent Traumatol 2008;24:170– 176. 2. De Vasconcellos LG, Brentel AS, Vanderlel AD, De Vasconcellos LMR, Valera MC, de Araujo MAM. Knowledge of general dentists in the current guidelines for emergency treatment of avulsed teeth and dental trauma prevention. Dent Traumatol 2009;25:578–583. 480
3. Cohenca N, Forrest JL, Rotstein I. Knowledge of oral health professional treatment of avulsed teeth. Dent Traumatol 2006;22:296–301. 4. Kay EJ, Kakarla P, Macleod AD, McGlashan TPL. Oro-facial and dental injuries in club rugby union players. Br J Sports Med 1990;24:271–273. 5. Yamada T, Sawaki Y, Tomida S, Tohnai I, Ueda M. Oral injury and mouthguard usage by athletes in Japan. Endod Dent Traumatol 1998;14:84–87. 6. Duarte-Pereira DMV, Del Rey Santamaria M, Javierre-Garces C, et al. Wearability and physiological effects of custom fitted vs self-adapted mouthguards. Dent Traumatol 2008;24:439–442. 7. Blignaut JB, Carstens IL, Lombard CJ. Injuries sustained in rugby by wearers and non-wearers of mouthguards. Br J Sports Med 1987;21:5–7. 8. Emerich K, Gazda E. Review of recommendations for the management of dental trauma presented in first aid textbooks and manuals. Dent Traumatol 2010;26:212–216. 9. Al-Asfour A, Anderson L. The effect of a leaflet given to parents for first aid measures after tooth avulsion. Dent Traumatol 2008;24:515–521. 10. Ma W. Basketball players’ experience of dental injury and awareness about mouthguard in China. Dent Traumatol 2008;24:430–434. 11. Gassner R, Tuli T, H€achl O, Rudisch A, Ulmer H. Craniomaxillofacial trauma: a 10 year review of 9,543 cases with 21,067 injuries. J Craniomaxillofac Surg 2003;31:51–61. 12. Emerich K, Kaczmarek J. First aid for dental trauma caused by sports activities. Sports Med 2010;40:361–366. 13. Kecßeci AD, Eroglu E, Baydar ML. Dental trauma incidence and mouthguard use in elite athletes in Turkey. Dent Traumatol 2005;21:76–79. 14. Andreasen JO. Etiology and pathogenesis of traumatic dental injuries. A clinical study of 1298 cases. Scand J Dent Res 1970;78:329–342. 15. Barbic D, Pater J, Brison RJ. Comparison of mouth guard designs and concussion prevention in contact sports. Clin J Sports Med 2005;15:294–298. 16. Banky J, McCrory P. Mouthguard use in Australian football. J Sci Med Sport 1999;2:20–29. 17. Mori GG, de Mendonca Janjacomo DM, Castilho LR, Pol WR. Evaluating the knowledge of sports participants regarding dental emergency procedures. Dent Traumatol 2009;25:305–308. 18. Flanders RA, Bhat M. The incidence of oro-facial injuries in sports: a pilot study in Illinois. J Am Dent Assoc 1995;126:491–496. 19. Finch C, Valuri G, Ozanne-Smith J. Sport and active recreation injuries in Australia: evidence from emergency department presentations. Br J Sports Med 1998;32:220–225. 20. Jagger RG, Abbasbhal A, Patel D, Jagger DC, Griffiths A. The prevalence of dental, facial and head injuries sustained by schoolboy rugby players: a pilot study. Prim Dent Care 2010;17:143–146. 21. Jennings DC. Injuries sustained by users and non-users of gum shields in local rugby union. Br J Sports Med 1991;25:159– 165. 22. Abu-Dewoud M, Al-Enezi B, Andersson L. Knowledge of emergency management of avulsed teeth among young physicians and dentists. Dent Traumatol 2007;23:348–355. 23. Blinkhorn FA. The aetiology of dento-alveolar injuries and factors influencing attendance for emergency care of adolescents in the north west of England. Endod Dent Traumatol 2000;16:162–165. 24. Pakev DI, Radtke PK. Postreplantation management of avulsed teeth: an endodontic literature review. Gen Dent 2000;48:176– 181. © 2014 Australian Dental Association
Dental trauma in rugby union 25. Levin L, Friedlander LD, Geiger SB. Dental and oral trauma and mouthguard use during sport activities in Israel. Dent Traumatol 2003;19:237–242. 26. Maeda Y, Kumamoto D, Yagi K, Ikebe K. Effectiveness and fabrication of mouthguards. Dent Traumatol 2009;25:556–564. 27. American Dental Assocation Council on Access. Prevention and Interprofessional Relations; American Dental Assocation Council on Scientific Affairs. Using mouthguards to reduce the incidence and severity of sports related oral injuries. J Am Dent Assoc 2006;137:1712–1720. 28. Quarrie KL, Gianotti SM, Chalmers DJ, Hopkins WG. An evaluation of mouthguard requirements and dental injuries in New Zealand rugby union. Br J Sports Med 2005;39:650–654. 29. Jolly K, Messer L. Promotion of mouthguard use among amateur football players in Victoria. Aust N Z J Public Health 1996;20:630–639.
© 2014 Australian Dental Association
30. Australian Dental Association Inc. Mouthguard Awareness Fact Sheet: What Type of Mouthguard Should I Wear? Available at: http://www.ada.org.au/app_cmslib/media/lib/0803/m122650_v1_ what%20mouthguard.pdf. 31. Australian Dental Association Inc. Prevention and Management of Oral Injuries. Policy Statement 2.2.5. 15–16 November 2012.
Address for correspondence: Dr Evanna Ilia PO Box 249 Thornleigh NSW 2120 Email: [email protected]
481
The official journal of the Australian Dental Association
Australian Dental Journal 2014; 59: 473–481 doi: 10.1111/adj.12223
Prevalence of dental trauma and use of mouthguards in rugby union players E Ilia,* K Metcalfe,† M Heffernan‡ *Private Dental Practice, Turramurra, New South Wales. †Westmead Centre for Oral Health, Westmead, New South Wales. ‡Discipline of Endodontics, Faculty of Dentistry, The University of Sydney, Camperdown, New South Wales.
ABSTRACT Background: There is a high prevalence of orofacial trauma in rugby union players. Mouthguards reduce complications following dental injuries, should dental injuries occur. The aim of this study was to investigate the prevalence of oral trauma and the significance of mouthguard use in adult amateur rugby union players in New South Wales, Australia. Methods: Questionnaires were distributed to players in rugby union clubs. It questioned players about their mouthguard use and orofacial trauma experience; the type of injury, complications, if a mouthguard was worn, where treatment was sought and outcome. Results: The prevalence of orofacial trauma in rugby union players is 64.9%. The most common injury was laceration to intraoral and extraoral soft tissues at 44.5%. Of all orofacial injuries reported, 41.9% were to the dentition. Following dental injury, loss of the tooth was the most common complication (34.7%). 76.9% of players wore mouthguards. By wearing a mouthguard, the risk reduction for ongoing complications following dental injuries was 18.5% (p-value = 0.009). Of these, 10.4% (p-value = 0.45) represented loss of the tooth. Conclusions: Rates of orofacial trauma and complications in amateur rugby union players are high in Australia. Use of mouthguards results in significant risk reduction for complications following dental injuries, including loss of tooth. Keywords: Orofacial, trauma, mouthguard, sports injury, epidemiology. (Accepted for publication 25 March 2014.)
INTRODUCTION Dental injuries are challenging, time consuming, costly to treat and can have aesthetic, functional, financial and psychological effects for the patient.1–10 Orofacial and dental trauma can result from falls, assaults, motor vehicle accidents and sporting accidents.11 Injuries consist of simple tooth concussion, fracture, luxation and avulsion, laceration of the gingiva, and jaw fractures.1–3,12 Orofacial and dental injuries commonly occur during sports participation, with as many as 31% of orofacial injuries reported to result from trauma while playing sports.4,12–14 Of 9543 patients treated over 10 years by a maxillofacial surgery department in an Australian hospital, sports injuries (31%) came only second to activities of daily life (38%) as the reason of presentation.11 Other causes of injury included violence (12%), traffic accidents (12%) and work accidents (5%).11 Contact sports are defined as sports in which players interact with each other, trying to prevent the © 2014 Australian Dental Association
opposing team or player from winning.9,15 Players of contact sports are at an increased risk of orofacial and dental trauma because of the high impact contact.1,4–7,12,13,15–18 Of the adults presenting to Australian accident and emergency departments with sports injuries, participants of cycling, hockey and rugby union commonly sustained injuries distributed to the head and upper extremities.19 Rugby union players were likely to injure the head and upper extremities, with 63% of trauma distributed in this region.19 A study of English rugby union players found that 41% of players had experienced dental injuries, of which 37% were fractured teeth.20,21 Another study found a high prevalence of soft tissue injuries, with 40% of Scottish rugby union players reporting injuries to the face or head requiring sutures.4,20 Several published studies have investigated the prevalence of orofacial and dental trauma in participants of contact sports. A high prevalence of dental injuries among schoolboy rugby union players in Australia and England has been reported.20 Additionally, 473
E Ilia et al. a cohort of 99 Scottish first division rugby union players was studied with the aim to identify the nature and severity of orofacial injuries that had been sustained by the participants.4 It was found that rugby union players frequently sustained orofacial injuries and the face was the most commonly injured part of the body.4 Soft tissue injuries were most prevalent but 30% of players had fractured their teeth, 19% had a tooth avulsed and 5% had fractured their mandible.4 Only a small amount of research has assessed the prevalence of orofacial trauma in adult Australian rugby union players. Previous studies have highlighted the high risk of orofacial and dental trauma associated with rugby union and other contact sports. Mouthguards can reduce the extent of injuries to the teeth and surrounding structures, should they occur.1,4,6,8,10,12,14,16,20 There are three types of mouthguards available: type I (stock) are for public sale and used without modification; type II (‘boil and bite’) are made of a thermoplastic material that is softened and then moulded to the dental arch by the user; and type III (custom-made) are made by a dentist using a mould of the patient’s dental arches.13,15,16,22 Custom-made mouthguards offer greater protection and wearers have fewer complaints about difficulty in breathing and speaking.6,7 Because of the high risk of orofacial trauma in contact sports it is important that players are made aware of the preventive role of mouthguards in dental injuries. Several studies have investigated mouthguard use by sports participants and the role of mouthguards in the prevention of orofacial and dental trauma. A survey of 236 basketball players in China assessed their knowledge about the value of mouthguards in the prevention of dental injuries.10 Player knowledge was high (80%) but only one player wore a custom-made mouthguard. These results show a discrepancy between player knowledge about injury prevention and their reported behaviour. A study of 961 Australian Rules football players that investigated player mouthguard use during training and matches found that a large proportion (72%) of players wore a mouthguard during competition, of which 73% were custom-made mouthguards.16 A study of Japanese high school soccer and rugby union players’ awareness of the value of mouthguards found that a greater proportion of rugby players owned a mouthguard compared to soccer players (24.1% vs. 0.8%).5 Almost all rugby union players acknowledged that mouthguards were necessary, with ‘boil and bite’ mouthguards being the most commonly used type of mouthguard (89.3%).5 Rugby union referees were given the power to enforce compulsory mouthguard use in all grades of domestic rugby union in New Zealand. Data on 474
injury compensation claims made before and after this policy was implemented shows the positive effects of compulsory mouthguard use on orofacial injury rates.23 The self-reported rate of mouthguard use increased from 67% to 93% after the introduction of these rules.23 There was a 43% reduction in dental injury claims. Rates of mouthguard use were lower during training than competition even though players often spend more time in training than in competition.23 The findings confirm the preventive value of mouthguards and provide evidence for the introduction of compulsory mouthguard use. There is published research looking at mouthguard use by players of a variety of sports.5,7,10,13,18,21 Questionnaires have commonly been used to gather this data. To date there is no published data evaluating mouthguard use by young adults playing rugby union. The aim of this study was to investigate the prevalence of orofacial trauma and assess mouthguard use and effect in amateur rugby union players in New South Wales, Australia. MATERIALS AND METHODS Ethics and grants Ethics approval was obtained by The University of Sydney Human Ethics Research Committee prior to commencement of the study. Data collection Data were collected for this cross-sectional analytical study between July 2010 and July 2011, by distributing a questionnaire to rugby union players from seven rugby union clubs in suburban Sydney and country New South Wales, Australia. A written participant information sheet was issued and participant consent given before the questionnaires were distributed. Participant confidentiality was maintained with no names recorded on the questionnaire. The researchers were present while the questionnaires were completed to ensure the answers were not discussed or researched. The questionnaire was collected immediately after it was completed by the participant. The questionnaire One questionnaire was used to collect the data. The questionnaire was validated by a pilot survey of 10 males aged 18–35 years. The questions asked in the questionnaire drew influence from questionnaires from previous studies.3,15,17,25 The questionnaire contained 27 multiple choice questions and was divided into four parts. Parts 1, 2 and 4 are relevant to this article © 2014 Australian Dental Association
Dental trauma in rugby union (Fig. 1). Players were asked for a dental injury risk rating for their sport, their orofacial and dental trauma experience and mouthguard use. Inclusion criteria To be included in this study, players had to be over the age of 18 years, fluent in verbal and written English and currently playing rugby union. Rugby clubs were contacted by the researchers and given an information sheet describing the study design and aims, and what would be expected of the players and the club should they decide to participate. Once the club gave consent to participate, a training session or competition day was attended to distribute the questionnaires.
Participants Questionnaires were collected from 240 participants (response rate 100%). Fifteen questionnaires were incomplete and therefore not included in the study. All participants were males aged 18 to 51 years. Data analysis method Data were entered into Microsoft Excel 2007 (Microsoft Corporation) for evaluation. All relevant data were used for analysis unless otherwise noted. Frequency proportions were produced by IBM® SPSS® Statistics Software, Version 19. Statistical significance was generated by the Spearman’s rank correlation, two-sided Pearson’s chi-squared test and two-sided Fisher’s exact test where appropriate. Data for orofa-
Fig. 1 The questionnaire. © 2014 Australian Dental Association
475
476
13 (8.90) 1 (0.68) 4 (2.74) 0 (0.00) 75 (51.37) 1 (0.68) 5 (3.52) 4 (2.74) 2 (1.36) 26 (17.81) 6 (4.10) 9 (6.16) 1 (0.68) 0 (0.00) 28 (19.18) 1 (50.00) 63 (63.34) 1 (50.00) 35 (24.66)
12 (63.16)
-
1 (50.00) 8 (9.09)
0 (0.00) 19 (19.19)
0 (0.00) 9 (8.08)
0 (0.00) 0 (0.00) 1 (0.68) 0 (0.00) 17 (11.46) 2 (8.70) 3 (15.79) 3 (13.04) 4 (21.05) 1 (4.35) 0 (0.00) 17 (73.91)
5 (25.00) 9 (60.00) -
66 (45.44)
9 (75.00) 1 (50.00) 120 (75.47) 4 (40.00) 2 (100.00)
13 (76.47)
5 (23.81) 4 (23.53) 3 (25.00) 1 (50.00) 39 (24.53) 16 (76.19)
80 (55.56) Total players
Dislocated jaw Other
5 (33.33) 6 (60.00) 0
11 (55.00)
20 (7.75) 15 (5.81) 10 (3.88) 2 (0.78) 146 (64.89)
9 (45.00) 10 (66.67)
8 (5.48) 9 (6.16) 2 (1.36) 4 (2.74) 2 (8.33) 22 (91.67) 8 (34.78) 15 (65.22)
7 (17.07) 25 (60.98) 14 (43.75) 9 (25.71) 26 (74.29) 14 (43.75) 32 (12.40)
18 (56.25)
15 (36.59) 41 (15.89)
23 (8.91)
15 (10.27) 13 (8.90) 11 (7.53) 7 (4.79) 13 (8.90) 12 (8.21) 2 (1.36) 0 (0.00) 3 (6.00) 3 (7.32) 15 (30.00)
4 (8.00) 6 (14.63) 28 (56.00) 16 (39.02) 13 (29.55) 31 (70.45)
33 (25.98) 94 (74.02) 52 (45.22) 63 (54.78)
Lacerations to lip, cheeks or tongue Fractured tooth/root Loosened tooth/ come out of place Broken jaw/bones of face Bleeding socket Avulsion
115 (44.57)
26 (63.41)
67 (45.89) 14 (9.59) 22 (15.07) 12 (8.21) -
Dentist & doctor n (%) Dentist n (%) Doctor/ hospital n (%) Lower posterior n (%) Lower anterior n (%) Upper posterior n (%) Upper anterior n (%) Complications n (%) Training n (%) Competition n (%) No mouthguard n (%) Yes mouthguard n (%)
Two hundred and twenty-five questionnaires were completed. Players were aged between 18 and 51 years; the average age was 24.12 5.72. The average length of time participants had played contact sport was 12.8 years, ranging from 1 to 42 years. The mean perceived risk of orofacial trauma reported by players was 6.67 (2.27) on a scale between zero and 10, with 10 indicating the sport carries the highest risk. The player’s assessment of risk was proportional to the length of time they had played contact sports, with each year playing, the perceived risk of receiving an orofacial injury increased by 0.277 (p = 0.13). A previous history of orofacial trauma was reported by 64.9% of players. The most common orofacial injuries experienced were lacerations to lips, cheeks or tongue making up 44.6% of all orofacial traumas. Injuries to the orofacial bones made up 12.8% of all injuries. Around 40% of participants (39.6%) had experienced a concussion while playing rugby union. Of the orofacial injuries reported, 41.9% were injuries to the dentition, i.e. avulsion, luxation, crown or root fracture (Fig. 2). Teeth in the anterior region were most commonly injured (82.8% of teeth injured). Maxillary anterior teeth were the most frequently injured teeth, accounting for 63.6% of teeth injured. Mandibular anterior teeth made up 19.2%, mandibular posterior teeth 9.1% and maxillary posterior teeth 8.1% of teeth injured. Complications following orofacial trauma were reported by 24.7% of players. Following dental injuries only, the need for extraction or loss of the tooth was the most common complication, accounting for 34.8% of all complications (Fig. 3). Of those players that had suffered complications; avulsions, luxations and crown fractures complications occurred in 60.0%, 43.8% and 39.0% of these players respectively. More complications were reported following an injury to maxillary posterior teeth and anterior mandibular teeth.
Total n (%)
RESULTS
Table 1. Orofacial injury types, whether a mouthguard was worn, timing of injury, complications, tooth affected and follow-up management
cial injuries were expressed as a percentage of the participants (Table 1). Calculations for regularity of wear were calculated from the total number of players wearing stock, ‘boil and bite’ and custom-made and mouthguards independently. Each response where the mouthguard was worn (training and/or competition) was given a value of 1 unit. If the participant wore a mouthguard at both training and competition, it was given a value of 2. The values were then divided by the total number of ‘wears’ possible by the player (2) and the ‘wear’ of both types of mouthguards compared.
No treatment n (%)
E Ilia et al.
© 2014 Australian Dental Association
Dental trauma in rugby union Prevalence of orofacial trauma by type 50 44.57
Prevalence (%)
40
30
20
15.89 12.40 8.91
10
7.75
5.81
3.88 0.78
0
Types of trauma
Fig. 2 Prevalence of orofacial trauma by type.
More orofacial injuries occurred during competition than training with 75.5% and 24.5% of players experiencing injuries in competition and training respectively. When the orofacial trauma occurred, 55.6% of players were wearing a mouthguard. When reviewing dental injuries only, i.e. fractured tooth, bleeding socket, avulsion and luxation injuries, 58.3% of players were not wearing a mouthguard. Over 60% of players that suffered avulsion injuries or a fractured tooth were not wearing mouthguards when the injury occurred. Following the injury, 19.2% of players sought treatment from a dentist and 11.5% from a doctor or hospital. Following the trauma, over 50% (51.4%) of respondents did not seek professional treatment. Players were less likely to seek treatment for soft tissue injuries, with 58.3% of players that reported these injuries, not seeking professional treatment. Most participants (97.3%) acknowledged that mouthguards have a role in the prevention of orofacial injury, but only 87.1% of players thought they were necessary (Table 2). Of the 76.9% of players that wore mouthguards, 57.2% wore them during competition only, 41.6% during both training and
Prevalence (%)
30
Table 2. Value of mouthguards Mouthguard use
Total n (% participants)
Mouthguards have a role in the prevention of orofacial injury Mouthguards do not have a role in the prevention of orofacial injury Mouthguards are necessary Mouthguards are not necessary
219 (97.3) 6 (2.7) 196 (87.1) 29 (12.9)
Table 3. Mouthguard use
Complications following orofacial trauma 40
competition and 1.2% during training alone. Some participants (23.1%) never wore a mouthguard (Table 3 and 4). There was no relationship between the age of the player and mouthguard use in players under the age of 31 years. A peak of non-use was noted at 24 years of age. Players over the age of 33 years were excluded from the analysis due to the limited sample size in this age group. The majority of players have been advised to wear a mouthguard (86.2%). Of these, the largest source of advice was from family, friends and parents (62.7%) and second from coaches or managers (50.7%), then dental professionals (48.9%). Only 14.2% had been advised to wear a mouthguard through media (Fig. 4). A large proportion of mouthguard wearers liked their mouthguard (53.2%), 17.9% disliked their mouthguard and 27.2% were indifferent to mouthguard use. Of the players that wore mouthguards, 0.6% wore stock mouthguards, 58.4% ‘boil and bite’ and 41.0% custom-made mouthguards. Players with custom-made mouthguards wore them 1.06 times more often than those with ‘boil and bite’ mouthguards. More wearers of custom-made mouthguards liked them (73.3%) compared with only 38.6% of players who wore ‘boil and bite’ mouthguards. Wearers of ‘boil and bite’ and stock mouthguards had more complaints about their mouthguards than players who wore custom-made mouthguards.
38.10
Mouthguard use
Total n (% participants)
28.57 23.81
Mouthguard wearers Mouthguard non-wearers
20
173 (76.9) 52 (23.1)
9.52
10
Table 4. When mouthguards are worn 0
Mouthguard use
Types of Complications
Fig. 3 Complications following orofacial trauma. © 2014 Australian Dental Association
Competition Competition and training Training only Total
Total n (% of wearers) 72 99 2 173
(57.2) (41.6) (1.2) (100) 477
E Ilia et al. most frequently reported injury in this study. Another study found a high prevalence of soft tissue injuries with 40% of rugby union players in Scotland suffering injuries requiring sutures.4 These findings confirm the high incidence of orofacial injuries associated with rugby union, which is likely to be related to the high contact nature of the sport. A large number of all orofacial injuries were dental injuries (those relating only to the teeth), including tooth fracture and luxation injuries. A high prevalence of crown fractures has also been seen in Scottish and Brazilian sport participants.4,17 Teeth in the maxillary anterior region were the most commonly injured teeth, a trend that correlates with findings from previously published studies.1,3,4,6,13,26 More injuries occurred during competition than training, which is likely to be due to the increased intensity and time playing full contact during games. A quarter of participants in this study who had experienced orofacial trauma suffered complications following the injury. The most common dental complications were loss of the tooth or the need for extraction of the tooth, change in tooth colour, and a need for further treatment. This may be due to a lack of appropriate first aid or professional management, as over one-quarter of players (27.0%) that suffered complications following orofacial injuries did not seek professional treatment. Dental injuries were more common and the complication rate was higher when a player was not wearing a mouthguard, notably for avulsion injuries and tooth fractures. By wearing a mouthguard the risk reduction for ongoing complications following dental injuries was 18.5% (p-value = 0.009). Of these, 10.4% (p-value = 0.45) represented loss of the tooth. This supports the findings published in previous studies that mouthguards can prevent complications if an injury does occur.4,6–8,12,16,20,27–29
Sources of advice to wear a mouthguard Parents/Family/Friends
62.7
Coach/Manager
50.7
Dentists Source
48.9
Media
14.2
Doctor
12.4
Other
0.9 0
20
40
60
80
Response (% of participants)
Fig. 4 Sources of advice for players in wearing a mouthguard.
Difficulty breathing (24.9% of players) and talking (15.1% of players) were the most common complaints reported by both wearers and non-wearers of mouthguards. Other complaints were poor fit and saliva build-up and gagging, which were reported by 10.7% of players (Fig. 5). DISCUSSION This study reports the high prevalence of orofacial trauma in amateur rugby union players in Australia. The majority of players will experience orofacial trauma during their time playing rugby union. Rates of dental injuries and complications following those injuries were increased in players not using mouthguards. As hypothesized, a high proportion of participants (64.9%) reported a past history of orofacial trauma. This trend was mirrored in an English study, with 41% of rugby union players reporting a past history of dental trauma.20,21 Rugby union players commonly sustain soft tissue injuries to the head and face with lacerations to the lips, cheeks or tongue being the
Reasons why mouthguards are disliked or not worn Difficulties Breathing Difficulties Talking
Reasons
Don't Need One
Fit Saliva Build up and Gagging Painful Custom Mouthgaurd
Cost
Boil and Bite Mouthguard, Stock Mouthguard
Other
Do Not Wear a Mouthguard 0
5
10
15
20
25
30
Response (%)
Fig. 5 Complaints by wearers and non-wearers of mouthguards by type of mouthguard worn. 478
© 2014 Australian Dental Association
Dental trauma in rugby union The player-perceived risk of orofacial trauma (6.67 2.27 out of 10) indicates that the majority of players were aware that rugby union is a high-risk sport. Surprisingly, there was no relationship between player perceived risk of injury and player past dental trauma experience, with those players who had and had not experienced orofacial trauma reporting a similar perceived risk of orofacial trauma. Despite this, 60% of players who were not wearing a mouthguard when they suffered an orofacial injury, now wear mouthguards; 40% in both training and competition. This shows experiencing dental or orofacial trauma acts as a motivator to wear a mouthguard, despite these players not admitting an ‘increased perceived risk of injury’. It is unfortunate that a large number of players need to suffer an injury before they start wearing a mouthguard. There was a relationship between length of time playing contact sports and player perceived risk. Players who had played contact sports for longer considered rugby union to carry a higher risk of orofacial injury, with the self-perceived risk of injury increasing 0.277 out of 10 (p = 0.13), each year they played contact sports. Although there was no statistical significance between the number of years played and risk assessment, the trend is important. The pattern may be due to players witnessing other players suffer injuries throughout their playing career, resulting in an increase in their perception of risk with time. The lower rate of mouthguard use during training may suggest a drop in the player’s perceived risk in this environment compared to competition. In this study, 50% of players did not wear mouthguards during training. It has been found that 80% of Australian Rules players wore mouthguards but only 13% wore mouthguards during training.29 Many contact sport participants spend more time in training than in competition, with a portion of training devoted to full contact practice. This emphasizes the lack of player understanding about the risk of injury during training, and the importance of mouthguard use in training and competition. Making mouthguard wear compulsory in both training and competition should be a focus of future legislation aimed at sports participants. ‘Boil and bite’ type mouthguards were the most commonly worn type of mouthguard. This is likely to be due to the reduced cost of ‘boil and bite’ mouthguards compared to custom-made mouthguards and players’ poor understanding of the advantages of custom-made mouthguards. Most mouthguard wearers liked their mouthguard (53%). Common complaints included poor fit and difficulty breathing which supports previous findings in the literature.5,6,16,22 More wearers of custom-made mouthguards liked their mouthguards than wearers of ‘boil and bite’ and stock mouthguards. Due to their specific and individualized © 2014 Australian Dental Association
adaption to the anatomy of the wearer’s oral tissues, custom-made mouthguards have been found to be superior in comfort, adaptability, stability and ability to talk and breathe.6 Custom-made mouthguards offer an individualized design according to the patient’s oral anatomy and an even distribution of material.6,30 The Australian Dental Association has advocated the use of custom mouthguards as the superior choice in the prevention of dental injuries.30,31 Therefore, custommade mouthguards should be recommended by dentists for better comfort, fit, stability and protection and more likely to be worn by the player.4,30 The most common source of advice for players with regard to the value of mouthguards in the prevention of orofacial trauma was family and friends. Importantly, almost half of the players were advised to wear a mouthguard by their dentist, suggesting this professional group has a significant influence. Coaches and managers also played a role in recommending mouthguard use, highlighting the importance of support staff knowledge of the benefits of mouthguard use. Given this, there needs to be a greater focus on educating all influences on the benefit of custom fit mouthguards specifically, in addition to the benefit of wearing mouthguards during both competition and training. Education could also be provided in the form of seminars for coaching staff and management, posters in changing rooms and team clubhouses, and verbal advice and written information sheets in dental surgery. Although the majority of players (86.2%) have been advised to wear a mouthguard, and less than half these numbers wear them during both training and competition. It is clear advice on mouthguard wear will not persuade some players to wear them, despite known and acknowledged benefits. Taking the positive effect of New Zealand’s legislation change as an example, changing laws to ensure compulsory, custom-made mouthguard use during training and competition in rugby union will have the biggest impact on players. Part of the questionnaire required players to recall past orofacial injuries. The retrospective nature of this study may affect the accuracy of the responses.20 Some injuries, particularly minor injuries may be forgotten and not reported in the survey. Additionally, some injuries and complications may be poorly understood by the player, particularly if they have poor knowledge of dental injuries or if the problem was not explained well by the treating medical or dental professional. In addition, self-diagnosis may not be accurate. An example may be the report of concussion, a medical diagnosis which has variability and a scope of grading systems. Diagnostic ambiguity may result in players incorrectly reporting injuries or complications or not identifying injuries or complications that have previously occurred. 479
E Ilia et al. The reasons for the peak of non-use of mouthguards at age 24 are unknown. It could be associated with risk-taking behaviour in this age group. Whereas 18-year-old players are still influenced by their parents and the education they received at school about the value of mouthguards, 24-year-olds may have become complacent and no longer influenced by family members. CONCLUSIONS Rates of orofacial trauma and complications in amateur rugby union players are high in Australia. Crown and root fracture are the most common dental injury, and tooth loss the most common complication following injury. Use of mouthguards results in significant risk reduction for complications following dental injuries, including loss of tooth. Age and previous history of injury does not significantly increase players’ perceived risk of injury. Acknowledging the benefits of mouthguards and advice to wear a mouthguard does not result in all players using a custom-made mouthguard in competition and training. Given players are influenced by family, friends, coaches and club administrators, the education of these people, dental professionals and players on the prevention of injury and subsequent complications by custom-made mouthguards, is essential. Legislation change to ensure compulsory custommade mouthguard wear during training and competition may result in the best outcome. ACKNOWLEDGEMENTS We wish to thank the Australian Dental Research Foundation and The University of Sydney for providing the funding for this study. Recognition to Dr Karen Byth for her assistance in the analysis of the results. Thanks also to Old Ignatians Rugby Union Football Club, Eastwood Rugby Union Football Club, Lindfield Rugby Club, Penrith Rugby Club, Colleagues Rugby Union Club, Hornsby Rugby Club and Bathurst Bulldogs Rugby Club for their contribution to this study. Dr Evanna Ilia and Dr Katie Metcalfe are the authors of this article, and Dr Michelle Heffernan was the research supervisor. REFERENCES 1. Lowe RM, Ponnambalam Y. Dental and maxillofacial skeletal injuries seen at the University of Otago School of Dentistry, New Zealand, 2000–2004. Dent Traumatol 2008;24:170– 176. 2. De Vasconcellos LG, Brentel AS, Vanderlel AD, De Vasconcellos LMR, Valera MC, de Araujo MAM. Knowledge of general dentists in the current guidelines for emergency treatment of avulsed teeth and dental trauma prevention. Dent Traumatol 2009;25:578–583. 480
3. Cohenca N, Forrest JL, Rotstein I. Knowledge of oral health professional treatment of avulsed teeth. Dent Traumatol 2006;22:296–301. 4. Kay EJ, Kakarla P, Macleod AD, McGlashan TPL. Oro-facial and dental injuries in club rugby union players. Br J Sports Med 1990;24:271–273. 5. Yamada T, Sawaki Y, Tomida S, Tohnai I, Ueda M. Oral injury and mouthguard usage by athletes in Japan. Endod Dent Traumatol 1998;14:84–87. 6. Duarte-Pereira DMV, Del Rey Santamaria M, Javierre-Garces C, et al. Wearability and physiological effects of custom fitted vs self-adapted mouthguards. Dent Traumatol 2008;24:439–442. 7. Blignaut JB, Carstens IL, Lombard CJ. Injuries sustained in rugby by wearers and non-wearers of mouthguards. Br J Sports Med 1987;21:5–7. 8. Emerich K, Gazda E. Review of recommendations for the management of dental trauma presented in first aid textbooks and manuals. Dent Traumatol 2010;26:212–216. 9. Al-Asfour A, Anderson L. The effect of a leaflet given to parents for first aid measures after tooth avulsion. Dent Traumatol 2008;24:515–521. 10. Ma W. Basketball players’ experience of dental injury and awareness about mouthguard in China. Dent Traumatol 2008;24:430–434. 11. Gassner R, Tuli T, H€achl O, Rudisch A, Ulmer H. Craniomaxillofacial trauma: a 10 year review of 9,543 cases with 21,067 injuries. J Craniomaxillofac Surg 2003;31:51–61. 12. Emerich K, Kaczmarek J. First aid for dental trauma caused by sports activities. Sports Med 2010;40:361–366. 13. Kecßeci AD, Eroglu E, Baydar ML. Dental trauma incidence and mouthguard use in elite athletes in Turkey. Dent Traumatol 2005;21:76–79. 14. Andreasen JO. Etiology and pathogenesis of traumatic dental injuries. A clinical study of 1298 cases. Scand J Dent Res 1970;78:329–342. 15. Barbic D, Pater J, Brison RJ. Comparison of mouth guard designs and concussion prevention in contact sports. Clin J Sports Med 2005;15:294–298. 16. Banky J, McCrory P. Mouthguard use in Australian football. J Sci Med Sport 1999;2:20–29. 17. Mori GG, de Mendonca Janjacomo DM, Castilho LR, Pol WR. Evaluating the knowledge of sports participants regarding dental emergency procedures. Dent Traumatol 2009;25:305–308. 18. Flanders RA, Bhat M. The incidence of oro-facial injuries in sports: a pilot study in Illinois. J Am Dent Assoc 1995;126:491–496. 19. Finch C, Valuri G, Ozanne-Smith J. Sport and active recreation injuries in Australia: evidence from emergency department presentations. Br J Sports Med 1998;32:220–225. 20. Jagger RG, Abbasbhal A, Patel D, Jagger DC, Griffiths A. The prevalence of dental, facial and head injuries sustained by schoolboy rugby players: a pilot study. Prim Dent Care 2010;17:143–146. 21. Jennings DC. Injuries sustained by users and non-users of gum shields in local rugby union. Br J Sports Med 1991;25:159– 165. 22. Abu-Dewoud M, Al-Enezi B, Andersson L. Knowledge of emergency management of avulsed teeth among young physicians and dentists. Dent Traumatol 2007;23:348–355. 23. Blinkhorn FA. The aetiology of dento-alveolar injuries and factors influencing attendance for emergency care of adolescents in the north west of England. Endod Dent Traumatol 2000;16:162–165. 24. Pakev DI, Radtke PK. Postreplantation management of avulsed teeth: an endodontic literature review. Gen Dent 2000;48:176– 181. © 2014 Australian Dental Association
Dental trauma in rugby union 25. Levin L, Friedlander LD, Geiger SB. Dental and oral trauma and mouthguard use during sport activities in Israel. Dent Traumatol 2003;19:237–242. 26. Maeda Y, Kumamoto D, Yagi K, Ikebe K. Effectiveness and fabrication of mouthguards. Dent Traumatol 2009;25:556–564. 27. American Dental Assocation Council on Access. Prevention and Interprofessional Relations; American Dental Assocation Council on Scientific Affairs. Using mouthguards to reduce the incidence and severity of sports related oral injuries. J Am Dent Assoc 2006;137:1712–1720. 28. Quarrie KL, Gianotti SM, Chalmers DJ, Hopkins WG. An evaluation of mouthguard requirements and dental injuries in New Zealand rugby union. Br J Sports Med 2005;39:650–654. 29. Jolly K, Messer L. Promotion of mouthguard use among amateur football players in Victoria. Aust N Z J Public Health 1996;20:630–639.
© 2014 Australian Dental Association
30. Australian Dental Association Inc. Mouthguard Awareness Fact Sheet: What Type of Mouthguard Should I Wear? Available at: http://www.ada.org.au/app_cmslib/media/lib/0803/m122650_v1_ what%20mouthguard.pdf. 31. Australian Dental Association Inc. Prevention and Management of Oral Injuries. Policy Statement 2.2.5. 15–16 November 2012.
Address for correspondence: Dr Evanna Ilia PO Box 249 Thornleigh NSW 2120 Email: [email protected]
481
