How to Prevent Dental Injuries – Part I
1. What is the most common problem you see in the dental health of athletes? What oral hygiene practices do you recommend for athletes?
Dr. Johnsen: The most serious problem for dental health of athletes continues to be injuries. The most common injuries are fracture and loosening of teeth. The best preventive practice, which is simple and inexpensive, is to wear a custom-fitted mouth guard during sports.
Dr. Till: Tooth decay caused by excessive consumption of decay-promoting foods and poor oral hygiene is another common dental health problem for athletes and non-athletes alike. Gentle brushing twice a day with a fluoride containing toothpaste is recommended by the American Dental Association (ADA). Use a "soft-scrub" action on all tooth surfaces. To clean (remove plaque) between the teeth, floss daily, preferably before going to bed.
Dr. Moss: In contrast to inattention to oral hygiene, some athletes brush too frequently or too aggressively, which can wear away their tooth enamel. Certainly, this problem is not restricted to athletes alone. Forceful brushing leads to sensitive teeth and pain when the athlete drinks a beverage that is hot or cold. Sound oral hygiene advice includes brushing gently with a soft-bristle brush. Athletes should avoid being compulsive about tooth brushing to avoid needless tooth wear. The teeth and gums do not benefit from brushing more than twice a day, nor do they benefit more from hard brushing.
Athletes may be at increased risk for a process called attrition. Attrition is the wearing away and chipping of teeth under physical pressure. Athletes instinctually clench their teeth because biting tightly and closing the teeth together temporarily enable the athlete to exert more muscular force. Clenching pressure might trigger the release of brain chemicals (neurotransmitters) that naturally reduce pain and make exertion easier. The best preventive approach to attrition from clenching and grinding is to maintain a regular, six-month checkup schedule, which enables the dentist to monitor the athlete for any tooth wear, and to use a mouth guard if there are early signs of tooth wear.
2. Dr. Johnsen mentioned traumatic injuries to teeth. What is the best emergency treatment for a severe tooth injury such as a fracture or an avulsed (knocked-out) tooth?
Dr. Till: The severity of a dental injury (fractured, displaced, or avulsed tooth) may not be immediately apparent. Often dental injuries are associated with other head and neck injuries, such as fractured facial bones, concussions, abrasions, bruises, soft tissue lacerations with bleeding, and jaw-joint problems. Thus, the injured athlete should be assessed for medical complications, including his/her ability to spontaneously maintain an airway, poor control of bleeding, shock, broken bones, and neurological impairment. Medical complications take precedence over dental injuries; therefore, the athlete who exhibits these symptoms should be escorted to an appropriate health-care facility.
After medical concerns are addressed, the extent of the dental injury should be evaluated. Any dental injury has the potential of being serious, and complications may arise weeks or years after the incident. In the case of dental avulsions, the tooth should be immediately recovered and reimplanted if possible. Keep in mind we are talking about adult or permanent teeth; primary teeth are not replanted. The speed with which reimplantation is accomplished is the single most important factor for a satisfactory outcome. If contaminated, rinse the tooth with saline or water before reimplanting. When immediate reimplantation is not possible, place the tooth in the best transport medium available.
The first choice is a tooth preserving system such as "Save-a-Tooth" marketed by 3M®. This kit can be stored in an athletic trainer's first aid case for such occasions. The tooth should be handled by the crown and placed into the container root first, as the directions indicate.
If the "Save-a-Tooth¨ kit is not available, the tooth or fragment should be placed in milk.
A third method is to place the tooth or fragment in a clean cloth, which in turn is placed in the athlete's mouth next to the cheek.
As a fourth option, a saline solution (e.g., contact lens solution) can be used. If none of these options exists, water can be used to transport the tooth. The injured athlete should see a dentist immediately. Delay of dental treatment, especially after physical exertion, may compromise the prognosis of the injured tooth, and the athlete may be at risk of further dental complications.
Dr. Johnsen: All dental injuries involving either fracture or loosening of a tooth should result in immediate contact with a dentist. The most important injury needing the immediate attention of athletic trainers, coaches, and even teammates, is the avulsion of a permanent tooth. The response that is widely agreed upon is the immediate reinsertion of the tooth so that it "looks like the corresponding tooth on the opposite side." Once the tooth is out of the socket, the likelihood of the body treating the tooth as a foreign object and resorbing the root becomes the problem. If the tooth is replanted immediately, the chances of saving the tooth with a root canal are very good; however, if the tooth is out more than 30 minutes, the chances of success begin to decrease. Teeth that are out for longer than about two hours have a very poor prognosis. Although wrapping a tooth in gauze soaked in saliva, water, or milk is better than leaving the tooth dry, the best management by far is reinsertion of the tooth.
Dr. Moss: If a tooth is fractured, find the missing piece as soon as possible and take it to the dentist on an emergency basis. Today, dentists have materials that can bond the fractured piece to the remaining portion of the tooth. Just as with the avulsed tooth, time is of the essence for treating the fractured tooth.
Dr. Cameron: With injuries in children, especially between six- and 12-years of age, the root development is often immature, and long-term prognosis will be determined by the urgency of care provided. In restoring an avulsed tooth, one of the keys to successful treatment is keeping the periodontal ligament cells alive. The steps outlined by Dr. Till will maximize the chances of achieving this goal.
Dr. Douglas: To reinforce Dr. Till's suggestion, examination of a fractured tooth should also include an evaluation of both the soft tissue and adjacent bone. If the dental trauma occurs in a place such as a football field where there is a good chance of contamination, you may want to consider prescribing antibiotics and also contacting the individual's physician for delivery of tetanus toxoid.
With oral injuries, it is also important to check for tooth fractures. Although immediate attention given by a dentist is desirable, time in attending to a fractured tooth is not as critical as in the case of treating a luxation (dislocation) injury. If the fracture is large enough to expose the yellow-colored dentinal layer that lies between the enamel and the pulp, it would be ideal if a protective filling material could be placed over the exposure. This would protect the dentinal tubules from being exposed to irritants such as bacteria. If the fracture exposes the pulp of the tooth, place a dressing over the exposure as soon as possible. If the exposure is left uncovered, the depth of pulpal inflammation will increase with time, decreasing the opportunity to maintain vitality.
ROUNDTABLE, Dental Care and Injury Prevention in Athletes, RT# 29 / Volume 8 (1997), Number 3
By Angus C. Cameron, B.D.S., M.D.Sc., F.R.A.C.D.S., Michael Till, D.D.S., D. Stephen Douglas, D.M.D., P.T., A.T.C., Stephen J. Moss, D.D.S., M.S., David C. Johnsen, D.D.S
Angus C. Cameron, B.D.S., M.D.Sc., F.R.A.C.D.S., Department Head, Pediatric Dentistry, Westmead Hospital Dental Clinical School, Clinical Senior Lecturer, Pediatric Dentistry, The University of Sydney, Australia
Michael Till, D.D.S. Dean, School of Dentistry, University of Minnesota, Minneapolis, MN
D. Stephen Douglas, D.M.D., P.T., A.T.C., Private Practice, Arlington Heights, IL, Chicago Bulls' Dentist
Stephen J. Moss, D.D.S., M.S., Professor Emeritus, New York University School of Dentistry, New York, NY
David C. Johnsen, D.D.S., Dean, School of Dentistry, The University of Iowa, Iowa City, IA
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