Sports Dentistry E-Book
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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Sprache: Englisch
Sports Dentistry: Principles and Practice is a comprehensive resource that addresses all aspects of this burgeoning field of dentistry. * Provides a comprehensive manual that covers the fundamental principles and practice of sports dentistry * Addresses all aspects of sports dentistry, including treatment of injuries, preventative measures, oral health and marketing and practice management * Offers information on providing dental facilities at sporting arenas * Presents suggestions for treating young children and the specific issues they present * Includes a companion website with illustrative case studies
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Table of Contents
Cover
Preface
1 Introduction
1.1 The Prevalence/Incidence of Dental Trauma During Sport
1.2 Dealing with Trauma to Teeth
1.3 The Role of Saliva in Tooth Surface Loss
1.4 The Role of Education
1.5 The Role of Sports Dentistry
References
2 Dealing with Dental Trauma: The Adult Athlete
2.1 Introduction
2.2 Classification of Injuries
2.3 Trauma to the Periodontal Ligament
2.4 Root Fractures
2.5 Splinting Techniques
2.6 Ankylosis
2.7 Soft Tissue Injuries
2.8 Developing an Emergency Dental Kit
References
3 Dealing with Sporting Dental Trauma in Paediatric Patients
3.1 Introduction
3.2 Dental Trauma: Children vs. Adults
3.3 Dental Development and Trauma
3.4 Alveolar Bone Growth and Trauma
3.5 Epidemiology
3.6 Preventing Trauma
3.7 Emergency Management of Dental Trauma
3.8 Management of Soft Tissue Injuries
3.9 Management of Trauma to the Primary Teeth
3.10 Dental Management of Trauma to the Permanent Teeth
3.11 Prognosis of Trauma in Young People
References
4 Restoration of Teeth Damaged by Trauma
4.1 Introduction
4.2 Principle Components of Modern Composite Resins
4.3 Restorative Techniques
4.4 Success with Anterior Composite Restorations
4.5 Clinical Sequence
4.6 Partial Bonded Porcelain Restorations/Minimally Invasive Bonded Porcelain
References
5 Dealing with Endodontic Problems Following Sporting Trauma
5.1 Introduction
5.2 Guidelines for Sports Doctors, Coaches, and Team Members
5.3 Nature of Injuries
5.4 Pulp Survival/Review of Pulp Status
5.5 Examination/History
5.6 Treatment
5.7 Review
References
6 Dealing with Tooth Wear in Athletes
6.1 Introduction
6.2 Types of Wear
6.3 Dental Erosion vs. Erosive Wear
6.4 Prevalence of Erosive Tooth Wear
6.5 Dietary Erosive Wear
6.6 Gastro‐Oesophageal Reflux Disease (GORD)/Laryngopharyngeal Reflux (LPR)
6.7 Eating Disorders
6.8 Effects of Alcohol
6.9 Rumination
6.10 Short‐term Causes of Erosive Wear
6.11 The Role of Saliva and Pellicle in Erosive Wear
6.12 Distribution of Wear Facets and Colour as an Indication of Progression
6.13 Erosive Wear in Elite Athletes
6.14 Management of Erosive Wear
References
7 Prevention of Sporting Dental Injuries
7.1 Introduction
7.2 Concussion
7.3 The Role of Schools in Mouth Guard Wear
7.4 The Use of Helmets in Preventing Sporting Trauma
7.5 Early Intervention Orthodontics
7.6 Mouth Guards
7.7 Helmets
7.8 Face Shields
7.9 Education About Diet
7.10 Sports Drinks
7.11 Prevention of Dental Diseases
7.12 Performance‐enhancing Mouth Guards
7.13 Conclusion
References
8 The Role of Nutrition in Sport: Current Sports Nutrition Advice
8.1 Introduction
8.2 What is the Optimal Diet for an Athlete? Is it Different for the Recreational Exerciser?
8.3 Hydration
8.4 Supplements
8.5 Gastro‐intestinal Complaints Related to Exercise
8.6 Eating Disorders in Sport
8.7 The Future
8.8 Summary
References
9 Oral Health, the Elite Athlete, and Performance
9.1 Introduction
9.2 Oral Health in Elite Athletes
9.3 Causes of Poor Oral Health in Elite Sport
9.4 Causes of Performance Impacts
9.5 Interventions for Athlete Oral Health
9.6 Centre for Oral Health and Performance
9.7 Summary
Acknowledgements
References
10 Screening for Dental Disease Amongst Elite Athletes
10.1 Dental Care of the Sportsperson
10.2 Exercise Effects on the Oral Cavity
10.3 Associated Dental Diseases
10.4 Tooth Surface Loss
10.5 Tooth Structure
10.6 The Acidic Challenge
10.7 Dental Caries
10.8 FA Initiative 2014
10.9 Acute and Chronic Infections
10.10 Temporomandibular Joint Dysfunction
10.11 Barotrauma
10.12 Mouth Guards
10.13 Other Issues
10.14 Sports Team Dentist Roles and Responsibilities
10.15 Screening Programmes
10.16 Prescribing
10.17 Prevention and Considerations for Care
References
11 Delivering Dental Facilities at Sporting Events
11.1 Introduction
11.2 Types of Sports Dentistry Support
11.3 Referral Pathway
11.4 Sports Dentistry Support for the Individual Athlete
11.5 Sports Dentistry Support for a Team
11.6 Sports Dentistry Support at a Competition
11.7 Sports Dentistry Support at Major Events
11.8 Level of Cover
11.9 Recruitment of Dentists and Dental Care Professionals
11.10 Training Recruits
11.11 Types of Equipment
11.12 Legacy
11.13 Conclusion
Reference
Index
End User License Agreement
List of Tables
Chapter 01
Table 1.1 Concussion rates for various sports.
Table 1.2 Showing the number and percentage of dental traumas due to cycling.
Table 1.3 Soft tissue injuries
Chapter 02
Table 2.1 Types of repositioning following an intrusion injury (courtesy of dentaltraumaguide.org) [8].
Chapter 06
Table 6.1 Examples of erosive foods and drinks.
Table 6.2 Examples of common drinks showing their pH and titratable acidity.
Table 6.3 Symptoms of GORD.
Table 6.4 Comparison between GORD and LPR.
Table 6.5 BEWE index for scoring erosive wear.
Table 6.6 Factors to consider when assessing acidic dietary intake
Chapter 08
Table 8.1 Energy sources from food and drinks.
Table 8.2 Classes, sources, and examples of different carbohydrates and artificial sweeteners.
Table 8.3 2010 Guidelines/Categories – daily needs for fuel and recovery (consider total energy needs, specific training needs, feedback from training) [4].
Table 8.4 Supplements that can be considered within a well‐balanced food plan.
Chapter 09
Table 9.1 London 2012 oral health data: participants.
Table 9.2 London 2012 oral health data: oral health conditions.
Table 9.3 Examples of oral health prevention actions. This is not a comprehensive toolkit but illustrates some of the possible actions. Note, there is much overlap and where one action may help other conditions, this is not duplicated. (Based on
Delivering Better Oral Health
3rd Edition [71].
Chapter 10
Table 10.1 Common signs and symptoms of tooth surface loss.
Table 10.2 Signs and symptoms that may be included in anorexia athletica.
Table 10.3 Zadik’s [45] summary of Frejentsik and Aker (1982) barotrauma classification.
Table 10.4 The advantages/disadvantages and considerations of screening.
Table 10.5 Objectives of dental screening.
Table 10.6 The advantages and disadvantages of a dental surgery‐based screening program vs. an on‐site training facility screen.
Table 10.7 Dental materials list.
Table 10.8 The important factors in caries assessment.
List of Illustrations
Chapter 01
Figure 1.1 Current IRB guidelines on dealing with concussion.
Figure 1.2 SCAT form to record levels of concussion.
Chapter 02
Figure 2.1 The main classification systems identified by da Costa Feliciano.
Figure 2.2 Standard arrangement of periodontal tissues.
Figure 2.3 Comparison of root resorption rates with extra‐oral period; three‐year follow‐up, following soaking in sodium fluoride [13].
Figure 2.4 Effects of using systemic antibiotics following reimplanting avulsed adult teeth [14].
Figure 2.5 Ellman mesh splint.
Figure 2.6 Kevlar thread.
Figure 2.7 Titanium trauma splint (Medartis AG, Basel, Switzerland).
Figure 2.8 Graph of transient ankylosis following replantation [23].
Figure 2.9 Graph of ankylosis following replantation [23].
Figure 2.10 The most common periodontal repair patterns observed during replantation [14].
Figure 2.11 Distribution of dental trauma in female field hockey players.
Figure 2.12 Contusion of gingival tissues.
Figure 2.13 Abrasion of upper lip.
Figure 2.14 Laceration of lower lip.
Figure 2.15 Penetrating wound from an air gun pellet.
Chapter 03
Figure 3.1 Increased overjet being measured.
Figure 3.2 Diagram of an upper permanent incisor tooth illustrating key structures.
Figure 3.3 Crown fractures of central incisors.
Figure 3.4 Radiograph showing root fracture in the middle part of a tooth.
Figure 3.5 Simple wire and composite splint.
Chapter 04
Figure 4.1 Clinical example and images of reattachment.
Figure 4.2 Palatal composite baskets.
Figure 4.3 Dehydrated teeth.
Figure 4.4 Rehydrated teeth.
Figure 4.5 Anterior tooth anatomy. Illustrated by Jurgita Sybaite.
Figure 4.6 A Class IV restoration before.
Figure 4.7 The final composite restoration.
Figure 4.8 Opalescence in natural teeth.
Figure 4.9 An attempt to recreate the effect in composite.
Figure 4.10 Wedges of dentine and enamel composite made from the actual material.
Chapter 05
Figure 5.1 Cross‐section of a tooth and supporting tissues.
Figure 5.2 The periodontium, showing its constituent parts.
(Images courtesy of Eleanor Robson)
.
Figure 5.3 A traumatized tooth showing its rotation and areas of compression (blue), and stretching and tearing (red).
Figure 5.4 CBCT showing the difference in anatomy that occurs around anterior teeth, resulting in different injuries.
Figure 5.5 (a) Transient apical resorption resulting in resorption of the root tips of mandibular incisor teeth (see arrows) followed by (b) complete healing.
Figure 5.6 The radiographic appearance of pulp obliteration.
Figure 5.7 Pulp necrosis, resulting in chronic apical periodontitis, seen radiographically as a periapical radiolucency.
Figure 5.8 Graph showing minimum and maximum prevalence of pulp necrosis for hard tissue injuries (infraction [4,5]; enamel fracture [7,8]; enamel/dentine fracture [8,9]; root fracture [10,11]).
Figure 5.9 The development of pulp necrosis in luxated [12] and avulsed [13] teeth.
Figure 5.10 A bore light (a) can be used to transilluminate teeth, when looking for infraction lines, and is covered with a clear plastic shield (b) for cross‐infection purposes.
Figure 5.11 A fractured crown of a permanent central incisor.
Figure 5.12 Pulp exposure, following a crown fracture.
Figure 5.13 Luxated right maxillary incisors which have been poorly splinted. Note their lower position when compared to the contra‐lateral teeth.
Figure 5.14 Colour changes in the crowns of teeth following luxation (a), after pulp necrosis (b) and root canal obliteration (c).
Figure 5.15 A cold refrigerant spray, used to thermally test the pulps of teeth.
Figure 5.16 An electric pulp tester used on an isolated tooth (a) and the patient holding the lip hook to complete the electrical circuit (b).
Figure 5.17 A crown fracture in a 9‐year‐old, showing its sub‐gingival nature due to the crown not being fully erupted.
Figure 5.18 Impact Air 45® handpiece.
Figure 5.19 A partial pulpotomy, following pulp amputation and haemostasis (a), application of calcium hydroxide (b) and sealing with IRM® (c).
Figure 5.20 The position of teeth, when marked on a rubber dam (a), often differ in position to those marked with a stamp (b). Marking the true positions on the dam make placement straightforward (c).
Figure 5.21 Placement of rubber dam when a splint is still attached to teeth, using an IVORY #9 clamp.
Figure 5.22 Radiographic images compared to actual anatomy, seen when root canals are stained and then cleared in a maxillary lateral incisor (left) and mandibular lateral incisor (right).
Figure 5.23 From the left, an access cavity when seen palatally, prepared through the cingulum, with a balanced preparation, and straight‐line access.
Figure 5.24 Hedstrom files, Flex‐o‐Files, and Gates Glidden burrs are often the only instruments required for root canal preparation.
Figure 5.25 An obliterated root canal can sometimes extend a good distance coronally (a) as well as being patent throughout its whole length and curved apically (b).
Figure 5.26 Sterile interdental brushes, used to clean wide root canals.
Figure 5.27 In root‐fractured teeth, instrumentation and obturation are completed up to the fracture line.
Figure 5.28 Several root‐fractured teeth reviewed five years after trauma, immobilised with a wire splint (a) and with healthy pulps (b), despite the accumulation of calculus.
Figure 5.29 A dense, uniform fill of calcium hydroxide, introduced with an amalgam carrier and packed with pluggers.
Figure 5.30 Chloroform‐customised gutta percha points often reveal the intricate anatomy at the end of the root canal at their tips.
Figure 5.31 An MTA obturation treatment in a tooth with an incompletely formed apex immediately after MTA was placed (a) and following completion of treatment (b).
Figure 5.32 A radiograph of traumatised maxillary central incisors in an eight‐year‐old patient, showing the relatively thin walls of the roots present at this age.
Figure 5.33 A resected root tip of a tooth with an obliterated root canal. Note the porous tertiary dentine in the centre of the tooth formed after dental trauma, which would remain unsealed following preparation and obturation of the main root canal in the centre of the tooth.
Figure 5.34 Retroplast® is a flowable composite, used to seal resected roots.
Chapter 06
Figure 6.1 Showing the interactions between various factors in erosive wear.
Figure 6.2 Picture showing erosive wear of teeth due to nocturnal reflux. The teeth on the left side are more affected than the right.
Figure 6.3 Picture showing erosive wear of teeth due to nocturnal reflux. The teeth on the left side are more affected than the right. This picture shows the wear facets more clearly on the left side.
Figure 6.4 Labial surfaces of upper and lower anterior teeth affected by wear. Early erosive wear is evident on the LL 1 and LL2. The upper teeth have been covered with composite as a temporary measure.
Figure 6.5 Palatal surfaces of the upper anterior teeth affected by erosive wear.
Figure 6.6 (a) A wedge‐shaped wear facet on the labial surface of a canine tooth primarily due to abrasion. (b) Wear facets on the labial/buccal surfaces of the teeth primarily due to erosion, having a typical washed out/dish‐shaped appearance.
Figure 6.7 Labial stained wear facets in a patient that has had erosive wear as a result of GORD.
Figure 6.8 Palatal surfaces of the teeth affected by erosive wear due to GORD.
Figure 6.9 Palatal restorations of the teeth shown in Figure 6.8 with Dahl effect composite restorations.
Figure 6.10 Labial surfaces of the teeth shown in Figure 6.7 showing indirect composite restorations.
Figure 6.11 A fixed metal Dahl appliance.
Chapter 07
Figure 7.1 Suitable cycle helmet with faceguard.
Figure 7.2 American Football helmet and mouth guard.
Figure 7.3 Ski helmet.
Figure 7.4 Severe overjet and incompetent lip morphology.
Figure 7.5 The Drufomat machine for fabricating custom‐made mouth guards.
Figure 7.6 Stock mouth guard for upper and lower teeth.
Figure 7.7 (a) Forces (F) acting on a tooth with and without the use of mouthguard during a soft object collision. (b) Forces (F) acting on a tooth with a high stiffness mouthguard. (c) Forces (F) acting on a tooth with a low stiffness mouthguard.
Figure 7.8 Ideal shape for mouth guard, labial view.
Figure 7.9 Ideal shape for mouth guard, occlusal view.
Figure 7.10 Cycle helmet.
Figure 7.11 Ice hockey half face shield and grill.
Figure 7.12 Cricket helmet with grill, showing the inadequacy of the protection.
Figure 7.13 Performance‐enhancing mouth guard.
Chapter 08
Figure 8.1 Energy supply systems.
Figure 8.2 Basic units of carbohydrates.
Figure 8.3 Use of different multiple transportable carbohydrates (glucose and fructose) results in greater fluid and carbohydrate delivery compared to glucose alone
Figure 8.4 Urine colour chart.
Figure 8.5 Monitoring fluid status.
Figure 8.6 Health consequences of relative energy deficiency in sport (RED‐S) showing an expanded concept of the female athlete triad to acknowledge a wider range of outcomes and the application to male athletes (* Psychological consequences can either precede RED‐S or be the result of RED‐S).
Figure 8.7 Potential performance effects of relative energy deficiency in sport (** aerobic and anaerobic performance).
Chapter 09
Figure 9.1 The Polyclinic (health centre) constructed for the London 2012 Olympic Games.
Figure 9.2 Prevalence of oral diseases in research data.
Figure 9.3 Examples of oral health problems in elite athletes. Track and field athlete with pain and swelling from acute pericoronitis. (a) Panoramic radiograph, (b) impacted, partially erupted third molar. (Images courtesy of Dr Geoff St George, Centre for Oral Health and Performance, UCL, London, UK). (c) Premier league professional footballer with severe pain showing extensive dental caries extending into dental pulp (nerve chamber).
Figure 9.4 Self‐reported impacts of poor oral health on athlete performance and wellbeing.
Figure 9.5 Complexity of factors determining oral health in athletes.
Figure 9.6 Model of mechanisms of impact of oral health on wellbeing and performance.
Figure 9.7 Illustration of estimated total surface area of ulcer within combined periodontal pockets in a person with generalised moderate to severe chronic periodontitis. The square on the palm represents the combined size of ulcerated epithelium [56].
Figure 9.8 (a) ‘Gob in a bag’ kit. Including key items for oral health care for athletes with recommended minimum athlete ‘drills’. (b) Athlete drills.
Chapter 10
Figure 10.1 The Stephan curve (from www.wrigleysoralhealthcare.co.uk).
Figure 10.2 Occlusal pitting and altered tooth anatomy with sharp edges and buccal abrasion lesions.
Figure 10.3 Palatal view of tooth surface loss with incisal edge pitting anteriorly.
Figure 10.4 Dental caries on tooth LL7 (a) and UL6 (b).
Figure 10.5 Tooth surface loss due to prolonged constant straw holding in between teeth and sipping from an energy drinks bottle in a triathlete.
Figure 10.6 Dental (abscess) swelling and chronic infection associated with upper (a) and lower (b) front tooth.
Figure 10.7 Clinical picture of poor oral hygiene with gingival inflammation and calculus.
Figure 10.8 Clinical pictures demonstrating cracked tooth syndrome from bruxism.
Figure 10.9 Custom‐made mouth guards fabricated on a dental model taken from an accurate impression.
Figure 10.10 Snus.
Figure 10.11 Typical dental surgery for optimal dental examination.
Figure 10.12 Off‐site dental screening facility will vary according to circumstances.
Figure 10.13 A screening examination sheet.
Figure 10.14 A screening report sheet.
Figure 10.15 A dental screening day is a good time to educate on optimal oral health measures and distribute oral health packs as above.
Chapter 11
Figure 11.1 An example of an on‐site screening facility.
Figure 11.2 Practice building via social media.
Figure 11.3 Oral laceration suffered during competition.
Figure 11.4 Mouth guard worn at time of injury.
Figure 11.5 Treatment of injury.
Figure 11.6 Treated soft tissue injury with sutures.
Figure 11.7 An example of on‐site impression facilities.
Figure 11.8 Providing support during Rio Olympic Games 2016.
Figure 11.9 An example of adequate space, boxing event at Baku Islamic Solidarity Games, 2017.
Figure 11.10 Laceration received during competition.
Figure 11.11 Warm‐up area before competition.
Guide
Cover
Table of Contents
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Sports Dentistry
Principles and Practice
Edited by
Peter D. Fine, BDS, PhD, DRGP, RCS (Eng)
Senior Clinical Teaching FellowDirector of the Sports Dentistry ProgrammeUCL Eastman Dental InstituteLondon, UK
Chris Louca, BSc, BDS, PhD, AKC
Professor of Oral Health EducationDirector and Head of SchoolUniversity of Portsmouth Dental AcademyPortsmouth, UK
Albert Leung, BDS, LLM, MA, FGDSRCSI, FFGDP(UK), FHEA
Professor of Dental EducationHead of Department of Continuing Professional DevelopmentProgramme Director for the MSc in Restorative Dental PracticeUCL Eastman Dental InstituteLondon, UK; andVice Dean, Faculty of DentistryRoyal College of Surgeons in IrelandDublin, Ireland
This edition first published 2019© 2019 John Wiley & Sons Ltd
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The right of Peter D. Fine, Chris Louca and Albert Leung to be identified as the authors of the editorial material in this work has been asserted in accordance with law.
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Library of Congress Cataloging‐in‐Publication Data
Names: Fine, Peter D., 1951– editor. | Louca, Chris, 1963– editor. | Leung, Albert, 1962– editor.Title: Sports dentistry : principles and practice / edited by Peter D. Fine, Chris Louca, Albert Leung.Description: Hoboken, NJ : Wiley Blackwell, 2019. | Includes bibliographical references and index. |Identifiers: LCCN 2018023762 (print) | LCCN 2018024973 (ebook) | ISBN 9781119332572 (Adobe PDF) | ISBN 9781119332589 (ePub) | ISBN 9781119332558 (paperback)Subjects: | MESH: Athletic Injuries–therapy | Stomatognathic System–injuries | Dentistry–methods | Stomatognathic Diseases–diagnosis | Stomatognathic Diseases–therapy | AthletesClassification: LCC RK56 (ebook) | LCC RK56 (print) | NLM WU 158 | DDC 617.6–dc23LC record available at https://lccn.loc.gov/2018023762
Cover Design: WileyCover Image: © Robert Stone; © Hero Images/Getty Images
This book is dedicated to all those athletes who have experienced dental trauma, dental disease, or oral health issues that have impacted on their professional, social, or general health throughout their lives. It is also dedicated to the small band of dedicated dental professionls who spend many hours attending postgraduate dental courses on sports dentistry, with the sole belief that they want to support athletes in their pursuit of excellence.
List of Contributors
Paul Ashley, PhDLead of Paediatric Dentistry, UCL Eastman Dental Institute, London, UK
Peter D. Fine, BDS, PhD, DRGP, RCS (Eng)Senior Clinical Teaching Fellow, Director of Sports Dentistry Programme, Deputy Director of Restorative Dental Practice Programme looking after the Master’s element, Department of Continuing Professional Development, UCL Eastman Dental Institute, London, UK
Geoffrey St. George, BDS, MSc, DGDP(UK), FDSRCS(Edin), FDS(Rest Dent)Consultant in Restorative Dentistry UCLH, Honorary Lecturer in Endodontology, UCL Endodontic Department, Eastman Dental Hospital, London, UK
John Haughey, BDSChief Dental Officer, VHI Dental, GPA Sports Dentistry Advisor, Dublin, Ireland
Gillian Horgan, BSc, RD, RSENAcademic Director (Health), SENR Accredited Sport Nutritionist and Dietitian, School of Sport, Health and Applied Science, St Mary’s University, London, UK
Albert Leung, BDS, LLM, MA, FGDSRCSI, FFGDP(UK), FHEAProfessor of Dental Education, Head of Department of Continuing Professional Development, Programme Director, MSc in Restorative Dental Practice, UCL Eastman Dental Institute, London, UK; Vice Dean, Faculty of DentistryRoyal College of Surgeons in IrelandDublin, Ireland
Chris Louca, BSc, BDS, PhD, AKCProfessor of Oral Health Education Director and Head of School University of Portsmouth Dental Academy Portsmouth, UK
Lyndon Meehan, BDS, BSc, MJDF(RCS), MSc EndoDentist with special interest in sports dentistry, dental trauma and endodontics, Dentist to Welsh Rugby Union, Welsh Football Association and Cardiff City FC, Clinical Lecturer in Endodontics, Cardiff University Dental School, Cardiff, UK
Rebecca Moazzez, BDS, MSc, FDSRCS (Eng), FDSRCS (Rest), MRD, PhDReader in Oral Clinical Research and Prosthodontics/Honorary Consultant in Restorative Dentistry, Director of Oral Clinical Research Unit, King's College London Dental Institute, London, UK
Ian Needleman, BDS, MSc, PhD, MRDRCS (Eng), FDSRCS (Eng), FHEAProfessor of Periodontology and Evidence‐Informed HealthcareCentre for Oral Health and Performance, UCL Eastman Dental Institute, London, UK;IOC Research Centre for Prevention of Injury and Protection of Athlete Health
Robert Stone, BDS, MSc, Con DentUCL Eastman Dental Institute, London, UK
Preface
The study of sports dentistry is a relatively modern specialty within postgraduate dental education that has lead the way in introducing the role of the general dental practitioner in dealing with the specific dental challenges that modern day sports can present us with. Initially seen as dealing with dental trauma, the teaching of sports dentistry has evolved into looking at the role of the dentist within the medical team, how dentists can support medical colleagues at major sporting events, how to introduce preventative measures in the sporting context, the role of oral health with elite athletes, and the importance of screening for common dental diseases.
The changing nature of restorative dentistry is reflected in the demands on dental practitioners to be able to advise and undertake treatment that is appropriate to this particular set of patients that perhaps have more demanding dental issues than our regular patient base. Although the field of sports dentistry is ever changing, the primary objectives of this book remain the same: (1) to inform dental and medical practitioners how to deal with orofacial trauma, both in the field of play and within the surgery environment; (2) to introduce the concept of dental screening, particularly during pre‐season assessments; (3) to prevent dental trauma of both an acute and chronic nature, acute being direct trauma to hard and soft tissues, chronic being tooth surface loss as a result of erosion; and (4) to investigate the role nutrition plays in elite and amateur athletes, with a view to reducing the need for them to require reparative restorative dentistry in the long term.
Acknowledgements
We would like to express our sincere thanks to all the authors who have contributed to the contents of this book. Their expertise in putting together this compendium of sports dentistry has been invaluable during the process of delivering what we hope will be a useful reference for dentists involved with sportsmen and women, medical colleagues who look after the general wellbeing of elite and amateur athletes and those allied professionals who witness dental challenges to their athletes.
We would also like to recognize the huge contribution made by Dr Barry Scheer for his foresight in developing the very successful Sports Dentistry Programme at UCL Eastman Dental Institute, London, UK. The programme, which continues to evolve, is believed to have been the first of its kind and has enabled many general dental practitioners from all over the world, with an interest in sport, to develop their skills and knowledge to deal with the specific problems experienced by athletes.
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1Introduction
Peter D. Fine, Chris Louca, and Albert Leung
This book is designed for both dental and medical professionals who either look after or who would like to be more involved in the care of both elite and recreational athletes. The role of specialist sports medicine practitioners has been well established for many years. The primary role of the sports medicine physician in competitive sport is the comprehensive health management of the elite athlete to facilitate optimal performance – the diagnosis and treatment of injuries and illnesses associated with exercise to improve athlete performance. Sports dentistry is a relatively new concept that is gaining momentum as the importance of good oral health and athletic performance become inextricably linked. For dental colleagues, this book will provide invaluable information about the recommended, evidence‐based manner to provide for the dental needs of all athletes. For medical colleagues, the book will give you an insight into dental issues commonly seen with athletes and some guidance on how to deal with certain dental/orofacial emergency situations if a dentist is not immediately present. Throughout the book we shall refer to sportsmen and women of all sports as athletes, and we shall refer to professional sportsmen and women as elite athletes. This book is intended to be used as a manual by the sports medicine fraternity in order to ensure that athletes suffering from dental/orofacial trauma or tooth surface loss as result of dietary considerations and those who are in need of preventative measures, can all be treated in an appropriate, speedy, and efficient manner. We are grateful for contributions to this book from specialists in dentistry from all over the world. The book is designed to support dental/medical colleagues with the ever‐increasing needs of athletes and the increasing role that dentistry/oral health has to play in athletic performance.
In this introduction, we look at the role that sports dentistry plays within sports medicine, the prevalence and incidence of dental trauma in the sporting arena, and outline the chapters that follow. With the exception of teeth that have been avulsed as a result of trauma, we shall consider dental trauma of teeth that are still in the oral cavity, and as such can be considered as cases of head injury. The relevance of head injuries will be considered in the relevant chapter from the point of view of their significance, but will not be dealt with in an exhaustive way as this is beyond the scope of this book. For more information the reader should refer to texts on concussion in sport or neurological information on the subject.
Sports and exercise medicine has been growing and gaining recognition around the world. In Britain it achieved official status in 2005, when the then Chief Medical Officer for England, Sir Liam Donaldson, promised to develop the specialty as a commitment to the London 2012 Olympic Games. Figures from the London 2012 Olympiad show that 45% of athletes seen in the poly‐clinic within the Olympic village or at any of the satellite sporting venues, were treated for musculo‐skeletal injuries, whilst 30% were seen regarding dental issues. This high proportion of dental patients seen during the 2012 games indicates the significance of sports dentistry in the current age. Figures collected at recent Olympiads show a steady increase in the number of dental cases seen during the competition period: Atlanta (1996) 906; Sydney (2000) 1200; Athens (2004) 1400; Beijing (2008) 1520; and London (2012) 1800. These figures do need to be seen in context as they represent all dental patients seen during the Olympic Games, which will include a small proportion of trainers, managers, coaches, and ancillary staff. The vast majority are athletes, many of whom use the four‐year cycle of the Olympic Games to get their teeth, eyes and hearing checked.
Therefore sports dentistry is not just about treating trauma to the teeth and jaws; the treatment and prevention of oral/facial athletic injuries and related oral diseases and manifestations is a significant part. Sports dentistry has evolved from a recognition that dental trauma is prevalent, particularly in contact sports, at all levels of sport, for all ages, and for both genders.
The Academy of Sports Dentistry was set up in San Antonio, Texas in 1983 as a forum for dentists, physicians, athletic trainers, coaches, dental technicians, and educators interested in exchanging ideas related to sports dentistry and the dental needs of athletes at risk of sporting injuries. Courses, seminars and symposia on sports dentistry are far more common today than in the 1980s. The role of the sports dentist is evolving continuously as new data become available. There is strong anecdotal evidence to suggest that poor oral health can have an impact on athletic performance and therefore the sports dentist has a more educational and preventative role to play than they might have done a few years ago. In Chapter 9 we will look into the implications of athletic performance and oral health. As dental professionals, we now recognise oral signs and symptoms, which can be indicators of systemic disease; recognising potential systemic problems from intra‐oral signs is important for all professionals, but when dealing with elite athletes this has a particular poignancy as we are generally dealing with young, generally fit and healthy adults, the detection of eating disorders, which we will cover in Chapter 6, being one example.
For some time the specialty of sports medicine has been well recognised in medical circles and in the sporting world. Professional and amateur sport has been aware of the impact that good medical practice, well‐trained medical specialists, and appropriate medical facilities can have on the enactment, well‐being, and performance of athletes. The input from sports medicine experts, physiotherapists, nutritionists, and sports psychologists in the care of athletes has been well documented for many years. No self‐respecting sports club would be without their professional or voluntary medical support, including the supportive and knowledgeable parents who give their time and expertise every weekend to support their sons and daughters. All major sporting events, like the Olympic Games, football world cups, rugby world cups, motor sports, and equestrian events, are well supported by medical professionals, often with a special interest in each individual sport. There is also a long history of medical professionals representing their country at various sports, including Sir Roger Bannister (athletics), Simon Hoogewerf (athletics), and JPR Williams (rugby).
In the world of modern professional sport, the medical team works closely with conditioning coaches, technical coaches, nutritionists, and psychologists to achieve the best results for the individual athlete and/or team. A lot of amateur sport is similarly well supported, sometimes by enthusiastic medical practitioners volunteering their time and knowledge, but also by well‐trained professionals. The first editor’s memory of taking a group of 17‐year‐old rugby players to tour South Africa in the 1990s included persuading the other coaches that we needed a professional physiotherapist with the team to make sure any youngster who really was not fit to take the field would not do so. It ended up that the professional physiotherapist was the busiest person on the trip and she quickly became a vital member of the support team, keeping players fit and more importantly advising the coaches on which players were not fit to play. Most athletes, whether keen amateurs or professionals, will want to continue playing their sport after an injury, therefore the involvement of knowledgeable professionals to support those athletes is paramount. None more so than in the situation of concussion following a trauma to the head. Current protocols about whether players who have suffered a head injury should be allowed to return to the field of play make the presence of a suitably trained person at every sporting event essential. The days of a willing parent saying a player is fit to return to the field of play should be behind us. The importance of head injuries should not be understated and the need to recognise head injuries and remove the player from the field of play is essential for the future well‐being of young sports men and women. There is anecdotal evidence of elite athletes having to retire early because of the implications of a further concussion on their general health. There are also well‐reported cases of traumatic injuries to the brain being fatal or career threatening. There is well‐documented evidence to suggest that an athlete who has suffered a blow to the head resulting in concussion is susceptible to a second episode of concussion, which could be fatal if they are allowed to continue playing. This is especially the case in contact sports such as rugby, boxing, and hockey. Whether repeated concussive or sub‐concussive blows to the head cause permanent brain injuries is complex and controversial. Press coverage in the 1970s highlighted the case of Jeff Astle the international footballer, where the coroner ruled that his death was due to ‘an industrial disease’, suggesting that the repeated heading of a football during his career had resulted in neurological decline [1]. This case was at odds with another footballer from the same era, Billy MacPhail, who in 1998 lost a legal battle to claim compensation for dementia that he claimed was due to repeatedly heading an old‐style leather football [2].
Concussion can be defined as a traumatic injury to the brain due to a violent blow, shaking, or spinning. A brain concussion can cause immediate and usually temporary impairment of brain function such as thinking, vision, equilibrium, and consciousness.
Although anyone can have a concussion, we will focus here purely for the purpose of example on athletes who suffer a concussion. The considerations can be generalized to the general population where there is a traumatic injury to the brain.
The signs of concussion observed by medical staff in athletes with a concussion, according to The American Medical Association (AMA), include the following:
Player might appear dazed, have a vacant facial expression, be confused about assignments; athletes might forget plays, be disorientated to the game situation or score. There can also be inappropriate emotional reaction, players can display clumsiness, be slow to answer questions, lose consciousness and display changes in typical behaviour.
Subjective symptoms reported by athletes with a concussion, according to the AMA, include the following: headache, nausea, balance problems or dizziness, double or fuzzy vision, sensitivity to light or noise, feeling slowed down, feeling “foggy ‘’ or “not sharp ‘’, reporting changes in sleep pattern, concentration or memory problems, irritability, sadness, and feeling more emotional.
Concussion has been shown to have an accumulative effect in both elite athletes and amateurs [3], and certainly concussion during a game can be exacerbated by an immediate return to play and a further blow to the head. This second blow can prove to be fatal. Some sports, like Rugby Union, have a protocol in place for the gradual return of its players to the game, depending on the severity of the concussion. At all times the health of the player should be our prime concern. The International Rugby Board (IRB) have drawn up guidelines for dealing with concussion that are regularly reviewed in the light of new knowledge. Figure 1.1 shows the current guidelines and Table 1.1 shows the concussion rates in several sports.
Figure 1.1 Current IRB guidelines on dealing with concussion.
Table 1.1 Concussion rates for various sports.
Source – 4th International Concussion Conference Presentation – Dr M Turner and subsequent publications.
Sport
Concussion rates per 1000 player hours
Horse racing (amateur)
95
Horse racing (jumps)
25
Horse racing (flat)
17
Boxing (professional)
13
Australian football (professional)
4–20
Rugby union (professional)
7
Ice Hockey (NFL)
1.5???
Following Rugby Union (youth)
1–2
Rugby Union (amateur, adults)
1–1.5
Soccer (FIFA)
0.4
NFL Football (NFL)
0.2???
It is conceivable that a dentist will be the most qualified healthcare professional attending a sporting event, especially at an amateur level, and therefore knowledge about the signs and symptoms of concussion is essential. It is of course prudent to refer any potential head injury to suitably qualified medical colleagues, who can carry out appropriate tests and monitor the recovery of the individual.
Apart from the immediate and mid‐term effects of a traumatic brain injury, there is some evidence to suggest that following a blow to the head, there could be long‐term implications from repeated episodes of concussion. During the 2015/16 rugby union season in Europe, a study led by Professor Huw Morris featured a premiership club in England who agreed to wear impact sensors to measure the force and direction of impact to the head. Professor Morris said: “The impact sensors have been providing us with data during matches and training but analysing players' blood biomarkers in conjunction with neuro‐imaging and psychometric testing will greatly expand this study. This is such a complex subject, we hope this is another step forward as we look to increase our understanding. We have a duty to look after our players, and nothing is more important than their welfare”. These ‘patches’ worn by players during training and competition were developed to address the inconvenience of wearing a wired mouthpiece to measure impact on the head during collisions [4].
There have been attempts to monitor and measure levels of concussion, but without a baseline measurement of individual athletes it is difficult sometimes to detect relatively minor levels of concussion. Pre‐season cognitive baseline testing is relatively new to youth sports. It is typically a short computerized test administered prior to the beginning of the season that measures selected brain processes and scores the test for each individual athlete; this establishes the athlete’s baseline. If it is suspected that the athlete may have sustained a concussion during the season, s/he can take a re‐test. The computer software will compare the baseline score to the re‐test score and alert the clinician that there has been a reliable change in the score. Computerized cognitive testing can also be used during management/treatment, even when a baseline has not been established. The changes/improvements in scores over time help to determine progress toward recovery. It is important to remember that computerized cognitive baseline testing is only a tool to be used by a trained clinician. It cannot diagnose a concussion and should always be used as one component of a concussion assessment.
The Sports Concussion Assessment Tool (SCAT) has been in use since 2005 as a reliable side‐line assessment of concussion. The SCAT3 was developed at the 2012 International Summit on Concussion in Zurich; the Child‐SCAT3 was released at the same time. The SCAT5 (the latest revision of SCAT3) is a standardised tool for evaluating injured athletes for concussion and can be used in athletes aged 13 years and older. It measures symptoms, orientation, memory, recall, balance, and gait. The SCAT5 can be administered by a licensed healthcare professional on the side lines or in the athletic trainer’s office once an athlete has been pulled off the field because a concussion is suspected. The Child‐SCAT5 is a standardized tool for evaluating children aged 5 to 12 for concussion and is designed for use by medical professionals. The Child‐SCAT5 recommends that “any child suspected of having a concussion should be removed from play, and then seek medical evaluation. The child must NOT return to play or sport on the same day as the suspected concussion. The child is not to return to play or sport until he/she has successfully returned to school/learning, without worsening of symptoms. Medical clearance should be given before return to play”.
Balance Error Scoring System (BESS) is included in the SCAT as part of a side‐line assessment. The SCAT form (Figure 1.2), includes the Glasgow Coma Score, which was first published in 1974 as a tool to measure the severity of a brain injury [5]. On their scale, Teasdale and Jennet proposed that levels of consciousness ranged from 3‐15; 3 indicating a coma and 15 a very mild level of injury.
Figure 1.2 SCAT form to record levels of concussion.
In the following chapters we shall consider different types of dental trauma, how to deal with trauma both on the ‘field of play’ and in the emergency room/surgery. We shall look specifically at trauma on young athletes and the implications of damage to teeth in children and teenagers. A further chapter will look at tooth surface loss as a result of erosion and include some aspects of eating disorders, the difficulty of restoring these teeth, and the impact of acid on tooth enamel. Nutrition will be dealt with in a separate chapter, where we will look at the role of nutrition in athletes with an emphasis on their general health and how different sports demand different dietary protocols. We will consider the influences of carbohydrates, proteins, and fats on elite athletes, as well as supplements to a normal balanced diet. As our knowledge about oral health and athletes increases, we shall look at the current data available indicating the importance of good oral health and its potential to influence athletic performance. There is much anecdotal evidence to suggest a strong link between the two; we shall look at evidence to support the connection between good oral health and performance in elite athletes.
The screening of athletes, particularly professional athletes, is a relatively new phenomenon. We shall investigate how to set up a screening programme, which could be applied to professional and amateur sport and which can involve the local General Dental Practitioner (GDP) attending their sports club to advise and if appropriate treat athletes. As with all screening, the idea of screening athletes is the early detection of disease and by so doing prevent pain, loss of training and game time, and to take a more preventative approach to dental diseases. The role of the dentist within the sports medicine team will be discussed. As we shall discuss later in this chapter, there is a higher incidence of trauma due to sports injuries than in other sections of the population, particularly in contact sports, therefore treatment is sometimes required for traumatic dental injuries as well as for a relatively high level of dental caries in the athlete who perhaps has not seen a dentist on a regular basis. Therefore we have included a chapter, which will be largely appropriate for dental practitioners, about building/restoring fractured teeth both directly and indirectly. This will include the use of modern restorative techniques, using appropriate materials, and being conservative when it comes to tooth preparation.
Major dental trauma may involve the pulp (nerve and blood supply to the teeth), so we have asked one of our specialists to include a section on dealing with these issues (endodontic problems). Chapter 5 will consider how to deal with pulpal problems, from pitch‐side emergency treatment to the final restoration in the dental surgery. It is important for sports medicine colleagues to be familiar with these issues, so we have included a section about recognising pulpal issues from a non‐dental perspective. Of course we should consider closely the opportunities to prevent dental trauma and so we have a chapter on prevention of trauma as well as prevention of tooth surface loss as a result of acid, either in the form of food and drink or from gastric reflux.
Finally, we will look at the requirements for setting up suitable dental facilities at sporting events. These will range from the local sports club perhaps needing mouth guards to be made for its athletes and a phone number to contact in the case of a traumatic dental injury of a player, through to the provision of dental treatment at a major sporting event like an Olympic Games. The latter will involve recruiting suitable personnel, designing adequate facilities, and estimating the likely workload that will occur prior to and during the period of competition.
1.1 The Prevalence/Incidence of Dental Trauma During Sport
There have been many studies carried out during the last 30–40 years indicating the prevalence of dental trauma in the sporting arena [6–9]. To put dental trauma related to sports in perspective, a study by Huang et al., indicated that sport and leisure were responsible for 30.8% of all dental trauma [10]. What we think is important is that we recognise trauma to the teeth and mouth, and the fact that trauma suffered in the orofacial area should be considered a head injury and appropriate precautions should be taken to deal with that. The history of sports dentistry is littered with anecdotal evidence of players having a tooth avulsed (knocked out completely) and the coach sending the player back onto the field of play before anything could be done to repair the damage. In fact an avulsion is quite a rare occurrence [11], but when it does happen it requires quick and effective treatment by whomever is available and appropriately trained to deal with the dental emergency. The importance of adequately accessing head injuries in sport has been a major concern in recent years and should be something that dentists attending a sporting event in a professional capacity, watching their children play sport, or perhaps where they are the only medically qualified person in attendance need to be proficient at. The current guidelines laid down by the Rugby Football Union in England are essential for all levels of sport (See Figure 1.1).
A study by Hendrick et al. highlighted the prevalence of orofacial injuries in female hockey players [9]. Of the respondents, 68% reported having received a facial injury, 11% had fractured facial bones, 19% had dental trauma, 10% reported loosened teeth, 5% avulsed at least one tooth and 3% had fractured a tooth. In Ice Hockey, Hayrinen‐Immonen reported that 29% of all injuries sustained during a match were dental [12]. Ice Hockey is a particularly violent sport where professional players see the loss of front teeth following a trauma as a badge of honour. Obviously the sports that are most likely to result in trauma to the orofacial region are contact sports. In rugby at the non‐elite level, Blignaut et al. showed that 30.5% of all injuries were dental [7]; Muller‐Bola et al. indicated that 29.6% of injuries in their sample were to the lower half of the face [13]. We will consider the work of Blignaut more fully in Chapter 7 when we look at various methods of prevention of dental injuries. A study looking at the aetiology of paediatric trauma reported that between 1.2 and 30% of all facial traumas were due to sporting trauma [8].
Since the recent success of British cyclists at Olympic and world events, there has been a boom in the number of recreational cyclists. Equally we see a larger proportion of facial injuries with cyclists and 3384 cases of hard dental tissues and 2061 cases of soft tissue injuries were reviewed by Haug et al. [8]. Table 1.2 shows the results for hard tissue injuries and Table 1.3, soft tissue injuries.
Table 1.2 Showing the number and percentage of dental traumas due to cycling.
Number
%
Crown fractures
975
28.8
Root fractures
45
1.3
Luxation injuries
1904
56.3
Losses of teeth
244
7.2
Contusions
68
2.0
Intrusions
148
4.4
Total
3384
100
Table 1.3 Soft tissue injuries
Soft Tissue Injury
n
%
Lacerations
1069
51.9
Excoriations
466
22.6
Contusions
285
13.8
Hematomas
241
11.7
Total
2061
100
Amongst 2061 soft tissue injuries in 1697 patients, 51.9% were lacerations, 22.6% were abrasions, 13.8% were contusions, and 11.7% were hematomas (See Table 1.3).
Soccer is played across the world and is particularly common throughout schools in many countries around the world. In Norway it was found that from a total of 7319 soccer players between 1979 and 1983, 17.4 % received dental trauma [14]. Studies comparing indoor [15] with outdoor [16] soccer injury rates indicate that indoor soccer players were six times more likely to encounter injuries than outdoor soccer players with similar hours of playing time. Higher injury rates in indoor soccer may be attributable to many factors, including the playing surface, and collisions between players and the walls bordering the field of play. Differences between artificial turf and natural grass playing surfaces account for variable injury rates among adult soccer players playing outdoors [17].
Flanders and Bhat reported that male and female soccer players were more likely to sustain an orofacial injury than football players [18]. This is probably due to the mandatory need for face shields and helmets to be worn in football. (It is worth emphasising here the difference in terminology: in the USA, football refers to american football and soccer refers to what Europeans call football.) They also reported a higher incidence of sporting trauma in basketball, lacrosse, and handball.
Whenever a major sporting event is held it is seen by elite athletes as an opportunity to have a dental examination. Studies undertaken at the London 2012 Olympic Games reported that 9% of elite athletes attending the games had never seen a dentist and 46.5% had not seen a dentist for over a year [19]. We will consider this aspect further in Chapter 8.
The London 2012 Olympic Games also proved to be an interesting opportunity to study elite athletes’ oral health and previous history (we will deal with this in Chapter 9).
Whenever a major sporting event is held it is seen as an opportunity for sports medicine specialists to learn more about injuries and how to deal with them. Similarly recent sporting events have proved to be ideal to investigate the prevalence of dental trauma. One such study was conducted during the Pan American Games [20]. This proved to be a good opportunity to compare different sports at the same time; what was surprising was that 49.6% of athletes reported a history of dental trauma and 63.3% of injuries were during sports of which the most prevalent were: wrestling 83.3%, boxing 73.7%, basketball 70.6%, and karate 60%.
1.2 Dealing with Trauma to Teeth
In Chapter 4, we will consider how to repair fractured teeth using conventional dental restorative techniques, but we shall be particularly conscious of the need to be conservative in our approaches. We have not looked at the replacement of teeth that are either lost or damaged beyond repair as the prosthodontic replacement of missing/damaged teeth is beyond the scope of this book. As sports dentists we are occasionally faced with a situation where we have to replace a missing tooth. Several options are available to us, including the use of resin‐retained bridges, conventional fixed‐bridge work, removable prosthodontic work, and implants. The dentist needs to consider the type of restoration needed by the athlete and take into account the likelihood of further trauma, aesthetics, the oral health status of the athlete, and their willingness to undergo restorative dental treatment. Treatment might be divided into immediate, interim, and definitive phases, which might include the use of any combination of the above treatment options. In the case of an elite athlete taking part in a contact sport, the definitive treatment of placing an implant may have to be delayed until the individual has ceased playing and an interim measure of a resin‐retained bridge be used for aesthetic, phonetic, and functional reasons.
The use of various restorative measures will need to be considered in conjunction with a well‐constructed mouth guard. This will be considered in Chapter 7.
1.3 The Role of Saliva in Tooth Surface Loss
We have not included a separate chapter in the book on saliva, but we do consider the role of hydration with athletes in some detail in Chapters 7 and 8. It is worth mentioning that saliva has a major role to play in hydration, and so the testing of a patient’s saliva is important, particularly when planning restorative treatment and instigating preventative measures. The important aspects to consider are: the buffering capacity of saliva, saliva flow rates, level of hydration as indicated by saliva volume, the consistency of saliva as this can be an issue if saliva is too viscous and does not naturally wash the dentition, the quantity of saliva being reduced due to medication, i.e. systemic bronchodilators, cardiac anti‐arrhythmics, expectorants, and tranquillisers. There are numerous saliva testing kits on the market, which can be used either in the surgery or at the sports venue (during screening) to advise athletes about the need for hydration and to test their salivary function.
In addition, the presence or absence of saliva has an important role to play in the immune response of saliva. Especially during endurance exercise, elite athletes who have a reduced saliva presence show a decrease in IgA levels, but it is unclear whether this is associated with an increase in upper respiratory tract infections [21]. Psychological stress has also been shown to decrease salivary IgA levels [22], but the relevance of this observation to immune fitness following fatiguing exercise is unclear.
