Mark E. Silberg, DMD
"Back to school" is here and so is the potential for injury as popular fall sports such as football, soccer, cheerleading and field hockey resume. According to the National Youth Sports Safety Foundation, over 25 million children in the United States between the ages of 6 and 16 participate in competitive, school-sanctioned sports and over 20 million children play organized sports outside of school.
Each year, more than three million of these student-athletes sustain sports-related injuries, 10-40% of which are facial injuries resulting in "knocked-out" (avulsed) teeth, delayed tooth loss, chipped or broken teeth, root canal treatment, or capped teeth. Athletes are also more prone to a condition called "attrition," the wearing away of teeth under physical pressure.
Studies show that the majority of sports-related injuries affect the upper front teeth. Children who play sports without mouth protection are particularly prone to these injuries. The lowest reports of tooth injury occur in football because of mandatory helmets, face guards and mouthguards. Tooth injuries are more common, therefore, in soccer, hockey, baseball and basketball.
Though dental injuries are fairly common in children - especially those in middle school and high school who actively participate in athletics - avulsed teeth are of particular concern because the tooth will be lost if special care is not administered immediately. Time is of the essence when treating a knocked-out tooth because if the cleaned tooth is not replanted in the socket within 30 minutes, the periodontal ligament cells begin to die off and the chances of saving the tooth decrease.
When a tooth has been dislodged, every effort should be made to find and replace it as quickly as possible. Caution the athlete to feel around his or her mouth and avoid swallowing the tooth. Look on the ground, check through the athlete's clothing and that of other players. If the tooth cannot be found, the player may be advised to have abdominal and chest x-rays to ensure the tooth has not gone into the lungs.
Once found, the tooth should be picked up by the crown - the hard enamel, white part - only . Do not touch the root. If the tooth is dirty, it can be rinsed with saline or water, but not scrubbed. Next, attempt to replant the tooth in the socket by gently inserting it into the socket so that the correct side is facing outward and that it is aligned with the surrounding teeth. There may be a clicking sound as the root locks into place. Bite down on a piece of gauze to hold the tooth in place and go immediately to a periodontist's office.
If the tooth cannot be reinserted, do not force it. Instead, keep the tooth moist in a commercial tooth preserving system such as "Save-a-Tooth." Alternately, teeth can be placed in milk while en route to the periodontist's office. If neither of these options is available, teeth should be wrapped in a cloth and placed in the athlete's mouth between gum and cheek, or as a last resort, submerged in saline (such as contact solution) or water.
The athlete should see a periodontist immediately. After two hours of separation, the likelihood of successful replacement of the tooth is all but diminished. However, even with proper and timely emergency care, the body may perceive the repositioned tooth as a foreign object and ultimately reject it.
By their very nature, children and teenagers are self-conscious and insecure. Unlike professional hockey players who wear their knocked-out teeth as a badge of honor, missing teeth to a student athlete can be embarrassing and even devastating. If the body does reject the tooth, athletes should talk to their periodontist about dental implants, a permanent tooth replacement option that is as close to real teeth as one can get. A periodontist with specialized training in the area of permanent tooth replacement can determine whether or not the athlete is a suitable candidate for dental implants. Otherwise, complications can occur later in life.
Key to preventing sports-related dental injuries is athletic mouthguards. In 1962, the United States mandated the use of mouthguards for high school football and subsequently, college football players were included in 1974. Since those requirements went into effect, the numbers and severity of dental injuries have been dramatically reduced. It has also been shown that mouthguards reduce the frequency of concussion.
It is estimated by the American Dental Association that mouthguards prevent approximately 200,000 injuries each year in high school and collegiate football alone. As part of the American Dental Association (ADA) and the American Academy of Pediatrics (AAP) annual back-to-school health promotion, when some 6 million high school students plan their participation in team sports, both health organizations remind parents that the use of mouthguards can help protect children from mouth injuries.
Mouthguards have many functions. They cover the teeth and thereby prevent the accidental biting of lips and tongue, protect the teeth from direct frontal blows to help avoid tooth fracture and loss, provide the lower jaw with resilient support to prevent jaw fracture and dislocation and facilitate prevention of brain injury by acting as a shock absorber between the jaws.
In addition, mouthguards thwart an athlete's capability to grind his teeth and hence, wear them down or chip them through the process of attrition. It is not uncommon for athletes to unconsciously clench their teeth while playing sports. This pressure releases chemicals in the brain, which instinctively reduce pain and ease exertion, giving the athlete a temporary jolt of physical strength.
Choosing the right mouthguard can be confusing. There are basically three types: stock, mouth-formed and custom-fitted (details of each are provided below). Regardless of the type, the mouthguard should be fitted to the top teeth, unless there is what dentists call a class-three malocclusion (see a professional for more details). Mouthguards must be close-fitting, cover the biting surfaces of all of the teeth, extend over the gums, be thick enough to absorb shock, be resilient, odorless, tasteless and comfortable to wear and not interfere with breathing.
Stock Mouthguards - Prefabricated mouthguards that can be purchased at sporting goods stores are the least expensive and, unfortunately, offer only minimal protection. They have no retention at all and must be kept in place with biting pressure. Since they are thin, they are not resilient and do not adapt well to the teeth. The dental profession considers them to be unacceptable.
Mouth-formed mouthguards - "Boil and bite" mouth-formed guards can be softened, molded and set in the mouth. They are moderately priced and offer some retention if properly fitted. They are usually too bulky at the periphery and too thin over the biting surfaces. Further, in 1993, the First International Symposium on Biomaterials reported that "boil and bite" mouthguards provide a false sense of protection due to the dramatic decrease in thickness over the tooth surfaces during the molding and fabrication process.
Custom-fitted mouthguards - Custom fitted mouthguards are considered optimal due to their intimate fit against the teeth and soft tissues, enhanced retention and comfort, and minimal interference with breathing and speech. The materials are superior to stock and "boil and bite" guards, conform more closely to the teeth and because the critical thickness over the biting surfaces can be more accurately controlled, they offer greater protection.
Serious consideration and care should be taken by parents when choosing a mouthguard, particularly because of the constant bombardment of clever marketing schemes, false claims and a variety of promotions from both stock and "boil and bite" mouthguard companies. The bottom line is that mouthguards bought off the shelf and the "boil and bite" variety are ill fitting and bulky, which can interfere with breathing and speaking. Of even greater importance, they do not provide the expected level of care and injury prevention that a properly fitted and fabricated custom made mouthguard does.
Dr. Mark Silberg, founder and executive director of The Silberg Center For Dental Science, is a Board Certified periodontist and a leading practitioner of permanent teeth implant technology. With over 25 years of experience in periodontics, Dr. Silberg has devoted his practice to replacing antiquated dental technologies, such as dentures and bridgework, with only the most advanced and effective periodontic treatments. A featured lecturer on implants and periodontics, Dr. Silberg is also the founder of the Discovery Study Club, which promotes continuing education and periodontal training for member dentists and their staffs.
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