suzely.moimaz@unesp.br

jorge.abou@hotmail.com

tania.saliba@unesp.br

fernando.chiba@unesp.br

osaliba@terra.com.br

*Full Professor, Department of Preventive and Restorative Dentistry

São Paulo State University (UNESP), School of Dentistry

Ph.D. in Preventive and Social Dentistry

São Paulo State University (UNESP), School of Dentistry

**Master in Preventive and Social Dentistry

São Paulo State University (UNESP), School of Dentistry

***Professor, Department of Preventive and Restorative Dentistry,

São Paulo State University (UNESP), School of Dentistry

Ph.D. in Legal Dentistry and Deontology, University of Campinas (UNICAMP)

****Assistant Professor, Department of Preventive and Restorative Dentistry,

São Paulo State University (UNESP), School of Dentistry

Ph.D. in Preventive and Social Dentistry,

São Paulo State University (UNESP), School of Dentistry

*****Full Professor, Department of Preventive and Restorative Dentistry

São Paulo State University (UNESP), School of Dentistry

Ph.D. in Preventive and Social Dentistry, São Paulo State University (UNESP)

School of Dentistry, Araçatuba, São Paulo

(Brazil)

Reception: 08/04/2019 - Acceptance: 04/11/2020

1st Review: 04/03/2020 - 2nd Review: 04/06/2020

Accessible document. Law N° 26.653. WCAG 2.0

 

Suggested reference: Moimaz, S.A.S, Rejaili, J.A., Saliba, T.A., Chiba, F.Y., & Saliba, O. (2020). Athletes and the prevalence of trauma involving the buco-maxillo-facial structure: knowledge and use of mouthguards. Lecturas: Educación Física y Deportes, 25(266), 30-43. Retrieved from: https://doi.org/10.46642/efd.v25i266.1875

 

Abstract

    Introduction: Epidemiological analysis of buco-maxillo-facial (BMF) fractures is important to provide measures for preventive care and effective treatment of these injuries. Objectives: To verify the prevalence of sport-related accidents involving the BMF structure and factors associated with sport modality, and knowledge and use of mouthguards. Method: This was a cross-sectional, descriptive, survey-based study involving 647 athletes participating in different sports in a Brazilian city in 2019. Respondents answered a questionnaire that addressed the primary outcome - occurrence of trauma to the head and neck region during sporting activities - and the knowledge and use of mouthguards. The following variables were investigated: marital status, sex, age, education, sport, affected region, and cause and consequence of trauma. Results: One hundred forty-eight athletes (22.87%) sustained trauma during sporting activities/competition. The mouth was the most affected site (30.40%) and contact with an elbow was the main cause. In 80 (54.05%) athletes, trauma occurred during game conditions and 68 (45.95%) during training. A total of 536 athletes (82.84%) were familiar with the concept of wearing a mouthguard; however, only 169 (26.12%) actually used one, 13 (7.69%) of whom were fitted with a custom mouthguard recommended by a dentist. There was a significant association between the occurrence of BMF trauma (BMFT) and knowledge of mouthguards (p=0.0042), sport modality (p<0.0001), education (p<0.0001), age (p< 0.0001), and sex (p=0.0421). Conclusion: The occurrence of BMFTs in athletes was high. Although most were familiar with mouthguards, their use was not a usual practice.

    Keywords: Trauma. Mouthguards. Athletes.

 

Resumo

    Introdução: A análise epidemiológica das fraturas bucomaxilofaciais (BMF) é importante para fornecer cuidados preventivos e tratamento eficaz dessas lesões. Objetivos: Verificar a prevalência de acidentes esportivos envolvendo as estruturas BMF e os fatores associados à modalidade esportiva, conhecimento e uso de protetores bucais. Método: Estudo transversal, descritivo, envolvendo 647 atletas participantes de diferentes esportes em uma cidade brasileira em 2019. Os participantes responderam a um questionário que abordava o desfecho primário - ocorrência de trauma na região da cabeça e pescoço durante atividades esportiva - e o conhecimento e uso de protetores bucais. As seguintes variáveis ​​foram investigadas: estado civil, sexo, idade, escolaridade, esporte, região afetada, causa e consequência do trauma. Resultados: Cento e quarenta e oito atletas (22,87%) sofreram trauma durante atividades esportivas/competição. A boca foi o local mais acometido (30,40%) e a cotovelada foi a principal causa. Em 80 (54,05%) atletas, o trauma ocorreu durante a competição e em 68 (45,95%) durante o treinamento. Um total de 536 atletas (82,84%) conheciam protetor bucal; no entanto, apenas 169 (26,12%) utilizavam; 13 (7,69%) destes usavam um protetor bucal personalizado recomendado por um dentista. Houve associação significativa entre ocorrência de trauma BMF (BMFT) e conhecimento de protetores bucais (p=0,0042), modalidade esportiva (p<0,0001), escolaridade (p<0,0001), idade (p<0,0001) e sexo (p=0,0421). Conclusão: A ocorrência de BMFTs em atletas foi alta. Embora a maioria conhecesse os protetores bucais, seu uso não era uma prática usual.

    Unitermos: Trauma. Protetores bucais. Atletas.

 

Resumen

    Introducción: el análisis epidemiológico de las fracturas orales y maxilofaciales (FOM) es importante para proporcionar atención preventiva y un tratamiento eficaz de estas lesiones. Objetivos: Verificar la prevalencia de accidentes deportivos que involucran estructuras OMF y factores asociados con el deporte, el conocimiento y el uso de protectores bucales. Método: estudio descriptivo transversal que involucró a 647 deportistas que participaron en diferentes deportes en una ciudad brasileña en 2019. Los participantes respondieron un cuestionario que abordaba el resultado primario -ocurrencia de trauma en la cabeza y el cuello durante actividades deportivas- y conocimiento y uso de protectores bucales. Se investigaron las siguientes variables: estado civil, sexo, edad, escolaridad, deporte, región afectada, causa y consecuencia del trauma. Resultados: Ciento cuarenta y ocho deportistas (22.87%) sufrieron trauma durante el deporte/competencia. La boca fue el sitio más afectado (30,40%) y el codo fue la causa principal. En 80 (54.05%) deportistas, el trauma ocurrió durante la competencia y en 68 (45.95%) durante el entrenamiento. Un total de 536 deportistas (82.84%) conocían protector bucal; sin embargo, solo 169 (26.12%) lo usaron; 13 (7.69%) de estos llevaban un protector bucal personalizado recomendado por un dentista. Hubo una asociación significativa entre la ocurrencia de trauma OMF (TOMF) y el conocimiento de los protectores bucales (p=0.0042), modalidad deportiva (p<0.0001), educación (p<0.0001), edad (p<0.0001) y género (p = 0.0421). Conclusión: La ocurrencia de TOMF en deportistas fue alta. Aunque la mayoría de la gente sabía sobre protectores bucales, su uso no era una práctica habitual.

    Palabras clave: Trauma. Protectores bucales. Deportistas.

 

Lecturas: Educación Física y Deportes, Vol. 25, Núm. 266, Jul. (2020)

---

 

Introduction 

 

    Athletes are more exposed to risks for accidents, and more attention has been devoted to the buco-maxillo-facial (BMF) region due to the higher frequency of injuries to this part of the anatomy (Yamamoto et al., 2018). The main causes of BMF trauma (BMFT) include motor vehicle accidents and aggressive altercations, as well as accidents during sporting activities and competitions (Gassner et al., 2004). The latter has attracted particular interest due to the popularity of sports around the world. According to some studies, approximately 3% to 18% of BMF fractures are sport related (Yamamoto et al., 2018; Piccininni et al., 2017; Yamsani et al., 2016; Kim et al., 2016; Walker et al., 2012; Vucic et al., 2016; Walker et al., 2012b), while others have reported that sport-related activities account for 31% of traumas. (Gassner et al., 2004)

 

    BMFT is very common in sports and its treatment can be costly. Many of these traumas, however, are preventable with proper preseason assessment and adequate, well-designed protection. Immediate identification and management of orofacial injuries, and appropriate follow-up are crucial to successful outcomes. (Piccininni et al., 2017; Levin et al., 2003)

 

    Data reported in the literature demonstrate that the occurrence of BMFTs during sports-related activities and competitions is variable (Walker et al., 2012; Walker et al., 2012b; Linn et al., 1986). High-contact sports, such as rugby, soccer, boxing, football, martial arts and ice hockey, are probably the most dangerous, causing extensive and even multiple injuries to athletes. (Yamamoto et al., 2018; Walker et al., 2012; Walker et al., 2012b; Crompton; Tubbs, 1977; Sandelin et al., 1985)

 

    Traumas to the BMF region sustained during sporting activities can be severe and need more extensive study according to various dimensions (Piccininni et al., 2017; Tanaka et al., 1996; Bathgate et al., 2002).As such, BMF injuries, including their prevalence among sports, and the influence of sex, geographical location or even between countries of different cultures, should be clarified. Epidemiological analysis of BMF fractures is crucial to identify traumatic burden, and to provide measures for preventive care and effective treatment of these injuries. (Boffano et al., 2014; Boffano et al., 2015; Arangio et al., 2014)

 

    The purpose in the present study was to verify the prevalence of sports injuries involving the BMF structure and factors associated with sport modality, as well as general knowledge and use of mouthguards.

 

Methods 

 

    The present study was a cross-sectional, descriptive, survey-based study involving athletes participating in different Olympic and non-Olympic sports in a Brazilian city. Lists of athletes registered in clubs and athletic associations in the municipality were obtained. All athletes, regardless of age or sex, belonging to municipal or private sports clubs and associations participating in official competitions, were included in the survey. Data collection was performed individually through interviews by a trained researcher with professional and amateur athletes from clubs and associations competing for a municipality in the state of São Paulo, Brazil. The athletes were approached for a private interview at their training locations, and the researcher had no influence on the respondents’ answers. Athletes who did not agree to participate in the research or those who did not provide informed written consent after three requests were excluded from the study.

 

    In the interviews, a questionnaire was used, which was first tested in a pilot study involving 40 athletes from different sports. The questionnaire addressed the primary outcome -occurrence of head and neck trauma during sports- and knowledge and use of mouthguards. The following variables were also investigated: marital status, sex, education, sport, affected anatomical region, and cause and consequence of trauma. The interviews were conducted individually and privately by a trained researcher at the clubs and/or associations. The researcher had no influence on the respondents' answers.

 

    Twenty-two sports were included, 18 of which are considered Olympic and 4 non-Olympic sports. A grouping of sports was performed as follows: group 1, ball and feet; group 2, ball and hand; group 3, fight/combat; group 4, equipment and ball; and group 5, individual.

 

    Descriptive statistical analysis was performed, and the data are presented in tables and graphs. To verify the association of the variables of interest with BMFT occurrence, the chi-squared test was used, adopting a significance level of 5%. The analyses were performed using Epi Info version 7.2 and Biostat 5.3 software.

 

    The study was approved by the Human Research Ethics Committee under the CAAE number: 16292219.4.0000.5420 and conducted in accordance with the Declaration of Helsinki.

 

Results 

 

    Of 647 respondents to the survey, 448 athletes (69.24%) were male and 199 (30.76%) female, most of whom were single (n = 496 [76.66%]), and a higher education level was reported by 327 athletes (50.54%) (Table 1).

 

Variable	n	%
Age (years)	n	%
07 - 10	29	4.48
11 - 20	242	37.40
21 - 30	219	33.84
31 - 40	93	14.38
41 - 66	64	9.90
Total	647	100.00
Marital status	n	%
Married	129	19.94
Separate	20	3.09
Not married	496	76.66
Widower	2	0.31
Total	647	100.00
Schooling	n	%
Elementary	99	15.3
Medium	221	34.16
Higher	327	50.54
Total	647	100.00

Source: Author's own elaboration.

 

    The sport modality with the most athletes was soccer, with 79 (12.21%) athletes, with 19 female (24.05%) and 60 (74.95%) male athletes (Table 2).

 

Group and sport	Trauma occurrence				Total
	No	%	Yes	%	n	%
Group 1. Ball and hand
Basketball	26	5.21	27	18.24	53	8.19
American football	18	3.61	8	5.41	26	4.02
Handball	12	2.40	14	9.46	26	4.02
Rugby	20	4.01	7	4.73	27	4.17
Volleyball	36	7.21	5	3.38	41	6.34
Subtotal	112	22.44	61	22.44	173	26.74
Group 2. Ball and feet
Field soccer	54	10.82	25	16.89	79	12.21
Futsal	20	4.01	8	5.41	28	4.33
Subtotal	74	14.83	33	22.30	107	16.54
Group 3. Equipment and ball
Badminton	24	4.81	2	1.35	26	4.02
Baseball	16	3.21	7	4.73	23	3.55
Field tennis	31	6.21	5	3.38	36	5.56
Table tennis	22	4.41	2	1.35	24	3.71
Subtotal	93	18.64	16	10.81	107	16.84
Group 4. Individual
Athletics	32	6.41	1	0.68	33	5.10
Cycling	24	4.81	2	1.35	26	4.02
Artistic gymnastics	14	2.81	1	0.68	15	2.32
Rhythmic gymnastics	16	3.21	0	0.00	16	2.47
Swimming	32	6.41	0	0.00	32	4.95
Triathlon	10	2.00	2	1.35	12	1.85
Subtotal	128	25.65	6	4.06	134	20.71
Group 5. Fight
Boxing	16	3.21	6	4.05	22	3.40
Jiu Jitsu	18	3.61	11	7.43	29	4.48
Judo	19	3.81	8	5.41	27	4.17
Karate	19	3.81	6	4.05	25	3.86
Taekwondo	20	4.01	1	0.68	21	3.25
Subtotal	92	18.45	32	21.62	124	19.17
Total	499	77.13	148	22.87	647	100.00

Source: Author's own elaboration

 

    Of the total, 538 athletes (83.15%) were familiar with mouthguards; 169 (26.12%) used mouthguards, being “boil and bite” the most used type with 110 athletes (65.08%). Among those who used mouthguards, it was found that 83 (49.11%) were used in game/competition and training. Discomfort with protectors was found in 55 athletes (32.54%) (Table 3).

 

Uses mouthguard	n	%
Not	478	73.88
Yes	169	26.12
Total	647	100.00
Protector type used	n	%
Stock	46	27.22
Boil and bite	110	65.09
Custom	13	7.69
Total	169	100.00
Frequency of use	n	%
Sporadic	21	12.43
Game	37	21.89
Game and training	83	49.12
Training	28	16.56
Total	169	100.00
Feel comfortable	n	%
Not*	81	47.93
Yes	88	52.07
Total	169	100.00

Source: Author's own elaboration

*Discomfort: Speaking (n = 55); breathing (n = 37); bad taste (n = 34); dry mouth (n = 27); 

bad breath (n = 22); nausea (n = 18). Some athletes experienced more than one type of discomfort.

 

    BMFTs were reported by 148 athletes (22.87%), with the mouth being the most affected region (30.41%) (Table 4). Eighty (54.05%) athletes sustained trauma during official competition and, of these, 50 (62.50%) had to withdraw because of it. It was found that the trauma resulted in a period of absence from sporting activities from 1 to 15 days in 39.19% of cases. Surgical intervention was performed in 14 (9.46%) athletes and hospitalization occurred in 11.49% of cases (Table 4). Contact with an elbow (32.54%) was the most frequent cause of BMFTs (Figure 1).

 

Affected Area *	n	%
Mouth	45	30.41
Skull	35	23.65
Teeth	6	4.05
Inferior jaw	29	19.59
Superior jaw	11	7.43
Nose	9	6.08
Eye	2	1.35
Neck	11	7.43
Total	148	100.00
Treatment Site	n	%
Ambulatory	32	21.62
Surgical	14	9.46
On site	66	44.59
Didn't need	36	24.33
Total	148	100.00
Number of days away from sport	n	%
0	71	47.98
01 - 15	58	39.19
20 - 30	13	8.78
60 - 365	6	4.05
Total	148	100.00
Number of days of hospitalization	n	%
0	131	88.51
01 – 07	15	10.13
15	1	0.68
30	1	0.68
Total	148	100.00

Source: Author's own elaboration.

*Study limitation: The lack of a head and neck figure for notation.

 

    There was a significant association between the occurrence of BMFT and knowledge of mouthguards (p = 0.0042), sport modality (p < 0.0001), education (p < 0.0001), age (p < 0.0001), and sex (p = 0.0421).

 

Source: Author's own elaboration

 

Discussion 

 

    The present study investigated the association between BMFT and sporting activities, and found a high prevalence and association with the sport modality practiced, with a higher risk for occurrence for athletes in sports involving contact with equipment or other athlete(s).

 

    Studies investigating BMFT have used different designs. Sporting preferences in countries are quite diverse and may, therefore, influence survey results (Newsome et al., 2001; Bergman et al., 2017; Aljohani et al., 2017; Yildirgan et al., 2016). The results of the present study revealed an association between trauma and sport modality. Other researchers have found that soccer and basketball were associated with the highest rates of BMFTs (Levin et al., 2003). In the present research, the frequency of trauma was higher than that reported in some other studies (Piccininni et al., 2017; Yamsani et al., 2016; Kim et al., 2016; Walker et al., 2012; Vucic et al., 2016; Walker et al., 2012b), and lower than others, which have associated sports with almost one-third of all traumas. (ADA Council on Access, Prevention and Interprofessional Relations, 2006)

 

    An injury prevention program for understanding risk factors can be instrumental in preventing undesirable events. There are two broad categories of risk factors for sports injuries: extrinsic and intrinsic (Taimela et al., 1990). Extrinsic factors are those that have the potential for trauma and are independent of the athlete, including: type of sport, as the trauma may be different (Chambers, 1979); method of training for competitions; supervision by individuals on the coaching staff; type of playing surface; equipment used; and climatic conditions (Cannel, 1986). Intrinsic risk factors refer to characteristics of the individual participating in the sport. It is the biological and psychosocial characteristics that predispose a particular individual to a type of sports injury. A review of intrinsic risk factors related to sports injuries has been performed. The authors presented evidence that intrinsic factors play an important role in the evolution of some sports traumas and concluded that these factors have received inadequate attention, and that further studies are needed to verify their importance in sports medicine and dentistry. (Taimela et al., 1989)

 

    Intrinsic factors include sex and age. In the present study, there was an association between trauma and these variables. In the literature and in the present study, the frequency of trauma in men was higher. This can be explained by the type of sport chosen by athletes. Generally, men compete in more violent sports with greater opportunities for physical contact (Stephens et al., 1985). Older athletes are less likely to sustain trauma. This fact was confirmed in the present study and others reported in the literature (van Hout et al., 2013; Ekstrand; Gilliquist, 1983). Most BMFTs occur during competition, which is not unexpected given the increased intensity and stakes of competition compared with training.

 

    The mouth and teeth are important in facial aesthetics and chewing function, and must be protected and, together, they were parts of the anatomy that sustained the most trauma. Most athletes were treated at the trauma site and did not require further treatment. The frequency of hospitalization, surgical procedures, and days without playing sports was low.

 

    Injury site, aetiology, treatment, and time away from practice due to sports trauma are not always recorded in a standardized manner in literature studies. However, standardization of the classification of the affected area(s) could facilitate a deeper understanding of the problem and, especially, enable objective comparisons among studies.

 

    Prevention of BMFT using mouthguards is important because even minor dental injuries can lead to pulp tissue necrosis and/or loss of the affected tooth (Ranalli, 2002; Emery et al., 2017). The American Dental Association advised participants of 30 sports to wear a mouthguard (ADA Council on Access, Prevention and Interprofessional Relations, 2006). International federations of rugby, football, and martial arts recommend the use of a mouthguard as one of several important accessories in preventing BMFT. (Knapik et al., 2007; Tanaka et al., 1996; Aljohani et al., 2017)

 

    In a study conducted in Israel in 2003, few athletes were familiar with mouthguards and only a minority used mouthguards in the 13 modalities surveyed (Levin et al., 2003). Research conducted in Italy in 2017, revealed that most mouthguards worn by athletes were stock retail or ‘boil and bite’ appliances (Piccininni et al., 2017). In 2015, researchers in Turkey observed that among individuals who participated in sports only on the weekend, very few were familiar with mouthguards and rarely wore them (Dursun et al., 2015). In the present study, most athletes had knowledge of mouthguards and a few used custom mouthguards, similar to that observed in previous studies (Piccininni et al., 2017; Levin; Zadik, 2012; Dursun et al., 2015). The use of mouthguards remains low, and this can cause irreversible trauma to the athlete. One solution to the discomfort of mouthguards reported by many athletes would be the use of an appliance fabricated by a dentist, which results in less difficulty in speech, breathing, adaptation, and better protection than stock retail mouthguards. Special attention should be devoted to athletes for the correct use and type of mouthguard. A limitation of the present study was that we did not to ask athletes if they were wearing a mouthguard when their trauma occurred. BMFT is very common in sports and treatment can be costly. Many of these injuries are preventable with preseason assessment and adequate protection. Immediate identification and management of BMFT and proper follow-up are crucial to successful outcomes. There have been significant recent advances in mouthguard design and manufacturing techniques (Piccininni et al., 2017). However, there is still much to be done for the dissemination and motivation for its use. All health professionals involved with athletes should encourage the use of mouth protection devices.

 

Conclusion 

 

    Approximately one-quarter of athletes sustained BMFT, which is a high rate. Most athletes are familiar with mouthguards; however, fewer than one-third wore them, and among those who did, their appliances provided little protection efficiency. BMFT was associated with age, sex, and type of sport.

 

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Lecturas: Educación Física y Deportes, Vol. 25, Núm. 266, Jul. (2020)