First Aid for Dental Trauma Caused by Sports Activities

First Aid for Dental Trauma Caused bySports ActivitiesState of Knowledge, Treatment and Prevention

Katarzyna Emerich1 and Jan Kaczmarek2

1 Department of Paediatric Dentistry, Medical University of Gdansk, Gdansk, Poland

2 Department of Technology, Gdansk University of Technology, Gdansk, Poland

Abstract In view of the widespread lack of knowledge of first aid procedures in casesof dental trauma, this article describes the current state of knowledge andhighlights the need for education of those likely to witness or be victims ofdental trauma while practising sports. Dental and oral injuries, the com-monest type of orofacial injuries, are often sustained by athletes playingcontact sports; indeed, they represent the most frequent type of sporting in-jury. Studies of a large group of children and adults have shown that as manyas 31% of all orofacial injuries are caused by sporting activities. Furthermore,current literature on the subject emphasizes that awareness of appropriatetriage procedures following dental trauma is unsatisfactory. Delay in treat-ment is the single most influential factor affecting prognosis.

What should we know and, more importantly, what should we do? Im-mediate replantation of an avulsed tooth is the best treatment option at thesite of the accident. If replantation is impossible, milk is the preferred trans-port medium for the avulsed tooth.

There is a general low level of awareness about the need for prompt triageof traumatic dental injuries sustained in sports, despite their relative fre-quency. When a cohort of Swiss basketball players was interviewed, only halfwere aware that an avulsed tooth could be replanted. Cheap, commerciallyavailable tooth storage devices containing an isotonic transport medium (so-called ‘Save-a-Tooth boxes’), can maintain the viability of an avulsed toothfor up to 72 hours, prior to replantation. More readily available storagemedia such as milk, sterile saline or even saliva may be used, but knowledge ofthis information is rare among sports participants. For example, just 6.6% ofthe Swiss basketball players interviewed were aware of the ‘Tooth Rescuebox’ products. Sporting organizations seem to offer very little informationabout sports-related risks or preventive strategies for orodental trauma.Having an attending dentist at sports events – amateur or professional – isclearly a luxury that is neither practical nor affordable. The solution must liein extending the knowledge of management of orodental trauma beyond thedental profession. Educational posters, when displayed prominently in sportsclubs, gym halls and dressing rooms of swimming pools, are a clear, accessibleand low cost method of presenting the appropriate procedures to follow after

CURRENT OPINIONSports Med 2010; 40 (5): 361-366

0112-1642/10/0005-0361/$49.95/0

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orodental injury. When the potentially avoidable financial burden and dis-comfort of protracted restorative or cosmetic dentistry are taken into ac-count, rarely can such significant morbidity be so easily prevented.

Our general health and well-being are amongthe most appreciated benefits of modern society.Few of us still need to be convinced that sportscan sustain and improve our physical conditionand, subsequently, our psychological state. Ac-tive participation in sport opens up new ways ofreaching our ambitions and satisfies our primaryneed for competition. Thanks to sports, society isbecoming and staying healthier. That is why indeveloped countries and societies, the practice ofsports is on the rise, stimulated by governmentswho, well aware of the multiple benefits, areputting all their energy into opening up all kindsof sports to children and adults. This sponsorshiphas resulted in a growing percentage of childrenand adults taking an active part in organizedsports events and competitions. Frequently,however, we forget that practising sports canhave negative consequences. Even during mod-erate sport practice, not to mention high levelcompetition, accidents do happen, with someleading to traumas that can handicap a personfor life. Sport-related injuries are a growing con-cern worldwide. For example, in children aged5–18 years the commonest injury location is thewrist/hand (28%), followed by the head/face(22%) and the ankle/foot (18%).[1]

In view of the widespread lack of knowledge offirst aid procedures in cases of dental trauma, wewould like to report the current state of knowl-edge and highlight the need for education of in-dividuals who are likely to witness or be a victimof sports-related dental trauma. Participants infast sport activities with close body contact areprone to orofacial injuries.[2] Dental injuries arethe commonest type of orofacial injuries,[3] andare often sustained by athletes playing contactsports. Contact sports are defined as those inwhich players physically interact with each other,trying to prevent the opposing team or personfromwinning.[4,5] Sports activities using bats and/or rackets present a particular danger of causing

dental injuries,[5,6] which occur more frequentlythan is commonly recognized.[1,7] Studies of alarge cohort of children and adults have shownthat as many as 31% of all orofacial injuries aresports-related.[3,8-11]

One of the most remarkable and relevantproblems regarding dental traumatology is thewide range of existing diagnostic classificationsystems. Over 50 distinct classification systemshave been identified in the literature.[12] In light ofthis discrepancy, some clinical and epidemio-logical studies have shown vast differences re-garding the prevalence and incidence of dentalinjuries. The consequences of dental trauma canvary from simple tooth fractures to complicatedtooth avulsion. However, in the literature themost frequently described consequences arecrown fractures, representing up to 79% of alldental injuries,[7] or 14% of sports-related dentaltrauma.[13] The most complex injury is the com-plete dislocation of the tooth from its alveolus.Tooth avulsion, which should be considered thereal emergency in dentistry, represents up to 21%of all dental injuries,[7,14,15] and 10% of sports-related dental injuries.[16,17]

What should we know and, more importantly,what should we do to minimize the effects of oro-dental injuries?

1. Awareness

To cope with such a large number of orodentalinjuries in a modern and effective manner, there isa pressing need to promote better education on thesubject to coaches, athletes, players and parents –those who can provide immediate help on thesports field tominimize long-lasting consequences.

Prevention of oral and dental trauma duringsport is an area where there is an almost total lackof information.[18] Education should be providedas early as possible in schools and within sportingclubs, primarily targeting instructors, coaches

362 Emerich & Kaczmarek

ª 2010 Adis Data Information BV. All rights reserved. Sports Med 2010; 40 (5)

and managers of sports facilities. This knowledgeand awareness could then be passed on to athletesand their families.[18] Compared with other out-patient injuries, traumatic dental injuries aremore time consuming and costly to treat.[19]

If every sports club, gym, sports hall, swim-ming pool or pitch displayed dental trauma firstaid explanatory posters, costly long-term conse-quences of complications arising from the delayedtreatment of teeth injuries could be prevented. Acampaign by the International Association ofDental Traumatology provided a good example,creating a multi-language poster entitled ‘SaveYour Tooth’.[20] Most available literature empha-sizes that awareness of the correct procedurefollowing dental trauma is unsatisfactory.[21-23] Itis recognized that the prognosis of traumaticdental injuries depends on the time between theaccident and initiation of treatment.[24,25] Para-doxically, the literature highlights the tendency todelay presentation for dental treatment. Onestudy showed that only 17% of children soughttreatment the same day or the day after the injuryoccurred, while 40% delayed treatment for morethan a month.[26] In other studies, the time be-tween the accident and presentation for medicalcare was 24 hours for almost half the studiedpopulation.[7]

It has been commonly accepted that all injuriesshould be treated on an emergency basis for thecomfort of the patient and to reduce woundhealing complications. Thus, a general rule for allsports participants is that earlier treatment is al-ways preferable to delayed treatment.[27]

2. Managing Tooth Avulsion

Tooth avulsion is a complex injury affectingmultiple tissues with the complete displacementof a tooth from its alveolar support, and shouldbe considered a genuine emergency requiringprompt and appropriate management to sig-nificantly improve prognosis.[28] Immediate re-plantation or maintenance of the avulsed tooth instorage media compatible for the survival ofperiodontal ligament cells before replantation isfundamental to a successful replantation proce-dure.[28-30] The longer the time elapsed between

tooth avulsion and replantation, the greater therisk of replacement resorption and inflammatoryroot resorption.[27,30] Although all participants insports activities should know that avulsed teethcan be replanted with relative ease, the literatureshows that this is not common knowledge.[21-23]

According to Perunski et al.,[21] just 51.9% of inter-viewees from Swiss basketball teams wereaware of the possibility of tooth replantation. Itmust be stressed that the most important factor inthe treatment of injured teeth is time. The bestway to preserve the vitality of periodontal liga-ment cells is immediate replantation at the siteof the accident, ideally within the first 30 min-utes.[31] If the root surface is contaminated, itshould be gently cleaned with a stream of salineor even cold tap water before replantation. Underno circumstances should the tooth be held by theroot, to avoid periodontal ligament damage.[20,27]

A temporary splint comprising aluminium foil,available in every kitchen or by unwrapping achocolate bar, can be applied before attending anemergency dental surgery.[32,33] Alternatively, ifthere is no one brave enough to replant and sta-bilize the tooth, an avulsed tooth can be placedin milk, which is the preferred transport medium,or in saliva (between the cheek and the lowermolars). Mori et al.[34] found that only 7% ofsports participants knew that milk is the idealstorage medium for an avulsed tooth. Otherpossible transport media – if available at the siteof the accident – are Viaspan, Hank’s BalancedSalt Solution and physiological saline.[30,35] Pro-ducts such as the ‘Save-a-Tooth box’ or ‘ToothRescue box’ are the best options for preservingthe vitality of periodontal ligament cells for up to72 hours.[36] However, only 6% of intervieweesfrom the Swiss basketball teams knew about suchproducts.[21] When the tooth is maintained in awet storage medium (i.e. milk), replantation canbe performed later and the chance of success issubsequently increased.[37-39] However, peopleoften allow the tooth to dry by keeping it wrap-ped in plastic or immersed in solutions inappro-priate for cell survival (e.g. hydrogen peroxide).[40,41]

This can lead to ankylosis and root resorption,which are both undesirable consequences oftooth replantation.[30]

First Aid for Dental Trauma 363


The best way to preserve the vitality of peri-odontal ligament cells is immediate replantation.In a hospital scenario, where first aid is given bymedical staff, fixation of an avulsed tooth can bemade by a suture using an easy-to-perform tem-porary fixation method.[42] All sports partici-pants should be aware of the first aid procedureto avoid extra-oral dry time of a tooth. For thefuture outcome of tooth avulsion treatment, theextra-oral dry time is far more important thanthe time when the patient was able to obtain adentist’s help. Based on 400 cases of replantation,20 minutes of both dry and wet storage only re-sulted in up to 15% of correct periodontal liga-ment healing and pulp healing.[35] It would seemobvious that an orofacial injury requires the at-tention of a dentist, but some studies show thatmany individuals fail to seek any treatment oradvice after an accident.[7,26,43]

If everyone would keep in mind six simplerules for managing traumatic dental injury, thecosts of treatment of tooth avulsion will dropsignificantly.[44] Those rules are:1. locate the tooth as quickly as possible;2. handle the tooth only by the crown (the whitepart);3. replace the tooth in its socket immediately(see the adjacent teeth as a guide);4. immobilize any loosened teeth (e.g. withaluminium foil);5. if the tooth cannot be replanted, immediatelyplace it into a physiological medium, keeping itwet at all times (e.g. use milk, saline or even saliva– place the tooth between the cheek and the lowermolars); and6. attend a dentist as soon as possible.

These rules could be presented in a simpleleaflet and distributed to schools and sportingclubs. As shown by Al-Asfour and Andersson,[45]

such a leaflet could be a valuable tool for con-veying the basic information to enhance theknowledge of how people should act if a toothavulsion occurs.

3. Prevention

Knowledge of aetiological factors that con-tribute to an increased risk of sport injury should

form the basis for preventive action.[46] Mal-occlusion or early stage orthodontic treatmentshould be considered predisposing factors totraumatic dental injury.[47] Thus, dentists shouldidentify and target patients who are at risk ofdental trauma, especially active sports partici-pants. Dental practitioners should also promotethe use of mouth guards as a prevention measureto all patients involved in sport.[16,48] Mouthguards have been proven to greatly reduce thenumber and severity of traumatic oral injuries,[49]

but studies have found that most people turn toprevention only after an accident has alreadyhappened.[21] Fakhruddin et al.[50] found thatonly 5.5% of school children wore mouth guardsfor school sports. The lack of awareness aboutthe benefits of wearing mouth guards and lack ofparental or coaching advice on mouth guardusage, as well as peer beliefs about aesthetics andfunction, were the main reasons for non-compliance.[50,51]

The low level of knowledge and lack of interestfor the problem of prevention and treatment ofdental injuries in all sports-related environmentsmakes it vital to introduce and continue educa-tion on a wide-ranging scale, targeted at bothactive and passive participants of all kinds ofsports. Instruction for the caregivers and onlook-ers in all sports-related environments should beshort and comprehensible. The message shouldbe ‘‘once the tooth is out of the mouth, replantimmediately, otherwise immediately place thetooth into a physiological medium, keeping it wetat all times, and see a dentist as soon as possible.’’

4. Conclusion

In the face of large numbers of dental injuries,there is an urgent need to promote better educa-tion on the subject of sports-related orofacialinjuries to coaches, athletes, players and parents –people who could provide instant help at the siteof an accident and minimize long-lasting con-sequences.

The extensive consequences of injury couldbe prevented with such simple knowledge andaction. Furthermore, efforts should be made totrain general medical practitioners and other



emergency room staff to perform appropriatefirst aid procedures for dental trauma. Thiswould result in an improved outcome for manythousands of sports participants worldwide whoinjure their teeth during play.

Acknowledgements

The authorswish to thankDrMikeHarrison, Consultant inPaediatric Dentistry from Cardiff University Dental Hospital,for his enthusiastic and untiring help and encouragement.

No sources of funding were used to assist in the prepara-tion of this article. The authors have no conflicts of interestthat are directly relevant to the content of this article.

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Correspondence: Dr Katarzyna Emerich, Assistant Professor,Department of Paediatric Dentistry, Medical University ofGdansk, ul. Orzeszkowej 18, 80-208 Gdansk, Poland.E-mail: [email protected]



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First Aid for Dental Trauma Caused by Sports Activities