Following our report on mouthguards in Ireland’s Dental published in July 2018, we highlight a session held in a County Down sports club that could signal the start of moves to improve outcomes following dental trauma

[ Words: Victoria Cave, Emma O’Donnell, Beth Burns & Niamh McGrath ]

An initiative to improve awareness of the action people should take if they or a teammate suffers dental trauma such as tooth avulsion has been launched in Northern Ireland with a session at GAA sports club in County Down.

Staged by dental core trainee Niamh McGrath, the session involved management and coaches of the boys, girls and senior teams. Niamh held a workshop that focused on the importance of gum shields and what to do during an avulsion. 

She said: “The age range for playing members starts at five and following the sessions coaches are more confident in managing avulsions should they happen during training or a match.

“What’s more, the club has made it compulsory to wear a gum shield if you wish to play. And there is a tie-up with a local dentist who has provided mouth guards.”

The idea for these type of sessions was first sparked in Glasgow where Niamh is a dental core trainee. Proposed by her fellow trainee Victoria Cave, the ‘It’s a Knock Out’ project, as it’s become known, was taken forward with the help of a third trainee Emma O’Donnell, and backing from Beth Burns, Consultant in Restorative Dentistry and Scottish national representative of Dental Trauma UK.

The three trainees were moved to take action after encountering the complications of dental trauma in Maxillofacial, Restorative and Oral Surgery. 

Niamh explained: “The project has been on the go for six months. It was meant to be small scale and concentrate in and around Glasgow, but it has grown arms and legs. 

“We started noticing that people were getting teeth knocked out and no one around them knew what to do. We would see them days down the line when there was no hope of the tooth lasting long term. We thought if we could get to those who are likely to be on hand we would eventually be able to improve outcomes.” 

She pointed out that brief research into the topic throws up some eye-opening statistics. By 14 years of age, 30 per cent of children have experienced a dental injury. Sports-related accidents account for 10-39 per cent of all dental injuries. 

“We started noticing that people were getting teeth knocked out and no one around them knew what to do. We thought if we could get to those who are likely to be on hand we would be able to improve outcomes”

Wearing a properly fitted mouthguard during high-risk sports has been shown to significantly reduce the risk of dental injury. However, for many high-risk sports in the United Kingdom, using a mouthguard is not compulsory. As a result, participants are at significant risk of traumatic dental injury. 

Victoria said: “If that does occur it often results in someone requiring multiple appointments over years, missing many days of work or school. And it represents a significant cost burden to the patient and the NHS – the average total cost of treating one patient with one traumatic injury has been cited as £856.”

Critical

It’s known that immediate management of avulsion injuries is critical for improved outcomes. A delay or inappropriate emergency treatment can cause long-term complications and affect tooth prognosis as well as the patient’s quality of life. Traumatic dental injuries most often involve the anterior maxillary teeth and can have a significant effect on dental and facial aesthetics. The significant consequences of dental trauma include crown discolouration, pulp necrosis, pulp canal obliteration, inflammatory root resorption either internal or external, ankylosis and aesthetic concerns. Avulsion leads to the greatest functional and aesthetic impairment due to its poor prognosis.

Most traumatic dental injuries in school-aged children occur at home or at school. Periodontal ligament cells become non-viable within 60 minutes, and to avoid damage to these cells the tooth must be either placed back in the socket, or in an appropriate storage medium (milk, Hank’s Balanced Salt Solution or saliva) within four minutes. 

The action of the first responder to an avulsion is therefore critical.

Niamh added: “Our aim was simple; to reduce the risk of dental trauma and improve outcome following avulsion injury by providing education on prevention and management of dental trauma in higher risk groups.”

As well as the County Down sessions, the project is being aimed at physical education and sports leadership students in Glasgow high schools, managers of local sports teams, and Scout and Girlguiding leaders. “We also want to encourage dentists to engage with their patients and local communities on prevention and immediate management of an avulsion injury,” said Niamh.

The response from the sports clubs, schools and Scout/Girlguiding groups has been overwhelmingly positive. Victoria explained: “We arranged 30-minute workshops where we targeted those who were deemed high-risk, with our main focus being on the importance of preventing dental trauma. 

“We provided ‘before and after’ questionnaires to gather the initial level of knowledge around avulsion. There were a variety of answers regarding how to store an avulsed tooth; in water, milk, tinfoil, the fridge and one vote for under your pillow!”

Meanwhile, many of those asked before the workshops said that accident & emergency was the most appropriate place to attend after having a tooth knocked out. This is borne out in research. Approximately one-third of patients present to an accident & emergency department when first seeking medical help after a traumatic dental injury. 

However, the best course of action is always to attend a dentist as soon as possible. Alternatively, if it’s out of hours or you are not registered, a patient can phone NHS24 who will direct them to an emergency dentist close by. Similarly, if the local A&E department is in a hospital with a maxillofacial unit there may be dentists on site who know to re-implant the tooth quickly. 

Niamh explained: “Meanwhile, it’s well documented that on-time and appropriate treatment, alongside clinical and radiographic follow-up, is important to lessen the effect of traumatic dental injuries and prevent complications.” 

Custom made

Those attending the workshops in Glasgow were involved in coaching, dance, martial arts, Gaelic football, rugby and football. Participants in contact sports such as rugby and Gaelic football recognised the need for mouthguards and some used them regularly. However, those taking part in sports such as football said they would never think of wearing a mouthguard – it isn’t the done thing and they think there’s no need to do so. The session covered the benefits of wearing a mouthguard, particularly one that’s custom made. Compared to the ‘boil and bite’ type, custom made mouthguards are less likely to dislodge on impact, and provide more uniform material thickness as well as improved cushioning. They may reduce the risk of injury to TMJ and it has even been suggested that they reduce concussion risk

There was also a short presentation, including videos from Dental Trauma UK, showing how to replace an avulsed tooth at the time of injury. The workshop content covered prevention, mouthguards, dental caries associated with sports drinks and Dental Trauma UK’s Pick It – Lick It – Stick It campaign, which includes posters and pitch side how-to sheets for first aid boxes. 

A practical element allowed participants to re-plant an avulsed ‘tooth’ on dental models. To conclude, there was information on other dental injuries including those that should be seen by accident & emergency, such as fractured jaw and loss of consciousness, as well as those that don’t need immediate management, like tooth fractures, intrusions and luxations

 After the workshop the questionnaire was distributed again. The results revealed an increase in participants’ knowledge and greater readiness to deal with a dental avulsion.

“So far, we have held approximately 10 workshops,” said Emma. “The numbers attending depend on the location of the workshop. In the cases of schools we can have an average of 40 students coming along and in the case of rugby we often address two team before a match and have a quick workshop afterwards, so there are upwards of 30 people there.”

However, the workshops have not been the only activities. The trainees have contacted other local sport teams and put them in touch with local dentists who are able to provide mouthguards.

Now that the first phase of workshops have taken place there are plans to visit more clubs in Northern Ireland and Glasgow schools. Dental Trauma UK is also working on recruiting dentists to regional representative positions to make sure the message is wide reaching. 

Education

Unfortunately, the acute management of dental trauma is rarely taught in first aid training courses and barely appears in first aid manuals and books.  “That’s why we are encouraging dentists join Dental Trauma UK,” said Emma. “They can use the excellent education resources available, and be active participants in their local communities. 

“Dentists should consider providing aid to local sporting teams to make sure they know what to do in these emergencies. They can signpost sports clubs and patients to guidance and how-to leaflets like those available through Dental Trauma UK*. 

“Equally, it would be beneficial if dentists were to promote a ‘no mouthguard no play’ rule for contact sports.”

She and her fellow trainees believe this sort of action can be a practice builder. And they are encouraging dentists to promote prevention by supplying custom fit mouthguards, as well as including a question on participation in high risk sports and mouthguard use on medical history forms. 

Niamh concluded: There’s no doubt if we work together, we can improve dental trauma outcomes for all of our patients.”

*Resources available at www.dentaltrauma.co.uk

Tags: Dental Trauma, mouth guards, Protection, Sports