Sport-related oral injuries and mouthguard use among athletes in Kelantan, Malaysia

Archives of Orofacial Sciences The Journal of the School of Dental Sciences Universiti Sains Malaysia Original Article Arch Orofac Sci (2012), 7(1): 21-27. Sport-related oral injuries and mouthguard use among athletes in Kelantan, Malaysia Mon Mon Tin-Oo*, Razliza Razali School of Dental Sciences, Universiti Sains Malaysia, 16150, Kubang Kerian, Kota Bharu, Kelantan, Malaysia. * Corresponding author: monmonto@kb.usm.my Received: 30/01/2012. Accepted: 21/06/2012. Published online: 21/06/2012. Abstract To assess their awareness and usage of mouthguard and occurrence of sports-related oral injuries in athletes who involve in various sports activities in Kota Bharu. A cross-sectional study was carried out among 180 athletes aged 12 to 27 years. A structured interviewer-guided questionnaire was used to determine the prevalence of oral injuries sustained during sport activities, the use of mouthguard as well as the athletes awareness of mouthguard use. The respondents consisted of 107 males (59.5%) and 73 females (40.5%) with a mean age of 16.7 years (SD 5.53). There were 60 (22.2%) athletes who had one or more types of sports-related oral injuries sustained. Laceration of lips, tongue and gums were the most frequent injuries (57.5%) while loosening of teeth and fracture of teeth sustained in 12.5% and 10.0% of athletes respectively. Malay traditional martial arts silat athletes, 17(68.0%) experienced the highest oral injuries among athletes. The prevalence of oral injuries was significantly different between ball sports, martial arts and other non-contact sports (p=0.002). Sixty-one athletes (33.9%) reported that they were aware of mouthguard; however none of the athletes used the mouthguards during their sports activities. Malay traditional martial arts silat was the most common susceptible to sustain oral injuries. None of the athletes were wearing mouthguard. Education on prevention of orofacial trauma should be given to the coaches and athletes. Wearing of mouthguard during sport activities should be compulsory during practice and competition events. Keywords: Athletes, mouthguard, oral injuries. Introduction People engaged in recreational and competitive sports activities for both physical and psychological well-being. Unfortunately, participating in sports activities is at risk of sustaining trauma to the oral hard or soft tissues such as chipped, luxated or avulsed teeth, maxillary or mandibular fractures, lip lacerations and other injuries to the gingivae, tongue or mucosa (Dale, 2000). Dental and soft-tissue injuries are common not only to high-risk contact sports such as boxing, hockey, rugby and lacrosse, but also to other, less obviously hazardous sports (for instance basketball and baseball) and non-contact activities (for instance gymnastics and in-line skating) (ADA Council on Access, Prevention and Interprofessional Relations; ADA Council on Scientific Affairs, 2006). In Germany, sports-related dental injuries account for 13% to 39% of all trauma cases (Mischkowski et al., 1999). The prevalence of dental trauma among Pan American games athletes was 49.6%, where 63.6% of them were related to activities during training or competition (Andrade et al., 2010). In the Czech Republic, the most frequent causes of injured permanent teeth in patients older than 11 years were sport activities (Hecova et al., 2010). The risk of oral injuries during performing sports 21

and exercise activities can be reduced substantially by using mouthguards (Woodmansey, 1999). Mouthguards offer protection by separating the cheeks and lips from the teeth, making users less susceptible to soft-tissue laceration and preventing opposing arches from traumatic contact and these protective devices provide a resilient, protective surface to distribute and dissipate transmitted forces on impact (ADA Council on Access, Prevention and Interprofessional Relations; ADA Council on Scientific Affairs, 2006). Studies have been done on wearing mouthguards and occurrence of dental injuries. Basketball players who use mouthguards had significantly lower rates of dental injuries and dentist referrals (Labella et al., 2002). A Nigerian study also showed that prevalence of orofacial injuries was significantly lower while wearing a mouthguard (Onyeaso, 2004). A survey in Switzerland, Germany and France found only one individual among all of squash players who experienced dental traumas wore a mouthguard (Persic et al., 2006). The importance of utilizing mouthguard was found in one Turkish study where 13.2% of university athletes had suffered from one or more form of oral injury while not wearing mouthguards (Cetinbaş and Sönmez, 2006). Oral injuries can cause disfigurement after healing to sufferer that might affect the athlete s quality of life. It is important that athletes should be aware of how they are at risk for dental and soft-tissue injuries and prevention of such injuries can be achieved if they utilized mouthguards during sport activities. This study was conducted to determine the incidence of oral injuries among athletes, their mouthguard use and awareness in Kota Bharu, Kelantan. Materials and methods This cross-sectional study was carried out from 9th June to 5th July 2008 at 10 sport clubs patronized by Majlis Sukan Negeri Kelantan (Kelantan State Sports Council) in Kota Bharu, Kelantan. Ten different sports (badminton, squash, gymnastics, silat, track and field, table tennis, cycling, tennis, sepak takraw and wushu) were played at the sport clubs. All athletes who aged 12 years and above, registered with the clubs and able to understand Malay language were invited to participate in the study. All participants were provided with written informed consent before interview was carried out. A structured, interviewer guided questionnaire (Fig. 1) was developed for data collection. The questionnaire contained 15 items including demography, type of sports that athletes are involved, period of time they had been practicing, whether any dental and soft-tissues injuries incurred specifically loosening of teeth, fracture of teeth, broken bones, bruises on the face and lacerations on lips, tongue or cheeks while participating in sports. Participants were asked whether they use mouthguard during sport activities and if not, state the reasons of not using and whether they believe mouthguard can prevent dental injury. Content validity and face validity were established by a panel of experts and pre-testing. The questionnaire was previously pretested on 15 sportsmen who were not included in the study to ensure its clarity and non-ambiguity. Feedback regarding problems understanding and answering the questionnaire was obtained and addressed. This study was approved by Research and Ethic Committee (Human) of Universiti Sains Malaysia. Statistical analysis Collected data were analyzed using Statistical Package for Social Science (SPSS) version 12.0 (Chicago IL, USA) statistical software. Frequency, mean and standard deviation were calculated for descriptive statistics. To analyze the differences of injuries sustained, the sports were categorized into three groups. Tennis, squash, sepak takraw, badminton and table tennis were grouped under ball sports, silat and wushu were grouped as martial arts and 22

gymnastic, track and field badminton and cycling were grouped as noncontact sports. Chi-square analysis was used to determine the differences of injury sustained on ball sports, martial arts and non-contact sports. The level of statistical significant was set at 0.05. 1. Gender: Male Female 2. Race : Malay Chinese Indian Others 3. Age:.years 4. Education level: primary school Secondary school Matriculation Diploma Bachelor 5. Type of sport you participate: 6. Period of time participating: year(s) month(s) 7. Do you experience of injury on Yes No face when you involve in sports? (if your answer is No, please continue to 13) 8. Did you have loosening of teeth? Yes No 9. Did you have broken of teeth? Yes No 10. Did you have broken of bones? Yes No 11. Did you have bruises on face? Yes No 12. Did you have cuts on lip, tongue or cheek? Yes No 13. Are you aware that mouthguard can prevent dental injury? Yes No 14. Do you use mouthguard? Yes No (if your answer is No, please continue to 15) 15. Why don t you use mouthguard? my coach does not tell me to use it is expensive it is uncomfortable it is not important for me Fig. 1 Example of survey on dental injuries and mouthguard used among athletes in the present study. Results A total 180 athletes from the 10 sport centers participated in the study. Demographic data of athletes was presented in Table 1. Male athletes (59.5%) were accounted more than female (40.5%). Their age ranged from 12 to 28 years and mean age was 16.7 (SD 5.53) years. Most of the athletes were Malay and majorities (83.8%) were secondary school students. The mean duration of involvement in the particular sports was 6.6 (SD 4.59) years. Table1 Demographic data of athletes and type of sports they involved (N=180) Variables Mean(SD) Frequency Sex Male 107 (59.5) Female 73 (40.5) Age (year) 16.7(5.53) Race Malay 151 (83.8) Chinese 29 (16.2) Education level Primary school 14 ( 7.8) Secondary school 150 (83.3) Matriculation 4 ( 2.2) Diploma 10 ( 5.5) Bachelor 2 ( 1.1) Length of time participating in sports (year) 6.6 (4.59) Table 2 Frequency of athlete involved in different type of sports (N=180) Type of sports Male Female Total Badminton 6 (3.3) 8 (4.4) 14 (7.8) Squash 11 (6.1) 10 (5.6) 21 (11.7) Gymnastic 6 (3.3) 8 (4.4) 14 (7.8) Silat Olahraga 18 (10.0) 7 (3.9) 25 (13.9) Track and field 8 (4.4) 12 (6.7) 20 (11.1) Table tennis 9 (5.0) 10 (5.6) 19 (10.6) Cycling 12 (6.7) 0 (0.0) 12 (6.7) Tennis 14 (7.8) 8 (4.4) 22 (12.2) Sepak Takraw 17 (9.4) 0 (0.0) 17 (9.4) Wushu 6 (3.3) 10 (5.6) 16 (8.9) Table 2 shows the distribution of male and female athletes according to sports. Silat had the highest number of participants (13.9%). More female athletes were participated in track and field, wushu and badminton. Orofacial injuries were found in 22.2% of athletes who participated in sepak takraw, silat, gymnastics, squash, and badminton. Athletes of silat had the most injuries (68.0%) followed by athletes of sepak takraw (52.9%) and gymnastics (50.0%) (Table 3). The most frequent injuries sustained were lacerations of lips, tongue and gum (57.5%) followed by bruises of face (50.0%). Affected to teeth by loosening of teeth and fracture 23

teeth were not more than 13% (Table 4). Significant more injuries were sustained in martial arts (41.5%), follow by ball sports (17.2%) and the least in non-contact sports (15.2%) (p=0.002) (Table 5). Table 3 Distribution of athletes participated in different type of sports, orofacial injuries sustained, mouth guard use and awareness (N=180) Type of sports Number of athletes Injuries sustained Mouthguard awareness Ball sports Tennis 22 0 (0.0) 5 (22.7) Squash 21 6 (28.6) 3 (14.3) Sepak 17 9 (52.9) 5 (29.4) Takraw Table tennis 19 0 (0.0) 7 (36.8) Badminton 14 1 (7.1) 5 (35.7) Martial arts Silat Olahraga 25 17 (68.0) 19 (76.0) Wushu 16 0 (0.0) 4 (25.0) Other non-contact sports Gymnastic 14 7 (50.0) 3 (21.4) Track and field 20 0 (0.0) 7 (35.0) Cycling 12 0 (0.0) 3 (25.0) Total 180 40 (22.2) 61 (33.9) Table 4 Distribution of types of injuries sustained (n=40) Types of injuries Tooth loosening 5 (12.5) Fracture teeth 4 (10.0) Fracture facial bone 2 ( 5.0) Bruises of face 20 (50.0) Laceration of lip, tongue and cheek 23 (57.5) None of the athletes were wearing mouthguard during their training and in competition. There were 61 (33.9%) athletes who were aware that mouthguard can help prevent dental injuries (Table 3). The reasons of not using mouthguard were shown in Table 6, where 46% of athletes reported that wearing mouthguard is not important for them. Not getting instruction to use mouthguard from coach was claimed by 32.2% and discomfort was concerned by 21.7%. The cost was not the reason for athletes not wearing the mouthguards. Discussion The present study reveals 22.2% of athletes had experienced one or more form of orofacial injury during sport activities. This result corroborate with other studies (Tulunoglu and Ozbek, 2006; Persic et al., 2006), where 22.3% and 20.4% of the participants reported to have experienced oral injuries respectively. Among the athletes who had injuries in this study, laceration of lip, tongue and cheek occurred most frequently (57.5%) followed by bruises on face (50.0%). As for hard tissue injuries namely loosening of teeth, fracture teeth and facial bone fracture were relatively lesser than that of soft tissue injuries which ware 12.5%, 10% and 5 % respectively. Commonly, these injuries incurred in athletes when they fall on their face or hit by hard objects from athletic equipments and collision between athletes; whether the type of sports they participated were either contact sports or non-contact sports. Table 5 The difference of injury sustained in contact sports and non contact sports Variable N Frequency (%) Injury sustained N= 44 No. of injuries N=139 X 2 statistic a (df) P - value Ball sports 93 16 (17.2) 77 (82.8) 12.003 (2) 0.002 Martial arts 41 17 (41.5) 24 (58.5)) Other sports 46 7 (15.2) 39 (84.8) a Chi-square test for independence 24

Table 6 mouthguard Reasons of athletes not using Reasons Coach does not advise the use 58 (32.2) It is expensive 0 (0.0) It is uncomfortable 39 (21.7) It is not important for me 83 (56.1) However, contact sports players are at higher risk to sustain oral injuries (Kay et al., 1990). Among Nigerian young adult athletes, contact sports accounted for 78.5% of the oral injuries, while only 21.5% were resulted from non-contact sports (Onyeaso and Adegbesan, 2003). In the present study, athletes participating in martial arts which is one of the contact sports suffered the highest injury rate (41.5%), than athletes participating in ball sports (17.2%) and other non-contact sports (15.2%) (p=0.002). Pieter (2005) reviewed paediatric injuries in martial arts and found that the head and face injuries in karate were the highest (51.3-90.9%). Likewise, the head and neck was the most frequently injured body region in taekwondo tournament (Oler et al., 1991). Silat is a traditional martial art contact sport in Malaysia that involves several activities such as punching, kicking, toppling down, sweeping, jumping, throwing and gripping in a hand to hand fighting situation. Twentyfive (13.9%) of the respondents in this study were silat athletes and 17 (68.0%) of them had experience some forms of injuries. Wushu is also a contact sport from Chinese traditional martial arts. In the present study, 16 (8.9%) players practice this sport but none had suffered any injury. Among ball sports athletes of the present study, 17.2% of them have experienced injuries. Squash is a ball sport with medium risk of causing dental trauma because of high velocity, close body contact and the use of rackets. Persic et al. (2006) found that 37.7% out of 600 squash players experienced an orofacial injury. In the present study, squash contributed to high percentage of injury sustained (28.6%). Another higher occurrence of injuries sustained among ball sports athletes were found in athletes of sepak takraw (52.9%). As sepak takraw is played in a court where players have to kick or head a ball made of hard rattan over the net, much similar to volleyball; the players have high risk to be kicked in the face during the game and sustained oral injuries. Research on injuries due to other ball sports such as tennis, table tennis and badminton are scarce. The incidence of dental injuries among Israeli tennis players was less than 5% (Levin et al., 2003). In New Zealand, tennis was not ranked in the top 10 sports claimed for insurance in the years of 1996-1998 (Love et al., 1998). In the present study, there were no injuries sustained in tennis and table tennis players and only one badminton player had oral injury. Gymnastics has also been rated a high-injury risk sport (Bayliss and Bedi, 1996). In the present study, 50.0% of gymnastic athletes had experience of oral injuries. Weise (1991) reported that among British gymnasts, 27% of them had cuts of mouth and tongue (27%) and 7% had sustained injuries of teeth. In addition, the author also documented that none of those gymnasts were wearing mouthguard during training. In the present study, athletes in track and field sports were involved in running, long jumping, high jumping and javelin throwing. Weise (1991) stated that acute injuries in track and field sports are rare compared to team or combatant sports (accident rate 0.4%- 1%) and acute lesions are most frequent in the muscular system, followed by ruptures of the larger tendons as well as of the ligaments and capsule of the large joints. Likewise, the track and field athletes from present study do not report any oral injuries. Levin et al., (2003) found in their study that cyclists experienced highest number of dental injuries (n=13) after 25

basketball players (n=31) and soccer players (n=30). A study of 889 injured permanent teeth by Hecova et al., (2010) also revealed that cycling was the most common cause of injuries in patients older than 11 years among various sport. However, none of the cycling athletes of the present study had sustained any injuries. Regarding the usage and awareness of mouthguard, none of the athletes in the present study were utilizing it. However, 33.9% of those athletes knew that a mouthguard can prevent orofacial injuries. Athletes not wearing mouthguards are also common in many other countries. A survey of tooth injury experience and attitude towards prevention in a group of Singapore schoolboys found 56% of boys knew about mouthguards but never use them (Teo et al., 1995). A study on mouthguard utilization rate during sport activities in Ankara, Turkey also showed none of 11-18 years old children and adolescents used mouthguards while participating in sports (Cetinbaş and Sönmez, 2006). Of 943 young adult Israeli sportsmen, only 27% of soccer and basketball players were aware of the mouthguards as protective devices however, only 3% actually used mouthguards (Levin et al., 2003). Similarly the majority of athletes in Brazil also demonstrated little utilization of mouthguard, in spite of good general knowledge of its benefits (Ferrari and Ferreria de Mederios, 2002). These findings support that knowledge alone on mouthguard use does not ensure its utilization. Collaborations between sports authorities and dental professionals are recommended to increase the awareness and promote the use of mouthguards among athletes and coaches. Regulatory bodies should also maintain regulations requiring all athletes to wear mouthguards. Furthermore, athletes should be informed that the physical impacts of having injuries far exceed the costs of purchasing and the inconvenience of wearing a mouthguard. The present study revealed that cost is not a factor in not wearing a mouthguard, but lack of consideration on the importance of mouthguard in preventing oral injury is the main reason for not wearing a mouthguard. The fear of discomfort was the reason given by 21.7% of athletes in the present study. Resistant for wearing of mouthguard might be due to uncomforted that interference with breathing and speech, and the effect on the players' image (Banky and McCrory, 1999). Another reason why athletes (32.2%) do not wear mouthguards was that their coaches did not urge them to wear. It is important to inform athletes and coaches the need of mouthguards for both contact sports and non-contact sports. In addition, athletes should be informed that properly fitted customfabricated mouthguards provide the greatest degree of fit, comfort and protection. Conclusions Sport-related oral injuries were the most frequent occurrence in martial art silat. Among ball sports, sepak takraw was the highest injury sustained sport and gymnastic was the third most frequently sustained injury. None of the athletes in this study wore mouthguard. Since most participants are secondary school students, mouthguard wearing could be integrated into school oral health programme as a trauma prevention activity. Athletes and coaches should be educated regarding the prevention of sports-related injuries and using of mouthguard should be encouraged. References ADA Council on Access, Prevention and Interprofessional Relations; ADA Council on Scientific Affairs (2006). Using mouthguards to reduce the incidence and severity of sports-related oral injuries. J Am Dent Assoc, 137(12): 1712-1720. Andrade RA, Evans PL, Almeida AL, da Silva Jde J, Guedes Am, Guedes Fr, Ranalli DN, Modesto A, Tinoco EM (2010). Prevalence of dental trauma in Pan American games athletes. Dent Traumatol, 26(3): 248-253. 26

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