Frequency of dentoalveolar trauma in high-performance athletes: a systematic review in multi-sport events in Latin America

Study design and database

We designed a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) 2020 recommendations and pre-registered it in PROSPERO (CRD 451763, on August 21, 2023). The research question was formulated using the PIO acronym.¹³ The population was high-performance athletes, the intervention was dentoalveolar trauma, and the outcomes were the prevalence of dentoalveolar trauma. The review was conducted in the following databases: Pubmed (MEDLINE), Scielo, Scopus, Wiley, ScienceDirect, EBSCO, Cochrane Library, Web of Science, and Lilacs. Additionally, we used Sportxiv, Dimensions, and Google Scholar. The identification of studies and their flow can be observed in Figure 1.

Figure 1. PRISMA 2020 Flowchart for the selection of studies.

Search strategy and inclusion criteria

For the search, we used the following Boolean descriptors and keywords (MESH terms): ((dental trauma OR oral trauma OR tooth injury OR tooth fractures OR orofacial injuries) AND (athletes OR elite athletes OR professional athletes OR high-performance) AND (Latin America OR Pan American AND (multi-sport event)). The manual search was conducted between December 15–22, 2022, and in two languages (English and Spanish).

The inclusion criteria were the following: (i) original articles, correspondence articles, and scientific letters, (ii) prevalence studies, (iii) dentoalveolar trauma studies in athletes during multi-sport events in Latin America between 1980 and 2022. We did not apply a time filter to limit the years of publication to a specific period. Moreover, in regard to exclusion criteria, we did not include the following: (i) studies from other continents, (ii) incidence or exploratory studies, (iii) dentoalveolar traumas in non-multi-sport events, and (iv) systematic reviews, meta-analyses, reflection articles, editorials, clinical cases, history articles, and method papers.

Data extraction and quality assessment

Two authors (F.A. and J.P.M.) independently evaluated the abstracts of each article and excluded those that did not meet the inclusion criteria. Subsequently, the full text of each selected article was reviewed according to the predetermined protocol, and any disagreements between the authors were resolved through consensus at each stage of the review. Cohen’s Kappa correlation test was used to assess the overall agreement between the reviewers, revealing a good level of agreement in the search process (k = 0.811).

Data Extraction Process involved retrieving relevant information from the included studies using the CASPe (Critical Appraisal Skills Program) template of a database in MS-Excel 2013 (Microsoft Corp., Redmond, WA, USA).¹⁴ The possible bias of identified documents was evaluated using the Cochrane risk of bias tool (Robvis 2.0). The studies that were considered to have a high risk of bias were those that did not include at least one outcome in their analysis.

Data analysis

We used the IBM SPSS version 23.0 (Armonk, NY, USA) for the data analysis. A descriptive analysis of the included studies was performed to estimate their respective frequencies. Due to heterogeneity among the identified documents, it was not possible to conduct a meta-analysis, and instead, a narrative analysis of the research, focused on the primary findings of each included study, was presented.

Search results

Initially, an extensive literature search was conducted using several databases, including PubMed (n = 4), Scopus (n = 43), Wiley (n = 67), EBSCO (n = 11), Web of Science (n = 5), LILACS (n = 7), ScienceDirect (n = 20), Dimensions (n = 498), and Google Scholar (n = 160), resulting in a total of 798 articles. After eliminating 58 duplicates and articles in languages other than English or Spanish, the remaining articles were reviewed based on their titles and abstracts, excluding those irrelevant to the research question. Subsequently, the full texts of the remaining articles were carefully reviewed, leading to the exclusion of 53 studies and leaving only one article for analysis.

Characteristics of the included study

The selected article for this study was written by Enrique Amy,¹⁵ a member of the Department of Physical Medicine, Rehabilitation, and Sports Medicine at the University of Puerto Rico School of Medicine. Published in the Dental Traumatology Journal in 2005, the main objective of the study was to investigate the incidence of dental and orofacial trauma in athletes participating in the Central American and Caribbean Games in six different editions: Cuba (1982), Dominican Republic (1986), Mexico (1990), Puerto Rico (1993), Venezuela (1998), and El Salvador (2002).

Among the 2107 athletes across six delegations in various editions of these games, our study specifically examined 279 athletes seeking dental treatment and evaluation at the Medical Center of the Puerto Rico delegation. The selection of athletes was randomized. Registration details for each athlete encompassed personal information like name, age, gender, sports type, medical and dental history, along with the reason for their dental consultation. Finally, Amy’s study¹⁵ presented an unclear bias, as described in Figure 2.

Figure 2. Bias assessment of the study included in this review.

Main findings

The main reasons for seeking dental care were the fabrication of mouthguards, resolution of acute dental and orofacial conditions, the need for restoration, and dental evaluations. Out of the total 279 athletes who received dental care, 133 (47.7%) were assessed for mouthguard fabrication, 18 (6.4%) for acute condition resolution, 52 (18.6%) for restorations, and 76 (27.2%) for dental evaluations. A detailed breakdown of the consultation reasons for each edition of the multi-sport event is provided in Table 1.

Among the 18 instances of acute dental conditions treated, the majority (6% of all dental consultations during the games) were associated with sports activities. Dental fractures were the predominant form of dentoalveolar trauma, with specific details of injuries and the corresponding sports outlined below:

Strengths

First, the study begins by highlighting a comprehensive literature search, using multiple accredited databases, grey literature, and thesis collections, showcasing a thorough strategy for data acquisition. Another strength of the study, to the best of our knowledge, is that it is the first review in Latin America that addresses dental issues in athletes. The results effectively communicate the reasons for seeking dental care, the breakdown of athletes’ visits for various purposes, and a detailed description of acute dental conditions and trauma treated during sporting events.

Main findings

The prevalence of dentoalveolar traumas varies mainly in relation to the type of sport practiced, finding very dissimilar prevalence among them, resulting in a great heterogeneity in the types of results found in relation to the variable under study. The World Dental Federation (FDI) classified sports into two categories based on the risk of dentoalveolar trauma: High risk (such as American Football, field hockey, ice hockey, lacrosse, martial arts, rugby, skates, skateboards, and mountain biking) and moderate risk (such as basketball, soccer, handball, diving, squash, gymnastics, parachuting, and water polo).¹⁶ For example, in non-contact sports like volleyball, a lower prevalence of dental trauma has been reported compared to contact sports such as taekwondo and ice hockey.^17,18 Similar studies have found that men are two to three times more likely to suffer some type of dental and orofacial trauma than female athletes.¹⁹ On the other hand, amateur athletes tend to suffer maxillofacial injuries more frequently than professional athletes. One study demonstrated that only 10% of patients who experienced this type of injury were professional athletes.²⁰

In Amy’s study,¹⁵ sports events in Cuba (1982), Dominican Republic (1986), Mexico (1990), Puerto Rico (1993), Venezuela (1998), and El Salvador (2002) were included. However, there are other sports events for which no reports on this topic have been made. As we approach the hosting of the upcoming Pan American Games in Chile 2023, there are aspects that have not been addressed in previous editions, as reviewed in the limited existing literature. The low incidence of dentoalveolar traumas found in this study may be due to the fact that the majority of “sporting hours” are spent during the practice and training of professional athletes. Unlike this study, as we analyze this variable during a short period of a multi-sport event. For example, according to a study conducted at the Lima 2019 Pan American Games,²¹ the prevalence rate of dentoalveolar traumas was so low that it was considered one of the problems that arose during the sporting event, along with acute pain, malar bone fracture, and adjustment of orthodontic appliances, representing only 9.2% of the issues consulted during the sporting event, demonstrating that the majority of oral problems faced by athletes already existed before the start of the event.

The prevalence of dental trauma has been shown to be related to predictive factors such as the intensity and speed of the sport, the level of contact among participants, and the use and type of sports protective equipment, including mouthguards.²² Several prevalence studies on dental trauma worldwide, such as the one conducted by Andrade⁶ at the Pan American Games in Rio de Janeiro 2017, have demonstrated variation in results due to different methodologies used. Most of these studies rely on retrospective self-reporting approaches, which do not reflect the incidence at the time of the multi-sport event, making it difficult to quantitatively and qualitatively determine the variable being analyzed in this systematic review. Moreover, self-reports do not accurately qualify these sports-related injuries, introducing bias because of the absence of a competent clinician to diagnose them. Therefore, the importance of generating epidemiological research protocols regarding the variable in question during multi-sport events in Latin America becomes crucial for creating public policies aimed at prevention and treatment of these injuries related to professional athletes. Among these public policies, the creation of an assessment and action protocol aimed at the multidisciplinary management of dentoalveolar trauma is essential.

It is important to consider these differences in the prevalence and risk of dentoalveolar traumas according to the sport and level of competition. These findings can be useful in informing orodental prevention and protection strategies in athletes in order to reduce the incidence of injuries and promote oral health in this population group. Moreover, further research is required to better understand risk factors and develop sport-specific interventions.

Limitations

In this systematic review, we have identified some limitations related to epidemiological research and management protocols regarding dentoalveolar traumas in Latin American multi-sport events. Firstly, we found limitations in the collection of specific epidemiological data and management protocols for these traumas. For instance, while dental fractures were reported as the most common type of dentoalveolar trauma, it was not specified whether these were enamel, enamel-dentin, or enamel-dentin-pulp fractures. This lack of detail hinders a precise understanding of the magnitude and severity of the traumas. Secondly, although we used meta-search engines and preprints to expand the number of evaluated studies,²³ we might have not included all relevant gray literature. This could mean that part of the available evidence was not taken into account in this review, which could have improved the results. Thirdly, we observed that sports events have not implemented a surveillance system that allows standardized registration and reporting of sports injuries, including dentoalveolar traumas. A Surveillance System for Injuries and Diseases (SVLE) has proven successful in recent Pan American sports events²⁴ and could be a valuable tool for registering and tracking dentoalveolar traumas in future events.

These limitations highlight the need for improved data collection and management protocols related to dentoalveolar traumas in multi-sport events. Furthermore, greater awareness is needed regarding the importance of implementing adequate surveillance systems to obtain accurate and comparable data between events. These improvements would allow a better understanding of the incidence, severity, and risk factors associated with dentoalveolar traumas, which in turn would facilitate the implementation of more effective preventive and management strategies for the benefit of athletes.