For citation purposes, the electronic version is the definitive version of this article:

Transcription

1 Professionl I s s u e s Use of Mouthgurds Among 12- to 14-Yer-Old Ontrio Schoolchildren Kusr Sdi Fkhruddin, BDS, MSc; Hereni P. Lwrence, DDS, MSc, PhD; Dvid J. Kenny, DDS, PhD, FRCD(C); Dvid Locker, BDS, PhD Contct Author Dr. Lwrence Emil: hereni.lwrence@utoronto.c ABSTRACT Objectives: To investigte the frequency of use of mouthgurds mong representtive smple of Ontrio schoolchildren, the type of mouthgurd most commonly used nd resons for noncomplince during sporting ctivities. Mterils nd Methods: A popultion-bsed, mtched csecontrol study ws undertken in totl of 30 schools in 2 suburbn Ontrio communities. Dentl hygienists trined in the use of the Dentl Trum Index screened 2,422 children 12 to 14 yers of ge. Of 810 children identified s potentil cses (with evidence of dentl trum) nd controls (no dentl trum), 270 responded to mil survey (135 cses nd 135 ge- nd sex-mtched controls). The children with dentl injuries provided informtion such s the ge t which the injury occurred nd the setting nd cuses of the injury. Children from both cse nd control groups nswered questions concerning use of mouthgurds during sports. Prents provided demogrphic nd other informtion. Results: Only 5.5% of children wore mouthgurds for school sports, nd 20.2% wore protection in legue sports. Of those who wore mouth protection, 48.2% wore boilnd-bite mouthgurds nd 21.4% wore stock-type mouthgurds; only 30.4% wore professionlly mde, custom mouthgurds. This high proportion of ill-fitting mouthgurds ws the mjor contributor to the commonly perceived problems of speech, brething discomfort nd poor ppernce ssocited with mouthgurd use. Boys were 1.52 times more likely to wer mouthgurds thn girls. Dt on history of dentl trum nd regulrly visiting dentist were not relted to mouthgurd use. The single most importnt predictor of mouthgurd use ws prents who hd privte dentl insurnce (p = 0.02), followed by hving fmily dentist (p = 0.16). Conclusion: Mouthgurd use ws very low in both school nd legue sports in this smple of Ontrio schoolchildren, nd the lrgest proportion of those who wore mouth protection used generic products rther thn custom-fitted mouthgurds. Lck of prentl or coching dvice on mouthgurd usge nd peer beliefs bout esthetics nd function were the min resons for noncomplince. For cittion purposes, the electronic version is the definitive version of this rticle: Vigorous physicl ctivities offer vriety of benefits for children, 1 but they lso plce prticipnts t incresed risk for dentl injury. 2 Sports-relted incidents ccount for 10% to 38% of ll childhood dentl injuries. 3,4 Locker recently reported prevlence of 18.5% for dentl injuries to the permnent incisors mong 14-yer-old schoolchildren in 6 Ontrio communities. 5 Mny dentl injuries could be voided or minimized JCDA July/August 2007, Vol. 73, No

2 Lwrence Tble 1 Severity nd tretment of dentl injuries mong 135 children with such injuries Code Definition Severity No. (%) of subjects 1 Untreted enmel frcture tht does not involve dentin Minor 86 (63.7) 2 Untreted enmel nd dentin frcture Moderte 8 (5.9) 3 Pulp involvement, sinus trct involvement, swelling, discolortion Severe 0 (0) 4 Tooth missing becuse of trum Severe 6 (4.4) 5 Frcture restored (crown, pontic, composite) Severe 43 (31.9) Some children hd more thn one injured incisor nd hence more thn one code ssigned. if sports prticipnts used proper protective equipment, such s custom-fitted mouthgurd, 2 yet mouthgurds re still not widely ccepted mong predolescents nd dolescents who engge in contct sports. 6 Two surveys 7,8 reported tht the use of mouthgurds by schoolchildren rnged from 4% to 6% despite n nnul orofcil injury rte of 31%. This study ws undertken to investigte the frequency of use of mouthgurds, the type of mouthgurd most commonly used nd resons for noncomplince during sporting ctivities in representtive smple of suburbn Ontrio schoolchildren. Mterils nd Methods The Reserch Ethics Bord of the University of Toronto pproved the project. This popultion-bsed csecontrol study ws undertken in community schools served by 2 Ontrio public helth deprtments: York Region nd Brnt County. A totl of 2,422 grde 6 nd grde 8 children were screened by trined dentl hygienists, who identified those with nd those without clinicl evidence of dentl injury. Any child with Dentl Trum Index 9 code 1 (enmel frcture) through 5 (restored frcture) for t lest 1 incisor ws designted s potentil cse (Tble 1). During the clinicl exmintion, dt were lso collected on the orl helth sttus of children, s mesured by the decyed, missing nd filled teeth (DMFT) index for permnent teeth. After the clinicl exmintion, helth unit stff sent 2 questionnires (one for the children nd the other for their prents), long with letter explining the ims nd objectives of the study, n informtion sheet nd consent form, to the home ddresses of the smple popultion of children with nd without dentl trum (n = 810). The children s questionnire contined section to be completed by injured children only, with questions bout the injury: the ge t which the injury occurred, the setting (home, school, community) nd the cuse of or event responsible for the injury (sports, fll, collision, violence/ssult, trffic incident). Another section completed by ll prticipnts (cses nd controls) contined questions on the use of mouthgurds during sporting ctivities. The prentl questionnire covered sociodemogrphic chrcteristics (fmily income, fmily size, mother s eductionl level, government support, country of birth nd fmily dentl insurnce) nd orl helth sttus indictors (self-reported child s dentl helth, fmily dentist nd yer of child s most recent dentl visit). The mother s level of eduction ws ctegorized into 1 of 4 groups: less thn high school, completion of high school, some college or university, or completion of college or university. Fmilies receiving benefits through government support progrms were identified. Dt on totl nnul fmily income before tx were dichotomized (up to $30,000 or more thn $30,000) ccording to the method nd clssifiction used in Sttistics Cnd s low-income rte, which mesures the percentge of fmilies below the lowincome cutoff. 10 Two reminder notices were sent to those who did not respond, nd second questionnire ws miled 1 month fter the first miling. A totl of 270 of the 810 eligible 12- to 14-yer-old children greed to prticipte in the study (33. 3%). The smple consisted of 152 boys (56.3%) nd 118 girls (43.7%). The χ 2 sttistic nd logistic regression were used to test the significnce of ssocition between vribles, with p 0.05 s sttisticlly significnt (2-tiled tests). Results Of the 270 respondents to the survey (out of the 810 who were rndomly selected), clinicl evidence of dentl trum to the incisors ws observed in 135 children. These 135 cses were mtched with 135 injury-free children of the sme sex nd closest in ge, who lso returned the questionnire nd served s controls. The men DMFT for the 270 cses nd controls ws 0.8 (stndrd devition [SD] 1.5, rnge 0 to 9) nd the men ge t which the dentl injury occurred in the 135 cses ws 9.5 yers (SD = 1.5; rnge 6 to 13 yers). There were no differences between prticipnts (n = 270) nd non- 505 JCDA July/August 2007, Vol. 73, No. 6

3 Use of Mouthgurds Tble 2 Mouthgurd use in reltion to sex, history of dentl injury nd cries experience (n = 270) Sex Yes (n nd %) Use of mouthgurds No (n nd %) Totl Odds rtio (95% CI) p vlue Boys 36 (23.7) 116 (76.3) ( ) 0.18 Girls 20 (16.9) 98 (83.1) 118 Dentl injury Injured 31 (23.0) 104 (77.0) ( ) 0.37 Not injured 25 (18.5) 110 (81.5) 135 Dentl cries DMFT > 0 21 (24.1) 66 (75.9) ( ) 0.34 DMFT = 0 35 (19.1) 148 (80.9) 183 CI = confidence intervl; DMFT = decyed, missing nd filled permnent teeth Obtined with the χ 2 test prticipnts (n = 540) in terms of men numbers of missing teeth, filled teeth or overll DMFT. There ws sttisticlly significnt difference for the decyed component of the DMFT index, but it ws not cliniclly meningful (0.2 ± 0.5 for nonprticipnts nd 0.1 ± 0.4 for prticipnts). Most of the cse children (86/135 or 63.7%) hd minor injury (code 1, for untreted enmel frcture). The prevlence of moderte injury (untreted enmel nd dentin frcture) ws 5.9% (8/135), nd tht of severe injury ws 36.3% (combined code 4, for tooth loss cused by trum, nd code 5, for restored injury) (Tble 1). Most of the injuries took plce either t school or t home. For boys, school ws the most frequent loction of injury, followed by home; the pttern ws reversed for girls. A high percentge of the 255 children who reported plying sports t school (whether or not they hd n injury) hd never worn mouthgurd (241/255 or 94.5%), wheres only 14 (5.5%) reported using mouthgurds sometimes or lwys during thletic ctivities in school. Among users of mouthgurds, there were no significnt differences in complince between boys nd girls. Similrly, of the 252 schoolchildren who plyed sports in clubs or legues, 201 (79.8%) reported tht they hd never worn mouthgurd, nd 51 (20.2%) reported tht they wore mouthgurds sometimes or lwys. The frequency of mouthgurd use ws 3.7 times higher for sports plyed t clubs or in legues thn for sports plyed t school. Among both cses nd controls who plyed sports in clubs or legues, more of the boys wore mouthgurds: injured group, 16/72 (22.2%) of the boys vs. 8/52 (15.4%) Percentge in injured nd noninjured group No one hs told me to w er one I don't think I need to w er one Too expensive Girls (injured group) Girls (noninjured group) I don't know w here to get one I don't look good wering one Resons mouthgurds were not worn Boys (injured group) Boys (noninjured group) Too uncomfortble Brething or tlking interference Figure 1: Resons cited for not wering mouthgurds, ccording to sex nd injury. of the girls; noninjured group, 18/73 (24.7%) of the boys vs. 9/55 (16.4%) of the girls. Among the 56 children who wore mouthgurds (both cses nd controls), 48.2% wore the boil-nd-bite type nd 21.4% used the stock type usully purchsed t sporting goods stores. Only 30.4% wore professionlly mde custom mouthgurds. Over 50% (148 of 270) reported tht they hd never been told to wer mouthgurd by prents nd/or coches, nd 40.7% (110) believed tht they did not need to wer one during sporting ctivities (Fig. 1). Other resons for not wering mouthgurd were discomfort, difficulty in brething nd tlking, nd ppernce. The odds of wering mouthgurd were 52% greter for boys thn for girls. Among children who hd hd dentl injury in the pst nd mong those with one or JCDA July/August 2007, Vol. 73, No b

4 Lwrence Tble 3 Assocition between mouthgurd use nd tretment for prior dentl injury (n = 135) Subject group Yes (n nd %) Use of mouthgurds No (n nd %) Totl Odds rtio (95% CI) p vlue With untreted injury 20 (21.7) 72 (78.3) ( ) 0.62 With restored injury 11 (25.6) 32 (74.4) 43 CI = confidence intervl Obtined with the χ 2 test Tble 4 Mouthgurd use in reltion to dentl history nd socioeconomic indictors Dentl insurnce Yes (n nd %) Use of mouthgurds No (n nd %) Totl Odds rtio (95%CI) p vlue Yes 41 (25.6) 119 (74.4) ( ) 0.02 No 15 (13.6) 95 (86.4) 110 Fmily dentist Yes 51 (22.2) 179 (77.8) ( ) 0.16 No 5 (12.5) 35 (87.5) 40 Mother s eduction Less thn high school or high school 23 (21.1) 86 (78.9) ( ) 0.87 At lest some college or university 33 (20.6) 127 (79.4) 160 Fmily income Low ( $30,000) 10 (15.6) 54 (84.4) ( ) 0.28 Middle or high (> $30,000) 46 (22.8) 156 (77.2) 202 Government socil support Yes 1 (8.3) 11 (91.7) ( ) 0.28 No 55 (21.3) 203 (78.7) 258 CI = confidence intervl Obtined with the χ 2 test more teeth ffected by dentl cries the odds were 31% nd 35% greter, respectively, but these findings were not significnt t the 5% level (Tble 2). No sttisticlly significnt ssocition ws found between children with treted or untreted dentl injuries nd the use of mouthgurds (Tble 3). Of the 4 socioeconomic indictors, only the presence of dentl insurnce ws ssocited with use of mouthgurds: the children of prents with dentl insurnce were 2.18 times more likely to report using mouthgurds thn those without such insurnce (Tble 4). Children with fmily dentist were 1.99 times more likely to wer mouthgurds, but this result did not rech sttisticl significnce (p = 0.16). The single most importnt predictor of wering mouthgurd in this dolescent popultion ws prents privte dentl insurnce (Tble 5). The ssocition between dentl insurnce nd mouthgurd use remined sttisticlly significnt fter djustment for sex nd prior history of dentl injury, s well s the other vribles studied. Discussion Although the highest percentge of dentl injuries occurred t school, nd flls were the mjor cuse of injuries (closely followed by sports-relted injuries), 11 only 5.5% of children wore mouthgurds while plying school sports. This my reflect lck of knowledge bout the benefits of mouthgurd use, school policies nd ttitudes towrd mouthgurd use mong stff teching physicl eduction, or the level of vigilnce of mouthgurd use by coching stff during school-sponsored prctices nd gmes. Although 20.2% of children reported wering 505c JCDA July/August 2007, Vol. 73, No. 6

5 Use of Mouthgurds Tble 5 Logistic regression model for mouthgurd use (n = 270) Adjusted odds rtio (95% CI) Indictors Dentl insurnce (no = 0; yes = 1) Sex (girl = 0; boy = 1) Fmily dentist (no = 0; yes = 1) Dentl injury (no = 0; yes = 1) DMFT (0 = 0; 1 = 1) Mother s eductionl level (less thn high school or high school completion = 0; t lest some college or university = 1) Fmily income (low income = 0; middle or high income = 1) Full model 1.99 ( ) 1.52 ( ) 1.39 ( ) 1.28 ( ) 1.22 ( ) Reduced finl model 2.18 b ( ) 1.00 ( ) 0.99 ( ) CI = confidence intervl, DMFT = decyed, missing nd filled permnent teeth p = b p = mouthgurds (either sometimes or lwys) while plying sports t loctions other thn school, lmost 80% never wore mouthgurds while plying club or legue sports. Even though mouthgurd use is mndted in some legue sports (e.g., hockey), it is rrely required for school sports. Moreover, previous injuries ppered to hve little effect on either boys or girls ccepting mouthgurds for prevention. Some sports, such s sktebording nd in-line skting, do not hve culture of mouthgurd use, nd for others, such s bsketbll nd street hockey, mouth protection is rrely used for recretionl ply. In this study, the min resons for noncomplince with mouthgurd use reported by children were relted to lck of instruction or dvice on usge by prents nd coches nd physicl fctors such s interference with brething nd speech, discomfort nd esthetics. Noncomplince mong those reporting physicl fctors s n influence might be explined by the fct tht lmost 70% of those who did wer mouthgurds used over-thecounter stock or boil-nd-bite brnds, which do not fit s well s custom-mde mouthgurds. In ddition to the need to educte prents tht mouth protection is necessry nd tht they need to be vigilnt bout complince, there is lso need to educte prents bout the best types of mouthgurds. Although ll mouthgurds re invsive, custom-fitted mouthgurd will be more comfortble nd effective nd will lst longer thn boil-ndbite or stock types. Although the children of prents who hd privte dentl insurnce exhibited the highest frequency of mouthgurd use, over 74.4% of these children still did not wer mouthgurds. Children whose prents were receiving socil support exhibited lower frequency of mouthgurd use, even though the support progrm would hve covered the fee for mouthgurds. 12 This suggests tht prents were unwre of this coverge or tht their lck of regulr dentl cre did not llow for eduction bout mouth protection. Grdiner nd Rnlli noted tht most prents hve little or no informtion bout mouthgurds or the risk of injury ssocited with certin physicl ctivities. 13 Furthermore, since prents often decide whether mouthgurds re worn, 14 they need more informtion to dvise their children on when nd how to select nd use mouth protection. Although most dentl injuries re produced by nonsporting ctivities, 15 sports represent niche of incresed risk for dentl injury. This study showed lck of wreness bout the benefits of wering properly fitted mouthgurds while plying sports either t school or in legues nd hence lck of perception of the need for such protection. The substntil use of ill-fitting mouthgurds identified in this study contributed to complints of interference with speech nd brething, discomfort nd poor ppernce. These problems cn be expected to reinforce peer perceptions, which in turn reduce complince with mouthgurd use mong schoolchildren. Complince checks must come from techers, coches nd prents who re ctully present t events. The vlue nd importnce of properly fitted mouthgurds must JCDA July/August 2007, Vol. 73, No d

6 Lwrence be understood by school thletic ssocitions, s well s sports ssocitions. Insurnce compnies should educte their clients bout the risk of dentl injuries nd the high cost ssocited with their tretment reltive to the cost of mouth protection. THE AUTHORS Acknowledgement: This study ws supported by grnt from the Ontrio Ministry of Helth nd ws conducted with the ssistnce of the dentl stff of the 2 public helth units who prticipted in the study. In prticulr, we would like to cknowledge the contribution of Dr. Dvid Wiebe, Dr. Joyce Sinton nd Ms. Hether Murry. Dr. Fkhruddin is recent grdute of the mster s degree progrm t the fculty of dentistry, University of Toronto, Toronto, Ontrio. Dr. Lwrence is ssocite professor, deprtment of biologicl nd dignostic sciences/community dentistry, fculty of dentistry, University of Toronto, Toronto, Ontrio. Dr. Kenny is stff peditric dentist nd senior ssocite scientist, Reserch Institute, The Hospitl for Sick Children, nd professor, University of Toronto, Toronto, Ontrio. Dr. Locker is director of Community Dentl Helth Services Reserch Unit, fculty of dentistry, University of Toronto, Toronto, Ontrio. Correspondence to: Dr. Hereni P. Lwrence, Deprtment of Biologicl nd Dignostic Sciences/Community Dentistry, Fculty of Dentistry, University of Toronto, 124 Edwrd St., Room 515D, Toronto, ON M5G 1G6. References 1. Cglr E, Krgul B, Tnbog I. Dentl trum nd mouthgurd usge mong ice hockey plyers in Turkey premier legue. Dent Trumtol 2005; 21(1): Rnlli DN. Sports dentistry nd dentl trumtology. Dent Trumtol 2002; 18(5): Jrvinen S. On the cuses of trumtic dentl injuries with specil reference to sports ccidents in smple of Finnish children. A study of ptient clinicl mteril. Act Odontol Scnd 1980; 38(3): Uji T, Termoto T. Occurrence of trumtic injuries in the oromxillry region of children in Jpnese prefecture. Endod Dent Trumtol 1988; 4(2): Locker D. Prevlence of trumtic dentl injury in Grde 8 children in six Ontrio communities. Cn J Public Helth 2005; 96(1): Perunski S, Lng B, Pohl Y, Filippi A. Level of informtion concerning dentl injuries nd their prevention in Swiss bsketbll survey mong plyers nd coches. Dent Trumtol 2005; 21(4): Rodd HD, Cheshm DJ. Sports-relted orl injury nd mouthgurd use mong Sheffield school children. Community Dent Helth 1997; 14(1): Mestrello-deMoy MG, Primosch RE. Orofcil trum nd mouth-protector wer mong high school vrsity bsketbll plyers. ASDC J Dent Child 1989; 56(1): O Brien M. Children s dentl helth in the United Kingdom Office of Popultion Censuses nd Surveys. London: HMSO, A working definition of Sttistics Cnd Low Income Cut-offs (LICOs). In: Ross DP, Shillington ER, Lochhed C, eds. The Cndin fct book on poverty. Ottw: Cndin Council on Socil Development; p. 11. Fkhruddin KS, Lwrence HP, Kenny DJ, Locker D. Etiology nd environment of dentl injuries in yer-old Cndin schoolchildren. Dent Trumtol (ccepted for publiction July 2006). 12. Ontrio Disbility Support Progrm. MCFCS Schedule of Dentl Services nd Fees Mrch Avilble from URL: downlods/mcfcs_dentl_1993.pdf. 13. Grdiner DM, Rnlli DN. Attitudinl fctors influencing mouthgurd utiliztion. Dent Clin North Am 2000; 44(1): Newsome PR, Trn DC, Cooke MS. The role of the mouthgurd in the prevention of sports-relted dentl injuries: review. Int J Peditr Dent 2001; 11(6): Skre AB, Jcobsen I. Etiologicl fctors relted to dentl injuries in Norwegins ged 7-18 yers. Dent Trumtol 2003; 19(6):3048. The uthors hve no declred finncil interests. This rticle hs been peer reviewed. 505e JCDA July/August 2007, Vol. 73, No. 6