Overview
Concussion of the tooth, often resulting from sports-related injuries, represents a significant yet often overlooked aspect of traumatic brain injuries (TBI) and orofacial trauma. Annually, approximately 1.4 million individuals present to emergency departments in England and Wales with TBI, with nearly 90% classified as mild traumatic brain injuries (mTBI) [PMID:36130754]. While the majority of concussions affect school-aged children and youth, particularly in contact sports like rugby and ice hockey, the incidence of dental injuries, including loosened or broken teeth and rare instances of avulsed teeth, highlights the multifaceted impact of these injuries [PMID:19566982, PMID:16422751]. Studies underscore the importance of sport-specific risk factors, with ice hockey players experiencing significantly higher orofacial injuries when not wearing mouthguards compared to soccer players [PMID:16422751]. Understanding the epidemiology, clinical presentation, diagnosis, management, and prognosis of concussion-related dental injuries is crucial for effective clinical intervention and prevention strategies.
Epidemiology
The epidemiology of concussion, particularly in the context of dental injuries, reveals distinct patterns across different populations and settings. In England and Wales, approximately 1.4 million emergency department visits annually are attributed to TBI, with a substantial proportion being mTBI [PMID:36130754]. Among these, sports-related injuries are prevalent, especially in youth and adolescent populations. Retrospective and prospective studies across various levels of rugby—school (n = 344 matches), university (n = 6 matches), and professional (n = 64 matches)—show a significant increase in concussion prevalence and more severe symptoms in away matches, correlating with longer recovery times [PMID:36843269]. This trend suggests environmental and logistical factors may exacerbate injury severity and recovery duration.
Moreover, the study by Lieger and von Arx highlights sport-specific risks, noting that ice hockey players without mouthguards are at a much higher risk (59%) of orofacial injuries compared to soccer players (24%) [PMID:16422751]. This disparity underscores the protective role of mouthguards in mitigating dental injuries. Despite the recognized benefits, compliance remains a challenge; only about 16% of athletes who acknowledge the benefits of mouthguards actually use them [PMID:16422751]. Additionally, a pilot study involving schoolboy cricketers from England and Australia found that while 24.1% and 25.5% of players, respectively, reported head, face, and dental injuries, the incidence of dental injuries was notably lower compared to other injuries [PMID:19566982]. These findings emphasize the need for targeted preventive measures, particularly in high-risk sports, to reduce the overall burden of dental trauma associated with concussions.
Clinical Presentation
The clinical presentation of concussion, including dental injuries, encompasses a broad spectrum of symptoms categorized into physical, cognitive, behavioral, and sleep disturbances. Physical symptoms may include headache, dizziness, and balance issues, while cognitive symptoms often involve memory problems, confusion, and difficulty concentrating [PMID:36130754]. Behavioral changes such as irritability, anxiety, and depression are also common, reflecting the multifaceted impact on mental health. Sleep disturbances, such as insomnia or excessive sleepiness, further complicate recovery [PMID:36130754].
In the context of dental injuries, clinical presentations often involve loosened or broken teeth, with avulsed teeth being less frequent but severe cases [PMID:19566982]. A study involving 411 schoolboy cricketers reported that while 16 players experienced dental injuries, including loosened or broken teeth, only two cases involved avulsed teeth [PMID:19566982]. This pattern indicates that while dental injuries are significant, they are generally less prevalent than other types of injuries but still warrant careful clinical attention. Parents play a crucial role in recognizing these symptoms, with 83% reporting the ability to identify concussion signs and symptoms in their teenagers, aligning with frameworks like the Sport Concussion Assessment Tool (SCAT) [PMID:19423976]. However, despite high awareness, practical compliance with protective measures, such as consistent mouthguard use, remains suboptimal, highlighting a gap in translating knowledge into behavior change [PMID:16422751].
Diagnosis
Diagnosing concussion, including associated dental injuries, requires a comprehensive and multifaceted approach. Traditional tools such as the Sports Concussion Assessment Tool, Fifth Edition (SCAT5), and ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing) are pivotal in assessing cognitive function and symptomatology [PMID:36130754]. These tools aim to standardize the evaluation process across various populations, including those traditionally underrepresented, such as older patients and individuals with mental health conditions [PMID:36130754]. Emerging biomarkers, particularly salivary microRNAs, show promise in enhancing diagnostic accuracy. A scoping review identified 49 salivary microRNAs associated with concussions, suggesting their potential as objective diagnostic tools [PMID:36867013]. However, these biomarkers are currently limited in their application due to exclusions for individuals with premorbid neurological conditions [PMID:36130754].
Clinical assessments also benefit from rapid sideline evaluations. The King-Devick (KD) test, for instance, has demonstrated utility in identifying both recognized and unrecognized concussions within a brief timeframe, facilitating immediate sideline assessment [PMID:23374885]. This test successfully identified 17 unrecognised concussions alongside 5 witnessed ones, underscoring its practicality in real-time clinical settings [PMID:23374885]. Additionally, tools like the Headache Electronic Diary for Children With Concussion (HED-CC) enhance symptom tracking and documentation, aiding clinicians in refining diagnosis and treatment plans [PMID:25654707]. These advancements collectively aim to streamline the diagnostic process, ensuring timely and accurate identification of concussions and associated dental injuries.
Management
Effective management of concussion, including dental injuries, involves a multidisciplinary approach tailored to individual needs and circumstances. Given the logistical challenges post-COVID-19, remote review methods have emerged as innovative solutions for monitoring recovery and providing ongoing support [PMID:36130754]. These methods can enhance accessibility and continuity of care, particularly for athletes requiring frequent reassessment.
For dental injuries, immediate dental care is crucial. The registered professional school nurse plays a vital role in coordinating care, collaborating with healthcare providers to guide students through academic and activity re-entry post-concussion [PMID:23600095]. Schools with robust protocols, such as those adhering to the Registered Interscholastic Lacrosse Officials (RIIL) standards, demonstrate higher compliance with immediate removal from play and requiring medical clearance before return to activities [PMID:25153057]. However, gaps remain in baseline neurocognitive testing and written return-to-play protocols, with only about half of RIIL schools implementing these measures comprehensively [PMID:25153057].
Sport-specific management strategies are also essential. For instance, professional rugby players exhibit longer recovery times and greater symptom severity when playing away games, suggesting the need for tailored rehabilitation plans based on environmental factors [PMID:36843269]. Multidisciplinary expert groups have developed comprehensive policy recommendations, emphasizing roles for parents, teachers, coaches, administrators, healthcare providers, and public health officials in concussion management within school settings [PMID:35508363]. These recommendations aim to standardize and enhance preventive and management practices, addressing gaps highlighted by organizations like the NCAA, whose inadequate enforcement of concussion protocols correlates with increased injury occurrences and severe outcomes [PMID:31087830].
Prognosis & Follow-up
The prognosis for individuals with concussions, including those with dental injuries, largely depends on the thoroughness of initial diagnosis, adherence to management protocols, and consistent follow-up care. Inadequate follow-up and management, particularly in settings where enforcement of concussion protocols is lax (e.g., NCAA), can lead to significant long-term health issues, including chronic cognitive impairments and psychological sequelae [PMID:31087830]. Regular monitoring and adherence to return-to-play guidelines are critical to prevent delayed recovery and secondary complications.
Remote follow-up methods have shown promise in maintaining consistent oversight, especially in the post-COVID-19 era, ensuring that athletes receive timely reassessment and adjustments to their recovery plans [PMID:36130754]. Clinicians should emphasize the importance of comprehensive follow-up, including cognitive, physical, and dental assessments, to ensure a holistic recovery process. Parents and caregivers play a pivotal role in recognizing ongoing symptoms and advocating for continued medical attention, despite high awareness levels, as only about half of parents are fully informed about specific return-to-play guidelines [PMID:19423976]. This underscores the need for ongoing educational initiatives to bridge knowledge gaps and improve long-term outcomes.
Key Recommendations
References
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12 papers cited of 13 indexed.