An Investigation Into Player Compliance and Level of Protection Afforded by Mouthguards Worn by Children Playing Sport in Ireland
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An Investigation into Player Compliance and Level of Protection Afforded by Mouthguards worn by Children Playing Sport in Ireland A thesis submitted in partial fulfilment of the requirements for the degree of Doctorate in Dental Surgery (D.Ch.Dent.) in Paediatric Dentistry 2020 Elaine Philippa Shore Supervisor: Dr. Anne O’Connell Division of Public and Child Dental Health Dublin Dental University Hospital Trinity College, The University of Dublin Declaration I declare that this thesis has not been submitted as an exercise for a degree at this or any other university and it is entirely my own work. I agree to deposit this thesis in the University’s open access institutional repository or allow the Library to do so on my behalf, subject to Irish Copyright Legislation and Trinity College Library conditions of use and acknowledgement. I consent to the examiner retaining a copy of the thesis beyond the examining period, should they so wish (EU GDPR May 2018). ___________________________ Elaine Philippa Shore I Glossary of Terms TDI Traumatic dental injury SRDI Sports-related dental injury MG Mouthguard MFMG Mouth-formed mouthguard (“boil and bite” type) CMG Custom mouthguard EVA Ethylene vinyl acetate SD Standard deviation IQR Interquartile range PIL Participant information leaflet II Summary Background: Dental trauma is a significant global public health issue, affecting 1 billion people worldwide. Up to 40% of dental injuries are sports related and preventable through the use of mouthguards. In Ireland, the Gaelic Athletic Association (GAA) introduced rules requiring the use of “properly fitted” mouthguards by players of all levels in 2014. Aims: This study aimed to investigate compliance with GAA mouthguard rules among children playing Gaelic football in Ireland, and to establish the types and quality of mouthguards being worn. Knowledge, attitudes and behaviours of children and parents on dental trauma and mouthguard use were investigated. Materials and methods: An observational cross-sectional cohort study was carried out using a convenience sample of 9-16-year-old boys and girls and their parents recruited from 4 Gaelic football teams from across Dublin city. Child and parent knowledge and attitudes regarding mouthguard use were established using questionnaires. Trained calibrated examiners examined the children’s dentition and mouthguards. Data were analysed using descriptive statistics, binary logistic regression analysis, and linear regression analysis. Results: One hundred and twenty-one children with 118 parents participated in the study. The median age of the sample was 12 years (interquartile range = 10- 13) and there were slightly more males (56.67%) than females (43.33%). It was a highly active population with most children playing multiple sports. There was poor agreement between child (17.5%) and parent (6.84%) reports of past dental trauma and dentist-observed signs of dental injury (11.66%). III Mouthguard use was greater for Gaelic football matches (99.17%) than for training (80.8%); binary logistic regression analysis concluded that older children are less likely to comply with mouthguard rules for training (OR = 0.18, p < .001). Most children were only wearing their mouthguard for Gaelic football. Most children (N = 87, 72.50%) reported that they liked their MG with few reported difficulties with wear (e.g. breathing, ability to speak). Knowledge of both parents and children regarding mouthguard hygiene was poor. Parents were willing to pay a median price of €35.00 (IQR = €20.00 - €50.00) for a custom mouthguard. Mouth-formed mouthguards were the most popular type in this study; only 4 children (3.77%) had custom mouthguards. Most mouthguards (>80%) had inadequate retention and labial extension. Mean labial and occlusal thicknesses were greater than those recommended in the literature. Mouth-formed mouthguards were significantly thicker than both stock and custom mouthguards. Conclusion: Mouthguards are routinely worn by children playing Gaelic football, with greater compliance during competition than during training. Compliance with mouthguard rules during training reduced as children grew older. Children and parents displayed favourable attitudes towards the use of mouthguards, though knowledge of hygiene measures was lacking. Most children were wearing mouth- formed mouthguards with poor retention and inadequate labial extension. The quality and fit of the majority of mouthguards worn by children in this study was poor. There is a need for dentists to liaise with GAA clubs, players and parents to educate them on what constitutes a properly fitted mouthguard and how to care for these devices. IV Acknowledgements There are many people without whom this research study would not have been possible, and I wish to take this opportunity to extend my thanks to each of them. To Ms Isabel Fleischmann, DDUH Librarian, for her help with constructing the search terms for the literature review. To Mr Glen Reid, DDUH laboratory technician, for fabricating the calibration mouthguards, and to Ardagh Dental, for sourcing and supplying the necessary EVA blanks for the calibration mouthguards. To Mr Noel Shore, for helping with modification and calibration of the callipers for data collection. To Dr Advan Moorthy, for being a willing volunteer for the calibration exercise. To Mr Gearóid Devitt and Mr Brendan Connolly and the Gaelic Athletic Association, and Ms Paula Prunty and the Ladies’ Gaelic Football Association, for their support and endorsement of this research being carried out in their member clubs. To those who facilitated contact with the GAA, LGFA, and individual clubs: Dr Sinead O’Sullivan, Mr Ryan Casey, Ms Marie Brady, Dr Joe Hennessy, Dr Frances O’Callaghan, and Ms Carol Maguire. To the executive committees, participants, and parents from Clanna Gael Fontenoy, St Vincent’s, Ballymun Kickhams, and Good Counsel GAA Clubs. To those who gave up their evenings after work to help with data collection: Dr Charlotte McCarra, Dr Emily Crossan, Dr Anne O’Connell, Dr Rona Leith, Dr Jennifer Maguire, Dr Hadeel Khraishi, Dr Niamh O’Kelly-Lynch and Dr Michael Donnelly. To Dr Maria van Harten and Dr Isabel Olegário da Costa for their guidance with the statistical analysis for this study. To Dr Anne O’Connell, my supervisor, for her time, encouragement and guidance throughout the past 3 years: I am truly grateful for everything. To Emily and Charlotte, for their support and friendship through the peaks and troughs of postgraduate life. To my sisters, Úna and MaryRose: Thank you for being great friends as well as wonderful sisters. To my husband, Conor – thank you for all the love, support and understanding, especially over the past 3 years, and for always being the voice of reason. Finally, to my parents: To my father, Philip, who encourages and supports me in working towards my ambitions, and makes sure my sense of humour stays intact; and to my late mother, Sheelagh, who was always so proud of my achievements, however small, and is dearly missed every day. I wouldn’t be where I am today without their example, their love and their encouragement. V Table of Contents Declaration .................................................................................................................................... I Glossary of Terms ....................................................................................................................... II Summary ..................................................................................................................................... III Acknowledgements ..................................................................................................................... V Table of Contents ....................................................................................................................... VI List of Tables .............................................................................................................................. XI Table of Figures ......................................................................................................................... XII 1 Chapter 1 Literature Review .............................................................................................. 1 1.1 Background – Dental Trauma........................................................................................ 1 1.1.1 Epidemiology of Dental Trauma ............................................................................ 1 1.1.2 Sports-Related Dental Injuries ............................................................................... 4 1.1.3 Consequences of Dental Trauma .......................................................................... 6 1.2 Prevention of Traumatic Dental Injuries ........................................................................ 7 1.3 Mouthguards .................................................................................................................. 9 1.3.1 History of Mouthguards in Sport ............................................................................ 9 1.3.2 Mode of Action: How Mouthguards Prevent Traumatic Dental Injuries ............... 10 1.4 Effectiveness of Mouthguards in Prevention of Traumatic Dental Injuries .................. 11 1.5 Mouthguards and Concussion ..................................................................................... 12 1.6 Mouthguard Policies in Sport Worldwide ..................................................................... 13 1.6.1 Mouthguards