Abstract. Traumatic dental injuries (TDIs) represent a substantial global health burden, with meta-analytic estimates indicating that more than one billion living people have experienced a TDI. Sports participation is a leading etiologic factor, particularly among children, adolescents, and young adults. This review summarizes the epidemiology of sports-related TDIs, characteristic injury patterns, the evidence base for mouthguard efficacy, and current International Association of Dental Traumatology (IADT) recommendations for acute management, with emphasis on avulsion of permanent teeth. Meta-analyses consistently demonstrate that mouthguard use substantially reduces the risk of dentoalveolar and orofacial injury in contact and collision sports, while evidence regarding concussion prevention remains inconclusive. Custom-fabricated mouthguards offer superior fit, retention, and wearer compliance relative to stock and mouth-formed alternatives.
Epidemiology
In a comprehensive meta-analysis of world TDI prevalence and incidence, Petti, Glendor, and Andersson estimated that over one billion living people have sustained a traumatic dental injury, and observed that TDI would rank fifth among the world’s most frequent acute and chronic diseases and injuries if included in such rankings.1 Sports activities account for a substantial share of these injuries in the permanent dentition, with the highest risk concentrated in patients aged 7 to 25 years — a window that spans mixed dentition through peak athletic participation.
In their 2019 systematic review and meta-analysis of athletes in contact and collision sports, Fernandes et al. reported an overall prevalence of dentofacial injuries of 27.6% among collision-sport participants.2 Notably, injury prevalence was dramatically stratified by protective equipment use: dental trauma prevalence was approximately 7.5% among mouthguard users versus roughly 48% to 59% among non-users. Basketball, soccer, and martial arts — sports without universal mouthguard mandates — contribute disproportionately to dental injury presentations in general practice.
Etiology and Injury Patterns
Sports-related TDIs result from direct impact (ball, elbow, equipment) or indirect transmission of force through the mandible. The maxillary central incisors are the most frequently injured teeth, with increased overjet and inadequate lip coverage recognized as anatomic risk factors. Fernandes et al. found that coronal (crown) fractures and avulsions were the most frequent injury types among athletes.2 Associated soft-tissue lacerations of the lips, tongue, and buccal mucosa are common, and luxation injuries — subluxation, lateral luxation, extrusion, and intrusion — frequently accompany or mimic uncomplicated crown trauma, underscoring the need for radiographic evaluation after any significant orofacial impact. Clinicians should also remain alert to comorbid parafunctional habits in athletes; the management considerations differ substantially from those discussed in our review of bruxism and temporomandibular disorders.
Mouthguard Efficacy: The Evidence
Knapik et al., in a systematic review with meta-analysis spanning multiple sports and study designs, calculated that the risk of orofacial sports injury was 1.6 to 1.9 times higher when a mouthguard was not worn.3 The more recent meta-analysis by Fernandes et al. reported even larger protective effects in collision sports, with mouthguard users 82% to 93% less likely to sustain dentofacial injuries.2 The protective mechanism is biomechanical: the resilient ethylene-vinyl acetate (EVA) material absorbs and dissipates impact energy, separates the dental arches, and redistributes forces over a broader area of the dentition and alveolus.
Three fabrication categories are recognized: stock, mouth-formed (boil-and-bite), and custom-fabricated guards. Boil-and-bite guards remain the most commonly used type among athletes,2 but custom-fabricated guards — pressure-laminated over a cast or printed model at adequate occlusal thickness (≥3 mm is commonly recommended) — provide superior retention, comfort, speech tolerance, and protection, which translates into better compliance. The American Dental Association recommends mouthguard use across a broad range of organized and recreational activities with fall or contact risk, not solely mandated collision sports.4 Evidence that mouthguards reduce concussion risk remains inconsistent, and no reliable conclusion can currently be drawn on that endpoint.3
Management of Acute Injuries
Management follows the 2020 IADT guidelines. For avulsed permanent teeth, prognosis is governed chiefly by extra-alveolar time and storage medium: immediate replantation at the point of injury is the treatment of choice; when not feasible, storage in milk, Hanks’ Balanced Salt Solution, or saliva preserves periodontal ligament cell viability, whereas dry storage beyond 30 minutes markedly worsens prognosis.5 Following replantation, splinting with a passive flexible splint for approximately two weeks, systemic antibiotics, tetanus review, and timely endodontic management (for teeth with closed apices) are indicated, with structured clinical and radiographic follow-up to monitor for ankylosis and external resorption. Avulsed primary teeth should not be replanted owing to risk of damage to the permanent successor. Crown fractures require assessment of pulp exposure; luxation injuries require repositioning and splinting per injury type, with pulp status monitored longitudinally.
Prevention and the Dental Team’s Role
General practices are well positioned to reduce injury burden: screening athletically active patients at recall visits, recommending sport-appropriate protection, fabricating custom mouthguards (with re-evaluation during growth and orthodontic treatment), and educating families on emergency management of avulsion. Team-level education is warranted, as immediate sideline response is the strongest modifiable determinant of outcome for avulsed teeth.5 A patient-oriented companion to this review, including practical mouthguard selection and care guidance, is available in our guide to sports mouthguards for families, and preventive protocols are integrated into our preventive care program.
References
- Petti S, Glendor U, Andersson L. World traumatic dental injury prevalence and incidence, a meta-analysis — One billion living people have had traumatic dental injuries. Dent Traumatol. 2018;34(2):71-86.
- Fernandes LM, Neto JCL, Lima TFR, et al. The use of mouthguards and prevalence of dento-alveolar trauma among athletes: A systematic review and meta-analysis. Dent Traumatol. 2019;35(1):54-72.
- Knapik JJ, Marshall SW, Lee RB, et al. Mouthguards in sport activities: history, physical properties and injury prevention effectiveness. Sports Med. 2007;37(2):117-144.
- American Dental Association. Athletic mouth protectors (mouthguards). ADA Oral Health Topics. Available at: ada.org/resources/ada-library/oral-health-topics/athletic-mouth-protectors-mouthguards.
- Fouad AF, Abbott PV, Tsilingaridis G, et al. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth. Dent Traumatol. 2020;36(4):331-342.
This article is provided for educational purposes for dental professionals and interested patients. It is not a substitute for individualized clinical judgment or professional dental care. Patients experiencing dental trauma should seek immediate care from a qualified dental professional.
