Dental Injuries in a Sample of Portuguese Militaries – A Preliminary Research

Dental Injuries in a Sample of Portuguese Militaries – A Preliminary Research Abstract Introduction Traumatic dental and maxillofacial injuries are very common and appear to affect approximately 20–30% of permanent dentition, with often serious psychological, economic, functional, and esthetic consequences. Militaries are a highest risk group for orofacial trauma, not only because they are constantly engaged in physical activity (which increase the risk of traumatic injuries) but also because they are exposed to many risk factors. The aim of this study was to evaluate the prevalence of orofacial injuries, militaries knowledge about first-aid procedures following a dental avulsion and the use of mouthguards in a sample of Portuguese militaries. Materials and Methods An observational cross-sectional study was conducted for forces of the Infantry Regiment n°14 of Viseu, Portugal. The study involved 122 members of the armed forces who were asked to complete a questionnaire, which enquired about: the occurrence of dental trauma, the use of mouthguards and militaries knowledge with regard to first-aid management of dental avulsions. Results In our sample, 5.7% reported having experienced a dental trauma. This was further broken down to reveal that 2.5% had experienced an avulsion and 3.3% had a dental fracture. All respondents who reported having suffered dental trauma, reported that this was the only time that they had experienced dental trauma. Within this group, 71.4% visited a dentist, however only one (20%) visited the dentist during the same day that the trauma occurred. In addition, 21.3% mentioned that they had seen a dental trauma in at least one colleague during military trainings/operations. In the case of dental avulsion, the majority (54.9%) did not know how to act. The rate of mouthguard’s use among militaries was very low (6.4%). The main reason reported for not using a mouthguard was thinking that it is not necessary (53.3%). Besides that, 31.1% did not know what a mouthguard was for. Conclusion Prevention programs and promoting actions with this population are important reflections and should be adopted to reduce the incidence of orofacial trauma and to increase knowledge about this topic. INTRODUCTION Traumatic dental and maxillofacial injuries are very common and appear to affect approximately 20–30% of permanent dentition, with often serious psychological, economic, functional, and esthetic consequences.1 The etiology of these injuries includes falls, sports, playing, thrusting of a “hard object” in the mouth and violence/forensic issues.2 There is a lack of information about the prevalence of dental injuries among high-risk adult population, mostly focusing on athletes and militaries.3–5 The latter are a highest risk group for orofacial trauma,6–8 not only because they are constantly engaged in physical activity (which increases the risk of traumatic injuries) but also because they are exposed to many risk factors (e.g., fistfights, vehicle crashes, weapons and other equipment).9 Dental traumas and oral tissue injuries are very common during operations and military training7,8,10 comprising 2–8% of all military dental emergencies.7,11,12 Even when practicing sport, dental trauma represents more than 30% of all dental trauma cases in this specific group.11,13 In the last century, during the Vietnam War (1968) 10–15% of U.S soldiers had an injury involving the maxillofacial region14 and in the Falklands War (1982) there were 29% of the British soldiers with maxillofacial injuries. Likewise, in a study about Brazilian Military Police population, traumatic injuries were the most prevalent findings and are directly associated with police activity.15 When a traumatic dental injury occurs, a correct diagnosis and coordination between all health professionals is essential if the correct treatment is to be administered.16 To improve prognosis of these teeth prompt and appropriate emergency management is necessary and fundamental.17,18 However, a lack of knowledge in dental trauma management has been found among many groups of professionals, including sports education teachers, military corpsmen and physicians.16,19–23 Mouthguards have been considered the primary appliance for minimizing oral injuries during sports and physical activities.24,25 However, there are also some authors who report that mouthguards had little or no beneficial role in preventing dental trauma in the sporting arena.26,27 Among militaries there were many studies about the importance of the frequent use of mouthguard regarding the reduction of dental injury rates,28,29 although it was reported a very low compliance rate among this specific group.30 The majority of studies concerning dental trauma among military personnel come from countries with mandatory military service’,6,7,11,13,30,31 where the number of injuries is likely to be higher due to larger numbers of personnel. Military service is not mandatory in Portugal, however there’ appears to be a lack of oral-health education related to militaries, and mouthguards are not promoted or distributed in the army. To our knowledge, there are no studies about dental injuries in Portuguese militaries published in the medical/dental indexed literature. The aim of this study was to assess the prevalence of orofacial injuries amongst the military, military’s knowledge about first-aid procedures in the case of dental avulsion and the use of mouthguard in a sample of Portuguese militaries. METHODS A pilot observational cross-sectional study was conducted in a sample of militaries of the Infantry Regiment n°14 of Viseu, Portugal, by mean of a questionnaire. The questionnaire used in this study was developed from questionnaires used in previous studies4,32–37 and were translated into Portuguese by a certified translator. To assist in the interpretation of the medical terminology used, explanations were added in a common-sense language (e.g., avulsion = loss of a tooth by a direct impact). In this way, we try to reduce a possible bias due to medical terms. Although other issues could be addressed in the questionnaire, this methodology was chosen in order to be able to compare the results obtained with those published by other authors. Questionnaires were delivered by the authors to the militaries who answered them autonomously. The questionnaire enquired about general body injuries, but with a main focus on: (1) occurrence of dental trauma, (2) use of mouthguards, and (3) militaries knowledge regarding first-aid management in case of dental avulsion. Sociodemographic information, like age and gender were also asked. Permission to carry out the study was obtained from the Army Chief of State. All the respondents agreed and authorized this study and they signed an informed consent. The questionnaire was given to all military personnel available in the Regiment, on a given day previously defined by the Army Chief of State, and they were collected immediately after they were completed. Statistical Analysis Data were analyzed using the computerized software Statistical Package for Social Sciences (SPSS) 23.0 for Windows (SPSS Inc, Chicago, IL, USA). The results of this study were analyzed using descriptive statistics. RESULTS The final sample examined consisted on 122 (95.9% male) of 408 militaries of Infantry Regiment n°14 of Viseu, Portugal (response rate of 29.9%). This relatively low number was due to the fact that many militaries were on missions overseas or were posted to do some tasks outside the regiment. The mean age of the sample was 25.83 ± 7.49 (range 18–52 yr), with a major group on 20–24 yr old (58.2%) (Table I). Table I. Age Distribution of Militaries (n = 122) Age Group-Years  Frequency  Percentage  18–20  20  16.4  21–24  55  45.1  25–29  26  21.3  30–34  5  4.1  35–39  4  3.3  40 and above  12  9.8  Total  122  100  Age Group-Years  Frequency  Percentage  18–20  20  16.4  21–24  55  45.1  25–29  26  21.3  30–34  5  4.1  35–39  4  3.3  40 and above  12  9.8  Total  122  100  Table I. Age Distribution of Militaries (n = 122) Age Group-Years  Frequency  Percentage  18–20  20  16.4  21–24  55  45.1  25–29  26  21.3  30–34  5  4.1  35–39  4  3.3  40 and above  12  9.8  Total  122  100  Age Group-Years  Frequency  Percentage  18–20  20  16.4  21–24  55  45.1  25–29  26  21.3  30–34  5  4.1  35–39  4  3.3  40 and above  12  9.8  Total  122  100  The majority of the sample (56.6%) undergo up to 5 military training sessions per week and 32% have between 5 and 10 training sessions, which include intense physical activities and defense training frequently with weapons. About 41.8% trained between 10 and 20 h per week. In this study, 27 militaries (22.2%) reported that an oral-health problem has already affected their military activities, 14 (11.5%) of which occurred during training and 13 (10.7%) occurred during official missions or operations. There were 29 militaries (23.8%) that suffered body lesions during military training, like muscle lesions (9%) and bone fracture (4.9%), for example. Only 1.6% have ever had a facial lesion and that was a soft tissue injury/laceration. In relation to dental traumas, the prevalence was 5.7% and occurred mostly (71.4%) in younger militaries (18–25 yr). Of those who suffered a dental trauma, 2.5% experienced an avulsion and 3.3% suffered a dental fracture and all of them reported that this had only happened once. After a dental trauma, five militaries (71.4%) had a dental appointment, however only one (20%) visited a dentist on the same day as the trauma. In addition, 21.3% mentioned that they saw a dental trauma in at least one colleague during military trainings/operations. According to the knowledge of militaries about first-aid measures, the majority (56.6%) affirmed that they did not know that it was possible to recover a tooth after an avulsion and 54.9% reported not knowing about simple first-aid measures to replace an avulsed tooth (Table II). Table II. Militaries Knowledge About First-Aid Measures in a Case of Dental Avulsion What Do You Do in a Case of Dental Avulsion?  Frequency  Percentage  I do not know how to act  67  54.9  Wash and disinfect very well the tooth and go to the dentist  47  38.5  Put the tooth in your place and go to the dentist  2  1.6  Put the tooth inside the mouth and go to the dentist  3  2.5  Put the tooth inside a glass of milk and go to the dentist  3  2.5  What Do You Do in a Case of Dental Avulsion?  Frequency  Percentage  I do not know how to act  67  54.9  Wash and disinfect very well the tooth and go to the dentist  47  38.5  Put the tooth in your place and go to the dentist  2  1.6  Put the tooth inside the mouth and go to the dentist  3  2.5  Put the tooth inside a glass of milk and go to the dentist  3  2.5  Table II. Militaries Knowledge About First-Aid Measures in a Case of Dental Avulsion What Do You Do in a Case of Dental Avulsion?  Frequency  Percentage  I do not know how to act  67  54.9  Wash and disinfect very well the tooth and go to the dentist  47  38.5  Put the tooth in your place and go to the dentist  2  1.6  Put the tooth inside the mouth and go to the dentist  3  2.5  Put the tooth inside a glass of milk and go to the dentist  3  2.5  What Do You Do in a Case of Dental Avulsion?  Frequency  Percentage  I do not know how to act  67  54.9  Wash and disinfect very well the tooth and go to the dentist  47  38.5  Put the tooth in your place and go to the dentist  2  1.6  Put the tooth inside the mouth and go to the dentist  3  2.5  Put the tooth inside a glass of milk and go to the dentist  3  2.5  The rate of mouthguard’ use among militaries was very low (6.4%) and only 3.3% of them use a custom-made mouthguard. The main reason for not using a mouthguard was thinking that it is not necessary (53.3%). Besides that, 31.1% did not know what a mouthguard was used for (Table III). Table III. The Rate of Mouthguard Use Among Militaries Militaries Compliance About the Use of Mouthguards  Frequency  Percentage  Do you use mouthguard during military training or operations?   Yes  8  6.4   No  114  93.4  What is the type of your mouthguard?   Custom-made  4  3.3   Boile and bite  4  3.3  Why do you not use mouthguard?   I do not know what is it  38  31.1   Esthetical reasons  6  4.9   I think that it is not necessary  65  53.3   Problems in communication with team mates  3  2.5   Breath problems  2  1.6  Do you use another type of protection?   Shoulders  2  1.6   Head  12  9.8   Knees  7  5.7   Shins  15  12.3   Shell  1  0.8  Militaries Compliance About the Use of Mouthguards  Frequency  Percentage  Do you use mouthguard during military training or operations?   Yes  8  6.4   No  114  93.4  What is the type of your mouthguard?   Custom-made  4  3.3   Boile and bite  4  3.3  Why do you not use mouthguard?   I do not know what is it  38  31.1   Esthetical reasons  6  4.9   I think that it is not necessary  65  53.3   Problems in communication with team mates  3  2.5   Breath problems  2  1.6  Do you use another type of protection?   Shoulders  2  1.6   Head  12  9.8   Knees  7  5.7   Shins  15  12.3   Shell  1  0.8  Table III. The Rate of Mouthguard Use Among Militaries Militaries Compliance About the Use of Mouthguards  Frequency  Percentage  Do you use mouthguard during military training or operations?   Yes  8  6.4   No  114  93.4  What is the type of your mouthguard?   Custom-made  4  3.3   Boile and bite  4  3.3  Why do you not use mouthguard?   I do not know what is it  38  31.1   Esthetical reasons  6  4.9   I think that it is not necessary  65  53.3   Problems in communication with team mates  3  2.5   Breath problems  2  1.6  Do you use another type of protection?   Shoulders  2  1.6   Head  12  9.8   Knees  7  5.7   Shins  15  12.3   Shell  1  0.8  Militaries Compliance About the Use of Mouthguards  Frequency  Percentage  Do you use mouthguard during military training or operations?   Yes  8  6.4   No  114  93.4  What is the type of your mouthguard?   Custom-made  4  3.3   Boile and bite  4  3.3  Why do you not use mouthguard?   I do not know what is it  38  31.1   Esthetical reasons  6  4.9   I think that it is not necessary  65  53.3   Problems in communication with team mates  3  2.5   Breath problems  2  1.6  Do you use another type of protection?   Shoulders  2  1.6   Head  12  9.8   Knees  7  5.7   Shins  15  12.3   Shell  1  0.8  Although these figures show a low compliance with mouthguards use, 29.5% of respondents reported using other type of protection during trainings, like shoulder (1.6%) and head (9.8%) protection. DISCUSSION The main limitation of this pilot research on the Infantry Regiment n°14 of Viseu, Portugal was the reduced sample of militaries (response rate of 29.9%). However, this happened due to the fact that many militaries were on missions in other countries or were posted to do some tasks outside the Regiment (e.g., forest surveillance) in the timespan defined by the Army Chief of State. This low response rate may lead to a possible bias, due to the fact that some of the absent militaries may have an higher risk of suffering a dental trauma during their military activities. Nevertheless, it is impossible to draw assertive conclusions in this issue. According to our results, body lesions occur during military trainings or operations were the most frequent type of injury; muscle lesions (9%) and bone fracture (4.9%) being the most prevalent. One of the most important reasons for that is the lack of protection.38,39 With regard to dental trauma, the number of militaries that have ever experienced dental trauma during their military service was 5.7%. This number is very low, when comparing to other studies published in the literature, that report values between 12.9% and 28%.5,7 These results may be due to the fact that in other countries with mandatory military service, in contrast with Portugal, the study groups were more exposed to risk tasks, which can lead them to specific traumas. Those who suffered a dental trauma, 71.4% were between 18 and 25 yr of age, which is in keeping with several other studies, where dental traumas occurred mostly in younger age groups.40 In our study, dental fracture and avulsion were the most common dental traumas. Likewise, in a study among the UK Armed Forces about dental morbidity, the lost or the fractured restorations/teeth was by far the most common reason for dental attendance (32.5%).41 The most common dental-alveolar injuries, like concussion and uncomplicated crown fracture are defined as non-urgent.1 However, injuries such as dental avulsion or complicated dental fractures are defined as urgent and need treatment within the first hours.42 Among the group that already suffered dental trauma, the majority (71.4%) visited the dentist after the dental trauma. Only one (20%) visited several days later after dental trauma occurred while the others visited in the same or next day (20% and 60%, respectively). These results are not in accordance with a study from Israel that showed that most dental injuries during military services were first seen by the emergency medical technicians or the physician, when compared to only 7.3% by a dentist.16 Regarding militaries’ knowledge of dental trauma, the majority (54.9%) did not know how to act in the event of a dental avulsion. Inclusively, 38.5% answered incorrectly about procedures for storage medium for avulsed teeth (e.g., wash and disinfect the tooth). Only, 6.6% respond in the recommended way reported in the literature (human saliva/buccal vestibule or milk).43 Even in a study about the knowledge of dental traumas among emergency dental technicians and physicians among Israeli Forces, 25% did not know what they should do in case of an avulsed tooth and 20.6% did not know the best medium for storing an avulsed tooth.16 In a reviewed paper, regarding lay people’s knowledge of dental trauma management, Glendor44 concluded that it is necessary to invest in regularly education of the dentists and emergency staff in order to reduce or prevent inadequate care and enhance their knowledge of dental trauma treatment. Many studies reported that better knowledge of the first aid of dental traumas increases the success rate of the teeth involved.7,12,45 Many studies concluded that the use of mouthguards routinely lead to a reduction in dental injuries rates among military populations.6,28,29 However, it is quite clear that mouthguard use presents a very low rate among militaries (only 6.4% of militaries use dental protection). It is in accordance with other studies that reported the extremely low compliance rate among this population.6,11,13,30,46 The majority of the militaries do not consider the use of a mouthguard to be important and necessary (53.3%). Furthermore, 4.1% consider that the use of a mouthguard cause communication problems with team mates or breathing difficulties. The results of this study showed that 31.1% of the respondents do not know about the existence of dental protection devices. Other studies reported the most common reason for not using mouthguards was due to discomfort11,13,47 or communication problems.29 An effort should be made to reduce the incidence of dental traumas among risk populations, such as militaries. Specific preventive recommendations, education and research are critical components of any successful injury prevention program.48 Our questionnaire was limited to know if the militaries used mouthguards during their military service. However, the study does not differentiate whether the device is used during military training, sports training or even in the gym. Although this may be considered a limitation of our study, the results present a very low number of militaries using mouthguard that would not allow a breakdown of these situations. Oral-health education (e.g., by mean of preventive programs and promoting actions) should be considered among all military population, and not only among the professional staff.49 In 2008, Zadik developed an algorithm of first-aid management of dental trauma for medics and corpsmen.50 This tool could be implemented among the Army personnel to help in the decision process after a dental trauma. In this way, it could improve the knowledge, the compliance to use mouthguards and the prompt referral to a dentist immediately after a dental trauma event. CONCLUSION Although the prevalence of dental trauma in our population was low, militaries are considered a high-risk group, due to their daily activities. Prevention programs and promoting actions and specific strategies among this population are important and will be adopted to reduce the incidence of orofacial trauma and to increases the knowledge about this issue. 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Dental Injuries in a Sample of Portuguese Militaries – A Preliminary Research

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Abstract Introduction Traumatic dental and maxillofacial injuries are very common and appear to affect approximately 20–30% of permanent dentition, with often serious psychological, economic, functional, and esthetic consequences. Militaries are a highest risk group for orofacial trauma, not only because they are constantly engaged in physical activity (which increase the risk of traumatic injuries) but also because they are exposed to many risk factors. The aim of this study was to evaluate the prevalence of orofacial injuries, militaries knowledge about first-aid procedures following a dental avulsion and the use of mouthguards in a sample of Portuguese militaries. Materials and Methods An observational cross-sectional study was conducted for forces of the Infantry Regiment n°14 of Viseu, Portugal. The study involved 122 members of the armed forces who were asked to complete a questionnaire, which enquired about: the occurrence of dental trauma, the use of mouthguards and militaries knowledge with regard to first-aid management of dental avulsions. Results In our sample, 5.7% reported having experienced a dental trauma. This was further broken down to reveal that 2.5% had experienced an avulsion and 3.3% had a dental fracture. All respondents who reported having suffered dental trauma, reported that this was the only time that they had experienced dental trauma. Within this group, 71.4% visited a dentist, however only one (20%) visited the dentist during the same day that the trauma occurred. In addition, 21.3% mentioned that they had seen a dental trauma in at least one colleague during military trainings/operations. In the case of dental avulsion, the majority (54.9%) did not know how to act. The rate of mouthguard’s use among militaries was very low (6.4%). The main reason reported for not using a mouthguard was thinking that it is not necessary (53.3%). Besides that, 31.1% did not know what a mouthguard was for. Conclusion Prevention programs and promoting actions with this population are important reflections and should be adopted to reduce the incidence of orofacial trauma and to increase knowledge about this topic. INTRODUCTION Traumatic dental and maxillofacial injuries are very common and appear to affect approximately 20–30% of permanent dentition, with often serious psychological, economic, functional, and esthetic consequences.1 The etiology of these injuries includes falls, sports, playing, thrusting of a “hard object” in the mouth and violence/forensic issues.2 There is a lack of information about the prevalence of dental injuries among high-risk adult population, mostly focusing on athletes and militaries.3–5 The latter are a highest risk group for orofacial trauma,6–8 not only because they are constantly engaged in physical activity (which increases the risk of traumatic injuries) but also because they are exposed to many risk factors (e.g., fistfights, vehicle crashes, weapons and other equipment).9 Dental traumas and oral tissue injuries are very common during operations and military training7,8,10 comprising 2–8% of all military dental emergencies.7,11,12 Even when practicing sport, dental trauma represents more than 30% of all dental trauma cases in this specific group.11,13 In the last century, during the Vietnam War (1968) 10–15% of U.S soldiers had an injury involving the maxillofacial region14 and in the Falklands War (1982) there were 29% of the British soldiers with maxillofacial injuries. Likewise, in a study about Brazilian Military Police population, traumatic injuries were the most prevalent findings and are directly associated with police activity.15 When a traumatic dental injury occurs, a correct diagnosis and coordination between all health professionals is essential if the correct treatment is to be administered.16 To improve prognosis of these teeth prompt and appropriate emergency management is necessary and fundamental.17,18 However, a lack of knowledge in dental trauma management has been found among many groups of professionals, including sports education teachers, military corpsmen and physicians.16,19–23 Mouthguards have been considered the primary appliance for minimizing oral injuries during sports and physical activities.24,25 However, there are also some authors who report that mouthguards had little or no beneficial role in preventing dental trauma in the sporting arena.26,27 Among militaries there were many studies about the importance of the frequent use of mouthguard regarding the reduction of dental injury rates,28,29 although it was reported a very low compliance rate among this specific group.30 The majority of studies concerning dental trauma among military personnel come from countries with mandatory military service’,6,7,11,13,30,31 where the number of injuries is likely to be higher due to larger numbers of personnel. Military service is not mandatory in Portugal, however there’ appears to be a lack of oral-health education related to militaries, and mouthguards are not promoted or distributed in the army. To our knowledge, there are no studies about dental injuries in Portuguese militaries published in the medical/dental indexed literature. The aim of this study was to assess the prevalence of orofacial injuries amongst the military, military’s knowledge about first-aid procedures in the case of dental avulsion and the use of mouthguard in a sample of Portuguese militaries. METHODS A pilot observational cross-sectional study was conducted in a sample of militaries of the Infantry Regiment n°14 of Viseu, Portugal, by mean of a questionnaire. The questionnaire used in this study was developed from questionnaires used in previous studies4,32–37 and were translated into Portuguese by a certified translator. To assist in the interpretation of the medical terminology used, explanations were added in a common-sense language (e.g., avulsion = loss of a tooth by a direct impact). In this way, we try to reduce a possible bias due to medical terms. Although other issues could be addressed in the questionnaire, this methodology was chosen in order to be able to compare the results obtained with those published by other authors. Questionnaires were delivered by the authors to the militaries who answered them autonomously. The questionnaire enquired about general body injuries, but with a main focus on: (1) occurrence of dental trauma, (2) use of mouthguards, and (3) militaries knowledge regarding first-aid management in case of dental avulsion. Sociodemographic information, like age and gender were also asked. Permission to carry out the study was obtained from the Army Chief of State. All the respondents agreed and authorized this study and they signed an informed consent. The questionnaire was given to all military personnel available in the Regiment, on a given day previously defined by the Army Chief of State, and they were collected immediately after they were completed. Statistical Analysis Data were analyzed using the computerized software Statistical Package for Social Sciences (SPSS) 23.0 for Windows (SPSS Inc, Chicago, IL, USA). The results of this study were analyzed using descriptive statistics. RESULTS The final sample examined consisted on 122 (95.9% male) of 408 militaries of Infantry Regiment n°14 of Viseu, Portugal (response rate of 29.9%). This relatively low number was due to the fact that many militaries were on missions overseas or were posted to do some tasks outside the regiment. The mean age of the sample was 25.83 ± 7.49 (range 18–52 yr), with a major group on 20–24 yr old (58.2%) (Table I). Table I. Age Distribution of Militaries (n = 122) Age Group-Years  Frequency  Percentage  18–20  20  16.4  21–24  55  45.1  25–29  26  21.3  30–34  5  4.1  35–39  4  3.3  40 and above  12  9.8  Total  122  100  Age Group-Years  Frequency  Percentage  18–20  20  16.4  21–24  55  45.1  25–29  26  21.3  30–34  5  4.1  35–39  4  3.3  40 and above  12  9.8  Total  122  100  Table I. Age Distribution of Militaries (n = 122) Age Group-Years  Frequency  Percentage  18–20  20  16.4  21–24  55  45.1  25–29  26  21.3  30–34  5  4.1  35–39  4  3.3  40 and above  12  9.8  Total  122  100  Age Group-Years  Frequency  Percentage  18–20  20  16.4  21–24  55  45.1  25–29  26  21.3  30–34  5  4.1  35–39  4  3.3  40 and above  12  9.8  Total  122  100  The majority of the sample (56.6%) undergo up to 5 military training sessions per week and 32% have between 5 and 10 training sessions, which include intense physical activities and defense training frequently with weapons. About 41.8% trained between 10 and 20 h per week. In this study, 27 militaries (22.2%) reported that an oral-health problem has already affected their military activities, 14 (11.5%) of which occurred during training and 13 (10.7%) occurred during official missions or operations. There were 29 militaries (23.8%) that suffered body lesions during military training, like muscle lesions (9%) and bone fracture (4.9%), for example. Only 1.6% have ever had a facial lesion and that was a soft tissue injury/laceration. In relation to dental traumas, the prevalence was 5.7% and occurred mostly (71.4%) in younger militaries (18–25 yr). Of those who suffered a dental trauma, 2.5% experienced an avulsion and 3.3% suffered a dental fracture and all of them reported that this had only happened once. After a dental trauma, five militaries (71.4%) had a dental appointment, however only one (20%) visited a dentist on the same day as the trauma. In addition, 21.3% mentioned that they saw a dental trauma in at least one colleague during military trainings/operations. According to the knowledge of militaries about first-aid measures, the majority (56.6%) affirmed that they did not know that it was possible to recover a tooth after an avulsion and 54.9% reported not knowing about simple first-aid measures to replace an avulsed tooth (Table II). Table II. Militaries Knowledge About First-Aid Measures in a Case of Dental Avulsion What Do You Do in a Case of Dental Avulsion?  Frequency  Percentage  I do not know how to act  67  54.9  Wash and disinfect very well the tooth and go to the dentist  47  38.5  Put the tooth in your place and go to the dentist  2  1.6  Put the tooth inside the mouth and go to the dentist  3  2.5  Put the tooth inside a glass of milk and go to the dentist  3  2.5  What Do You Do in a Case of Dental Avulsion?  Frequency  Percentage  I do not know how to act  67  54.9  Wash and disinfect very well the tooth and go to the dentist  47  38.5  Put the tooth in your place and go to the dentist  2  1.6  Put the tooth inside the mouth and go to the dentist  3  2.5  Put the tooth inside a glass of milk and go to the dentist  3  2.5  Table II. Militaries Knowledge About First-Aid Measures in a Case of Dental Avulsion What Do You Do in a Case of Dental Avulsion?  Frequency  Percentage  I do not know how to act  67  54.9  Wash and disinfect very well the tooth and go to the dentist  47  38.5  Put the tooth in your place and go to the dentist  2  1.6  Put the tooth inside the mouth and go to the dentist  3  2.5  Put the tooth inside a glass of milk and go to the dentist  3  2.5  What Do You Do in a Case of Dental Avulsion?  Frequency  Percentage  I do not know how to act  67  54.9  Wash and disinfect very well the tooth and go to the dentist  47  38.5  Put the tooth in your place and go to the dentist  2  1.6  Put the tooth inside the mouth and go to the dentist  3  2.5  Put the tooth inside a glass of milk and go to the dentist  3  2.5  The rate of mouthguard’ use among militaries was very low (6.4%) and only 3.3% of them use a custom-made mouthguard. The main reason for not using a mouthguard was thinking that it is not necessary (53.3%). Besides that, 31.1% did not know what a mouthguard was used for (Table III). Table III. The Rate of Mouthguard Use Among Militaries Militaries Compliance About the Use of Mouthguards  Frequency  Percentage  Do you use mouthguard during military training or operations?   Yes  8  6.4   No  114  93.4  What is the type of your mouthguard?   Custom-made  4  3.3   Boile and bite  4  3.3  Why do you not use mouthguard?   I do not know what is it  38  31.1   Esthetical reasons  6  4.9   I think that it is not necessary  65  53.3   Problems in communication with team mates  3  2.5   Breath problems  2  1.6  Do you use another type of protection?   Shoulders  2  1.6   Head  12  9.8   Knees  7  5.7   Shins  15  12.3   Shell  1  0.8  Militaries Compliance About the Use of Mouthguards  Frequency  Percentage  Do you use mouthguard during military training or operations?   Yes  8  6.4   No  114  93.4  What is the type of your mouthguard?   Custom-made  4  3.3   Boile and bite  4  3.3  Why do you not use mouthguard?   I do not know what is it  38  31.1   Esthetical reasons  6  4.9   I think that it is not necessary  65  53.3   Problems in communication with team mates  3  2.5   Breath problems  2  1.6  Do you use another type of protection?   Shoulders  2  1.6   Head  12  9.8   Knees  7  5.7   Shins  15  12.3   Shell  1  0.8  Table III. The Rate of Mouthguard Use Among Militaries Militaries Compliance About the Use of Mouthguards  Frequency  Percentage  Do you use mouthguard during military training or operations?   Yes  8  6.4   No  114  93.4  What is the type of your mouthguard?   Custom-made  4  3.3   Boile and bite  4  3.3  Why do you not use mouthguard?   I do not know what is it  38  31.1   Esthetical reasons  6  4.9   I think that it is not necessary  65  53.3   Problems in communication with team mates  3  2.5   Breath problems  2  1.6  Do you use another type of protection?   Shoulders  2  1.6   Head  12  9.8   Knees  7  5.7   Shins  15  12.3   Shell  1  0.8  Militaries Compliance About the Use of Mouthguards  Frequency  Percentage  Do you use mouthguard during military training or operations?   Yes  8  6.4   No  114  93.4  What is the type of your mouthguard?   Custom-made  4  3.3   Boile and bite  4  3.3  Why do you not use mouthguard?   I do not know what is it  38  31.1   Esthetical reasons  6  4.9   I think that it is not necessary  65  53.3   Problems in communication with team mates  3  2.5   Breath problems  2  1.6  Do you use another type of protection?   Shoulders  2  1.6   Head  12  9.8   Knees  7  5.7   Shins  15  12.3   Shell  1  0.8  Although these figures show a low compliance with mouthguards use, 29.5% of respondents reported using other type of protection during trainings, like shoulder (1.6%) and head (9.8%) protection. DISCUSSION The main limitation of this pilot research on the Infantry Regiment n°14 of Viseu, Portugal was the reduced sample of militaries (response rate of 29.9%). However, this happened due to the fact that many militaries were on missions in other countries or were posted to do some tasks outside the Regiment (e.g., forest surveillance) in the timespan defined by the Army Chief of State. This low response rate may lead to a possible bias, due to the fact that some of the absent militaries may have an higher risk of suffering a dental trauma during their military activities. Nevertheless, it is impossible to draw assertive conclusions in this issue. According to our results, body lesions occur during military trainings or operations were the most frequent type of injury; muscle lesions (9%) and bone fracture (4.9%) being the most prevalent. One of the most important reasons for that is the lack of protection.38,39 With regard to dental trauma, the number of militaries that have ever experienced dental trauma during their military service was 5.7%. This number is very low, when comparing to other studies published in the literature, that report values between 12.9% and 28%.5,7 These results may be due to the fact that in other countries with mandatory military service, in contrast with Portugal, the study groups were more exposed to risk tasks, which can lead them to specific traumas. Those who suffered a dental trauma, 71.4% were between 18 and 25 yr of age, which is in keeping with several other studies, where dental traumas occurred mostly in younger age groups.40 In our study, dental fracture and avulsion were the most common dental traumas. Likewise, in a study among the UK Armed Forces about dental morbidity, the lost or the fractured restorations/teeth was by far the most common reason for dental attendance (32.5%).41 The most common dental-alveolar injuries, like concussion and uncomplicated crown fracture are defined as non-urgent.1 However, injuries such as dental avulsion or complicated dental fractures are defined as urgent and need treatment within the first hours.42 Among the group that already suffered dental trauma, the majority (71.4%) visited the dentist after the dental trauma. Only one (20%) visited several days later after dental trauma occurred while the others visited in the same or next day (20% and 60%, respectively). These results are not in accordance with a study from Israel that showed that most dental injuries during military services were first seen by the emergency medical technicians or the physician, when compared to only 7.3% by a dentist.16 Regarding militaries’ knowledge of dental trauma, the majority (54.9%) did not know how to act in the event of a dental avulsion. Inclusively, 38.5% answered incorrectly about procedures for storage medium for avulsed teeth (e.g., wash and disinfect the tooth). Only, 6.6% respond in the recommended way reported in the literature (human saliva/buccal vestibule or milk).43 Even in a study about the knowledge of dental traumas among emergency dental technicians and physicians among Israeli Forces, 25% did not know what they should do in case of an avulsed tooth and 20.6% did not know the best medium for storing an avulsed tooth.16 In a reviewed paper, regarding lay people’s knowledge of dental trauma management, Glendor44 concluded that it is necessary to invest in regularly education of the dentists and emergency staff in order to reduce or prevent inadequate care and enhance their knowledge of dental trauma treatment. Many studies reported that better knowledge of the first aid of dental traumas increases the success rate of the teeth involved.7,12,45 Many studies concluded that the use of mouthguards routinely lead to a reduction in dental injuries rates among military populations.6,28,29 However, it is quite clear that mouthguard use presents a very low rate among militaries (only 6.4% of militaries use dental protection). It is in accordance with other studies that reported the extremely low compliance rate among this population.6,11,13,30,46 The majority of the militaries do not consider the use of a mouthguard to be important and necessary (53.3%). Furthermore, 4.1% consider that the use of a mouthguard cause communication problems with team mates or breathing difficulties. The results of this study showed that 31.1% of the respondents do not know about the existence of dental protection devices. Other studies reported the most common reason for not using mouthguards was due to discomfort11,13,47 or communication problems.29 An effort should be made to reduce the incidence of dental traumas among risk populations, such as militaries. Specific preventive recommendations, education and research are critical components of any successful injury prevention program.48 Our questionnaire was limited to know if the militaries used mouthguards during their military service. However, the study does not differentiate whether the device is used during military training, sports training or even in the gym. Although this may be considered a limitation of our study, the results present a very low number of militaries using mouthguard that would not allow a breakdown of these situations. Oral-health education (e.g., by mean of preventive programs and promoting actions) should be considered among all military population, and not only among the professional staff.49 In 2008, Zadik developed an algorithm of first-aid management of dental trauma for medics and corpsmen.50 This tool could be implemented among the Army personnel to help in the decision process after a dental trauma. In this way, it could improve the knowledge, the compliance to use mouthguards and the prompt referral to a dentist immediately after a dental trauma event. CONCLUSION Although the prevalence of dental trauma in our population was low, militaries are considered a high-risk group, due to their daily activities. Prevention programs and promoting actions and specific strategies among this population are important and will be adopted to reduce the incidence of orofacial trauma and to increases the knowledge about this issue. 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Military MedicineOxford University Press

Published: May 23, 2018

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