Awareness of sports‐related dental emergencies and prevention practices among Libyan contact sports coaches: A cross‐sectional study

Abstract

Background and aims

Despite the high incidence rate of dental trauma and its possible devastating physical and psychological consequences on children, little is known about sport‐related dental trauma and its prevention and management among Libyan sports coaches. The present study aimed to assess the knowledge and attitude of Benghazi contact sports coaches regarding sport‐related dental trauma and its prevention and management.

Methods

A cross‐sectional study design was used. Two hundred and thirty‐one contact sports coaches were recruited from different public and private youth sports centers across Benghazi. The data were collected using a self‐administered questionnaire translated into Arabic and piloted to evaluate its validity and clarity. In addition, Mann–Whitney U, Kruskal–Wallis, and χ ² tests were used to check associations between the variables.

Results

A total of 151 contact sports coaches returned a completed questionnaire; the majority of coaches (74%) have seen orofacial injuries during their coaching career, whereas less than half of them (47%) personally experienced these injuries. Only one participant said he would preserve the tooth in milk, and four indicated that they would replant it. Most coaches (89.4%) knew what a mouthguard is, but 53.6% would recommend its use, and these were more likely to have previously used mouthguards (p ≤ 0.001). About 41.1% received previous training on TDIs‐related emergencies. Higher knowledge scores were observed among coaches who previously received training (p = 0.023).

Conclusion

The findings of this study indicate low awareness of how to manage and prevent orofacial injuries among Libyan contact sports coaches, even though they commonly encounter these injuries and believe in mouthguards' effectiveness. Previous training on managing emergencies and experience appeared to influence the coaches' knowledge. Training coaches on preventing TDIs and their early management in sports fields should be an implemented policy and a prerequisite to obtaining a training license.

1. INTRODUCTION

The World Health Organization (WHO) considers physical activities and sports essential for healthy development and well‐being. ¹ However, such activities may increase the risk of physical injuries. ² Dental and orofacial injuries are common among individuals participating in contact sports activities. ³ Traumatic Dental Injuries (TDIs) are the fifth most prevalent dental condition. ⁴ , ⁵ It has been reported that one‐third of TDIs affecting children and adolescents were caused by sport‐related activities. ⁶ Many studies have reported that around 15% of contact sports players have experienced dental trauma. ⁷ , ⁸ TDIs can cause functional and esthetic impairment, lead to costly treatments, and may negatively impact the quality of life. However, early management and appropriate measures to protect the orofacial structures can prevent TDIs and minimize their adverse impacts. ⁹ The high incidence of injuries in contact sports emphasizes the critical role of contact sports coaches as the first individuals to intervene at the injury site.

TDIs are generally classified into soft and hard tissue injuries. They can range in severity from chipping tooth enamel to tooth avulsion, which has the worst prognosis and requires the most complicated treatment of all TDIs. ¹⁰ , ¹¹ The success of avulsed tooth treatment depends on its extra‐alveolar time and immersion in appropriate transport media. On the other hand, the inaccurate handling of the avulsed tooth may permanently damage the periodontal ligaments, which causes external or replacement root resorption, leading to tooth loss. ¹¹ , ¹² Sports coaches must know how to prevent and manage sports‐related TDIs on the training site. Early and appropriate intervention of TDIs could improve the prognosis of affected teeth and minimize the psychological and physiological damage after trauma. ¹³ Although mouthguards have proven their efficacy in preventing dental injuries, many athletes do not use them because of difficulties in breathing, speaking, and esthetic reasons. ¹⁴ , ¹⁵ Sports coaches that are aware of mouthguards' role in preventing dental injuries can promote their use among the trainees. ¹⁶ , ¹⁷ However, a significant body of literature has shown that coaches do not always have the appropriate knowledge to handle orofacial injuries, including dental trauma. ¹⁸ , ¹⁹

Libya is a North African country that has recovered from civil wars and witnessed economic prosperity in different sectors. However, it has been noticed that there is an increase in sports centers for children and adolescents who may become at increased risk for orofacial injuries. A recent survey of Libyan school children reported that 10.3% of 12‐years‐old suffered from TDIs, most of which were due to falling. ²⁰ This observation emphasizes the importance of developing effective prevention programs and interventions in different settings to manage sport‐related TDIs. ²¹ , ²² However, it is unclear to what extent the coaches in sports centers in Benghazi, Libya, are prepared to handle emergencies caused by TDIs. Therefore, this study aimed to assess the knowledge and attitude of Benghazi contact sports coaches regarding the prevention and management of sport‐related TDIs.

2. METHODS

The Ethics Committee of the University of Benghazi, Faculty of Dentistry (UoB‐Dent‐0027) approved this study before commencing data collection, and it was conducted following the ethical standards of the Declaration of Helsinki. Participation was voluntary, and informed consent was obtained from all coaches included in this study.

A cross‐sectional study design using a self‐reported paper‐based survey was employed in the present study. The study was conducted in Benghazi, located on the eastern province's Libyan coast. Benghazi is the second‐largest city in the country and the capital of one of its three central provinces. The city has recently witnessed an increase in public and private training sports centers, especially football, a trendy sport in the country. The survey included all sports coaches who work in public and private sports centers registered in the Libyan Ministry of Youth and Sport and accepted participation in the study. The data were collected between June and August 2021, when the pandemic restrictions were loosened, and the questionnaires were physically handed out to participants.

The questionnaire was developed based on a previous study that assessed polo coaches' knowledge and attitude toward sport‐related dental emergencies and prevention. ¹⁹ The English questionnaire was first translated into Arabic by two independent bilingual dentists. The Arabic questionnaire was then assessed for face and content validity by a group of 12 dental academics, considering the cultural difference and variations in concepts to ensure that it would be well understood by individuals of different educational levels (Figure 1). For example, one question about the meaning of an avulsed tooth was removed because the experts' committee found the translation self‐explanatory, and there is no appropriate Arabic term for tooth avulsion. The questionnaire was then pilot‐tested among 20 individuals from different educational levels, including teachers, healthcare workers, university students, and sports coaches, to ensure its clarity and understandability.

Figure 1.

Flow of participants in the study

The final version of the questionnaire consisted of 26 questions divided into five sections (Supporting Information). The first section contained eight questions collecting demographic data and the history of practising sports and coaching experience. The second section had (five questions) covering the coaches' personal experiences of dental injuries during sports activities. The third section consisted of five questions assessing coaches' awareness of dental emergency procedures during sports activities. The fourth section had five questions about awareness of mouthguards and whether they believe in their effectiveness and recommend their use. The last part of the questionnaire had three questions that focused on the coaches' previous training about sport‐related dental injuries and their preferences for such training in the future. The responses to questions included multiple options, yes/no and open‐ended answers.

All accessible coaches in 39 training centers registered with the ministry of health were invited to participate in the study. A total of 231 questionnaires were distributed to sports coaches in both public and private training centers in Benghazi. The inclusion criteria involved being a contact sports coach, above 18 years of age, and providing consent to participate in the study. The exclusion criteria included non‐Libyan contact sport coaches. A trained research assistant (RA) approached the coaches personally at their workplace and handed the questionnaire to them. The RA explained the aim of the study and obtained informed consent before giving out the questionnaire. The coaches were given 2 days to complete the questionnaire, which was collected from the reception desk at the training center. The RA provided his phone number and offered his presence while completing the questionnaire to answer any queries.

All data were tabulated in a Microsoft Excel sheet and then analyzed using the Statistical Package for Social Sciences (SPSS) computer software (SPSS 25, Inc.). Counts and percentages were used to describe the characteristics of the study sample and responses to the questionnaire items (awareness and prevention practices). The total awareness score was computed by counting the correct answers to five questions regarding dental trauma in emergency management and prevention (Marked by an Asterisk in Table 3). Respondents' characteristics compared the awareness scores: level of education (University vs less than University), previous training in dental trauma emergencies (yes vs. no), and years of experience (5 years or less, 6–10 years, and more than 10 years), whether the club is private or public and whether the coaches experienced traumatic injuries before, using Mann–Whitney U and Kruskal–Wallis tests. A χ² test was used to compare the proportion of coaches who recommended mouthguards. Statistical significance was set at p < 0.05. Quantitative content analysis was used for the open‐ended questions (5, 7, 11c, and 12c). The answers were analyzed verbatim to be coded into categories, and then the emerging categories were counted and transformed into quantitative data. Two independent researchers performed the coding, and any conflict was sorted out through discussion with the research team. ²³

Table 3.

Management of avulsed and broken tooth (n = 151)

Variable			N (%)
What would you do if tooth avulsed for your athlete	Throw the tooth away		36 (23.8)
	Clean the tooth underwater		35 (23.2)
	Wrap the tooth in clean handkerchief or gauze		70 (46.4)
	Preserve the tooth in milka		1 (0.7)
	Preserve the tooth in saline solutiona		2 (1.3)
	Preserve the tooth in disinfectant		3 (2.0)
	Reimplant the tooth		4 (2.6)
What would you do if injury occurred during your coaching activities	Take the victim to the nearest hospital		83 (55)
	call the team doctor		67 (44)
	contact the parents		1 (0.7)
If there is only part of tooth missing would look for ita		Yes	36 (23.8)
		No	115 (76.2)
Think broken fragment could be reattacheda		Yes	8 (5.3)
		No	143 (94.7)
Heard of a storage media for avulsed tootha		Yes	7 (4.6)
		No	144 (95.4)

^a Right answers used for developing awareness score.

3. RESULTS

Out of 231 questionnaires distributed, 151 coaches returned complete questionnaires, giving a response rate of 65.4%. All respondents were males coaching contact sports, with a mean age of 40.1 ± 9.18 years and an age range from 22 to 73 years. Most respondents were coaches in public sports centers (113, 74.8%) and obtained a university degree (105, 69.5%). Most of the coaches (78, 51.7%) had less than 5 years of coaching experience and were coaching football (116, 77%) (Table 1).

Table 1.

Sociodemographic characteristics of study participants (N = 151)

Variable		N (%)
Club category	Private	38 (25.2)
	Public	113 (74.8)
Coaching experience	≤5 years	78 (51.7)
	≤10 years	41 (27.2)
	≥11 years	32 (21.2)
Coaches practicing sports	Stopped playing sports	47 (31)
	Sometimes play sports	29 (19)
	Always play sports	75 (50)
Sports coaching	Basketball	7 (4.6)
	Football	116 (77)
	Handball	4 (2.6)
	Combat sports	8 (5.3)
	Rugby	7 (4.6)
	Volleyball	9 (6)
Education level	University education	105 (69.5)
	Less than University	46 (30.5)
Age in years	Range	22–73
	Mean ± SD	40.1 ± 9.18

Table 2 shows the responses to questions related to previous experience with oral‐facial and dental injuries. Less than half of the respondents (71, 47%) experienced oral‐facial injuries themselves, while most respondents (112, 74.2%) witnessed such injuries during their careers. Injuries to the face and bruises were the most common experiences of facial injuries (47, 31.1%). Dental injuries of teeth were experienced by (35, 23.2%) of the respondents and witnessed by (93, 61.6%). Fractured teeth were the most commonly witnessed (51, 33.8%) and experienced (21,13.9%) injury. Avulsion was the least experienced injury by the coaches (4, 2.6%), but luxation was the least witnessed by them (22, 14.6%).

Table 2.

The distribution of facial and dental injuries experienced and seen by the coaches

Variable	Statistics
Dental injuries during sporta	Experienced Injuries N (%)a	Seen Injuries N (%)a
Overall orofacial injuries	71 (47%)	112 (74.2)
Injury in face	67 (44.3)	105 (69.5)
Bruises in face	47 (31.1)	73 (48.3)
Wounds in face	22 (14.6)	78 (51.7)
Fracture in face	6 (4.0)	23 (15.2)
Overall Dental Injuries (Teeth)	35 (23.2)	93 (61.6)
Fracture in teeth	21 (13.9)	51 (33.8)
Avulsion	4 (2.6)	27 (17.9)
Luxation	12 (7.9)	22 (14.6)

^a Questions have multiple options.

Table 3 shows the responses to questions related to the management of avulsed teeth. Wrapping the tooth in a clean handkerchief or gauze (70, 46.4%) was the most chosen option, followed by “throwing the tooth” (36, 23.8%) and “cleaning the tooth” (35, 23.2%). One participant would store the tooth in milk and two others in saline. Only seven coaches heard of storage media. Replanting the tooth was the respondents' choice (4, 2.6%).

Regarding the question (If there is only part of a tooth missing, would you look for it?), Less than a quarter (36, 23.8%) would look for a broken tooth fragment, and (8, 5.3%) of respondents thought it could be reattached. In response to the question “what would you do if a dental injury occurred during training?”, more than half of the coaches (83,55%) would take the victim to the nearest hospital, and (67,44%) would call the team doctor. Only one respondent would contact the parent (Table 3). Table 4 describes coaches' awareness and attitude toward using mouthguards. Most coaches (135,89.4%) knew a mouthguard, but less than a quarter (36,23.8%) used it as athletes. The most common reasons for not using a mouthguard were difficulty breathing (29,26.3%), unavailable (25,25.3%), and the belief that it is not essential (29,29.3%). On the other hand, most coaches considered a mouthguard an effective tool to prevent dental injuries (109,72.2%) and recommended its use for their players (81,53.6%). Regarding dental injury mechanisms of intervention training, less than half of the coaches received training on trauma management (62,41.1%), mainly through lectures (42,67.7%). However, most respondents prefer lectures (122,80.8%) over online training courses.

Table 4.

Awareness and use of mouthguards among coaches

Variable			N (%)
Know mouthguard (n = 151)		Yes	135 (89.4)
		No	16 (10.6)
Wore mouthguard as an athlete (n = 135)		Yes	36 (23.8)
		No	99 (76.2)
Recommend mouthguard for your players (n = 135)		Yes	81 (53.6)
		No	54 (56.4)
Think mouthguard effective in preventing dental injuries (n = 135)		Yes	109 (72.2)
		No	26 (27.8)
Reasons for not wearing mouthguard as athlete (n = 99)a	Difficulty in breathing or speaking		29 (26.3)
	Affect the facial esthetics		18 (18.2)
	Not available		25 (25.3)
	Not important in this sport		29 (29.3)
	Difficult to wear in this sport		2 (2.2)

^a Questions have multiple answers.

The average awareness score of the whole study sample was 1.27 (SD = 0.75) and ranged between zero and five. Table 5 shows comparisons of awareness scores according to the attributes of study participants. The only significant difference was previous training about managing dental trauma emergencies. Those who received previous training had higher knowledge scores than those who did not receive training (mean = 1.41 and 1.13, p = 0.023). Table 6 shows comparisons of recommending mouthguards by previous knowledge of mouthguards and experiences of trauma and use of a mouthguard. Significantly higher proportions of coaches who used mouthguards as athletes and those who think it is an effective preventive tool recommend using mouthguards among their players than those who did not (p ≤ 0.001).

Table 5.

Comparisons of awareness scores by characteristics of study participants

Variable		Mean (SD)	p‐Value
Club category	Private	1.26 (0.64)	0.914
	Public	1.25 (0.80)
Coaching experience	≤5 years	1.21 (0.59)	0.679
	≤10 years	1.26 (0.81)
	≥11 years	1.34 (1.04)
Received education on emergencies	Yes	1.41 (0.84)	0.023
	No	1.13 (0.68)
Education	University education	1.37 (0.88)	0.208
	Less than University	1.20 (0.69)
Experienced Traumatic Injuries	Yes	1.34 (0.89	0.320
	No	1.18 (0.61)

Note: Mann–Whitney U test used with all variables except “coaching experience” where Kruskal–Wallis test was used.

Table 6.

Comparisons of recommending mouthguard by previous experiences and knowledge

Variable	Recommend N (%)	Do not recommend N (%)	p‐Value
Experienced injuries (n = 64)	43 (67.2)	21 (32.8)	0.072
know mouthguard (n = 135)	80 (59.3)	55 (40.7)	0.791
Wore mouthguard as an athlete (36)	35 (97.2)	1 (2.8)	≤0.001
Think mouthguard effective in preventing dental injuries (109)	81 (74.3)	28 (25.7)	≤0.001
Received previous education (60)	38 (63.3)	22 (36.7)	0.367

Note: Chi‐squared test was used to compare proportion of coaches who recommended mouthguards.

4. DISCUSSION

The current questionnaire‐based survey explored awareness and prevention practices among Libyan contact sports coaches regarding TDIs. The respondents demonstrated low awareness of managing dental trauma emergencies and what they can do to prevent them during coaching activities, even though many experienced or witnessed such injuries throughout their lifetime as athletes or coaches.

The present study's findings mirror those of the previous studies conducted among contact sports coaches in other countries such as Croatia, Switzerland, and Saudi Arabia and demonstrated poor awareness among basketball, water polo, and taekwondo coaches regarding emergency procedures related to TDIs and their prevention. ¹⁸ , ¹⁹ , ²¹ , ²⁴ , ²⁵ Similar findings were reported among other groups, such as parents, school teachers, and pediatricians, that may provide immediate management of traumatic injuries and improve prognosis. ²⁶ , ²⁷ , ²⁸ However, only four participants indicated that they would replant the avulsed tooth in the present study, and one respondent used milk as storage media. These figures are much lower than those observed in studies conducted in western countries, where the majority of handball, taekwondo, and water polo coaches and players were aware of the possibility of replantation of the avulsed tooth. ⁸ , ²¹ , ²⁹ However, the present study's findings are comparable to that of studies conducted in middle eastern countries such as Iran and Saudi Arabia. ²⁴ , ³⁰ Although avulsion was the least experienced injury, it is well known that it has the worst prognosis, and its early management plays a crucial role in treatment success. ¹⁰ Therefore, training efforts should be directed toward coaches to increase their awareness of the importance of early intervention and appropriate management of avulsed teeth.

The current study found that orofacial injuries, including dental trauma, were commonly encountered by Libyan contact sports coaches, consistent with several previous studies conducted among sports coaches and athletes. ¹⁸ , ¹⁹ , ²¹ , ²⁴ , ²⁵ This finding raises concerns about the low awareness of appropriate management of TDIs‐related emergencies, reported among Libyan coaches, which could be attributed to the lack of appropriate training on this topic. The current study demonstrated that less than half of the participants received instruction on dental trauma management. Although these participants had significantly higher awareness scores than those who did not receive training, it was impossible to know the contents of these training efforts from the present study. In addition, previous studies have reported that a single lecture was not enough to train people on managing dental trauma emergencies. ³⁰ , ³¹ Although this explanation remains an assumption that needs further study; it sheds light on the urgent need to develop educational and training programs to provide coaches and other groups with the knowledge and skills to avoid negative consequences.

Another interesting finding in the present study was that most coaches in the present study knew about mouthguards and believed in their effectiveness in preventing sport‐related dental injuries. However, a lower percentage would recommend their use, and still, a lower percentage used them when they played sports themselves as athletes. Similar observations were reported in previous studies conducted in different countries and among various contact sports coaches where a mouthguard is essential as a preventive tool. ⁷ , ¹⁹ , ²¹ , ³¹ , ³² Speaking and breathing problems were the main reasons for not wearing a mouthguard, consistent with previous studies conducted among coaches. ¹⁴ , ²¹ Coaches who used mouthguards as athletes and those who think it is an effective preventive tool reported that they would recommend using mouthguards among their players more than those who did not. This study's findings highlight the need to increase awareness about the importance of mouthguards in preventing dental injuries, especially for football players who are considered at high risk of dental injuries. ³³

While the present study provided baseline data that can be used for further research, it has some limitations that are worth discussing. First, using a self‐reported questionnaire may be subject to social desirability and recall bias, though the respondents were assured about their confidentiality, and no personal identifiers were requested. Second, there was no comprehensive list of coaches, so that the sample might have missed some participants. However, a complete list of the training centers was obtained, and these centers were used as the sampling unit. In addition, comparing responders and nonresponders indicates similarity in terms of gender, types of sport (mainly football), and club type. Hence, the sample can represent the whole trainers' population. Finally, the study was conducted in the city of Benghazi and hence may not reflect the whole Libyan population. However, the city of Benghazi is considered the country's melting pot, and its population represents the whole spectrum of Libyan culture and races. However, further research to include coaches from different Libyan cities would provide a broader picture of how contact sports coaches deal with traumatic emergencies.

Our study has important implications for regional and international contexts by providing unique data collected in the post‐conflict environment, such as Libya, where the number of sports centers is expected to increase, hence the odds of traumatic injuries. Therefore, a collaboration of government, health policymakers, oral health care professionals and international organizations are required to develop and implement policies to prevent and manage sport‐related dental injuries. The present study highlighted the need to prepare sports coaches and training centers to be equipped with essential emergency kits to deal with sport‐related dental trauma. Therefore, these issues should be considered an integral part of the licencing process for coaches and training centers. The use of sport‐mouthguard is another important preventive measure that should be made mandatory and part of sport‐related policies.

5. CONCLUSION

The present study showed that players and coaches commonly encountered orofacial injuries in the Libyan contact sports context. However, knowledge of how to manage dental trauma emergencies was poor. Most coaches knew about mouthguards and their preventive role, but only half would recommend them for athletes. Variations in knowledge and recommendation of mouthguards were observed by previous experience and education. The results highlight the need of interventions that should address tailored preventive training about the management of sports‐related dental emergencies.

AUTHOR CONTRIBUTIONS

Iman Elareibi: Conceptualization; data curation; investigation; methodology; writing – original draft. Sarah Fakron: Data curation; formal analysis; investigation; methodology. Amal Gaber: Visualization; writing – original draft; writing – review and editing. Martijn Lambert: Writing – original draft; writing – review and editing. Maha El Tantawi: Writing – original draft; writing – review and editing. Arheiam Arheiam: Conceptualization; formal analysis; methodology; project administration; supervision; writing – original draft; writing – review and editing.

TRANSPARENCY STATEMENT

The lead author Iman Elareibi affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

Supporting information

Supporting information.

Elareibi I, Fakron S, Gaber A, Lambert M, El Tantawi M, Arheiam A. Awareness of sports‐related dental emergencies and prevention practices among Libyan contact sports coaches: a cross‐sectional study. Health Sci Rep. 2022;6:e977. 10.1002/hsr2.977

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author upon reasonable request.