Posts Tagged ‘pre-participation examination’

Sports Dentistry: Why is it Critical to have Dentists Part of the Pre-participation Examination?

Monday, March 13th, 2017

Posted March 13, 2017

Kurt Andrews

By Kurt Andrews M.S., ATC, PES, CES

It’s not even day 1 of the new season yet. It’s the first time the lights have been turned on in the athletic training facility since an early exit in playoffs gave rise to a dramatic ending and unexpected offseason. Memories of the holidays remain fresh but need to be stored in the long-term memory bank as it is now time to get things prepared for the upcoming season.

The offseason has brought many changes within the organization as old faces have gone on to new challenges where new and old faces have assumed new positions. In preparation for the upcoming physicals, it’s encouraging to know that the medical staff has remained the same, thus ensuring continuity and efficiency at the doctor’s office.

All stations are set, the orthopedic doctors are set to do their exams, the podiatrist is confirmed to come down and scan everyone and the primary care providers are all set for electrocardiogram (EKG) testing. The doctor’s office has hired nurses to run all the tests for general health, the ophthalmologist is ready to do the annual eye exam and the chiropractors are coming by to do spinal evaluations. The dietician is ready to sit down and do one on one evaluations with all the athletes, the neuropsychologist is ready to impact test everyone and the performance staff is ready to put the team through physical test to get an understanding of the performance perspective. Amongst the organized chaos in the doctor’s office is a familiar face, one that doesn’t get much sideline attention during games.  But, one who is a crucial component of the sports medicine staff, the team dentist.

Sports dentistry is a new area of sports medicine specialization, not so much in terms of utilization amongst the athletes and athletic departments, but more so in its utilization in prevention principles of potential oral and facial injuries involved in the related sports. Sports dentistry also focuses on the prevention of any oral diseases and manifestations that may occur along with the maintenance and treatment of oral and facial injuries.

Dental trauma in sports is the major link between sports and dentistry, thus making dentists a necessity at pre-participation examination (PPE). During the team physicals the team dentist conducts oral health screenings and is involved with the fabrication of custom made mouth guards for certain sports such as  football, hockey, lacrosse, basketball or wrestling. They also make themselves available for any sort of emergency care or dental procedures that need to take place before the season starts preventing athletes from missing time during the season. Dentists should also be playing an active role in educating the public and athletes on the use of protective equipment for sporting activities not only to prevent injuries but also to reduce healthcare costs (Ramagoni et al., 2014).

Many sports related traumatic dental injuries are preventable with the use of appropriate, properly fitted and protective athletic equipment. These include but are not limited to helmets, facemasks and custom mouth guards. The National Youth Sports Foundation for the Prevention of Athletic Injuries, Inc. estimates that during the season of play athletes have a 10 percent chance of sustaining an injury to the face or mouth (Ramagoni et al., 2014). The most common orofacial sports related injuries include soft tissue injury and hard tissue injury including those to the teeth and facial bones such as tooth intrusions, luxations, crown/root fractures, complete avulsions and dental facial fractures (Saini, 2011).

The front teeth are the most affected by dental trauma with the maxillary central and lateral incisors being the most commonly injured teeth. The most common tooth injury is an uncomplicated crown fracture (Soares et al., 2014). Most of the time these injuries occur from a direct hit by a ball or from player to player contact. On the rare occurrence, while on the road for a game, it can be critical for an Athletic Trainer to have the team dentist available via phone or text to assist in the trouble shooting of a problem and come up with a short-term solution until the team comes back home.

By having a team or university dentist involved during the entrance physical, this professional can help facilitate the custom fabrication of mouth guards for the athletes involved in contact sports. These custom made mouth guards are superior to the stock or “boil and bite” mouth guards because of their adaptability and retention but are also believed to interfere the least with breathing and speech. Mouth guards should be worn when there is a possibility of any sort of physical contact with an opponent because they can help to prevent injuries to the teeth, lips, gingiva, tongue and mucosa. They cushion the blows that could cause jaw fractures, dislocations and trauma to the temporomandibular joint (Saini, 2011). According to the American Dental Association, the use of faceguards and mouth protectors prevent more than 200,000 orofacial injuries in football annually (Saini, 2011).

During the Athens Olympics in 2004, dental services were the second most utilized service in the Olympic village behind physiotherapy. The most common procedures were dental fillings (313 permanent and 31 temporary), root canals, pericoronitis treatment and mouthguard fabrications. The entrance physical is a perfect place for the dentist to be involved so every athlete can have a dental assessment. This will ensure that their oral health status is verified and cleared and any issues that may come up can be handled in the preseason.

In a study from 2003 to 2006, professional soccer players from the Spanish team Barcelona were compared with students of Dentistry and Medicine from the University of Barcelona. The researchers found that the average active dental cavity was significantly higher among professional soccer players compared to the dental student (Soares et al., 2014). What this shows is that the students practiced what they preached and were more willing to participate in dental hygiene practices, but that’s because they are familiar with them. The take home message from a study like this is that these dental issues are more widely spread amongst  athletes and the team dentist needs to establish a program encouraging oral health to the athletes of a university, college, professional or amateur teams.

A different study looking at 400 medical records of 353 amateur and 47 professional soccer players, found the results of poor oral health far worse for amateurs than the pros. In the amateur athletes, they found 283 cavity lesions (71 percent), 109 root canals (27 percent), 33 abscesses (9 percent) and 78 tooth extractions (22 percent). When compared to the professional athletes, they found 32 cavity lesions (68 percent), 11 root canals (23 percent), no cases of abscesses (0 percent) and 24 tooth extractions (51 percent) (Soares et al., 2014).

Swimmers have also been found to have a higher than normal tooth enamel decay. Researchers have found that swimming athletes are affected with biocorrosion of enamel because of the chlorine used to keep the pools clean; the acidic water in contact with the teeth causes irreversible tooth structure wear especially to the anterior teeth (Soares et al., 2014).

It is easy to understand now how important it is to have a dentist involved within the sports medicine team, and why they could and should be involved during the PPE or entrance physical exam. The duty of the sports dentist is to work alongside the athletic training staff to ensure the oral healthcare of the athletes, identify any individual risks, and develop prevention plans so that the athletes can avoid any major dental issues. The inclusion of a dentist to your sports medicine program can be a major component of your injury prevention model.

Dr. Padilla’s (Team Dentist for LA Galaxy) Top Tips for Dental Health

1. Regular scheduled dental exams and professional cleanings.

2. Be proactive rather than reactive. Complete any necessary treatment in a timely manner. Don’t put off treatment because it doesn’t hurt yet. This will insure minimal treatment performed.

3. Have good home dental hygiene care. Brush and floss at least twice a day.

4. Diet can contribute to dental problems. Limit excessive acidic drinks like sodas, fruit juices and sports drinks. These acidic drinks may dissolve tooth enamel which may contribute to tooth erosion and cavities. Rinse and hydrate with water after taking these acidic drinks.

5. Avoid smokeless tobacco, which can cause periodontal and oral cancer complications.

6. Wear custom made athletic mouth guards in competing in trauma related sports.


Ramagoni, N. K., Singamaneni, V. K., Rao, S. R., & Karthikeyan, J. (2014). Sports dentistry: A review. Journal of International Society of Preventive & Community Dentistry4(Suppl 3), S139.

Saini, R. (2011). Sports dentistry. National journal of maxillofacial surgery2(2), 129.

Soares, P. V., Tolentino, A. B., Machado, A. C., Dias, R. B., & Coto, N. P. (2014). Sports dentistry: a perspective for the future. Revista Brasileira de Educação Física e Esporte28(2), 351-358.

About the Author

Kurt Andrews, originally from the metro Detroit area, graduated with his bachelor’s degree in Exercise Science in 2008 from Oakland University. He has been a BOC Certified Athletic Trainer since 2011 where he earned his master’s in Athletic Training from the entry level master’s program at the University of Arkansas. He currently is in his fifth year as an assistant Athletic Trainer for the Major League Soccer (MLS) club LA Galaxy. He currently holds memberships with NATA, CATA and PSATS where he serves on the sponsorship, continuing education and research committees and was presently serving as the Western Conference senator.


Cardiac Screening in High School and College Aged Athletes

Friday, March 3rd, 2017

Beth Druvenga

Posted March 3, 2017

By Beth Druvenga, M.S. Ed, LAT, ATC

The inherent risk of injury when participating in some form of competitive athletics is widely accepted. Athletes suffer sprains, strains, concussions, fractures, contusions and lacerations to name a few injuries. A risk not so widely accepted is the risk of sudden cardiac arrest (SCA) or sudden cardiac death (SCD).

We have all seen the stories on the news or read the articles: A young athlete gone too soon. Athletes are in shape and generally in good health; they are not supposed to be participating one minute and unresponsive the next. As an empathetic, reasoning and rational culture, we cannot accept young lives being taken unexpectedly during athletic participation. But, it does happen. As an Athletic Trainer (AT) there is a list of potentially fatal events which may occur every day. I have to take a time out before games to internally review my emergency action plan (EAP), to prepare myself for the worst.

According to a 2011 study by Harmon et al., “SCD is the leading medical cause of death in NCAA athletes, is the leading cause of death during sport and exercise, and occurs at a much higher rate than previously accepted.”1 Hypertrophic cardiomyopathy and coronary artery anomalies account for 53 percent of all sudden cardiac deaths.2 Universally, professionals in the cardiac and sports medicine world alike have a common goal of preventing sudden cardiac death in athletes.4

To help prevent SCD, scientists and researchers have encouraged cardiac screening as a tool to detect underlying cardiac disorders and take the necessary steps for prevention. In fact, the Fédération Internationale de Football Association or International Federation of Association Football (FIFA) and the Union of European Football Associations (UEFA) have made cardiac screening mandatory before competition, and the International Olympic Committee encourages it as best practice.3 However, in the United States, only the National Basketball Association (NBA) mandates electrocardiograms (ECGs) or echocardiography annually.2

In Italy and Israel, it is required as part of a pre-participation examination (PPE) to have a cardiac screening.4 While in the United States a PPE involves a medical questionnaire and physical examination by a healthcare professional.2 And although the American Heart Association (AHA) supports pre-participation cardiovascular screening, it also acknowledges that it is not practical in mass context or nationwide mandate, due to the cost being an estimated 2 billion dollars per annum. Thus, the question remains. How do we move forward?

Until a nationwide, homogenous standard for cardiovascular screening is established for all high school and college aged athletes, take a look at some ways to combat SCA and SCD.

- Review your PPE questionnaire to confirm it includes questions the AHA supports for detection of potential cardiovascular disorders. Verify that these exams are being performed by a physician, nurse practitioner or physician assistant; someone who is trained and comfortable with detection of cardiovascular problems. According to the AHA, there is an increasing trend of states allowing chiropractors and naturopaths to perform PPE screenings, though they lack the cardiovascular screening training.2

- Review your facility’s EAP with not only your sports medicine staff but with people in the building who will be present when the EAP is put in to action. I am certain there are coaches and administrators who receive their EAPs but fail to read them and are not familiar enough to confidently put them into action.

- Get an automated external defibrillator (AED). I repeat, get an AED! Early defibrillation is essential during SDA to increase the chances of survival. If your school doesn’t have an AED, there are many grants and resources available to assist you in acquiring one.

- Consider providing cardiac screening for your school. There are many companies that perform cardiac screening, so reach out to your community and see what is out there. The most basic cardiac screening consists of a 12-electrode ECG which analyzes resting heart rhythm. This can help detect cardiac anomalies which may require further testing.

You, as an AT, are the best resource. Advocate for your athletes. I know ATs who have lost a student athlete to SCD. My hometown lost a student athlete to SCD during a wrestling tournament a little over a year ago. It all begins with YOU. Do your research to help prevent SCD and protect your athletes. Below are resources for cardiac screening and resources for AED grants, and I urge you to utilize them.

Cardiac Screening Resources

Parent Heart Watch:

AED Resources

Sudden Cardiac Arrest Foundation:


1. Harmon, K., Asif, I., Klossner, D., & Drezner, J. (2011). Incidence of Sudden Cardiac Death in National Collegiate Athletic Association Athletes. Circulation, 1594-1600.

2. Maron, B., Thompson, P., Ackerman, M., Balady, G., Berger, S., Cohen, D., et al. (2007). Recommendations and Considerations Related to Preparticipation Screening for Cardiovascular Abnormalities in Competitive Athletes: 2007 Update. Circulation, 1643-1655.

3. Schmied, C., & Borjesson, M. (2013). Sudden cardiac death in athletes. Journal of Internal Medicine, 93-103.

4. Steinvil, A., Chundadze, T., Zeltser, D., Rogowski, O., Halkin, A., Galily, Y., et al. (2011). Mandatory Electrocardiographic Screening of Athletes to Reduce Their Risk for Sudden Death: Proven Fact or Wishful Thinking? Journal of the American College of Cardiology, 1291-1296.

About the Author

Beth Druvenga is an Athletic Trainer currently living in northern Virginia. She has experience working in both a collegiate and high school setting. Druvenga is originally from Iowa where she earned her Bachelor of Arts degree in Athletic Training from Central College in 2012. She graduated from Old Dominion University in 2014 with a Master of Science in Education. Her professional interests include patient-reported outcomes, psychology of injury and rehabilitation as well as using yoga to increase flexibility.





Would ECHO testing during the PPE prevent sudden cardiac death?

Wednesday, November 2nd, 2016

Mike McKenney, MS, ATC

Posted November 2, 2016

By Mike McKenney, MS, ATC

During the pre-participation examination (PPE), many healthcare practitioners employ a traditional cardiac questionnaire and physical examination to detect potential abnormalities and other serious medical conditions that may impact safe participation in sport. However, a physical examination and history are not always sufficient to detect abnormalities of the heart that can result in sudden cardiac death (SCD). More recently, there has been increasing support for broader implementation of electrocardiograph (ECG) testing at all levels of sport. This includes attempts to mandate ECG testing for all high school athletes. Barriers to mandatory ECG testing typically revolve around cost, but there are other factors to consider before requiring this form of screening in an athletic population.

The intended purpose of an ECG is to assess electrical activity of the heart and assist clinicians in determining if a cardiac abnormality is present, whether it be genetic, structural or conductive in nature. However, only 3 percent of cases that result in SCD are of conduction-related causes.1, 2 In young, competitive athletes, structural abnormalities represent the largest percentage of SCD, 84 percent of reported cases,1 which includes conditions such as hypertrophic cardiomyopathy (HCM). Simply put, mandating ECG testing in sport may not be the best step forward due to the test’s limitations in screening for the primary causes of SCD.

The difficulty in utilizing ECG to detect structural abnormalities is reflected in a high false-positive rate due to detection of cardiac adaptations regularly found in trained athletes,1, 3 and other variations that are common with normal cardiac rhythm.3Furthermore, ECG lacks the specificity to reliably detect HCM,3 which is a condition that is largely asymptomatic until an SCD event occurs.2 Additionally, results can be interpreted differently between physicians if consistent standards are not being applied.4 Due to the aforementioned factors, athletes are often subject to unnecessary referrals for further screening that often turn out to be of no concern,4 and add further cost to the evaluation process.2

Echocardiograms (ECHO) are the gold standard for visualizing the heart and are what athletes typically receive when referred to a cardiologist for advanced evaluation. Traditionally, the ECHO is performed in a cardiologist’s office. However, with advances in portable ultrasound technology, there is an emerging application for ECHO testing to be conducted by a front-line physician at a school’s sports medicine facility.2 At Northeastern University, a study5 was conducted utilizing this procedure and found that referral to a cardiologist was reduced by 33 percent. There were no differences between measurements obtained by the school’s physician and an outside cardiologist. In addition, research currently in review found the portable ECHO procedure to be significantly quicker than a traditional history and physical or ECG.2 This finding could potentially lead the way to a more thorough and efficient PPE process.

The costs associated with cardiac screening will always be a point of contention, but results of the previously discussed research are going to shift the discussion in a new way. It is not yet known if on-site portable ECHO testing will be a cost saving measure.  However, in theory, a reduction in unnecessary referrals should reduce the overall cost of screening. Moreover, clinicians will have the added benefit of being able to visualize conditions that can result in SCD, instead of trying to infer their presence from electrical activity alone. If we are to continue advocating for access to advanced cardiac screening, future efforts should be focused on methods and services that provide a more efficient and accurate assessment.


1. Maron BJ, Thompson PD, Ackerman MJ, et al. Recommendations and considerations related to preparticipation screening for cardiovascular abnormalities in competitive athletes: 2007 update: a scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism: endorsed by the American College of Cardiology Foundation. Circulation. 2007;115(12):1643-1455.

2. Kerkhof D, Gleason C, Basilico F, Corrado G. Is there a role for limited echocardiography during the preparticipation physical examination?. PM & R: The Journal of Injury, Function, And Rehabilitation. March 2016;8(3 Suppl):S36-S44.

3. Maron B, Friedman R, Thompson P, et al. Assessment of the 12-lead ECG as a screening test for detection of cardiovascular disease in healthy general populations of young people (12-25 Years of Age): a scientific statement from the American Heart Association and the American College of Cardiology. Circulation.2014;130(15):1303-1334.

4. Hainline B, Drezner J, Thompson P, et al. Interassociation consensus statement on cardiovascular care of college student-athletes. Journal Of The American College Of Cardiology. 2016;67(25):2981-2995.

5. Yim E, Basilico F, Corrado G. Early screening for cardiovascular abnormalities with preparticipation echocardiography: utility of focused physician-operated echocardiography in preparticipation screening of athletes. Journal Of Ultrasound In Medicine: Official Journal Of The American Institute Of Ultrasound In Medicine.2014;33(2):307-313.

About the Author

Mike McKenney is an Athletic Trainer (AT) at Northeastern University in Boston, Massachusetts, where he is the Medical Coordinator for their Division I men’s ice hockey program.  Prior to Northeastern University, he served as an AT in multiple settings including secondary schools, Division I athletics and professional cycling; additionally, he worked as an AT who extends the services of a physician for a large orthopedic group.  He has also provided services for many organizations to include the Boston Marathon, USA Cycling and USA Volleyball.

McKenney is a hydration and electrolyte replacement consultant for the Atlanta Hawks of the NBA.  His professional interests include hydration, electrolyte replacement, thermoregulation in sport and postural restoration.  McKenney completed his athletic training education at Gustavus Adolphus College in Saint Peter, Minnesota and master’s degree at North Dakota State University in Fargo, North Dakota.  His graduate research was published in the February 2015 edition of the Journal of Athletic Training.