The Redwoods Group
Articles of Interest Series
Topic: PROTECT YOURSELF AND YOUR ATHLETES BY REQUIRING PROPERLY FITTED MOUTHGUARD'S AS STANDARD EQUIPMENT
Michael D. Kurtz, DDS & Richard F. Breitweiser, ESQ
This article will focus on the most common elements of a cause of action brought by injured athletes against their coach, an example of a case brought against a coach for dental injuries, ADA statistics on dental injuries, and the importance in having a custom fitted mouthguard to prevent serious injury.
BASIS FOR LIABILITY
Because the coach has the most direct control over participants in their respective sports, they are normally the targets of lawsuits when injuries occur. The basis for liability is generally negligence.
A cause of action for negligence requires: (1) a duty of care requiring the coach to conform to a standard of conduct that protects participants from unreasonable risk of harm; (2) a breach of that duty (i.e., the coaches' failure to conform to the standard of conduct); (3) a causal connection between the breach of the duty and the resulting injury (i.e., proximate cause and cause in fact); and (4) resulting injury or damages.(1)
The most critical factor in determining whether a coach is liable for injuries to his players is whether the coach breached the requisite duty of care. In general, coaches have a duty to exercise reasonable care to prevent foreseeable risks of harm to others. Various specific duties have emerged: (1) supervision; (2) training and instruction; (3) ensuring the proper use of safety equipment; (4) providing competent and reasonable personnel; (5) warning of latent dangers; (6) providing prompt and proper medical care; (7) preventing injured athletes from competing; and (8) matching athletes of similar competitive levels(2). We will focus on the proper use of mouthguards as safety equipment.
ENSURING THE PROPER USE OF SAFETY EQUIPMENT
Coaches are responsible for ensuring that participants have both proper and reasonable safety equipment to compete in games and practices. If the player does not have the proper equipment, the coach may be compelled to prohibit the player from participating in the game. The coach should establish procedures to inspect players' equipment before the players engage in the activity to ensure that the players are using proper and non-defective equipment. (3)
COACH BLAMED FOR DENTAL INJURY
On September 29, 1989, a 16 year-old female student at Briarcliff Manor High School, New York, was struck in the mouth and sustained dental injuries while participating in a field hockey varsity practice. She was not wearing her mouthguard and brought a negligence action against the school and her coach(4). Briarcliff argued that the suit should be dismissed because she assumed the risk of injury by participating in the sport and by not wearing her mouthguard.
The New York court held that the school failed in its responsibility to exercise reasonable care in properly supervising students as well as instructing them as to the significance of safety equipment. It was the Court's opinion that the Coach should have given safety instructions regarding mouthguards and failed to advise the student of the risks involved in not wearing a mouthguard. The court accepted an affidavit of an expert in scholastic sports. It stated: "It is the duty of the Coach to check safety equipment before the start of each practice session and make sure it is used. Failure to monitor and enforce wearing of safety equipment is contrary to sound coaching practices. Extensive discussions must take place between coaches and students concerning all aspects of safety. Written material must be given to the players to review and much time must be devoted to the dangers involved in the sport. The importance of wearing a mouthguard and the risks and dangers of failing to wear one must be explained by the coach to the players." (5)
NEITHER THE PARTICIPANT OR COACH SHOULD BE THE VICTIM OF A PREVENTABLE INJURY
No matter what sport you are coaching or participating in, there is always a risk of injury. Mouthguards have historically been used in contact sports such as football, boxing, ice hockey, lacrosse and field hockey. Mouthguards help cushion blows that may otherwise cause broken teeth and injuries to the lips, tongue, face or jaw. Their role in preventing and lessening the degree and severity of other important medical injuries is noteworthy.
According to the American Dental Association (ADA)(6), before facemasks and mouthguards were worn in football, half of all injuries occurred in or around a player's mouth. There was a one-in-ten chance of receiving a mouth injury during the playing season. With the advent of mouthguards, over 200,000 football injuries to the mouth and face have been prevented each year.
However, you don't have to be coaching or participating in football or hockey to benefit from a mouthguard. New findings in sports dentistry show that even in non-contact sports, such as gymnastics, mouthguards help protect participants.
The ADA and the Academy for Sports Dentistry(7) recommend mouthguards for the following sports:
Acrobatics Gymnastics Skiing Bandi Handball Skydiving Baseball Ice Hockey Soccer Basketball Inline Skating Softball Bicycling Lacrosse Squash Boxing Martial Arts Surfing Equestrian Events Racquetball Volleyball Field Events Rugby Water Polo Field Hockey Shotputting Weightlifting Football Skateboarding WrestlingTHE ADVANTAGES OF A CUSTOM-FITTED MOUTHGUARD
Custom-fitted Athletic mouthguards (D9941) are fabricated on stone models made from a dental impression. Unlike stock mouthguards or mouth-formed (boil & bite) mouthguards they cannot be purchased off-the-shelf at any store. Neither can they be obtained by a consumer through mail order. A licensed dentist is required to properly fit the mouthguard to the athlete (not the athlete to the mouthguard as is the case with one- size-fits-all over-the-counter imposters. A properly fitted mouthguard should be snug enough to stay in place even when your mouth is open and you are on the move. In many cases this means that an athlete can participate vigorously without having to keep their teeth together. Besides protecting your teeth against injury, custom mouthguards are important for several other reasons. They have been shown to reduce the risk and degree of severity of other injuries as well. Most notably the list includes: cervical injuries, TMJ injuries and jaw fractures and cerebral concussions.
CERVICAL INJURIES
Dr. John Stenger's classic 5-year clinical study on Notre Dame football players began in 1958 and was published in 1964(8). Dr. Stenger, the initiator of the concept of physiologic dentistry, based much of his work on that of James B. Costen, MD, a Washington University otolaryngologist(9). By means of before and after cephalometric radiographic tracings, Stenger demonstrated differences in the position of the mandibular condyle, the hyoid bone, and the cervical vertebrae (C2-C4) when the teeth were in centric occlusion versus when the bite was opened by a custom-made mouthguard to the vertical dimension of the freeway space (approximately 2-4 mm).
In the spring of 1963, with the encouragement of then trainer Gene Paszkiet, a decision was made to equip the entire Notre Dame football team with a new model ethylene vinyl acetate (EVA) mouthguard. As expected, the number of injuries to the teeth and jaws declined. There was also an impressive reduction in cerebral concussions. A serendipitous correlation between wearing the mouthguards and a decrease in neck injuries was an important finding.(10;11) A reduction in the number of neck injuries was an unexpected result of wearing the mouthguards. Neck injuries had increased since the use of the face bar had become mandatory. During the 1962 season at Notre Dame, six or seven players had chronic neck problems, and four of them wore cervical collars. Cervical traction was routine therapy for these players. An automatic traction device was ordered by the athletic department and delivered during the summer to replace the manual one in use. Fortunately, because of the mouthguards worn by the players prone to neck injuries, the new machine, ordered in anticipation of more injuries, has never been unpacked. Furthermore, not a single Notre Dame player who faithfully wore his mouthguard during the 1963 season found it necessary to wear a cervical collar."(12;13)
CEREBRAL CONCUSSIONS
Cerebral concussion may be defined as a trauma-induced alteration in mental status that may or may not involve loss of consciousness(14). Confusion and amnesia can accompany concussion. Recognition of concussion is imperative for coaches, trainers and allied healthcare personnel so athletes in need receive prompt evaluation and treatment by an appropriate physician.
Hickey, et al, studied the relation of two custom-fabricated mouth protectors to cranial pressure and bone deformation in 1967(15). An impact-producing mechanism was used to deliver uniform blows to the inferior border of the chin on an intact male cadaver. Results indicated a significant reduction in both the amplitude and duration of the intracranial pressure wave when a mouth protector was in place as compared to when the teeth were together in centric occlusion. A similar reduction in temporal bone deformation as measured by a strain gauge was observed. The results were extrapolated by the authors to conclude that custom-fitted mouthguards were an effective means of reducing cerebral concussions in contact sports. “…the primary cause of concussion is shear stress in the brain stem area immediately over the foramen magnum. This shear stress is produced whenever dynamic pressures are set up within the cranial cavity. The magnitude of the shear stress is dependent on the magnitude of the pressure produced and its duration."(16) According to the American Academy of Neurology's Practice Parameter concussions are graded into mild, moderate and severe classifications(17). A Grade 1 (mild concussion) is characterized by no loss of consciousness, transient confusion, concussion symptoms or mental status abnormalities of less than 15 minutes duration versus Grade 2 (moderate concussion) of more than 15 minutes duration. Grade 3 (severe concussion) involves any loss of consciousness.
Symptoms of concussion are divided into early and late categories(18). Early symptoms include headache, dizziness or vertigo, lack of awareness of surroundings, nausea and vomiting. Late symptoms include: persistent low-grade headache, lightheadedness, poor attention and concentration, memory dysfunction, easy fatigability, irritability and low frustration tolerance, intolerance of bright lights, difficulty focusing vision, intolerance of loud noises, sometimes ringing in the ears (“bell ringer”), anxiety and depressed mood, and sleep disturbances.
Neuro-behavioral features of concussion include: vacant stare, gross observable incoordination, befuddled facial expression, stumbling, inability to walk tandem / straight line, delayed verbal and motor responses, emotionality out of proportion to circumstances, slow to answer questions or follow instructions, distraught, crying for no apparent reason, confusion and inability to focus attention, any period of loss of consciousness, easily distracted and unable to follow through with normal activities, paralytic coma, unresponsiveness to arousal, disorientation memory deficits, walking in the wrong direction, unaware of time, date and place, asking the same question, inability to memorize, slurred or incoherent speech and recall 3 of 3 words or 3 of 3 objects in 5 minutes.
The American Academy of Neurology arrived at a consensus practice parameter on the management of concussion in sports(19) summarized in the table below and endorsed by 14 medical and athletic organizations. These included: The American Academy of Orthopedic Surgeons, American Academy of Pediatrics, American Orthopedic Society for Sports Medicine, American Osteopathic Society for Sports Medicine, National Academy of Neuropsychology, International Neuropsychological Society, others.
| AAN Practice Parameter on the Management of Concussion in Sports10 ( Abbreviated from Neurology 48: 581-585, 1997) |
|
Grade 1 (mild concussion) |
|
Grade 2 (moderate concussion) |
|
Grade 3 (severe concussion) |
Cerebral concussion is a common injury among football players being the fifth most common injury in college football.(20) Football helmets are intuitively the sports safety equipment first line of defense against concussion. Several studies over the past 25 years have reported the incidence of concussions in football players. In one study, “data allowed a look at the impact of a history of cerebral concussion within the previous 5 years on the risk of sustaining another concussion. During this period 2.1% of the players with no previous history of cerebral concussion suffered a new concussion, while 12.2% of the players with a previous history suffered a new concussion. Thus, those players with a history of cerebral concussion any time during the previous 5 years were six times as likely to incur a new concussion. Further analyses showed that this result was not affected by player position or type of play at the time of injury. …Epidemiological studies of field performance data in the future should become an integral part of the process of monitoring the performance of critical sports safety equipment"(21)
It is important to note that the practice of returning to play even after minor head injuries must be reconsidered in view of clinicians who have reported “second impact” fatalities in football players. It is believed that an initial concussive event in some individuals may cause swelling and loss of compliance in brain tissue. A subsequent head injury before complete recovery may lead to further swelling and death.(22;23) The deaths of several boxers, football players and hockey players have been ascribed to Second Impact Syndrome (SIS).(24) The CDC in Atlanta unofficially estimates that there are approximately 500 deaths from sports-related traumatic brain injuries each year. In 1997 they also estimated 300,000 sports-related cerebral concussions occur each year in the United States.(25) "It is time for the sports medicine community to reconsider the current practice of sending a player back in as soon as he or she can see straight (and the athletic trainer may have to bear the brunt of that burden)."(26)
Certainly, properly fitted custom athletic mouthguards have contributed significantly in helping to reduce the number and severity of concussions in football and other contact sports like boxing, wrestling, martial arts and hockey. Their value in sporting activities like bicycling, inline skating and skateboarding is just now beginning to be realized. Prevention of dental sports injuries makes economic sense too.
FOR FURTHER INFORMATION
The Academy for Sports Dentistry was founded in 1983 in San Antonio, Texas, as a forum for dentists, physicians, trainers, coaches, dental technicians, and educators interested in exchanging ideas related to Sports Dentistry and the dental needs of athletes at risk to sports' injuries. Activities include the collection and dissemination of information on dental athletic injuries and the encouragement of research on the prevention of dental injuries to athletes.
The reader is invited to explore the following interesting web sites:
SportsDDS.com
Academy for Sports Dentistry
National Athletic Trainers Association
SOURCES
1. - W. Page Keeton Et al., Prosser and Keeton on the Law of Torts § 30, at 164-65 (5th ed. 1984) Back To Article
2. - Anthony S. McCaskey & Kenneth W. Biedzynski, Coaches' Liability, 6:1, Seton Hall Journal of Sports Law (1996) Back To Article
3. - Id. at 26. Back To Article
4. - Baker v. Briarcliff School District, 613 N.Y.S. 2d 660 ) N.Y. App. Div. 1994) Back To Article
5. - Id. at 663 Back To Article
6. - For more information, see http://www.ADA.org Back To Article
7. - For more information, see http://www.acadsportsdent.org Back To Article
8. - Stenger, J et al, Mouthguards: Protection Against Shock to Head, Neck and Teeth, JADA, Vol 69, Sept 1964, pp 273-281. Back To Article
9. - Costen J, Neuralgias and ear symptoms involved in general diagnosis due to mandibular joint pathology, J Kansas Med Soc 315-321, 1935. Back To Article
10. - Stenger, J: Physiologic dentistry with Notre Dame athletes, Basal Facts 2(1):8-18, 1977. Back To Article
11. - Stenger, J et al, Mouthguards: Protection Against Shock to Head, Neck and Teeth, JADA, Vol 69, Sept 1964, pp 273-281. Back To Article
12. - Stenger, J et al, Mouthguards: Protection Against Shock to Head, Neck and Teeth, JADA, Vol 69, Sept 1964, pp 273-281. Back To Article
13. - Kurtz, Michael D., Camp, Joe H. & Andreasen, JO. Dental Injuries in Sports Medicine; Principles of Primary Care. C.V. Mosby Publishing Co, St. Louis, 147-174, 1997. Back To Article
14. - Kelly JP, Nichols JS, Filley CM, Lillehei KO, Rubinstein D, Kleinschmidt-Demasters BK. Concussion in sports: Guidelines for the prevention of catastrophic outcome. Journal of the American Medical Association 226: 2867-2869, 1991. Back To Article
15. - Hickey J, et al: The relation of mouth protectors to cranial pressure and deformation, JADA 74:735-740, 1967. Back To Article
16. - Gurdjian, ES and others. Intracanial pressures and acceleration accompanying head impacts in human cadavers. Surg Gynec Obstet 113:185 Aug., 1961. Back To Article
17. - American Academy of Neurology - Practice Parameter: The management of concussion in sports (summary statement). Neurology 48: 581-585, 1997 Back To Article
18. - Cantu, RC. Athletic head injuries. Clinics in Sports Medicine 16(3): 531-542, 1997. Back To Article
19. - American Academy of Neurology - Practice Parameter: The management of concussion in sports (summary statement). Neurology 48: 581-585, 1997 Back To Article
20. - Zemper ED. Injury rates in a national sample of college football teams: a two-year prospective study. Phys Sportsmed. November 1989;17:100-113. Back To Article
21. - Zemper E. Analysis of cerebral concussion frequency with the most commonly used models of football helmets. Journal of Athletic Training 29: 44-50, 1994. Back To Article
22. - Kelly JP, Nichols JS, Filley CM, Lillehei KO, Rubenstein D, Kleinschmidt-DeMasters BK. Concussion in sports: guidelines for the prevention of catastrophic outcome. JAMA. 1991 ;266:2867-2869. Back To Article
23. - Saunders RL, Harbaugh RE. The second impact in catastrophic contact sports head trauma. JAMA. 1984;252:538-539. Back To Article
24. - Mendonca D. Return to Contact Sports Following Concussion. Sports Medicine, http://publish.uwo.ca/~ahpandya/spprev.html Back To Article
25. - Centers for Disease Control and Prevention: Sports-related recurrent brain injuries: United States. MMWR 1997;46(10):224-227 Back To Article
26. - Zemper E. Analysis of cerebral concussion frequency with the most commonly used models of football helmets. Journal of Athletic Training 29: 44-50, 1994. Back To Article
ABOUT THE AUTHORS
Mike Kurtz
Mike Kurtz' grew up in Sunnyside, Queens. He attended P.S. 150 until fourth grade. In 1959 the family relocated to Hollis Park Gardens where he went to General Nathaniel Woodhull School (P.S. 35). A product of the New York City public school system he completed programs at Queens Village JHS 109 (1966) and Jamaica High School (1969). Afterward he pursued simultaneous studies at Boston and Harvard Universities. Dr. Kurtz is a graduate of Columbia's School of Dental and Oral Surgery (1977) where he is a member of the Faculty and an Officer of the University. An expert in the history of dentistry, Dr. Kurtz is renowned for his Award Winning article, "Columbia University; And Those That Made It the Mecca of Dental Education." In 1986, he donated an impressive collection of rare medical & dental books to Columbia's Augustus Long Health Sciences Library. Dr. Kurtz is also a former Board Member of the American Red Cross.
For almost 10 years, Dr. Kurtz was an independent consulting dentist to St. John's University. Under Coach Lou Carnesecca, HOF '92, he cared for members of the elite 1985 "Redmen" Basketball Team. That team made it to the NCAA Final Four. He is author of a major textbook chapter in Mosby's Sports Medicine; Principles of Primary Care. This became the genesis for his trademark Internet handle; SportsDDS.com .
Michael D. Kurtz' interests in electronics and computer networks have earned him recognition from Harvard, MIT, RPI, NYU and AT&T Bell Labs. As a past President of the Union Turnpike Merchants Association Dr. Kurtz used his technical abilities to encourage members to adopt e-mail as their official means of communication. He pioneered one of the first major merchant association web sites in New York City. The New York Times, Newsday and New York Daily News acclaimed its sophistication.
Mike Kurtz is an advocate for Parks and an environmentalist. NYC Parks Commissioner Henry Stern (Starquest) conferred the honorary name of "Shorty" upon him. Dr. Kurtz serves as Second VP to Friends of Cunningham Park and is a supporter of APEC.
As a photojournalist, his lens has captured everything from presidents, international dignitaries and clergy to victims of the Colombian Earthquake of 1999. This year he is recipient of a New York Press Association Award for Spot News Coverage of Swissair Disaster Flight #111. His unforgettable photos of Peggy's Cove, Nova Scotia appeared in the Queens Courier Newspaper.
On June 8th, 1999 he served as Distinguished Honoree for the NY World's Fair Commemorative Gala on behalf of Queens Museum of Art. Dr. Kurtz was awarded the coveted Winged Victory. Honorees have included: Hon. Rudolph Giuliani, Mayor of the City of New York; Esther Silver-Parker, President of the AT&T Foundation; Thomas Hoving, Jr., Director, Metropolitan Museum of Art; David Marmion, President, United States Tennis Association; Hon. Claire Shulman, President of the Borough of Queens. Dr. Kurtz was personally congratulated by the Hon. Sheldon S. Leffler, NYC Council Member, Hon. Nita M. Lowey, Member of Congress, Hon. Gregory W. Meeks, Member of Congress and First Lady Hillary Rodham Clinton.
He considers himself the lucky father of four terrific kids: Marina Lee, Adrienne Dorothy, Jefferson Adams and Nina Maria.
Richard F. Breitweiser
Richard F. Breitweiser joined the Redwoods Group in October 1999 as the Vice President of Claims and Director of the Dental Program. Prior to Redwoods, Rick spent 10 years as the Claim Manager of the Professional Liability Department of Risk Enterprise Management (formerly The Home Insurance Company). While Claim Manager, Rick oversaw a large professional liability unit that handled multiple professional liability lines in all States. Rick was also instrumental in the development and implementation of claim handling “best practices” and quality assurance. Prior to REM/The Home, Rick practiced law in the State of New Jersey and held various claim management positions with Crum and Forster and CIGNA.
Rick is a 1981 cum laude graduate of Upsala College and a 1988 cum laude graduate of Seton Hall University School of Law. Rick is admitted to practice law in the State of New Jersey and the U.S. District Court. Rick is a 3 time US Adult National Figure Skating medalist and a 3 time ISI World medalist. In 1995, Rick was the recipient of the Governor's Trophy (NJ) for his accomplishments in figure skating.
Rick resides in New Jersey with his wife, Nancy and two children, William and Kyra.
