Dental Injuries In Children Research Articles

Traumatic Dental Injuries in Children and Adolescents from a Major Dental Clinic in Bosnia and Herzegovina: A 5-Year Retrospective Study

The aim of this study was to investigate the epidemiology of dental trauma in a public dental clinic in Banja Luka, Bosnia and Herzegovina, from 2019 to 2024. Methods: This research was conducted as a retrospective cross-sectional study. The data were analysed and compared between injured primary and permanent maxillary and mandibular teeth. Results: The review of the dental records revealed 73 patients (49 boys and 24 girls) with TDIs, involving 55 primary and 64 permanent teeth. Most of the patients (27 patients, 36.98%) were aged 7–9 years. The main cause of TDI was falls in both dentitions (81.81% of injured primary teeth and 73.43% of injured permanent teeth). The time of arrival after a TDI for assistance in the dental clinic for most cases was after 24 h in both dentitions, 45.45% of injured primary teeth and 48.43% of permanent teeth. For both dentitions, enamel fractures were the most common injury of hard dental tissues and the pulp, and the necrosis of the maxillary central incisor was the most common complication. Conclusions: It is very important to improve trauma management and increase public knowledge on the way parents seek proper treatment for the TDIs of their children, and in due time.

Individual and contextual determinants associated with traumatic dental injuries in children eight to ten years of age: a multilevel analysis.

Investigate individual and contextual determinants associated with traumatic dental injuries in schoolchildren. A cross-sectional study with 739 pairs of parents and children. Parents answered a sociodemographic questionnaire, the Family Adaptability and Cohesion Evaluation Scale and a questionnaire on the child's use of electronic devices. Examinations of the children were conducted at the school by calibrated examiners using the diagnostic criteria proposed by Andreasen. Contextual variables of the school were also collected. Multilevel Poisson regression for complex samples was performed (p < 0.05). The individual factors associated with the outcome were children of single parents (PR = 2.33; 95% CI: 1.79-2.66), practice of sports (PR = 2.46; 95% CI: 1.70-3.22), the daily use of electronic devices (PR = 1.78; 95% CI: 1.31-1.81), more than 2 h per day of screen time (PR = 3.84; 95% CI: 1.94-4.28) and chaotic family adaptability (PR = 4.22; 95% CI: 3.44-4.99). The contextual variables were studying at a public school (PR = 1.77; 95% CI: 1.02-3.05) and the presence of rigid floor in the school courtyard (PR = 1.99; 95% CI: 1.15-3.15). Individual determinants, studying at a public school and the presence of rigid floor in the school courtyard were associated with traumatic dental.

Patterns and characteristics of traumatic dental injuries in children – a retrospective study in a dental hospital in Kolkata, India

Introduction and aim. Traumatic dental injuries (TDIs) in children can have aesthetic, functional, and psychological conse quences. This retrospective study aimed to investigate the epidemiology and patterns of TDIs in a hospital-based population. Material and methods. Patient records from the Department of pediatric and Preventive Dentistry in a dental college and hospital in Kolkata, India, were reviewed. A total of 381 patients, aged 1 to 12 years, who presented one or more traumatized an terior teeth between September 2018 and August 2022, were included. Data on age, sex, mechanism of injury, type of trauma, dentition type, and number of affected teeth were collected. The World Health Organization classification system was used to classify the type of dental trauma. Results. Among the study population, there were 235 males (61.7%) and 146 females (38.3%), with a mean age of 7.67±3.87 years. Falls were the most common cause of trauma (52.2%). The maxillary central incisors were the most frequently affected teeth in both primary and permanent dentitions. Conclusion. Falls were the most common cause of trauma and the maxillary central incisors were the most commonly affected teeth in children.

Management of Lateral Luxation Injury in a 3½-year-old Boy

This case report documents the trauma and follow-up care of lateral luxation injury of upper central incisors in a 3½-year-old boy. Traumatic dental injuries in children occur very frequently and lateral luxation is a kind of injury in which the tooth is displaced in either labial or palatal/lingual direction. Lateral luxation injuries are one of the most severe periodontal injuries in dental trauma. A correct diagnosis followed by repositioning of the tooth in the right position is fundamental to the periodontal ligament healing. A 3½-year-old boy reported with a fall on his upper front tooth while laying at home and his upper central incisors got laterally luxated. The teeth were repositioned by digital pressure subsequently, on finding necrotic changes pulpectomy was performed in 51 and 61. Clinical and radiographic follow-up of 7 months is presented showing uneventful healing. Immediate repositioning along with occlusal relief, endodontic management, and proper follow-up with adequate patient engagement can be considered for treating lateral luxation injury.

The Impact of COVID-19 Pandemic on the Pattern and Presentation of Traumatic Dental Injuries in Children in a Tertiary Health Institution.

COVID-19 pandemic brought adaptive changes in lifestyle with possible impact on the incidence of traumatic dental injuries. This study compared the presentation and pattern of traumatic dental injuries in children during the pre-COVID-19 and COVID-19 pandemic periods. This was a retrospective study done using clinical records of children aged 16 years and below who presented at the paediatric dental clinic of the University of Port Harcourt Teaching Hospital. Information such as demographics, aetiology, type of injuries, and dentition type were elicited from the 1284 clinical records from March 2019 to February 2021. Data were analysed and the level of significance was set at P ≤ 0.05. One hundred (7.8%) patients presented with traumatic dental injuries (TDIs; 71 [8.5%] and 29 [6.5%] pre-pandemic [March 2019 to February 2020] and pandemic periods [March 2020 to February 2021], respectively) and their mean age was 7.0 (±4.2) years. The male-to-female ratio before and during the pandemic periods was 1.54:1 and 1.42:1, respectively. The commonest aetiology and type of TDI were falls 82 (82%) and injuries to tooth-supporting structures 45 (45%), respectively. There were no statistically significant differences in sex (P = 0.86), aetiology (P = 0.31), type of TDI (P = 0.16), and dentition affected (P = 0.97) between the pre-pandemic and pandemic periods but the difference in the age groups was significant (P = 0.02). The incidence of TDIs was higher in the pre-pandemic period. The younger age group had more dental injuries than the older ones at both periods. This may be due to difficulty in enforcing restrictions on young children even during COVID-19 restrictions.

Research hotspots for pediatric fractures from 2017 to 2022: A bibliometric and visual analysis via Citespace.

This review provides guidance and ideas for researchers through a comprehensive and comparative analysis of the present state, trends, and hotspots in the pediatric fracture literature over the past 6 years. We used Citespace 6.1.R6 software to explore the country/region distribution, institutions, journals, keyword analysis, and co-cited references of the literature from Web of Science core database. There are 6472 pieces of pediatric fracture-related literature, including 2962 from 2017 to 2019 and 3510 from 2020 to 2022. The country with the most papers is the United States, and US institutions and journals also have a pivotal position in this field. Research hotspots for pediatric fractures in 2017-2019: The topic with the most attention is bone mineral density leading to related bone diseases. Treatment for pediatric fractures, including supracondylar humeral fractures, Monteggia fractures, forearm fractures, knee fractures, and ankle fractures in children, is another topic of greater interest. Brain injuries and dental injuries in children due to abuse and trauma are also concerning issues. Research hotspots for pediatric fractures in 2020-2022: comparison with 2017-2019 revealed a relative decrease regarding ankle-related epiphyseal injuries, but there is a higher focus on the epidemiology of fractures in children, risk factors, and reasons for childhood trauma. We have confirmed through literature co-citations that the literature of high interest is also in these aspects. Researchers and clinicians can quickly learn about topics of interest through authoritative journals and highly cited literature and rapidly master the current status and frontiers of the field through study, providing ideas for future work.

Aesthetic dental rehabilitation of children after dental trauma to anterior teeth with pulp chamber exposure. A clinical case

Relevance. The prevalence of dental injuries in children reaches 52.3%, based on age. Currently, the number of traumas of anterior maxillary teeth tends to increase. The search and application of the most optimal treatment options for dental injuries in an aesthetic area in children remains relevant.Description of the clinical case. The article presents the treatment results of an 8-year-old boy diagnosed with S02.52 according to ICD-10: fracture of the crown of tooth 2.1 within the enamel, dentin layers with pulp involvement. Vital amputation of the crown pulp with a direct pulp capping with "Rutdent", an MTA-based product, was chosen as the tactic of dental care. A tooth fragment was attached with a composite material (using an adhesive protocol) for aesthetic rehabilitation. The function and aesthetics of the tooth were restored. The result was stable six months after the treatment.Conclusion. The popularization of various sports events can lead to an increase in the incidence of dental traumas to anterior teeth in children. A pediatric dentist should be able to apply modern methods of diagnosing acute dental trauma to make the correct diagnosis and choose the optimal treatment method. The opportunities of modern pediatric dentistry allow the restoration of all dental functions lost during trauma: anatomical, aesthetic and physiological.

Improving data quality from routine clinical appointments-Development of a minimum dataset for traumatic dental injuries in children and adolescents.

It is currently difficult to evaluate the success or not of treatment for dental injuries due to poor recording of diagnostic and treatment codes in clinical dentistry. A minimum dataset comprises a standardised minimum set of outcomes along with a specified outcome measurement instrument, to allow aggregated use of data from routine clinical care appointments. This study aimed to determine which outcomes should be included in a minimum dataset for traumatic dental injuries (TDI). This is a three-stage sequential, mixed-methods study, using evidence-based best practice for dataset development. Normalisation process theory informed the development of the study protocols. In Stage 1, semi-structured interviews with patients and their parent or guardian were undertaken to identify outcomes of importance to patients. In Stage 2, an online Delphi survey was undertaken to identify outcomes of importance to clinicians. In Stage 3, a National Consensus Meeting was undertaken involving patient representatives, clinicians and other stakeholders, to agree which outcomes should be included in the minimum dataset. Stage 1: Eleven participants were recruited, five children and six parents. Two key themes emerged from the analysis-communication and aesthetics. In Stage 2, 34 dentists were recruited, and 32 completed both rounds of the survey (97% retention). Most outcomes were deemed by participants to be of 'critical importance', with three outcomes deemed 'important' and none to be 'of limited importance'. In Stage 3, 15 participants took part in the consensus meeting. Participants agreed that the dataset should comprise a list of clinician-important outcomes (pulp healing, periodontal healing, discolouration, tooth loss) and a list of patient-important outcomes (communication, aesthetics, pain, quality of life). A Minimum Dataset for TDI has been developed using a robust and transparent methodology.

Traumatic dental injuries in children: experience during the Covid-19 pandemic and parents' knowledge about their management.

The social isolation measures adopted during the critical phase of the COVID-19 pandemic led children to spend most of their time at home. Isolation may alter the pattern of traumatic dental injury occurrences, inasmuch as studies point out that most traumatic accidents occur at home. Considering this scenario and the influence of emergency management on the prognosis of the injury, the aim of this study was to evaluate the experience of traumatic dental injuries in children before and during the pandemic, and the knowledge of this topic by the children's guardians. This cross-sectional study was conducted with guardians of children aged 0 to 6 years, residing in Juiz de Fora, MG, Brazil. The guardians answered an online questionnaire addressing personal information, traumatic dental injury experience before and during the pandemic, and knowledge of this topic. Descriptive and statistical analyses were performed using Pearson's chi-square test at a 5% significance level. The total sample consisted of 343 volunteers. A total of 95 and 92 injuries were reported before and during the pandemic, respectively; the home was the place of greatest occurrence. Most volunteers (88.1%) agreed that traumatic dental injuries are emergency situations, and were aware that the tooth/fragment had to be taken to the dentist after a fracture or avulsion (97.4%). This study revealed that the traumatic dental injury experience was similar before and during the pandemic, and that the volunteers had satisfactory knowledge, especially in recognizing the importance of immediate attention for a more favorable prognosis of these injuries.

Benefits and Risks of Orthodontic Treatment: A Systematic Review

Background: Malocclusion is one of the main problems of oral and dental health, ranked third after caries and periodontal diseases. In Asian population, the percentage of class II and III Angle malocclusion is 21.42% and 5.76% respectively. Thus, orthodontic treatment is still needed by the people. However, not every patient knows the potential risks that orthodontic treatment, and whether the treatment will bring them benefits they want to achieve. Purpose: this study aimed to describe benefits and risks of orthodontic treatment on the patient and operator through scooping review. Review(s): The search of literatures show that orthodontic treatment increases patient’s oral health related quality of life, reducing the risk of traumatic dental injuries in children with large overjet, and reducing the incident of muscle tenderness, and myofascial pain. However, orthodontic treatment poses the risk of damage to the teeth, oral and mucosal pain, speech problems, allergic reactions, and orthodontics relapse. Conclusion: Orthodontic treatment can provide benefits to patients’ oral health related quality of life, as well as reducing the incidence of temporomandibular disorder and traumatic dental injuries in children with large overjet. But these benefits must outweigh the risks that can occur in the patient such as teeth damage, oral and mucosal pain, speech problems, allergic reactions, and the probability of relapse must also be minimized.

Prevalence, Etiology, and Risk Factors of Traumatic Dental Injuries in Children with Special Needs of Puducherry.

Background/aimDental trauma draws attention in special children due to its risks and consequences. The aim of this study was to estimate the prevalence, etiology, and risk factors of traumatic dental injuries in children with special healthcare needs of Puducherry.Materials and methodsA cross-sectional survey among 121 special children aged 4–18 years was carried out in Puducherry. The children were examined for the presence of traumatic dental injuries (TDI) and associated risk factors for the occurrence of trauma and classified according to the WHO epidemiological field survey classification.ResultsPrevalence of TDI was 40.5%. The majority of them were restricted to enamel fractures and the most commonly affected were permanent maxillary central incisors. The most common cause of injury was ˝falling over˝ and home was the frequent place of injury to occur. The risk factors associated with TDI were mesoprosopic facial form, convex facial profile, increased overjet, Angles Class II molar relationship, posterior facial divergence, and incompetent lips which were statistically significant.ConclusionThe study concludes the prevalence of TDI is more prevalent in CSHCN, thereby it is necessary to create awareness, health education, and periodic screening for efficient treatment.How to cite this articleMartin AG, GS Prathima, Sanguida A, et al. Prevalence, Etiology, and Risk Factors of Traumatic Dental Injuries in Children with Special Needs of Puducherry. Int J Clin Pediatr Dent 2022;15(1):104–108.

Educational Dental Program and Its Impact on Emergency Management of Traumatic Dental Injuries in Children

Educational Dental Program and Its Impact on Emergency Management of Traumatic Dental Injuries in Children

Replacement Resorption in Children: The Root of All Evil?

Replacement resorption is a common complicating factor in teeth that have been avulsed or intruded. Poor short- and long-term management of dental injuries in children can have a significant impact on a child's dental function, aesthetics and ultimately their quality of life. This article aims to provide clarity on the physiological process of replacement resorption, the clinical presentation and an overview of interceptive treatment that is available.

Cross-sectional cohort study on the use of mouthguards by children playing Gaelic football in Ireland.

Up to 40% of dental injuries in children occur during sports and may be prevented by using mouthguards (MG). The use of mouthguards is mandatory in some sporting organizations. Knowledge of the benefits of protection does not always result in mouthguard use. The aim of this observational cross-sectional cohort study was to measure and compare knowledge of 9-16-year-old Gaelic football players and their parents on MG use and compliance with MG rules. A convenience sample of players and their parents was identified and were assessed at their sports facility. Parents completed a questionnaire while children were asked standardized questions and MG type was verified by a dentist. Data were analysed using descriptive statistics and binary logistic regression analysis for comparison. One hundred and twenty-one children with 118 parents participated in the study. According to players, MG use during competition (N = 119, 99.2%) was greater than during training (N = 97, 80.8%). As age increased, children were less likely to comply with MG rules during training (OR =0.18, p<.001). Children played a median of 2 contact sports (IQR=1). Only 32 parents (27.1%) and 17 children (14%) reported that the child wore a MG for all sports. Only four children (3.8%) had a custom MG even though most parents (N=87, 73.7%) believed that they provided superior protection. Knowledge of players and their parents on how to care for the MG was variable. Compliance with the Gaelic Atheletic Association's MG rules was lower during training than competition. Children were less likely to comply with MG rules during training as they grew older. Most parents believed a custom MG would best protect their child's teeth, yet few children had a custom MG. Players and parents had variable knowledge in relation to MG hygiene.

Causes of primary tooth avulsion and replantation treatment

During primary dentition, the etiology changes by age group. For instance, traumas secondary to collisions and falls are attributable to early movement within the first six years, while accidents secondary to frequent playing are the main reason within the following nine years, and violence is the most common etiology until the age of 25 years old. Previous studies have estimated that traumas from falls, sporting activities, bicycling, traffic accidents, and violence were the most common causes of dental injuries in children. Iatrogenic causes also contribute to 0.04-12% of dental injuries, including avulsions. According to the current evidence, whether to use reimplantation or not is still controversial and further investigations are needed. Among the various case reports, damage to the permanent successors, root resorption, clot formation, and pulp necrosis were documented as potential complications and adverse events with intended reimplantation. However, many techniques were reported to overcome these problems. Besides, favorable outcomes following reimplantation could be hypothetically obtained as sound articulation, proper mastication, and proper dentition. Therefore, this encourages reimplantation, however, further evidence is still needed to validate the proposed advantages and disadvantages of the approach.

Reliability of information on YouTube™ regarding pediatric dental trauma.

Traumatic dental injuries are a common health problem in children. The aim of this study was to evaluate the quality of the video contents on YouTube™ regarding traumatic dental injuries in children taking into account the information of IADT, and to analyze whether it is useful for patients and dentists. A search was performed on YouTube™ using the search term "trauma in pediatric dentistry" with the default filter set to "sort by relevance". Based on this search, 127 videos were included. Demographic data such as the source, type, duration, upload date, number of likes and dislikes, interaction index, and viewing rate of the videos were recorded. Using a 23-point scale for video content analysis, they were classified into groups as low, moderate, and high content. A total of 127 videos were analyzed. Most of the videos were uploaded by healthcare professionals (n=90; 70.8%). The average length of the videos was 16.4min (range: 0.6-122.9min; median: 7.8). The average number of views of each video was 3702.9 views (range: 4-87 103). The average interaction index (views/day) was 2.4 views (range: 0.00-19.5). The average viewing rate was 522.3 (range: 1.8-6381.2). The average number of "likes" was 45.0 (range: 0-619) and the average number of "dislikes" was 2.1 (range: 0-81). The mean number of days since the uploading of the video was 772.8days (range: 23-3805). Most of the videos (94.4%, n=120) were educational videos and 27 (21.2%), 40 (31.4%), and 60 (47.2%) were classified as high-content, moderate-content, and low-content groups, respectively. YouTube™ videos can be a useful resource for dental trauma in children. However, there is a need to improve the quality of YouTube™ videos uploaded by oral health professionals.

English

BACKGROUND Every child is prone to traumatic injuries, the impact of these injuries is directly related to the intensity, force and direction from which the trauma is inflicted. Trauma to the oral cavity is rather more common in children and adolescents as compared to the adult population. Since dental trauma is unanticipated, instantaneous and accidental, it often needs immediate and emergency management, depending on the severity of the injury. Thus, it is tremendously important to understand the patterns of incidence, prevalence, aetiology and risk factors associated with traumatic dental injuries. This article aims to review the epidemiology, incidence, prevalence, aetiology, risk factors and current trends of traumatic dental injuries in children and adolescents. The aetiologic factors vary among countries and within different age groups. The risk of sustaining traumatic dental injuries is generally dependent on several elements like age, circumstance, geography, behaviour and culture. Changing lifestyle especially related to urbanisation has led to amplification in the prevalence of dental trauma. The emergence of new trends in the modern society has led to creation of newer patterns and risk factors for the same. Traumatic dental injuries are linked to biological, social, financial and psychological factors. This article provides an overview on the epidemiology of traumatic dental injuries. This topic is of public health importance. This review is important to understand the underlying risk factors in order to reduce the prevalence and incidence of dental trauma. Educating the public regarding this will reduce the incidence of dental trauma. KEY WORDS Dental Trauma, Aetiology, Risk Factors, Epidemiology, Prevalence, Prevention, Paediatric Dentistry

A 5-year data report of traumatic dental injuries in children and adolescents from a major dental trauma center in Greece.

Prevalence and demographic characteristics of traumatic dental injuries (TDI) differ in different countries. The aim of this retrospective study was to assess TDI in primary and permanent teeth among children and adolescents who presented to the Department of Paediatric Dentistry, National and Kapodistrian University of Athens, Greece, during the last 5years. Dental records of 236 new patients who presented with dento-alveolar trauma to the Postgraduate Dental Clinic from 1/1/2014 to 31/12/2019 were reviewed. Data recorded were gender, age, month of the year the injury occurred, type of trauma, and number of traumatized teeth. Injuries were classified as fracture, luxation, or combination injuries. Descriptive statistics, chi-squared (x2 ), and Fisher's exact tests were used to evaluate the results. Level of significance was set at 5%. The age of the patients ranged from 1 to 18years old, with a mean of 8.63years (SD: 3.52). There were 395 anterior traumatized teeth and 2 cases with traumatized posterior teeth. Children suffered trauma more often at the ages of 5years, 7years, and 11years. In this cohort, 60% were boys who had a higher chance of having trauma than girls (odds ratio=1.418 95% CI=0.724, 2.777). Most TDI occurred in March and May, followed by June and February, and most traumatized teeth were permanent (80%). Maxillary central incisors in both dentitions were injured most often and significantly more compared to lateral incisors (p< 0.01). The most common type of injury was a fracture in the permanent dentition (60%) and luxation injuries (69%) in the primary dentition. Traumatic dental injuries in this cohort occurred mostly in spring, affected boys more than girls, permanent teeth more than primary teeth, maxillary incisors more than mandibular incisors, and central incisors more than lateral incisors, while children aged 5, 7, and 11years old had the most injuries.

Primary Care Dentists' management of permanent dentition traumatic dental injuries in 7- to 16-year-olds: A sequential mixed-methods study.

Primary care dentists play a pivotal role in the management of traumatic dental injuries in children, despite little evidence on the barriers they face in providing care. The aim of this study was to explore and contextualize the knowledge and attitudes of general dental practitioners regarding their management of permanent dentition traumatic dental injuries in children aged 7-16years old. A two-phase sequential mixed-methods study included a questionnaire that was disseminated to all 619 primary care dentists, identified via a triangulated sampling strategy, based across the north-east of England (Phase I). Statistical analyses were performed using Mann-Whitney U- and Kruskal-Wallis tests, Spearman's correlation and chi-square test. Multivariate factor analysis, with principal components extraction, was used to test between multiple ordinal variables. Respondents were invited to a face-to-face or telephone semi-structured interview (Phase II). Interviews were transcribed verbatim and analysed using inductive thematic analysis. Primary care dentists were less confident in managing complex dental trauma. Inadequate financial remuneration was the main reason for not providing care, often prompting a referral to the local dental hospital. This was more apparent for those who qualified before 2000. More recently qualified dentists felt the long-term costs, related to traumatic dental injuries, were insufficiently remunerated. Most still provided emergency management, irrespective of remuneration, as long as they had the requisite knowledge and skills. Four major themes arose: impact of traumatic dental injuries on patients, parents and primary care dentists; barriers to providing treatment; educational opportunities for primary care dentists; and interactions between primary and secondary care services. There is high confidence in managing simple traumatic dental injuries but less for complex injuries. A lack of sufficient financial remuneration associated with the long-term management of dental trauma was the main barrier for dentists to manage these cases.

A study to assess the knowledge, attitude, and practice of dental injuries in children engaged in Sports

Background: Maintaining a physically active lifestyle is must for a healthy body and mind. Regular exercise is known to be associated with reduced mortality and reduced incidence of systemic diseases. It has been documented that children between the ages of 7 and 14 years are more prone to injuries, especially dental as they have not developed proper coordination and less aware of the prevention of injuries while playing. Dental injuries include lip lacerations, avulsion of teeth, fractures of teeth, and jaws. Prognosis of dental trauma is better if the first-line treatment received by the patient is done by person who is aware and knows all the possible treatment modalities. Aims and objectives: The main objective of the study was to take into consideration the knowledge the population has about the dental trauma and the various preventive measures for the same. Materials and Method: For the study, a sample size of 150 patients were included and divided into a group of 75 amles and 75 females respectively. The participants were selected on the basis of inclusion and exclusion criteria. Parents of children who were engaged in contact and non contact sports were included to complete the study. Results: The p-value was calculated for the study and was highly non significant as the knowledge about the dental trauma and preventive measures were found to be similar between the male and female participants. More than half of the population had no clue about re-plantation of the avulsed tooth from the oral cavity. Conclusion: Majority of the study population had knowledge about fractured tooth and lip laceration, on the other hand they had little or no knowledge regarding the preventive measures for the dental trauma. The studies for larger sample size and wide range of age groups in different areas in Maharashtra are recommended to overview the Knowledge and various preventive measures that an individual can take when injured while playing sports.