Prevalence of sensitive teeth and associated factors: a multicentre, cross-sectional questionnaire survey in France.

BACKGROUND: As far as we know, little data, whether obtained from self-administered questionnaires or upon dental clinical examination, has been published on the prevalence of sensitive teeth (ST) in the French adult population. The objectives of the present work were to estimate ST prevalence and characteristics in the general population of France and to explore the associated factors. METHOD: A multicentre cross-sectional study was conducted between November 2011 and March 2013 in six French cities. Adult passers-by in public places were invited to answer an electronic questionnaire on a tablet computer. Only people who declared having at least one natural tooth were included in the study. A logistic regression model was used for the multivariate analysis. RESULTS: The prevalence of ST during the previous 12 months reported by the sample of 2413 participants was 42.2% [95% CI: 40.2-44.1%]. The final logistic regression model showed significant statistical associations between ST and female gender, use of tobacco, consumption of soft drinks, limited access to oral care and poor oral hygiene habits (p < 0.05). CONCLUSIONS: This study provides prevalence data on ST in a general population in France, which seems to remain high despite the existence of many therapies. It should alert professionals to a clinical manifestation that is becoming increasingly prevalent and that they will have to take into consideration to help reduce the discomfort arising from it.

Effectiveness of Resin-Based Sealants with and without Fluoride Placed in a High Caries Risk Population: Multicentric 2-Year Randomized Clinical Trial.

A split-mouth randomized clinical trial was carried out to assess the effectiveness of sealants in preventing carious ICDAS (International Caries Detection and Assessment System) 3-6 lesions within a 2-year follow-up. We evaluated the effectiveness of 2 types of resin-based sealants, with and without fluoride, their retention rates, and the caries risk factors related to their outcomes. The study included 663 tooth pairs in 400 children (aged 5-15 years) considered to be at high individual caries risk (ICR) and presenting permanent molars free of caries or affected by ICDAS 1-2 lesions. In the first randomization, molars were either randomized to the treatment group receiving a dental sealant or the control group (nontreatment), and in the second randomization the sealant material to be used in the intervention group was selected. Uni- and multivariate Cox proportional hazard models were employed. At the 2-year follow-up, 483 tooth pairs were assessed: sealed molars had 83% (adjusted HR = 0.17; 95% CI: 0.15-0.20) less risk of developing ICDAS 3-6 lesions than molars without sealant. The magnitude of the protective effect was lower among teeth with ICDAS 1-2 lesions or with occlusal deep fissures than without. If the total retention rate of sealants was 70% at 2 years, sealant loss was not associated with the risk of caries (HR = 1.29, 95% CI: 0.92-1.79, p = 0.14). Sealants allow the prevention of new ICDAS 3-6 lesions or progression of noncavitated carious lesions in children at high ICR, and the effect of the sealant was similar regardless of whether it contained fluoride or not.

WITHDRAWN: Root canal posts for the restoration of root filled teeth.

BACKGROUND: The foundation for the reconstruction of endodontically-treated teeth can be provided by a metal or a non-metal post and core system but no guidelines exist for choosing one or the other in particular clinical cases. OBJECTIVES: To assess the effectiveness of different post and core systems for the restoration of endodontically-treated teeth. The primary objective of this review was to compare the clinical failure rates of the different types of posts. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2005, Issue 3), MEDLINE (from 1966 to September 2005), Scopus (from January 1985 to December 2004) and EMBASE (until December 2004). We looked through reference lists of articles and dental conference proceedings. We contacted researchers in the field and manufacturers. SELECTION CRITERIA: Randomised or quasi-randomised clinical trials (RCTs) comparing failures on endodontically-treated permanent teeth with different types of post. The outcomes were loss of retention, post fracture and root fracture. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed the quality of trials and extracted data. Study authors were contacted for additional information. MAIN RESULTS: Two trials involving 317 participants were included but only one of them, involving 200 participants, compared metal to non-metal posts. The other answered to the secondary objective. The risk of failure was greater with metal-cast posts (9/98) compared to carbon fibre posts (0/97) (risk ratio (RR) = 0.05 (95% confidence interval (CI) 0.00 to 0.90)) but the study was at high risk of bias. Thus fewer failures occurred when using non-metal posts but the evidence is unreliable. AUTHORS' CONCLUSIONS: Our systematic review could not specify which type of post and core system should be used when two or three dentine walls remain. More RCTs are needed to confirm whether fibre-reinforced post and core systems are superior and to clarify the influence of the remaining tooth structure on the treatment outcome of the different post and core systems available. Well-defined inclusion criteria focusing on the number of dentine walls (two or three) should be used.

Inter- and Intra-Operator Reliability of Facial and Dental Measurements Using 3D-Stereophotogrammetry.

OBJECTIVES: The goal of this study was to assess the reproducibility of an innovative method for facial analysis with three-dimensional-stereophotogrammetry (3D-spg). METHODS: Twelve subjects with no obvious malocclusion participated in this study. For each of them, four photographs were acquired using the LifeViz(TM) , an absolute calibration 3D-spg system. The facial reconstructions were analyzed with the DermaPix(TM) image management software. Two different operators recorded distances between landmarks and each operator repeated the measurements after one week. The intra- and inter-examiner reproducibilities were assessed using the Intraclass Correlation Coefficient (ICC). RESULTS: This study showed reproducible intra and inter-examiners results for facial measurements (ICC comprised between 0.732 and 0.976) except for measurements that involve the inner part of the dental corridor (ICC comprised between 0.598 and 0.914). CONCLUSION: The measurements recorded by 3D-LifeViz(TM) system are accurate and reliable for research and clinical use. Moreover, it is simple and inexpensive compared with other 3D methods (laser scanner, 3D Computed Tomography, and 3D Cone Beam CT). CLINICAL SIGNIFICANCE: The inter- and intra-operator reliability of the LifeViz(TM) 3D-spg method was demonstrated. The LifeViz(TM) 3D-spg method might be a useful method to accomplish indirect 3D measurements that are relevant to dental and facial diagnosis. (J Esthet Restor Dent, 2016).

An innovative solid oral nutritional supplement to fight weight loss and anorexia: open, randomised controlled trial of efficacy in institutionalised, malnourished older adults.

BACKGROUND AND OBJECTIVE: To evaluate the impact of a solid nutritional supplement on the weight gain of institutionalised older adults>70 years with protein-energy malnutrition. The innovation of these high-protein and high-energy cookies was the texture adapted to edentulous patients (Protibis®, Solidages, France). DESIGN: An open, multicentre, randomised controlled trial. SETTING: Seven nursing homes. PARTICIPANTS: One hundred and seventy-five malnourished older adults, aged 86±8 years. INTERVENTION: All participants received the standard institutional diet. In addition, Intervention group participants received eight cookies daily (11.5 g protein; 244 kcal) for 6 weeks (w0-w6). MEASUREMENTS: Five visits (w-4, w0, w6, w10 and w18). MAIN OUTCOME: Percentage of weight gain from w0 to w6 (body mass in kg). SECONDARY OUTCOMES: Appetite, rated using a numerical scale (0: no appetite to 10: extremely good appetite); current episodes of pressure ulcers and diarrhea. RESULTS: Average weight increased in Intervention group (n=88) compared with Control group (n=87) without cookies supplementation (+1.6 versus -0.7%, P=0.038). Weight gain persisted 1 month (+3.0 versus -0.2%, P=0.025) and 3 months after the end of cookies consumption (+3.9 versus -0.9%, P=0.003), with diarrhea reduction (P=0.027). There was a synergistic effect with liquid/creamy dietary supplements. Subgroup analysis confirmed the positive impact of cookies supplementation alone on weight increase (P=0.024), appetite increase (P=0.009) and pressure ulcers reduction (P=0.031). CONCLUSION: The trial suggested that, to fight against anorexia, the stimulation of touch (finger food; chewing, even on edentulous gums) and hearing (intra-oral sounds) could be valuable alternatives to sight, smell and taste alterations.

Dental erosion in French adolescents.

BACKGROUND: Since the 2000s, different epidemiological studies focusing on the prevalence or the aetiology of DE in adolescents recognised them as an at-risk population due to their eating behaviours. None was carried out in French adolescents. The primary objective of this study was to assess the prevalence of dental erosion (DE) using the total BEWE score among adolescents in the department of Alpes Maritimes, France. The secondary objectives were to observe changes in prevalence estimates depending on both the cutoffvalue of total BEWE score with different teeth/dental surfaces examined, and to identify the related risk factors. METHODS: A cross-sectional study in a multistage random sample of 339 14-yr-old schoolchildren was carried out in 2014. The children completed a self-administered questionnaire concerning diet and oral habits. Caries was assessed with ICDAS-II (International Caries Detection and Assessment System-II) criteria and erosion with BEWE (Basic Erosive Wear Examination) index. The total BEWE score was calculated to assess the DE prevalence with two cutoff values (3 and 1). Data were analysed using descriptive statistics and logistic regression models. RESULTS: The 331 children were aged 14.4 ± 0.5 years. The DE prevalence was 39 % using a total BEWE score ≥ 3. With a cutoff total BEWE score of 1 (at least one affected tooth), the prevalence varied from 3.9 to 56.8 % depending on the teeth/surfaces that were used for the analysis. The DE prevalence, assessed with only first molars and maxillary incisors, was about 54 %. The risk factors for DE (total BEWE score ≥ 3) were daily consumption of acidic beverages (OR: 4.0; 95 % CI: 2.1-7.6) and acidic sweets (OR: 3.2; 95 % CI: 1.2-8.0), low socio economic category (OR: 2.4; 95 % CI: 1.1-5.0) and visible dental biofilm (OR: 2.0; 95 % CI: 1.2-3.4). CONCLUSION: Depending on the method chosen, the prevalence varied from 3.9 to 56.8 % among these adolescents. Thus, a consensus on choice of index, teeth to examine and age at assessment is necessary to standardise measurement of DE prevalence.

Patient responses to Er:YAG laser when used for conservative dentistry.

The utilization of laser technology in conservative dentistry offers several advantages compared with traditional instruments, but one of the still unsolved problems is the difficulty in describing and explaining these advantages to patients. The aims of this study were to verify the efficacy of the way patients are informed and to evaluate their satisfaction with laser-assisted treatment. Before treatment, 100 patients were given a brochure that explained the relevant laser-assisted dental procedures, and after dental treatment an 11-item questionnaire was administered to the patients to evaluate their satisfaction with the treatment. Statistical analysis showed high levels of satisfaction for all the questions, especially those regarding the choice between laser therapy and traditional instruments (100%), choosing laser in the future (89%), and recommending it to family and friends (84%). This study may be relevant when determining the overall satisfaction of patients with this new technology.

Definition of at-risk occlusal surfaces of permanent molars--a descriptive study.

UNLABELLED: THE OBJECTIVE of this descriptive study was to define the at-risk occlusal surface to guide the practitioner in the decision of whether to seal or not. METHOD: All dentists affiliated with the French Society of Pediatric Odontology (SFOP) and general practitioners (GP) registered in postgraduate courses in three French dental schools answered the same questionnaire illustrating four occlusal surfaces of permanent molars. It was focused on obtaining an optimal definition of an at-risk occlusal surface. The corresponding four molars were later sectioned to check the answers. Univariate logistic regression analyses and multivariate logistic regression models were tested to identify the factors associated with the at-risk occlusal surface. RESULTS: Eighty-six SFOP dentists and 136 GP filled in the form. Multivariate logistic regression models stratified by type of practice demonstrated that stained fissures (p =0.001) were only associated with at-risk occlusal surface among GP and the morphology of primary fissure (p=0.001) when considering SFOP dentists alone. The multivariate analyses demonstrated that stained fissures, and primary and secondary fissures were linked to the perception of an at-risk occlusal surface. CONCLUSION: An at-risk occlusal surface has narrow and deep primary fissures. Numerous secondary fissures could increase the risk. The coloration of fissures should not be used in the definition because it depends on tooth integrity.

Retention of resin-based pit and fissure sealants: A systematic review.

The aim of the present study was to perform a systematic review on the retention of resin-based sealants (RBSs) according to the material used and the clinical procedure. An electronic search in MEDLINE, EMBASE, Cochrane library and SCOPUS was completed by a hand search in conference proceedings. One hundred and twenty-four studies were identified, 31 of which were included. The retention rate of auto-polymerized and light-cured RBSs did not differ significantly. Light-cured RBSs had a significantly higher retention rate than fluoride-containing light-cured RBSs at 48 months (RR = 0.80, 95% CI: 0.72-0.89) and more. Concerning the clinical procedure, the scarcity of well-conducted studies made judgement difficult, except for the isolation stage. If using a rubber dam did not affect retention of auto-polymerized RBSs, it did for fluoride-containing light-cured RBSs (RR = 2.03, 95% CI: 1.51-2.73).

Effectiveness of school-based dental sealant programs among children from low-income backgrounds: a pragmatic randomized clinical trial with a follow-up of 3 years.

AIM: A split-mouth randomized clinical trial was carried out to assess the effectiveness of a school-based dental sealant (SBDS) program for French children from low-income backgrounds within 3 years of follow-up. The secondary objectives were to determine the risk factors for the occurrence of new carious lesions (ICDAS 3-6) on first permanent molars, to evaluate the effectiveness of the program according to risk factors and to assess sealant retention. METHODS: The study included 276 6- to 7-year old pupils (457 pairs of first permanent molars) from Nice. The sealing was performed in first- or second-grade children. The first permanent molars were randomized into two groups: One received resin-based sealant and the other formed a nontreatment group. Carious lesions ICDAS 3-6 on permanent and primary teeth, visible plaque, streptococcus mutans and/or lactobacillus counts were recorded at baseline to assess individual caries risk (ICR). The putative confounders recorded at baseline were sex, grade level, and characteristics of first permanent molars. An intent-to-treat analysis was performed, where the study outcome was the occurrence of new carious lesions within 3 years of follow-up. Univariate and multivariate Cox proportional hazards models (hazard risk, HR) using the procedure PHREG with the option of Covsandwich were performed in SAS to assess the effectiveness of the SBDS program. RESULTS: At 3 years of follow-up, 228 children (378 tooth pairs) remained in the analysis. The survival analysis showed that first permanent molars that received sealants had 67% (adjusted HR: 0.33; 95% CI: 0.24-0.46) less risk of developing new carious lesions during all the follow-up than molars without sealant. In addition, children with carious lesions ICDAS 3-6 on permanent and primary teeth, that is, high ICR, had three times the risk of having a new carious lesion than others without, independently of the sealant treatment (adjusted HR: 3.00; 95% CI: 1.55-5.75). Effectiveness of the SBDS program at 3 years of follow-up depended on the presence of carious lesions ICDAS 3-6 (HR in 173 children with carious lesions: 0.32; 95% CI: 0.23-0.46) at baseline (HR in 103 children without carious lesions: 0.42; 95% CI: 0.16-1.12). Finally, the overall retention rate was 32.3%. CONCLUSION: The effectiveness of the SBDS program was demonstrated in low socioeconomic areas. Selection of schoolchildren according to the presence of carious lesions ICDAS 3-6 should be considered in a SBDS program.

Scanning electron microscopy analysis of experimental bone hacking trauma.

The authors report on their macro- and microscopy study of bone lesions made by a sharp force instrument (a single blade knife), and a sharp-blunt instrument classified as a chopping weapon (a hatchet). The aim of this work was to attempt to identify the instrument by analyzing the general class characteristics of the cuts. Each weapon was used on human bones. The results indicate that macroscopic analysis is more problematic. The microscopic analysis assessed that characteristics examined were effective in distinguishing sharp from sharp-blunt injury to the bone. The microscope facilitates analysis unachievable with macroscopic methods, some three-dimensional characteristics not visible to the naked eye being clearly defined with its use. Emphasis has been placed on the value of SEM as an anthropologist's tool in bone lesion injuries.

Microleakage of a pit-and-fissure sealant: effect of air-abrasion compared with classical enamel preparations.

PURPOSE: The aim of this study was to assess the microleakage of a pit-and-fissure sealant after classical enamel preparations (prophylaxis followed by acid etching alone and mechanical widening with bur) and after air abrasion. MATERIALS AND METHODS: Ninety noncarious freshly extracted third molars were randomly assigned to three groups of 30. In each group, the mesial halves of the fissures were treated with air abrasion and conditioned with acid etching for 15 s. In group 1, the distal halves were treated with acid etching alone. In group 2, the distal halves of the fissures were widened mechanically with a bur and etched for 15 s. In group 3, the distal halves were prepared with air abrasion alone. Then the sealant (Clinpro) was applied on the occlusal fissures of all teeth, according to the manufacturer's recommendations. The teeth were thermocycled and the samples placed in a 1% methylene blue dye solution. The teeth showing microleakage and the means of infiltration were assessed with an image analysis system. RESULTS: The microleakage of sealants prepared with air abrasion alone displayed significantly greater microleakage (80%) (p < 0.0001) than the ones placed after prophylaxis and etching (13.33%), bur and etching (20%), or air abrasion and etching (22.2%). The samples prepared with air abrasion alone also showed the highest mean microleakage (1.14 +/- 1.4 mm) when compared to samples receiving prophylaxis and acid etching (0.12 +/- 0.41), bur and acid etching (0.08 +/- 0.26), or air abrasion and acid etching (0.09 +/- 0.4) (p < 0.05). No significant difference was noted between the three types of enamel preparation when etching was performed. CONCLUSION: Air-abrasion treatment does not eliminate the need for etching the enamel surface before applying the sealant.

Age estimation from teeth in children and adolescents.

The aim of this cross-sectional study was to evaluate the dental formulas according to age because of possible changes during the last decades. From these dental formulas, the median age of emergence for the permanent teeth was deduced. The study population corresponded to the 1 to 15 year-old children who had consulted either a pediatric dentist or orthodontist in the city of Nice (France). Data were collected from the 5,848 patients' charts that included an orthopantomography. This permitted the observation of emerged teeth and agenesis. Bar charts were used to indicate the dental formula according to age. There was no significant difference in the emergence pattern of both controlateral maxillary and mandibular teeth. Only the anterior tooth emergence significantly differed according to the maxillary. The lower central incisor was the lone tooth with a median age earlier than others; the remaining teeth had an age equivalent to those of previously estimates.

Comparative study of microleakage of a pit and fissure sealant placed after preparation by Er:YAG laser in permanent molars.

PURPOSE: The aim of this study was to assess the microleakage of a pit and fissure sealant on enamel treated with a laser, with and without etching. METHODS: Sixty non-carious extracted molars were randomly assigned to 2 groups. For both groups, in the mesial halves, the fissures were widened mechanically with a bur and etched for 15 seconds. In group 1, the distal half was prepared with a laser alone; in group 2, a laser was followed by etching. Then the sealant was applied on all teeth. RESULTS: Laser alone showed the highest number of specimens with microleakage (63%) (P < .02) and the highest mean of microleakage (0.76 mm vs 0.12 mm, 0.17 mm, and 0.18 mm; P < .01). CONCLUSIONS: No significant difference was noted between the 2 types of enamel preparation when etching was performed. Laser irradiation did not eliminate the need for etching the enamel surface before applying the sealant.

Effectiveness of school-based dental sealant programs among children from low-income backgrounds in France: a pragmatic randomized clinical trial.

OBJECTIVES: A split-mouth randomized clinical trial was carried out to assess the effectiveness of a school-based dental sealant (SBDS) program for French children from low-income backgrounds. The secondary objectives were to determine the effectiveness of the program according to the baseline individual caries risk (ICR) and to assess the sealant retention. METHODS: The study included 276 pupils from Nice. The sealing was performed in the first or second grades. The permanent first molars were randomized into two groups: one received resin-based sealant and the other no treatment. Active caries on permanent and temporary teeth, visible plaque, Streptococcus mutans (SM) and Lactobacillus counts were recorded at baseline to assess ICR. An intent-to-treat analysis was performed based on the occurrence of new caries at 1 year of follow-up (study outcome). Univariate and multivariable conditional tooth-matched logistic regression analyses (Proc phreg; SAS) were used to assess the effectiveness of the SBDS program. RESULTS: At 1 year of follow-up, 253 children (421 pairs) remained in the analysis. In the adjusted analysis, first permanent molars that received sealants were less at risk of developing new caries at 1 year of follow-up compared with those from the control group (OR = 0.26, 95% CI: 0.14-0.49). Independently of the treatment, SM count, and all other covariates, only the variable 'active caries at baseline' remained related to new caries on first molars at 1 year (OR = 3.11, 95% CI: 1.27-7.62). The effect of the sealants was significant only when the analyses included subjects with active caries (OR = 0.25; 95% CI: 0.12-0.50) or with a high SM count (>10(5) , OR = 0.20; 95% CI: 0.10-0.41) at baseline. At the 1-year follow-up, total retention was recorded in 52.7% (n = 222) of the treated teeth. CONCLUSION: The 1-year effectiveness of the SBDS program was demonstrated in low socio-economic areas. Selection of schoolchildren according to individual caries risk factors should be considered in a SBDS program.

Density of dental practitioners and access to dental care for the elderly: a multilevel analysis with a view on socio-economic inequality.

OBJECTIVES: To examine the relations between density of dental practitioners (DDP) and socio-economic and demographic factors shown to affect access to dental care for the elderly. METHODS: Data are taken from a cross-sectional survey - 2008 Disability Healthcare - Household section Survey (HSM). HSM is a representative random sample of French people living in their own domiciles. Our study focuses on the 9233 individuals aged 60 years and above. Multilevel models are employed to disentangle the relations between the determinants of dental care utilisation and DDP. Statistical analyses are conducted using SAS 9.2 and HLM 6. RESULTS: Low-income and lack of complementary health insurance are associated with higher odds of not having visited a dentist, revealing a high unequal access to dental care. By using multilevel modelling, DDP appears to be a significant factor to access to dental services. When considering the intricate relations between income gradient and DDP, the latter lessens the income-related inequality to access dental services. CONCLUSION: DDP seems favouring a more equitable access to dental care, mitigating under-caring of the poorest. This point is to be added in the debate about density of healthcare suppliers.

Microleakage of resin-based sealants after Er:YAG laser conditioning.

The aim of this in vitro study was to investigate the effects of Er:YAG laser pretreatment procedures in fissure sealing. The fissures of 90 third molars were prepared in the mesial halves with Er:YAG laser (lambda = 2,940 nm, 250 mJ/pulse, 4 Hz, fluence 32 J/cm(2)) and acid etched. They were randomly assigned to three groups, and the fissures in the distal halves were prepared differently according to the group: acid etching alone, bur and etching or Er:YAG laser alone. The fissures were sealed using Clinpro sealant (3M). The extent of microleakage was measured with a digital-image analyzer. The sealants prepared with Er:YAG laser alone displayed greater microleakage than the others (p < 0.05). Er:YAG laser irradiation does not eliminate the need for etching the enamel surface before sealing.

A survey of disinfection of irreversible hydrocolloid and silicone impressions in European Union dental schools: epidemiologic study.

PURPOSE: The objective of this cross-sectional study was to describe corresponding procedures for irreversible hydrocolloid and silicone impressions taught and used in European Union dental schools. MATERIALS AND METHODS: A self-administered questionnaire requesting information about rinsing and disinfection methods was sent to each of the 373 heads of prosthodontic, pedodontic, and orthodontic departments in the 131 European Union dental schools. Response rate was 94%. Statistical analysis included chi-square or Fisher exact tests, and ANOVA or Kruskall-Wallis tests. RESULTS: Of the responding departments, 92% systematically rinsed their impressions. Fifteen percent of the departments, mostly orthodontics, never disinfected irreversible hydrocolloid impressions, and 11% never disinfected silicone impressions. The immersion method was used by 65% for irreversible hydrocolloid impressions (73% for silicone), with a disinfection time of 10.3 +/- 6.3 minutes (11.8 +/- 7.4 for silicone). The disinfected impressions were not rinsed by 16% for irreversible hydrocolloid and 14% for silicone. Most departments used brand-name products. CONCLUSION: The same disinfection procedure for both irreversible hydrocolloid and silicone impressions was used by 78% of departments. There was great diversity, however, between departments in the procedure used for each impression material.

Orofacial trauma and rugby in France: epidemiological survey.

A stratified epidemiological survey was carried out among the best French rugby players to assess the prevalence of trauma to the lower or middle part of the face (TLMPF) and the frequency at which the mouthguards (MGs) were worn. The 1140 randomized players (elite 1, elite 2 and national 1 clubs) filled in the same form anonymously. The variables were first subjected to univariate analysis (Chi-square, anova). Secondly, they were included in a multivariate model (logistic regression). Some 29.57% of players had already been affected by a TLMPF. The risk increased for the oldest forward players. It also increased with the number of yearly competitions and number of hours of weekly training. Some 64.3% of players used a MG. The frequency at which it was worn increased with the number of yearly competitions, for those who had experinced a previous trauma and for the pack players who had been playing for a long time.