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The roar from the crowd rose to a crescendo as the two pugilists in the ring above us were squaring up to each other, with the local Turkmen kick-boxer just a few points away from securing a gold medal. Their arms, legs and head were well protected by the thick padding of their protective equipment, but judging from the primitive mouth guards that the coaches were removing between rounds, we knew that the likelihood of having to deal with a multitude of orofacial injuries at the end of this bout was high.

These were the Fifth Asian Indoor and Martial Art Games in Ashgabat, Turkmenistan (See Figure 1), in September 2017. Drs Peter Fine and Torsten Moehl were invited to be part of the medical team, in the capacity of Sports Dentists, to support the athletes taking part in these games. The combination of indoor sports including chess and e-games was drastically contrasted by martial arts sports including kick-boxing and Muay Thai boxing. Since the recognition in the 1980s for the need to establish a subgroup in dentistry that deals specifically with the dental demands of the athlete, it is beginning to become more common to include sports dentists within the medical team at sporting events. These games in Turkmenistan would prove to be a particular challenge, and past experiences at other sporting events, such as the London and Rio Olympics, would be heavily drawn upon to try and penetrate language, cultural and ethnic barriers to provide the best care for the athletes of 60 different countries that would be represented here.

Figure 1
figure 1

Map of Turkmenistan

The challenge of this assignment was already evidenced in our journey to Ashgabat, involving flights from London via Frankfurt and Baku in Azerbaijan, with arrival at around midnight at an airport designed to handle 17 million passengers a year in a country that has an annual tourist number below 120,000. Security is tight in this insular Asian country that is slightly smaller than Spain in size, and situated on the Caspian Sea to the west of Afghanistan, with Ashgabat, the capital and by far largest city, a stone's throw away from the Iranian border to the south beyond the Kopet Dag mountains. Our accreditation passes as members of the medical team did speed up the complicated immigration process, but no-one gets to enter without having fingerprints, photographs and retinal scans taken, as well as luggage checked for any offending items. This all seemed somewhat futile as the members of the athletes' support teams far outweighed the number of spectators arriving. The transit from the airport to the Olympic Village, which would be our home for the duration of the games, involved a police-led convoy of busses and cars through curfew-enforced deserted streets of a city that is home to just over a million inhabitants. The only people about were groups of workers that ensure that this city, that boasts a Guinness Book of Records entry as having the most buildings clad in white marble, would also be one of the cleanest that we have visited. And so our convoy rushed past massive water fountains and grandiose monuments, and row upon row of white apartment buildings that provide the canvas to an ever-changing kaleidoscope of coloured halogen lighting. We finally caught sight of the sporting complex, with its impressively lit main arena, above which was the 'Olympic' torch atop a massive horse's head mounted loftily at one end. The horse's head is reported to be the largest concrete horse's head in the world.

Having passed through a further set of heavy security, we were escorted to our shared accommodation in a marble-clad high-rise building by another friendly young Turkmen student who was part of the 8,000 'First Stars' volunteers that were helping out during the duration of the games. The similarity of their role to the games-makers of the London 2012 Olympics was no coincidence, since it was the same British company that organised that event which was now commissioned to make the Ashgabat games a reality. Since its independence from Russia in 1991, Turkmenistan remains a very insular country led by a unique leadership emblematic to that region and history. Just as some other former Soviet Asian countries are opening their doors a small crack at a time, such as Azerbaijan hosting the F1 Grand Prix, so the present leader of Turkmenistan, Gurbanguly Berdymukhamedov (a dentist by profession!) envisaged show-casing his country by hosting a sporting event under the auspices of the Asian affiliate to the International Olympic Committee (IOC), and financed through the country having the fifth largest natural gas reserve in the world. A reported US $5 billion infrastructure investment created a multi-sports facility of note (Fig. 2), including 15 venues hosting 21 different sports, from track cycling to belt wrestling, with only four of these sports part of the Olympic Games programme. The use of the term Olympic village is also interesting as it was reported that the IOC had not actually given the games organisers clearance to use the word 'Olympic' nor indeed use the five rings symbol! Adjacent to the sporting complex was the village that would accommodate over 6,000 delegates and athletes to the games, and we formed part of the international team that would assist in delivering this event.

Figure 2
figure 2

The main sports arena

A typical day

There were two martial arts venues running alongside each other, and each of us were assigned to one venue. Peter covered the Muay Thai and Kickboxing events, while Torsten was in the other arena covering Kurash and Sambo over separate days. A typical day would start at 9 am; breakfast was a buffet in the staff building in the satellite village some five minutes' walk from the main village, and the sporting venues were another 15 minutes' walk from there. We were typically working 12 hour days, with a three hour break over the lunchtime, while there was a break in the competition. Sadly, this meant we had little chance to view other sporting events even though we possessed a pass to access all areas. The medical cover in each venue consisted of a lead paramedic or sports doctor, supported by a sports physiotherapist and a dentist. Several venues did not have such comprehensive cover but we were available to visit other venues should the need arise. Importantly, we also had in attendance a group of local doctors who were charged with learning field-of-play stabilisation of the patient and evacuation techniques from the field of play to the on-site medical room, where the patient was triaged and treated, if possible. Should the injury be more serious, the patient was then moved to the polyclinic on the Olympic complex, which was staffed with doctors, physiotherapists, radiologists and sports therapists. If the patient's condition was deemed to be unstable, a further referral to a local hospital would be made where local personnel would treat the condition.

Within the very well-equipped polyclinic was also a single dental surgery manned by local Turkmenistan dentists who had received their clinical training in Russia. Despite having a reasonably well-equipped surgery, they appeared to be content with extracting any dental problem that appeared. Our brief, therefore, was not just to treat the patient but also to leave behind a legacy by teaching the local doctors, nurses and dentists a structured procedure in managing sports-related injuries. This seemed strange at first, since we were working with highly educated medical personnel, such as anaesthetists, general and cardiac surgeons and so forth, but it soon became clear that there are different approaches to medicine in different parts of the world, and the skill set applicable to their local hospital setting did not always translate well to the sporting arena. This certainly provided a great challenge in respecting the status of the local team members, yet subtlety guiding them to provide the best care for the patient, with a language barrier thrown in between for good measure; (neither of us speak Russian or Turkmenistan).

The other great challenge was to manage the injured combatant, who arrived into the arena medical room with adrenaline pumping after a bout, gushing blood from either a facial injury or intra oral laceration or harbouring a contusion injury that has never been properly managed because of the inadequate facilities back home. To many of them this was their one chance to gain recognition in an international arena, and one quickly learnt that perfect patient management protocols were often refused because there was another fight to complete later in the day. The more serious injuries including dealing with unconscious patients and athletes with concussion were dealt with in consultation with our medical colleagues from the UK.

So what exactly was our role as sports dentists at these games?

From past experiences at other international sporting events, the greatest need of most of the combatants is adequate mouth protection. Our offer to bring with us the necessary equipment to manufacture well-fitting mouth guards was not accepted, and so we encountered such poor quality mouth guards that these contributed to a great degree to the intra-oral soft tissue injuries sustained, and probably even hampered the athlete from producing the best result because of breathing difficulties. Our task was therefore to educate these athletes and their coaches, as best we could, to the advantages of properly fitted mouth guards, which are, of course, not always available in their countries.

The largest group of injuries dealt with in the orofacial region would be soft tissue, which were managed through compression and/or suturing. The value of our presence there was certainly enhanced when Peter splinted a displaced bilateral fracture of the mandibular symphysis, which allowed safe passage of the patient to hospital (Fig. 3), and diagnosed a 'blow-out' fracture of the orbit, which was immediately referred to the polyclinic for scans and then to hospital. But our brief did not restrict us to maxillofacial injuries only, since we were part of a medical team that possessed a myriad of experience, which engendered a fantastic camaraderie among us. We soon were tasked to apply crepe bandages, glue eyebrows together and monitor pulse oximeters, and ensure the injured athlete did not get lost in transit to the polyclinic, as so often happened because of a conflict of roles between the local and the non-local volunteer medical staff.

Figure 3
figure 3

Fractured mandible of Vietnamese kick boxer following temporary fixation in the medical room

These games would generate much commentary in the foreign media because of the style of governance and social welfare in the country, and one may even question the value of being a part of such a perceived extravagance. In a society where foreign travel is heavily restricted, just having the presence of different cultures around from 60 different nations must have some effect on the younger generation of this country. Our encounters with our medical counterparts and the many young 'First Star' volunteers, who were by and large the nicest people one could meet, allowed a respectful dialogue and exchange of ideas. As sports dentists, we hope that our lasting legacy to these games, and those that will inevitably follow in this part of the world, will have been the value of a pre-match dental assessment of the athlete, the importance of good oral health in enhancing sporting results, the techniques for manufacturing proper mouth guards, and the adequate treatment of oral hard and soft tissue injuries.

For the general dentist who would like to be involved with elite and amateur athletes, and enjoys a sense of adventure in attending events such as these Asian Games to support our medical colleagues, these invaluable skills can be gained by attending a bespoke Sports Dentistry Certificate programme, such as that organised by Dr Peter Fine at UCL Eastman Dental Institute.