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james mirtle

Dushan Milic for the globe and mailThe Globe and Mail

The puck hit Keith Tkachuk just below his nose, shattering his upper jaw and crushing the bone so badly, four teeth simply dropped out of his mouth.

By result, the recently retired St. Louis Blues forward started a year-long adventure in a dentist's chair, an odyssey familiar to hockey players everywhere. The peril seems to intensify in the playoffs as the action gets nastier, seen gruesomely a few weeks ago when Eric Belanger of the Capitals plucked a bloody tooth from his mouth after Marc-André Bergeron of Montreal caught him with a high stick. Belanger lost seven teeth in all.

The image of the toothless hockey player harkens back to the game's rough-and-tumble era when helmets - never mind mouthguards - weren't in vogue. Returning to the ice to score a goal after losing a tooth is part of hockey lore, the type of tale fans revere. According to those who treat the damage, however, the injuries can be devastating, causing intense physical pain and potentially long-term psychological damage.

Yet team dentists estimate that only about half of the players in the NHL wear mouthguards.

"The only thing that compares to the dental injuries we see in the NHL would be maybe car crashes," St. Louis team dentist Glenn Edwards said. "People hit their faces on the steering wheel or they're not buckled in and they hit the dash.

"It's ridiculous that these players have to go through these devastating injuries."

A mouthguard couldn't help Tkachuk, though. On Jan. 2, with the Blues trailing the Chicago Blackhawks 6-2, Tkachuk was patrolling the front of the net just as he had done for much of his 18-year career. A shot from the point zipped between bodies into Tkachuk's face - deflecting into the net for his 535th goal.

It was one of the last he would score, and one he wishes had never happened.

Sitting behind the Blues' bench, as he has for the past 20 years, Edwards saw the play unfold and rushed down to the tunnel at ice level.

"He was in agony," Edwards said. "He couldn't walk, he was in so much pain."

Edwards had saved many players' teeth by reinserting them immediately. With Tkachuk, that wasn't an option.

"There wasn't any bone left to hold the teeth in," Edwards said.

While Tkachuk's injury was only a footnote in most game stories, Edwards spent three hours that night picking fragments of bone and teeth from his mouth. Tkachuk's surgery this week involved a transplant of bone from his hip to restore his upper jaw. If that process is successful, false teeth will be implanted when the area is healed.

"You just don't realize," Tkachuk said. "It's by far the worst injury I've ever had. I wouldn't wish this on anybody."

He sat out only three games, returning to the ice after 10 days with six front teeth missing.

Tkachuk's injury is an extreme example of the damage that sticks and pucks inflict on players' mouths, but even minor blows can create a mess. Roughly half of the players in the league are missing at least some teeth, according to team dentists, with those 30 and over more likely to have had restorative work done.

Root canals are common, even for star players. (Tkachuk has had seven.)

And because the inner areas of human teeth have the highest density of nerve endings in the body, catastrophic injuries can be more anguishing than broken limbs or torn ligaments.

As a result, the team dentist is vital, and 19 NHL clubs list one or more on their website. The Chicago Blackhawks have four. On average, dentists have to evaluate a player every two or three games and do significant work about once a month.

Some newer arenas even have a small dental suite in them.

Perhaps the busiest dentist in recent years has been the Washington Capitals' Thomas Lenz, who helped repair former captain Chris Clark's broken palate bone in 2006 - "it was basically sitting in the back of his throat when I got to him" - in one of the more horrific dental injuries.

When Belanger took a stick to the mouth in Game 5 of the first round, he performed a little self-dentistry on the bench by fishing a broken tooth from his mouth. It's already become one of the enduring images of these playoffs, replayed over and over on the Internet and television.

Belanger was not wearing a mouthguard and Bergeron's stick - a composite model wrapped in Kevlar to make it more durable - tore a labial frenulum (a muscle attachment) inside his mouth.

"I felt my teeth shatter right away," he said. "I knew I was in trouble."

"They're often a little bit scared," Lenz said. "As soon as we calm them down and reassure them that whatever's going on can be handled, they immediately want to know, how quick can I get back on the ice?"

The rest of the game for Belanger was, in Lenz's words, "brutal." He played about 10 minutes after some minor repair work between periods, but the cold arena air stung his broken teeth with every breath.

By the end, he had swallowed so much blood that he was nauseous.

"Eric suffered everything," Lenz said. "Usually you see that with the impact of a puck rather than a high stick."

Team dentists have differing opinions on a culture that insists players play through their injuries.

Lenz said he views hockey players as old-school athletes, throwbacks who will play through anything. "These guys are amazing," he said.

Edwards laments the fact these injuries are often treated as trivial by players, coaches and fans, and advocates for full facial protection.

"For some reason, if they get a serious dental injury, they're expected to finish the game," he said. "If they get any other kind of injury, they're done for the night, shut it down, we're going to check on you tomorrow.

"It's kind of sad, from my perspective, being a dentist. I like teeth. And I see the psychological damage when you get hit in the face, with a stick, puck, even a fist."

Tkachuk jokes about his ordeal now - "you learn how to chew with your back teeth," he says - but Edwards said he went through a period of depression after the injury.

Tkachuk believes the NHL's ramped-up speed and emphasis on putting pucks to the net have made the offensive zone a more dangerous place to play than it was 20 years ago.

"I think the old guard used to know where pucks were going," said Tkachuk, who had never lost a tooth before this season. "With the new sticks, people shoot it harder and they shoot higher - the goalies are so tough to beat you've got to do everything possible to score."

After rebuilding players' mouths the past two decades, Edwards said he wouldn't step on the ice to play in an NHL game.

"If you get a slap shot in the face, I don't care what you're wearing in your mouth, you don't have a chance," he said. "I wouldn't sign up for it. I really wouldn't. I just can't imagine that."