Athletic Mouth Guards
Do athletic mouthguards have a role in reducing the incidence and severity of cerebral concussion in sports?
This is a controversial question now being asked by the sporting world, especially for high-impact sports such as hockey and football. The apparent increase in concussion rates has led to claims by dentists and over-the-counter mouthguard suppliers regarding the use and effectiveness of athletic mouthguards in reducing concussions. Numerous minor hockey leagues have introduced mouthguard rules as a possible result of concussion, rather than dental concerns.
Though anecdotal, there are three possible theories on the potential benefits of properly-fitting athletic mouthguards and the reduction of the incidence or severity of concussions. It should be noted that these are theories, which in most cases are NOT PROVEN in the medical/dental literature.
- Direct dissipation and/or absorption of force of an upward blow to the jaw.
- Increased separation of the head of the condyle and glenoid fossa
- Increased head stabilization by activating and strengthening neck muscles.
Dissipation of forces
Mouthguard materials by nature must have shock absorption qualities. They must be resilient and yet soft enough to absorb impact energy and reduce transmitted forces. The thickness of mouthguard material is directly related to energy absorption and inversely related to transmitted forces when impacted. However, wearer comfort is also an important factor in their use. Thicker mouthguards are often not user-friendly. Transmitted forces through different thicknesses of the most commonly-used mouthguard material (ethylene vinyl acetate – EVA – Shore Hardness of 80) were compared when impacted with identical forces capable of damaging the oro-facial complex. The results showed that the optimal thickness for EVA mouthguard material with a Shore Hardness of 80 is around 4 mm. on the occlusal surface. All teeth must be properly covered and the bite balanced accordingly. Increased thickness, while improving performance marginally, may result in less wearer comfort and acceptance.
Stenger, in 1964, reported that forces from mandibular impact would be attenuated with a mouthguard, resulting in fewer injuries. Hickey discussed that mouth protectors reduced pressure changes and bone deformation within the skull in a cadaver model. He demonstrated a decrease of 50% in the amplitude of the intracranial pressure after a blow to the chin when wearing a mouthguard.
Increased head stabilization by activating and strengthening neck muscles
Dr. Karen Johnston, a prominent Canadian concussion researcher, noted that: “The force required to concuss a fixed head is almost twice that required to concuss a mobile head”. Further, there is some correlation between the degree of rotation that the head goes through on impact and the severity of the concussion that might result.
By activating additional head and neck muscles at the time of impact this arc of rotation might be decreased, leading to less harmful movement of the brain inside the skull. Some researchers have begun to show that by being able to clench down harder on a mouthguard the activation of the head and neck muscles might serve to stabilize the head. Some have suggested further that this effect might be in place whether or not the athlete sees the impact coming.
Increased Condylar Separation
When a properly-fitted and balanced custom-made mouthguard is in place there is a forward/ downward movement of the jaw, thus opening the space between the glenoid fossa and the condylar head. This may reduce the opportunity for the condylar head to directly impact the glenoid fossa after an upward blow to the jaw, thus reducing the impact and acceleration forces to the entire temporal region. Again, while it might be advantageous to significantly open this space for protection, an excessive thickness of material on the biting surface might compromise both comfort and performance.
The Bottom Line
As Dr. Paul McCrory once stated about the connection between mouthguards and concussions “Absence of proof is not proof of absence”. We should always remember that the primary role of mouthguards is the protection of the teeth and orofacial structures, and mouthguards should be primarily designed to accomplish this goal – with adequate protection in the areas most likely to be traumatized (maxillary incisor teeth).
However, there are some basic design elements that can and should be included in any mouthguard that might enhance the potential concussion-prevention aspects of mouthguards. All mouthguards should have an adequate thickness and should cover as much of the occlusal surface as the athlete can tolerate. Mouthguards must have proper retention built into them to ensure that they stay in place at the moment of impact. Mouthguards should not be over trimmed in the posterior, which might actually force the condyles into the glenoid fossae. All mouthguards should be balanced occlusally to ensure an even distribution of force across the entire surface.
Athletic Mouth Guard Types
Properly diagnosed, designed, and custom fabricated mouthguards are essential in the prevention of athletic oral/facial injuries.
In Dr. Raymond Flander’s 1995 study, he reported on the high incidence of injuries in sports other than football, in both male and female sporting activities. In football where mouthguards are worn, .07% of the injuries were orofacial. In basketball where mouthguards are not routinely worn, 34% of the injuries were orofacial. Various degrees of injury, from simple contusions and lacerations to avulsions and fractured jaws are being reported.
The National Youth Sports Foundation for the Prevention of Athletic Injuries, Inc. reports several interesting statistics. Dental injuries are the most common type or orofacial injury sustained during participation in sports. Victims of total tooth avulsions who do not have teeth properly preserved or replanted may face lifetime dental costs of $10,000 – $15,000 per tooth, hours in the dentist’s chair, and the possible development of other dental problems such as periodontal disease.
It is estimated by the American Dental Association that mouthguards prevent approximately 200,000 injuries each year in high school and collegiate football alone. A properly fitted mouthguard must be protective, comfortable, resilient, tear resistant, odorless, tasteless, not bulky, cause minimal interference to speaking and breathing, and (possibly the most important criteria) have excellent retention, fit, and sufficient thickness in critical areas.
Unfortunately, the word “mouthguard” is universal and generic, and includes a large range and variety of products, from “over the counter” models bought at the sporting goods stores to professionally manufactured and dentist prescribed custom made mouthguards.
Presently, over 90% of the mouthguards worn are of the variety bought at sporting good stores. The other 10% are of the custom made variety diagnosed and designed by a health professional (dentist and/or athletic trainer).
The stock mouthguard, available at most sporting good stores, come in limited sizes (usually small, medium, and large) and are the least expensive and least protective. The prices range approximately from, $3 to $25. These protectors are ready to be used without any further preparation; simply remove from the package and immediately place in the mouth. They are bulky and lack any retention, and therefore must be held in place by constantly biting down. This interferes with speech and breathing, making the stock mouthguard the least acceptable and least protective. This type of mouthguard is often altered and cut by the athlete in an attempt to make it more comfortable, further reducing the protective properties of the mouthguard. It has been suggested and advised in the medical/dental literature that these types of mouthguards not be worn due to their lack of retention and protective properties.
As sports dentists and health professionals interested in injury prevention, we do not recommend this type of mouthguard to our patients and athletic teams. See photo of Stock Mouthguard after use for several weeks.
Mouth formed or Boil and Bite Mouthguard
Presently, this is the most commonly used mouthguard on the market. Most marketing and advertising in the past has been for this type mouthguard. Made from thermoplastic material, they are immersed in boiling water and formed in the mouth by using finger, tongue, and biting pressure. Available in limited sizes, these mouthguards often lack proper extensions and repeatedly do not cover all the posterior teeth. Dental mouth arch length studies have shown that most boil and bite mouthguards do not cover all posterior teeth in a majority of high school and collegiate athletes. Athletes also cut and alter these bulky and ill fitting boil and bite mouthguards due to their poor fit, poor retention, and gagging effects. This in turn further reduces the protective properties of these mouthguards. When the athlete cuts the posterior borders or bites through the mouthguard during forming, the athlete increases their chance of injury, especially concussion, from a blow to the chin. Some of these injuries, such as concussion, can cause life long effects. (See concussion section of Sports Dentistry On Line). Certain thicknesses and extensions are necessary for proper mouthguard protection.
Dr. Keith Hunter, Australian sports dentist, reported that mouthguards should be of certain thickness, without being bulky. He suggests a thickness of 3mm. It should be noted that each athlete should be evaluated individually for thickness and design as to promote comfort and sufficient protection.
Joon Park, PhD et al, at the First International Symposium on Biomaterials in August of 1993 reported that boil & bite mouthguards provide a false sense of protection due to the dramatic decrease in thickness occlusally during the molding and fabrication process. Dr. Park further stated that “Unless dramatic improvements are made, they (boil and bite mouthguards) should NOT be promoted to patients as they are now.”
Care should be taken by the public when bombarded with clever marketing schemes, claims, and promotions by stock and boil and bite mouthguard companies. The bottom line is that Stock and Boil and Bite Mouthguards do not provide the expected care and injury prevention that a properly diagnosed and fabricated custom made mouthguard does. Why is there a general belief that mouthguards are uncomfortable, do not fit, are bulky, and interfere with breathing and speaking? Could it be because 90% of today’s mouthguards worn are of the stock or boil and bite variety, and it is the perception by the public and coaches that these are the only available mouthguards? Indeed, most mouthguards today do not fit, are bulky, and do interfere with speaking and breathing because they are wearing stock or boil and bite mouthguards! The majority of athletes are not wearing properly made dentally diagnosed and designed custom made mouthguards provided by your sports dentist.
As sports dentists and health professionals interested in injury prevention, we do not recommend store bought boil and bite mouthguards to our patients and athletic teams. The public deserves the best quality of care in injury prevention and boil and bite mouthguards DO NOT provide this quality. See photo of Boil and Bite Mouthguard after use for several weeks.
Custom made mouthguards are supplied by your dentist. Custom mouthguards provide the dentist with the critical ability to address several important issues in the fitting of the mouthguard. Several questions must be answered before the custom mouthguard can be fabricated. These questions include those addressed at the preseason screening or dental examination. Is the mouthguard designed for the particular sport being played? Is the age of the athlete and the possibility of providing space for erupting teeth in mixed dentition (age 6-12) going to affect the mouthguard? Will the design of the mouthguard be appropriate for the level of competition being played? Does the patient have any history of previous dental injury or concussion, thus needing additional protection in any specific area? Is the athlete undergoing orthodontic treatment? Does the patient present with cavities and/or missing teeth? Is the athlete being helped by a dentist and/or athletic trainer or by a sporting good retailer not trained in medical/dental issues? These are important questions that the sporting good store retailer and the boil & bite mouthguard CANNOT begin to address.
The custom made mouthguards are designed by your dentist and are the most satisfactory of all types of mouth protectors. They fulfill all the criteria for adaptation, retention, comfort, and stability of material. They interfere the least with speaking and studies have shown that the custom made mouthguard has virtually no effect on breathing.
By acknowledging these significant differences in mouthguards, the public will be better informed and educated to seek their dentistry from dental health professionals and not from sporting good retailers.
Mouth Guard Facts
Facts from the National Youth Sports Foundation for Safety
- Dental injuries are the most common type of orofacial injury sustained during participation in sports; the majority of these dental injuries are preventable.
- An athlete is 60 times more likely to sustain damage to the teeth when not wearing a protective mouthguard.
- The cost of a fractured tooth is many times greater than the cost of a dentist diagnosed and designed professionally made mouthguard.
- Every athlete involved in contact sport has about a 10% chance per season of an orofacial injury, or a 33-56% chance during an athletic career.
- The cost to replant a tooth and the follow-up dental treatment is about $5000.
- Victims of knocked out teeth who do not have a tooth properly preserved or replanted may face lifetime dental costs of $15,000-$20,000/tooth, hours in the dental chair, and the possible development of other dental problems such as periodontal disease.
- It is estimated that faceguards and mouthguards prevent approximately 200,000 injuries each year in high school and college football.
- The stock mouthguard which is bought at sports stores without any individual fitting, provide only a low level of protection, if any. If the wearer is rendered unconscious, there is a risk the mouthguard may lodge in the throat potentially causing an airway obstruction.
Facts from the American Dental Association and the California Dental Association
- A properly fitted mouthguard reduces the chances of sustaining a concussion from a blow to the jaw.
- Mouthguards should be worn at all times during competition; in practice as well as in games.
- Contact your local dental society and association for information on dentists and mouthguard programs in your area.
- The American Dental Association recommends wearing custom mouthguards for the following sports: acrobats, basketball, boxing, field hockey, football, gymnastics, handball, ice hockey, lacrosse, martial arts, racquetball, roller hockey, rugby, shot putting, skateboarding, skiing, skydiving, soccer, squash, surfing, volleyball, water polo, weightlifting, wrestling.
Mouth Guard FAQs
Who needs a mouthguard?
Anyone who plays a sport where there is a risk of collision with another person or a hard surface should wear a mouthguard. The obvious sports are football, rugby, lacrosse, hockey (ice, field, roller), martial arts, boxing, wrestling, MMA and basketball. Not as obvious but just as important are baseball, volleyball, soccer, water polo, gymnastics, softball, skiing, snowboarding, BMX bicycling, racquetball, acrobatics and skateboarding. All these sports have the potential for facial and oral injuries, and a mouthguard is recommended.
What is the best type of mouthguard?
As recommended by the ADA and the Academy for Sports Dentistry, a pressure-laminated, custom fitted mouthguard offers the best protection in contact sports. A custom-fitted mouthguard allows for a more comfortable, stable fit that won’t dislodge during collisions. Also, breathing and speaking are much easier, and the risk of concussions and damage to the jaw is greatly reduced.
How long will my mouthguard last?
An adult mouthguard can last several years, depending on the frequency of use, the care of the mouthguard, and if the mouthguard has been torn or bitten through, in which case it must be replaced. Loss of teeth, new restorations such as crowns, bridges or large fillings can affect the fit of the mouthguard, and a new one should be made if the fit is compromised.
A child’s mouthguard should be replaced more frequently than an adult’s due to growth of the jaw, loss of baby teeth and eruption of adult teeth. Any of these factors could affect the fit of the mouthguard and make it uncomfortable to wear and less protective.
How do I care for my mouthguard?
After use, mouthguards may be rinsed in cold, soapy water. If an odor develops, they may also be rinsed with mouthwash. After they are clean and dry, your mouthguard should then be placed in a plastic container.
Mouthguards may distort under higher temperatures, so they should not be stored in direct sunlight, left in a car on a hot day, or placed in hot water to disinfect.
What if I have braces or a loose tooth?
We can make a mouthguard for you if you wear braces. Usually, special wax is placed over the braces during the impression, so the impression material does not get stuck in the brackets or the wires.
Loose teeth should be removed before taking a mouthguard impression. Space will be left in the mouthguard for the adult tooth – it is especially important to wear a mouthguard at this time, because the developing tooth must be protected.
Why is a custom fitted mouthguard more expensive than the store bought kind?
Store bought mouthguards are made by the thousands, with a one-size-fits-all mentality. If you think about it, an adult custom fitted mouthguard, if cared for properly, will outlast several of the store bought kind. But the fact is, you can’t get a better fit than with a custom mouthguard. Superior material, time to individually manufacture them, great fit and comfort with ease of breathing and speaking all make the custom mouthguard a premium piece of sports equipment.
You wouldn’t skimp on your athletic shoes or any of your other protective equipment. So why not give yourself the best protection for your mouth? The cost of repairing damage to the teeth and gums can run into the thousands, and leave you with a permanently compromised dentition, not to mention the increased risk of debilitating concussions.
So do your mouth a favor, and Cushion Your Collision!
NOTE: The authors would like to stress and emphasize that the above information is theory ONLY and has not yet been proven in the medical/dental literature. We DO NOT support the claims made by mouthguard manufacturers and other dentists that there is a definite relationship between mouthguards and cerebral concussion. Until it is proven in the medical literature, this stand will continue. Athletic mouthguards, until proven different, are primarily for the reduction of orofacial injury.
Westerman B, Stringfellow PM, Eccleston JA., EVA mouthguards: How thick should they be? Department of Mathematics, The University of Queensland, Brisbane, Australia. Dental Traumatology, Vol. 18 Issue 1 Page 24 February 2002
Duhaime CF, Whitmyer CC, Butler RS, Kuban B., Comparison of Forces Transmitted Through Different EVA Materials, Department of Dentistry, The Cleveland Clinic Foundation, Cleveland, OH 44195, USA. Dent Traumatol. 2006 Aug;22(4):186-92.
Stenger JM,Lawton EA, Wright JM, Ricketts J, Mouthguards: Protection Against Shock to Heqad, Neck and Teeth, Basal Facts. 1987;9(4):133-9. PMID: 2975489
Stenger JM,Lawton EA, Wright JM, Ricketts J, Mouthguards: Protection Against Shock to Head, Neck and Teeth, J Am Dent Assoc. 1964 Sep;69:273-81.PMID: 14178758
McCrory, Paul. Do mouthguards prevent concussions? Br. J. Sport Med. vol. 35, pp. 81 – 82, 2001
K.M. Johnston et all, 2001
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