The whistle blows and play is suspended while Joey's Mom cuts off the back of the gnarly, chewed-up mouthguard. The play-by-play man announces: "Oh, what a blow to the Cardinals. With just seconds left in the game, Joey Generic loses his lunch and more at the feet of the goalie, Chris Custom. The ice is ruined at the Cardinals crease, and it looks like they're not going to be able to close the gap in the score before time runs out."
Or it could be just another hockey game — suspenseful because of the score — not the lack of protective mouthguards.
by Shirley Gutkowski, RDH, BSDH
Mouthguards are the fashion rage this year! They're seen from all the runways at skateboarding parks to the spotlights lighting up the courts and diamonds. Wouldn't it be great if that were true? Wouldn't it be great if kids never again walked past your treatment room with the tear-stained faces and blood-splattered shirts, sobbing en route to unknown restorative strategies in the doctor's treatment room?
Mom explains to the assistant, "The skateboard flipped and hit him in the mouth." Dad explains, "The softball had a bad bounce in the outfield and caught her in the mouth." Fat, swollen, and lacerated lips are the least of the possible concerns when sports injuries involve the mouth. Broken teeth and concussions are also possible outcomes of a violent blow.
The ADA has assembled quite a list of sports for which mouthguards are recommended: acrobatics, baseball, basketball, bicycling, boxing, equestrian events, field events, field hockey, football, gymnastics, handball, ice hockey, in-line skating, lacrosse, martial arts, racquetball, rugby, shot put, skateboarding, skiing, skydiving, soccer, softball, squash, surfing, volleyball, water polo, weight lifting, and wrestling.
The governing bodies of five sports — boxing, football, ice hockey, men's lacrosse, and women's field hockey — require mouth protection. That's it, just five.
The goal of wearing a mouthguard during active sports has two basic objectives. The first is to protect the teeth against a blow from an object or body part. The second is to protect against concussions.
Dig out a skull from the back of one of your closets. Watch the TM joint move. Simulate an upward frontal blow to the chin. When the teeth are in full occlusion, where does the condyle go? Insert a folded plastic bag between the teeth. How much relief from that blow will a skull get with that amount of protection? A sturdy, properly fitted mouthguard will increase the distance between the condyle and the skull. It protects the vulnerable temporal bone, which houses blood supplies and nerves as they exit the base of the brain — not to mention all of the systems associated with the auditory system. A crushing blow from another athlete or sports equipment that is transferred through the mandible, up the ramus, and into the skull can cause severe damage — not just unconsciousness but a concussion that can have long-lasting consequences.
So, a study of Virginia dentists in Pediatric Dentistry (1999) is baffling. Out of 834 respondents to a survey, 21 percent of general dentists recommend stock or mouth-formed mouthguards, and 59 percent recommend customized mouthguards. The reason most often cited (63 percent) by dentists for not recommending mouthguards was because a patient can obtain the mouthguard from a much less expensive source than a dental office. Ten percent responded that the dentist is not the one to recommend a mouthguard. The report begs the question: Whose job is it?
The rules say...
Children, for the most part, follow the rules set out by the sports organizations. They wear the athletic gear required by regulation committees — helmets, cups, elbow pads, knee pads, shoulder pads, cleats, and so forth. If mouthguards are required and worn by all of the other participants, they'll be worn. It's better if the sports committees make the rules rather than some outside source such as insurance companies.
Insurance companies hire people who work in the basement, crunching numbers. The sound is thunderous, as these number-crunchers, better known as actuaries, make our lives safer. Without insurance companies pinching every penny and actuaries actually masticating numbers, we wouldn't have as many safety features and annoying safety codes as we have now. Consider, for example, the recent earthquake in Seattle. A quake of the magnitude 6.7 on the Richter scale in almost any other country would have killed thousands. Toppled buildings would lie there in a pile of dust. Fewer than five lives were lost in that rumble in Seattle.
Without proactive measures on the part of parents, coaches, officials, dentists, and dental hygienists (prevention specialists), the insurance industry may find cause to start setting safety standards for sports — a resort at which many would cringe.
Coaches at Florida high schools were asked if they would recommend mouthguards, if they were free. Thirty percent said no. If 10 percent of dentists do not think it's dentistry's place to recommend mouthguards — and 30 percent of coaches wouldn't recommend mouthguards even if they were free — who's left?
Here are the highlights of the report on the group of Florida high school coaches who oversee more than 1,000 athletes:
- One-third of the athletes sustained one orofacial injury per season
- 4 percent use mouthguards
- There is a seven times greater chance of injury when competing without a mouthguard
- 46 percent of the coaches based their decision on requiring mouthguards on cost, not quality or percent of protection
- 57 percent of the coaches would not encourage use
Parents can't know everything, and physicians do not know the mouth. Hygienists do. We recommend "off label" all the time. Prevention is what we're educated to understand and teach others. Mouthguards can be our responsibility.
Officials also need to be part of the sextet. If parents and coaches insist that athletes wear properly fitted mouthguards, officials must hold up their end. High school football, for example, has strict penalties for players who do not wear their protective gear, including properly fitted mouthguards. The penalties may include the loss of a timeout or worse, yet some officials are hesitant to enforce those penalties. Some jurisdictions demand mouthguards with high visibility colors. Officials who do not enforce these rules are leaving players with a few thoughts that we don't want them to have:
- Officials enforce only the rules they want to
- Safety is not important
- If you don't make a scene, no one will notice you're breaking a rule
- Rules are for sissies
We hope our children don't develop such impressions about organized sports.
The decision to wear a mouthguard is made for children by their parents and the coaches, and is enforced by officials in organized play. What about unorganized sports? A second look at the list provided by the ADA indicates that synchronized swimming is about the only sport not on the list. Interestingly, age is not addressed. This should mean that an adult participating in any of these sports should also be wearing protective mouth gear. How is a person on a recreational softball team any less vulnerable than a high school student playing baseball? Many of these adult team sports permit a can of beer or two before or even during the game, making the players all the more vulnerable. There are very few organized rollerblading activities. A casual in-line skate trip around the block with a 13-year-old daughter should include protective mouth gear along with the rest of the equipment.
Where's the money?
By now, you must be wondering how a family can afford to buy an 11-year-old child participating in hockey, Little League baseball, and basketball three customized mouthguards each year. A reality check will reveal one of two scenarios. Either the parents will not supply a properly fitted mouthguard for a sport that doesn't require one, such as basketball and baseball, or the parents will purchase an inexpensive mouthguard from a store. One remedy is to decrease the cost of customized mouthguards so that parents can afford to supply their children with three or four different sizes throughout the year. Such an approach increases the overall profit to the dental office and saves the patient thousands of dollars in end costs of restoring a tooth or teeth, or suffering one of a series of concussions.
The mouthguards bought in stores are easy to chew through, and they distort with chewing (primarily in the distal direction), causing an uncomfortable choking sensation that both children and adults avoid at all costs. Imagine a rousing game of basketball with two posterior bitewings in place. This acute sensation renders the wearer totally distracted by the gag reflex and ineffective on the playing field.
Should we ask parents of an 11-year-old child to pay almost $100 for a lab appliance? They can go to any discount or sporting goods store and buy the boil-and-bite variety for next to nothing. The cheaper alternative may be especially appealing when you consider the number of oral and dentition changes occurring in 10- to 15-year-olds.
Boil-and-bite types of mouthguards are good for working on computers, doing needlepoint, and maybe driving a car. For active children and adults, they are just this side of useless for protecting against a force strong enough to cause a concussion or break a tooth.
In some states, an assistant, hygienist, dentist, or even the receptionist (if the phones are quiet) can make a quality, vacuum-formed mouthguard in the office. Customized mouthguards do not necessarily mean that valuable doctor or hygiene time needs to be factored in when trying to make mouthguards cost-effective.
The gender gap
Within kids' organized sports lies a gender gap. Even if it were true that girls throw, hit, or run like girls, the danger of an orofacial trauma is still equal to that of boys sports. As hygienists, we can encourage female patients and their mothers to wear protective mouth gear. Why use reason when we have actual facts? The related chart comes from the Journal of Public Health Dentistry (1998).
It is obvious that girls are just as susceptible to injury — even more so in some cases — as boys in contact and non-contact sports. Females are closing gender gaps every year that have kept them free from many illnesses and accidents once thought of as reserved primarily for males. In safety and health, women would be better off to keep the gender gap as wide open as possible. A short list of afflictions that have women nipping at the heels of men include: heart attacks, strokes, concussions, violent deaths, gun wounds, car crashes, lung cancer, and obesity.
As health-care providers in a clinical setting, hygienists often counsel patients on various topics unrelated to the mouth. The subject of this article directly involves the mouth, and, as we are painfully aware, the mouth is attached to the body (in this case, the skull). We can help subvert a possible calamity by educating our patients/clients and their parents.
In short, in order to be worn, a mouthguard must be comfortable. Comfort includes affordability and the ability to breathe, swallow, and speak. Quarterbacks, for example, need to be understood in the huddle. If it ain't comfortable, it ain't goin' in. In order to be comfortable, the mouthguard must be custom-fitted.
Properly fitted mouthguards are indicated for all activities that require gear, including sticks, bats, wheels, helmets, gloves, glasses, pads, saddles, boots, and more. Any gear that's used for any sport should include a properly fitted mouthguard. They come in fun colors, even with team logos or animal designs. They have become as fun-looking as helmets. Dental hygienists should also approach active parents and encourage them to wear mouth protection during their sporting activities. These activities include weight machines and jogging. Parents are role models for their own children, as well as their children's friends. Wearing protective gear, ranging from raincoats to mouthguards, is a marvelous way to show kids that to be safe adults is in vogue and all the rage.
Shirley Gutkowski, RDH, BSDH, has been practicing in Madison, Wis., since 1986. Gutkowski presents seminars for nurses and nursing assistants on oral infection control in long-term care facilities. She can be contacted by e-mail at [email protected]
The sextet of responsibility:
- Dental hygienists
Photos courtesy of Glidewell Laboratories