Mouthguards

Give your patients’ smiles a sporting chance

by Patti A. Sooy, RDH, BS

How often have we had someone walk through the office door with a fat lip and broken tooth fresh from practice or a game? I’ve seen it many times through my years as a dental hygienist. My first question after examining the injured area is, “Do you have a mouthguard?” Then I ask, “Were you wearing it?” These victims often own a mouthguard but choose not to use it, or they don’t own one and haven’t been educated on the importance of wearing a mouthguard. I have watched my own son participate in a multitude of sporting activities — soccer, baseball, wrestling — throughout his 20 years. I made him several different sports guards that he rarely wore. Of course at the time he said he would, but out on the field or on the mats, it slipped his mind. (More likely no one else was wearing one, so why would he?) Fortunately he kept his beautiful smile intact. Now he plays rugby in college — a dental hygiene mother’s nightmare! They wear no padding, no helmets, no face protection, and anything goes. It’s absolutely brutal. However, his team does wear mouthguards faithfully. Hallelujah! So he may break an arm, dislocate a shoulder, or bruise his legs, but his teeth are protected.

Here are the reasons you must recommend athletic mouthguards to your patients in sports, and the choices they have in mouthguards.

The American Dental Association estimates that mouthguards prevent approximately 200,000 injuries each year in high school and collegiate football alone. Currently, only boxing, football, ice hockey, men’s lacrosse and women’s field hockey require players to wear mouthguards. Other sports traditionally classified as non-contact sports, including basketball, baseball, bicycling, rollerblading, soccer, wrestling, racquetball, surfing, and skateboarding could also greatly benefit from properly fitted mouthguards. Unfortunately, dental injuries can be a negative aspect of participating in these sports.

Direct blows to the teeth (from baseballs, footballs, elbows, the ground, and more) can be cushioned by a mouthguard. This cushion can prevent broken teeth and injuries to the lips, tongue, face, or jaw. A person with braces has an even higher risk for lip and cheek laceration. Sports mouth protectors can act as a buffer and help minimize the effects of mouth trauma. The rounded contours of a comparatively soft mouthguard can protect lips, cheeks, and even the tongue.

For athletes with missing teeth, the plastic of a custom-formed mouthguard can fill in and surround their remaining teeth, thus providing support to those areas. This means that a removable dental appliance such as a partial denture can be left out, thus avoiding any potential damage to it. For those with orthodontics, fixed dental bridgework, implants, or dental appliance, a mouthguard is highly recommended to protect their dental investment. It may occasionally be suggested to wear a sports guard on the lower jaw for protection also. A retainer or other removable appliance should never be worn during any contact sport.

The National Youth Sports Foundation for the Prevention of Athletic Injuries reports several interesting statistics. Dental injuries are the most common type of oral facial injuries sustained during sports participation. Victims of tooth avulsions who do not have their teeth properly preserved or replanted will face lifetime dental costs estimated from $10,000 to $15,000 per tooth, hours spent in the dental chair, and other possible dental problems.

Dr. Raymond Flanders’ 1995 study reported on the high incidence of injuries in sports other than football in both male and female 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 reported.

Mouthguard design and fabrication are extremely important. Idiosyncrasies of the teeth and jaw should be noted and evaluated during mouthguard design and fabrication. These may include:

• Jaw relationships: mouthguards may have to be designed on the mandibular arch for a Class III prognathic bite.
• Mixed dentition (ages 6 to 12): design should allow for eruption during the season. (Boil and bite mouthguards do not allow for this eruption space.)
• Ortho patients: special designs are essential to allow for orthodontic movement without compromising injury prevention and fit.

A properly fitted mouthguard must be protective, comfortable, resilient, tear resistant, odorless, tasteless, non-bulky, cause minimal interference to speaking and breathing, and possibly the most important criteria, have excellent retention, fit, and sufficient thickness in critical areas. Currently over 90% of mouthguards worn are the type bought at sporting goods stores. The other 10% are the custom made variety diagnosed and designed by a dental professional. This may be why so many athletes refuse to wear their mouthguards during practice and competition — improper fit and poor design.

There are three types of mouth protectors:

• Stock — Stock mouth protectors are inexpensive, come preformed, and are ready to wear. The stock mouthguards, available at most sporting good stores, come in limited sizes (small, medium, and large), and are the least expensive and least protective. Costs range from $3 to $25. These protectors are ready to be used without any further preparation. Simply remove from the package and 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 its protective properties. It has been suggested in medical and dental literature that these types of mouthguards not be worn due to their lack of retention and protective properties.

• Boil and bite — Boil and bite mouth protectors can also be purchased at sporting goods stores and may offer a better fit than stock mouth protectors. These are presently the most commonly used mouthguards on the market. Made from thermoplastic material, they are immersed in hot water and formed in the mouth by using finger, tongue, and biting pressure. Available in limited sizes, these mouthguards lack proper extensions and do not cover all the posterior teeth. If you don’t follow the directions carefully, you could wind up with a poor fitting mouth protector.

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 mouthguards due to their poor fit, poor retention, and gagging effects. This further reduces any protective properties. Certain thicknesses and extensions are necessary for proper mouthguard protection. Joon Park, PhD, et al., reported at the First International Symposium on Biomaterials in August of 1993 that boil and bite mouthguards provide a false sense of protection due to the dramatic decrease in thickness occlusally during the molding and fabrication process. He reported that boil and bite mouthguards decrease in occlusal thickness 70% to 99% during molding, thus taking away the protective properties of the mouthguard.

• Custom fit — Custom fit mouthguards are designed by a dentist and are the most satisfactory of all 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 mouthguard has virtually no effect on breathing. Providing custom mouthguards to athletes allows dentists to address several important issues while fitting the protector. Several questions should be answered before fabrication.

• Is the mouthguard designed for the sport being played?
• Is the age of the athlete and providing space for erupting teeth in mixed dentition (ages 6 to 12) going to affect the mouthguard?
• Will the design of the mouthguard be appropriate for the level of competition?
• 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?

There are two types of custom mouthguards that provide excellent fit and comfort to the athlete.

A) Single-layer vacuum fitted protectors

The vacuum mouthguard is made from a stone cast of the mouth, usually of the maxillary arch, using an impression fabricated by the dentist. A thermoplastic mouthguard material is adapted over the cast with a special vacuum machine. The most common material for this is a poly (ethylene vinyl acetate-EVA) copolymer. It is trimmed and polished to allow for proper tooth and gum adaptation and comfort in the vestibule. All posterior teeth should be covered and muscle attachments unimpinged. Vacuum machines are adequate for single-layer mouthguards. However, it is now being shown in the dental literature that multiple layer mouthguards (laboratory pressure laminated) may be preferred to the single layer vacuum mouthguards.

B) Multiple layer, pressure laminated protectors

The pressure laminated mouthguard can be modified for full contact sports by laminating two or three layers of EVA material to achieve the necessary thickness. Lamination is the layering of mouthguard material to achieve a defined result and thickness under a high heat and pressure environment. Efficient and complete lamination cannot be achieved under low heat and vacuum. The layers will not properly fuse together with the vacuum machine, but will chemically fuse under high heat and pressure with special machines.

Protective thickness is important because as the thickness of the mouthguard material increases, the transmitted impact force decreases. Dr. Keith Hunter reported that mouthguards should be a certain thickness, without being bulky. He suggested labial thickness of 3 mm, palatal thickness of 2 mm, and occlusal thickness of 3 mm. The thicker materials (3 mm to 4 mm) are more effective in absorbing impact. The mouthguard material should be biocompatible and have good physical properties that last for at least two years. They must maintain minimal and consistent thicknesses in critical areas. These thicknesses may vary according to the athlete’s individual needs for optimal protection.

Dr. Hunter further stated the advantages of pressure formed lamination:

• Precise adaptation
• Negligible deformation when worn for a period of time
• The ability to thicken any area as well as place any inserts needed for additional protection

There are two ways to obtain a pressure laminated mouthguard — dentist fabrication with special pressure laminating machines in the dental office, or referral to a laboratory that uses the pressure lamination technique.

Do athletic mouthguards reduce the incidence and severity of cerebral concussion in sports?

This is a controversial question in the sporting world, especially for high-impact sports such as hockey and football. Some studies suggest that wearing a mouthguard can help reduce the incidence or severity of concussions. Forces delivered to the jaw bones will be transmitted to the skull bones that surround a person’s brain, thus producing the potential for concussion. A mouthguard can buffer these transmissions by partially absorbing and dispersing them. The theory is that this effect can lessen the forces of the blow and therefore the likelihood for concussion. Numerous minor hockey leagues have introduced mouthguard rules to help prevent concussion rather than dental concerns.

The Bottom Line

Dr. Paul McCrory said of the connection between mouthguards and concussions, “Absence of proof is not proof of absence.” We should remember that the primary role of mouthguards is to protect teeth and orofacial structures, and they should be 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 should be included in any mouthguard that can enhance the potential concussion-prevention during sporting activities.

• Adequate thickness
• Full occlusal coverage
• Proper retention built to stay in during impact
• Should not be overtrimmed in the posterior to avoid forcing the condyles into the glenoid fossae
• Balanced occlusally to ensure an even distribution of force across the entire surface

In conclusion, the importance of wearing a mouthguard as a protective device during all athletics is well documented. The pain, cost, and time investment, not to mention the inconvenience of oral injury, should be a motivator to athletes and their parents to wear an athletic mouthguard. It is our job as dental professionals to educate patients and their parents about the importance of wearing mouth protection from a very young age. Custom mouthguards are by far the best choice; however, it is my personal opinion that some protection is better than none at all. Patients must be informed concerning the risks and benefits and treatment options. This needs to be discussed on a regular basis if the patient continues to be active in sports. Tell patients stories about the injuries you’ve witnessed, the discomfort people have experienced, and the lifetime costs of repair and replacement. More importantly, educate schools and coaching staffs about the statistics. When schools set the standards for protection, more athletes will be required to wear mouthguards during sporting activities.

More than anything, be an example with your own children and yourself. This may be all it takes to get the coaches and other players to follow your lead.

References

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, p. 24, Feb 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, Dent Traumatol. 2006 Aug;22(4): p. 186-192

Stenger JM, Lawton EA, Wright JM, Ricketts J. Mouthguards: Protection Against Shock to Head, Neck and Teeth, Basal Facts. 1987;9(4): p. 133-139. 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: p. 273-281.PMID: 14178758

McCrory P. Do mouthguards prevent concussions? Br. J. Sport Med. vol. 35, p. 81-82, 2001

Johnston KM, et al, 2001

Web sites: ADA.org, Oralhealth.deltadental.com, Sportsdentistry.com

* Glidewell Laboratories makes a great pressure laminated mouthguard called PLAYSAFE.

About the Author

Patti A. Sooy, RDH, BS, is an author, speaker, and owner of Dynamik Dental Systems. Her passion and enthusiasm for coaching teams to outstanding care is contagious. She has practiced clinical dental hygiene for over 25 years, taught restorative and clinical hygiene, practices assisted hygiene and restorative hygiene, and serves as office manager in her current dental office. She partners in producing the High Performance Perio Webinars for advanced dental learning, which will inspire you to be exceptional in your practice. To learn more about Patti, go to www.dynamikdental.com or contact her at [email protected].