Play it safe

Sept. 1, 2003
Be on guard and avoid misfortunes in the mouth.

by Karen Kaiser, RDH

After years of steel brackets, arch wire changes, itsy-bitsy elastomere rubber bands, and meticulous home care, the much-anticipated event has arrived - debonding. Through combined efforts of patient and dental professional, the carefree 14-year-old completes the treatment process and gleefully leaves the office with a perfectly aligned smile — a fledgling to the use of removable appliances, retainers, and guards.

Less than two weeks later, the scheduling coordinator receives a frantic call from the parent of the post-orthodontic teen. While engaging in extracurricular sports, this newly aligned athlete had diagonally fractured the crown portion of a front tooth, perpetrated by an unexpected knee to the chin. Now this young athlete is no longer all smiles and is faced with the possibility of lifelong dental trauma. Unforeseen events, where dental trauma and concussions can occur, can be painlessly averted by wearing mouth protection.

A blow taken to the mouth could damage brackets, fixed appliances, or the teeth to which they are bonded in athletes with orthodontics. To minimize the risk of breaking newly aligned teeth, or injuring the cheeks, lips, tongue or gingivae, using a mouthguard during sporting activities can be a great protective measure. Mouthguards, which generally shield the maxillary teeth, can soften a blow to the face. Often, braces or other dental appliances such as lingual retainers or space maintainers are fixed on lower teeth as well, and a maxillary mouthguard may not provide enough overall protection. In these situations, consider also recommending use of a lower guard for cushioning the teeth and hardware.

When engaging in activities where there is a strong chance of contact with players or pavement, athletes with orthodontics or fixed bridgework should consider wearing protective guards. Instruct these athletes also to take out retainers and other removable appliances and promptly insert a fitted mouthguard before engaging in contact activities.

There is a growing number of dental injuries to younger athletes as children begin recreational leagues and instructional camps at a much younger age. Risk-taking behavior without fear of consequence is normal for young athletes. This is a dilemma since children as young athletes can be clumsy as they go through growth spurts, so accidents can happen. When children encounter early mouth trauma, damaged teeth may exfoliate abnormally or permanent teeth may fail to erupt. There may be color changes in teeth or infections in which painful abscesses may develop. Also, possible injury to underlying permanent teeth or actual tooth loss can leave unwanted open spaces. When constructing custom mouthware, keep in mind that teeth are erupting and exfoliating as young folk move into mixed dentitions.

Educating the parents and patient during a dental visit on the subject of wearing mouthguards may be the best preventive measure. Discuss the unfortunate, yet preventable, consequences of oral injuries. Parents sometimes remain unaware of the dangers posed to young athletes while playing sports and may not be familiar with the amount of physical contact required for play. Contact activities like football, boxing, hockey, lacrosse, martial arts, and rugby are but a few of the activities that warrant the wearing of mouthguards.

Since 31 percent of all sporting injuries result in injury to the teeth, mouth, or head area, substantial research has been conducted demonstrating the need for and effectiveness of mouth protection. What's more, athletes are 60 times more likely to sustain damage to the teeth if they opt to not wear a protective mouthguard. With these supportive statistics, it would seem that athletes of many different sports should be wearing protective guards. Unfortunately, that is not always the case. Compliance for wearing guards remains low when the mouthguard is overly bulky, breathing is hindered or speech is muffled. One would hope that avoiding fractured teeth (not to mention tissue trauma and brain concussion) could thwart those statistics and players could be persuaded to consistently use mouth protection. Furthermore, severe focal injuries such as fractured jaw, cerebral hemorrhages, and episodic unconsciousness could be prevented or lessened by wearing a custom fabricated mouthguard.

So, how do athletes defend themselves against these traumas? By selecting the correct guard for maximum protection and consistently using it. First, help your athletic patients make an informed decision as to where to obtain guards to protect their smiles. The stock variety and "boil-and-bite" types, available in the sporting goods department, may be appealing due to the inexpensive cost, but the amount of protection they offer over other types may be less than one suspects.

Interestingly enough, some companies offer "per tooth injury warranties" for these economically purchased mouthguards. For the initial cost of the mouthguard (starting at under $1), companies offer warranties anywhere between $100 or more per tooth repair if an athlete is injured wearing their brand. The catch is that the mouthguard is warranted for up to one year, with sales receipt. In addition, a written statement of treatment from a dentist, along with a statement from the game official regarding and verifying the injury must accompany a claim.

Incidentally, the worn and ragged mouthguard must be returned to the manufacturer for payment.

These over-the-counter guards are available in limited sizes. Some offer pleasant flavors. Some generic mouthguards, because of their undersizing, do not offer enough coverage for the posterior teeth to be shielded. Additionally, when the bite is not registered into the softened material properly (biting too hard), these guards can become dangerously thin in the occlusal, giving wearers a lower level of protection. Ideally, guards must be stiff enough so as to not deform when the athlete does clench, remain comfortable, and not obstruct breathing or speech. Most "boil on a burner" guards offer modest conformity to the teeth and are held in place only when the mouth is closed and the athlete is constantly holding them in place by biting down on them. Fit is important. A shifting mouthguard offers greatly reduced protection.

When using a snug fitting, single-arch mouthguard, the teeth are slightly separated. This separation can guard against chipping teeth and fractures, and possibly reduce concussions. Consequently, when deciding not to use a mouthguard, the teeth are unprotected, positioned biting together — usually clenching tightly during active play — so any impact could harm tissues, fracturing teeth.

A promising type of dual arch mouthguard covers the upper and lower teeth and is marketed as protection for the jaw joint. Dual arch designs claim to not only cushion the joint but protect the teeth and tissues as well. Standard mouthguards fit over the maxillary teeth only, protecting them from impact type of breakage.

Unfortunately, in a collision, a maxillary guard does not lock the hinge so it cannot adequately absorb the force alone and the teeth may slide over the smooth mouthguard surface. Reduced protection is available if the jaw is open during contact. Moreover, for a maxillary guard to be of help, the jaw needs to be closed if an impact is taken.

For better overall retention, a custom fabricated, dental office dispensed guard may be ideal. These are vacuum-formed, multi-laminated, and come in a range of colors and a general thickness of anywhere between three and five millimeters, offering ample protection without being bulky. When the athlete has a particular dental concern to protect, the guard can be built up thicker — like a bumper. These varieties require impressions of the athlete's teeth to ensure a good fit.

The effectiveness of mouthguards in preventing lifelong facial, dental, and brain injuries is indisputable. The prevention of concussion continues to be demonstrated statistically every year. Give your patients a sporting chance — recommend mouthguards for all sports that involve equipment!

The role of mouthguards in lessening the impact of concussions

Traditional mouthguards will adequately protect teeth from a vertical blow but a horizontal blow can cause a concussion. Statistically, 90 percent of concussions are a direct result of blows to the mandible. The reason for the concussion, a horizontal hit, is still capable of shoving the lower jaw in a posterior direction.

Regrettably, many impacts are taken from blows to the front and side of the mandible — jamming back and up the joint. When a chin blow is received, the lower jaw's condyle (resting on the thinnest part of the skull) takes the force and radiates energy from the mandible, up to the temporomandibular joint (TMJ) and as a final point reaches the skull base (temporal bone). The TMJ and base of the skull take the brunt of the upward blow.

This impact site is the source of nerve endings and blood supplies to the brain. Spinal nerves exit the spine through the foramen at the base of the skull. All this transferred force tosses the brain around inside the skull; a concussion is the adverse consequence. To prevent diffused concussions, dual arch mouthguards form a shock-absorbing cushion for the condyle. This separation provides ample parting of the teeth and evenly distributes force.

Unfortunately, there is no set number of symptoms that automatically indicates a concussion and an athlete does not always need to be unconscious to have a concussion. What's more, severe symptoms can take hours or days to become evident. Severity of concussions is categorized by a grade scale from one to three, established by the American Academy of Neurology.

Grade three is the most severe, with total loss of consciousness. The player will likely experience traumatic amnesia (loss of memory) in attempting to recollect the event. Persons with grade two concussions will experience confusion, or feel foggy and dazed, without going totally unconscious, and symptoms are experienced for longer than 15 minutes. Grade one concussions, the type most often experienced, will have duration of less than 15 minutes. There is no loss of consciousness and only moments of confusion. Commonly found symptoms for all stages range from having dilated pupils, vomiting, feeling dizzy, headache, blurry vision or slurred speech, coordination and balance difficulties, irritability, and mental status disturbances (i.e. memory loss and disorientation). Despite the fact that an athlete does not experience total loss of consciousness, consider the possibility that they still may have a concussion.

Sometimes the hit can result in microscopic damage to the brain's 100 billion neurons without obvious structural damage to the skull. The brain (three to about four pounds of delicate tissues) cannot break out from the limits of the skull if it is impacted. Since it has no place to extrude from, it swells, and this swelling compresses blood flow and encumbers vessels. Swelling has the potential to elevate the concussion's seriousness and cause bruising of the brain matter. The brain, seriously lacking in blood flow, is depleted of needed oxygen and, as a result, a stroke can occur.

In most cases, though, an athlete should fully recover from a concussion within a few hours or days. In more severe cases of concussion, they can last up to several weeks. Post-Concussion Syndrome, a rare complication from the primary concussion, occurs when the athlete has not fully recovered from the initial concussion and is still experiencing symptoms. He or she then goes out to the field again to take another blow.

A promising product, the Brain Pad® mouthguard, on the market since 1997, positions the jaw in a fixed down-and-forward position. The benefit of this design is that the mandible is locked into position and cannot easily push up into the skull base on impact, dramatically reducing the occurrence of concussions. The drawback is that the jaw is locked into position and cannot move for effective communication.

These mouthguards are made of a shock absorbing copolymer material found in familiar products such as footwear, adhesive, waterproofing coatings and road pavement. This substance helps dissipate the force of impacts and concussions up to 50 percent, while promoting better breathing and re-alignment — all fashioned using a boil-and-bite concept.

Care of mouthguards

Because mouthguards are constructed from layers of multi-laminated materials, they can be distorted by prolonged direct sunlight, placing them in very hot water, or extreme heat. This distortion of the guard can alter the fit. Another word of caution: If the mouthguard absorbs a strong blow while in use, chances are it will need to be replaced to maintain full protection. Also, mouthguards wear out over time.

When an athlete fails to replace a worn and torn guard, the decreased protection can become regrettable. Encourage patients with mouth protectors to bring them in for evaluation at recare visits so dental professionals can inspect them for tears, make adjustments, or recommend a cleaning routine.

Care must be taken to keep the mouthguard as germ-free as possible. Hygienic measures include brushing with a non-abrasive toothbrush, or cleaning with lukewarm water and mild soap. Rinsing with a mouthrinse to keep bacteria at bay will keep the guard fresher smelling. Remind guard wearers to rinse the protector prior to and after each use with water and store the guard in a sturdy container that is vented so airflow is not restricted; otherwise the mouthguard will become a haven for growing bacteria.

Karen Kaiser, RDH, practices high-tech hygiene at the Center for Contemporary Dentistry in Illinois. She received her degree from Forest Park College in St. Louis in 1994. She is a 2002 Award of Distinction recipient from the John O. Butler Company and RDH magazine. She does consulting for 3M ESPE and is on their Dental Hygiene Advisory Panel. She may be contacted by e-mail at kjkaiser@