Preventing Sports-Related Oral Injuries

Traumatic dental injuries, frequently the result of athletic activities, can be mitigated by the proper use of mouthguards.^1–5 Despite the protection offered by mouthguards, athletes are often reluctant to wear them.^2–4 In fact, a survey conducted by the American Association of Orthodontists (AAO) found that 67% of parents reported their children do not wear a mouthguard while playing sports.⁶ By incorporating a discussion and education on mouthguards, oral health professionals may be able to reduce the risk for short-term oral injuries as well as concussions.⁷

Types of Mouthguards

A mouthguard is an acrylic resin appliance usually worn on the maxillary arch to protect athletes from trauma to the teeth and surrounding oral mucosa.^1,4,8,9 Today, there are three categories of mouthguards: stock, mouth-formed, and custom (Table1).

Considered the least protective, stock mouthguards are available over the counter. They are ready to use and often sold in bulk. Stock trays cannot be molded or adjusted, which may result in a fit that is too loose or too small. Their low cost makes stock mouthguards a popular choice among athletes. While stock guards offer minimal protection and poor fit, they may be the only option for athletes with mixed dentition and for those with orthodontic appliances due to rapidly changing occlusion.²

Mouth-formed mouthguards, also known as “boil and bite” guards, are purchased over the counter and formed to the athlete’s detention. This type tends to fit the athlete better than stock mouthguards and provides more protection. Mouth-formed guards are a user-friendly option especially for entire teams because they are inexpensive and offer more protection than stock mouthguards.²

Custom mouthguards are manufactured by oral health professionals in a dental office or laboratory.⁴ Evidence shows that custom mouthguards decrease soft tissue lacerations, provide optimal fit, dissipate impact, decrease risk of concussion, and impede breathing the least, without impacting performance.¹ Their use, however, requires additional trips to the dental office and can cost hundreds of dollars.²

Intraoral Protection

A well-fitting mouthguard can prevent tooth avulsion, intrusion, extrusion, and fracture. Stock, mouth-formed, and custom mouthguards all reduce oral injury by accomplishing the following:²

1. Absorbing a fraction of energy transmitted to the oral hard and soft tissues after impact
2. Distributing the stress of the impact more evenly throughout the orofacial complex

Extraoral and Cranial Protection

Studies have found that mouthguards may also reduce temporomandibular joint (TMJ)-related injuries.¹⁰ In high-contact sports, the condyle can be forcibly moved posteriorly out of its functional position, possibly damaging retrodiscal tissues.^10,11 If the athlete is wearing a properly fitting mouthguard, it will help to absorb and redistribute the forces to other structures, preventing or reducing TMJ injury.¹⁰

Mouthguard use may also help reduce the severity of concussion. A concussion is a type of traumatic brain injury caused by the brain moving back and forth in the skull or banging against the skull in response to an impact.¹² In the United States, 3.8 million concussions occur each year because of contact or collision sports.¹³

Excessive biochemical trauma to the brain can cause long-term neurological imbalance, impairing overall brain function.⁷ Wearing a mouthguard during high-contact sports may reduce bone deformation and intracranial pressure by 50%.⁸ Additionally, some impact forces that would otherwise be transmitted superiorly to the brain are absorbed by the mouthguard; this may decrease head acceleration, possibly preventing or reducing the severity of a concussion.⁸

A study of college athletes found that when a mouthguard was in place and a blow was delivered to the inferior border of the chin, the amplitude of the intracranial pressure wave was reduced and deformation of the cranial bones moderately decreased.⁷ The same study showed that those who wore a mouthguard more frequently experienced fewer sports-related concussions.

Barriers to Mouthguard Compliance

While athletic mouthguards provide significant protection, many athletes still do not wear them routinely. Some of the most common reasons reported are discomfort, speech impairment, cost, desire to conform, and lack of mandatory regulations.²

While comfort is important, impaired speech may hinder the athlete’s ability to properly play certain sports as many high-collision sports require communication for positive outcomes.³ A mouthguard that is uncomfortable and/​or reduces speech often stems from a poor fit.

Specific characteristics that may affect comfort level and speech are the thickness of the material, ability to adjust the mouthguard, risk for xerostomia, and ability to swallow.¹⁴ Thicker, bulky guards may increase discomfort and interfere with breathing.¹⁴ Research shows athletes are more likely to wear mouthguards if they can be adjusted to extend labially to within 2 millimeters of the vestibular reflection, allow for even occlusion, are rounded at the buccal peripheries, and taper at the palatal edges.¹⁴

Cost is also a factor in mouthguard selection and compliance. As protection increases, so does the cost.² When playing contact sports where wearing a mouthguard is not mandated, coaches and athletes must decide whether the added expenditure is warranted. In some instances, coaches and athletes may rely on cheaper, less effective mouthguards to reduce costs. However, treatment of sports injuries is much more costly.¹⁵

The desire to conform to what other players are doing can negatively impact mouthguard compliance. If no one else on a sports team decides to wear a mouthguard, the player who is considering it may decide against it. In a survey of high school athletes, 33.7% stated they do not wear mouthguards because no one on their team wears one.¹⁴

Many states require sports organizations to mandate mouthguard use in specific activities. The National Federation of State High School Associations (NFHS) and the National Collegiate Athletic Association require mouthguard use in football, field and ice hockey, and lacrosse. The American Dental Association (ADA) encourages all participants in contact or collision sports to wear a mouthguard.⁵ Without mandated use, however, mouthguard compliance is hindered.

Role of the Dental Hygienist

Oral health professionals are well positioned to overcome these barriers to mouthguard compliance. However, a study of dentists found that one of the most common reasons they did not recommend mouthguards was a lack of formal training on the fabrication and use of mouthguards.¹⁶

Oral health professionals—including dental hygienists—need to stay educated about mouthguard use. The ADA offers resources at: ada.org/​resources/​research/​science-and-research-institute/​oral-health-topics/​athletic-mouth-protectors-mouthguards. These include a discussion of mouthguard types, orofacial injuries they can prevent, sports with mandates for mouthguard use, and efforts to raise awareness about the importance of mouthguard use.⁵

The Academy for Sports Dentistry (ASD) includes position papers on the importance of athletic mouthguards and resources for oral health professionals at: academyforsportsden
tistry.org/​position-statement.

A search for “mouthguard” on the American Academy of Pediatric Dentistry (AAPD) website (aapd.org) brings up myriad research papers on the topic.

Another quick and efficient option is to add a question to the medical history regarding whether the patient is a player, coach, or mentor in athletics. This can help identify patients who will most likely benefit from education regarding mouthguards.

Ilia et al¹⁴ found that when parents, family, and friends talk to others about wearing mouthguards, 62.7% of individuals chose to wear a guard; when coaches advocate usage, 50.7% of athletes take their advice.

These data emphasize the importance of including athletes’ entire support systems when educating about mouthguards. Coaches who are properly informed about sports-related oral injuries are more likely to be proactive than reactive.

Caries Risk

When providing education on the benefits of wearing athletic mouthguards, the increased risk for dental caries should be discussed. Athletes often consume sugary sports drinks to remain hydrated and maintain energy. If players use their mouthguard directly following consumption, the guard will trap the drink’s sugar and acid while blocking vital saliva.⁷

While caries is a possibility, this risk should not mitigate the professional recommendation of athletic mouthguards. Instead, dental hygienists should stress the importance of proper oral hygiene and increased topical fluoride applications. Patients should also bring their mouthguards to their dental appointments for evaluation and cleaning.²

Education Is Key

Visual aids can be helpful in gaining mouthguard compliance.¹⁷ The display of mouthguard models in the operatory can start conversations about style and fit.

Educational handouts may also spark discussion. Brochures are easily placed in take-home bags so the information can be shared with caretakers, athletes, coaches, and mentors. Brochures can be ordered through the ADA at: catalog.ada.org/​catalog/​mouthguards-and-sports-safety-1104, or printed for free from the American Association of Oral Maxillofacial Surgeons (AAOMS) at: aaoms.org/​media/​april-is-national-facial-protection- month/​informational-material.^18,19

An informational video in the dental operatory or waiting room may also be helpful. YouTube has a variety of mouthguard-related videos available at no charge.

Dental practices may also want to promote National Facial Protection Month. Every April, five organizations— ASD, AAPD, AAO, ADA, and AAOMS—promote the importance of orofacial protection in preventing sports-related orofacial injuries.⁵

The AAOMS has created social media graphics and information guides that can be shared on personal or professional social media accounts in just a few clicks.¹⁹

Conclusion

Mouthguards are effective in protecting athletes from injuries to the oral cavity. However, the general public may not be familiar with the positive and protective effects of mouthguards.

Dental hygienists can help reduce the risk for sports-related oral injuries with simple steps such as starting a conversation with athletes and their support systems, posting positive messages about athletic mouthguards on social media, and displaying visual aids in their operatories.

References

1. Ferreira GB, Guimaraes LS, Fernandes CP, et al. Is there enough evidence that mouthguards do not affect athletic performance? A systematic literature review. Int Dent J. 2019;69:25–34.
2. Sliwkanich L, Ouanounou A. Mouthguards in dentistry: current recommendations for dentists. Dental Traumatol. 2021;37:661–671.
3. Karaganeva R, Pinner S, Tomlinson D, et al. Effect of mouthguard design on retention and potential issues arising with usability in sport. Dental Traumatol. 2019;35:73–79.
4. Knapik JJ, Hoedebecke BL, Rogers GG, Sharp MA, Marshall SW. Effectiveness of mouthguards for the prevention of orofacial injuries and concussions in sports: systematic review and meta-analysis. Sports Med. 2019;49:1217–1232.
5. American Dental Association. Athletic Mouth Protectors (Mouthguards). Available at: ada.o/​g/​resources/​research/​science-and-research-institute/​oral-health-topics/​athletic-mouth-protectors-mouthguards#:~:text=Mouthguard%20use%20has%20been%20shown,dental%20trauma%20or%20orofacial%20injury. Accessed January 11, 2023.
6. American Academy of Pediatric Dentistry. Policy on Prevention of Sports-Related Orofacial Injuries. Available at: aapd.org/​media/​polici_​s_​guidelines/​p_​sports.pdf. Accessed January 11, 2023.
7. Ono Y, Tanaka Y, Sako K, Tanaka M, Fujimoto J. Association between sports-related concussions and mouthguard use among college sports players: a case-control study based on propensity score matching. InJ J Environ Res Public Health. 2020;17:4493.
8. Green JI. The role of mouthguards in preventing and reducing sports-related trauma. Prim Dent J. 2017;6:27–34.
9. Harrison N, Hogan S. The tooth-shattering history of mouthguards. Available at: houstonspediatricdentist.com/​blog/​the-tooth-shattering-history-of-mouthguards/​. Accessed January 11, 2023.
10. Tribst JPM, Dal Piva AM de O, Bottino MA, Kleverlaan CJ, Koolstra JH. Mouthguard use and TMJ injury prevention with different occlusions: A three-dimensional finite element analysis. Dent Traumatol. 2020;36:662–669.
11. Smith WS, Kracher CM. Sports-related dental injuries and sports dentistry. Dent Assist. 1998;67:12–16.
12. Collins C, McKenzie L, Roberts K, Fields S, Comstock RD. Mouthguard BITES (behavior, impulsivity, theory evaluation study): what drives mouthguard use among high school basketball and baseball/​softball athletes. J Prim Prev. 2015;36:323–334.
13. Maestrello CL, Mourino AP, Farrington FH. Dentists’ attitudes towards mouthguard protection. Pediat Dent. 1999;21:340–346.
14. Ilia E, Metcalfe K, Heffernan M. Prevalence of dental trauma and use of mouthguards in rugby union players. Aust Dent J. 2014;59:473–481.
15. University of Michigan. Concussions in Athletes. Available at: uofmhealth.org/​conditions-treatments/​brain-neurological-conditions/​concussion-athletes-neurosport#:~:text=Concussions%20in%20athletes%20are%20extremely,in%20any%20given%20sports%20season. Accessed January 11, 2023.
16. Young EJ, Macias CR, Stephens L. Common dental injury management in athletes. Sports Health. 2015;7:250–255.
17. Anderson M, Jiang J. Teens, social media and technology. Available at: pewresearch.org/​internet/떒/葑/葫/​teens-social-media-technology-2018. Accessed January 11, 2023.
18. American Dental Association. Patient Education Products About Teens. Availableat: catalog.ada.org/​catalog/​mouthguards-and-sports-safety-1104. Accessed January 11, 2023.
19. American Association of Oral and Maxillofacial Surgeons. April Is National Facial Protection Month: Informational Material. Available at: aaoms.org/​media/​april-is-national-facial-protection-month/​informational-material. Accessed January 11, 2023.

From Dimensions of Dental Hygiene. February 2023; 21(2)28,31-33.