Mouthguards for the prevention of oro-facial trauma in sport
A well-fitting mouthguard should be used by all athletes if there is an anticipated risk of oro-facial trauma (including dental injury) during competition and training. Mouthguard use is associated with both a reduction in the risk of sustaining an oro-facial injury1,2 and a reduction in the severity of dental injuries in athletes.3 Clear guidance on mouthguard use, how to fit and on how to maintain mouthguards can help to promote athlete welfare and is a key injury prevention tool.4
Target readership
Sport and exercise medicine practitioners and scientists, health professionals, sports participants, schools, coaches and parents. The guidance was produced with athlete involvement.
Key recommendations
All athletes:
1 – Athletes at risk of dental trauma or orofacial injury should wear a well fitted mouthguard.
2 – Custom made mouthguards, fitted by a dental professional offer the highest level of protection against dental trauma.
3 – Off the shelf mouthguards offer the lowest level of protection and may be bulky, of uneven uniform thickness and poorly retained in the mouth.
Paediatric specific recommendations:
4 – The recommendations also apply to school age children participating in sport with a risk of dental trauma or orofacial injury. Changes in the position and number of teeth in children from growth and orthodontic treatment will complicate mouthguard fabrication in this group.
Recommendation for mouthguard maintenance:
5 – The mouthguard fit should be checked before and cleaned after each use. An older mouthguard may become worn, thin, and ill fitting.
6 – The mouthguard should be checked by a dental professional at each dental check-up or when there is any doubt about the fit and protection of an existing mouthguard.
The burden of orofacial trauma in sport
The consequences of sport related oro-facial trauma may be immediately obvious, but can also have long term impacts on function, and aesthetics for athletes.4 In some instances this may also lead to an ongoing need for maintenance of restorative dental treatment. In children, with a developing dentition, there is a potential for lifetime impacts on dental health and wellbeing. It is therefore important to advocate for the use of a well fitted dental mouthguard to prevent or at least minimise the severity of dental injuries sustained during sport.5
| Mouthguard Type | |
| Custom made Offer the best level of protection against oro-facial and dental trauma. 6 |
Custom made mouthguards offer the best protection and are most comfortable to wear. Comfort is important to promote adherence to mouthguard use. They should be fabricated only after a full mouth dental health assessment, and any outstanding dental treatment is completed. The custom-made mouthguard is constructed using an accurate impression or scan of the sportsperson’s dentition and surrounding oral structures taken by a dental professional. It ensures maximum protection, comfort, optimal uniform thickness, retention and minimises breathing and gagging problems. It can be tailor made to the individuals request and sport. Optimal maxillomandibular occlusal relations (upper and lower teeth contacts) are also obtained. A dental professional can also allow space within a custom fitted mouthguard for development of the dentition in the young sportsperson. |
| Off the Shelf Mouthguard Types | |
| Boil & bite |
Boil and bite mouthguards are self-moulded by impression from the athlete, after immersion in hot water. The fit and quality is compromised as it is dependent on the materials used and the user’s technique, when forming the mouthguard. |
| Stock Mouthguards |
Stock mouthguards are pre-fabricated and are not moulded to fit the athlete. Stock mouthguards are liable to poor fit and offer the least protection against orofacial trauma. |
A well-fitting and retentive mouthguard offers protection and significantly reduces the risk of injury to the dentition, soft tissues, the temporomandibular joint (TMJ) and intraoral bony structures.6 It has also been demonstrated that well fitted custom made mouthguards have no negative impacts on performance, are well tolerated and do not impede communication between athletes7,8. Consistent messaging on mouthguard use is therefore a key injury prevention message to support athlete welfare and health and can reduce the risk of athletes needing complex or sustained restorative dental treatment.
Cost and lack of awareness are the two main barriers to the consistent use of mouthguards in sport, especially at community and grassroots levels. However, some sports such as amateur boxing mandate their use at all levels of competition. No mouthguard no play policies, in some sports have reduced the risk of oro-facial trauma4.
Understanding the risk of dental trauma in sport
The incidence of oro-facial trauma has reported to vary by individual sports. However, studies have shown that athletes at both the grassroot and elite level, competing in “at risk” combat sports, contact sports and non-contact sports are affected. Non mouthguard wearers have been reported to be at in increased risk of oro-facial trauma (relative risk, 2.33) compared to mouthguard users.1
In addition to this, compliance with mouthguard use is low in “at risk sports”. It has been reported that 9.8% of ‘weekend warriors’ experienced dental trauma but only 2.9% reported using mouthguards.9 There are reported to be significant differences in mouthguard awareness and use and injury rates, i.e., athletes who do not wear mouthguards tend to have more injuries. Traumatic injuries to teeth are significantly more frequent among contact athletes than among noncontact athletes.9 Limited mouthguard awareness could be due to lack of information and education on dental injuries and their prevention.10
List of “at risk” contact sports (this list is not exhaustive)
Contact sports:
Basketball, Boxing, American Football, Handball, Hockey (Ice and Field), Lacrosse, Martial Arts, Rugby, Water Polo, Wrestling, Australian Rules Football, Gaelic Football.
Limited Contact Sports and Recreational Activities:
Acrobatics, Baseball, Bicycling, Equestrian Events, Field Events, Gymnastics, In-Line Skating, Racquetball, Shot-Putting, Skateboarding, Skiing, Skydiving, Softball, Squash, Surfing, Volleyball, Weightlifting, Extreme Sports.
Specific considerations for the paediatric athlete
Changes in the number and position of teeth from growth and orthodontic treatment will complicate mouthguard fabrication in this group and will likely mean that mouthguards need to be replaced more frequently. Fabrication techniques such as blocking out teeth that are likely to be lost as part of growth in the near future should allow mouthguards to last for more than one season. Mouthguards can also be fabricated for children undergoing orthodontic treatment.
Mouthguards can be checked as part of routine dental visits and the decision made as to whether to replace it made then. As with adults poorly fitting or retained mouthguards are unlikely to be as protective.
The following checklist is an easy way to ensure a mouthguard is well maintained and functional.
Four steps to check fit and function
1 – Store it: Check that mouthguard has been kept in a clean container
2 – Check it: Check that the mouthguard is in good condition, not worn through or contains any defects.
3 – Wear it: Ask the athlete to place the mouthguard in their mouth and then open wide. Make sure that the mouthguard stays in place when the mouth is open and does not need additional support to stay in place.
4 – Clean it: At the end of the session, clean the mouthguard dry and store in a vented container.
Recommendations for mouthguard care
Mouthguards should be checked at the beginning of each competition season. If they are loose or worn, they should be replaced.
Mouthguards should be checked and cleaned after each use by brushing with a toothbrush and toothpaste or soap, followed by rinsing with cool water. They should be stored in a vented container after cleaning so that they can dry completely.11
Authors
Dr Irfan Ahmed1, Dr Julie Gallagher2, Professor Ian Needleman2, Ms Rachel Bower3,4, Professor Paul Ashley2, Dr John Haughey2, Dr Peter Fine2
1. Addenbrookes Hospital
2. UCL Eastman Dental Institute, Centre for Oral Health and Performance
3. Head Coach Rathbone Amateur Boxing Club
4. England Boxing Talent Pathway Coach
Patient and participant involvement (PPI) – This document was developed with the guidance of Rachel Bower (Current Coach and former National Amateur Boxing Champion)
References
1 – 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 Aug; 49(8):1217-1232. doi: 10.1007/s40279-019-01121-w. PMID: 31148073.
2 – Knapik J, Marshall S, Lee R, Darakjy S, Jones S, Mitchener T, Delacruz G, Jones B, Mouth guards in Sport Activities: History Physical Properties and Injury Prevention Effectiveness 2007; Sports Med 2007; 37(2) 117-144
3 – ADA Council on Access, Prevention and Interprofessional Relations; ADA Council on Scientific Affairs. Using mouthguards to reduce the incidence and severity of sports-related oral injuries. J Am Dent Assoc. 2006 Dec;137(12):1712-20; quiz 1731. doi: 10.14219/jada.archive. 2006.0118. PMID: 17138717.
4 – Ahmed I, Fine P ‘Injury prevention versus performance’: has the time come to mandate the use of mouthguards in all contact sports? BMJ Open Sport & Exercise Medicine 2021; 7: e000828. doi: 10.1136/bmjsem-2020-000828
5 – Fine PD, Louca C, Leung A. Sports dentistry: Principles and practice. Hoboken, NJ: Wiley Blackwell; 2019 pp103-119
6 – Patrick D, Van Noort R, Found M. Scale of protection and various types of sports mouth guard, Br J Sports Med 2005;39:278–281. doi: 10.1136/bjsm.2004.012658
7 – Caneppele TMF, Borges AB, Pereira DM, et al. Mouthguard use and cardiopulmonary capacity – a systematic review and meta-analysis. Sports Med Int Open 2017;1:E172–82.doi:10.1055/s-0043-117599pmid:http://www.ncbi.nlm.nih.gov/pubmed/30539104
8 – Ahmed I, Gordon D, Pinto JM, et al. Investigating the impact of custom-made mouthguards on maximal aerobic performance in amateur boxers .Medicine and Science in Sports and Exercise 2021; 53(8S):389-389 DOI: 10.1249/01.mss.0000763768.53311.80
9 – Dursun E, Ilarslan YD, Ozgul O, Donmez G. Prevalence of dental trauma and mouthguard awareness among weekend warrior soccer players, J Oral Sci. 2015; 57(3):191-4. doi: 10.2334/josnusd.57.191. PMID: 26369482.
10 – Tiwari V, Saxena V, Tiwari U, Singh A, Jain M, Goud S. Dental trauma and mouthguard awareness and use among contact and noncontact athletes in central India, J Oral Sci. 2014; 56(4):239-43. doi: 10.2334/josnusd.56.239. PMID: 25500920.
11 – American dental association. MouthHealthy., Available from: https://www.mouthhealthy.org/all-topics-a-z/mouthguards/ [accessed 2023Apr24].