Valley Health Magazine

By David P. Forester, D.D.S., & T. Gary Forester, D.D.S.

Sports and athletic competition is at the core of American culture. Young boys grow up dreaming of making the big leagues, and men reminisce about that incredible play in the big game. Girls grow up playing softball, and look up to their home-town heroes, who played in the College World Series. Kids play sports at the playground and on organized teams. Adults compete in community leagues, and play with friends on the weekends.

Because so much of our lives revolve around playing sports, the likelihood of adults and children suffering some kind of sports-related injury is high. However, when it comes to protecting your mouth or your child's, the preventative measures available are easy and effective.

THE FACTS ABOUT SPORTS INJURIES
Fact: It is estimated that one in ten athletes risk orofacial injury (injury to the oral and facial structures) during a single athletic event (National Youth Sports Foundation for Prevention of Athletic Injuries, Inc.).

There are 15 million dental injuries in the United States per year, and five million with trauma related tooth loss. Research shows that sports injuries may account for anywhere between13-39% of those dental injuries.

KNOWLEDGE IS POWER
Raising awareness about these problems with our families and in our communities is an important health goal. Injuries can be expensive and life-changing. This is especially important in regards to children, since traumatic injuries risk interfering with growth and development. Putting our families at risk is pointless when injuries can be prevented. Preventative measures are easy, relatively inexpensive, and very effective if they are put into practice. The evidence is overwhelming—sports mouthguards are an effective and efficient way to reduce the severity of orofacial injuries.

THE NATURE OF OROFACIAL INJURIES
• Teeth–fractures, dislocations, tooth loss, required root canals
• Soft tissue– lacerations (cuts), contusions (bruises), infections, scarring
• Jaw bones– fractures, dislocations, malalignment
• Concussion– traumatic injury to the brain. Can be caused by a severe blow to the lower jaw. The jaw is thrust upwards and backwards into the thin bone (the glenoid fossa) lining the brain.

These injuries are caused by serious impacts or blows that are most likely to occur with high contact and collision sports.

MOUTHGUARDS, SPORTS AND TRAUMA
A landmark study in 1964 showed that mouthguards significantly reduce the number of concussions in high school football. This and other research resulted in mandates for high school and college football players to wear a mouthguard. Prior to mandated wear, 50% of all football injuries were orofacial. Mouthguard use has since decreased orofacial injuries to 0.07%.

Currently, only five amateur sports (football, ice hockey, boxing, men's lacrosse and women's field hockey) and one professional sport (boxing) have mandated mouthguard use. This has shown to be effective in reducing facial and dental trauma in each sport.

What about other contact sports and recreational activities that do not require mouthguards? The American Academy of Pediatric Dentistry (AAPD) is concerned that baseball, basketball, soccer, softball, wrestling, volleyball, and gymnastics all have significant histories of orofacial injuries. This indicates that mouthguard mandates should be put into effect. Skateboarding, rollerblading and bicycling are high risk sports, however, they are not as easily mandated as organized sports teams. The American Dental Association and the Academy for Sports Dentistry have a new, more comprehensive list, including raquetball, handball, squash, tennis, skiing, and waterpolo.

In several studies, soccer is shown to have a higher incidence of orofacial injury than football. The AAPD reports that nearly half of sports related mouth injuries occur in basketball and baseball. In basketball, 32% of all injuries were orofacial, which was reduced to only 4.7% when a mouthguard was worn. In a study of 50 Division I basketball teams, in the 1999-2000 season, there were four times as many dental injuries and twice as many fractured teeth without mouthguard protection.

MOUTHGUARD MISHAPS
In non-mandated sports, only 4-6% of athletes wear a mouthguard. People reported abstaining from mouthguard use for the following reasons: speech and breathing difficulties, appearance and image, fitting difficulties, bulkiness, cost, orthodontic treatment, and physical characteristics like rigidity, smoothness, odor, taste. These reasons may be more true for "less than ideal" mouthguards.

Characteristics of a well-fitted mouthguard
• Protective
• Comfortable
• Doesn't interfere with breathing/speaking
• Good retention—stays in place. One that does not stay in place may not be in the proper position at the moment of impact.
• Able to wear with orthodontics
• Sufficiently thick in critical areas
• Does not cause gagging, not too bulky
• Tasteless and odorless
• Tear resistant, durable
• Able to accommodate a growing child's mouth

The use of a mouthguard can be compared to the shocks of a car. When a mouthguard of sufficient thickness is in place during a blow to the chin, it acts as a shock absorber. Just as the shocks on a car provide for a smoother ride, the mouthguard absorbs the shock that would normally be transferred from the lower jaw to the base of the skull. Thus, it decreases the potential for concussion or other serious brain injury.

TYPES OF MOUTHGUARDS
There are three basic types of mouthguards available. Each differs in size, fit, price, comfort, and user compliance. They are categorized into types by their ability, or lack thereof, to meet the requirements listed above.

Type I is the prefabricated stock mouthguard, sold at sporting good stores (<$10). It is not formed to the teeth, but rather relies upon a clinched jaw to keep it in place. This is by far the bulkiest and least protective mouthguard. It impedes upon the athlete's ability to speak and breath, and increases the likelihood of gagging.

Type II is the boil and bake type of mouthguard also available over the counter ($5-30). Unlike the stock type, an attempt is made to fit the teeth, with fair success. There is instability and uneven distribution of the material after the mouth has formed the guard. This leads to improper fit and poor shock absorbing potential between back teeth due to thinness. When compared to Type I stock mouthguards, its increased comfort, fair
retention, and relatively inexpensive price are all reasons why the Type II mouthguard is the most commonly used.

The Type III mouthguard is a custom appliance made by a dentist using a
dental cast ($25-250). This is the recommended type by dental and sports organizations. When compared to the other types, Type III has the best retention, material stability, and adaptation to the oral structures. The dentist has excellent control of material thickness during custom fabrication; this ensures the best protection of the gums and teeth, and increased shock absorption for the jaw joint (leading to less chance of a concussion). Within the Type III category, there are two methods of fabrication: single layered and dual layered. The dual layered is the ideal of the two, providing 3-4mm of material thickness between the back teeth for protection.

The custom made mouthguard has the least interference with speaking and breathing, and is the most comfortable when compared with the other types. When athletes were surveyed, the custom fitted mouthguard was the preferred type, hands down. Research shows that Type I and Type II mouthguards do not have significant protective effects, when compared to wearing no mouthguard at all. Therefore, the Type III mouthguard is superior in overall quality and function. It is true that any mouthguard is better that no mouthguard at all. However, compared with the cost and time spent repairing an injury as well as the increased potential for user compliance, a custom fitted mouthguard is worth the investment.

Although the type of mouthguard is significant, compliance with wearing it is by far the most important factor in protecting orofacial health. The mouthguard cannot protect when it is not inside the mouth. Therefore, a mouthguard that the athlete is comfortable wearing must be considered, so they will actually wear it. It is important to talk with your dentist about your growing child. Mouthguards are appropriate with deciduous (baby) teeth, assuming that growth, development, and the fit of the appliance are evaluated on a yearly basis. Consult your dentist with any questions and for more information on mouthguard specifics.

BRINGING IT HOME
Often times the only advice for wearing a mouthguard is given by a parent or coach. Parents need to know about the level of contact and potential for serious dental injuries involved in the sports their child participates in. Coaches need to be aware about the importance of mouthguards for the health of their athletes. They should know the ideal types, and how to get them. It is important for people to be informed, so that they know to ask their dentist about mouthguard use. As a profession, dentistry needs to be more proactive in mouthguard education and orofacial injury prevention.

The facts are overwhelming: our families are at risk for orofacial injury with participation in sports and recreational activities. We all need to work together: parents, coaches, and dental professionals. This should be included in the pursuit of comprehensive dentistry. Just as dental professionals work to prevent tooth decay, periodontal (gum) disease, and Temporo-Mandibular Joint disorders, we need to come together as a community to prevent orofacial injuries with the simple use of a mouthguard.

FOR MORE INFO:
American Academy of Pediatric Dentistry
www.aapd.org