Athletic mouthguards: What features are important?

- The level of protection a guard can provide is determined by its design. This page outlines what features you need.

Picture of a stock athletic mouthguard.

A Stock athletic mouthguard. - This type of appliance may be familiar but doesn't usually make the best choice.

What is an athletic mouthguard?

Sports guards are dental appliances that help to protect the hard and soft tissues of the mouth (teeth, jawbones, lips, cheeks, gums and tongue) from injury caused by forceful blows.

How important is wearing one?

It would be hard to overstate the value of an athlete wearing one of these appliances.

It should be obvious to anyone that the protection it provides could easily prevent an injury that might affect them for the remainder of their life. The adage that begins with "a stitch in time ..." really applies when it comes to athletic mouthguards.

General statistics about sports-related oral injuries:
  • As many as one-third of all injuries treated by dentists are sports-related.
  • During any single season, it's estimated that an athlete runs about a 10% chance of experiencing some sort of orofacial (facial/dental) injury.
  • An athlete's lifetime risk for this type of trauma has been estimated to run around 45%.
  • Most sports-related dental emergencies occur during pick-up games (unorganized sporting events).
  • As evidence of the effectiveness of wearing a guard, nowadays less than 1% of high school football injuries involve the mouth. Prior to the widespread use of mouthguards, the incident rate was over 50%.

(Knowlton 2014, Krachner 2016) [reference sources]

What features are important to have?

Here's a list of characteristics that a good sports mouthpiece should have.

#1) Good fit and comfort.

It may seem silly for us to say but two of the most important properties for a guard to have are:

  • It should be comfortable to wear.
  • It should stay in place well.

Surprisingly enough, many of the lower-cost (and therefore most-sold) types of guards don't even come close to meeting these two basic requirements. And if an appliance doesn't, it probably won't be worn, at least not all of the time.

How fit affects speaking and breathing.

Athletes sometimes complain that wearing their mouth protectors makes it hard for them to speak and/or breathe. In most cases, both of these difficulties stem from the same problem, a loose-fitting appliance.

If a guard doesn't have good retention the person wearing it will tend to hold it in place by way of clenching their teeth together. It's this constant clenching action that makes it difficult for them to speak and breathe.

#2) A suitable design.

This point really isn't an issue on its own. But it is important to understand why a guard might be designed as a single or dual-arch appliance.

Picture of a boil-and-bite mouthguard, before customization.

Single-arch, boil-and-bite mouthguard (before customization).

a) Single-arch designs.

Most sports mouthguards are only fitted to the athlete's upper jaw. Here's why.
  • The lower jaw's joint allows it to move freely. That means when it's struck by a blow, some of the force will be buffered by the jaw's reactive motion.
  • In comparison, the upper jaw is fixed in position. And because of this, traumatic forces directed to it will be fully absorbed (by it and the teeth it holds).


Takeaways from this section.

This difference in the amount of force each jaw can help to dissipate explains why the upper front teeth (especially the central incisors) are the ones most likely to be damaged in an accident.

Simply due to their positioning, they frequently end up receiving a large amount of the force delivered by a blow. And because they're a part of the upper (immovable) jaw, the force tends to remain focused on and around them, thus resulting in breakage.


b) Dual-arch designs.

Some mouthguards have a design where they fit over both the upper and lower jaws. The advantages of this style are:

  • It provides a greater level of protection for the lower teeth.
  • It may provide greater protection for the jaw joint too.

As a disadvantage, this type of mouthpiece can be more uncomfortable to wear than a single-arch design, and as a result not worn as consistently.

Protection for orthodontic patients.

A dual-coverage appliance can offer a solution for athletes whose lips and cheeks need protection from their dental braces.

#3) Proper shape and outline form.

As general rules of thumb:

  • The size and shape of a sports mouthpiece should be one where it covers over all of the athlete's teeth, including their molars.
  • The outline form of the appliance should extend beyond just the teeth and onto the surrounding gum tissue too.
Takeaways from this section.
  • Extension of the appliance onto the gums helps to disperse the forces of a blow away from the teeth and onto the jawbone.
  • Some studies suggest that guard designs that fail to include a significant number of back teeth place the athlete's lower jaw at a greater risk of fracture.
  • However, the need for an appliance to cover over erupted wisdom teeth (3rd molars) is debated.


A vacuum-molded Custom mouthguard.

Picture of a custom mouthguard.

A Custom sports mouthguard typically offers the greatest level of protection.

#4) Adequate thickness.

Different sporting activities are generally associated with different levels of probable forces.
As an example, it's easy to imagine how a boxer's expected risk for oral injury would be greater than a tennis player's.
Along these lines of thought, the thickness of a guard is frequently tailored for the specific type of sporting event for which it will be worn.

(This seems a reasonable enough trade-off. After all, if a tennis player is given the same type of thick, heavy mouthguard that a boxer would wear, the outcome might be that it simply won't get worn.)

Rules of thumb.

  • For sports that don't entail a high degree of physical contact, a thickness as thin as 1/16th of an inch (2mm) is sometimes considered adequate.
  • However, in its guidelines (2010) the Academy of Sports Dentistry states that an appliance should have a minimum thickness of 3mm.
  • Heavy-contact sports necessitate thicker protection, more along the lines of 1/8th of an inch (4mm) or more.

(These thickness measurements are for the occlusal (the "biting") and labial (cheek-side) surfaces of the appliance.)

Even / Balanced Occlusion

The shape/thickness of the occlusal ("biting") surface of the guard should be such that when the wearer closes their teeth, they all make contact with the guard simultaneously. (As opposed to the situation where one or a few teeth make the first contact and then, as the person closes further, the remainder of their teeth then touch.)

Achieving this balanced state may require equilibration (selective trimming) of the appliance. If so, a check must be made afterward that adequate occlusal surface thickness still remains.

#5) Proper resiliency and stiffness.

a) The resiliency (sponginess) of a mouthpiece is important because it helps to absorb some of the force delivered by traumatic blows. Also, if a mouthguard isn't at least somewhat flexible, it may be uncomfortable to wear.

b) A guard's stiffness has more to do with the level of protection it provides than its resiliency. Rigidity helps to distribute the forces of a blow over a larger area, thus buffering the level of force directed to any one tooth or region.

Choosing the right type of appliance.

To the uninitiated, all athletic mouth protectors may seem pretty much the same. In fact however, even similar-looking products may differ greatly in their design, and thus the level of protection they can provide.

As outlined in our next page, there are three basic types of guards: Stock, Boil-and-bite, and Custom.

  • Custom appliances typically have a design that can fulfill the requirements outlined above.
  • In comparison, some Boil-and-bite (mouth-formed) products may be able to meet these same criteria but not always.
  • In most cases, the design of Stock appliances is deficient.


What sports require mouth protection?

A) Recommendations made by national associations.

Here are some of the guidelines that have been suggested by various organizations:

  • The American Academy of Pediatric Dentistry recommends that all children and youths participating in any type of organized sporting activity should wear a guard.
  • The American Dental Association recommends that a protector should be worn when participating in any of these 29 sports and activities:

    acrobatics, basketball, bicycling, boxing, equestrian events, extreme sports, field events, field hockey, football, gymnastics, handball, ice hockey, inline skating, lacrosse, martial arts, racquetball, rugby, shot putting, skateboarding, skiing, sky diving, soccer, softball, squash, surfing, volleyball, water polo, weight lifting, wrestling

  • The National Federation of State High School Associations only mandates the use of mouth protection for football, ice hockey, lacrosse and field hockey.

(Knowlton 2014)

B) Use your own judgment.

It's important to realize that a person's greatest risk may lie with activities whose potential for dental trauma isn't generally recognized.

For example, consider the findings of Soporowski (1994). This paper evaluated 159 injuries treated in dental offices.

  • It found that 62% of injuries occurred when participating in unorganized sports.
  • The most likely age group to experience trauma was 7 to 10 years (59% of study subjects).
  • Of the cases investigated, baseball was associated with the highest number of injuries (45%) followed by biking (37%). Hockey and basketball were 3rd and 4th respectively.

We've cited this study because it demonstrates that the level of risk associated with sporting activities and age groups may be different than you'd expect.


A second study.

Kumamoto (1996) evaluated 3,411 athletes and determined that the greatest incidence of orofacial (facial/dental) trauma was associated with the following sports:

  • Males: Wrestling - 1st, Basketball - 2nd.
  • Females: Basketball - 1st, Field hockey - 2nd.

Once again (and especially for males), the activities listed aren't necessarily those that first come to mind when thinking about the potential for dental trauma.

What types of protections and benefits can wearing a sports mouthpiece provide?

While the obvious function of wearing a mouthguard is to provide protection for oral structures, they can, or at least have been suggested to be able to, provide some additional benefits too.

▶ Information about how to handle dental emergencies.

For those looking for information about how to handle an emergency situation, the website of the International Association of Dental Traumatology offers their Dental Trauma Guide. ◀

A) Protection for teeth and soft oral tissues.

Minimizing the effects of blows directed to teeth and oral soft tissues (lips, cheeks, gums) is the primary function of a sports guard. The box below explains some of the different types of tooth damage that can occur as a result of trauma.

Types of tooth trauma.

The simple act of wearing a sports mouthguard can help to mitigate or even prevent the following types of traumatic dental injuries.

Tooth Intrusion - With this type of injury the tooth has been driven into the jaw bone and as a result appears shorter than its neighbors. This is the most severe form of displacement injury.

96% of intrusive events result in the death of the tooth's nerve, thus creating a need for root canal treatment. Some types of orthodontic work or temporary splinting will likely be needed to bring the tooth back into position. (Krachner, 2016)

Tooth Extrusion - In this case, the tooth has been partially displaced out of its socket. The tooth appears abnormally long as compared to those around it.

Since the fibers that held the tooth in place have been torn, the tooth is loose. Repositioning and temporary splinting will be needed.

Tooth Avulsion - An avulsed tooth has been completely dislodged from its socket./p>

While this is one of the most dramatic types of dental trauma, the long-term outlook for the tooth can be favorable if the proper steps are taken within the first hour after the accident. At a point 2 hours and after, the chance for success is greatly reduced.

Crown Fracture - A tooth's "crown" is that portion that is visible above the gum line. A fracture involving a tooth's crown is the most common type of oral injury.

It will take a dentist's evaluation to determine what level of treatment is required. Minor cracks in the tooth's enamel (crazing) may not require repair. At the other extreme, the most severe crown fractures may involve the loss of large portions of the tooth and nerve damage and therefore require extensive repair procedures.

Root Fracture - Damage can occur to a tooth's root. The tooth itself may show signs of mobility. Repair may not be possible.

B) Protection for the jaw joint (TMJ).

Most blows to the lower jaw do not result in fracture but enough force can be transmitted that aspects of the tempromandibular joint (TMJ, "jaw joint") are disrupted, possibly resulting in permanent injury.

Wearing a dual-arch appliance (one that covers over both jaws) can help to reduce and redirect the forces of a blow away from the TMJ.

C) Protection from secondary sources of trauma.

Sometimes it's not the blow itself but the chain of events it triggers that results in oral injury. And wearing a guard may help to prevent these types of events.

  • With some accidents, the athlete's jaws are forced together violently. The cushioning provided by the occlusal ("chewing") surface of a guard can help to prevent tooth damage, or tongue, lip or cheek injury.
  • In the case where an athlete is missing teeth, a custom-formed mouthpiece can fill in these spaces and support and stabilize the teeth on either side. This also means that removable appliances (such as a partial denture) can be left out, thus avoiding the potential damage they may cause in an accident situation.


D) Protection from a concussion.

Some sources suggest that wearing a mouthguard can help to reduce the likelihood or severity of concussions. However, this idea is not universally accepted by the dental community as a whole.

The explanation that's given by proponents usually takes the following form:

  • Traumatic forces directed to the jawbones are, in turn, transmitted to the bones of the skull (this is what creates the potential for concussion).
  • Wearing a mouthguard can help to absorb and disperse (and therefore lessen) these forces.

In a position statement (2011), the Academy for Sports Dentistry states that none of the research they've evaluated on this subject meets quality standards that allow them to support or refute these claims.

E) Psychological / Strength-enhancement benefits.

  • It's easy enough to spin the argument that wearing a mouthguard provides a psychological edge for an athlete, in the sense that they may feel more confident (and therefore perform better) when they know they have proper mouth protection.
  • And there are proponents of the theory that wearing a guard (usually stated as one that "repositions" the lower jaw in a certain way) can enhance an athlete's strength performance.

In the same position statement mentioned above, the Academy for Sports Dentistry states that the quality of studies they've reviewed on this subject neither allows them to support or refute these claims.

Their call is for further research on this subject that can be "substantiated by sound, peer-reviewed independent scientific data published in credible journals."