Athletic mouthguards: Essential features to look for.

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

A stock athletic mouthguard.

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

Sports mouthguards are a type of dental appliance that when worn can help to protect the hard and soft tissues of the mouth (teeth, jawbones, lips, cheeks, gums and tongue) from injury caused by traumatic blows.

How important is it to wear a guard?

It would be hard to overstate the value of wearing one of these appliances. The protection provided could easily prevent injury that might affect a person for the remainder of their life.

Here are some general statistics:

  • 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?

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

A) Good fit and comfort.

Two of the most important properties for a guard to have are:

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

If it doesn't meet these two simple criteria, it probably won't be worn, at least not all of the time.

How appliance fit tends to affect speaking and breathing.

Athletes sometimes complain that wearing their mouth protector 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 clenching their teeth together. It's this constant clenching action that makes it difficult for them to speak and breathe normally.

B) Appliance Type / Design

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 the force the jaw absorbs explains why the upper front teeth (especially the central incisors) are the most likely ones to be damaged in an accident.

As compared to other teeth in the mouth, they typically end up receiving a larger amount of the force delivered by a blow.

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 therefore not worn as consistently.

Protection for orthodontic patients.

Dual-coverage appliances can be beneficial for athletes whose lips and cheeks need protection from their braces.

C) Proper shape and outline form.

As general rules:

  • The overall shape of a sports mouthpiece should cover 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.
Takeaways from this section.

This latter issue helps to disperse the forces of a blow away from the teeth and onto the jawbone.

Some studies suggest that guards that fail to include a significant number of back teeth place the wearer's lower jaw at greater risk of fracture.

There is, however, some debate about the need for an appliance to cover erupted wisdom teeth (3rd molars).

A custom mouthguard.

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

D) Adequate thickness.

Different sporting activities are generally associated with different levels of anticipated risk.

As an example, it's easy to imagine how a boxer's expected risk for mouth injury would be greater than a tennis player's.

A long these lines, the thickness of a guard is sometimes tailored for the specific type of sporting event for which it will be worn.

(This seems a reasonable trade-off. After all, if a tennis player is given the same type of thick, heavy mouthguard as designed for a boxer, the result may be that it simply won't be 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) may be considered adequate.
  • Heavy-contact sports necessitate thicker protection, more along the lines of 1/8th of an inch (4mm) or more.
  • In its guidelines (2010), the Academy of Sports Dentistry states that appliances should have a minimum thickness of 3mm.

(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 first contact and then, as the person closes further, the remainder of their teeth then touch.)

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

E) Resiliency and Stiffness

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.

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 on 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.

Who needs mouth protection?

A) Recommendations by organizations.

Here's a listing of some of the guidelines suggested by various national organizations:

  • The American Academy of Pediatric Dentistry recommends that all children/youths participating in any type of organized sporting activity should wear a guard.
  • The American Dental Association recommends wearing a protector when participating in 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, skate boarding, 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 keep in mind that a person's greatest risk may lie with activities whose potential for dental trauma isn't generally considered a great concern.

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 resulted in 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 benefits can sport mouthpieces provide?

While the main function of mouthguards is providing protection for oral structures, they can (or at least have been suggest to be able to) provide additional benefits too.

A) Protection for teeth and soft oral tissues.

Minimizing the effects of blows directed to teeth (see box below) and oral soft tissues (lips, cheeks, gums) is the primary function of sports guards.

Dental emergencies.

For information about handling dental emergencies, the website of the International Association of Dental Traumatology offers their Dental Trauma Guide (use menu on left side of page).

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 type 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 alvulsed 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. 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.

C) Protection from secondary sources of trauma.

Sometimes it's not the blow itself but the chain of events triggered by it that has caused oral injury. Wearing a guard may help to prevent these types of complications.

  • 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 situation where an athlete's jaws are forced together violently.
  • In the case where an athlete is missing teeth, wearing a custom-formed mouthpiece can fill in these spaces and support and stabilize the teeth that exist. This means removable appliances (such as a partial denture) can be left out, thus avoiding the potential damage they may inflict in an accident.

D) Protection from concussion.

It's been suggested that wearing a mouthguard can help to reduce the likelihood or severity of concussions. This idea is not, however, universally accepted by the dental community as a whole.

The usual explanation is as follows:

  • 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 allows them to support or refute these claims.

E) Psychological / Strength Enhancement benefits.

You can 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 claims are made that wearing a guard (often one that "repositions" the lower jaw in a certain way) can enhance strength performance.

In the same position statement referred to 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."



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