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Properly diagnosed, designed, and custom fabricated
mouthguards are essential in the prevention of athletic
oral/facial injuries.
In Dr. Raymond Flander's 1995 study, he reported on
the high incidence of injuries in sports other than
football, in both male and female sporting activities.
In football where mouthguards are worn, .07% of the
injuries were orofacial. In basketball where mouthguards
are not routinely worn, 34% of the injuries were orofacial.
Various degrees of injury, from simple contusions and
lacerations to avulsions and fractured jaws are being
reported.
The National Youth Sports Foundation for the Prevention
of Athletic Injuries, Inc. reports several interesting
statistics. Dental injuries are the most common type
or orofacial injury sustained during participation in
sports. Victims of total tooth avulsions who do not
have teeth properly preserved or replanted may face
lifetime dental costs of $10,000 - $15,000 per tooth,
hours in the dentist's chair, and the possible development
of other dental problems such as periodontal disease.
It is estimated by the American Dental Association
that mouthguards prevent approximately 200,000 injuries
each year in high school and collegiate football alone.
A properly fitted mouthguard must be protective, comfortable,
resilient, tear resistant, odorless, tasteless, not
bulky, cause minimal interference to speaking and breathing,
and (possibly the most important criteria) have excellent
retention, fit, and sufficient thickness in critical
areas.
Unfortunately, the word "mouthguard" is universal
and generic, and includes a large range and variety
of products, from "over the counter" models
bought at the sporting goods stores to professionally
manufactured and dentist prescribed custom made mouthguards.
Presently, over 90% of the mouthguards worn are of
the variety bought at sporting good stores. The other
10% are of the custom made variety diagnosed and designed
by a health professional (dentist and/or athletic trainer).
There are four types of mouthguards presently available.
Each type will be discussed.
Stock Mouthguard: The stock mouthguard, available
at most sporting good stores, come in limited sizes
(usually small, medium, and large) and are the least
expensive and least protective. The prices range approximately
from, $3 to $25. These protectors are ready to be used
without any further preparation; simply remove from
the package and immediately place in the mouth. They
are bulky and lack any retention, and therefore must
be held in place by constantly biting down. This interferes
with speech and breathing, making the stock mouthguard
the least acceptable and least protective. This type
of mouthguard is often altered and cut by the athlete
in an attempt to make it more comfortable, further reducing
the protective properties of the mouthguard. It has
been suggested and advised in the medical/dental literature
that these types of mouthguards not be worn due to their
lack of retention and protective properties.
As sports dentists and health professionals interested
in injury prevention, we do not recommend this type
of mouthguard to our patients and athletic teams. See
photo of Stock Mouthguard after use for several weeks.
Photo of stock mouthguard after
several weeks of use
Mouth formed or Boil and Bite Mouthguard: Presently,
this is the most commonly used mouthguard on the market.
Most marketing and advertising in the past has been
for this type mouthguard. Made from thermoplastic material,
they are immersed in boiling water and formed in the
mouth by using finger, tongue, and biting pressure.
Available in limited sizes, these mouthguards often
lack proper extensions and repeatedly do not cover all
the posterior teeth. Dental mouth arch length studies
have shown that most boil and bite mouthguards do not
cover all posterior teeth in a majority of high school
and collegiate athletes. Athletes also cut and alter
these bulky and ill fitting boil and bite mouthguards
due to their poor fit, poor retention, and gagging effects.
This in turn further reduces the protective properties
of these mouthguards. When the athlete cuts the posterior
borders or bites through the mouthguard during forming,
the athlete increases their chance of injury, especially
concussion, from a blow to the chin. Some of these injuries,
such as concussion, can cause life long effects. (See
concussion section of Sports Dentistry On Line). Certain
thicknesses and extensions are necessary for proper
mouthguard protection.
Dr. Keith Hunter, Australian sports dentist, reported
that mouthguards should be of certain thickness, without
being bulky. He suggests labial thickness of 3mm, palatal
thickness of 2mm, and occlusal thickness of 3mm. The
mouthguard material should be biocompatible and have
good physical properties. These are recommended thicknesses.
It should be noted that each athlete should be evaluated
individually for thickness and design as to promote
comfort and sufficient protection.
Joon Park, PhD et al, at the First International Symposium
on Biomaterials in August of 1993 reported that boil
& bite mouthguards provide a false sense of protection
due to the dramatic decrease in thickness occlusally
during the molding and fabrication process. Dr. Park
further stated that "Unless dramatic improvements
are made, they (boil and bite mouthguards) should NOT
be promoted to patients as they are now." He
reported that boil and bite mouthguards decrease in
occlusal thickness 70%-99% during molding thus taking
away the protective properties of the mouthguard.
Care should be taken by the public when bombarded with
clever marketing schemes, claims, and promotions by
stock and boil and bite mouthguard companies. The bottom
line is that Stock and Boil and Bite Mouthguards do
not provide the expected care and injury prevention
that a properly diagnosed and fabricated custom made
mouthguard does. Why is there a general belief that
mouthguards are uncomfortable, do not fit, are bulky,
and interfere with breathing and speaking? Could it
be because 90% of today's mouthguards worn are of the
stock or boil and bite variety, and it is the perception
by the public and coaches that these are the only available
mouthguards? Indeed, most mouthguards today do not fit,
are bulky, and do interfere with speaking and breathing
because they are wearing stock or boil and bite mouthguards!
The majority of athletes are not wearing properly made
dentally diagnosed and designed custom made mouthguards
provided by your sports dentist.
As sports dentists and health professionals interested
in injury prevention, we do not recommend store bought
boil and bite mouthguards to our patients and athletic
teams. The public deserves the best quality of care
in injury prevention and boil and bite mouthguards DO
NOT provide this quality. See photo of Boil and Bite
Mouthguard after use for several weeks.
Boil and bite mouthguard after improper fabrication.
Note excessively thin material after forming.
Custom-made Mouthguards: Custom made mouthguards are supplied by your dentist.
Custom mouthguards provide the dentist with the critical
ability to address several important issues in the fitting
of the mouthguard. Several questions must be answered
before the custom mouthguard can be fabricated. These
questions include those addressed at the preseason screening
or dental examination. Is the mouthguard designed for
the particular sport being played? Is the age of the
athlete and the possibility of providing space for erupting
teeth in mixed dentition (age 6-12) going to affect
the mouthguard? Will the design of the mouthguard be
appropriate for the level of competition being played?
Does the patient have any history of previous dental
injury or concussion, thus needing additional protection
in any specific area? Is the athlete undergoing orthodontic
treatment? Does the patient present with cavities and/or
missing teeth? Is the athlete being helped by a dentist
and/or athletic trainer or by a sporting good retailer
not trained in medical/dental issues? These are important
questions that the sporting good store retailer and
the boil & bite mouthguard CANNOT begin to address.
The custom made mouthguards are designed by your dentist
and are the most satisfactory of all types of mouth
protectors. They fulfill all the criteria for adaptation,
retention, comfort, and stability of material. They
interfere the least with speaking and studies have shown
that the custom made mouthguard has virtually no effect
on breathing. There are two categories of custom
mouthguards, the Vacuum Mouthguard and the Pressure
Laminated Mouthguard.
The Vacuum Mouthguard is made from a stone cast
of the mouth, usually of the maxillary (upper) arch,
using an impression (mold) fabricated by your dentist.
A thermoplastic mouthguard material is adapted over
the cast with a special vacuum machine (See photo).
Vacuum Machine
The most common material for this use is a poly (ethylene
vinyl acetate-EVA) copolymer. The vacuum mouthguard
is then trimmed and polished to allow for proper tooth
and gum adaptation. All posterior teeth should be covered
and muscle attachments unimpinged. Vacuum machines are
adequate for single layer mouthguards. However, it is
now being shown in the dental literature that multiple
layer mouthguards (laboratory pressure laminated) may
be preferred to the single layer vacuum mouthguards.
It should be noted that these custom mouthguards
are still superior to the store bought stock and boil
and bite mouthguards because they have a much better
fit, made from a mold of your mouth, and are designed
by your dentist.
Strap attachments to helmets may be requested and are
easily adapted to the custom made mouthguard, although
not needed because of the good fit. Custom made mouthguards
can be fabricated through the dental office or commercial
laboratory for a nominal fee.
A custom made multiple layered mouthguard,Laboratory
Pressure Laminated Mouthguard can be modified for
full contact sports by laminating two or three layers
of EVA material to achieve the necessary thickness.
Lamination in defined as the layering of mouthguard
material to achieve a defined end result and thickness
under a high heat and pressure environment. Efficient
and complete lamination cannot be achieved under low
heat and vacuum. The layers will not properly fuse together
with the vacuum machine, but will chemically fuse under
high heat and pressure with machines such as the Drufomat,
the Erkopress 2004, or the Biostar. See Photo
 Drufomat
Machine
Protective thickness is important because as the thickness
of the mouthguard material increases logarithmically,
the transmitted impact force decreases logarithmically.
Also, the mouthguard does not fully adapt to the model
with so little pressure and vacuum. Until recently,
vacuum fabricated mouthguards have been the standard
of care for protective mouthguards.
Dr. Keith Hunter reported that mouthguards should be
of certain thickness, without being bulky. He suggests
labial thickness of 3mm, palatal thickness of 2mm, and
occlusal thickness of 3mm. The mouthguard material should
be biocompatible and have good physical properties and
last for at least 2 years. These are recommended thicknesses.
It should be noted that each athlete should be evaluated
individually for thickness and design as to promote
comfort and sufficient protection.
Dr. Hunter further states the advantages of pressure
formed lamination to be:
- Precise adaptation.
- Negligible deformation when worn for a period of
time. The combination of the relatively high heat
and pressure used in construction of laminated mouthguard
means that the mouthguard material has virtually no
elastic memory.
- The ability to thicken any area as required as well
as place any inserts that may be needed for additional
wearer protection.
Therefore, mouthguards must maintain minimal and consistent
thicknesses in critical areas. These thicknesses may
have to vary according to the athletes individual needs
for optimal protection. The thicker materials (3-4mm)
are more effective in absorbing impact energy and the
thinner materials show marked deformation at the site
of impact. These mouthguards are not bulky and uncomfortable.
The clinician cannot expect that a 3mm thick material
will remain 3 mm thick after fabrication. This is a
physical impossibility due to shrinkage during fabrication
adaptation. Vacuuming a commercially laminated 3mm sheet
of EVA will give the same unsatisfactory results. Therefore,
laboratory pressure lamination procedures must be used
incorporating two or more EVA materials to achieve our
end result of 3mm - 4mm thickness occlusally. This will
allow the clinician to monitor and measure these results
before delivery of these mouthguards.
There are presently two ways of obtaining a Pressure
Laminated Mouthguard; dentist fabrication with either
the Drufomat, Erkopress-2004 or Biostar in the dental
office; or referral to a qualified commercial laboratory
presently using the pressure lamination technique.
In cases where the dentist does not wish to construct
the pressure laminated mouthguard in their office, there
are laboratories in the United States that fabricate
the pressure laminated mouthguards.
As sports dentists and health professionals, we highly
recommend the custom made mouthguard, especially those
of the laboratory lamination type for the very best
in oral/facial protection as well as concussion deterrence.
This section has presented a discussion of the various
issues relating to injury prevention and mouthguards.
By acknowledging these significant differences in mouthguards,
the public will be better informed and educated to seek
their dentistry from dental health professionals and
not from sporting good retailers.
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