Little on Size Big on Protection

by: Dan Brett, D.D.S
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Mouthpieces are one of the required and fundamental pieces of equipment of football. Yet, many coaches do not realize that there are more options than just "boil and bite". Despite this requirement, a study of Arizona High School coaches states that 53% of coaches polled believes that not all of their players wore mouthguards. This same study shows that 33% of these same coaches believe they have the greatest influence over compliance of their athletes. Yet, many coaches do not realize that there are more options than just "boil and bite". The purpose of this article is to help football coaches understand how mouthguards protect athletes, the types available, and the advantages and disadvantages of these types.

Orofacial (face and mouth area) injuries were quite common (estimated at 50%) in football prior to 1973 when mouthguards were mandated. Since then these types of injuries have decreased to less than two percent. While there has been a decrease in the number of face injuries, other injuries are on the increase. Obviously mouthguards are satisfying their apparent function of decreasing face and mouth injuries. It does not seem like a year goes by without reading about a prominent football player who career has be shorten by multiple concussions.

Mouthguards provide protection to football players in three different ways. Mouthguards protect against concussions by serving as a shock absorber, they protect against neck injuries, and they protect the teeth by distributing the force of a blow over all the teeth by lessening the contact between upper and lower jaws. In football where the incidences of mouth injuries are low the most important function of a mouthguard maybe in the prevention of concussions and brain injuries. A mouthguard with the proper thickness and material between the teeth (material should be shock absorbent and at least 3mm thick) can reduce the rate of concussions by preventing the lower jaw hinge from being forced into the base of the brain from a blow to the lower jaw. One study states that ninety five percent of all football concussions are transmitted through the lower jaw to the brain. Though this number may be high it demonstrates that concussion prevention may be the most important value of a mouthguard especially in the helmeted sports.

A "stinger" or "burner" is a common neurological injury in the sport of football. For years we thought that this injury came from stretching the large nerves that run along side of the neck just underneath the trapezius muscle. We realize now, that most stingers are a result of the nerve being compressed or pinched by the cervical vertebrae as the head is forcefully shoved back. Many times, athletes who have experienced such an injury will continue to have recurrences. Over time, this can become a very debilitating injury.

Several clinical trials have shown that mouth guards may help to prevent this injury and may help to reduce occurrence once such an injury has been sustained. Though the mechanism is not completely understood, it appears that opening the bite and the distance between upper and lower teeth of an athlete causes an indirect repositioning of the cervical vertebra reducing the likelihood of nerve root compression. The level of protection increases as the separation of the bite increases with the greatest benefit shown as the bite separation approaches 5-6 mm. Therefore many of the over-the-counter, boil-and-bite mouth guards do not afford protection against this injury, as the bite separation with such a device is insufficient.

Mouthguards may be classified into three types, stock, "boil and bite", and custom-fitted (from a dental model). The main advantages of the stock and "boil and bite" is there availability and relative low cost. Stock mouthguards are store bought ones that come right out of the bag and into your mouth without any forming. These protectors come in limited sizes, are bulky and lack retention. They are held in place by constantly biting down, thus interfering with speech and breathing. Often these mouthguards become dislodged at impact when protection is needed most.

"Boil and bite" mouthguards are the most widely used today. These mouthguards become formable in boiling water. This provides them an advantage over the stock type because they can be formed to the mouth. Despite this formability there is limited retention, which can hinder speech and breathing. Since the athlete is asked to bite down during the forming process, the thickness of the material between the teeth is decreased 70% to 99%. This thinning of the biting surface eliminates protection where it is needed the most in decreasing the chance of concussion and trauma to the teeth.

Custom fitted mouthguards are provided by dental professional and are fabricated over a stone model of the athletes teeth made from a dental impression. Plastic is heated and forced over the model with vacuum pressure so it conforms precisely to the teeth and gums. Being truly customized these mouthguards offer superior fit and comfort. Since they stay in the mouth better they also allow the player to communicate and breathe more effectively.

There are differences in custom fitted mouthguards that need to be pointed out. Many are made with a single sheet of plastic which produces a mouthguard of about 2 millimeters. The recommendation is that a mouthguard should have a thickness of 3-5 millimeters in-between the teeth to reduce the rate of concussion. Multi laminated mouthguards (more than one layer of plastic fused together) allow for increased thickness in this crucial area. A study was done at a Division 1 college football program where "boil and bite" mouthguards were replaced by multi-laminated custom fitted ones the following year. The total number of concussions dropped from 9 to 3 and the number of missed days of practices and games was decreased form 25.5 to 9. Even though this is not a large enough sample to be considered statistically significant it is one of many similar study that show a similar trend. These multi-laminated often allow for placing a label of the athletes name into the guards for ease of identification. The obvious disadvantages to these types of mouthguards are that they require a visit to a dental professional and the cost. The cost factor should be outweighed by the potential comfort and health benefits if a willing dentist is identified.

Tips for forming Boil and Bite mouthguards.

• Water should be boiling and not just hot
• Leave in boiling water for the recommended amount of time
• After removal from boiling water quickly dip in cold water to avoid burning gum tissues
• Have athlete bite down GENTLY to maintain as much thickness between the teeth as possible
• Use fingers to help push and adapt material to teeth
• Create a suction (like using a straw) so guard adapts to roof of mouth
• Trim areas of irritations
• Do not let player shorten guard it will decrease the protective nature

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