Mouth Guards

The ADA has taken an active stance since the mid-1990s recognizing the preventive value of orofacial protectors, endorsing their use by those who engage in recreational and sports activities; and encouraging widespread use of orofacial protectors with proper fit, including mouth guards.¹

Both the ADA Council on Scientific Affairs and the Council on Advocacy for Access and Prevention recognize that dental injuries are common in collision or contact sports and recreational activities.² Numerous surveys of sports-related dental injuries have documented that participants of all ages, genders and skill levels are at risk of sustaining dental injuries in sporting activities, including organized and unorganized sports at both recreational and competitive levels. While collision and contact sports, such as boxing, have inherent injury risks, dental injuries are also prevalent in limited- and non-contact activities and exercises, such as gymnastics and skating (see Table 1).^3-5

​Table 1. Sports for which the ADA advocates use of a properly-fitted mouth guard.^{2, 6}

Contact/Collision Sports
Basketball	Martial Arts
Boxing	Rugby
Football	Soccer
Handball	Water polo
Hockey (Ice and Field)	Wrestling
Lacrosse
Limited-Contact and Other Sports
Acrobatics	Skateboarding
Baseball	Skiing
Bicycling	Skydiving
Equestrian Events	Softball
Field Events	Squash
Gymnastics	Surfing
In-Line Skating	Volleyball
Racquetball	Weightlifting
Shot-Putting	"Extreme Sports"

The Councils promote the importance of safety in maintaining oral health and the use of a properly fitted mouth guard as the best available protective device for helping reduce the incidence and severity of sports-related dental injuries.² The Councils are committed to promoting oral health and injury prevention for sports participants.

Standards
ANSI/ADA Standard No. 99:2001, Athletic Mouth Protectors and Materials sets the technical specifications for athletic mouth guards as well as instructions to manufacturers regarding labeling and packaging.⁷

According to the ADA Council of Scientific Affairs and the Council on Advocacy for Access and Prevention,² an ideal mouth guard should:

• be properly fitted to the wearer’s mouth and accurately adapted to his or her oral structures;
• be made of resilient material approved by the U.S. Food and Drug Administration and cover all remaining teeth on one arch, customarily the maxillary;
• stay in place comfortably and securely;
• be physiologically compatible with the wearer;
• be relatively easy to clean;
• have high-impact energy absorption and reduce transmitted forces upon impact.

Types of Mouth Guards
ANSI/ADA Standard No. 99:2001 defines three categories of mouth guards, typically made up of thermoplastic ethylene vinyl acetate (EVA), but varying in cost, adaptability, comfort, level of contact with dentist, and safety efficacy.^{2, 8, 9}

Stock (ready-made)
This is the most commonly available and least expensive type of mouth guard, available at retail establishments such as department and sporting goods stores, and does not require visits to the dentist. Because it is only available in a limited range of sizes, requires the mouth to be shut to keep it in place, and is not adapted to the user’s mouth, research suggest it is the least effective type of mouth guard.^{2, 8, 10}

Mouth-formed (boil and bite)
These self-adapting mouth guards are designed to soften when placed in hot water, then cooled and placed into the mouth.^{2, 8, 10} The product is then adapted to the user’s mouth by bite pressure and manipulation by the tongue and fingers.^{2, 8} A dental professional may provide assistance with the final molding, particularly if the user has orthodontic appliances,^{2, 8} but boil and bite mouth guards are widely available at retail establishments such as sporting goods stores and are generally designed for home use.

Custom-made
Custom mouth guards are fabricated in a dental office or laboratory from individual patient impressions. They provide the best fit, adaptability and efficacy, but are the most expensive option and require dental visits.^{2, 8, 10} More information for the dentist may be found in “Fabricating a custom-fitted mouth guard” in this 2006 JADA article.

Dentofacial Injuries
Studies have consistently shown reductions in orofacial injuries with the use of mouth guards, particularly custom-fitted mouth guards, in a wide range of active individuals including water polo players¹¹ and elite commando fighters.¹² A 2002 prospective study of 70,836 college basketball players found a rate of 0.12 dental injuries per 1000 exposures in players wearing custom-fitted mouth guards, compared to a rate of 0.67 in players who didn’t wear a mouth guard.¹³ In a 2007 meta-analysis of 14 studies of a number of team contact sports, researchers found an increased risk of orofacial injury of 1.6 – 1.9 times in players who did not use a mouth guard of any type.⁴

A 2018 systematic review and meta-analysis found the prevalence of dental trauma among mouth guard users to be 7.5% to 7.75% compared to 48.31% to 59.98% to non-users, and that mouth guard users were between 82% and 93% less likely to suffer dentofacial injuries.⁹ Coronal fractures and tooth avulsions were the most frequent injuries, and boil-and-bite mouth guards were the most commonly used type.⁹ The study emphasized that type of mouth guard may influence outcome, but that “mouth guards should continue to be recommended and used in sports activities with a high risk of dental trauma.”⁹

Concussions
Evidence for reduction in concussion rates among athletes has been less consistent than for orofacial and dental injuries. A 2002 study of college basketball players found no significant difference in the rate between players who did and did not use a mouth guard.¹³ A number of studies have found evidence for concussion reduction elusive or inconsistent,^{2, 14} including two studies from 2014 of high school football players, one of which found a higher risk of concussion to users of custom mouth guards compared to OTC mouth guards,¹⁵ while the other study found a significantly reduced risk to users of custom mouth guards.¹⁶ Due to the lack of investigations as well as quality of the research conducted, researchers tend to agree with the ADA Councils in recommending further studies.²

It is important for mouth guards to be safe; however, to be effective, they also have to be used. Examples of reasons given for why mouth guards are not used include cost, lack of requirement for their use or awareness of potential benefit.¹⁷

Despite the prevalence of dentofacial injuries during sports, mouth guard use has been fairly limited to specific high-contact sports, such as football, notwithstanding the 2007 JADA article which found the highest incidence of dental trauma to basketball players.¹⁸ Despite the prevalence of dental trauma in athletic activities not normally considered high-contact, mouth guard usage remains low unless required by a governing organization.^{2, 8}

Currently, the National Federation of State High School Associations (NFHS) and the National Collegiate Athletic Association (NCAA) mandate the use of mouth guards in football, field and ice hockey and lacrosse.^{19, 20} Along with the ADA, the American Academy of Pediatric Dentistry and the American College of Prosthodontists recommend the use of mouth guards during contact and collision sports.^{10, 21} Boxing is the only professional sport for which mouth guards are mandated.²

There have been several “Patient Pages” in JADA for use by dentists to help engage patients in conversations about mouth guards and facilitate discussion to encourage their use. Each of these “Patient Pages” underscores the importance of mouth guard use and informs consumers about the 3 types - ready-made, boil and bite, and custom made.^22-26

Recent trends to increase ‘realism’ in video games has resulted in their incorporating more actual player behaviors including what they do with their mouth guard while at the free-throw line.²⁷ While perhaps not the most desirable behavior, it raises the profile and awareness of mouth guards. Further, by having a sport idol model their use, it can help serve to increase mouth guards’ ‘coolness’ factor.

In April 2016, five health organizations including the ADA reminded athletes of the importance of mouth guards to protect teeth from injury by establishing April as National Facial Protection Month.² During this month, the American Academy of Pediatric Dentistry, the Academy for Sports Dentistry, American Association of Orthodontists and the American Association of Oral and Maxillofacial Surgeons promote orofacial protection, including the use of mouth guards, to the general public.^{2, 28}

While still being able to highlight the benefit of custom fit mouth guards, dentists can also recommend the use of over-the-counter mouth guards with the ADA Seal of Acceptance. The ADA Seal provides assurance that the product has been objectively evaluated for safety and efficacy by an independent body of scientific experts, the ADA Council on Scientific Affairs. A product earns the ADA Seal for athletic mouth guards by providing scientific evidence, which is evaluated according to objective requirements, demonstrating the safety and efficacy of ready-to-use and mouth-formed (boil-and-bite) mouth guards.

To qualify for the Seal of Acceptance, the company must provide evidence that:

• The product components are safe for use in the mouth and do not harm or irritate oral soft tissues.
• Mouth-formed appliances can be prepared by the average person with low risk of injury to oral hard or soft tissues, or damage of orthodontic appliances.
• The mouth guard is free of sharp or jagged edges.
• The mouth guard passes tests outlined by the American National Standards Institute/American Dental Association for hardness, ability to resist tearing and withstand impact; as well as a measurement of the amount of water absorbed.⁷

Comparison finds custom mouth guards made by dentists to perform best;²⁹ having an over-the-counter option that meets ANSI/ADA standards could help with the cost barrier to engagement while still affording the consumer with a safe method of helping protect their teeth.

Asking patients if they participate in team sports or other activities with risks of injury to the teeth, jaw and oral soft tissues (mouth, lip, tongue, or inner lining of the cheeks) can help identify those who could benefit most from information about mouth guards. The Councils recommend use of a properly fitted mouth guard in any sporting or recreational activity that may pose a risk of injury.² The Councils also encourage dentists to educate patients about mouth guards and orofacial injury risks, including appropriate guidance on mouth guard types, their protective properties, costs and benefits.² The key educational message is that the best mouth guard is one that is utilized during sport activities.

Orofacial Protectors (Trans.1994:654; 1995:613; 2016:322)

Resolved, that the American Dental Association recognizes the preventive value of orofacial protectors and endorses the use of orofacial protectors by all participants in recreational and sports activities with a significant risk of injury at all levels of competition including practice sessions, physical education and intramural programs, and be it further

Resolved, that the ADA supports collaboration with international and national sports conferences, sanctioning bodies, school federations and others to mandate the use of orofacial protectors.

American Dental Association
Adopted 1994; amended 1995 and 2016

1. American Dental Association. Orofacial Protectors (Trans.1994:654; 1995:613; 2016:322). American Dental Association, Current Policies 1954 - 2017; 2016. p. 181.
2. ADA Council on Access Prevention and Interprofessional Relations, ADA Council on Scientific Affairs. Using mouthguards to reduce the incidence and severity of sports-related oral injuries. J Am Dent Assoc 2006;137(12):1712-20; quiz 31.
3. Fasciglione D, Persic R, Pohl Y, Filippi A. Dental injuries in inline skating - level of information and prevention. Dent Traumatol 2007;23(3):143-8.
4. Knapik JJ, Marshall SW, Lee RB, et al. Mouthguards in sport activities : history, physical properties and injury prevention effectiveness. Sports Med 2007;37(2):117-44.
5. Kumamoto DP, Maeda Y. A literature review of sports-related orofacial trauma. Gen Dent 2004;52(3):270-80; quiz 81.
6. American Dental Association. The importance of using mouthguards: Tips for keeping your smile safe. The Journal of the American Dental Association 2004;135(7):1061.
7. ANSI/ADA. ANSI/ADA Standard No. 99:2001 (R2013), Athletic Mouth Protectors and Materials; 2013.
8. Parker K, Marlow B, Patel N, Gill DS. A review of mouthguards: effectiveness, types, characteristics and indications for use. Br Dent J 2017;222(8):629-33.
9. Fernandes LM, Neto JCL, Lima TFR, et al. The use of mouthguards and prevalence of dento-alveolar trauma among athletes: A systematic review and meta-analysis. Dent Traumatol 2018.
10. American College of Prosthodontists. Mouthguard Use in Sports. Position Statement. Chicago, IL: American College of Prosthodontists; 2015.
11. Zamora-Olave C, Willaert E, Montero-Blesa A, Riera-Punet N, Martinez-Gomis J. Risk of orofacial injuries and mouthguard use in water polo players. Dent Traumatol 2018;34(6):406-12.
12. Zadik Y, Levin L. Orofacial injuries and mouthguard use in elite commando fighters. Mil Med 2008;173(12):1185-7.
13. Labella CR, Smith BW, Sigurdsson A. Effect of mouthguards on dental injuries and concussions in college basketball. Med Sci Sports Exerc 2002;34(1):41-4.
14. Schneider DK, Grandhi RK, Bansal P, et al. Current state of concussion prevention strategies: a systematic review and meta-analysis of prospective, controlled studies. Br J Sports Med 2017;51(20):1473-82.
15. McGuine TA, Hetzel S, McCrea M, Brooks MA. Protective equipment and player characteristics associated with the incidence of sport-related concussion in high school football players: a multifactorial prospective study. Am J Sports Med 2014;42(10):2470-8.
16. Winters J, DeMont R. Role of mouth guards in reducing mild traumatic brain injury/concussion incidence in high school football athletes. Gen Dent 2014;62(3):34-8.
17. O'Malley M, Evans DS, Hewson A, Owens J. Mouthguard use and dental injury in sport: a questionnaire study of national school children in the west of Ireland. J Ir Dent Assoc 2012;58(4):205-11.
18. Cohenca N, Roges RA, Roges R. The incidence and severity of dental trauma in intercollegiate athletes. J Am Dent Assoc 2007;138(8):1121-6.
19. Altschuler C. Sporting Mouthguards:  Preventing Sports-Induced Orofacial Injuries. AGD Impact 2014;42(8):19-25.
20. National Federation of State High Scool Associations. Position Statement and Recommendations for Mouthguard Use in Sports; 2014.
21. American Academy on Pediatric Dentistry Clinical Affairs C, American Academy on Pediatric Dentistry Council on Clinical A. Policy on prevention of sports-related orofacial injuries. Pediatr Dent 2008;30(7 Suppl):58-60.
22. For the dental patient. Do you need a mouthguard? J Am Dent Assoc 2001;132(7):1066.
23. Mouth guards lower dental injuries. J Am Dent Assoc 2002;133(3):278.
24. For the dental patient. The importance of using mouthguards. Tips for keeping your smile safe. J Am Dent Assoc 2004;135(7):1061.
25. For the dental patient ... Protecting teeth with mouth guards. J Am Dent Assoc 2006;137(12):1772.
26. For the dental patient. Keep sports safe--wear a mouth guard. J Am Dent Assoc 2012;143(3):312.
27. Stephen Curry's mouth guard routine gets video game treatment.  2015.
28. American Dental Association. Five Dental Organizations Team Up For National Facial Protection Month; 2017.
29. DeYoung AK, Robinson E, Godwin WC. Comparing comfort and wearability: custom-made vs. self-adapted mouth guards. J Am Dent Assoc 1994;125(8):1112-8.
    

What products have earned the ADA Seal of Acceptance?
Get a complete list of ADA Accepted Sports Mouthguards

Professional Resources

ANSI/ADA Standard No. 99-2001(R2013) Athletic Mouth Protectors and Materials

Search JADA for articles related to mouthguards

Search the ADA Catalog for products related to mouthguards

Patient Resources

JADA “For the Patient” pages:

• Sealing the Deal: Buying Products That Have the ADA Seal of Acceptance (January 2013)
• Keep Sports Safe—Wear a Mouthguard (March 2012)
• Keeping your teeth and mouth safe (June 2017)

ADA MouthHealthy.org:

• Mouthguards
• Quiz: Test Your Knowledge About Mouthguards
• 3 Things All Athletes Should Do for Their Teeth