Athletic mouth protectors (mouthguards)

Key Points

  • Participating in athletic and recreational activities, particularly collision, contact or high-velocity sports, can place individuals at increased risk of dental trauma or orofacial injury. 
  • Mouthguard use has been shown to reduce the risk of sport-related dental injuries.
  • The ADA recommends wearing a properly fitted mouthguard to reduce the incidence and severity of oral injury in sporting or recreational activities, particularly activities with significant risk of dental trauma or orofacial injury. 
  • Mouthguards should have adequate retention to provide a resilient, protective surface on the dental arch that is considered to be at highest risk of injury (typically the maxilla), and to offer protection from soft tissue injuries to the lips and cheeks. 
  • The ADA Council on Advocacy for Access and Prevention and the ADA Council on Scientific Affairs encourage patient education about the benefit of mouthguard use.
     
Introduction

The ADA recognizes, as a matter of Association policy, the preventive value of orofacial protectors and endorses their use by those who engage in recreational and sports activities.1 The ADA supports widespread use of orofacial protectors with proper fit, including mouthguards, to reduce the incidence and severity of dental trauma or orofacial injury.

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-contact, non-contact, and high-velocity activities, such as gymnastics and skating (see Table 1).3-7


Table 1. Common sporting/recreational activities in which mouthguard use is recommended.2, 7-11
 
 Contact/Collision Sports
 Basketball  Lacrosse
 Boxing  Martial Arts
 Combat Sports  Rugby
 Football
 Soccer
 Handball
 Water polo
 Hockey (Ice and Field)
 Wrestling
 Limited-Contact and Other Sports
 Acrobatics  Skateboarding
 Baseball  Skiing
 Bicycling  Skydiving
 Equestrian Events  Softball
 Field Events  Squash
 Gymnastics  Surfing
 Inline Skating  Volleyball
 Racquetball  Weightlifting
 Shot-Putting


The Councils recommend wearing a properly fitted mouthguard to help reduce the incidence and severity of sports-related dental injuries.2 The ADA’s consumer website, MouthHealthy, also promotes the use of athletic mouthguards when participating in sporting activities with risk of injury.

Construction and types of mouthguards
Standards

ANSI/ADA Standard No. 99:2001 (reaffirmed 2013), Athletic Mouth Protectors and Materials sets the technical specifications for athletic mouthguard characteristics and physical properties, as well as instructions to manufacturers regarding labeling and packaging.12 In 2016, the American Society for Testing and Materials (ASTM) published ASTM F697-16--Standard Practice for Care and Use of Athletic Mouth Protectors as an updated standard for the care and use of intraoral mouthguards, including design considerations and special limitations (e.g., individuals with orthodontic appliances are advised to have their mouthguard provided only under the supervision of a dentist).13

According to the ADA Council of Scientific Affairs and the Council on Advocacy for Access and Prevention,2 an ideal mouthguard 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 to reduce or limit transmitted forces upon impact.

Types of mouthguards

ANSI/ADA Standard No. 99:2001 defines three categories of mouthguards, which are typically comprised of ethylene vinyl acetate (EVA), but vary in cost, adaptability, comfort, level of contact with dentition, and safety/efficacy.2, 14, 15

Custom-made

Custom mouthguards are fabricated in a dental office or laboratory from individual patient impressions using thermoforming techniques, which typically employ vacuum-forming or pressure-forming methods.7, 16 Materials used to fabricate custom mouthguards include ethylene vinyl acetate, polyolefin and polystyrene-polyolefin copolymer.7, 17 Such mouthguards can be customized to the requirements or personal preferences of the user. One recent study recommended fabricating custom mouthguards with balanced occlusion and maximum number of contacts with mandibular anterior teeth to reduce risk of mouthguard displacement from an impact force during athletic activity.18 

Custom mouthguards can be fully customized and provide athletes with an optimal fit with adaptability and efficacy, but they are the most expensive option and require dental visits for fitting and customization.2, 14, 19 While custom mouthguards are considered by many to be the most protective option, other mouthguards can be effective if properly fabricated and consistently worn. Additional information on preparing custom mouthguards may be found in “Fabricating a custom-fitted mouthguard” in this 2006 JADA article.

Mouth-formed (boil-and-bite)

These self-adapting mouthguards are designed to soften when placed in hot water for a short period of time (approximately 15 seconds), and are then cooled and placed into the mouth for customized fitting.2, 14, 19 The product is adapted to the user’s mouth by bite pressure and manipulation using the tongue, fingers and lips.2, 14 A dental professional may provide assistance with the final molding, particularly if the user has orthodontic appliances,2, 14 but boil-and-bite mouthguards are widely available at sporting goods stores, and are generally designed to be fitted by the user at home. 

Boil-and-bite mouthguards typically employ thermoplastic copolymers, such as EVA, which can be easily adapted with heating to facilitate molding and formation of a stable dental impression.20 The process of “boil and bite” mouthguard adaptation should be performed according to manufacturer instructions to ensure proper heating and molding of the thermoplastic material, and to avoid imprecise or superficial shaping of the mouthguard to the wearer’s bite, which can result in a poorly fitted device.21

Stock (ready-made)

Stock (or ready-made) mouthguards are the most commonly available and least expensive type of mouthguard. Stock mouthguards are available at various department and sporting goods stores, but they are manufactured in a limited range of sizes, prefabricated without adaptation to the user’s mouth, and require the mouth to be shut to keep the device in place. The stock mouthguard is considered the least effective mouthguard type due to its generic design, improper fit and inadequate retention (with frequent repositioning) during sporting activities.2, 14, 19, 20

Injury prevention

Dentofacial injuries

Contact, collision and high-velocity sports are strongly associated with increased risk for dentofacial injury, 7, 22 and mouthguard use has been found to contribute significantly to a lower risk of dental trauma.15 One recent meta-analysis determined that the overall prevalence of dentofacial injuries among collision sports participants was 27.6%.23 A 2019 systematic review concluded that, when compared with mouthguard users, individuals who did not use mouthguards had more than twice the increased risk of orofacial injury.24 This finding is consistent with numerous studies that have consistently shown reductions in orofacial injuries with the use of mouthguards in a wide range of active individuals, including water polo players25 and elite commando fighters.26 A 2002 prospective study of 70,936 college basketball players found the rate of dental injuries was five times lower among players wearing custom-fitted mouthguards than players who did not use mouthguards (dental injury rate of 0.12 vs. 0.67 per 1,000 exposures in mouthguard users versus non-users, respectively).27 In a 2007 meta-analysis of studies of team contact sports, researchers found that the risk of orofacial injury was 1.6 – 1.9 times higher in players who did not use a mouthguard of any type.5

A 2019 systematic review and meta-analysis found the prevalence of dental trauma among mouthguard users to be 7.5% to 7.75% compared to 48.31% to 59.98% among non-users, and that mouthguard users were between 82% and 93% less likely to suffer dentofacial injuries.15 Coronal fractures and tooth avulsions were the most frequent injuries, and boil-and-bite mouthguards were the most commonly used type.15 The study emphasized that type of mouthguard may influence outcome, but that “mouthguards should continue to be recommended and used in sport activities with a high risk of dental trauma.”15

Concussions

Evidence on the role of mouthguards in reducing concussion rates among athletes has been relatively mixed and less consistent than for orofacial and dental injuries.24 A 2002 study of college basketball players found no significant difference in the rate between players who did and did not use a mouthguard.27 A number of studies have found the evidence for concussion reduction to be elusive or inconsistent,2, 28 including two studies from 2014 of high school football players, one of which found a higher risk of concussion among users of custom mouthguards compared to over-the-counter mouthguards,29 while the other study found a significantly reduced risk among users of custom mouthguards.30  

Researchers have continued to investigate whether mouthguard usage offers protection against concussion incidence in sporting activities. One systematic review described mouthguard use as having a modest influence on concussion incidence, with mouthguard non-users estimated to have 25% higher risk of sustaining concussion than mouthguard users.24 Other recent studies have reported that mouthguard wearing was associated with decreased incidence of concussion incidence among ice hockey players (youth and collegiate levels) and high school football players.30-32 However, a 2009 systematic review concluded that mouthguard use did not demonstrate any significant effect on concussion incidence among professional ice hockey players (mouthguard non-users, though, were found to have higher concussion symptom severity measurements).33 Further research is required to confirm the effectiveness of mouthguard use in reducing concussion risk and severity in sporting activities with high risk of orofacial injury (e.g., through absorbing or dissipating transmitted forces to the orofacial complex or by stabilizing the head and neck region during impact).

Utilization

It is important for mouthguards to be safe; however, to be effective, they also have to be used. Examples of reasons given for why mouthguards are not used include cost, lack of requirement for their use or lack of awareness of potential benefit.34

Despite the prevalence of dentofacial injuries during sports, mouthguard use has been fairly limited to specific high-contact sports, such as football, although one study found basketball players had the highest incidence of dental trauma.35 Despite the prevalence of dental trauma in athletic activities not normally considered high-contact, mouthguard usage remains low unless required by a governing organization.2, 14

Currently, the National Federation of State High School Associations (NFHS) and the National Collegiate Athletic Association (NCAA) mandate the use of mouthguards in football, field and ice hockey and lacrosse (NFHS also requires that wrestlers wearing braces must wear mouthguards).36, 37 Along with the ADA, the American Academy of Pediatric Dentistry and the American College of Prosthodontists recommend the use of mouthguards during contact and collision sports.19, 38 Boxing is the only professional sport for which mouthguards are mandated.2 United States military personnel are also required to wear mouthguards during various military training activities.39 

Raising awareness

Several “For the Patient” pages” have been published in JADA for use by dentists to help engage patients in conversations about mouthguards and facilitate discussion to encourage their use. The “For the Patient” pages underscore the importance of mouthguard use and provide information about the three primary mouthguard types (ready-made, boil and bite, and custom-made).8, 40-43

In April 2016, five health organizations including the ADA launched a facial-protection awareness campaign by establishing the month of April as National Facial Protection Month.44 During this month, sponsoring dental organizations, including 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 the importance of orofacial protection, including helmets, faceguards and mouthguards, in preventing sports-related orofacial injuries.2, 44

At the community level, dentists are ideally positioned to advise athletic patients who participate in sports or recreational activities, particularly ones with significant orofacial injury risk, to use properly fitted mouthguards and/or orofacial protectors. Dentists can also promote public health and injury prevention by educating parents, guardians and coaches about the importance of using properly fitted mouthguards in team sports and recreational activities that carry a risk of orofacial injury.

ADA Seal of Acceptance

Depending on the circumstances, dentists might recommend the benefit of a custom-fit mouthguard or a properly fitted “boil-and-bite” mouthguard, such as an over-the-counter (OTC) mouthguard 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 mouthguards by providing scientific evidence, which is evaluated according to objective requirements, demonstrating the safety and efficacy of OTC mouth-formed (boil-and-bite) mouthguards.

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 mouthguard is free of sharp or jagged edges.
  • The mouthguard 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.12

One comparative study found that custom mouthguards made by dentists provided improved comfort and wearability.45 Having an over-the-counter mouthguard product that meets ANSI/ADA standards could help with the cost barrier to engagement while still affording the consumer with a safe, cost-effective method of helping protect their teeth.7

Summary

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 using an athletic mouthguard or receiving information about mouthguards. The Councils recommend use of a properly fitted mouthguard to reduce the incidence and severity of oral injury in sporting or recreational activities, particularly activities with significant risk of dental trauma or orofacial injury.2 The Councils also encourage dentists to educate patients about mouthguards and orofacial injury risks, including appropriate guidance on mouthguard types, their protective properties, costs and benefits.2 The key educational message is that the best mouthguard is one that is utilized during sport activities.

ADA policy on Orofacial Protectors
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

References
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  25. 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.
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  35. 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.
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  39. U.S. Army Public Health Center. Mouthguards can prevent injuries (fact sheet; FS no. 12-002-0321).  2021:1-2.
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  45. DeYoung AK, Robinson E, Godwin WC. Comparing comfort and wearability: Custom-made vs. self-adapted mouthguards. J Am Dent Assoc 1994;125(8):1112-8.
Reviewed by: Prevention Subcommittee, ADA Council on Advocacy for Access and Prevention
Last Updated: October 19, 2021

Prepared by:

Department of Scientific Information, Evidence Synthesis & Translation Research, ADA Science & Research Institute, LLC.


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