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 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.
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 (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