- Email: [email protected]
Mouth Protectors: 11 Years Later
Mouth protectors: 11 years later B u r e a u o f D e n ta l H e a lt h E d u c a tio n C o u n c il o n D e n ta l M a t e r ia ls a n d D e v ic e s
Eleven playing seasons have been completed since the National Alliance Football Rules Committee first required mouth protectors for football players. The results are quite impres sive, and the future holds great promise for fur ther extending this safety feature into other areas o f athletics. Studies have shown that when a satisfactory protector is in place, oral injuries are drastically reduced. Before the introduction of the face guard and the mouth protector, oral injuries con stituted 50% of all football injuries. Each play er had one chance in ten of receiving such an injury during any playing season.1 A 1955 study conducted with member schools o f the Wiscon sin Interscholastic Athletic Association indicat ed that face guards eliminated about half the oral injuries.2 The use of mouth protectors has most substantially reduced the remainder. A projection o f these figures indicates that the use o f face guards and mouth protectors together may prevent more than 100,000 oral injuries an nually among the more than 1 million players participating in games o f the National Federa tion o f High School Associations, the National Association of Intercollegiate Athletics, and the National Junior College Athletic A ssoci ation. There is also scientific support for the effec tiveness of the custom-fabricated protector in reducing the incidence of concussion from a blow to the chin, and of injuries to the neck. In a study conducted with the Notre Dame foot ball team, Stenger and co-workers3 observed a distinct reduction in the number o f concussions and neck injuries after all members of the team were fitted with custom-fabricated protectors. H ickey and co-workers4 studied the effect of the custom-fabricated protector on pressure changes and bone deformation within the skull following a blow to the chin. They noted a def
inite reduction in the amplitude o f the intracra nial pressure wave and moderate decrease in bone deformation with the protector in place. Recent observations at the University of Con necticut also support the effectiveness of mouth protectors against concussion.5 Renewed interest in regulations at this time is stimulated by the passage o f a protector re quirement by the National Collegiate Athletic Association Football Rules Committee. When it becomes effectivé with the 1973 playing sea son, more than 33,000 additional players will be affected. The American Dental Association has been intimately involved with the development of mouth protector requirements. In response to growing concern on the part o f coaches, athlet ic directors, and dentists about the number of oral injuries incurred in football, the Bureau of Dental Health Education under the direction of the late Perry J. Sandell was authorized in 1959 to cooperate with the American Association for Health, Physical Education and Recreation in a study of mouth protectors. These two associ ations worked with the National Federation of State High School Associations, the National Association of Intercollegiate Athletics, and the National Junior College Athletic A ssoci ation. The resulting report of the Joint Commit tee on Mouth Protectors2 was published in 1960. It reviewed literature to that time, reported the effectiveness and limitations of face guards alone, and described and evaluated the types of mouth protectors and materials available. For many years, the A D A has encouraged constituent and component societies to work with teams at the high school level to develop effective mouth protector programs that are mu tually satisfactory to school and dentist. An out standing contribution has been made by the so cieties and by the individual dentists who have
REPORTS OF COUNCILS AND BUREAUS / JADA, Vol. 86, June 1973 ■ 1365
participated as volunteers or with minimal re muneration. Three types o f protectors satisfy the National Alliance requirements. The stock protector is purchased ready to use and comes in several shapes. The mouth-formed variety is a firm out er shell with a softer inner material. It is posi tioned in the mouth, permitted to mold to the player’s teeth, and then thermoset or chemoset. The custom-fabricated protector must be con structed over a model o f the player’s teeth. Preparation of a custom-fabricated protector requires that a dentist take the impression, su pervise pouring of the cast and construction of the protector, and place the appliance in the mouth. Placement o f the mouth-formed protec tor by a dentist is advisable for best results, al though some manufacturers state that this type can be fitted by coaches or players. The custom-fabricated protector has the high est level o f player acceptance. Its lack of effect on speaking ability in particular was demonstrat ed during a meeting of the N C A A Football Rules Committee. A proponent of mouth protectors spoke at length to the group, and then startled skeptics by publicly removing his previously undetected custom-fabricated protector. When satisfactorily fitted, the mouth-formed protector is also well accepted. Improper place ment can result in poor fit and considerable dis comfort. Very little can be done to adjust the fit o f a stock protector. This type is generally consid ered the least desirable. Despite the fact that, by 1967, all N C A A play ers had worn protectors in high school, a ran dom survey1 showed that only a fourth of them continued the practice in college. Conversa tions with players and trainers indicated that many protectors worn in high school were un acceptable because of factors related to com fort. This also has been true o f many protectors worn in colleges. Failure to realize the impor tance of protectors and unwillingness to “ take the trouble” have also played a part.1 Since comfortable appliances can be made available, why do many schools settle for less? One reason is cost. Although the money spent on dentist-placed, custom-fabricated or mouthformed protectors is a small fraction o f that cus tomarily expended for total protective equip ment, cost has served as a barrier in some in stances. In some areas, problems have been posed by unavailability of dentists or inconven ience of arranging for services.
What of the future? Since all high school and college football players are covered in 1973 by a mouth protector requirement, attention must be given to other aspects of adequate dental care and protection for athletes. If at all possible, a team should have a team dentist. The team dentist, occupying a position analogous to that of the team physician, should have three principal responsibilities. First, he should make certain that a preseason oral ex amination is conducted, preferably by each player’s family dentist. H e should provide this service himself if a player does not have a fam ily dentist. This will help to prevent loss of a player during the season because o f dental dif ficulties and will identify those with oral dis ease who should not wear a mouth protector until treatment has been undertaken. Some play ers with cleft palate or other malformations will need special professional attention in the place ment o f protectors. Second, he should coor dinate the mouth protector program in cooper ation with the athletic department and coaching staff. Third, he should arrange for treatment of any dental emergency occurring to a player when the family dentist is unavailable. Attention must also be given to other football-playing populations. Pop Warner and most other organized junior football leagues have mouth protector rules. But sandlot players are rarely safeguarded, and coverage of some ju nior high school football players is probably in adequate.
Mouth protectors and other sports Although many oral injuries occur in other sports, the use of mouth protectors is much less frequent than in football. U se by players in ice hockey probably ranks second. The Minnesota State High School Association has established a mouth protector requirement for ice hockey players under its jurisdiction. One collegiate league and several N ew England and Canadian leagues for young players also have protector regulations. Other sports in which the use o f mouth pro tectors should be greatly encouraged include basketball, field hockey, lacrosse, wrestling, skiing, automobile racing, baseball, parachut ing, karate and judo, Rugby and soccer, and gymnastics including trampolining. A s women increasingly engage in sports that
1366 ■ REPORTS OF COUNCILS AND BUREAUS / JADA, Vol. 86, June 1973
expose them to potential oral injury, special concern should be given to encouraging their use o f mouth protectors. Although some women already wear protectors, considerable progress is yet to be made.
retain thrombin and absorbable gelatin sponges over the extraction site in patients with a ten dency toward abnormal bleeding.6 Other ap plications include minor tooth movement, oral shields, and teeth cushioners for players of wind instruments.
What dentists can do Future programs of the Association A large number of component dental societies across the country have cooperated with schools to develop and implement highly effective pro grams for mouth protection, especially in foot ball. Through these programs the services of dentists have been offered on a voluntary basis or with minimal compensation. Vital to the suc cess o f these efforts has been the devoted work and expert knowledge o f the component soci ety’s mouth protector chairman. Many dentists have also provided invaluable service through their activities as team dentists. There are some specific things that individual dentists can do to encourage the use of mouth protectors where they are needed and to im prove the oral health o f America’s young ath letes. Any dentist interested in participating in a mouth protector program or becoming a team dentist should contact his component dental so ciety. Through the society, an appropriate and mutually agreed on arrangement for such ser vice can be made with the particular school. In their own practices, dentists should inform boys and girls and their parents of the impor tance o f wearing mouth protectors in all sports in which oral injuries are likely to occur. In the absence of other arrangements, individual den tists should be prepared to provide protectors on request.
Other professional applications There are a number of additional applications for mouth protector technology. Fabrication of bruxism appliances to be worn at night is easily accomplished and should be more widely under taken. Protectors increasingly are being rec ommended to safeguard the anterior teeth dur ing procedures such as endotracheal anesthesia, bronchoscopy, and tonsillectomy.6 Topical fluorides and other therapeutics, in cluding radium needles, have been held in place in the oral cavity by mouth protectors. They have also been used as hemostatic splints to
A t present there is available a large variety of materials used in the fabrication o f mouthguard devices, and there is evidence of an increased use as other sports adopt this method of safety protection. Because of this the Council on D en tal Materials and D evices is studying possible programs of evaluation to include specifications and review o f clinical safety and effectiveness for acceptance of these devices. The Council will then be in a position to provide definitive guidelines and suggestions for the mouth pro tector devices.
Summary Individually and through their professional or ganizations, dentists have played a vital part in development of effective protection programs for high school and college football players. N ow that all of these players are covered by mouth protector requirements, those concerned with oral safety in athletics must concentrate on improving present programs and developing more complete coverage for younger football players. Protection o f both male and female par ticipants in other sports must be emphasized. There is also increased awareness of other pro fessional applications for mouth protector tech nology.
1. Heintz, W.D. Mouth protectors: a progress report. JADA 77:632 Sept 1968. 2. Report of Joint Committee on Mouth Protectors of the American Association for Health, Physical Education and Rec reation and the American Dental Association. Chicago, Amer ican Dental Association, 1960. 3. Stenger, J.M., and others. Mouthguards: protection against shock to head, neck and teeth. JADA 69:273 Sept 1964. 4. Hickey, J.C., and others. The relation of mouth protectors to cranial pressure and deformation. JADA 74:735 March 1967. 5. News of Dentistry. Fitted mouthguards afford key protec tion. JADA 84:531 March 1972. 6. Nicholas, N.K. Mouth protection in contact sports. NZ Dent J 65:14 Jan 1969.
REPORTS OF COUNCILS AND BUREAUS / JADA, Vol. 86, June 1973 ■ 1367
Eleven playing seasons have been completed since the National Alliance Football Rules Committee first required mouth protectors for football players. The results are quite impres sive, and the future holds great promise for fur ther extending this safety feature into other areas o f athletics. Studies have shown that when a satisfactory protector is in place, oral injuries are drastically reduced. Before the introduction of the face guard and the mouth protector, oral injuries con stituted 50% of all football injuries. Each play er had one chance in ten of receiving such an injury during any playing season.1 A 1955 study conducted with member schools o f the Wiscon sin Interscholastic Athletic Association indicat ed that face guards eliminated about half the oral injuries.2 The use of mouth protectors has most substantially reduced the remainder. A projection o f these figures indicates that the use o f face guards and mouth protectors together may prevent more than 100,000 oral injuries an nually among the more than 1 million players participating in games o f the National Federa tion o f High School Associations, the National Association of Intercollegiate Athletics, and the National Junior College Athletic A ssoci ation. There is also scientific support for the effec tiveness of the custom-fabricated protector in reducing the incidence of concussion from a blow to the chin, and of injuries to the neck. In a study conducted with the Notre Dame foot ball team, Stenger and co-workers3 observed a distinct reduction in the number o f concussions and neck injuries after all members of the team were fitted with custom-fabricated protectors. H ickey and co-workers4 studied the effect of the custom-fabricated protector on pressure changes and bone deformation within the skull following a blow to the chin. They noted a def
inite reduction in the amplitude o f the intracra nial pressure wave and moderate decrease in bone deformation with the protector in place. Recent observations at the University of Con necticut also support the effectiveness of mouth protectors against concussion.5 Renewed interest in regulations at this time is stimulated by the passage o f a protector re quirement by the National Collegiate Athletic Association Football Rules Committee. When it becomes effectivé with the 1973 playing sea son, more than 33,000 additional players will be affected. The American Dental Association has been intimately involved with the development of mouth protector requirements. In response to growing concern on the part o f coaches, athlet ic directors, and dentists about the number of oral injuries incurred in football, the Bureau of Dental Health Education under the direction of the late Perry J. Sandell was authorized in 1959 to cooperate with the American Association for Health, Physical Education and Recreation in a study of mouth protectors. These two associ ations worked with the National Federation of State High School Associations, the National Association of Intercollegiate Athletics, and the National Junior College Athletic A ssoci ation. The resulting report of the Joint Commit tee on Mouth Protectors2 was published in 1960. It reviewed literature to that time, reported the effectiveness and limitations of face guards alone, and described and evaluated the types of mouth protectors and materials available. For many years, the A D A has encouraged constituent and component societies to work with teams at the high school level to develop effective mouth protector programs that are mu tually satisfactory to school and dentist. An out standing contribution has been made by the so cieties and by the individual dentists who have
REPORTS OF COUNCILS AND BUREAUS / JADA, Vol. 86, June 1973 ■ 1365
participated as volunteers or with minimal re muneration. Three types o f protectors satisfy the National Alliance requirements. The stock protector is purchased ready to use and comes in several shapes. The mouth-formed variety is a firm out er shell with a softer inner material. It is posi tioned in the mouth, permitted to mold to the player’s teeth, and then thermoset or chemoset. The custom-fabricated protector must be con structed over a model o f the player’s teeth. Preparation of a custom-fabricated protector requires that a dentist take the impression, su pervise pouring of the cast and construction of the protector, and place the appliance in the mouth. Placement o f the mouth-formed protec tor by a dentist is advisable for best results, al though some manufacturers state that this type can be fitted by coaches or players. The custom-fabricated protector has the high est level o f player acceptance. Its lack of effect on speaking ability in particular was demonstrat ed during a meeting of the N C A A Football Rules Committee. A proponent of mouth protectors spoke at length to the group, and then startled skeptics by publicly removing his previously undetected custom-fabricated protector. When satisfactorily fitted, the mouth-formed protector is also well accepted. Improper place ment can result in poor fit and considerable dis comfort. Very little can be done to adjust the fit o f a stock protector. This type is generally consid ered the least desirable. Despite the fact that, by 1967, all N C A A play ers had worn protectors in high school, a ran dom survey1 showed that only a fourth of them continued the practice in college. Conversa tions with players and trainers indicated that many protectors worn in high school were un acceptable because of factors related to com fort. This also has been true o f many protectors worn in colleges. Failure to realize the impor tance of protectors and unwillingness to “ take the trouble” have also played a part.1 Since comfortable appliances can be made available, why do many schools settle for less? One reason is cost. Although the money spent on dentist-placed, custom-fabricated or mouthformed protectors is a small fraction o f that cus tomarily expended for total protective equip ment, cost has served as a barrier in some in stances. In some areas, problems have been posed by unavailability of dentists or inconven ience of arranging for services.
What of the future? Since all high school and college football players are covered in 1973 by a mouth protector requirement, attention must be given to other aspects of adequate dental care and protection for athletes. If at all possible, a team should have a team dentist. The team dentist, occupying a position analogous to that of the team physician, should have three principal responsibilities. First, he should make certain that a preseason oral ex amination is conducted, preferably by each player’s family dentist. H e should provide this service himself if a player does not have a fam ily dentist. This will help to prevent loss of a player during the season because o f dental dif ficulties and will identify those with oral dis ease who should not wear a mouth protector until treatment has been undertaken. Some play ers with cleft palate or other malformations will need special professional attention in the place ment o f protectors. Second, he should coor dinate the mouth protector program in cooper ation with the athletic department and coaching staff. Third, he should arrange for treatment of any dental emergency occurring to a player when the family dentist is unavailable. Attention must also be given to other football-playing populations. Pop Warner and most other organized junior football leagues have mouth protector rules. But sandlot players are rarely safeguarded, and coverage of some ju nior high school football players is probably in adequate.
Mouth protectors and other sports Although many oral injuries occur in other sports, the use of mouth protectors is much less frequent than in football. U se by players in ice hockey probably ranks second. The Minnesota State High School Association has established a mouth protector requirement for ice hockey players under its jurisdiction. One collegiate league and several N ew England and Canadian leagues for young players also have protector regulations. Other sports in which the use o f mouth pro tectors should be greatly encouraged include basketball, field hockey, lacrosse, wrestling, skiing, automobile racing, baseball, parachut ing, karate and judo, Rugby and soccer, and gymnastics including trampolining. A s women increasingly engage in sports that
1366 ■ REPORTS OF COUNCILS AND BUREAUS / JADA, Vol. 86, June 1973
expose them to potential oral injury, special concern should be given to encouraging their use o f mouth protectors. Although some women already wear protectors, considerable progress is yet to be made.
retain thrombin and absorbable gelatin sponges over the extraction site in patients with a ten dency toward abnormal bleeding.6 Other ap plications include minor tooth movement, oral shields, and teeth cushioners for players of wind instruments.
What dentists can do Future programs of the Association A large number of component dental societies across the country have cooperated with schools to develop and implement highly effective pro grams for mouth protection, especially in foot ball. Through these programs the services of dentists have been offered on a voluntary basis or with minimal compensation. Vital to the suc cess o f these efforts has been the devoted work and expert knowledge o f the component soci ety’s mouth protector chairman. Many dentists have also provided invaluable service through their activities as team dentists. There are some specific things that individual dentists can do to encourage the use of mouth protectors where they are needed and to im prove the oral health o f America’s young ath letes. Any dentist interested in participating in a mouth protector program or becoming a team dentist should contact his component dental so ciety. Through the society, an appropriate and mutually agreed on arrangement for such ser vice can be made with the particular school. In their own practices, dentists should inform boys and girls and their parents of the impor tance o f wearing mouth protectors in all sports in which oral injuries are likely to occur. In the absence of other arrangements, individual den tists should be prepared to provide protectors on request.
Other professional applications There are a number of additional applications for mouth protector technology. Fabrication of bruxism appliances to be worn at night is easily accomplished and should be more widely under taken. Protectors increasingly are being rec ommended to safeguard the anterior teeth dur ing procedures such as endotracheal anesthesia, bronchoscopy, and tonsillectomy.6 Topical fluorides and other therapeutics, in cluding radium needles, have been held in place in the oral cavity by mouth protectors. They have also been used as hemostatic splints to
A t present there is available a large variety of materials used in the fabrication o f mouthguard devices, and there is evidence of an increased use as other sports adopt this method of safety protection. Because of this the Council on D en tal Materials and D evices is studying possible programs of evaluation to include specifications and review o f clinical safety and effectiveness for acceptance of these devices. The Council will then be in a position to provide definitive guidelines and suggestions for the mouth pro tector devices.
Summary Individually and through their professional or ganizations, dentists have played a vital part in development of effective protection programs for high school and college football players. N ow that all of these players are covered by mouth protector requirements, those concerned with oral safety in athletics must concentrate on improving present programs and developing more complete coverage for younger football players. Protection o f both male and female par ticipants in other sports must be emphasized. There is also increased awareness of other pro fessional applications for mouth protector tech nology.
1. Heintz, W.D. Mouth protectors: a progress report. JADA 77:632 Sept 1968. 2. Report of Joint Committee on Mouth Protectors of the American Association for Health, Physical Education and Rec reation and the American Dental Association. Chicago, Amer ican Dental Association, 1960. 3. Stenger, J.M., and others. Mouthguards: protection against shock to head, neck and teeth. JADA 69:273 Sept 1964. 4. Hickey, J.C., and others. The relation of mouth protectors to cranial pressure and deformation. JADA 74:735 March 1967. 5. News of Dentistry. Fitted mouthguards afford key protec tion. JADA 84:531 March 1972. 6. Nicholas, N.K. Mouth protection in contact sports. NZ Dent J 65:14 Jan 1969.
REPORTS OF COUNCILS AND BUREAUS / JADA, Vol. 86, June 1973 ■ 1367