As part of my weekly routine I work in the Oral Surgery Department of the CUH Dental Hospital. I have seen enough damage to athletes mouths, teeth, gums, and jaws after weekend games to say that gumsheilds are an essential piece of kit. The use of mouthguards in Ireland is fairly hit and miss. Organisations like Irish Rugby Union and, recently, the GAA have insisted on players wearing mouthguards but injuries can happen in any sport where contact with another player, the ground or goal posts is likely. For instance, a study (Pribble 2004) stated that up to 30% of all injuries in soccer are to the mouth area. 

Very few schools or clubs have a mandatory mouthguard policy despite all evidence pointing to the very great need for one. In a recent study carried out by HSE Dental Services examining mouthguard use by school children in the West of Ireland in 2012 it was found that one in ten children had suffered a sports accident in the previous year, of which 51% injured teeth. On a positive note, of these, 72% visited a dentist within two hours (Immediate care after a dental injury has been shown to increase the chance of survival of a damaged tooth and reduce the risk of post- injury complications).

 Imagine what it would be like if you or your child suddenly lost one or two front teeth. Smiling, talking, eating—everything would suddenly be affected. Injuries to teeth in particular can be very distressing both to children and to parents, and can have a significant social, psychological and economic impact. When it comes to protecting your mouth, a mouthguard is an essential piece of athletic gear that should be part of your standard equipment from an early age. The dangers of not wearing a mouthguard are very real. In fact, studies show:

• that athletes are 60 times more likely to suffer harm to the teeth if they’re not wearing a mouthguard
• The US Surgeon General’s report on oral health found that sporting activities are linked to nearly one-third of all dental injuries
• A study by Castaldi has shown that dental and facial injuries contribute up to 39% of total injuries experienced in youth sport
• The lifelong financial cost for a lone avulsed (knocked out) tooth is estimated to be €18,000
• In Ireland, Stewart et al. found that sports injuries accounted for 23% of children attending Cork emergency services for dental trauma treatment
• The average cost of emergency dental treatment was €214.23 among injured children in the HSE study

Several reviews of studies on mouthguards have shown that they are effective in reducing hard and soft oral tissue injuries, jaw fractures and neck injuries. As a result, a number of sporting organisations in several different countries promote their use or have made them compulsory (e.g., rugby union, American football, ice hockey). The Gaelic Athletic Association (GAA) and the Gaelic Players Association (GPA) provided custom- made mouthguards to every inter-county senior football squad. Mouthguards are now mandatory for all juvenile and senior football players as of 2014. Studies have shown that this has had a significant impact on reducing the incidence of dental trauma, dental injury costs, and the number of dental insurance claims.

Investing in a mouthguard should be an automatic decision. In the following sections we will explore Mouthguards in more detail. It makes sense as a player, parent, coach, club rep or teacher to educate yourself on this very important piece of sporting equipment.

What are sports Mouth Guards?

An athletic mouthguard is an appliance constructed out of resilient plastic that encases its wearer's teeth and adjacent jawbone.

When worn, it provides protection for the hard and soft tissues of the mouth (teeth, gums, lips, cheeks and bone) by way of absorbing and redistributing the forces created by traumatic blows.

Design and construction

To the uninitiated, all sports mouthguards may seem similar. There are, however, three distinct types (based on their method of construction). They are:

1) Custom (€50- €250)    2) Boil-and-bite (€3-€30)    3) Stock (€2.50 and €12)

In general, you get what you pay for. 

Individualised well-fitting mouthguards (provided by a dentist) have been shown to deliver the best protection. These require a dental impression, dentist models, and a forming process based on vacuum or pressure. This involves one to two visits to a dentist. The cost of an individualised mouthguard is €80 at Mint Dental.

At the other end of the scale, stock appliances are generally the cheapest but their fit and level of protection are typically substandard. Boil-and-bite guards are the most used type and offer a middle ground between the two.

What Type of Mouthguard is Best?

Custom Mouthguards are the best for obvious reasons. They offer superior fit, comfort and protection because they are made from the highest quality material molded from an impression of your individual teeth.  Better fit means better protection, not least because you are more likely to wear it if it's comfortable. 

A properly fitted mouthguard, with the correct thickness and material, separates the mandible (lower jaw) from the maxilla (upper jaw). Therefore, when impact occurs, the shock is absorbed and equally distributed throughout the mouthguard. This reduces the force going to the base of the skull and ultimately to the brain cavity. Children who begin wearing custom-made mouthguards at an early age tend to continue this habit into the future.

We recommend that athletes wear custom-made mouthguards because they offer:

Optimal protection – Custom mouthguards are better at reducing the risk of injury, including:

• Concussions or brain damage
• Jaw dislocation or fracture
• Fractured or lost teeth
• Cuts or bruises to the mouth or face
• Stress to the neck

Optimal comfort –

• Custom mouthguards fit better than standard mouthguards.
• They feel better in the mouth.
• They allow athletes to breathe and speak more easily.
• An athlete is more likely to wear a comfortable mouthguard, thereby minimizing the risk of injury.

Benefits / Applications

1) Protection for teeth and dental work.
     a) Tooth-to-object impact.

One of the most obvious benefits of wearing a sports mouthpiece is providing protection for the athlete's teeth and dental work.

When a blow is delivered to the mouth, the energy of the impact will be absorbed by you one way or another. A mouthguard can minimise the trauma as it minimises the total amount of force that any one tooth or mouth region is exposed to.

• The spongy resiliency of a guard can absorb some of the energy of a blow.
• Its stiffness can help to distribute a blow's forces over a greater surface area.

Both of these factors help to lessen the total amount of force that any one tooth is subjected to and therefore lessen the likelihood that chipping, breaking, or even dislodgement will occur.

     b) Tooth-to-tooth impact.

Some collisions are such that they forcefully slam an athlete's jaws together. In these situations, the thickness and resiliency of the portion of a guard's plastic that covers over the chewing surface of the wear's teeth can help to cushion the effects of this reaction and therefore help to prevent tooth damage.

2) Jawbone protection.

Wearing a sport mouthpiece may help to prevent jawbone fracture. Similar to the teeth above, both its resiliency and stiffness can help to minimize the total amount of force that any one area of bone must absorb.

3) Soft tissue protection.

A mouthguard can act as a buffer between the soft and hard tissues of the mouth.

Blows to the face can force a person's lips or cheeks against their teeth, dental work, or dental appliances. This can cause soft tissue to be pierced or torn. Additionally, violent jaw movements caused by a blow or collision can cause you to bite your lips, cheeks, or tongue.

4) Braces.

Sports guards, especially those that have a dual-arch design can help to protect the lips and cheeks of athletes who wear dental braces. If you have a retainer or other removable appliance, do not wear it during any contact sports.

5) Partial dentures.

The contours of customized mouthguards (Custom-made, Boil-and-bite) will fill in where teeth are missing and provide support for the remaining ones. This makes it possible for an athlete to leave their removable partial denture out when they play.

6) Protection from concussion.

Some studies suggest that wearing a mouthguard can help to reduce the incidence or severity of concussion. This fact is not universally agreed upon by all researchers but certainly there is no downside to wearing a mouthguard.

7) Improved athletic performance.

The use of a mouthguard may help to improve an athlete's performance, in the sense that they may play more aggressively knowing that their risk of mouth injury is less.

Features / Design considerations

A) Fit and comfort.

A mouthguard must have a good snug fit and be comfortable to wear. If it's not, it probably won't get worn, at least not all the time. If it's too loose, you will tend to hold it in place by clenching your teeth. Doing so can interfere with your ability to breathe and speak. Not a great outcome!
If a guard is irritating to teeth or soft tissues, people have been known to adjust it by trimming off a portion. Doing so, however, can compromise the level of protection that it provides.

(Custom mouthguards are known for their idealized fit. Customized boil-and-bite products may fit well. Stock appliances seldom do.)

B) Design considerations.

Single-arch design.

Most sports mouthguards have a design where they just cover over the athlete's upper teeth. That's because, anatomically speaking, the nature of the upper and lower jaws are quite different.

• The lower jaw is capable of motion (it can move left, right, forward, or backward and open and close). This range of motion helps to disperse the intensity of any blow that's directed to it. 
• In comparison, the upper jaw is fixed in position and this places it, and the teeth it holds, at greater risk for receiving the full force of any blow that lands on it. (This difference is one reason why upper front teeth are the most likely ones to be damaged in an accident.)

Dual-arch design.

Some sports mouthpieces are designed so they fit over the upper and lower jaws.

• As an obvious advantage, dual-arch design provides protection for the lower teeth and jaw. It may also provide some protection for the jaw joint.
• As a criticism, some people will find this type of design more difficult to wear than its single-arch counterpart.
• As a side note, this type of guard provides an obvious benefit for athletes who wear braces.

Tooth coverage.

A sport mouthguard should have an outline form where it covers over all of its jaw's teeth. Those that don't may place the athlete for greater risk of lower jaw fracture.

A guard should extend onto that portion of the gums and jawbone that immediately surround the teeth. This feature helps to distribute the force of a blow over a larger area (as discussed below).

C) Thickness / Stiffness.

A mouthguard's overall thickness, resiliency (sponginess) and stiffness are important design factors.

The resiliency of a guard can help to absorb some of the intensity of forces directed to it.
The overall stiffness of a guard will help to distribute the intensity of a blow over a larger surface area, thus helping to diminish the amount of force directed to any one tooth or mouth region.

The Cost of not using a mouth guard

Wearing a sport mouthguard can be looked on as being a form of insurance, both in the sense of protecting an asset (your teeth) as well as spending a small amount of money now as a way of avoiding the potential for needing to spend a larger amount if some sort of tooth damage does occur.

A total of 10% of parents in the West of Ireland Study reported that their child (children) had suffered a sports-related accident in the past year, with 52% of these sustaining injuries to teeth. The majority of injuries to teeth were to permanent incisors (87%). Of the parents whose children had injured their teeth, treatment from a dentist was sought for all those that had injured permanent teeth and for 50% of those that had injured deciduous teeth. Almost three-quarters (72%) visited a dentist immediately or within two hours of the injury. The average cost of emergency dental treatment was €214.23. 

The American Dental Association estimates that a third of all dental injuries are sports related. The use of a mouth guard can prevent thousands of injuries to the mouth each year. It's been estimated that during any one season an athlete runs about a 10% chance of experiencing some sort of orofacial (mouth) injury, ranging from the very slightest to most catastrophic type of event.

Recenty the GAA highlighted the vast amount of dental literature to support the use of mouth guards in the prevention of dental injuries and plenty of evidence too that dental injuries are a major drain on the resources of their Player Injury scheme. In the five year period from 2002- 2006, they estimate the average number of claims per year for dental injuries was 438. They have since made the wearing of mouth guards mandatory for all players.

The Canadian Dental Hygienists Association cites a study that found that the total costs for repairing one displaced tooth were 20 times the cost of a customised mouthguard (€1500-€2000). 

Long term cost examples of not wearing a mouth guard

In the case of minor tooth repair (such as having a small filling placed to repair a chipped front tooth) will cost you €90 per composite (white) filling.

In those cases where a greater degree of damage has occurred, you can expect that your dental costs will be more.

• Placing a dental crown to repair a fractured tooth will cost €700.
• Having us perform root canal treatment for a tooth (€300-€370) and then place a dental post and crown .
• Replacing a missing tooth with a dental bridge or implant can cost unto €3000.
• Buying a sports guard really can be money well spent and is a good insurance.

The examples above demonstrate that the cost to repair teeth after a sports injury can easily be 10 to 20 times the cost of a custom mouthguard. 

These arbitrary costings obviously don't take into consideration the amount of suffering that can be associated with an accident or the amount of time that will be spent completing the dental treatment that is required.

As a hidden cost, you need to consider the long-term implications of a sports injury. Even the best dental work cannot be expected to last forever. That means you will have to anticipate that at least a portion of your treatment will need to be replaced at other times in your life.

Before injuring your teeth and soft tissue athletes should consider the following lifetime costs to fix damaged teeth.

•  implants,
• crowns,
• surgery,
• root canals,
• periodontal treatments,
• whitening treatments,
• controls, etc.

Its worth considering a Mouthguard if it can reduce the likelihood of injury.

Types of Dental Injuries

Injuries to the teeth can be grouped in three different categories with care specific to each type.

Fracture - can be classified as a root fracture, broken tooth or chipped tooth

• - if possible, stabilize portion of tooth still in mouth by gently biting on towel to control bleeding
• - athlete and tooth fragments should be transported immediately to a dentist
• - best methods of transport of the tooth are in Hank's Balanced Salt Solution, milk, saline soaked gauze, or under the athlete's tongue

Avulsion - entire tooth, including root, knocked out

• - do not handle tooth by the root (tooth should be handled by the crown)
• - do not brush, scrub, or sterilize tooth
• - if tooth is dirty, gently rinse with water
• - if possible, place tooth back in socket and have athlete gently bite down on towel
• - if unable to reimplant tooth, transport tooth with the athlete as described above to the dentist immediately

Luxation - tooth in socket, but in wrong position

• - Extruded Tooth - tooth appears longer than surrounding teeth
• - Lateral Displacement - tooth pushed back or pulled forward

For extruded or laterally displaced teeth, provide the following care:

• The tooth will need to be repositioned in socket using firm finger pressure. This is probably best done by trained dental/medical personnel.
• Have the athlete gently bite down on a towel and transport immediately to a dentist

Intruded tooth - tooth looks short, pushed into gum.

• Do not attempt to reposition tooth
• transport athlete immediately to a dentist

It is important to remember time is critical when handling dental injuries. Do not allow the athlete to wait until the end of the game to seek treatment for a dental injury. Transport them to a dentist within 2 hours for the best outcomes.

Tooth knocked out? Here's what you can do to save it

When teeth do get knocked out, the key is to act quickly, yet calmly, and follow these five simple steps to save the tooth:

The high-impact nature of most sports means that teeth can be knocked out at almost any time. But with the proper preventive measures and quick thinking, your teeth can be saved to last a lifetime.

Sports Mouthguards: Care and cleaning

An athletic mouth protector doesn't require a lot of care but there are some maintenance tips that you can use to help to keep yours looking new and lasting longer.

• When you are wearing your appliance, don't clench or chew on it. Doing so can tear, pierce, or deform it, thus compromising the level of protection it can provide.
• After wearing it, wash it off. At least give it a good rinsing with cold water. Better yet scrub it gently with your finger or a better yet a toothbrush. The use of a mild soap is a good idea too.
• Soaking your appliance in a household-bleach solution (1:10 bleach to tap water) can help to clean and disinfect it, as well as remove stains and odors.
• A mouthguard may warp or distort if it's exposed to high temperatures. Don't place yours in hot water or store it in a high-heat environment (i.e., glove box) or on a hot surface (i.e., car dashboard). This is not really an issue most of the time in Ireland unfortunately!
• Store your mouthguard in a hard, perforated container. Doing so will help to protect it from physical harm. It will also allow it to dry out thoroughly between uses. Our sports guards come with a plastic box included.

Remember your mouthguard is supposed to wear out.

Over time, an athletic mouthpiece will gradually deteriorate and finally wear out. For example, the fit of a guard will become slack as if it starts to deform. Keep on the lookout for rips, tears, and holes that may alter its fit or the level of protection it provides.