The Newsmagazine for the General Dentist August 2014, Vol. 42, No. 8 Sporting Mouthguards Preventing Sports-Induced Orofacial Injuries

Dealing With Negative Reviews 3 Steps to Team Success

White House Concussion Summit Constituent Advocacy: Georgia AGD Healthy People 2020 Report Update AGD Members’ Advocacy Efforts

888.AGD.DENT / www.agd.org Sporting Mouthguards Preventing Sports-Induced Orofacial Injuries

BY CLAIRE ALTSCHULER

chool and community sports provide life- According to the American Dental Association’s long benefits for athletes, offering them the Council on Scientific Affairs, “Surveillance studies Sopportunity to achieve physical fitness and of mouthguard users and nonusers have consis- improve their overall health. However, many tently shown that mouthguards offer significant of these high-impact activities, such as foot- protection against sports-related injuries to the ball, soccer, ice hockey, wrestling, boxing, and teeth and soft tissues.” Learn more about the types lacrosse, pose serious health risks as well. of mouthguards your patients may be using, and Impact during these sports can lead to chipped how you can help them protect their smiles with or lost teeth, facial lacerations, broken bones, and custom-made athletic mouthguards. other injuries. According to the American Academy of Pediatric Dentistry’s Policy on Prevention of Types of mouthguards Sports-Related Orofacial Injuries, sports accidents To help prevent injuries, there are a number of account for 10 to 39 percent of all dental injuries mouthguard types available to patients that offer in children. varying degrees of protection. Both stock guards According to Richard Knowlton, DMD, MAGD, and mouth-formed “boil-and-bite” guards are past president of the Academy for Sports Dentistry available to athletes over-the-counter and can be (ASD), athletic mouthguards can “reduce the sever- purchased at most sporting goods stores. Custom- ity and prevent the occurrence of injuries, such as made mouthguards, which are created from a coronal and radicular fractures, corpus fractures cast of the individual athlete’s dentition, require of the mandible, and fractures of the alveolar pro- the expertise of a dentist and special fabrication cesses, condyle, and gonial angles.” Mouthguards equipment. also prevent tooth avulsion and displacement, as well as “soft tissue lacerations to the gingiva and Over-the-counter devices oral mucosa.” According to Sports Dentistry Online, more than These painful injuries take time to treat 90 percent of mouthguards used are purchased by and heal, and treatment can be expen- athletes at sporting goods stores. Of these, stock sive, especially when an athlete guards are the least expensive ($3 to $25 each). requires a crown These guards are made of rubber and come in a or root canal. A limited number of sizes that cannot be altered to report published improve fit. Because of this, athletes must hold the in the January mouthguard in place with their teeth, constantly 2003 edition of biting down on the device. Stock guards offer Sports Medicine, the least amount of protection, and they also can “Overview of Injuries interfere with breathing and speech. in the Young Athlete,” Boil-and-bite mouthguards, made of a thermo- estimated the annual cost for all plastic material called ethylene-vinyl acetate (EVA), sports-related pediatric orofacial injuries to are heated in water and allowed to cool for about be as high as $1.8 billion. 20 seconds before being placed in the athlete’s

20 AGD Impact | www.agd.org | August 2014 mouth, where they are formed to the teeth with pressure from the mouth and fingers. While these devices fit better and offer more protection than stock mouthguards, they tend to be bulky and uncomfortable, also interfering with breathing and speech. They also can be difficult to fit around braces and other orthodontic devices, which can result in damaged appliances, or cut lips and cheeks when a player is hit in the mouth. Carl Vorhies, DDS, MAGD, team dentist for the Portland Winterhawks junior ice hockey team in Portland, Ore., says boil-and-bite devices provide limited protection because of the way they are made. When the material is stretched to form the guard, its thickness “depends on how it is placed [in the mouth], how large the individual’s teeth are, and how deeply they bite into it,” he says. “You don’t have very much control over the end result.” Additionally, he has found that many athletes also trim these mouthguards for a more comfort- able fit, leaving their posterior teeth uncovered. According to Dr. Vorhies, because boil-and-bites can be uncomfortable, players often chew on them, or stop wearing them altogether. Chewing on mouthguards or wedging them in helmets (another common practice) degrades the devices, which means they often don’t last through an entire season. However, the prices for these mouthguards are fairly consumer-friendly, ranging from $15 to $50 (though frequent replacement increases costs).

August 2014 | www.agd.org | AGD Impact 21 Many patients find that custom-made devices provide the most comfortable fit and the best protection against injuries, and they are more durable than many over-the-counter varieties.

Despite some limitations, boil- interfere with play, and athletes keep various areas of the guard can provide and-bite mouthguards can prevent them in their mouths. For example, he greater protection. many orofacial injuries when formed says, “a quarterback can easily keep it in Improving fit by tailoring the device properly and worn consistently. The his mouth when he’s calling out signals.” to an individual’s unique needs makes large demand for these over-the-counter As in the vacuum process, the first them more comfortable and allows the devices (They remain the most popular.) step in creating a pressure-laminated athlete to breathe easier—increasing also means manufacturers are continu- mouthguard is making a mold of the compliance. Modifications also can be ally working to improve them. player’s dentition. The cast is then made “to accommodate gaggers and placed in the pressure laminating different occlusions,” adds Dr. Vorhies. Custom-made mouthguards machine. Rather than sucking air out Dentists also can offer patients a Many patients find that custom-made and creating a vacuum to pull the mate- variety of ways in which to customize devices provide the most comfortable fit rial around the cast, pressure lamination these devices, including colors, designs, and the best protection against injuries, involves pushing air into the chamber and even team logos. Dentists charge and they are more durable than many and pressing the plastic down and varying amounts for these devices, with over-the-counter varieties. Dentists can around the cast at high heat. some practices choosing to utilize this easily create these custom mouthguards Pressure lamination allows the thick- service as a production improver. by taking an impression of the athlete’s ness in each part of the mouthguard mouth and either sending the cast to to be adjusted precisely, ensuring that Recent innovations a dental laboratory for fabrication or the finished device has the best con- Though there are numerous products making the device in-house using their figuration for the individual player and available to athletes, the mouthguard own equipment. These mouthguards provides the best protection. According market continues to grow. Andrew D. can be fabricated using either the to the ASD’s position statement “A Gould, DMD, team dentist for the AHL vacuum method or the pressure- Properly Fitted Mouthguard,” these Hershey Bears Hockey Club in Hershey, laminated technique. devices should “cover and protect both Pa., believes another type of custom- The vacuum process involves heating the teeth in the arch and the surround- made mouthguard, which is made of a single layer of thermoplastic and ing tissues” and have “a minimum of acrylic, a material that “adds stability stretching it onto the cast of the ath- 3 mm thickness in the occlusal [and] to the bite and the occlusion,” can lete’s dentition. The vacuum then sucks labial areas” in order to absorb and help prevent injuries. He recommends the air out, pulling the plastic tight so it dissipate energy from a blow. Optimal the Maher Orthotic, a device created adheres to the mold’s shape. palatal thickness is 2 mm. by Gerald Maher, DMD, FAHND, a Many agree that pressure-laminated While most dentists don’t make temporomandibular joint specialist. In mouthguards are the standard of care entirely different guards for differ- addition to providing these mouthguards because they provide athletes with the ent sports, custom fabrication does for his patients, Dr. Maher is the team greatest levels of comfort and protec- allow them to tailor the device to the dentist for the New England Patriots. tion. The technique creates devices individual player and his or her sport, Unlike other custom mouthguards, with multiple layers of thermoplastic increasing both comfort and protection. the Maher Orthotic is made like a den- that provide more cushion, as well as “The advantage of customized lamina- ture—acrylic is syringed into a cast of the a fit that is superior to that of over-the- tion,” says Dr. Vorhies, “is that the patient’s dentition and cured overnight. counter mouthguards. design and thickness can be modified.” Dr. Maher says the device is worn on the Although they consist of several layers Dr. Knowlton agrees. Some sports, lower teeth because athletes find it more rather than one, pressure-laminated such as basketball, wrestling, and comfortable. It is designed to advance mouthguards are still “relatively thin boxing, involve more hits to the front the mandible forward, increasing the and small,” says Timothy Kosinski, DDS, teeth, for example, while skiing or the space in the oral pharynx and making it MAGD, of Bingham Farms, Mich., who luge often involve more impact to the easier to breathe and speak. provides his local high school teams with occlusal areas of the teeth. He believes “It works very similarly to a sleep mouthguards. As a result, they don’t the ability to increase the thickness in apnea appliance,” Dr. Maher says. “The

22 AGD Impact | www.agd.org | August 2014 Mouthguards and Head Injuries Can These Devices Help Reduce the Incidence of Concussions?

Recent dental research has shown that properly fitted mouthguards may help reduce the incidence of severe concussions or sports-related mild traumatic brain injuries (MTBI) in athletes. Richard Knowlton, DMD, MAGD, past president of the Academy for Sports Dentistry, says that the theory that mouthguards can prevent concussions is based on the position of the brain relative to the jaw. The brain sits directly above the temporomandibular joint, A skull without a pressure-laminated mouthguard in position (left), and a skull with such a mouthguard in place which is formed by the connection (right). The pressure-laminated mouthguard creates a separation of the condyle that some researchers believe between the mandible and the may reposition or align the mandible to better absorb, dissipate, or reduce possible concussion forces. temporal bone. When an athlete is struck in the jaw, the energy Source: Adapted from General Dentistry, May/June 2014; reproduced with permission from the Academy for Sports from the impact can travel to the Dentistry brain, causing injury. Some experts believe that a mouthguard with adequate thickness and a proper a properly fitted mouthguard ‘neuromythology’ rather than hard mouthguards with more than 3 fit that increases the space in the should retain “a space between science.” A 2011 Clinical Sports mm thicknesses in the posterior temporomandibular joint could the end of the jaw, the condyle, Medicine study reported that “there occlusal area statistically reduced help dissipate this energy before it and the temporal bone in the [was] not yet significant evidence the incidence of MTBI/concussion reaches the brain, preventing, or at temporomandibular joint.” If the to advocate [helmets’ and mouth- injury when compared to OTC least lessening, damage. space and cushioning in that area guards’] effectiveness in preventing mouthguards.” The crucial issue for both oral is inadequate, a hit to the jaw could concussion.” The paper’s authors “Previously, the rap was health and MTBI prevention, Dr. result in a temporal bone fracture. recommended further study. that mouthguards don’t make a Knowlton says, is “the amount of Until recently, evidence sup- However, research published in difference, but I disagree,” believes mouthguard material that is on the porting the mouthguard’s ability to the May/June 2014 issue of General Dr. Winters. Even though properly top surface, the occlusal surface reduce the incidence of concussion Dentistry, “Role of Mouthguards fitted mouthguards won’t prevent of the teeth.” When fabricated was mostly anecdotal. In the British in Reducing Mild Traumatic Brain all concussions, Dr. Winters says correctly, the guard can provide a Journal of Sports Medicine in 2001, Injury/Concussion Incidence in High his study shows they can play a cushion and keep the lower teeth Paul McCrory, MD, wrote, “The School Football Athletes,” suggests role in prevention, and he hopes from hitting the upper teeth if the ability of mouthguards to protect that a custom-made, properly fitted these results will stimulate further jaw is thrust upward. against head and spinal injuries mouthguard may reduce the inci- research. In addition, Dr. Knowlton says, in sport falls into the realm of dence of sports-related concussions. Dr. Knowlton believes additional Authors Jackson Winters, DDS, and study is necessary to determine if Richard DeMont, PhD, CAT(C), ATC, and how mouthguards can impact performed a randomized, prospec- concussions. “As time goes on, and tive study of six high school football we have better and better research, teams (412 total players). Players on I believe you are going to find that three teams wore over-the-counter a quality mouthguard can make a (OTC) mouthguards, while players difference,” he says. on the other three teams wore custom-made, pressure-laminated mouthguards. All players wore the same helmets. ONLINE This study found a “nearly EDITION 2-to-1 ratio between the two groups’ incidence of MTBI/concus- Read the May/June 2014 sion injury, which was statistically General Dentistry study on significant.” The researchers mouthguards. concluded that “custom-made, properly fitted, pressure-laminated

August 2014 | www.agd.org | AGD Impact 23 Mouthguard Requirements for Athletes

High School Athletes

Per the National Federation of State High School Associations (NFSH), mouthguards are currently required for participation in these high school sports: • Football • Field hockey • Ice hockey • Lacrosse • Wrestling (for wrestlers wearing braces) All mouthguards, excluding wrestling devices, must be made with a visible color—not white or clear. Additionally, NFSH rules require all mouthguards used in wrestling (for those with braces) to cover both the upper and lower orthodontic appliances.

Source: NFSH 2011 Position Statement and Recommendations for Mouthguard Use in Sports

College Athletes

The National Collegiate Athletic Association’s (NCAA) 2012–2013 NCAA Sports Medicine Handbook requires athletes to use mouthguards when participating in several sports. Stock, mouth-formed, and custom mouthguards are recognized as acceptable devices.

Sport Position Intraoral Mouthguard Color Covers All Upper Teeth When

Field Hockey Field Mandatory; strongly Not specified Not specified Regular season recommended for competition and goalkeepers NCAA Championships

Football All Mandatory Readily visible color Yes Regular season (not white or transparent) competition, postseason competition, and NCAA Championships

Ice Hockey All Mandatory Recommended Covers all the Regular season remaining teeth competition and on one jaw NCAA Championships

Women’s Lacrosse All Mandatory Not Specified Yes Regular season competition and NCAA Championships

Men’s Lacrosse All Mandatory Yellow or any other Yes Regular season visible color competition and NCAA Championships Adapted from: 2012-2013 NCAA Sports Medicine Handbook

24 AGD Impact | www.agd.org | August 2014 Published with permission of the Academy of General Dentistry. © Copyright 2014 by the Academy of General Dentistry. All rights reserved. For printed and electronic reprints of this article for distribution, please contact [email protected].

big difference between my guard and others is that it is based on the By offering these devices, dentists temporomandibular joint. It’s an orthopedic device that places the joint can set themselves apart from in the best physiological position.” By balancing the articular disk and others, helping them expand and the condyles in the joint, he says, the mouthguard keeps the muscles on both enhance their practices. sides of the joint in harmony. The Maher Orthotic also keeps the jaw slightly open, which helps reduce the impact when an athlete is hit during play. “That is the whole key to the device—its balance,” Dr. Maher says. The rest of the cost covers the The patient, a 17-year-old ice hockey Increasing the space in the jaw allows dentist’s time, as well as the fabrication player, was hit in the mouth by a the device to disperse energy and equipment, if the dentist decides to puck at practice. According to Dr. lessen the impact of a blow. Dr. Gould make the mouthguard in his office. Vorhies, the patient’s injuries included charges patients $450 for the Maher Most vacuum machines cost $300 to a “severe laceration of the upper lip Orthotic; prices vary by provider. $500; pressure laminating devices run [and] a lost lateral tooth, a central $2,500 to $3,000. For those sending the incisor was pushed backwards, and The role of the general dentist cast out for fabrication, Dr. Knowlton the whole buckle plate of that anterior As research continues to point to says laboratory fees can run anywhere segment was shattered.” A mouth- the importance of mouthguards for from $30 to $120 per device. These costs guard may not have prevented all of athletes, dentists increasingly find should all be taken into account when those injuries, Dr. Vorhies says, but it themselves in a position to help determining the prices for these devices. “certainly would have made a differ- their patients and local communities Dr. Kosinski says that in addition ence.” He believes dentists, coaches, improve sports safety and reduce to providing an important service to and referees should insist that players dental injuries—and it all starts with patients and the community, making wear their mouthguards whenever a conversation about mouthguards. mouthguards for local teams also can they play and enforce the rule in both “I challenge the dentists out there to be a good marketing tool. By offering practice and competition. get involved,” Dr. Kosinski says. “It’s these devices, dentists can set them- General dentists can provide a very rewarding. And the kids really selves apart from others, helping them valuable service by educating athletes, appreciate it.” expand and enhance their practices. parents, coaches, trainers, and other Dr. Kosinski began making custom Before providing a mouthguard, school officials about mouthguards mouthguards when a close friend the dentist should assess the patient’s and their proper use, and the ASD asked him to recommend one for his oral health, including any cavities or encourages general dentists who offer son who had taken up wrestling. The missing teeth; determine what sport mouthguards to take the lead in their friend had seen a child lose a tooth he or she plays and at what level; communities. during a match and wanted to protect and consider whether he or she is his son from the same fate. receiving any orthodontic treatment Mouthguards may be small, but they Dr. Kosinski says he offered to make or expects to in the near future. The can make a big difference in protecting custom-fitted mouthguards for the answers to these questions will help athletes from orofacial injuries. By wrestling team, first vacuum-formed the dentist to determine which device educating patients on the importance and eventually pressure-laminated to recommend. Many athletes are of properly fitted athletic mouth- devices. Over the years, he has cre- unfamiliar with custom-made mouth- guards, general dentists can help care ated an efficient system for making guards, so reviewing all of the options for athletes both in the office and on mouthguards that do not require much could be enlightening—and result in the playing field. u time for him or his staff. better protection for the player. According to Dr. Knowlton, material Dentists also should take the Claire Altschuler is an award-winning health costs for pressure-laminated mouth- opportunity to discuss sports safety care journalist and medical writer. Her stories guards run approximately $20 per with their athletic patients and encour- have appeared in the Chicago Tribune and device. Each sheet of EVA costs about age them to wear mouthguards during Satisfaction magazine, and several have been $6.50, while the impression material practice as well as in competition—as nationally syndicated. She also works as a is about $1 for each guard. (Vacuum- injuries can occur in both situations. communications consultant to many of the formed mouthguards use only one sheet In fact, Dr. Vorhies says, one the most nation’s top health care organizations and of thermoplastic, so they are slightly significant injuries he’s encountered nonprofits. She lives in New York City. Contact less expensive.) occurred during a practice session. her at [email protected].

August 2014 | www.agd.org | AGD Impact 25