Concussion Prevention: Are Mouthguards the Answer?

My understanding, diagnosis, treatment and return-to-play decisions for mild traumatic brain injury continue to evolve. Early in my sports medicine career, I followed published "guidelines" dogmatically. With experience and clinical observation, my management also evolved synthesizing experience and science (as scant as it is). With experience, I more critically reviewed the evidence governing concussion management finding it more opinion than science. Slowly, much of the dogma I stubbornly used and defended, has been appropriately questioned as "concussion science," has developed. I continue to be intrigued by those studies that question concussion doctrine.

Researchers from the University of North Carolina have performed such a study. This study questioned the value of mouthguards in preventing concussion in athletes. A widely accepted argument favoring mouthguards has been the potential for mouthguards to reduce concussion risk in sports. This argument has been solely supported by a cadaver study published in 19671. In this study, a measured, controlled amount of force was delivered to the chin of male cadavers. Results demonstrated a decrease in the amplitude of intracranial pressure and less bone deformation in cadavers fitted with mouth protectors. How, or if, these results translate into clinical application and/or protection against concussion has yet to be proved. Nevertheless, lacking clinical application and study, this notion has influenced decision-making regarding mouthguard use in sports. Mouthguards have been mandated in high school football since 1962 and college football since 1974. High school and college hockey have also instituted mouthguard requirements. In other collision and contact sports, mouthguards are still optional.

The researchers recruited Division I basketball programs throughout the United States, evenly distributed geographically. The athletic trainers at these schools submitted reports weekly recording concussions, oral soft tissue injuries, dental injuries, dental referrals, and practices and games missed due to injury. Three kinds of mouthguards were included in the study: over-the-counter, "boil and bite," and custom-fitted mouthguards. Each athlete's practice and game participation were counted as a single athlete-exposure, using the same injury rate designation as the NCAA.

Of the 50 participating schools, 82% of the athletic trainers were able to report data for 15 weeks. There were a total of 1000 possible reportable weeks in the basketball season. Data were reported for 863 of these weeks (86% overall response).
The results proved quite interesting. From a total of greater than 70,000 athlete-exposures, 37 concussions and 43 dental injuries were reported. For details, see the accompanying table. There was so little use of over-the-counter and "boil and bite" mouthguards that these data were eliminated from the study.

Table
Sports Injuries: No Mouthguards vs. With Mouthguards

	No Mouthguard	With Mouthguard
Exposures	62,273	8663
Concussions	34 (0.55 A-E)*	3 (0.35 A-E)
Oral soft tissue injuries	66 (1.06 A-E)	6 (0.69 A-E)
Dental injuries	42 (0.67 A-E)	1 (0.12 A-E) p<0.05
Dentist referrals	45 (0.72 A-E)	0 (0.00 A-E) p<0.05
*A-E represents athlete exposure

There was no statistically significant difference between mouthguard use and no mouthguard use for both concussions and oral soft tissue injuries. Consequently, in basketball, mouthguards had no protective effect against concussion. Likewise, oral soft tissue injuries were not reduced by mouthguard use. As expected, the risk of dental injury was markedly reduced by the use of mouth protectors.

COMMENTARY BY ROB JOHNSON, MD.

It is difficult to generalize the results of a concussion study in basketball to collision sports like football and hockey where concussions are more common. Since mouthguards are required in both football and hockey, no similar study can be conducted. Soccer offers an opportunity to study concussion and mouthguards. Mouth protection is not required, but is often used. The concussion rate (according to NCAA statistics) is similar to that of football. A similar soccer study represents a logical extension of this project to further investigate the role (if any) of mouthguards in preventing concussion.

A load of justification has been heaped upon the 1967cadaver study cited earlier. There is no clinical correlation between the findings of a decreased amplitude in intracranial pressure and decreased bone deformation from a blow to the chin. This study represents an attempt to bridge this gap between basic science and clinical application. This first effort demonstrates no concussion reduction. As would be expected, there was no difference in oral soft tissue injuries. The overwhelming value of mouthguard use is in the reduction in dental injuries and subsequent dental consultations. Since very little time was lost from practice and competition, the value is cosmetic and economic.

Slowly, our traditional assumptions about concussion are being replaced with evidence. This evidence must be incorporated into practice to allow us to administer and advise our athletes more effectively. The search for further clinical evidence continues.

Source: Labella CR, Smith BW, Sigurdsson A: Effect of mouthguards on dental injuries and concussions in college basketball. Med Sci Sports Exerc 2002;34(1):41-44.

References
1. Hickey JC, Morris AL, Carlson LD, Seward TE. The relation of mouth protectors to cranial pressure and deformation J Ant Dent Assoc 1967; 74:735-740

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Title	Concussion Prevention: Are Mouthguards the Answer?
Source	Sports Medicine Alert
Vol (iss)	8(1)
Date	January 2002
Pages	1-2
SIRC ID #	s-815134

 

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