Dentistry and Public Health: Rules, Policy, and Politics

Fig. 8.1

Impacts on mouthguard policy

8.1.1 Scientific Evidence

Scientific consensus is just one of the influencing factors in creating a public policy regarding mouthguard use. The literature is generally supportive of the role of mouthguards in preventing orofacial injury. In a review of the literature ([6], pp. 270–280; quiz 281), the authors concluded that “Mouthguards have been shown to reduce the number of dental injuries.” In another comprehensive review of mouthguard effectiveness ([7], pp. 117–144), the authors stated that “Meta-analysis indicates that the overall risk of an orofacial injury is 1.6–1.9 times higher when a mouthguard is not worn.” However, in a subsequent evidence-based dental review of this article, it was noted that “A major limitation of the current study is that although the authors performed a thorough systematic review and meta-analysis, no diagnostics were performed for publication bias and evaluating for heterogeneity. Not addressing publication bias leads to question the validity of the meta-analysis findings.” Similarly, the Task Force on Community Preventive Services, an independent, nonfederal group of national, regional, and local public health and prevention services experts ([8], pp. 55–80), stated that “For the other interventions reviewed in this report… population-based interventions to encourage use of craniofacial protective equipment in contact sports—all systematic reviews found insufficient evidence of effectiveness or ineffectiveness.” They go on to say that “It should be noted again that a finding of insufficient evidence is not a recommendation for or against use of an intervention, but rather a reflection both of the lack of qualifying studies on which to base a recommendation and of the need for more and better research on intervention effectiveness. In the absence of evidence that meets current standards for effectiveness, some organizations based recommendations for action on other factors, described briefly in this report. Until research findings become available, state and local health departments, funders of public health programs, and policymakers and other decision makers can judge the usefulness of these interventions based on other criteria and approaches.”

This illustrates one of the underlying conundrums in advancing public policy in the area of mouthguard use. While there are many articles which demonstrate the effectiveness of mouthguards in preventing orofacial injury, either the quality of the evidence or the focus of the article does not conform to the standards necessary for government and other groups who advise decision-makers to recommend implementation of mandatory use. This appears to be a broader problem as Klugl et al. noted in their paper ([9], pp. 407–412): “less than 2% of the studies over the past 3 years examined the effectiveness of prevention programs in a real-world context. Although this study was not designed to determine why this is so, it is clear that these intervention studies are very difficult to perform. This difficulty, however, should not deter researchers from seeking the evidence to prevent injuries in real-life situations. Research in the area of regulatory change is underrepresented, yet numerous studies have shown that it might represent one of the greatest opportunities to prevent injury.” In an effort to address these issues, the International Association of Dental Traumatology (IADT) is working on a core outcome set ([10], pp. 1–8) for traumatic dental injuries in children and adults. On their website the IADT state that:

Dental trauma is common and can occur throughout life. Numerous treatment options and interventions are available, depending on the specific traumatic injury sustained. Evidence-based comparisons of treatments and interventions can be challenging because of the diversity of outcomes reported in clinical studies. Outcomes need to be relevant to patients, clinicians and policy makers if the findings of research are to influence practice and future research. Furthermore, there is evidence to show that clinical researchers may favour reporting of outcomes that enhance results – this is known as outcome reporting bias. These issues could be addressed through the development and use of an agreed standardised collection of outcomes, known as a core outcome set (COS). The reporting of core outcomes in published studies allows researchers to compare outcomes from different studies and where appropriate, using meta-analysis techniques, to combine the results from studies in a particular area.

If adopted widely, this has the potential to strengthen the scientific basis for public policy regarding the use of mouthguards and other orofacial protective devices.

8.2 Professional Organizations/Governing Bodies

8.2.1 Professional Organizations

Issues with the variability in the quality of the literature have not prevented national and international organizations that represent members of the scientific and practicing communities from putting out official policy recommendations. The American Academy of Pediatric Dentistry (AAPD) has had its “Policy on Prevention of Sports-related Orofacial Injuries” from at least 1991 ([11], p. 67). In the most recent update, they state that “Popular sports such as baseball, basketball, soccer, softball, wrestling, volleyball, and gymnastics lag far behind in injury protection for girls and boys.” They go on to recommend “Mandating the use of properly-fitted mouthguards in other organized sporting activities that carry risk of oro-facial injury.”

The House of Delegates of the American Dental Association (ADA) [12] voted in 1994 for the following resolution which is still listed in the current policies of the ADA:

Resolved, that the American Dental Association recognizes the preventive value of orofacial protectors and endorses the use of orofacial protectors by all participants in recreational and sports activities with a significant risk of injury at all levels of competition including practice sessions, physical education and intramural programs, and be it further

Resolved, that constituent and component dental societies be urged to adopt formal policies and programs aimed at encouraging the widespread use of properly fitting orofacial protectors (such as mouthguards, face shields and helmets) by athletes in their communities, and be it further

Resolved, that the ADA work actively with international and national sports conferences, sanctioning bodies, school federations and others to mandate the use of orofacial protectors, and be it further

Resolved, that the appropriate Association agency make the implementation of this policy a priority item.

However, on their current website [13], they do not mention the mandatory or required use of mouthguards, yet they state that “Reasons given for why mouthguards are not used include awareness, cost, and lack of requirement for their use.”

The Academy for Sports Dentistry [14] in their online position statements say that “The ASD strongly supports and encourages a mandate for use of a properly fitted mouthguard in all collision and contact sports.”

The American Association of Endodontists (AAE) in their position paper [15] states:

The American Association of Endodontists recommends the use of mouth guards during participation in sports as their use may minimize the effect of impact injuries on the dentition and supporting structures. Participants in sporting events are encouraged to contact their dentist for fabrication of a custom mouth guard. In addition, organizers and coaches of children’s sports are encouraged to recommend and/or require the use of mouth guards for all of their participants.

The American Academy of Pediatrics states on their website [16] that “Mouthguards can help protect your child from a dental emergency. They should be worn whenever your child is participating in sports and recreational activities.”

The Canadian Dental Hygienists Association ([17], pp. 1–18) states in their position paper “The CDHA therefore strongly recommends that dental hygienists play an integral role in the prevention of orofacial injury in sports and promote properly fitted mouthguards as an essential piece of protective equipment, in sports that present a risk of orofacial injury at the recreational and competitive level, in both practices and games.”

The American Public Health Association, in their 1995 position paper [18] stated:

Noting the efficiency and effectiveness of mouthguards in preventing oro-facial injury and

Recognizing that mouthguards are often required in men’s but not women’s contact sports and

Aware that few insurance plans or state Medicaid programs offer coverage for preventive, quality fitted mouthguards, while often including treatment costs for facial and dental injuries; therefore

Recommends to schools and other sponsoring organizations that all participants involved in contact sports be required to wear quality fitted protective mouthguards;

Urges that the health insurance industry cover the cost of oro-facial injury prevention quality fitted mouthguards in health plans, as well as specifically in dental insurance managed care organizations, e.g., school insurance plans;

Recommends that health insurance companies and managed care organizations promote quality fitted mouthguards as established devices for preventing oro-facial injuries;

Recommends that the Health Care Financing Administration, Congress, and the states take steps to assure that Medicaid recipients and the uninsured population have quality fitted mouthguards when indicated for contact sports;

Urges that studies of cost-effectiveness of mouthguards be conducted; and

Recommends that schools and other sponsoring organizations teach the value of quality fitted mouthguards to all athletes in health education/health promotion or physical education classes.

Other organizations have mouthguard-related information on their websites. For example, the American Association of Orthodontists has information related to “National Facial Protection Month” and features information for consumers and professionals about mouthguard use. The National Facial Protection Month is also sponsored by the American Association of Oral and Maxillofacial Surgeons, the American Academy of Pediatric Dentistry, the Academy for Sports Dentistry, and the American Dental Association. Those organizations have similar materials on their respective websites.

8.2.2 Sports Governing Bodies

There is a great deal of sporting activity that goes on in the United States and in the world, which is not regulated by a larger body. In addition to team sports that are played in less formal settings (flag football, pickup basketball games etc.), recreational activities such as skateboarding, bicycling, and inline skating also have a significant risk of orofacial injury. In the United States, the main regulatory bodies for sporting activities are at the high school, college, amateur, and professional levels. Most sports have at least one governing body which typically is sanctioned by the United States Olympic Committee. For sports that are played at the high school level, the National Federation of State High School Associations (NFHS) is the governing body for member schools. Collegiate sports are governed primarily by the National Collegiate Athletic Association (NCAA). Professional sports are generally governed by their professional league. Other sports, for example, sports played at the X games [19] are governed by the sponsor of the event, in this case ESPN.

Tuna and Ozel ([20], pp. 777–783) noted that “According to the American Dental Association and the International Academy of Sports Dentistry, mouthguards should be used in the following 29 sports or exercise activities: acrobatics, basketball, bicycling, boxing, equestrian events, extreme sports, field events, field hockey, football, gymnastics, handball, ice hockey, inline skating, lacrosse, martial arts, racquetball, rugby, shot putting, skateboarding, skiing, skydiving, soccer, softball, squash, surfing, volleyball, water polo, weight lifting, and wrestling.” ◘ Table 8.1 shows selected sports and their governing bodies.

Table 8.1

Selected sports and their governing bodies


US governing bodies


National Collegiate Acrobatics and Tumbling Association

USA Cheer


USA Basketball

National Basketball Association


USA Cycling


USA Boxing

World Boxing Association

Association of Boxing Commissions

World Boxing Federation

Equestrian events

United States Equestrian Federation

Field events

USA Track & Field

Field hockey

USA Field Hockey


USA Football

National Football League


USA Gymnastics


United States Handball Association

Ice hockey

USA Hockey

National Hockey League

Inline skating

USA Roller Sports


US Lacrosse

Major League Lacrosse

Martial arts

USA Karate

USA Taekwondo

Association of Boxing Commissions (Mixed Martial Arts)


USA Racquetball


USA Rugby

Shot putting

USA Track & Field


USA Roller Sports (some dispute)


US Ski and Snowboard Association


US Parachute Association


US Soccer Federation

Major League Soccer


Amateur Softball Association/USA Softball


US Squash


Surfing America


USA Volleyball

Water polo

USA Water Polo

Weight lifting

USA Weightlifting


USA Wrestling

High school athletics

National Federation of State High School Associations

College athletics

National Collegiate Athletic Association High School Athletics

The National Federation of State High School Associations (NFHS) writes the rules of competition in 16 high school sports for girls’ and boys’ competition [21]. Their official position statement [22] states that the “NFHS currently mandates the use of mouthguards in football, field hockey, ice hockey, lacrosse and wrestling (for wrestlers wearing braces). The Sports Medicine Advisory Committee (SMAC) of the NFHS recommends that athletes consider the use of a properly fitted, unaltered mouthguard for participation in any sport that has the potential for oral-facial injury from body or playing apparatus (stick, bat, ball, etc) contact.” The NFHS also adds detail to the requirements: “All goalkeepers shall wear tooth protectors, which may be attached to the facemask/helmet. A tooth protector shall be of any readily visible color, other than white or clear. A tooth and mouth protector (intraoral) which shall include an occlusal (protecting and separating the biting surfaces) and a labial (protecting the teeth and supporting structures) portion and covers the posterior teeth with adequate thickness. It is recommended the protector be properly fitted: (1) Constructed from a model made from an impression of the individual’s teeth or (2) Constructed and fitted to the individual by impressing the teeth into the tooth and mouth protector itself.” For ice hockey, their rules “Requires that all players, including goalkeepers, wear an internal/external mouth protector which should cover all the remaining teeth or one jaw.” For wrestling “each contestant who has braces or has a special orthodontic device on their teeth, shall now be required to wear a tooth and mouth protector that covers the teeth and all areas of the braces or special orthodontic device with adequate thickness.”

Each state high school athletic association belongs to the NFHS. However, not all schools in each state belong to the state association. In some states, some private schools might not belong to the state association. This is important because while the NFHS offers guidance and recommendations on the use of orofacial protective equipment, it only governs member schools.

A recent article ([23], pp. 35–40) reviewed mandatory mouthguard rules for high school athletes in the United States. The author noted three state high school athletic associations that mandated mouthguard use in at least one sport beyond what the NFHS requires. The New Hampshire Interscholastic Athletic Association [24] states that mouthguards are required in:

  • Soccer

  • Field hockey

  • Football

  • Basketball

  • Ice hockey

  • Lacrosse

  • Wrestlers with braces

The Maine Principals’ Association [25] states in their soccer bulletin that:

All players shall wear a mouth guard that is made of a readily visible color (may be multicolored but not clear or white) that must cover all upper molars, as well as upper front teeth. Shock mouth guards are acceptable. Mouth guards must be worn in all practices and competitions (including during pregame warm-ups) and are required of all participants at all levels (e.g. freshman, junior varsity, and varsity for boys and girls).

Play should not be stopped immediately for infringement of this rule.

  1. 1.

    Coaches assume the responsibility to make certain that each player is wearing a legal mouth guard.


The Massachusetts Interscholastic Athletic Association [26] in their handbook states that for lacrosse “All participants must wear mouth guards.” They also state that “Mouth guards are recommended for all baseball players while on the field,” “Mouth guards are highly recommended for all basketball players while on the court,” and “Mouth guards are highly recommended for all soccer players while on the field.”

Additionally, in 2013, the Connecticut Interscholastic Athletic Association’s (CIAA) board endorsed the requirement for all boys’ and girls’ high school soccer goalies to wear a mouthguard. The CIAA [27] also requires mouthguards in middle school for baseball, ice and field hockey, football, lacrosse , soccer, and softball.

Also, the New York State Public High School Athletic Association [28] states “a mouthpiece shall be worn by the soccer goalie for protective purposes.”

Although the NFHS requires mouthguards for both ice and field hockey, the Rhode Island Interscholastic League [29] gives an additional rationale for its use:

“In order to avoid any liability for dental injuries as well as to ensure no unfair competitive advantage to teams not observing the rule, ‘All players, including goalkeepers, shall wear and have properly inserted into their mouth during the course of play a properly fitted tooth and mouth protector’.” It is interesting that they felt it necessary to reinforce an already existing rule. This speaks to the public perception realm of mouthguard use that will be discussed later in the chapter.

In their 2014–2015 Athletic Trainers Packet, the West Virginia Secondary Schools Activities Commission [30] states: “Mouth Guard Policy for Basketball, Soccer, and Wrestling – The use of mouth guards is recommended for all practices and matches. Please note the mandatory requirement has been replaced by a recommendation.”

While the NFHS mandates the use of a mouthguard for wrestlers with braces, the Wisconsin Interscholastic Athletic Association [31] states in their October 2013 newsletter that “A wax substance that covers the braces of a wrestler may meet the requirements of a suitable mouth guard. It will have to be inspected and approved by of the referee. This was an interpretation made last season.” College Athletics

The NCAA [32] currently requires mouthguards in ice hockey, field hockey, football, and lacrosse. For basketball (men and women), the rulebook states “mouth guard protectors are appropriate equipment when they meet the qualifications outlined in this rule.” The wrestling rulebook states that “It is recommended that all wrestlers wear a protective mouth guard.” There are no other recommendations in other published NCAA rulebooks regarding mouthguards. Amateur Athletics

The US Olympic Committee [33], through its component organizations , currently requires mouthguard use in multiple sports:

  1. 1.

    Boxing : “Gumshields (mouth piece) must be worn by Boxers during all Bouts.” “Boxers who wish to compete with braces are required to have attached to their passbooks a completed Release To Compete With Braces form (Appendix). This form requires the written approval of their dentist, parents, and/or guardian (if under 18 years of age) and a dentist-molded mouthpiece. This includes upper and/or lower braces. Boxers competing with braces waive the right to dental coverage under the USA Boxing insurance program.”

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Aug 25, 2019 | Posted by in General Dentistry | Comments Off on Dentistry and Public Health: Rules, Policy, and Politics
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