Introduction
The objectives of this research were to identify the beliefs and practices of orthodontists about mouthguard use in orthodontic patients and to survey orthodontic patients currently playing school-sponsored basketball and/or football about mouthguards.
Methods
Fifteen orthodontists were interviewed about mouthguard use in their patients. Patients (aged 11-18 years) playing organized school basketball (n = 53) or football (n = 22) from 13 of those 15 orthodontic practices participated in an online survey about mouthguards.
Results
Approximately half of the orthodontists interviewed had initiated discussions about mouthguards with their patients. Although boil-and-bite mouthguards were recommended most often by orthodontists with only a single orthodontist recommending a stock type, stock was the most commonly used type (football [59%], basketball [50%]) followed by boil-and-bite (football [27%], basketball [35%]). Only 2 of the 75 patients surveyed (<3%) reported using a custom mouthguard. All football players reported using a mouthguard, as mandated by this sport. Basketball does not mandate mouthguard use, and only 38% of basketball players reported wearing one. Players who used mouthguards cited forgetting as the most frequent reason for not always using one. A greater percentage of football (91%) than basketball (32%) players reported that their coach recommended a mouthguard ( P <0.001).
Conclusions
Orthodontists differ in how they approach mouthguard use by their patients, which likely reflects a lack of evidence-based guidelines. The beliefs, recommendations, and practices of orthodontists concerning mouthguard use and the use of mouthguards by orthodontic patients are discussed. Research directions to improve mouthguard use are suggested.
Highlights
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Orthodontists and patients were questioned about mouthguards for student athletes.
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Half the orthodontists surveyed talked to their athlete patients about mouthguards.
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Football coaches were more likely to recommend mouthguards than basketball coaches.
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Evidence-based guidelines on mouthguard use are lacking.
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Research directions to improve mouthguard use are suggested.
Over 7.9 million high school students participated in school-sponsored athletics during the 2016-2017 academic year in the United States, increasing their risk of injury, including dental trauma. Estimates are that 10%-39% of all dental injuries in children occur during sports-related activities. Trauma to maxillary incisors account for up to 80% of all dental injuries. , Because such injuries can have lasting negative effects on a young athlete’s oral health– and health-related quality of life, the American Dental Association (ADA) Council recommends wearing a mouthguard to reduce the risk and severity of sports-related dental injures.
Use of a properly fitted mouthguard reduces the incidence of orofacial injuries in sports. , A 2002 prospective cohort study on National Collegiate Athletic Association Division I men’s college basketball teams compared injury rates of athletes who wore custom-fitted mouthguards over an entire season with those who did not. Mouthguard users had substantially lower rates of dental injuries than nonusers. Similarly, a 2007 meta-analysis indicated that when a mouthguard is not used, risk of injury to the orofacial complex increases by 60%-90%. Injuries that can be reduced by wearing a mouthguard include orofacial injuries such as tooth fracture and dislocation, lip and soft-tissue laceration, jaw fracture, and in some reports risk of concussion by absorbing forces to the jaw normally transmitted to the brain. , , Although the latter claim has been promoted by mouthguard manufacturers, studies have consistently failed to link the use of mouthguards to lowered concussion risk. , ,
Most traumatic dental injuries occur during childhood and adolescence, especially when participating in contact sports. , Many individuals receive orthodontic treatment during this same developmental period, and having full fixed orthodontic appliances (ie, wires and brackets) can increase the risk of soft-tissue injury to the patient-athlete and his or her opponent. Three categories of mouthguards are available: (1) over-the-counter, ready-to-use stock, (2) over-the-counter, mouth-formed (eg, boil-and-bite), and (3) dentist-fabricated, custom-made. Custom-made mouthguards are generally preferred by dental professionals because they are believed to offer the best fit, retention, comfort, durability, and protection. However, providing a custom mouthguard to orthodontic patients whose teeth are moving or who are wearing fixed orthodontic appliances can pose difficulties. Thus, despite a potential benefit to the orthodontic patient, difficulty obtaining a comfortable, well-fitting mouthguard that does not interfere with braces or tooth movement can reduce the likelihood that a mouthguard is recommended and/or used.
Since the mid-1990s, the ADA has promoted the protective value of wearing properly fitted mouthguards while participating in activities that carry a risk of dental injury. Yet, in a large survey commissioned by the American Association of Orthodontics (AAO) as part of their 2009 Play It Safe campaign, 67% of 1014 parent responders with children aged 9-17 years reported their child did not wear a mouthguard during organized sports (AAO, unpublished data, 2009). If a mouthguard is the best available protective device for reducing the incidence and severity of sports-related dental injuries, why are not more children wearing them? Furthermore, 31% of these parents responded their child had played an organized sport while being treated with braces or other orthodontic appliances, but the survey did not address how orthodontic treatment influenced mouthguard selection or its use.
Several reviews have described mouthguard use and barriers to their use, , but there is a paucity of research related to mouthguard use for orthodontic patients. In 2014, Bussell and Barreto found that orthodontists in the United Kingdom most frequently recommended a boil-and-bite, followed by custom-made and then stock-type mouthguards for their patients. In 1999, Maestrello et al found that general dentists and pediatric dentists most frequently recommended custom mouthguards, whereas orthodontists most frequently recommended prefabricated stock-type mouthguards. Orthodontists were more likely than other providers to recommend mouthguards for patients playing basketball. However, there are few data describing orthodontists’ beliefs and practices about mouthguard use or their role(s) in the prevention of sports-related dental injuries. Similarly, there is a scarcity of data about mouthguard use by patient athletes receiving orthodontic therapy. This study is an initial, descriptive investigation to better understand these issues.
There were 2 primary goals. First was to conduct semistructured interviews with orthodontists to ascertain their beliefs about mouthguard use, to describe their existing practices regarding mouthguard recommendations, and to identify how they perceive their role(s) in the prevention of sports-related dental injuries. Second was to survey orthodontic patients involved in school-sponsored basketball and/or football to determine how often they wear mouthguards, their reasons for wearing or not wearing mouthguards, their overall views of mouthguards, the types of mouthguards they wear, and who advises and educates them about mouthguards. Football is 1 of 5 sports mandating (required by rule) mouthguard use by the National Federation of State High School Associations (ie, football, ice hockey, field hockey, and lacrosse for all athletes and wrestling only for those wearing orthodontic braces). Basketball, a nonmandated sport, was also selected because the study by Maestrello et al found that orthodontists, pediatric dentists, and general dentists recommended mouthguard use for football and basketball more than any other sport. High school basketball players are also at more risk of oral injuries than players in most other sports.
Material and methods
A sample of Washington State orthodontists (n = 15) in private orthodontic practice was recruited to participate in a semistructured interview using a snowball sampling method. Snowballing, also known as chain referral sampling, is a method of purposive sampling. One of the authors (N.E.B.) identified local orthodontists with an interest in mouthguards, who then suggested other possible orthodontists to interview until 15 orthodontists completed the phone interview. A sample size of 15 orthodontists was judged to provide a sufficient sample to approach the point of saturation, after which little new information would be derived from additional interviews.
Subjects (aged 11-18 years) were patients undergoing active orthodontic treatment with fixed appliances or clear aligner therapy at participating orthodontic offices. Subjects were currently playing football or basketball on their school team. Patients participating in the online survey about mouthguards were recruited from 13 of the offices participating in the orthodontist interview; orthodontists from 2 practices completed the interview but did not allow recruitment in their offices.
All study procedures and materials were approved by the Institutional Review Board of the University of Washington, Seattle, Washington. Informed consent was obtained from all participants before the interviews and electronic surveys.
Semistructured interviews were conducted with the orthodontists. A semistructured interview guide containing open-ended and follow-up questions was created to allow for a 10-15-minute guided interview ( Supplementary Appendix 1 ). All interviews were conducted one-on-one by the lead author (N.E.B.) in person or by phone. Each orthodontist gave permission to have the interviews digitally recorded for transcription ( Rev.com , San Francisco, Calif) and analysis. At the end of the interview, each orthodontist was asked whether their patients playing football or basketball could be recruited to participate in the online survey.
Orthodontists who agreed to allow patient recruitment in their offices were given an 8.5 × 11-inch recruitment poster ( Supplementary Appendix 2 ) to display during the appropriate 2016-2017 sports season (ie, football poster from September-December and basketball from November-February). The poster described study inclusion criteria and stated eligible patient participants would receive a $10 gift card for completing a brief online questionnaire. Receptionists were told to give interested subjects an instruction card explaining how to participate in the survey ( Supplementary Appendix 3 ). Cards directed subjects to an online survey programed in REDCap (Research Electronic Data Capture) and hosted by the University of Washington. REDCap is a secure, Web-based data collection service designed for freely programmable survey research. Participants could complete the survey using a smart phone or computer. Each instruction card had a unique code allowing access to the survey and prevented individuals from completing it more than once. This code also linked the survey to their orthodontist’s office location.
At the beginning of each survey, participants were informed that taking the survey was voluntary and all information gathered would be deidentified and would not impact their orthodontic care. Consent to participate was received when participants entered the Web site and clicked a checkbox agreeing to take the survey. Consent was not required from the subjects’ parents as determined by the human subject’s review. Once consent was obtained, subjects received a series of questions about their experience with mouthguards ( Supplementary Appendix 4 ). Each participant was given the opportunity to upload directly to the REDCap survey (or text message to N.E.B.) a photo of his or her mouthguard for entry into a lottery for an additional $40 gift card. All participants were asked to provide their own or their parent’s email address for the sole purpose of being able to receive the electronic gift card.
The 15 transcribed orthodontist interviews were assessed for accuracy by the interviewer. All transcripts were coded by 2 study investigators (N.E.B. and L.J.H.) using a mixed-method, qualitative approach. All responses from the interviews were compiled into a comprehensive data summary. Responses to each interview question were recorded and organized into themes, codes, and quotes.
Statistical analysis
Descriptive statistics were calculated for the survey data for frequency of mouthguard use, frequency of reasons for using or not using a mouthguard, frequency of types of mouthguards worn, and frequency of who recommends mouthguard use to the athletes. A 2-sided chi-square test comparing 2 proportions for independent groups was used to evaluate whether athletes report receiving different recommendations for mouthguard use from relevant stakeholders (coaches, parents, orthodontists, and dentists).
Results
Descriptive data are provided for the interviewed orthodontists ( Table I ) and for survey participants ( Table II ). One female patient completed the football survey, but her data were not included in Table II or the analysis. This decision was made because it was impossible to aggregate her data with other female participants or calculate descriptive statistics for female survey participants.
| Description | Male | Female |
|---|---|---|
| Orthodontists interviewed, n | 9 | 6 |
| Years in practice, mean (SD, range) | 11.1 (7.9, 3-26) | 16.5 (7.5, 6-23) |
| Orthodontists providing subjects, n | 8 | 5 |
| Patients per orthodontist, mean (SD, range) | 6.4 (3.2, 2-12) | 4.8 (4.5, 1-12) |
| Description | Football | Basketball | |
|---|---|---|---|
| Male ∗ | Male | Female | |
| Patients, n | 22 | 27 | 26 |
| Patient, mean age, y (SD, range) | 14.3 (1.3, 11-16) | 14.2 (1.9, 11-18) | 14.0 (1.4, 11-18) |
| Orthodontists providing patients, n | 10 | 11 | 10 |
| Patients per orthodontist, mean (SD, range) | 2.2 (1.2, 1-4) | 2.5 (2.3, 1-9) | 2.6 (1.8, 1-7) |
| Patients with fixed appliances, n | 20 | 24 | 21 |
| Patients with aligners, n | 2 | 3 | 5 |
∗ One female participant reported playing football; this participant’s data are not included in this table.
Orthodontists were asked about their approach to mouthguards for their patients who play sports and are in active treatment with braces or aligners. Four general themes with 15 subthemes were identified from the interviews. (Quotations from orthodontist interviews representing these themes are available online in Supplementary Table SI ).
- (1)
Talking with patients about mouthguards
- (a)
Responsibility to educate patients about mouthguards: Most orthodontists believed responsibility should be shared among the orthodontist, general dentist, coach, and parent for educating student-athlete patients about mouthguard use.
- (b)
Sports in which patients should wear a mouthguard: More than half of the orthodontists stated they recommended mouthguards for all sports, particularly those with a potential for incurring trauma to the face.
- (c)
Initiating conversation about mouthguards: Over half of the orthodontists indicated they or their staff routinely initiated conversations about mouthguards with patients at the time of consent, at the initial exam, at the time of consultation, and/or at the bonding appointment.
- (a)
- (2)
Considerations when recommending a mouthguard
- (a)
Patient characteristics: Activity level and degree of competitiveness of the sport and degree of increased overjet were considered when recommending mouthguards.
- (b)
Types of mouthguards: Most (n = 9) orthodontists recommended a boil-and-bite mouthguard, followed by a custom mouthguard made in-office (n = 4) and then a stock mouthguard (n = 2).
- (c)
Specific brand-name mouthguards: Six orthodontists recommended a specific brand of mouthguard: Shock Doctor (Fountain Valley, CA) brand (n = 2), Under Armour (Baltimore, MD) mouthguard (n = 2), Totalgard (Woburn, MA) (n = 1), and Shock Doctor or Under Armour (n = 1).
- (d)
Mouthguard cost: Four orthodontists said cost influences their mouthguard recommendation, each of them recommending a boil-and-bite type as an inexpensive option.
- (e)
Fees vs no fees: Most (n = 11) orthodontists said they do not charge a fee when providing a mouthguard. One orthodontist only charges when providing a custom mouthguard but usually provides a boil-and-bite mouthguard at no charge.
- (f)
Perceptions of liability: Personal liability was a concern for 3 orthodontists; 1 required a waiver be signed before providing a mouthguard, whereas another recommended a Shock Doctor mouthguard because of the company’s dental warranty of up to $10,000.
- (a)
- (3)
Factors influencing orthodontists’ approaches
- (a)
Influence of previous doctor: Four orthodontists stated they formed their approach and recommendation for mouthguards based on the approach used by the doctor from whom they purchased their orthodontic practice.
- (b)
Experience with traumatic injuries: Most (n = 12) stated past experiences with patients presenting with trauma had a major influence on their approach and practices concerning mouthguards.
- (c)
Belief that orthodontic appliances can be protective: Some (n = 4) orthodontists viewed braces as having protective qualities, protecting the teeth and reducing the severity of trauma, while also indicating a potential increased risk of soft-tissue trauma with braces. Five orthodontists viewed wearing aligners during sports as being “safer than not wearing anything.”
- (a)
- (4)
Mouthguard characteristics
- (a)
Obstacles for mouthguard use: Most orthodontists described barriers for mouthguard compliance, including fit and/or comfort, “because they are bulky, and the patient has difficulty breathing,” and interference with speech.
- (b)
Inhibit or hinder tooth movement: Six orthodontists reported they believe a mouthguard will inhibit tooth movement, or it will no longer fit well once the teeth are moving.
- (c)
Techniques for custom-made mouthguards: Base-plate wax, Triad gel, blue block-out resin, and play-doh were all reported to block-out or create space around the braces to allow insertion and removal of the appliance from the mouth and to provide relief to accommodate expected tooth movement. Laminating 2 layers of ethylene vinyl acetate was used most commonly.
- (a)
Orthodontic patients who currently play school-sponsored sports were asked via an online survey about how often they wear a mouthguard, reasons for wearing and not wearing mouthguards, their views of mouthguards, the types of mouthguards they use, and who is advising and educating them about mouthguards.
All football players (n = 22) reported wearing a mouthguard at least “most of the time” during their current football season ( Table III ). Twenty (20 of 22; 91%) football players reported wearing a mouthguard “always” during the season, whereas 2 (9%) reported wearing their mouthguard “most of the time.” No football players reported using mouthguards “half of the time,” “only sometimes,” or “never.” Conversely, basketball players were less likely to report frequent mouthguard use than football players. Compared with football players, fewer basketball players reported using a mouthguard “always” (5 of 53; 9%) or “most of the time” (11%) ( Table III ). Most basketball players reported using a mouthguard “only sometimes” or “never” during their sport season (67% of males, 81% of females).
