Effect of mouthguards on dental injuries and

concussions in college basketball

CYNTHIA R. LABELLA, BRYAN W. SMITH, and ASGEIR SIGURDSSON
Division of Sports Medicine and Department of Endodontics, The University of North Carolina at Chapel Hill,
Chapel Hill, NC

ABSTRACT
LABELLA, C. R., B. W. SMITH, and A. SIGURDSSON. Effect of mouthguards on dental injuries and concussions in college
basketball. Med. Sci. Sports Exerc., Vol. 34, No. 1, 2002, pp. 41 44. Purpose: Dental injuries can be permanent and disfiguring. They
are also universally expensive to treat. Many dentists, sports physicians, and athletic trainers recommend mouthguards for athletes
participating in certain competitive sports, including mens college basketball, because of a common perception that mouthguards
afford protection from dental injuries, and even some concussions. However, there are few reliable reports of the incidence of dental
injuries and concussions in mens college basketball, and good evidence that mouthguards reduce the risk of these injuries in this
population of athletes is notably lacking. This study prospectively recorded dental injuries and concussions among 50 mens Division
I college basketball teams during one competitive season, then compared injury rates between mouthguard users and nonusers.
Methods: During the 1999 to 2000 basketball season, athletic trainers from 50 mens Division I college basketball programs used an
Internet Web site to submit weekly reports of the number of athlete exposures, mouthguard users, concussions, oral soft tissue injuries,
dental injuries, and dentist referrals. Results: Response rate was 86%. There were 70,936 athlete exposures. Athletes using
custom-fitted mouthguards accounted for 8663 exposures. Injury rates were expressed as number of injuries per 1000 athlete exposures.
There were no significant differences between mouthguard users and nonusers in rates of concussions (0.35 vs 0.55) or oral soft tissue
injuries (0.69 vs 1.06). Mouthguard users had significantly lower rates of dental injuries (0.12 vs 0.67; P 0.05) and dentist referrals
(0.00 vs 0.72; P 0.05) than nonusers. Conclusion: Custom-fitted mouthguards do not significantly affect rates of concussions or oral
soft tissue injuries, but can significantly reduce the morbidity and expense resulting from dental injuries in mens Division I college
basketball. Key Words: ORAL INJURIES, MOUTH PROTECTORS, EPIDEMIOLOGY, SPORTS INJURIES, INTERCOLLE-
GIATE ATHLETES

D
ental injuries can be permanent and disfiguring.
They are also universally expensive to treat (18).
Many dentists, sports physicians, and athletic train-
ers recommend mouthguards for athletes participating in
certain competitive sports, including mens college basket-
ball, because of a common perception that mouthguards
afford protection from dental injuries, and even from some
concussions. However, there are few reliable reports that
document the incidence of dental injuries and concussions
among mens college basketball players, and good evidence
that mouthguards reduce the risk of these injuries in this
population of athletes is notably lacking.
Ever since rules mandating mouthguard use were estab-
lished for high school football in 1962 and for college
football in 1974, the number and severity of dental injuries
in these two populations of athletes have been significantly
reduced (2,7,13). Although mouthguards are commonly re-
garded as protective devices, proof of their effectiveness in
sports other than football has been predominantly subjec-
tive. All of the available information about dental injuries in
basketball has been collected through written surveys of
0195-9131/02/3401-0041/$3.00/0
MEDICINE & SCIENCE IN SPORTS & EXERCISE
Copyright 2002 by the American College of Sports Medicine
Submitted for publication November 2000.
Accepted for publication October 2001.
41
athletes, coaches, or athletic trainers (1,5,6,9 12,14 16).
The majority of these surveys studied high school athletes.
The few that have specifically focused on college basketball
are limited by poor response rates, lack of control for ex-
posure time, or small sample size. Importantly, almost all
are retrospective in design, which means that subjectivity
and recall bias are significant limitations. Truly prospective
studies are notably scarce. The National Collegiate Athletic
Association (NCAA) prospectively records injury surveil-
lance data each year for a number of college sports, includ-
ing mens basketball. Unfortunately, these reports lack de-
tail with regard to specific dental injuries. In addition, they
provide no information about dentist referrals, and the data
collected about mouthguards does not allow for an evalua-
tion of their effect on injury rates (17). Before a firm
recommendation can be made about mouthguard use in
mens college basketball, a well-designed prospective study
that evaluates the protective effect of mouthguards in this
particular population of athletes is clearly needed.
Evidence that mouthguards protect athletes from concus-
sions is similarly lacking. There has been one laboratory
study, published by Hickey et al. in 1967, in which a
controlled amount of force was delivered to the inferior
border of the chin of a male cadaver. Results showed a
reduction in the amplitude of the intracranial pressure wave
and a decrease in bone deformation when a custom-fitted
mouthguard was in place (8). The only clinical evidence to
suggest that mouthguards may protect athletes from con-
cussions is provided by a limited number of case reports and
small retrospective surveys of high school and college foot-
ball players and primary school-aged rugby players
(3,4,6,12,20). There has not yet been a well-designed pro-
spective study to show that mouthguards reduce the inci-
dence of concussions in any population of athletes.
This study prospectively recorded the number of concus-
sions, soft tissue oral injuries, dental injuries, and dentist
referrals among 50 mens Division I college basketball
teams over the course of the 1999 to 2000 competitive
season. Participating athletic trainers used an Internet Web
site to report injury and exposure data every week. Personal
electronic mail communication with athletic trainers each
week helped to ensure compliance with the prospective
method of data collection. Injury rates were calculated and
expressed as number of injuries per 1000 athlete exposures,
which is the same method used by the NCAA. This method
provides a more accurate estimate of injury risk than the
standard practice of using the total number of players as the
denominator. Injury rates were then compared between
mouthguard users and nonusers.
METHODS
In August of 1999, letters explaining the studys purpose
were sent to the athletic trainers for 100 mens college
basketball teams. All teams from the following nine Divi-
sion I conferences were included: America East Conference,
Atlantic Coast Conference, Atlantic Ten Conference, Big
East Conference, Big Ten Conference, Big Twelve Confer-
ence, Conference U.S.A., Southeastern Conference, and Pa-
cific Ten Conference. These conferences were arbitrarily
chosen, and collectively represent 40 states and all four U.S.
geographic regions (East, South, Midwest, and West) as
defined by the NCAA (17). Of these 100 athletic trainers
who were initially approached, 50 agreed to participate.
These 50 athletic trainers represented schools from 38
states, and were distributed among the four U.S. geographic
regions as follows: 14 schools in the East, 15 schools in the
South, 13 schools in the Midwest, and eight schools in the
West. Each participating athletic trainer was assigned a
unique identification number and given instructions via
electronic mail about how to use the designated Internet
Web site. For a detailed explanation of the Web site con-
struction, refer to Sigurdsson and LaBella (19). During the
1999 to 2000 regular basketball season, participating ath-
letic trainers were required to access this Web site every
week, using their unique identification numbers. Each week,
they were required to report the total number of practices
and total number of games. For each practice and game, they
were required to report the total number of athletes partic-
ipating, the number of participating athletes wearing mouth-
guards (any type), the number of participating athletes wear-
ing custom-fitted mouthguards, the number of concussions,
and the number of mouth injuries. For each mouth injury,
they were required to select all that applied from the fol-
lowing list: maxilla fracture, mandible fracture, tooth frac-
42 Official Journal of the American College of Sports Medicine
TABLE 1. Injuries and exposures reported by 50 Division I mens college basketball
teams for the 1999 to 2000 season.
Without With
Mouthguard Mouthguarda
Exposures 62,273 8663
Concussions 34 3
Oral soft tissue injuries 66 6
Lip lacerations 59 6
Tongue lacerations 7 0
Dental injuries 42 1
Tooth fractures 23 1
Tooth luxations 16 0
Tooth avulsions 1 0
Mandible fractures 2 0
Maxilla fractures 0 0
Dentist referrals 45 0
a
All mouthguards were custom-fitted.
ture, tooth luxation, tooth avulsion, lip laceration, and
tongue laceration. For each concussion and each mouth
injury, they were required to indicate 1) whether the injured
player was wearing a mouthguard, and if so, whether it was
an over-the-counter, a boil and bite, or a custom-fitted
appliance; 2) whether the injury required referral to a dentist
or oral surgeon; and 3) whether the injury caused the athlete
to miss at least one practice or game.
At the conclusion of each week, all athletic trainers were
sent a general electronic mail message instructing them to
enter the data for that week. A few days later, the database
was examined for missing identification numbers, and those
who had not yet entered data for that week were sent a
follow-up electronic mail message reminding them to do so.
Only one athletic trainer did not have electronic mail and so
received phone calls as reminders instead. After all the data
were collected, several athletic trainers were contacted by
phone and asked whether any of the lacerations they re-
ported required sutures and/or referral to a plastic surgeon.
Injury rates were calculated by dividing the number of
injuries by the total number of athlete exposures. An athlete
exposure was defined as one athlete participating in one
practice or contest where he was exposed to the possibility
of injury. This is the same definition used by the NCAA.
Chi-square tests were used to analyze the data, with a P
value 0.05 deemed statistically significant.
RESULTS
Thirty-seven out of the 50 participating athletic trainers
(74%) reported data for all 20 wk of the season. Forty-one
athletic trainers (82%) reported data for 15 or more weeks.
Of a possible 1000 total reportable weeks, we received data
for 863, for an overall response rate of 86%.
Athletes using custom-fitted mouthguards accounted for
8663 exposures. Those using either over-the-counter or
boil and bite mouthguards accounted for 388 exposures.
Because this number was so small, and because both the
over-the-counter and boil and bite mouthguards are struc-
turally different from custom-fitted mouthguards, these 388
exposures and one associated injury (a concussion) were
excluded from the results (Table 1).
There were 37 concussions and 43 dental injuries (0.52
and 0.61 per 1000 athlete exposures, respectively). There
http://www.acsm-msse.org
TABLE 2. Comparison of injury rates between mouthguard users and nonusers:
rates are expressed as number of injuries per 1000 athlete exposures.
Without With
Type of Injury or Event Mouthguard Mouthguarda
Concussions 0.55 0.35
Oral soft tissue injuries 1.06 0.69
Dental injuries 0.67 0.12b
Dentist referrals 0.72 0.00b
a
All mouthguards were custom-fitted.
b
(P 0.05).
were 18 occasions where two injuries were reported for a
single athlete exposure. Most of these were a combination of
a dental injury plus soft tissue injury or a dental injury plus
concussion. There was one occasion where four injuries
were reported for a single athlete exposure (concussion,
tooth avulsion, tooth luxation, and lip laceration). Fifty-
seven percent of the concussions and 12% of the dental
injuries caused the injured athlete to miss at least one
practice or game. None of the isolated soft tissue injuries
resulted in any restriction from play. Of the 65 lip lacera-
tions reported, additional information regarding treatment
was obtained for 41 (63%). Ten (24%) of these 41 lip
lacerations required suturing by the team physician. None
required referral to a plastic surgeon. There were no signif-
icant differences between mouthguard users and nonusers in
the rates of concussions or oral soft tissue injuries (Table 2).
Mouthguard users had significantly lower rates of dental
injuries and dentist referrals than nonusers (P 0.05).
DISCUSSION
This study collected a large amount of information about
dental injuries and concussions in a selected population of
mens Division I college basketball players. The participa-
tion rate of 50% was considerably greater than the partici-
pation rate of 14% for mens Division I schools in the
NCAA Injury Surveillance System (17). Although the total
number of athlete exposures was only slightly larger than
that recorded by the NCAA for the same season (67,581), it
is notable that the rates of both dental injuries and concus-
sions in this study were significantly greater (P 0.05) than
those reported by the NCAA. The most likely reason for this
disparity is that the NCAA defines a reportable injury as one
that results in restriction of the athletes participation for 1
or more days beyond the day of injury. A sole exception
exists for dental injuries, which are to be reported to the
NCAA regardless of time loss. In contrast, whereas this
study elicited information about whether any practices or
games were missed as a result of the injury, time loss was
not a requirement for reporting the injury. Given that 42%
of the concussions, 88% of the dental injuries, and 100% of
the isolated oral soft tissue injuries in this study resulted in
no time loss from competition, it is reasonable to assume
that many of these injuries may not have been reported to
the NCAA. Despite the fact that the NCAA requires all
dental injuries to be reported regardless of time loss, it is
conceivable that this sole exception to the NCAA reporting
requirements may be overlooked, especially since the dental
MOUTHGUARDS AND DENTAL INJURIES IN BASKETBALL
injury rate reported by the NCAA was significantly lower
than that reported in this study. Perhaps a more likely
explanation for this disparity is that athletic trainers found
the Internet reporting system to be easier and more conve-
nient than the traditional paper method, and therefore were
more compliant with reporting every dental injury. This
theory is supported by the high response rate (86%) seen
with the Internet reporting system, as well as the comments
collected from participating trainers at the end of the study
(19). These results suggest that current NCAA data may be
an underestimate of the true incidence of dental injuries and
concussions in mens basketball.
Custom-fitted mouthguards were not observed to reduce
the incidence of concussions. In theory, a mouthguard is
supposed to protect the athlete from those concussions
caused by blows to the mandible from under the chin.
Because of the nature of the sport of basketball, it is rea-
sonable to assume that concussions are unlikely to occur by
this mechanism. Future studies should attempt to document
mechanism of injury, as this information may help to ex-
plain why mouthguards were not observed to affect concus-
sion rates in this population of athletes.
It appears that custom-fitted mouthguards can signifi-
cantly reduce the risk of dental injuries but not oral soft
tissue injuries in mens Division I college basketball. This
result is not surprising, given that mouthguards are designed
to shield the upper teeth, and are not made to protect the lips.
Although oral soft tissue injuries occurred more often than
dental injuries in this study, less than a third of the lip
lacerations required sutures and none required referral to
plastic surgery. This suggests that most of these soft tissue
injuries probably heal uneventfully, without significant
morbidity or expense. In contrast, dental injuries frequently
require costly restorative procedures.
Information about dentist referrals not only gives an es-
timate of injury severity but also gives some indication of
potential cost to the athlete and/or respective athletic pro-
gram. Previous reports have recognized that treatment costs
for dental injuries are invariably high, and out of proportion
to their absolute numbers compared with other athletic in-
juries (18). A serious dental injury, such as a tooth fracture,
commonly requires an artificial crown, with root canal ther-
apy necessary in many cases as well. Current costs for these
treatments are approximately $750 and $550, respectively.
It is important to know that many of these dental treatments
are not final. Artificial crowns require replacement approx-
imately every 10 yr. Therefore, not only is the initial cost of
treatment for a tooth fracture relatively high, but it is only a
fraction of the total cost generated over the athletes life. In
this study of 50 teams, there were 45 dentist referrals in one
season. All of these referrals were for injuries in athletes
without mouthguards. This is an average of almost one
referral per team per season. A conservative estimate of the
minimum initial cost per dentist referral for treatment of a
serious dental injury is $1000. This does not include the cost
of crown replacement approximately every 10 yr. There is
no question that this total is substantially more expensive
than the cost of providing an entire team with custom-fitted
Medicine & Science in Sports & Exercise 43
mouthguards, for which the direct cost in materials is less
than $20 per player, and properly trained athletic trainers
can perform the majority of the labor required for
construction.
In summary, there is a measurable risk of dental injuries
and concussions for participants in Division I mens college
basketball. The magnitude of this risk is probably underes-
timated by current NCAA injury surveillance data. Custom-
fitted mouthguards do not significantly affect rates of con-
cussions or oral soft tissue injuries, but can significantly
REFERENCES
1. BERG, R., D. B. BERKEY, J. M. TANG, D. S. ALTMAN, and K. A.
LONDEREE. Knowledge and attitudes of Arizona high-school
coaches regarding oral-facial injuries and mouth guard use among
athletes. J. Am. Dent. Assoc. 129:14251432, 1998.
2. BUREAU OF DENTAL HEALTH EDUCATION, AND BUREAU OF ECONOMIC
RESEARCH AND STATISTICS. Mouth protectors: 1962 and the future.
J. Am. Dent. Assoc. 66:539 543, 1963.
3. DE WET, F. A., M. BADENHORST, and L. M. ROSSOUW. Mouth guards
for rugby players at primary school level. J. Dent. Assoc. South
Afr. 36:249 253, 1981.
4. Fitted mouth guards afford key protection: news of dentistry.
J. Am. Dent. Assoc. 84:531, 1972.
5. FLANDERS, R. A., and M. BHAT. The incidence of orofacial injuries
in sports: a pilot study in Illinois. J. Am. Dent. Assoc. 126:491
496, 1995.
6. GARON, M. W., A. MERKLE, and T. J. WHITE. Mouth protectors and
oral trauma: a study of adolescent football players. J. Am. Dent.
Assoc. 112:663 665, 1986.
7. HEINTZ, W. D. Mouth protectors: a progress report. J. Am. Dent.
Assoc. 77:632 636, 1968.
8. HICKEY, J. C., A. L. MORRIS, L. D. CARLSON, and T. E. SEWARD. The
relation of mouth protectors to cranial pressure and deformation.
J. Am. Dent Assoc. 74:735740, 1967.
9. KVITTEM, B., N. A. HARDIE, M. ROETTGER, and J. CONROY. Inci-
dence of orofacial injuries in high school sports. J. Public Health
Dent. 58:288 293, 1998.
10. LEE-KNIGHT, C. T., E. L. HARRISON, and C. J. PRICE. Dental injuries
at the 1989 Canada Games: an epidemiological study. J. Can.
Dent. Assoc. 58:810 815, 1992.
11. MAESTRELLO-DEMOYA, M. G., and R. E. PRIMOSCH. Orofac-
ial trauma and mouth-protector wear among high school
44 Official Journal of the American College of Sports Medicine
reduce the morbidity and expense resulting from dental
injuries in Division I mens college basketball. This is valuable
information for those concerned with both injury prevention
and cost reduction in competitive college athletics.
The authors acknowledge Brad Argeus for his technical assis-
tance in setting up the Internet Web site and database.
Address for correspondence: Bryan W. Smith, M.D., Ph.D.,
CB#7470, Student Health Service Building, The University of North
Carolina at Chapel Hill, Chapel Hill, NC 27599-7470; E-mail:
smithbw@email.unc.edu.
varsity basketball players. ASDC J. Dent. Child. 56:36 39,
1989.
12. MCNUTT, T., S. W. SHANNON, J. T. WRIGHT, and R. A. FEINSTEIN.
Oral trauma and adolescent athletes: a study of mouth protectors.
Pediatr. Dent. 11:209 213, 1989.
13. MOON, D. G., and D. F. MITCHELL. An evaluation of commercial
protective mouthpiece for football players. J. Am. Dent. Assoc.
62:568 572, 1961.
14. MORROW, R. M., and T. BONCI. A survey of oral injuries in female
college and university athletes. Athletic Training JNATA. 24:236
237, 1989.
15. MORROW, R. M., T. BONCI, R. R. SEALS, JR., and G. M. BARNWELL,
JR. Oral injuries in southwest conference women basketball play-
ers. Athletic Training JNATA. 26:344 345, 1991.
16. MORROW, R. M., R. R. SEALS, JR., G. M. BARNWELL, JR., E. A. DAY,
R. M. MOORE, and M. K. STEPHENS. Report of a survey of oral
injuries in male college and university athletes. Athletic Training
JNATA. 26:339 342, 1991.
17. NATIONAL COLLEGIATE ATHLETIC ASSOCIATION. NCAA Division I
Mens Basketball Injury Surveillance System, 1999-2000. India-
napolis, IN: National Collegiate Athletic Association, 2000, pp.
19.
18. SANE, J. Comparison of maxillofacial and dental injuries in four
contact team sports: American football, bandy, basketball, and
handball. Am. J. Sports Med. 16:647 652, 1988.
19. SIGURDSSON, A., and C. R. LABELLA. Use of an interactive Web site
in acquisition of data in a dental trauma study. Dent. Traumatol.
(in press).
20. STENGER, J. M., E. A. LAWSON, J. M. WRIGHT, and J. RICKETTS.
Mouthguards: protection against shock to the head, neck and teeth.
J. Am. Dent. Assoc. 69:273281, 1964.
http://www.acsm-msse.org