The Triple Role of Individual Mouthguard in Athlethe Health

Simonetta D’Ercole, Diego Martinelli and Domenico Tripodi

Department of Medical, Oral, and Biotechnological Sciences, Dental School,

University “G. D’Annunzio” of Chieti-Pescara, Chieti, Via dei Vestini,31, Italy

Keywords: Sports, Oral Health, Saliva, Mouthguard, Sports Dentistry.

Abstract: Prevention of oral pathologies, traumatic events and gnatological disorders is a cornerstone of modern

dentistry. Oral health may limit athletes ability, both during training and competitions. Careful analysis

indicates that the athletes' health can be at risk in a wide range of sports disciplines. Role of sport dentist is

crucial, and a dental specialist should be included in the team that follows the athlete. In addition, it is crucial

to alert the whole sporting world to the importance of using individual mouthguards. The custom-made

mouthguard, is an effective device helping to avoid dental trauma. Additionally it can provide the trasmission

of such substances as chlorhexidine, fluorine and casein to control the ecological variation of the oral cavity

induced by the sport itself. It also offers a psychological support and better occlusal stability, which have a

positive impact on sports performance. Thus an individual mouthguard should be adopted in all disciplines

and sports categories where there is a potential risk of dental injuries. But it should be designed and

manufactured by specialized dentists and dental technicians.

1 INTRODUCTION

Sports-related dentistry focuses on the study, review,

prevention and treatment of oral diseases and focuses

on maintaining athlete's dental health and

disseminating new knowledge within the sports

medicine community.

Sports dentistry can be considered as a pre-

eminent area of dentistry, since oral health can limit

the skills of athletes, both professionals and non-

professionals, during training and competitions.

The clinical and scientific work carried out over

the years by sport dentist has shown that athletes are

affected by various pathologies, including traumas,

caries, erosions, gnathological disorders, and many

variations occurr in oral cavity, such as in salivary

pH, salivary flow, microbial load and S-IgA levels.

2 DISCUSSION

In this work a great attention was then given to the

use of individual mouthguard and its triple role: the

well-known protective function against dental

traumas; reservoir for substances, such as

chlorhexidine, fluoride and casein to prevent oral

pathologies; for athlete's performance by controlling

and stabilizing the occlusion through mandibular

repositioning and postural improvement.

In order to achieve the athlete's health it is

necessary that Sport Dentistry is placed as an integral

part of a fundamental multi-factorial framework, in

which one can include different professional health

specialists, such as: general practitioner, pediatrician,

psychologist, allergist, speech therapist,

otolaryngologist, physiatrist, physiotherapist and

non-health specialists, such as: instructors and

coaches of various sports.

The active Italian population is composed of 35

million 593 thousand individuals who practice one or

more sports or some physical activity in their free

time. (ISTAT, 2017)

Between 6 and 10 years of age the 59.7% of

children are sporty and regulary practice sport.

Oral health is a fundamental element of general

health and well-being. The quality of life of the

sportsman (Needleman et al., 2017) is also related to

the social context and physical activity. Traumas,

gnathological disorders, alterations and / or oral

diseases, such as tooth decay, erosions, dental

discolorations, periodontal disease and respiratory

infections represent main problems in sport activity

directly related to the conditions treated by dentistry.

132

D’Ercole, S., Martinelli, D. and Tripodi, D.

The Triple Role of Individual Mouthguard in Athlethe Health.

DOI: 10.5220/0006929301320138

In Proceedings of the 6th International Congress on Sport Sciences Research and Technology Support (icSPORTS 2018), pages 132-138

ISBN: 978-989-758-325-4

A review of the literature on the connection

between physical activity and oral health shows that

athletes’s oral situation seems to be at risk in a wide

range of sports disciplines. (Needleman et al., 2015;

Escartin et al., 2000) Needleman et al. report an

incidence of caries between 15 - 75%, dental erosions

between 36 - 85%, periodontal diseases 15% among

the athletes (Needleman et al., 2015; Ashley et al.

2015).

Gay Escoda et al (Gay Escoda et al., 2011) in a

study conducted on footballers of Cf Barcelona,

describe plaque indices of 2.3 and DMFT of 5.7 and

those are bad values because the score should be

equal or proximus to 0 in a healthy mouth. Poor

attention to oral health is also demonstrated by young

players characterized by a greater plaque index,

increased dental discoloration, increased frequency of

spoiled habits (atypical swallowing, onychophagia),

and lower frequency of daily brushing compared to

subjects who did not practice any type of sport

activity. (D’Ercole et al., 2013)

Particular exposure to the onset of extrinsic dental

discolorations is reported in swimmers, with varying

incidence in reported by different authors (D'Ercole

et al, 11.76%, Escartin et al, 60.2%) (D’Ercole et al.,

2016; Escartin et al., 2000) This may be attributed to

a differnce in: pH of pool water, salivary pH, hours of

pool training, disinfectants used in swimming pools,

eating habits.

No difference has been found on the incidence of

the different pathologies among the athletes of the

developed countries as compared to the athletes from

developing Countries. Poor oral health is common in

all professional athletes. This could affect athletic

performance: 28-40% of athletes are concerned that

their oral health has an impact on their lives and 5-

18% of athletes have the impression that this has

effect also on sports performance. (Needleman et al.,

2015; Ashley et al., 2015) The oral cavity has a

resident microbial population with a characteristic

composition that exists, in the majority of cases, in

harmony with the host; it is very individual and

includes protozoa, fungi, bacteria and viruses.

The environment in the oral cavity is not uniform

and the conditions vary throughout life in relation to

lifestyle, hygiene habits, eating habits, possible

administration of drugs and not least with the carrying

out of sports activities. (Spinas, 2009).

Nutrition, weekly attendance and hours of

training, climatic conditions and psychophysical

stress conditions may have repercussions on the oral

health of athletes, since they determine important

changes in oral ecosystem. (Spinas, 2009)

Several authors have reported that an intense

physical exercise causes a reduction of salivary flow,

decreases the production of secretory

immunoglobulin S-IgA, and consequent decrease in

the host defenses and therefore increased

susceptibility to pathologies as infections of the first

respiratory tract. (D’Ercole et al., 2016; Spinas, 2009;

Laing et al.,1993; Giuca et al., 2014).

The negative effects of the lowering of S-IgA,

linked to a lower salivary flow rate compared to the

beginning of competitions, remain during the whole

training day. (Nieman et al., 2002) The decrease of S-

IgA occurs after a short exercise completed in

maximum effort, and the low levels remain even if

there is a 5 minute pause between one exercise and

another, because there is a general decrease in

salivary flow rate. (Ozcelik et al., 2006)

D'Ercole et al (D’Ercole et al., 2013) showed that

the young soccer players analyzed had a statistically

superior salivary microbial load, related to cariogenic

strains such as S. mutans, Lactobacillus spp., if

compared to general population, both before and after

training. In post-training there was also a statistically

significant decrease in S-IgA concentration. Young

players seem to run a greater risk in developing oral

diseases than sedentary individuals, because of poor

attention to their oral health and by the effects of

microbiological and immunological alterations that

occur during training.

D'Ercole and Tripodi (D’Ercole and Tripodi,

2013) showed that in young swimmers training for 2

hours a day for 5 days a week, the presence of

pathogenic strains such as S. mutans, S. sanguis, L.

fermentum and A. gerenseriae increases in a

statistically significant way after training.

Furthermore, average bacterial load values were

significantly higher in swimmers than in sedentary

populations. Training time is the period characterized

by a more intense salivary function and physiological

response, such as the decrease in S-IgA production

and therefore can be considered an open window for

exposure to diseases of the oral cavity.

However, swimming at a competitive level

involves higher average values of S-IgA, both before

and after training, compared to non-agonist

swimmers. In addition, agonist swimmers has in their

oral cavity in addition to cariogenic microorganisms,

such as S. mutans and S. sobrinus, an high percentage

also protective bacteria, such as S. sanguinis, which

in this case is associated with a lower incidence of

active caries, compared to non-agonist swimmers.

(D’Ercole et al., 2016)

Dental traumas are frequent events in some sports

and can be linked to multiple situations and these

The Triple Role of Individual Mouthguard in Athlethe Health

133

events reflect on the quality of athlete’s life, imposing

attention not only to immediate treatment, but also to

the resolution of sequelae that could manifest

themselves in the future, with a consequent health and

economic commitment.

Dento-alveolar traumatic lesions are very frequent

events in both deciduous and permanent dentition. On

average, it is calculated that 3 subjects every 10 suffer

an oral injury (Andreasen and Andreasen, 1990) and

at least one of these subjects supposes it can be caued

by sporting activity. (Glendor, 2009)

Pre-adolescent age groups in permanent dentition

(8-12 years) and subjects in the age group 1-3 years

in deciduous dentition are above all particularly

exposed to such lesions.

The traumas occurred during the sport practice

oscillate around a percentage of 25-30% of the total

at charge of dentition. They are more frequent

between 8 and 21 years of age. Their frequency

decreases with increasing age of the subjects. (Dursun

et al., 2015)

In a study conducted by our group at the

Department of Medical, Oral and Biotechnological

Sciences of the University of Chieti-Pescara, 234

athletes between the ages of 6 and 13, 348 with an age

equal to or greater than 14 years, (a total of 582

athletes) practicing different sports with a high risk of

trauma were evaluated with questionnaires and

clinical examinations

In mixed dentition is observed as there is a high

prevalence of traumas (43.60%) in the sample, while

in permanent dentition the percentage of traumas

decreases (36.20%).

The athletes were also evaluated according to the

use of the mouthguard. A low use of mouthguards

(5.13%) was shown for the sub-group in mixed

dentition, which increases (15.50%) in permanent

dentition.

In particular, the use of mouthguards was

motivated by the previous traumatic experience in

90% of the subjects examined. Dividing athletes by

discipline practiced, it was seen that in the sports

played by subjects with a lower average age, the

percentage of use of the mouthguard is almost nil. As

the average age increases, this percentage increases

but in all sports there were high prevalences of dento-

alveolar traumatism (11.11% - 54.50%).

Mouthguard or oral protector is a resilient device

inserted into the oral cavity to reduce traumas

involving the oromaxillofacial region, in particular

the teeth and periodontal tissues, during physical

activity. (Sethi et al., 2016) Sport mouthguards are

designed to protect intraoral and soft lips and tissues

from tears, teeth from fractures and avulsions and

jaws from fractures and dislocations. (Gould et al.,

2016)

In Italy, around one million mouthguards are

purchased almost exclusively at sports stores. These

are not custom-made and often of “one size fit all”

types.

The Italian Society of Sports Odontostomatology

(SIOS) has for years actively promoted the use of

individual mouthguards.The individual mouthguard

is a product made in dental laboratory on dentist

prescription. It must be protective, adapt to the oral

structures, retentive, minimally interfering with the

phonation and breathing, with an adequate thickness

in critical areas, comfortable, space-saving, odorless

and tasteless.

The individual mouthguards have all these

features and are made from proven and certified

materials. Depending on the type of sport, different

thicknesses are used: up to 6mm thick in contact

sports.

For the realization of an individual mouthguard

that meets all the ideal characteristics, specific

training is required for both the dentist and the dental

technician.

In some countries the use of the mouthguard is

made mandatory for young and senior athletes during

competitions, and it is estimated that, in countries

where it is not mandatory, only 4-6% of athletes use

the mouthguard. (D’Ercole and Tripodi, 2017)

The Italian Ministry of Health has intervened on

the issue (sport and traumas) spreading the guidelines

for the prevention and clinical management of

traumas and recognizing mouthguard as the best

method of prevention for dental traumas giving

importance to social and public health aspects linked

to dental traumatology, especially in subjects in the

developmental age. The use of the oral protector is

necessary, as well as in contact sports even in sports

that use tools, ball, since these responsible for 74% of

maxillofacial injuries. The loss of a tooth or worse the

fracture of the maxillary bones can prevent the athlete

from competing for long periods, therefore, it is

necessary that professional athletes do not

underestimate these aspects.

The material indicated today as the most suitable

for the production of dental protections is ethylene

vinyl acetate (EVA) known for its characteristics of

high flexibility, elasticity and certified

biocompatibility. Even when using proper material,

mouthguard should be properly designed and

manufactured.

Worn and jagged edges may cause injury to oral

mucosa, such as hyperkeratosis, erythema and

ulceration. From these continuous solutions, caused

icSPORTS 2018 - 6th International Congress on Sport Sciences Research and Technology Support

134

by oral mouthguards, there could be a diffusion in the

bloodstream of all the microorganisms present in the

oral cavity, with consequent opportunistic infections

at the systemic level (eg: endocarditis, pericarditis,

pneumonia, asthma, etc.). (Glass et al., 2009; Barton,

2016; Glass et al., 2007). The prolonged stay in the

mouth of the device causes changes in the ecological

factors of the oral cavity, as the mouthguard increases

the plaque index, bleeding index, and causes salivary

pH and buffer capacity to be reduced. The

mouthguard therefore increases the retentive capacity

against plaque and inhibits the protective capacity of

saliva. (D’Ercole et al., 2014) Studies conducted on

hockey and football players have reported that "boil

and bite" mouthguards harbor a high number of

pathogenic and opportunistic bacteria, yeasts and

molds. (Glass et al., 2007; Glass et al., 2011).

The prevention of oral damage that the pathogenic

flora of a mouthguard can cause, could be carried out

through different strategies, for example using of

protective substances slowly released by a

mouthguard. EVA material itself provides a growth

support for different microbial species. The addition

of chlorhexidine into the mouthguard counteracts

these effects and inhibits microbial growth on the

medium itself. It also increases the value of salivary

pH and buffer capacity, while reducing the salivary

load of S. mutans and Candida spp. (D’Ercole et al.,

2017)

It is also essential to respect the basic rules of oral

hygiene and cleansing the device after each use. One

of the factors that determines poor compliance by the

users is the difficulty in preserving and cleaning the

mouthguard, which tends to accumulate both plaque

and dawn in its interior and consequently emanates a

bad odor; this drawback is amplified by the presence

of bacteria and salivary and food residues. This can

be prevented by properly caring over a mouthguard

by placing it in the box provided by the dentist and

carrying out a correct and constant disinfection

(water, commercial detergents, hydrogen peroxide).

The athlete's task is to take care of and constantly

monitor the wear and tear of his mouthguard,

subjecting him to periodic checks by the specialists.

Individual mouthguards have much longer life, do

not deform over time and are worn longer without

replacement as compared to semi-individual and

standard devices. Del Rossi reports a reduction in

occlusal thickness of 16% in the anterior region and

23% in the molar region after 6 weeks of sporting

activity at a competitive level in individual

mouthguards (Del Rossi et al., 2007). Glass and coll.

(Glass et al., 2011) have shown a significant

deterioration of the stock mouthguard after a few

weeks of activity. Through the use of SEM images,

the authors explain how the increase in the numbers

of pathogenic microorganisms present in the

mouthguard can depend precisely on the wear of the

material itself and perhaps by the difficulties of

conservation for athletes during and after

performances.

Futhermore the mouthguard can be of help in the

athlete's performance, ensuring a psychological

advantage (sense of protection) and another physical

because an individual mouthguard allows all the

normal physiological functions of speaking,

whistling, rinsing, drinking and even eating during

the sport activity.

Although the role of the mouthguard is known,

significant efforts are still required to educate sport

community about the use of oral protectors. Athletes

are often reluctant to wear mouthguards, despite

being aware of the risks they can run, because they

are very often linked to known problems created by

commercial mouthguards.

The International Dental Federation (FDI)

recommends that national dental associations should

inform the population and oral health pratictioners

about the benefits of using mouthguards during

physical activities.

Surely, it’s clear that more information campaigns

about comfort, possibility of communicating between

athletes, possibility of not altering one's eating habits

(drinking or chewing during sporting activities),

should be promoted. This promotion will lead the

athlete to wear more willingly the mouthguard.

One of the most interesting aspects of modern

dentistry is the evaluation of correlations between the

stomatognathic apparatus and the body posture. In the

last decade the relationships between postural

imbalances, malocclusions and craniomandibular

disorders have been widely analyzed. The interest in

this field of Dentistry has also been favored by the

great social impact resulting from the growing

information, linked to the disclosure of these issues

by the mass media. The formulation of numerous

hypotheses of correlation between occlusion and

posture is fundamentally justified by the presence of

anatomical-functional connections between the two

body districts. An analysis of the scientific literature

shows that the existence of a correlation between

dental occlusion and posture is very probable:

different mandibular positions determine a different

postural attitude and the use of a gnathologic bite can

improve postural control in some subjects allowing a

better muscle relaxation and therefore can help in the

treatment of algic diseases derived from incorrect

postural attitudes. (Bernkopf, 2003; Baldini and

The Triple Role of Individual Mouthguard in Athlethe Health

135

Cravino, 2011; Spinas et al., 2014; Raquel et al.,

2017)

This correlation seems to be important also in the

sports field because in recent years it has been

realized that malocclusion can actually affect the

athlete's posture, thus compromising sports

performance and increasing the risk of injuries.

(Needleman et al., 2017)

In professional sportsmen, in particular, even a

slight change in balance can result in changes in

intensity of strength and coordination skills, as well

as causing the onset of a state of muscular tension that

negatively affects the whole body, decreasing the

overall athletic potential.

The lack of occlusal stability would create an

energetic vanishing point similar to the slipping of the

athlete's support foot and an imbalance between the

agonist and antagonist muscles, connected together in

synergistic chains, which could be the cause of

injuries and repeated muscle tears. (Bernkopf, 2003)

Therefore the mouthguard could be used also with

the aim of establishing a better neuromuscular

balance of the masticatory muscles.

In order for an individual mouthguard to have a

positive influence on the athletic performance and

physical condition of the athletes it is necessary that

it is developed and perfected by a qualified Sport

Dentist and dental technician, according to the

established rules, which provide an accurate

gnathological visit and the aid of various instrumental

examinations such as stabilometric platform,

electromyography, computerized occlusion analysis

devices, thermography, etc.

Having ascertained that in the sport activity the

muscles of the cranio-cervicomandibular district are

involved, it is still uncertain whether the application

of an individual mouthguard may or may not improve

sports performance. The studies in the literature are

few and appear to be discordant. The reason for this

discrepancy lies in the inter-individual variability that

assumes a fundamental role, because it can lead to the

failure of any treatment despite the best quality

standards are respected. Surely each athlete should be

assessed individually with appropriate clinical and

instrumental analysis. (Baldini and Cravino, 2011)

Raquel et al (Raquel et al., 2017) reported that

with the use of the individual mouth guard, the

electromyographic parameters measured before and

after training remain unchanged. According to this

study mouthguard therefore allows stable muscle

activity during training.

Another study was conducted at the Department

of Medical, Oral and Biotechnological Sciences of

the University of Chieti-Pescara, to analyze

masticatory muscles activity in athletes wearing

individual mouthguards. This was carried on by use

of electromyographic examination and wanted to

evaluate the variations on the neuromuscular balance

of the masticatory musculature, inducted by the use

of the same mouthguard, making the comparison with

the dental occlusion of the subject in maximum

intercuspidation.

It has been shown that the individual mouthguard

significantly improves the neuromuscular balance of

the masticatory musculature, symmetrizing the work

of the masseter and temporal muscles to the point of

better balancing the distribution of occlusal loads

both in the anterior-posterior direction and in the

lateral direction and offers the possibility of produce

more muscle work.

The task of the Sports Dentist is to monitor any

variations that occur at an oral level of athletes from

different sports. The visit protocol of an athlete

(agonist or not) provides a thorough medical history,

knowledge of the characteristics of the sport followed

(training hours, etc.), knowledge of oral hygiene

habits, eating habits, clinical examination of the oral

cavity, use of quantitative and qualitative salivary

analysis, gnathological examination, postural

assessment using a stabilometric platform,

electromyographic evaluation of the stomatognatic

musculature even with the aid of new technologies

such as thermography and accelerometer. In sports

where it is recommended, it is essential to employ an

individual mouthguard for athletes. Mouthguard

should be realized after all previous analysis to ensure

the best function to the athelte.

At the same time to evaluate the efficiency of the

mouthguard in the health benefit and performance

improvement, the Sport Dentist, in collaboration with

the Sports Physician and the athletic trainer,

establishes, for each sporting discipline, specific

Physical efficiency tests to be performed in the gym

under strict control, with and without mouthguard.

3 CONCLUSIONS

It is important to establish the changes that occur in

the oral cavity of people who perform competitive

and non-competitive sports, and implement all the

available related prevention measures, in order to

preserve oral health, especially in young athletes.

It is evident that sports clubs in their screening and

medical-sports evaluation plans should have to plan

and schedule the athlete's subjection to periodic oral

health assessments, inserting a sports dentist into their

staff. A good campaign to raise awareness among

icSPORTS 2018 - 6th International Congress on Sport Sciences Research and Technology Support

136

sports doctors, sports clubs, coaches, masseurs, the

entire sports health team and parents in the case of

athletes in developmental age would be appropriate.

For proper prevention at several levels (disciplinary,

medico-legal and insurance) it is essential the

mandatory use of the individual type of mouthguard,

which ensures, among the various advantages, greater

durability and protection compared to commercial

devices, as highlighted by Glass et al. can be

considered "as single-use mouthguards." (Glass et al.,

2009)

As amply demonstrated, the mouthguard is

recommended by the authors for its triple function:

traumatological protection, reservoir of substances,

aid in the performance of the athlete.

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