Position Statement and Recommendations for Custom-Made Sport Mouthguards
Funding: The authors received no specific funding for this work.
ABSTRACT
Sports-related traumatic dental injuries (TDIs) are a significant global concern, particularly in contact sports, where the risk of orofacial injuries is high. Custom-made sports mouthguards (CSMs) are recognized as the most effective means of preventing these injuries, providing both protection and comfort without impairing athletic performance. Despite their proven benefits, there is no globally standardized approach to mouthguard design, fabrication, or usage, primarily due to varying regulations, awareness levels, and cultural attitudes toward sports safety across different countries. This document from the European Association for Sports Dentistry (EA4SD) outlines the latest guidelines for selecting, constructing, clinical use, and maintaining CSMs. It emphasizes the need for mouthguards fabricated from FDA-approved materials, designed to absorb and distribute impact forces effectively, and customized to ensure optimal fit and comfort. The EA4SD also highlights the importance of education for dental professionals and athletes on the benefits of CSMs, advocating for their mandatory use in high-risk sports to reduce the prevalence of TDIs and related complications.
1 Introduction
Physical activity and competitive sports offer various health benefits, improving athletes' physical, mental, and psychological health [1]. However, traumatic dentofacial injuries (TDI) during sports activities reached up to 15%, and recent studies indicate that they are present more frequently in individuals who avoid using protective mouthguards [1-3]. Trauma to the orofacial complex (teeth, soft tissues, facial bone, and temporomandibular joints) dominates among sports-related injuries [2, 3].
Players engaging in sports activities requiring physical contact have a 10% chance of facial injuries during a sporting season, a rate that can rise to 50% by the end of their career [3].
Tooth-related injuries may lead to functional, aesthetic, and psychological complications [4]. Unlike other injuries, dental tissue damage may be irreversible and expose the individual to long-term and costly treatments [4]. Growing awareness of these issues has stimulated the development of protective devices such as mouthguards and general preventive oral care for athletes [5].
Guidelines for Preventing Traumatic Dental Injuries by The International Association of Dental Traumatology (IADT) and the Academy for Sports Dentistry (ASD) are there to ensure the safety of athletes. They strongly encourage the use of mouthguards, and athletes and coaches need to follow these guidelines to take responsibility for their safety [2, 6, 7].
Custom-made sports mouthguards (CSM) are removable appliances that are resistant to deformation, reduce the risk of dental trauma, and protect the surrounding structures [8]. CSMs provide superior protection, fit, and comfort compared to prefabricated and boil-and-bite mouthguards. They offer the reassurance of safety, as they are designed to absorb and distribute forces effectively, making them a strong recommendation for all athletes participating in high-risk contact sports. Other mouthguards, particularly boil-and-bite, are generally not recommended because they offer less protection and are often ill-fitting. Their primary function is to absorb and evenly distribute the forces applied to intraoral structures during physical activity, without affecting the athlete's ability to communicate and perform [9, 10].
Dentists should educate their patients, athletes, parents, coaches, teachers, and authorities about the importance of using protective appliances to prevent dental trauma during sports activities [11].
Dental schools often overlook incorporating sports mouthguard construction and proper maintenance into their curriculum [12, 13]. Also, many practicing dentists need to gain knowledge of sports mouthguard fabrication and clinical use. The European Association for Sports Dentistry (EA4SD) informs all involved institutions, healthcare providers, and individuals in Europe and the world about the current gold standard for preventing, managing, and treating sports-related orofacial injuries. Another objective of EA4SD is to promote Sports dentistry through dentists' education, research, and clinical practice in Europe. For these reasons, EA4SD formed an expert committee to collect, analyze, and create a position statement and recommendations for custom-made sports mouthguards. The workshop participants had been selected and invited by EA4SD, achieving a balanced representation of international European practitioners with solid professional experience in sports dentistry and mouthguard maintenance.
This document provides the most up-to-date and valid information regarding custom-made sports mouthguard (CSM) and forms guidelines for their proper selection, construction, clinical use, and maintenance.
2 Position Statements and Recommendations for CSM According to the EA4SD
2.1 Recommendations
2.1.1 Sport-Related Criteria
- Full contacts or collision sports.
- Sports with increased risk of falls.
- Sports with interaction with equipment.
- Special need or situation.
2.1.2 Material-Related Criteria
- Fabricated from a material approved by the U.S. Food and Drug Administration (FDA) and the EU public health authorities.
- Constructed from Ethylene Vinyl Acetate (EVA) copolymer, Cyclic Olefin Copolymer (COC), soft acrylic resin or polyvinyl acetate-polyethylene (pEVA), elastomers or 3D materials [14-20].
- Laminated multi-layered with at least one layer (soft/elastic) for absorbing the force and one layer (rigid) for transmitting the force over the dental arch. There is a wide range of multi-layered designs available [21].
- Odorless [14].
2.1.3 Fabrication-Related Criteria
- Be fabricated in a dental laboratory/dental office using a vacuum- or pressure-forming process on a working cast obtained from intraoral impressions [15, 16].
- Each mouthguard should be specifically tailored to accommodate areas with tooth loss, implants, or orthodontic conditions to offer greater comfort and adequate protection [22-28].
- The labial surface of central incisors should be a minimum thickness of 3–4 mm (maximum in high-risk contact sports). However, the dimensions are related to the material used and fabrication methods.
- The thickness of the sport mouthguard should be maintained at 1.5–2 mm over the incisal edges of the anterior teeth for optimal protection [29, 30].
- Extend up to, at least, the distal surface of 1st maxillary molars. The labial extension should reach conically tapered as far as possible to the vestibular sulcus, considering the anatomical conditions. Palatally, the mouthguard should be as little as possible to allow effective retention. For example, be just beyond the cervical margin of the palatal surface of the teeth, tapered in cross-section [18-20, 22].
- Based on a dentist-made bite registration, it is articulated, and adjusted to the opposite dentition in a balanced, preferably myocentric position.
- Be clinically evaluated by a well-trained dentist during insertion.
- Have labial flanges with rounded edges and palatal flanges, if any, with tapered edges [23].
2.1.4 Adaptation/Retention-Related Criteria
- Provide optimal intraoral adaptation, maximum retention, and resistance to dislocation during impact force application and dislodgement during speech and must allow everyday communication between athletes [31, 32].
- Provide comfort without causing soft tissue irritation and ulceration [23].
- Not result in tooth migration after long-term use [25].
2.1.5 Function-Related Criteria
- Maintain space between maxillary and mandibular teeth and between the condyle and temporal bone in the temporomandibular joint [25].
- Βe comfortable, not impede communication, breathing, lip closure, and deglutition [9, 10, 12, 13].
- Be made according to the athlete's age, needs, frequency of use, and the type of sport [24].
- Βe clinically re-evaluated by a well-trained dentist at scheduled recall appointments [4].
- Should not negatively affect performance-relevant functions such as nasal breathing, positioning of the tongue on the palate, and speech formation [26-30, 33-36].
2.1.6 Maintenance-Related Criteria
- Be rinsed with cold water before or after use and then be placed in a container [32, 37].
- Be cleaned after each use, either mechanically with neutral hand soap and a soft toothbrush or chemically with dissolving tablets [37-41].
- It should be disinfected depending on the material used (see manufacturer's instructions) in ultrasonic cleaners, either from dental professionals or athletes in cases they have cleaners using oxygen peroxide, 0.5% sodium hypochlorite, and other commercially available topical agents, such as chlorhexidine, fluoride, and casein [32, 37, 38].
- Should be stored in a perforated plastic container, in dry conditions at room temperature, out of sunlight [42, 43].
- Any chewing is detrimental and appropriate instruction should be given.
- It should remain in the mouth and in the correct position for the entire duration of the sporting activity (during competition and training). Constant removal and reinsertion should be avoided to prevent infection and ensure the protective function.
- Must be worn correctly and replaced if flanges are deformed.
- Should allow the person wearing the mouthguard to drink liquids whilst it is in place.
3 Discussion
There are no internationally agreed standards on sports mouthguards primarily due to varying levels of awareness, regulations, and cultural attitudes towards sports safety across different countries. Each nation has its governing bodies for sports, which develop regulations based on their specific needs, resources, and public health priorities. For instance, some countries may emphasize the mandatory use of mouthguards in contact sports due to a higher prevalence of dental injuries. In contrast, others might have less stringent requirements or focus more on other protective equipment. Additionally, differences in healthcare systems, economic capabilities, and market regulations contribute to the inconsistency in mouthguard standards globally. These variations lead to a lack of a unified international approach to sports mouthguard specifications, materials, and usage protocols. For these reasons, the EA4SD, based on the literature and the reported Guidelines for Preventing Traumatic Dental Injuries from IADT and ASD, formed the most up-to-date and valid information regarding CSM.
The EA4SD recommends custom-made, sports mouthguards instead of prefabricated or boil-and-bite ones. CSMs are recommended and should be mandatory for amateurs, professional, or semi-professional (e.g., high-school teams) athletes [11]. However, professional athletes can act as role models and motivate improved compliance. The impact of the mouthguard in protecting the orofacial complex is crucial, as the risk of orofacial injuries increases by up to 86% for users without a mouthguard [2, 6, 7].
These polymer-based mouth protectors could also prevent or reduce concussion, known as mild traumatic brain injury or minor head trauma [43, 44]. Concussion can be defined as a “complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces” [45]. It is the most common type of traumatic brain injury in youth sports, accounting for more than 15% of the total injury burden [43]. Ιt can be caused in collision sports and significantly restrain athletes from future participation in physical activities, while it may also lead to “post-concussion syndrome” [43]. Although the evidence on whether using mouthguards can reduce the risk and severity of concussion in sports is not robust or conclusive; their use is suggested recommended to provide a protective effect [46, 47].
One main concern of athletes is the potential negative impact of mouthguards on their performance. CSM showed the smallest range of changes in players' performance compared to other mouthguards [23]. Evidence indicates no difference or potential improvements in performance indicators, such as anaerobic power, upper body load power, and gas exchange. Even though scientific evidence should be interpreted with caution due to data heterogeneity, the dental community should strongly support and highlight the minimal influence of mouthguards on professional athletes' performance [48, 49]. The aim is to ensure that the athletes do not perceive the mouthguard as a nuisance. This requires early familiarization, beginning at a young age. CSM should induce closing the mouth in correlation with nasal breathing to ensure optimal cerebral oxygen utilization.
Recent publications show the possibility of a positive influence on performance parameters depending on pre-existing malocclusion and a bite registration in balanced occlusion in different bite positions (e.g., myocentrics after physiotherapeutic deprogramming of the masticatory and hyoid muscles). Independent sports medical measurement of performance parameters relevant to the type of sport should be used to assess the effect of mouthguards used, particularly in high-performance sports [50, 51]. The rapid development of computer-aided design (CAD)/computer-aided manufactured (CAM) technology in dentistry may offer new perspectives in mouthguard construction [17]. As new methods and materials become increasingly available, a fully digital workflow may be viable, but thermoforming prelaminated (EVA, COC) sheets remain the gold standard in mouthguard construction [51].
Mouthguards are prone to microbial infections that may cause oral and systemic diseases. Therefore, proper cleaning and storage are essential for their maintenance. Washing with sterile water in a ventilated environment is indicated for the hygienic storage of dental devices made of EVA [52]. Sports mouthguards must be replaced when deformed and/or jagged [51].
Using “mixed splints” to combine different materials must be improved and evaluated in future research to take full advantage of different characteristics and properties. The future use of 3D printing in constructing sports mouthguards holds great promise, offering enhanced customization, comfort, and protection. With 3D printing technology, mouthguards can be precisely tailored to an athlete's dental profile, ensuring a perfect fit and optimal performance. This innovation allows for advanced materials that provide superior shock absorption and durability, reducing the risk of injuries. As the technology continues to evolve, 3D-printed mouthguards are expected to become more accessible and affordable, revolutionizing athlete safety and comfort across all sports [51].
4 Conclusion
The selection and recommendation of a custom-made sports mouthguard should be individualized and based on specific fabrication, function, and care criteria. These recommendations educate and encourage the scientific community to generate further evidence. Individually manufactured mouthguards should be reproducibly fabricated by internationally agreed standards and always comply with the current state of scientific knowledge.
Custom-made sports mouthguards offer the highest possible safety level without the athletes' functional impairment. The latest studies provide evidence of a possible positive influence on performance factors.
Author Contributions
All authors have contributed equally to the manuscript's conception, design, data acquisition, analysis, and interpretation. Each author has played an integral role in drafting, revising, and approving the final manuscript; all are accountable for its content. This manuscript reflects a collaborative effort with equal contributions from each author.
Conflicts of Interest
The authors declare no conflicts of interest.
Open Research
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.
