Journal of Athletic EnhancementISSN: 2324-9080

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Research Article, J Athl Enhancement Vol: 3 Issue: 5

Individualized and Mouthformed (boil-and-bite) Mouthguards: Comparative Analysis on a Soccer Team

Lauren Cardoso Alves Aznar1, Patrícia da Silva Barbosa2, Ricardo Gutierrez3, Giselle Rodrigues de Sant´Anna4*
1Master´s student of Cruzeiro do Sul University, Brazil
2Phd student of Cruzeiro do Sul University, Brazil
3Under graduate student of Cruzeiro do Sul University, Brazil
4Under graduate and post graduation professor of Cruzeiro do Sul University, Brazil
Corresponding author : Giselle Rodrigues de Sant’Anna
Cruzeiro do Sul University. R. Galvão Bueno, 868, São Paulo, Brazil, Tel: +55 11 9 94969465;
E-mail: [email protected]
Received: May 23, 2014 Accepted: August 30, 2014 Published: September 05, 2014
Citation: Aznar L, Barbosa P, Gutierres R, de Sant’Anna GR (2014) Individualized and Mouth-formed (boil-and-bite) Mouthguards: Comparative Analysis on a Soccer Team. J Athl Enhancement 3:5 doi:10.4172/2324-9080.1000166

Abstract

Individualized and Mouthformed (boil-and-bite) Mouthguards: Comparative Analysis on a Soccer Team

Considering the importance of mouthguards on the prevention of orofacial injuries during sports practice, the purpose of this study was to evaluate two mouthguard types: individualized and mouthformed (boil-and-bite) mouth –mouthguards, during a performance of two soccer teams. The mouthguards were analyzed according to its effectiveness, satisfaction after using and dimensional changes. The participants (n= 16) were divided in two groups: G1 (n=8), individualized and G2 (n=8), mouth-formed (boil-andbite) mouthguard. The athletes received the mouthguards to use it in two soccer games. After this, the mouthguards were sent to three blind expertise examiners which analyzed three items: integrity, cleanliness and the quality of material through scores. For data collect, a questionnaire was developed to investigate the sociodemographic data from the participants and also to evaluate the satisfaction after using.

Keywords: Mouthguards; Sports dentistry; Temporomandibular joint

Keywords

Mouthguards; Sports dentistry; Temporomandibular joint

Introduction

Soccer is one of the most popular sports in the world, especially in Brazil, where there is a national passion and millions of people play or support their teams on the local leagues [1]. Although not considered a violent sport, soccer also presents a high risk of injury for athletes, including injuries affecting the craniofacial and oral regions [2]. Frequently, during the soccer matches, the head is used [3], and the major consequences of this practice are the craniofacial injuries, considering the impact between heads or even head and elbow [4].
Some reviews of studies on mouthguards have shown its effectiveness in reducing hard and soft oral tissue injuries, jaw fractures and neck injuries [5-6]. Besides that, other studies have shown its significant impact on reducing the incidence of dental trauma, dental injury costs, and the number of dental insurance claims [7-8]. Despite the benefits associated with the mouthguard use, soccer players rarely use them [9].
Mouthguards are generally made from ethylene vinyl acetate (EVA) because of its non-toxicity, minimal moisture absorption, elasticity, and ease of manufacture [10]. There are three major kinds of mouthguards: the individualized, the mouth-formed mouthguard and also the stock mouthguard. The individualized mouthguard is provided by a dentist [11] and it requires a dental impression, dentist models, and a forming process based on vacuum or pressure [12]. This process can involve one to two visits to a dentist [13]. This type of mouthguard has been shown a better protection according to some authors [11,14]. The mouth-formed mouthguard consist in a preformed thermoplastic tray that loosely fits over the teeth [15]. This type of protector can be found in stores and is worn without modification; though, these offer limited protection [16]. The difference of mouth-formed ‘boil-and-bite’ mouthguards from the stock and the individualized mouthguards is that they are moulded by the user after softening it in hot water and forming it in the mouth with pressure from fingers, tongue and cheeks [12]. And two benefits of, mouth-formed mouthguards are that they offer a better protection and comfort comparing to stock mouthguards and the cost is lower than individualized [11]. However more researches are necessary to prove its effectiveness.
Even knowing the mouthguards are effective in reducing craniofacial injuries, in Brazil, their use by the athletes is mandatory only in boxing practice [2]. The low rate of use could be related to discomfort caused by the appliances [17]. Reasons cited for non-utilization mainly are the difficulties with breathing and communication during play [18]. Respiratory function is a major concern about the mouthguards effectiveness [19], especially for athletes with high aerobic demands, such as soccer players [17].
The aim of this study was to evaluate two mouthguard types: individualized and mouth-formed (boil-and-bite) mouthguards, during a performance of two soccer teams. The evaluation was done by a questionnaire, which considered sociodemographic data and the satisfaction degree when using the mouthguard during the soccer practice. Besides that, three blinded expertises examiners classified the mouthguard material through photographies, considering all dimensional changes after the soccer performance.

Materials and Methods

It was an interventional study with athletes belonging to two Brazilian no professional soccer teams of the Southeast part of Brazil. All athletes were male, and the ones that were aged more than 18 were invited to participate in the study, totalizing the number of 16 participant athletes.
All study participants were informed about the study protocol and were asked for a written consent form. The study protocol was approved by the Local Ethics Committee of the Cruzeiro do Sul University (# 366/082012).
For data collect, a questionnaire was developed to investigate the sociodemographic data from the participants and also to evaluate the satisfaction after using the mouthguards in a soccer practice. The purpose of our research was explained to both soccer teams’ coaches. After getting their permission and clarifying the possible questions, a questionnaire was applied to the soccer players at the same day of the soccer practice and right after the mouthguard using.
The participants (n=16) were divided in two groups: G1 which used the individualized mouthguard and G2 that used the mouthformed (boil-and-bite) mouthguard. After the explanation to the coaches, the G1 group was called to the clinical procedures and then, the players signed the consent form. Ethyl vinyl acetate (EVA) sheets (Bio-Art Dental Equipment Ltda) 3.0 mm thick were used to fabricate the individualized mouthguards Upper-jaw impressions were taken by standard trays using alginate impression material and were poured with dental stone to produce working models where the individualized mouthguards were made (Figure 1A). The mouthformed (boil and bite) mouthguard shape was like a “horseshoe”, without covering the palate. Its dimensions 7,5×3×7 cm (w × h × l) (Figure 1). The mouth-formed mouthguard Pretorian ™ (Figures 1B and 2) was given to the athletes. This mouthguard type is composed by silicone. For its confection, the instructions from the manufacturer were followed. Each athlete dipped the mouthguard in hot water (almost boiling) for about one minute and then, when the silicone got a little soft, was possible to mold the material in to the athlete’s upper arch. The athletes were instructed to put the mouthguard in their upper arch and bite it for some seconds until the mouthguard could shape in to their arcade (Figures 1B and 2). This procedure was carried out under the supervision of a researcher.
Figure 1: A: Individualized mouthguards - Upper-jaw impressions B: Individualized mouthguards - Gingival margin
Figure 2: Mouth-formed (boil-and-bite) mouth guard molded by athlete.
After the athletes received the mouthguards, they used it in two soccer games. By the end of the second game, the researcher took the mouthguards of both groups and had pictures taken from it. After this, the mouthguards photos were sent to three blind expertise examiners which analyzed three items: integrity, cleanliness and the quality of material through scores. The data were statistically analyzed by t student test, for comparing the means of age from the two groups and to test the homogeneity between the answers proportions in the questionnaire, the Fisher exact test was used. The significance level used for the tests was 5%. To test the dental materials expertise examiners opinion, Wilcoxon test was used for the evaluation in pairs.

Results

All 16 players who completed the study were men aged 26–40 years (32, 07± 3,71) (t Student, p=0,110).
Sociodemographic questionnaire
According to the data on the Table 1, the groups did not show significant difference in age, race, marital status, number of people in residence, education and income.
Table 1: Frequency distribution of volunteers in relation to race, marital status, number of people in residence, education, family income, according to the study group.
Mouthguards questionnaire
Related with comfort, performance and safety, according to data Table 2, no significant difference was found between comfort, performance and safety (Tables 3-7).
Table 2: Distribution of frequencies of volunteers in relation to comfort, performance and safety, according to the study group.
Table 3: Distribution of frequencies of volunteers regarding the mouthguard frequency of use, the alteration of respiratory capacity and concentration during sports practice, according to the study group.
Table 4: Frequency distribution of volunteers in relation to the frequency of making the mouthguard at a dentist office, buying the mouth-formed (boil-andbite) mouthguard, recommending the use for other people and a technician recommended, according to the study group.
Table 5: Frequency distribution of volunteers in relation to the mouthguard time of the exchanging and the protection purpose, according to the study group.
Table 6: Mouthguards dimensional changes, according to the three blind expertises examiners, considering score 0, when there were no dimensional changes, none perforation, none changes on the original shape; score 1, when there were light dimensional changes, light perforation, light changes on the original shape; score 2, when there were high dimensional changes, high perforation, high changes on the original shape.
Table 7: Non-parametric Wilcoxon test between the examiners evaluation.

Discussion

The American Dental Association (ADA) [20], in 2001, published some orientations about the three types of mouthguards available for the patients use. The ADA considered that the three kinds are capable of conferring protection, however, explained that it varies in comfort and cost. According to the ADA, the most effective mouthguard should be resilient, resistant and comfortable. It must have proper fit, be durable and easy to clean without restricting speech or breathing. Also provided recommendations on the use and cleaning and recommended a periodically exchange.
According with Eroğlu [21] ,in 2006, besides the different types of mouthguards available provide a sufficient level of protection, the individualized mouthguards were considered the best option because they offer better protection with more comfort, without causing difficulties to breathe or talk during the match. Agreeing with the data obtained by Eroğlu [21], this study showed that 50% athletes from the individualized group never felt any difficult on breathing and none from this group reported difficult to breathe with extreme frequency, although only 25% athletes from mouth-formed (boil-and-bite) mouthguard group reported that they never had difficult to breathe during practice and 37,5% athletes had difficult to breathe too often or with extreme frequency.
According to the data obtained by the questionnaire, 50% athletes from the mouth-formed (boil-and-bite) mouthguard group considered the right time to exchange the mouthguard when a silicone detrition was found. Comparing with the individualized group, 37, 5% considered the silicone detrition the right time for exchanging, also 37,5% from this same group considered the right time for exchange when there was a perforation on the mouthguard.
According to the examiners evaluation, only examiner B considered no dimensional changes on the mouth-formed (boil-andbite) mouthguards. Coto [22] studied the mechanical behavior of mouth protectors prepared with ethylene and vinyl acetate copolymer (EVA), and was concluded that thickness of the mouthguard is an important factor, because the variation of this alters the mechanical behavior of the EVA. So, when the individualized mouthguards are made, the thickness should be considered to offer a longer durability. However, despite the examiners of this study are expertise in dental materials, they were few and such results in this study should be evaluated with restrictions.
In another study, Patrick et al. [23], in 2005, found that the individualized mouthguard have a better adaptability and comfort, allowing the athlete to swallow liquids and to speak concurrently with its use. The primary purpose of preventing oral and dental trauma is more effective than in the others kinds and therefore, had the best rating in the range of mouthguards effectiveness [23]. In this study, 87% athletes from both groups considered that the primary purpose for the mouthguards use was the protection from broken teeth and only 12,5% athletes from the mouth-formed (boil-and-bite) group considered the importance on preventing injuries on the tongue.
Considering the answers about the influence of different types of mouthguards on breathing, 50% athletes from the individualized group reported that they have never ever felt some alteration in respiratory capacity, while in the mouth-formed (boil-and-bite) mouthguard group, 25% of the athletes reported that the mouthguard influenced the respiratory capacity too often. Some studies identified breathing difficulty as one of the main reasons for not using mouthguards [18,19]. However, Collares et al. [17] disagreed with this assumption, because according with a survey about the influence of individualized mouthguards, levels of acceptance regarding breathing and communication statistically significant increased after mouthguards usage. The survey also showed that stability was the parameter with the highest acceptance. In this study, the athletes reported safety during the soccer performance in 50% from the individualized group and 62, 5% from the mouth-formed (boiland- bite) group. Boffano et al. [24], found in the answers from their survey with a questionnaire applied to athletes of four amateurs rugby teams that the most commonly reported problem associated with using a mouthguard was the discomfort on speech, followed by difficulty in closing lips, adversely affected breathing, adversely affected swallowing and slipping sensation. Now, the data obtained by Collares et al. [17] survey, suggest that the level of acceptance of mouthguards can increase by its usage; for that, athletes should have some knowledge about the existence of this apparatus.
According to the data obtained by the questionnaires, only six volunteers (37,5%) had knowledge about the mouthguards, from this six athletes, five (62.5%) were from the individualized group and one (12.5%) from the mouth-formed (boil-and-bite) mouthguard group. In another study of Sepet et al. [25], when analyzing 359 athlete’s questionnaire answers, 41.1% were aware of the possibility of oral injuries during sports practice 55.4% knew about mouthguards, but only 11.2% of the participants reported to use them. Comparing this data with another study from Correa et al. [2], which considered the health professionals knowledge, it showed that the majority of health professionals had knowledge about custom-made mouthguards (68.4%) but also, only 21.6% of the physicians interviewed in this study recommended the regular use of mouthguards for the players. Knowing this, can be observed that probably, the health professionals have more information about the mouthguard use than the athletes, but even knowing that it was a protector device, Correa et al. [2] could find that a minority of health professionals would indicate the use of it. The low rate was attributed to the lack of information regarding to this protective device, considering the physician’s belief that they are not necessary (50.0%). The data obtained about the mouthguard use indication in this study with athletes shows that 75% from both groups would recommend the use. And 75% from the individualized group would go to a dentist to have the mouthguard done.
Dupont et al. [26], in 2010, reported the occurrence of injuries and the characteristics of it, during a professional soccer practice. Not only for professional sports, but also for children sports practice, the mouthguard should be indicated. O´Malley et al. [27] studied the extent of mouthguard use, dental trauma and barriers to use among children. This study found that 75% athletes from both groups would wear an individualized mouthguard, made by a dentist, while none athlete from the individualized group would purchase a mouth-formed (boil-and-bite) mouthguard and 37,5% athletes from the mouth-formed (boil-and-bite) group would purchase the mouthguard . According to O´Malley et al. [27], the reasons for not wearing mouthguards include cost, lack of knowledge and information, and lack of a mouthguard policy. The survey also found that one in ten children had suffered a sports accident in the previous year, of which 51% injured teeth.
As a suggestion to improve the situation reported in this study is that necessary the inclusion of health professionals on sports practices, which should help with the information about protective devices besides dentists should also be aware of the appropriate time for exchanging the mouthguards, as was found that even the individualized had some changes on its shape. Other consideration is that physicians need to be informed about the importance of oral health for a good systemic performance. Also Pribble et al. [28] suggested that more physicians need to make an effort to inform their patients about proper protective equipment for soccer athletes. Moreover, Correa et al. [2], in this context, considered that Sports Dentistry has gained an increased interest and dental professionals should be aware of this new area of clinical practice.
When analyzing the results of this research, the small sample of athletes should be considered, but the results found in this study suggest that the lack of information about the importance of using mouthguards could be observed, for both, players and technicians. However, dental professionals should also be concerned with the development of areas in dentistry which could be inserted in sports field , so that the professional of dentistry can be capable of direct the professionals of sport about the preventive dentistry maneuvers in sports and also, when indicate the use of mouthguards, aware them the right time to exchange it.
The results found in this study, should be carefully evaluated, regarding the small sample number not only for athletes, but also for examiners.

Conclusion

Although a limitation of this study was the small number of athletes, it was possible to observe both groups considered that mouthguards offer a good protection for dental trauma. There were no differences between the individualized mouthguard and the mouthformed mouthguard from the perspective of these athletes studied. The sample size should be increased. More information about the importance of the mouthguards in the prevention of orofacial injuries on sports activities should be given not only to athletes, but also to their coaches.

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