A guide to the different types of mouth guards available for sports and why 'custom made are so important for maximum comfort and protection.

1. Mouth Guards for Sport
Introduction:-
Mouth Guards for sports are a widely misunderstood
subject by the public who might need them, but also
by some GDP’s … General Dental Practitioners.
How many dentists know their patients participate
in sports or past times that could benefit for oral
protection? A simple poster or narrowcasting via a
big screen in the clinic would let patients know they
can ask their dentist for advice and service.
How many patients will go to their dentist to get
advice, or just search the internet and ask friends for
recommendations? Only through public awareness
can we correct this.
If the patient does ask the Dental Clinic about a
Sports Mouth Guard, will the clinic have the
knowledge to prescribe, make , or order one from a
competent lab? Through education is the answer!
Lastly how many dental labs really understand what
is needed and how to construct a comfortable and
protective mouth guard for the sport practiced?
By Peter Sheffield, Director of “The Torque and Angulation Lab”
Chiang Mai, Thailand.

2. Well the good news is that there has been a lot of
work done to improve mouth guard education for
both the public and the dental profession recently.
Companies are making better machines and
materials for the “Thermoforming Techniques”, Labs
are getting good training and Dr’s will look for the
reputable labs. Now we even have a book from my
friend Fabio Fantozzi!
A ‘Mouth Guard’ is a flexible shield placed in
the mouth to protect firstly the teeth from
damage, but also the surrounding soft
tissues such as lips, cheeks and gums, plus
the hard structures of the jaw. It should be
made of a suitable shock absorbing material
like EVA and of a thickness required
according to the dangers of the sport. For
example, although boxing is a high impact
sport, gloves are worn which disperse the
point of impact over a wider area, In contrast
to MMA, Muay Thai and some types of
Karate, where the gloves are minimal. But
also there are dangers from Elbows, Knees,
Shin bones and feet, thus the point of impact
can be very focused and from a hard object!
Right: Old vacuum
forming machine
Below: New ‘Pressure
forming machines.

3. History
It is believed that Mouth guards or “gum shields” were first developed by Woolf Krause
in 1890, a London dentist, although others say another Dentist in London called Jack
Marles actually made the first real mouth guard in 1902. They wanted to protect boxers
from lip lacerations, as such injuries were common would often lead to the fight being
stopped prematurely. The Krause version was originally made from ‘gutta percha’ and
was held in place by clenching the teeth. His son Philip Krause, who was both a dentist
and amateur boxer, modified the design and materials used, using ‘vella rubber’. Later
in 1916 it is thought that Thomas Carlos, a dentist from Chicago made the first mouth
guard in the U.S.A. There have been other claims to the invention of the mouth guard
as well. In the early 1900s, Jacob Marks created a custom fitted mouth guard also in
London. Another dentist from Chicago, E. Allen Franke, also claimed to have made many
mouth guards for boxers by 1919. The relevance was again highlighted in a 1927 boxing
match when McTigue, who was winning for most of the fight, chipped a tooth and cut
his lip, forcing him to forfeit the match. From then on, mouth guards were ruled
acceptable and soon became commonplace for all boxers. In 1930 Dr. Clearance Mayer,
a dentist and boxing inspector for the New York State Athletic Commission, described in
a dental journal how custom mouth guards could be manufactured from impressions
using wax and rubber. Steel springs were even recommended to reinforce soft
materials!
By the 1930s, mouth guards were part of the ‘standard boxers' equipment and have
now become mandatory in most fighting sports, such as Wrestling, Karate, Taekwondo,
MMA, Kickboxing, etc.. Plus they are now being used in any sports where accidents and
impacts can occur…American Football, Rugby, Ice Hockey and even basketball.

4. What are the options?
Basically there are 3 types of Mouth Guard available, these are then split into
different groups made of differing materials, with different styles and different
thicknesses.
Standard Stock Mouth Protectors Rubber or
Polyvinyl can be found in sports shops and on
the internet. They are preformed in a few sizes,
come ready to wear and are usually inexpensive.
They cannot be adjusted to fit the individual,
therefore they are often bulky making breathing
and talking difficult, and they provide little or no
protection. Dentists do not recommend their
use.
Boil & Bite Mouth Guards are widely available on
the internet in many forms and styles. They have a
process that the users have to follow to get some
sort of ‘fit’ with their own mouth. This involves
softening the mouth guard in boiling water and
adapting directly in the mouth. The procedures can
be complicated for the user and mistakes are easily
made, getting the occlusion wrong could be the
most dangerous. They vary in cost and seem to be
the most popular, purely due to good marketing.

5. Custom Made Mouth Guards without a doubt are the
best option for maximum protection and comfort.
Research has shown multiple times that they reduce
dental trauma. There are also claims to improve strength
and reduce the effects of concussion, however I think
more research is needed to verify this.
They are made from a model of your mouth, so should fit
perfectly. The dentist will take and impression and then
send it to a qualified Dental Laboratory to fabricate a
‘custom made mouth guard’ ( CMG ).
The material used is usually food grade EVA plastic which
is non-toxic, durable, comes in many colours! It can also
be laminated, which is a very important point.
There are different types of ‘custom made’. Some popular
ones will even send you a kit to take your own
impression, however as a dental technician and someone
doing combat sports for the last 40 years, wearing mouth
guards, I would not recommend this procedure. A change
in the bite for example could have serious consequences
and also we need certain parts of the mouth to fabricate
the ‘CMG’, so if your impression was what we call “short”
or had seriously air blows, then it wouldn’t be suitable for
a good fitting ‘CMG’. And it’s the FIT that makes a big
difference!

6. Today most custom made mouth guards are made for contact sports and are laminated
using multiple layers of EVA under high pressure and heat, just like your car windscreens!
This technique gives the best protection against tooth fracture when tested in research labs
for impact resistance with instruments like the “pendulum test”. It also allows a lot of
customization in the design, with logos and names being inserted between the layers or
specific designs such as incorporating hard inserts over the incisors for ball or missile sports
or the use of more shock absorbing material for collision sports. For the last decade I have
done 3 layer lamination in the anteriors section and 2 in the posterior sections in our mouth
guards for contact sports . I have actually been laminating mouth guards since the 1980’s,
when I made the former World Karate Champion, Aiden Trimble’s guard and his team for
the Championships in the US. Wearing what you make and testing it gives great feedback!
A custom fitted design will ensure retention of the mouth guard in collision and not fall out
when the person wearing it gets tired. This also enables the wearer to breath easily, speak if
necessary and does not adversely affect concentration, giving them a psychological edge
with increased confidence. The cheaper ones are uncomfortable, plus often interfere with
breathing and speech.

7. Sports Injuries
Dental trauma in Sports have always been around but now
we are aware of the reasons, it seems crazy not to take
insurance in the form of a mouth guard especially in contact
sports.
However the new and unexpected traumas are coming
from ‘non-contact sports’ purely because the participants
think they do not need a mouth guard. Ball sports such as
baseball and football have quite a few dental traumas, with
basket ball being the highest in accidental contact via
elbows and hands, due to the physicality and speed of the
game.
Most of the injuries, at around 80% are to the two front
upper teeth (Central Incisors) due to their positioning and
morphology , with almost all the remainder being with the
other upper front teeth (lateral incisors).
For most official sports now, where there is a risk of dental
trauma, mouth guards have become compulsory and
without one you cannot compete. Most colleges in Europe
and the US have followed suit to protect the young people.
Certainly dental treatment following a trauma is likely to be
more expensive than even a ‘Custom Made’ mouth guard
and certainly more painful!

8. Exerts about statistics… food for thought
The following are exerts from Journal of American Dental Assocciation:-
“In an issue of the Journal of the American Dental Association (JADA), it was reported that 13-39% of all dental injuries are sports-related, with 2-18% of the
injuries related to the maxillofacial. Males are traumatized twice as often as females, with the maxillary central incisor being the most commonly injured
tooth. Even in football, a sport requiring protective gear, only about two-thirds of athletes are in compliance. In soccer, where rules are not uniform on
wearing mouth guards, only 7% of the participants wear them. In baseball and softball, again only 7% wear mouth guards. Recent studies show basketball
had the highest injury rate with both male and female students due to hand or elbow contact or by collision with other players. The close contact of
basketball players, as well as the speed of the game increases the potential for possible orofacial trauma.Currently, the National Federation of State High
School Associations mandates mouth guards for only four sports: football, ice hockey, lacrosse, and field hockey. It is evident from past research studies
there is a need for more research on the topic of sports dentistry. There is also a need to educate communities of interest including more regulations for
mouth guard use in sports.
The American Academy of Pediatric Dentistry recommends a mouth guard for all children and youth participating in any organized sports activities.
A study conducted on high school varsity basketball teams in Florida assessed the benefit of mouth guard use in sports other than football. It was found that
31% of surveyed Florida varsity basketball players sustained orofacial injuries during the season. Fifty-three percent reported more than one injury during
the season. Of the 1,020 players, fewer than half wore mouth guards and only 2 of these sustained oral injuries not requiring professional attention during
the season. It was concluded by the authors that there is a high risk of orofacial injury competing in basketball without a mouth guard, which would
increase a player’s chance of orofacial injury almost sevenfold. Soporowski and others found that of all the injuries presented to dental offices, 62%
occurred while the patient was participating in an unorganized sport. Children between the ages of seven and ten have the highest number of injuries
(59.6%). Baseball had the most injury sites, 72 of 159 injuries, biking followed with 59, and hockey and basketball were third and fourth respectively.
Another study was conducted with 3,411 athletes. The highest incidence of orofacial injury for the male athletes was noted in wrestling and basketball. For
females, it was basketball and field hockey. None of the athletes who sustained an injury was wearing a mouth guard.
A study conducted on high school athletes, in which researchers interviewed 2,470 junior and senior high school football players, showed 9% of all athletes
sustained some form of orofacial injury with 3% reporting loss of consciousness. Fifty-six percent of all concussion and 75% of all orofacial injuries occurred
while the athlete refrained from mouth guard protection. In Alabama, a study on 754 football players revealed that 52% of all orofacial injuries occurred in
sports other than organized football. Basketball and baseball continue to have the highest incidence of sports-related dental injuries with children 7-17
years old. With non-organized sports, bicycles are the most common consumer sports product that contributes to dental injuries of children. Other
recreational sports include skateboarding and roller or inline skating. Morrow and Kuebker conducted surveys in selected Texas high schools to determine
the incidence of orofacial injuries on approximately 122,000 male and female athletes. They measured the types of mouth guards worn and dental injury
experienced in football, and later indicated that soccer and basketball had higher dental injury rates than football. The number and nature of dental injuries
experienced by male athletes showed that lip and tongue lacerations were the most frequently reported injuries. In addition, fourteen jaw fractures were
reported with as many fractures in baseball and soccer as there were in football.
All athletes constitute a population that is extremely susceptible to dental trauma. Dental injuries are the most common type of orofacial injury. An athlete
has a 10% chance of receiving an orofacial injury every season of play. In addition, athletes have a 33-56% chance of receiving an orofacial injury during
their playing career.”

9. For my personal experiences over 39 years of doing combat sports the evidence of “eye
witness” events is overwhelming. My first Mouth Guard was a ‘Boil & Bite’ that was sold in a
local sports shop, I bought it when I was doing amateur boxing. The club attracted a few
rough individuals who liked to vent their anger in the ring, local bouncers and the likes. As a
tall but lean middle weight I would often end up sparring in this tiny ring above a pub with
these monsters. My mouth guard was knocked out or more than not, just fell out after getting
tired through running around the ring to get away from them!
In the early 80’s I became a dental technician and after learning from a friend about a new
mouth guard made by an Ortho lab in Sheffield, I ordered one. “The Lynx” Mouth Guard.
After receiving it and trying it, it occurred to me that maybe the people making it had never
worn one in combat. So I started studying the journals and texts to find out more about how
to make one. I bought a Vacuum forming machine and scoured the suppliers for better
materials. Back then only 3 colours were available, all not very nice and hard to get, but the
suppliers were not eager to find more as there was little demand. I made my first for me, then
more for my friends, as by now I was doing Karate in a tough school, and have been making
them since.
Over the years in training halls and at competitions I have seen teeth knocked out, lips and
cheeks cut open, mouth guards fly across the ring or mats, and one serious case where a shop
stock mouth guard had caused all four incisors to snap owing to the material and fit. This
happened when the owners head and met an up coming knee! Seeing was believing, wearing
was believing…my occlusion is not that good being ‘edge to edge’, but I have never suffered a
dental trauma and never had a custom made guard knocked out or displaced and that
includes a couple of years of Muay Thai in Thailand!
The last all styles Karate combat I attended was in France and left bodies all over the mats,
KO’s, cuts and damaged limbs, so for those who think it is ‘no contact’ and a game of tag,
think again! In any sport where there is speed, accidents happen!
Lastly I would like to show you a mouth guard made by a dental clinic for a guy doing Muay
Thai. This was either the scariest lack of knowledge or bad communication I have ever seen. I
have shown it here on the right and you can see 2 separate vacuum formed guards, made of
thin EVA. The material will stretch and can lose up to 60% of its original thickness, so making
a “Night Guard” is not the same as a protective ‘Mouth Guard’ for sports. After the guy
received his first right hook in the gym, his jaw ached for a week! Not wearing them and
clenching would have done him more good! He came to us with his models and we made him
a real one for Muay Thai…the Gold and Black shown here with 3 layers at the front.
Personal Experiences
Me on the right with my friend and instructor
World Champion Aiden Trimble.
Boxing in the UK…19 and fit!
Thailand 1999
Poorly made mouth
guards as described
right and below
The replacement
 right and below

10. Conclusions
1. For protection and comfort “Custom
Made” are the best choice, preferably
from a lab via a Dentist. The Dentist
should be knowledgeable on the
subject and can advise whether the are
any underlying problems and reasons
for a specific design.
2. For cost effectiveness, then also the
‘Custom Made’ is better. It might be
more expensive at first, but could
surely save a lot of money and misery
later…how much do you value your
smile?
3. Lastly more studies need to be done
before we can make further claims
about reduction of concussion or brain
damage through wearing a Mouth
Guard, however they are effective at
reducing dental trauma, to the teeth,
gums, lips and cheeks, this has been
evident the last century!

11. References:-
American Dental Association, Policy Statement on Orofacial Protectors. Transactions; 1995. p. 613.
ADA Council on Access, Prevention and Interprofessional Relations; Council on Scientific Affairs. Using mouthguards to reduce the
incidence and severity of sports-related oral injuries. J Am Dent Assoc 2006;137(12):1712-20; quiz 31.
Knapik JJ, Marshall SW, Lee RB, et al. Mouthguards in sport activities : history, physical properties and injury prevention
effectiveness. Sports Med 2007;37(2):117-44.
Kumamoto DP, Maeda Y. A literature review of sports-related orofacial trauma. Gen Dent 2004;52(3):270-80; quiz 81.
Gould TE, Piland SG, Shin J, Hoyle CE, Nazarenko S. Characterization of mouthguard materials: physical and mechanical properties of
commercialized products. Dent Mater 2009;25(6):771-80.
For the dental patient. Do you need a mouthguard? J Am Dent Assoc 2001;132(7):1066
Center for Scientific Information, ADA Science Institute
Reviewed by: ADA Council on Access, Prevention and Interprofessional Relations
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[14] Stenger JM, Lawson EA, Wright JM, Ricketts J. MouthGuards: Protection against Shock To Head, Neck and Teeth. J Am Dent
Assoc. 1964;69:273–81. [PubMed]
[15] Reed RV Jr. Origin and early history of the dental mouthpiece. Br Dent J. 1994;176(12):478–80. [PubMed]
[16] Scott J, Burke FJ, Watts DC. A review of dental injuries and the use of mouthguards in contact team sports. Br Dent J.
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[17] Chapman P. Mouthguards in sport. Sports Health. 1983;1:13–15.
[18] Chapman P. Concussion in contact sports and importance of mouthguards in protection. Aust J Sci Med Sport. 1985;3:170–4.
[20] Ferrari CH, Ferreria de Mederios JM. Dental trauma and level of information: mouthguard use in different contact sports. Dent
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Sports Mouthguards, What is indispensable to know, Fabio Fantozzi, Edizioni Martina, Jan 2015
The History of Athletic Mouth Guards: Keystone Industires 2013
In a League of Flying Elbows, the Use of Mouth Guards Soars, New York Times
By ANDREW KEHFEB. 10, 2015
Why Did Old Timey Boxers All Pose For Photos the Same Way?
December 2, 2016 Karl Smallwood