Peer reviewed American Academy of Orofacial Pain study
We are now certifying team dentists
Abstract: The Use of a Custom Mandibular Athletic Mouthguard in the Prevention of Concussions in NFL Football Players
Jeffry R Shaefer DDS MS MPH
Objective: Observe the benefit of a mandibular appliance for the control of concussions among football players. Concussions in contact sports are an ongoing problem. In relation to football, Pellman, funded by the NFL, showed that oblique blows to the head causing head acceleration are the most dangerous, while quarterbacks, wide-receivers and linebackers are the type of players most at risk for concussions (1-3). Blows to the chin are dangerous as there is no protection from such a blow to prevent direct transmission of the force to the brain, while forces from other directions can be controlled by the player’s helmet and facemask (4). Various studies have examined the benefit of mouth guards to prevent force transmission through the mandible from blows under the chin (5-13). The consensus from these studies is that mouth guards are successful in protecting oral structures but that their benefit in controlling concussions is unclear. Methods: A case series report. Results: Maher reports excellent compliance, satisfaction, and control of concussions in a case series of 22 New England Patriot football players who used a concussion prevention mouth appliance he constructed (14). Eleven of the Patriots had a prior history of concussions and controlled their potentially career-ending concussions with Maher’s appliance. The use of Dr Mayer’s patented appliance has allowed the New England Patriots football team players to have the lowest number of concussions in the league (14). Conclusion: a retrospective analysis of NFL football players use of athletic mouth guards and the corresponding rate of orofacial injuries and concussions and a prospective study to measure the affect of this appliance on concussion rates in players with and without a prior history of concussion is warranted.
Although the use of correctly fitting mouthguards can reduce the rate of dental, orofacial, and mandibular injuries, the evidence that they reduce cerebral injuries is largely theoretical, and no clinical evidence for a beneficial effect in reducing concussion rates has yet been demonstrated clinically.
A recent study of the incidence of concussions in college basketball players showed no statistical difference (.35 vs .55 per 1000 exposures) between wearers and non mouthguard wearers (Labelle 2002). Wisniewski (Dent Trauma 2004) found no positive affect for a custom-made mouthguard compared to a “boil and bite” type appliance for the prevention of orofacial injuries or concussions in a study of Division I football players. Barbic observed the effect of the dual arch Brain-Pad appliance worn for one season by Canadian college athletes playing contact sports.
Gusenbauer proposes three explanations for a positive benefit for the prevention of concussions from the use of a dental appliance:
Dissipation of forces directed to the jaw
Stabilization of neck muscles when clenching on a mouthpiece so as to resist head acceleration
Distraction of the condyle from the glenoid fossa decreasing force transfer via the temporal bone
Conclusion: Concussions in contact sports are a great concern, especially among adolescents. Athletes whom have had a concussion are 4-6 times at greater risk for a second concussion. Powell and Barber-Foss report that 3.9-7.7% of high school and college athletes sustain a MTBI (minor traumatic brain injury) each year. Many of these athletes will continue to play despite these increased risks and feel protected by appliances such as the Maher mouthpiece (see Boston Globe story).
To present to the Academy a case series of subjects using a single arch mandibular appliance to prevent concussion.
Background and discussion:
The claim that athletic mouthpieces worn during contact sports are helpful in the prevention of concussions is controversial. Two trials that have been commonly used to support this claim; Stenger’s study on Notre Dame footballers and Hickey’s cadaver study have methodological problems. In fact McCrory (Br J Sports Med 2001) states that only anecdotal evidence points to a dental appliance effect against concussion. He summarizes:
With mouthpiece, dentist tackles concussions
NFL says more evidence needed
By Keith Reed, Globe Staff | March 30, 2006
If New England Patriots wide receiver Deion Branch never has another
concussion, he can thank former boxing champ ''Marvelous" Marvin Hagler and Gerald Maher, his Weymouth dentist.
In 1980, the Brockton-bred pugilist called Maher, a specialist in jaw
structure and facial pain, to ask why his crushing punches floored some
opponents, while others walked away from them.
Maher's answer was that the alignment of the jaw made some people
susceptible to concussions -- catch somebody with his mouth in the wrong position, and it's lights out. He created a mouthpiece that kept Hagler's jaw in the right spot, preventing Hagler -- and many other professional athletes since then -- from suffering the injury, which results from a violent jarring of the head that renders the victim unconscious and in some cases induces vomiting or permanent
Now Maher, who has filed for a patent, is pushing the National Football
League, which doesn't require its players to wear mouthpieces, to study
whether his device or others like it could protect athletes from concussions that might end their careers -- or worse.
''For safety reasons, I think it would help every player, and I'm interested in the safety of every player in the NFL," Maher said.
He has fitted about two-thirds of the Patriots for the devices, and
hand-delivered a mouthpiece to former Patriots nose tackle Ted Washington in Houston on the day of the 2004 Super Bowl.
None of the players Maher has outfitted have suffered concussions using the equipment, he said. The Patriots reported no concussions last season.
That's not enough to convince league officials to change their policy,
''The New England Patriots might be wearing this mouthpiece, but can anyone guarantee me that there may not be an incidental component that occurs that is not desirable?" Pellman said.
A Patriots spokesman declined to comment.
But scores of athletes, from high school footballers to professional
basketball stars, have pushed Maher's device between their teeth, convinced it will help protect them.
Maher said he has applied for a $125,000 grant from the NFL to fit a team other than the Patriots -- perhaps a college football squad -- with his mouthpieces so their effectiveness can be objectively studied. Pellman said he's unaware of the status of that application, but that the league, along with Wayne State University, is building a sophisticated model to study the effectiveness of several mouthpieces, including Maher's, in preventing concussions.
If the NFL wants more evidence, Duxbury High School's football coach might be worth calling. Eleven of the team's players had previously suffered concussions, some three or four times. After hearing about Maher's mouthpieces, the coach, Dave Maimaron, asked the dentist to fit the players who had suffered concussions. There were no concussions last season, and Duxbury went undefeated, taking a state championship.
''I almost feel like we had an advantage this season," Maimaron said.
''Everybody should be wearing this thing. I'd be very surprised if that
Concussions are common in volatile sports like boxing, whose very object is to hit your opponent harder than your opponent hits you, and football, where 200- to 300-pound men collide and send each other into the ground over and over.
Maher's mouthpieces are designed on the principle that keeping an athlete's jawbone and temporal mandibular joint properly aligned absorbs the force of blows that would otherwise literally rattle their skulls and cause a concussion. The most susceptible position, he argues, is when the mouth is tightly closed. Then, the force of a blow can travel unobstructed up the jawbone and into the skull. Helmets protect against concussions and other injuries caused by blows to the crown of the head, but their chin straps keep players' jaws in precisely the position that Maher argues puts them at risk.
His mouthpieces separate the jawbone from the joint slightly, helping to absorb the blows. They also fit tightly over the bottom row of teeth, letting football players talk to each other. Besides Branch, Patriots Asante Samuel, Vince Wolfolk and Daniel Graham wear the mouthpieces.
Maher said he doesn't think he can eradicate concussions, but he thinks many are preventable.
''You would never say to an athlete that they're not going to get a
concussion," he said. ''But I want to put them in the best position to try and prevent that."
Keith Reed can be reached at email@example.com.
© Copyright 2006 Globe Newspaper Company.
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