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ORIGINAL ARTICLE
Year : 2018  |  Volume : 21  |  Issue : 3  |  Page : 318-326

Dentists' Attitudes and perceptions toward protective mouthguards


1 Department of Orthodontics, Government Dental College, Alappuzha, Kerala, India
2 Department of Oral Medicine and Radiology, Apollo White Dental Clinics, Delhi-NCR Region, New Delhi, India
3 Department of Prosthodontics, Crown and Bridge and Implantology, Jaipur Dental College, Kukas, Jaipur, Rajasthan, India

Date of Acceptance10-Aug-2016
Date of Web Publication09-Mar-2018

Correspondence Address:
Dr. S Raghavan
Department of Orthodontics, IDST, Modinagar - 201 201, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_336_16

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   Abstract 


Objectives (Background): Risk of dental injury from contact sports can be prevented by the use of mouthguards. Dentists provide excellent information regarding mouthguards. Thus, the aim was to assess the awareness among dentists regarding the same, the level of training in fabricating a mouthguard and whether they regularly recommend one for their athletically active patients. Materials and Methods: This institutional cross-sectional survey was conducted in the Department of Orthodontics, Government Dental College, Kottayam, and Kerala, India. An online form was sent out to 1500 offices and departments in dental institutions through email with a time period of 1 month given to fill responses and was analyzed using descriptive statistics. Results: A response from 640 was recorded; most of them had not received or had fabricated a mouthguard during their dental training or private practice, even though one-third recommended one to their athletically active patients with a lack of formal training being the reason for not routinely advocating mouthguard usage. Most were aware of more than one type of mouthguards and recommended customized one for the same, however, more than half were not aware of a different type intended for orthodontic patients. Conclusion: It is not a routine practice currently, among general dentists and specialists alike, in our country, to prescribe a mouthguard. It is time that the dental fraternity spread awareness for the prevention of injuries. A relook into the academic curriculum while advocating the use of customized mouthguards to patients due to contact sports is required.

Keywords: Awareness, dental fraternity, mouthguard, perception


How to cite this article:
Raghavan S, Dayal P, Philip K, Gahlot M S. Dentists' Attitudes and perceptions toward protective mouthguards. Niger J Clin Pract 2018;21:318-26

How to cite this URL:
Raghavan S, Dayal P, Philip K, Gahlot M S. Dentists' Attitudes and perceptions toward protective mouthguards. Niger J Clin Pract [serial online] 2018 [cited 2019 Nov 17];21:318-26. Available from: http://www.njcponline.com/text.asp?2018/21/3/318/226968




   Introduction Top


The participation in contact sports carries the risk of sustaining some form of dental injury. Different reports conclude sports-related facial fractures to be 4%–18% of all sports injuries.[1] According to Saini, about 11%–40% of all sports-related injuries involve the face.[2] This can be prevented by the use of protective mouthguards. A mouthguard is in basic concept a device or appliance of resiliency placed intraorally usually to prevent or reduce the incidence/onset of oro-dental injuries. These mouthguards fabricated primarily for contact sports are made in such a way that they protect and prevent lacerations of intra- and extra-oral soft tissues, dental fractures and avulsions, and fractures and dislocations of the jaws.[3],[4] There have been several articles written on this subject and the protection they accord for subjects undertaking various sporting activities. However, most of the literature elaborate on the player/athletes', instructors', judges', sporting or school officials' awareness and attitudes regarding protection against such injury using mouthguards.[5],[6],[7],[8] Very few articles have extolled on the attitude of dentists toward mouthguards, which is surprising, considering they are the prime point of contact in case of any sports injury to the orofacial region. What is of equal consequence is that after tooth trauma only 8% referred or visited a local dentist indicating a deficiency in knowledge/lack of awareness toward this matter.[9]

As early as 1962, organizations like the National Alliance Football Rules Committee made mouthguard protection mandatory at the high school and collegiate level.[3],[10] Since then, dentists have made an active effort to aid in the prevention of orofacial injuries occurring during athletic competitions, the inception of the Academy of Sports Dentistry in 1983 being one of the most evident endeavors. While the need for making mouthguard use mandatory for all players of contact sports is very well documented and thereby implied and understood, presently worldwide only ice hockey, football, martial arts such as taekwondo, karate, men's lacrosse, boxing (amateur and professional), and field hockey for women enforce mandatory protection by mouthguards.[7]

In 1984, Davis and Knott in their study determined that one-third of cumulative dental trauma was attributed to accidents occurring during sports.[11] Mouthguards can help in the prevention of cerebral hemorrhage and concussions as the upward displacement of the condyles against the glenoid fossa does not occur, hence, decrease the severe increase in intracranial pressure and subsequent deformation of the bone.

Generally stock, “boil or bite” or “mouth formed,” and custom made are the three types of mouthguards available.[5],[12] The stock ones come in set graded sizes and are retained by biting firmly. Boil-and-bite mouthguards are adapted for an individual after initial warm water softening, then by biting firmly finally dipping the guard in cold water to harden. The custom-made type is made first by taking an upper arch impression for Class I or Class II patients or a lower one for Class III, following which a thermoplastic sheet is thermovacuum adapted to the cast following which it is then trimmed and polished for the optimal fit. Thus, this type of guard is the most recommended one, but as described above it requires the skills of a dentist.

The anatomical and technical knowledge of the oro-facial structures and suitable appliance fabrication respective makes dental surgeons an excellent and one of the prime sources for disseminating information regarding mouthguards, their indication and how pertinent their usage is.

Thus, the aim of the study was to assess the awareness among dentists for the use and necessity of using mouthguards. It also aimed to assess the training of various specialties in fabricating a mouthguard and whether they regularly recommend one for their athletically active patients.


   Materials and Methods Top


This institutional cross-sectional survey was conducted in the Department of Orthodontics, Government Dental College, Kottayam. An online form (standardized survey form obtained from a similar study[5] and modified for the Indian Dental fraternity) was sent out to 1500 offices and departments in dental institutions through email-Annexure 1 [Additional file 1]. These offices were chosen from respective state and national dental directories of different specialties. The target subjects included general dentists, orthodontists, pedodontists, prosthodontists, oral surgeons, periodontists, endodontists, and public health dentists. A time period of 1 month was given for the willing respondents to fill out the online survey form. Those who had the ticked the option for “yes” were directed toward two further questions following which they moved on to the next subset, while those that ticked the option for “no” were directed toward one extra question. More than one response was allowed for questions that usually could be answered by a single one. These responses were subsequently summarized and reported. Respondents who answered the form after the prescribed date were not considered. This apart from non-willing respondents constituted the exclusion criteria. Each response was recorded maintaining anonymity of the respondents and analyzed using descriptive statistics (Statistical Package for the Social Sciences - SPSS version 20) (SPSS Inc., Chicago, Ill, USA), i.e., percentage of positive/negative responses.


   Results Top


Out of the 1500 survey forms sent out, we recorded a response on 640 forms; thus, enlisting a response rate of 42.67%. Following are the questions with their percentage of positive/negative responses.

Most dentists recorded a negative (85.63%, 548 dentists) in receiving training for fabrication of mouthguards during their dental education [Figure 1]. Only 4.8% (31) dentists had fabricated a mouthguard during their dental education [Figure 1], and only 9.7% (62) dentists were fabricating mouthguards in their dental practice [Figure 2].
Figure 1: Percentile distribution of the responses for questions “did you receive training for fabricating mouthguards during your dental education and did you fabricate any mouthguards during your dental education?”

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Figure 2: Percentile distribution of the responses for “if you are practicing, have you fabricated any mouthguards in your dental practice and how many years have you been in private practice?”

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Out of that, around 14.2% dentists had been in practice/teaching for <5 years, 57% have been in practice/teaching from 5 to 10 years, 14.37% had been practicing/teaching between 10 and 25 years, and 4.8% for more than 25 years [Figure 2].

Only 33.4% (214) dentists recommended mouthguards for their patients who engage in sporting activities regularly [Figure 3]. The target audience comprised orthodontists 14.2%, general dentists 16.4%, oral surgeons 14.2%, pedodontist 9.68%, endodontist 6.56%, periodontist 6.25%, oral medicine specialists 9.53%, public health dentists 6.4%, and prosthodontist 16.5% [Figure 3].
Figure 3: Percentile distribution of the responses for “do you routinely recommend mouthguards for your athletically active patients and what is your specialty or area of practice?”

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The recommended arenas of use of mouthguards, according to the dentists surveyed ranged from football (47.65%), basketball 23.75%, hockey 38.1%, martial arts such as karate and judo 71.4%, cricket 14.21%, boxing 90.62%, wrestling 90.46%, roller skating 52.34%, ice skating 38.1%, gymnastics 23.75%, tennis 4.8%, track and field events 14.21%, water sports 4.8%, and cycling 23.9% [Figure 4]. Dentists who recommended mouthguards to patients generally recommended the customized mouthguards (90.2%), followed by mouth-formed mouthguards (5%) and stock (4.8%) [Figure 4].
Figure 4: Percentile distribution of the responses for “which of the sporting activities would you recommended the usage of a mouthguard and if yes to the question of recommending mouthguards, which of following types do you usually recommend or would recommend to your patients?”

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Most were aware of the availability of more than one type of mouthguards (66.7%) [Figure 5]. However, more than half the dentists (52.35%) were not aware that different mouthguards were available for patients undergoing orthodontic treatment [Figure 5].
Figure 5: Percentile distribution of the responses for “Are you aware that there are more than one type of mouthguards available for the patient and are you aware that they are different mouthguards available for patients undergoing orthodontic treatment?”

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Moreover, the dentists who did not usually recommend mouthguards, did so because they did not have formal training (71.4%), had no responsibility to prescribe a mouthguard (14.4%), did not consider a specific health benefit to the patient (4.8%), and also that it was too costly for the patient (9.4%) [Figure 6].
Figure 6: Percentile distribution of the responses for “If you do not usually recommend mouthguards, could you kindly mention the reason for not doing so?”

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   Discussion Top


An orofacial injury is a risk for anyone who participates in contact sports competitively or sometimes during regular recreational activities as well. The majority of studies have found mouthguards to be the most effective way of preventing dental injuries, yet this treatment option is yet to be explored to its full potential. The American Dental Association has estimated that these guards prevent approximately 200,000 injuries each year at the school and collegiate level itself which is a significant number.[13] Several internationally as well as nationally conducted survey on the prevalence of facial and dental sports-related injuries have highlighted the absence of or limited awareness of mouthguards among the dental fraternity, athletes as well as the coaches. Public awareness in this subject is extremely crucial and pertinent as it serves as an important preventive measure, for which the dental surgeon has a pivotal role to play.

This study was conducted to determine the professional attitude of dental surgeons (general as well as specialists) toward the usage and fabrication of mouthguards. The recorded response rate in this study was 42.67%. This response rate was similar to the one conducted by Maestrello et al. in 1999.[5] The dentists targeted ranged from general to specialty dentists, so as to document heterogeneity of data in the awareness and practices of various dentists around the country. Most dentists (85.63%) had not received any formal training for the fabrication and use of mouthguards in the course of their dental education, and 609 out of 640 respondents revealed that they had never fabricated mouthguards during dental school. Once out into the real world of dental practice, almost 90% of the fraternity had still not fabricated a mouthguard for their patients, despite the fact our study sample included several senior dental surgeons having a good number of years to count as experience. These data highlight a gray area in the current curriculum of dental education in India, which does not take into account the sporting injuries while drafting the course of dental education, and thus underpreparing the hence passed-out dentists about the same. Castaldi, similarly in his study had mentioned the responsibility that dental schools/colleges have in promoting the up to date training required for fabricating a good mouthguard to match the forecasted need for the same at the high school and collegiate level according to the US Public Health Service.[14] In concurrence, about 84% of the dentists in Nigeria also mentioned the inadequacy of such training in Nigerian dental schools as well.[15]

Only 214 of the 640 respondents (33.4%) regularly recommended mouthguards to their athletically active patients. This is in contrast to the 71% of dentists prescribing mouthguards to similar patients in a survey in Virginia.[5] However, in a Nigerian dental survey in 2004, about 82% dentists due to lack of proper acuity and training in this subject had answered “not recommended” mouthguard protection for their patients as a response.[15] The respondents in our study ranged from general to specialty dentists, with prosthodontists (16.5%) and general dentists (16.4%) making up the majority of the dental population interviewed.

Kujala et al. in a Finland study found that sports that involved stronger (in terms of force) and repetitive body contact had shown larger overall injury rates and that a very unique injury profile was noted to be specific for a given sport.[16] Oro-dental injuries (including fractures) were most commonly seen in ice hockey and karate while least commonly so in volleyball. The authors had recommended preventive measures specific to each sport which included mouthguards, to reduce the number of violent contacts between competitors, along with improvising rules and guided by referees who exercise care and precaution. Cricket accounted for the highest repeated cause for such along with minor incidences in sports such as skating and hockey. The etiological factors of trauma due to play/sports in a study conducted in school children in a district in Southern Indian was girls about 24.5% and boys about 35.60%.[17] Ramagoni concluded that participation in various competitive sports activities showed a greater participation in cricket (72.9%) followed by football, basketball, badminton, and hockey, respectively.[18]

In our study, 14 different sporting activities were listed and the dentists were further surveyed for the type of sporting activity which mandated mouthguard use. Boxing (90.62%) and wrestling (90.46%) received a maximum response, followed by martial arts, roller skating, football, hockey, ice skating, basketball, cycling, gymnastics, cricket, track/field events, tennis, and water sports. Thus, more number of sporting activities needs mandatory mouthguard protection than what is currently practiced.

Out of the dentists who did prescribe mouthguards to their patients, almost 90.2% utilized the custom mouthguards; and 66.7% were aware that more than one type of mouthguards was available to the patient. Custom mouthguards are customized to the arch of each patient and is hence judged to be better than the standard ones. However, 52.35% respondents were not aware that there were different mouthguards available for patients undergoing orthodontic treatment.

Out of the dentists who did not routinely prescribe mouthguards, their reasons were mostly because of no formal training received, while 14.4% felt that it was not their responsibility to prescribing one, as well as mouthguards being too costly for the patient to afford and that they did not ascertain a health benefit of prescribing the same. In a similar study, respondents had indicated that this responsibility of prescribing mouthguards would fall on those who were inept to assess the oral environment cavity and to subsequently decide on a properly fitting mouthguard. Coaches, parents, local league officials are usually placed in the above-mentioned category. This resonates with our belief that not just the general public, but awareness amongst dentists of the benefits of mouthguards in preventing sports injuries, ranked an all-time low. This highlights the need to relegate responsibility to the primary point of contact after an orofacial injury, i.e., dentists. Parents may not even be aware of the heightened risk of such injury associated with competitive and recreational sporting activities which their child may be involved in. Therefore, in our humble opinion, the authors of this paper recommend that the use of mouthguards be made mandatory for all sports involving active contact and used as a precautionary tool for non-contact sports as well including recreational sports where accidental and inadvertent injury or fall may occur.


   Conclusion Top


Athletically active patients require mouthguards to prevent various sports injuries to the oro-facial region. Even though it is generally agreed on by even the dentists that contact sports require mouthguard protection, it is not a routine practice currently, among general dentists and specialists alike, in our country, to prescribe the same. It is time that the dental fraternity spread awareness and take responsibility for the prevention of such traumatic injuries since prevention is always better than cure. The authors recommend a re-look into the drafting of the academic curriculum and making it imperative for prescribing custom mouthguards to patients who are at high risk of injury due to contact sports. More such surveys are recommended on a larger scale, so as to highlight the current practice trends and spread awareness among the dental fraternity about their role in prescribing mouthguards.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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6.
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Onyeaso CO, Arowojolu MO, Okoje VN. Nigerian dentists' knowledge and attitudes towards mouthguard protection. Dent Traumatol 2004;20:187-91.  Back to cited text no. 15
    
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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