US Lacrosse Sports Science & Safety Committee
Position Statement on the Use of Mouth Guards in Lacrosse
(Adopted: October 29, 2003)

I. Data on Oral-Facial Injuries in Sports
In any sport where an object flies through the air such as a ball or puck; where an object is used to hit the flying object such as a bat, stick, or racquet; or where incidental or purposeful contact with another player is likely; the incidence of oral-facial injuries has been shown to be very significant. Some of these injuries can be fairly minor with only soft tissue damage such as a bruise or scrape. However, many are more serious injuries resulting in expensive and long term care and significant pain and inconvenience. Dental fractures, avulsed teeth, facial fractures, concussion, or permanent severe damage to an eye with total loss of vision are reported in organized sports. These types of injuries occur less frequently but with equal severity and complications in recreational activities like cycling, skate boarding, surfing, skiing, etc. More than 5 million teeth are knocked out each year during sports activities according to one survey.

An athlete participating in contact sports has a 10% chance of sustaining a significant oral-facial injury each season and better than a 50% chance during his/her secondary school career. Men’s and women’s lacrosse rank 8^th and 10^th respectively for injuries per exposure during games and 13^th and 11^th respectively in practices of the 16 teams followed by the NCAA.A significant number of these injuries involve the face, and mouth, especially in women’s lacrosse.

In lacrosse, like many other sports, players have gotten faster, stronger and more skilled and equipment has also been improved with a resultant increase in the speed of balls and the speed of the stick when it is being utilized. As these factors have altered the nature of many sports in a manner that increases injury risk, often rule changes have not kept pace to reflect needed protection to enhance safety.

II. Evidence of Benefit if Mouth Guard Use
Unequivocal data has been reported in study after study by the American Dental Association, American Academy of Pediatric Dentistry, American Academy for Sports Dentistry, and other medical groups that convincingly show the reduction of oral-facial injuries with the use of mouth guards. These specifically include decreased chipping and fracturing of teeth and teeth roots, protection of lips, cheeks and gums, decreased jaw fractures, protection of toothless spaces in an athlete's mouth and protection of teeth and soft tissue in those wearing dental appliances like braces. One of the smallest, least expensive, and most effective piece of protective equipment that is available for athletes is a mouth guard.

Prior to the use of mouth guards and facemasks, over 50% of football players' injuries were oral-facial. Now they represent less than 1% of injuries. In a study involving hockey and several other collision sports, the sport with most collisions (hockey) had the lowest percentage of dental injuries. This was attributed to the greater than 90% mouth guard use in this particular survey. By comparison soccer reported 1.4% use, basketball 2.1% utilization, and handball showed 4.0% use. A study comparing oral-facial injuries in basketball showed a 7 times higher incidence of this type of injury in those not wearing mouth guards compared to those that did wear them.Information on the compliance rate of mouth guard use in lacrosse is not available.

There is now being reported some data to support the concept that a proper fitting mouth guard may also decrease the incidence and/or severity of concussions and even upper extremity stingers. The evidence is not as definitive for this purported benefit but is gaining converts as more data is released. Specific information on mouth guard thickness (>3mm) is now described for effective prevention of Minimal Traumatic Brain Injury (MTBI).

III. Philosophy on Use
Whether or not mouth guards decrease the incidence and/or severity of MTBI, the protection of teeth and the oral-facial area is reason enough to consider use of mouth guards in nearly all sports, organized and recreational, where risk is significant. Sports medicine societies and organizations uniformly recommend use of mouth guards for football, lacrosse, basketball, soccer, field hockey, ice hockey, wrestling, and volleyball. The ADA and Academy of Sports Dentistry add many other sports to their recommended use list: baseball, gymnastics, shot put, tennis, acrobatics, boxing, handball, martial arts, racquetball, roller hockey, rugby, skate boarding, skiing, skydiving, squash, surfing, water polo and weight lifting.

Properly educated about the risks and benefits surrounding mouth guard usage, every parent should require their children and every athlete should want to consistently wear mouth guards during participation to avoid the pain, disfigurement and great cost of dealing with damaged teeth or an injured mouth. Coaches, too, should want to avoid these injuries to minimize lost participation time of athletes. Most researchers feel that the rate of dental and mouth injuries is much higher than the reported incidence. This occurs for many reasons including the fact that frequently no time loss occurs from participation with these injuries. It is also important to point out that the cost for treatment of dental injuries alone, without consideration of other facial injuries, is disproportionately high compared to such injuries as a broken arm. Initial management is estimated to be in excess of $1000. It is not uncommon for ongoing problems and expenses to occur for needed root canals, crown replacements every ten years, and other very expensive follow-up if bone resortionoccurs with an avulsed tooth. Nearly all of these expenses and ongoing difficulties can be prevented with a $20 mouth guard.

Intuitively, the choice to wear a mouth guard would seem to be a no-brainer for athletes, parents, and coaches. Why do athletes choose not to voluntarily utilize a mouth guard? Even more surprising, why are athletes and even parents so resistant to using mouth guards? Why are mouth guards not mandated in all sports? Why is there such low compliance in the few sports where it is required?

Strong resistance to mouth guard use has occurred in a number of states and with a number of sports where attempts have been made to implement mandated use. The first argument is always that mouth guards are uncomfortable, inhibit good communication with team members, and might be dangerous by facilitating choking or breathing difficulties. Another argument is the concern about additional cost to an athlete and his/her family to participate if a mouth guard is required. Yet another argument against use of mouth guards is concern that additional protective equipment will produce a false sense of security and lead to more aggressive play that could alter the nature of the game and increase risk.

A properly fitting mouth guard has been shown consistently not to impede communication, breathing, or create any hazards to the airway or oral cavity. The box below shows the types of mouth guards available and the relative advantages and disadvantages of each.

TYPE OF MOUTH GUARD	ADVANTAGES	DISADVANTAGES
Stock	Cheap	Doesn't fit as well Poor compliance
Boil and Bite	Accessible Fits well Inexpensive Removable strap	Deteriorate over time Pressure on cheeks and gums If not fitted well
Custom Made	Most protection Most comfortable	Most expensive Several trips to dentist needed

Two additional problems exist with reference to mouth guard use. One is the tendency to alter the mouth guard for actual participation. Many youngsters do this for comfort and communication, especially if they do not have a properly fitting guard. Many others do this to hide its presence because of peer pressure to not use a mouth guard. The other problem is the failure of referees to enforce the rules in sports where such devices are mandated. A study conducted on NCAA ice hockey showed 93% of certified athletic trainers acknowledged the benefits of mouth guards, but only 74% of coaches and medical staff enforced use.Only 63% of players consistently wore mouth guards. Only 19 penalties were reported during the entire season on 94 teams who answered the survey.

IV. Recommendation on Mouth Guard Use

• There is a significant incidence of oral-facial injury in men’s and women’s lacrosse.
• The pain, inconvenience, and expense can be very significant from dental injury.
• Mouth guard use has been shown to reduce the injury rate significantly in sports where it has been mandated.
• Voluntary use of mouth guards shows very low compliance.
• There is no contraindication or indications that the use of mouth guards creates any adverse effect on the game of lacrosse or the safety of the participants.
• Many lacrosse players who wear mouth guards do so only for games when officials will check to see that they are using a mouth guards, but they don’t use them during practice.
• Many lacrosse players alter the integrity of the mouth guard by cutting some of the guard, especially over the back molars, and this decreases the safety effectiveness of the mouth guard.

Therefore, the US Lacrosse Sports Science and Safety Committee recommends the following actions:

1. Mandate mouth guard use in all practices and games at any level of play in which mouth guards are not currently required.

2. At those levels of play in which mouth guards are currently required, reinforce the mandate that all lacrosse players at all levels wear a mouth guard during all practices and all games.

3. Educate coaches, who have the most influence on their players, to enforce the use of mouth guards at all times.

4. Educate athletes and parents about the value of mouth guards and the proper use of this effective safety equipment.

5. Require officials to regularly check for mouth guard use and/or alteration. Institute mouth guard spot checks throughout games, like stick checks, to ensure they are being used throughout the game. Require bright colored mouth guards so that officials can more easily monitor use.