Aim To evaluate attitude towards mouthguard utilization among school children.
Methods This cross-sectional study was conducted among students of both genders, aged between 8 to 16 years, attending school in Riyadh, Saudi Arabia. A structural questionnaire was prepared consisting of questions related to the demographic details, attitude, and conception of children towards using a mouthguard. The questionnaire was sent to the school teachers to distribute among the respective school children. Descriptive statistics were used to analyze the data.
Results A total of 1116 children completed the survey form, of which 488 were female and 628 male. The prevalence of use of mouthguard among Saudi school children was found to be 3.32%. Out of the total study subjects, 72.68% of the subjects believed that mouthguards could protect them from injuries. The most common reasons for not wearing mouthguards were: they never thought about it (38.47), they felt it was not necessary (30.58%), it was expensive (11.02%), and they never had any injury (19.93%). Out of 37, 2 subjects never experienced any problem with mouthguards. The most common problems with the mouthguards were: difficulty in speech, being uncomfortable and expensive, followed by interference with breathing.
Conclusion The prevalence of mouthguard use was 3.32% in Saudi school children aged between 8-16 years. The most common reason for not using it was found to be lack of knowledge. Counseling the young children interested in sports activities is the need of the hour.
Key words: mouthguard, orofacial trauma, school children, sports injuries
*Corresponding author: Mallineni SK, Associate Professor, Department of Preventive Dental Science, College of Dentistry, Majmaah University, Al Majma’ah, Saudi Arabia, 11952. Email: drmallineni@gmail.com, s.mallineni@mu.edu.sa
Submitted: 26 October 2021; Accepted: 30 December 2021; Published: 31 January 2022
©2022 Alomar M S et al.
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International (CC BY-NC-SA 4.0). License (http://creativecommons.org/licenses/by-nc-sa/4.0/)
A mouthguard, also known as gum shield, mouth protector, or sports guard, is an appliance that covers the teeth and surrounding mucosa to prevent trauma to the dentition, gingival tissue, lips, and jaws.1 The mouthguard is usually worn on the maxillary arch, and it separates the maxillary and mandibular teeth, protecting the teeth from the surrounding soft tissue, thereby absorbing or redistributing shock and stabilizing the mandible during traumatic jaw closure.2,3 They may also help prevent concussion by absorbing the impact forces that would get transmitted through the base of the skull to the brain.4 Athletic mouthguards are intended to protect the lips and intraoral tissue from injuries, teeth fractures and avulsions, and jaws from fractures and dislocations. The three most common types of mouthguard are categorized as follows: stock mouthguards (ready to use and are believed to give the least protection), the boil and bite type (which are heated in hot water, placed in the mouth, and molded to the teeth), and custom-made mouthguards (which are usually made by the dentist on a stone model of the maxillary teeth and surrounding tissue, and are thought to give the most protection).2,4 These devices can be prepared from different materials, but ethylene-vinyl acetate is the most popular material.5
The need for such a device was realized as far back as 1927.2 In addition to the importance of utilizing a mouthguard, other studies showed that mouthguards in contact sports assume new importance in addition to preventing mechanical injury to the oral tissues.3 Subsequently, they effectively prevent oral trauma in sports, and became popular even in non-contact sports to protect the teeth, periodontal tissues, and temporomandibular joints from excessive occlusal force.4 In a Swedish county, approximately 25% of oromaxillofacial injuries occurred in the age interval of 7–30 years during the period of 1989–1990 due to sports activities.5 In addition, another study showed that sports account for 3% to 29% of facial injuries and 10% to 42% of facial fractures.6 Mouthguards or mouth protectors are the appliances worn by athletes to protect their dentition.6 Recently, there has been a significant increase in injuries caused by sports activities. To prevent or minimize such injuries, using a protective equipment such as a mouthguard can be helpful. It is the duty of a dentist to create awareness on the importance, advantages, and necessity of utilizing the mouthguard throughout the community, especially among parents to educate, influence, and encourage their children to make use of it during their daily practices, accidents, or even sports practice or exercise.
A comprehensive literature search was done using keywords “mouthguard” and “children” on PubMed from January 2000 - December 2020. The search was confined to literature in the English language, and only full text available online was taken for the analysis. The studies involving school children only were included in the study. Studies involving adults, football players, and sports persons were excluded. There were six studies available on school children, and one study was performed on both adults and children (Table 1). Fakhruddin et al.8 reported that 5.5% of the study subjects from Canada used mouthguards. Ramagoni et al.9 reported mouthguard usage of about 1.25% among South Indian school children. Another study from India reported by Sethi et al.11 found that only 4.25% used mouthguards while playing sports. Pribble et al.7 found that 14% of the American subjects used mouthguards. An Irish study10 found that 12% of the study participants use mouthguards. A Croatian study12 found that 41% of the children were using the mouthguards of 229 subjects. The literature review showed a discrepancy in the prevalence of utilization of mouthguards among school children.
Table 1. Prevalence of Mouthguard use in previous studies
| Author | Year | Place | Aim | Subjects | Age (years) | Prevalence |
|---|---|---|---|---|---|---|
| Pribble et al.7 | 2004 | United States of America | To understand factors that influence parental perceptions regarding mandatory mouthguard use in competitive youth soccer. | 120* | 11.8±1.5 | 14% wore mouthguards, and 11% suffered orofacial injuries. |
| Fakhruddin et al.8 | 2007 | Canada | To investigate the frequency of use of mouthguards among Ontario school children. | 2422 children | 12 to 14 | 5.5% of children wore mouthguards for school sports, and 20.2% wore protection in league sports. |
| Ramagoni et al.9 | 2007 | India | To assess the levels of awareness regarding orofacial injuries and the use of mouthguards. | 719 children | 11 to 14 | Mouthguard usage was about 1.25%. |
| O’Malley et al. 10 | 2012 | Ireland | To determine the extent of mouthguard use, dental trauma, and barriers to use among children. | 1111 children | 9 to 13 | Mouthguards were worn by 22% of children during sports. |
| Sethi et al. 11 | 2016 | India | To evaluate the attitude toward mouthguard utilization among 8–11-year-old athletically active school children. | 2000 children | 8 to 11 | The prevalence of mouthguard use was found to be 4.25%. |
| Galic12 | 2018 | Croatia | To assess athletes’ attitudes and habits regarding mouthguard use. | 229 children | 12.9 ± 3.2 | Most participants were aware of mouthguards for dental trauma prevention and considered them efficient for preventing dental injuries during sports activities, but only 94 (41%) used them. |
*Parents of 120 children participated in the study
Additionally, the mouthguard seems not a comfortable device, especially for very young children, according to a study conducted with the aim to examine children’s compliance on wearing mouthguards at the Hadassah School of Dental Medicine, who received free mouthguards.13 The prevalence of mouthguard use has been reported be low in various studies conducted across the globe.7-12 However, educating and motivating the children and their parents is an important key to reducing the prevalence of injuries. Also, the dentist plays such an important role in the procedure. Thus, the present study aimed to evaluate the attitude towards mouthguard utilization among 8-16 year old participants who are athletically active in the Arabic children schools.
A cross-sectional survey was conducted among the children aged between 8 to 16 years of both genders in Saudi Government schools. A stratified random sampling was used to select the children from government schools across different provinces of Riyadh, Saudi Arabia. A total of 20 schools were selected, from which a sample of 1116 was considered for the present study. Consent was taken from the parents of the included children.
Inclusion criteria: The children of both genders between the ages of 8-16 in Saudi Arabia, and those active in sports activities of the schools were included in the study.
Exclusion criteria: The adults of both genders in Saudi Arabia were excluded. Children who never participated in any sports activities were also not considered as study subjects for the present study.
Questionnaire: The questionnaire was prepared in English and the local language by the Senior Pediatric Dentist based on the previous studies.11 A pilot study was conducted on 50 school children (not included in the final analysis) to check the validity of the questionnaire. The confusion related to the questionnaire was critically analyzed, and the questions were accordingly modified. The questionnaires were given to the respective teachers to distribute to the included children. The questionnaire included information about the use of any type of mouthguard, their conceptions regarding the protective part of the mouthguard, and the reason for not using it. The mouthguard users were asked about their age, and their attitude towards playing without a mouthguard. The ethical approval was received from Deanship of scientific research, Majmaah University, Al Majama’ah, Saudi Arabia. The distribution of questionnaires and data collection was done a month after the initial approval from the university ethical committee. Also, the children were asked about the problems associated with mouthguard usage. Children were given 5 minutes to read and fill the questionnaire; in case of any confusion, they were free to ask their doubts from the author (present to help, in case of any doubt only).
The responses from the participants were computed into a Microsoft Excel worksheet, and then coded, cleaned, and analyzed using SPSS (version 17.0, Chicago, USA) used for descriptive statistics.
A total of 1116 children filled the survey form. Of the 1116 children who filled the survey form, 488 (43.72%) of them were female and 628 (56.27%) were male (Table 2). Most of the included subjects were 13 years old. The prevalence of mouthguard use was found to be 3.32%. Out of 37, 25 students used the boil and bite mouthguards, while the remaining 12 used custom-fabricated mouthguards. Male students (28) were more comfortable wearing the mouthguard than girls (9). The reasons for not wearing mouthguards included: being expensive (11.02%), not necessary (30.58%), lack of knowledge (Never thought about it), and never having any sports injury. A total of 72.68% believed that mouthguards could protect them from injuries, while 23.56% did not believe in using the mouthguards (Table 2). When asked about the age at which the children started using mouthguards, out of 37 subjects, 21 (56.76%) participants reported that they started using it at the age of 10, and only 5 (13.51%) were found using it from an age lesser than 5 years. When asked about their feeling while playing or training without using mouthguards, 26 (70.28%) children said that they would be willing to play without a mouthguard, while four children said that they would be reluctant to play without a mouthguard, and only seven subjects accepted that they would not play without it. Of the total 37 subjects who wore mouthguards, 2 (5.40%) subjects never experienced problems with their mouthguard. However, the common problems faced by the subjects are: difficulty in speaking, discomfort, affects the looks, feels loose, interferes with breathing, and expensive (Table 3).
Table 2. Demographic characteristics of the study participants
| Details | N | % | |
|---|---|---|---|
| Age | 9 | 24 | 2.2% |
| 10 | 169 | 15.1% | |
| 11 | 246 | 22.0% | |
| 12 | 218 | 19.5% | |
| 13 | 326 | 29.2% | |
| 14 | 98 | 8.8% | |
| 15 | 32 | 2.9% | |
| 16 | 3 | 0.3% | |
| Gender | Female | 488 | 43.7% |
| Male | 628 | 56.3% | |
| Class | Fifth-grade primary school | 257 | 23.0% |
| First-grade intermediate school | 315 | 28.2% | |
| Fourth-grade primary school | 171 | 15.3% | |
| Second-grade intermediate school | 118 | 10.6% | |
| Sixth-grade primary school | 230 | 20.6% | |
| Third-grade intermediate school | 25 | 2.2% | |
Table 3. Overall responses of the study participants
| Question | Response | N | % |
|---|---|---|---|
| Have you ever used mouthguards? | No | 1079 | 96.68% |
| Yes | 37 | 3.32% | |
| If yes, what mouthguard do you use? N=37 | Boil and bite | 25 | 2.24% |
| Custom made | 12 | 1.08% | |
| If no, why? N=1079 | It is not necessary | 330 | 30.58% |
| Never had an injury | 215 | 19.93% | |
| Never thought about it | 415 | 38.47% | |
| Too expensive | 119 | 11.02% | |
| Do you believe that mouthguards protect your teeth? N=1116 | Don’t know | 42 | 3.76% |
| No | 263 | 23.56% | |
| Yes | 811 | 72.68% | |
| How old were you when you first started wearing a mouthguard? N=37 | 10 years | 21 | 56.76% |
| 8 years | 6 | 16.22% | |
| 6 years | 5 | 13.51% | |
| Less than 5 years | 5 | 13.51% | |
| How would you feel before playing or training without using your mouthguard? N=37 | I would be reluctant to play without it | 4 | 10.81% |
| I would be willing to play without it | 26 | 70.28% | |
| I would not play without it | 7 | 18.91% | |
| Have you ever experienced problems with your mouthguard? N=37 | May be | 16 | 43.24% |
| No | 2 | 5.40% | |
| Yes | 19 | 51.36% | |
| What problems do you think are to occur after wearing a mouthguard? N=35 (may choose more than 1 option) | Difficult to speak | 22 | 59.45% |
| Don’t know about it | 1 | 2.7% | |
| Feels loose | 5 | 13.5% | |
| Interferes with breathing | 8 | 21.6% | |
| Too expensive | 11 | 29.7% | |
| Uncomfortable/ does not look good | 20 | 54.0% |
Many children traumatize their anterior teeth even before reaching adolescence during sports activities. Mouthguards are designed for young athletes to prevent such orofacial injuries. With this background, the present study was designed to evaluate the attitude of 8-16 years old athletically active school children in Saudi Arabia towards mouthguard utilization. In the present study, out of 1116 participants, 2.24% used the boil and bite mouthguards. In the survey conducted by Sethi et al.11 it was found to be 3.65%, which is in concordance with the present study. However, the survey conducted by Fakhruddin et al.8 reported that 48.2% of the subjects wore boil and bite mouthguards. Custom made mouthguards were worn by 12 out of 37 subjects in the present study, similar to the survey conducted by Sethi et al.11 High impact activities like martial arts, football, wrestling, and boxing can cause serious health risks if not played correctly. The impact of these sports can lead to avulsed teeth, facial injuries, and fractured facial bones. In this study, 72.68% of the children believed that mouthguards could protect them from injuries. Similar to the present study results, other authors9,11 found that 73.2% and 78.2% of the population, respectively, had a positive knowledge about the protective role of mouthguards. Biagi et al.14 from Italy reported that 80% of the population believed that mouthguards could protect their teeth from sports injuries. On the other hand, 23.56% of the population of this study believed that mouthguards do not protect them from injuries, while Perunski et al.15 reported it as 60%, which is not in favor with the present research. Sethi et al.11 reported that 21.8% of the children believed that mouthguards do not protect them from injuries, which is in favor of this study. An athletic mouthguard should be placed inside the mouth to reduce direct and indirect impact on the teeth and the surrounding structures. This must be inculcated in children from the very beginning by their respective coaches, parents, and dentist. A review by Yadiki et al.16 highlights the awareness and utilization of mouthguards and reasons for not wearing the mouthguards. In the present study, when the children were asked about the reasons behind not wearing a mouthguard, 38.53% revealed that they never thought about it, and 28.6% revealed that they could not see a reason to wear one. While 55.51% and 17.91% respectively selected the same option in a south Indian study.11 This could be probably due to a lack of knowledge among the study participants. Proper guidance must be provided to the children regarding the protective effects of mouthguards during sports to avoid sports related dentofacial injury. Furthermore, in this study, only 9% of the population did not wear the mouthguards as they are too expensive. Sethi et al.11 found it as 10.81%, favoring the present study. Matalon et al.13 reported the compliance of children and youngsters in the use of mouthguards. It was reported that 20.8% of children had never possessed a mouthguard due to its significant expense.
Among the participants in the present study using mouthguards, 21(56.76%) of the 37 subjects started using the mouthguards at the age of 10 years, followed by 16.22% at the age of 8 years. The results are in concordance with the study conducted by Sethi et al.11. It could be attributed to children becoming sports oriented around 8-10 years of age. When we asked about their attitude towards the use of mouthguards, 70.28% of the participants were willing to play without them. They never suffered from any orofacial injuries while playing any sports. Sethi et al.1 found it as 74%. The findings from the study by Sethi et al. are in favor of the present study. When asked if they faced any problems with mouthguards, most said that it caused difficulty in speaking (59.45%), followed by being uncomfortable/does not look good (54%). In another study on the compliance of children and youngsters in the use of mouthguards, 44.9% reported that they did not wear the mouthguards because they forgot, and 42% reported that the reason for not wearing the appliance was because it was not comfortable.13 A Canadian study8 reported that a high proportion of ill-fitting mouthguards was the major contributor to the commonly perceived problems of speech, breathing discomfort, and poor appearance associated with mouthguard use.8 Further studies also reported the reason for not wearing mouthguard as: impaired breathing, is too expensive, feels loose, and interferes with breathing.8-11 Children who participate in contact games are more prone to dental injuries. Hence, it is imperative to wear mouthguards to avoid dental trauma in those children and be aware of oral health.17-18 Furthermore, wearing mouthguards during non-contact events such as skateboarding, biking, and mountain climbing also benefit the children. The percentage of children using mouthguards is low in the present study despite having a lack of awareness regarding mouthguards. The usage of mouthguards in the study population is very low, and it is imperative to educate the school children regarding the mouthguard. Traumatic dental injuries (like avulsion, laceration, etc.) are more common among preschool and young school children. So, it is essential to teach children about mouthguards at a very early stage when they are naïve in the sports field. It is known that trainers have a massive influence on the attitude of their players. They follow their teachers’ instruction much better than anyone else. So, coaches/Trainers can educate the school children and their parents about the risk of dentofacial injuries associated with contact sports and the cost and morbidity they carry. Wearing of mouthguards during sports activities should be compulsory during practice and competition events.19,20 Moreover, as parents have knowledge about the significance of using protective appliances and mouthguards during sports activities, they might be encouraged to look for the use of mouthguards for their children. In layman language, mouthguards help to prevent broken and chipped teeth. They protect the child’s lips, tongue, and face and help redistribute forces. The American Dental Association recommends wearing custom mouthguards for the following sports: basketball, boxing, field hockey, football, gymnastics, handball, ice hockey, lacrosse, martial arts, racquetball, roller hockey, skateboarding, skiing, skydiving, soccer, squash, and surfing.21 Hence, mouthguards should be a mandatory equipment in sports activities, and awareness should be raised among children and their parents.22 Even though the study has a reasonably good sample size, the comparisons were not made based on gender and education. However, these are considered potential limitations. This study could stand as a good reference for further research. This study also explains the need to create awareness regarding mouthguards among school children. Future studies must be conducted in different parts of the country with more sample size. Also, the Arabic population must be educated about the importance of mouthguards.
It was evident that the attitude of the enrolled children toward the protection role of mouthguards was positive, and most of the participants (96.68%) were not using it due to the lack of guidance by their parents, dentists, or coaches. Thus, increasing awareness in children about the risk of injuries, and focusing on the protective role of mouthguards at an early age is recommended. Dentists need to recommend a properly fitted custom made mouthguard to improve the positive attitude towards mouthguards and decrease its problems.
The raw data supporting the conclusions of this article will be made available by the authors without undue reservation.
The authors declare that there is no conflict of interest.
The study was approved by the institutional ethical committee, Majmaah University, Saudi Arabia, under the No MUREC-September.16/COM-2021/5-2.
The authors would like to thank the Deanship of Scientific Research at Majmaah University for supporting this work.
1. Green JI. The Role of Mouthguards in Preventing and Reducing Sports-related Trauma. Prim Dent J. 2017 May 1;6(2):27–34. 10.1308/205016817821281738
2. Watts G, Woolard A, Singer CE. Functional mouth protectors for contact sports. JADA. 1954;49(1):7–11. 10.14219/jada.archive.1954.0132
3. Hickey JC, Morris AL, Carlson LD, Seward TE. The relation of mouth protectors to cranial pressure and deformation. JADA. 1967;74(4):735–740. 10.14219/jada.archive.1967.0145
4. Takahashi M, Koide K, Mizuhashi F. Influence of color difference of mouthguard sheet on thickness after forming. J Prosthodont Res. 2012;56(3):194–203. 10.1016/j.jpor.2011.11.002
5. Eilert-Petersson E, Andersson L, So¨rensen S. Traumatic oral vs non-oral injuries. An epidemiological study during one year in a Swedish county. Swed Dent J. 1997;21:55–68.
6. Magunacelaya MB, Glendor U. Surfing for mouth guards: assessing quality of online information. Dent Traumatol. 2011 Oct;27(5):334–43. 10.1111/j.1600-9657.2011.01017.x
7. Matalon V, Brin I, Moskovitz M, Ram D. compliance of children and youngsters in the use of mouth guard. Dent tramatol.2008 Aug;24(4):462. 10.1111/j.1600-9657.2008.00600.x
8. Fakhruddin KS, Lawrence HP, Kenny DJ, Locker D. Use of mouthguards among 12-to 14-year-old Ontario schoolchildren. J Can Dent Assoc. 2007;73:505.
9. Ramagoni NK, Shetty YR, Hegde AM. Do our children play safe? J Clin Pediatr Dent. 2007;31:160–3.10.17796/jcpd.31.3.br41784v5u852p6t
10. Sethi HS, Kaur G, Mangat SS, Gupta A, Singh I, Munjal D. Attitude toward mouthguard utilization among North Indian school children. J IntSocPrev Community Dent. 2016;6(1):69–74. 10.4103/2231-0762.175417
11. Pribble JM, Maio RF, Freed GL. Parental perceptions regarding mandatory mouthguard use in competitive youth soccer. Inj Prev. 2004;10:159–62. 10.1136/ip.2003.004754
12. Galic T, Kuncic D, Pericic TP, Galic I, Mihanovic F, Bozic J, et al. Knowledge and attitudes about sports-related dental injuries and mouthguard use in young athletes in four different contact sports-water polo, karate, taekwondo and handball. Dental traumatology 2018;34(3):135–213.10.1111/edt.12394
13. O’Malley M, Evans, DS, Hewson A, Owens J. Mouthguard use and dental injury in sport: a questionnaire study of national school children in the west of Ireland. Journal of the Irish Dental Association. 58(4):205–211.
14. Biagi R, Cardarelli F, Butti AC, Salvato A. Sports-related dental injuries: Knowledge of first aid and mouthguard use in a sample of Italian children and youngsters. Eur J Paediatr Dent. 2010;11:66–70.
15. Perunski S, Lang B, Pohl Y, Filippi A. Level of information concerning dental Injuries and their prevention in Swiss basketball--a survey among players and coaches. Dent Traumatol. 2005; 21:195–200. 10.1111/j.1600-9657.2005.00310.x
16. Yadiki J, Alshammari NTT, Awareness and Utilization of Mouthguards- An Overview. Saudi Journal of Oral and Dental Research. June 2019;4(6):359–365.
17. AlBlehed AK, AlThumairy AF, AlTurayri WS, Alassaf A , Almulhim B, Alghamdi S, et al. Assessment of knowledge, attitude and practices regarding oral hygiene followed by parents of preschool children in Riyadh, Saudi Arabia: A cross-sectional study. Ann Med Health Sci Res. 2021;11:S2:82–86.
18. Alyousef AM, Almehrej BA, Alshahrani MA, Almutairi KM, Muhannad Abdulrahman Alqasir MA, Alassaf A, et al. Arabian parents’ knowledge, attitude, and practice towards their children’s oral health and early childhood caries resided in Riyadh Province: An online-based crosssectional survey. Ann Med Health Sci Res. 2021;11:S2:73–81.
19. Goswami M, Kumar P, Bhushan U. Evaluation of knowledge, awareness, and occurrence of dental injuries in participant children during sports in new Delhi: A pilot study. Int J Clin Pediatr Dent 2017;10(4):373–378. 10.5005/jp-journals-10005-1468
20. Sathyaprasad S, Philip PA, Vijaynath S, Neethu SK, Rekha R. Attitude and awareness of using mouthguard among physical instructors in Sullia: A questionnaire study. J Dent Res Rev. 2018;5:124–7. 10.4103/jdrr.jdrr_41_18
21. American Dental Association. Using mouthguards to reduce the incidence and severity of sports-related oral injuries, JADA. 2006;137(12):1712–1720.10.14219/jada.archive.2006.0118
22. Gregoric S, Vranic ND, Bakarcic D, Ivancic Jokic N. Parental knowledge and attitudes toward dental trauma and prevention in handball and basketball athletes in Rijeka, Croatia. Madridge J Dent Oral Surg. 2016;1(1):1–3. 10.18689/mjdl-1000101