Overcoming Objections: Providing Professionally Made Custom Mouthguards Ray Padilla, DDS

Dentistry today, Septiembre 2000

While sitting at home one evening reading my dental journals and newsletters, I came across an article written by Robert Davis, DDS, editor of Tools 'R' Us, an excellent subscription newsletter on dental technology. He was describing in editorial form why some dentists don't use modern technology. It really hit home with me because I often ask myself the similar frustrating question, "Why don't most dentists prescribe and make custom-made mouthguards for their patients?" The objections Davis ascribed to using modem technology were the exact same excuses many dentists use to explain why they avoid providing this important preventive modality.

As I lecture throughout the nation on oralfacial trauma treatment and prevention, I am struck by the amazing list of objections to diagnosing and providing professionally made custom mouthguards to our patients. It is sometimes difficult and threatening to attempt new modalities in dentistry. Remember the first time we heard of someone introducing acid etching? How dare we use acid in the mouth! Don't place the acid on the dentin. Remember porcelain veneers? They are too thin. No metal backing. They will break. No way will we use them!

A Tools 'R' Us motto is appropriate in such situations: "The mind is like a parachute, it only functions well when open."

OVERCOMING OBJECTIONS

Here is a partial list of objections to dental technology we have all heard. These same objections apply to mouthguards:

Objection No.1: They are too expensive

This is relative. Expensive as compared to what? Reconstructive surgery? Cosmetic porcelain dentistry? Pain and disfigurement? If you are comparing the price to an over-the- counter mouthguard found in stores, then I invite you to investigate the true protective properties of these ill-fitting, uncomfortable pieces of plastic.

There are advantages to being the first dentist in your community to provide professionally made mouth-guards. I receive many of my new patients from the mouthguard program I offer in my office. But that is not why I do it. The bottom line is you are providing a higher standard of care. A health professional is diagnosing and providing the dental prostheses, not a sporting goodsretailer.

Objection No.2: It doesn't work

There are many new innovations in mouthguard design, fit, and compliance that are working successfully in the hands of dentists. Dental laboratories are now providing pressure-laminated mouthguards, which are relatively new to the United States.

The dental literature cites the many differences between store-bought mouthguards and professionally made custom mouthguards. But many of our colleagues still persist in keeping their heads firmly anchored in the sand by raising yet another objection.

Objection No.3: My patients won't go for it

Not unless we educate them. Dialogues are important. You need to be knowledgeable and familiar with the differences between store bought and professionally made custom mouthguards. It is important that you believe in what you are doing. When it sounds and feels right to your patients, they will accept it. They trust your professional judgment. That is why they are seeking your professional opinions. We are all in a lot of trouble when our patients seek the help of the sporting goods retailer rather than us for their dental trauma prevention.

Objection No.4: My staff won't go for it

Same story as No.3. You will be surprised. Lay some groundwork. Have a meeting and explain what you want to do, and why! Invite their input. It works. However, I have spoken to staffs who see the need and advantages to both the doctors and the patients, but the doctors still won't do it.

Objective No.5: It isn't proven yet

That depends on what type of "proof " you require. If it is encouraged and endorsed in the literature, supported by the dental associations, and somebody somewhere is doing it and it is working, it is probably worth investigating. If you want more proof, attend Continuing Education courses provided on this subject, especially the annual symposium sponsored by the Academy for Sports Dentistry.

Objection No.6 Insurance won't pay for it

This is not a reason to do or not do anything in dentistry. Dental insurance is drying up. In fact, it really isn't insurance at all. It's now just a prepaid benefit that is nice but will never pay for much of what patients need anymore. Patients don't have Nike or gasoline insurance, but they still buy Nike shoes and gas. They will "buy" dentistry and professionally made protective mouthguards in the same way if they can just see the benefit. Educate your patients. Let them decide.

Objective No.7: Where is the literature on mouthguards?

There is a great deal of literature on this subject. Refer to http://www.sportsdentistry.com for a partial bibliography and literature on athletic mouthguards. Join the Academy for Sports Dentistry for ongoing information on the subject. How long does it take to accept the literature and how much is enough? With low-risk technologies, there is little need to wait dozens of years for the literature to catch up with the innovation. Pressure-laminated mouthguards have been in use in Europe and Australia for at least 14 years. Their papers endorse this mouthguard. They play football (rugby) in shorts and tee shirts without helmets and pads. Who are we to question them?

Objection No.8: It might be dangerous

For whom, the dentist or the patient? Education and training relieve anxiety. If we see a technology that is attractive and useful, we should go and get training. Find a mentor. Spend some time on it. What is dangerous about providing a higher quality of care and keeping our patients away from the denturists of mouthguards, the sporting goods retailers? Our patients are in danger of receiving dental care from a non-health professional. That is the true danger.

Objection No.9: It's just a fad

If it is generating better patient care, it probably isn't a fad. Fads come and go quickly. Solid innovations and technology endure. Those calling it a fad are those not involved in it. Our patients deserve better.

Objective No.10. I could get sued

In today's legal climate you could get sued for anything. Use good judgment. Provide a high standard of care. Get some good training. Be nice to your patients. I'm more concerned about getting sued for "failure to disclose" to our patients that there is such a thing as a professionally made custom mouthguard. What if they get injured wearing a store-bought mouthguard (and I have many cases demonstrating such injuries) and then say that their dentist did not disclose to them that there was something better? Let our patients make the final decisions on what they want to wear. Disclose all options for an educated decision.

Objection No.11: Oh, that old thing (dentists' reaction when the term "mouthguard" is used)

The final "kiss off' excuse. The doctor has now waited so long that the technology has become merely "mainstream," and not worthy of his/her full disdain, only a brief dismissal.

How sad that so much good technology is not experienced because of all these excuses. As dentists and health professionals, we can provide professionally made mouthguards for our patients. There are many advantages to wearing professionally made custom mouthguards for both the patient and the dentist. Don't let salesmen and sporting goods retailers tell you that the over-the-counter, boil-and-bite mouthguards are custom-made. Their packaging methods are deceiving. By definition, according to the American Society for Testing and Materials (ASTM), custom-made means fabricated from an impression and model of the mouth.

TYPES OF MOUTHGUARDS

The following types of mouthguards are currently available:

Stock Mouthguard

The stock mouthguard, available at most sporting good stores, comes in limited sizes (usually small, medium, and large). This so-called protector is ready to be used without any further preparation; simply remove from the package and immediately place in the mouth. It is bulky and lacks any retention, and therefore must be held in place by constantly biting down. This interferes with speech and breathing, making the stock mouthguard the least acceptable and least protective. This type of mouthguard is often altered and cut by the athlete in an attempt to make it more comfortable, further reducing the protective properties of the mouthguard. It has been suggested and advised in the medical/dental literature that this type of mouthguard not be worn due to its lack of retention and protective properties.

Boil-and-Bite Mouthguard

Presently, this is the most commonly used mouthguard on the market. Made from thermoplastic material, it is immersed in boiling water and formed in the mouth by using finger, tongue, and biting pressure. Available in limited sizes, this mouth- guard often lacks proper extensions. Athletes also cut and alter this bulky and ill-fitting mouthguard due to its poor fit, poor retention, and gagging effects. This in turn further reduces the protective properties of it. When the athlete cuts the posterior borders or bites through the mouthguard during forming, chances of injury are increased, especially concussion from a blow to the chin. Some of these injuries, such as concussion, can cause lifelong effects. Certain thicknesses and extensions are necessary for proper mouthguard protection.

Joan Park, et al, at the First International Symposium on Biomaterials in August of 1993, reported that boil-and-bite mouthguards provide a false sense of protection due to the dramatic p. decrease in thickness occlusally during the molding and fabrication process. The investigators further stated that "Unless dramatic improvements are made, they [boil-and-bite mouthguards] should not be promoted to patients as they are now." They reported that boil-and-bite mouthguards decrease in occlusal thickness 70% to if 99% during molding, thus taking away the protective properties of the mouthguard.

Care should be taken by the public when bombarded with clever marketing schemes, claims, and promotions in sporting goods stores by stock and boil-and-bite a mouthguard companies. The bottom line is that stock and boil-and-bite mouthguards do not provide the expected care and injury prevention that a properly diagnosed and fabricated, custom-made mouthguard does.

Custom-made Mouthguards

This type of mouthguard is supplied by the dentist. Custom mouthguards provide the dentist with the critical ability to address many important issues in the fitting f of the mouthguard. Several questions must be answered before the custom mouthguard can be fabricated. These questions include those addressed at the preseason screening or dental examination. Is the mouthguard designed for the particular sport being played? Is the age of the patient and the possibility of providing space for erupting teeth in mixed dentition (ages 6 to 12) going to affect the mouthguard? Will the design of the mouthguard be appropriate for the level of competition being played? Does the patient have any history of previous dental injury or concussion, thus needing additiona1 protection in any specific area? Is the patient undergoing orthodontic treatment? Does the patient present with cavities and/or missing teeth? These are important questions the sporting goods store retailer and the boil-and-bite mouthguard cannot being to address.

Custom-made mouthguards are designed by the dentist and are the most satisfactory of all types of mouth protectors. They fulfill all the criteria for adaptation, retention, comfort, and stability of material. They interfere the least with speaking and have virtually no effect on breathing. There are two categories of custom mouthguards, the vacuum mouthguard and the pressure-laminated mouthguard.

The vacuum mouthguard is made from a stone cast of the mouth, usually of the maxillary (upper) arch, using an impression (mold) fabricated by the dentist. A thermoplastic mouthguard material is adapted over the cast with a special vacuum machine. The most common material for this use is a polyethylene vinyl acetate-EVA) copolymer. The vacuum mouthguard is then trimmed and polished to allow for proper tooth and gum adaptation. All posterior teeth should be covered and muscle attachments should be unimpinged. Vacuum machines are adequate for single-layer mouthguards. However, it is now being shown in the dental literature that multi- ple-layer mouthguards (laboratory pressure-laminated) l may be preferred to the single-layer vacuum mouthguards. It should be noted that these vacuum custom mouthguards are still superior to the store-bought stock and boil-and-bite mouthguards because they have a much better fit, being l made from a mold of the patient's mouth, and designed by the patient's dentist.

The laboratory pressure-laminated mouthguard, also made from a stone cast, is a custom-made multiple-layered mouthguard that has been considered the state-of-the-art mouthguard in Europe and Australia for years. It can be modified for full-contact sports by laminating two or three layers of EVA material to achieve the necessary thickness. Lamination is defined as the layering of mouthguard material to achieve defined end result chemically fuse under high heat and pressure with machines such as the Drufomat, the Erkopress 2004, or the Biostar.

Protective thickness is important because as the thickness of the mouthguard material increases logarithmically, the transmitted impact force decreases logarithmically. Dr. Keith Hunter, an Australian sports dentist, reported that mouthguards should be of a certain thickness, without being bulky. He suggests a labial thickness of 3 mm, palatal thickness of 2 mm, and occlusal thickness of 3 mm. The mouthguard material should be biocompatible, have good physical properties, and last for at least 2 years. These are recommended thicknesses. It should be noted that each athlete should be evaluated individually for thickness and design to promote comfort and sufficient protection.

Dr. Hunter further states the advantages of press-formed lamination to be:

1. Precise adaptation.

2. Negligible deformation when worn for a period of time. The combination of the relatively high heat and pressure used in construction of laminated mouthguards means the mouthguard material has virtually no elastic memory.

3. The ability to thicken any area as required as , well as place any inserts that may be needed for additional wearer protection.

Mouthguards must maintain minimal and consistent thicknesses in critical areas. These thicknesses may have I to vary according to the athlete's individual needs for optimal protection. The thicker I materials (3 to 4 mm) are 1 more effective in absorbing impact energy, and the thinner materials show marked deformation at the site of impact. These mouthguards are not bulky and uncomfortable.

The clinician cannot expect that one sheet of 3-mm thick material will remain 3mm thick after fabrication. This is a physical impossibility due to shrinkage during fabrication adaptation. Vacuuming a "commercially laminated" 3-mm sheet of EVA gives the same unsatisfactory results. Therefore, laboratory pressure-lamination procedures must be used incorporating two or more EVA materials to achieve the result of 3 to 4 mm thickness occlusally. This allows the clinician to monitor and measure these results before delivery of these mouthguards.

There are presently two ways of obtaining a pressure-laminated mouthguard: dentist fabrication with either the Drufomat Machine, the Biostar Machine, or the Erkopress machine in the dental office, or referral to a qualified commercial laboratory presently using the pressure-lamination technique.

CONCLUSION

We live in exciting times in which we may deliver the highest quality care to our patients in terms of injury prevention. Dentist-diagnosed, custom-made mouthguards deliver this protection. We must remember: if we don't take care of our patients, somebody else will. We have the education and skills. Let's put them to good use. Our , patients deserve the best.

References

1. Davis, Robert, DDS. The Clinical Chronicle. Tools 'R. Us. Sept.-Oct. 1997;1(8). For subscription call (408) 724-6017 or e-mail drtooth@ cruzio.com.

2. Types of Athletic Mouthguards. Sports Dentistry On Line. Available at: http:/ /www.sportsdentistry.com.

3. Hunter, K. Modern Mouthguards. Dent Outlook. 1989;15:63-67.