Effectiveness of Mouthguards for the Prevention of Orofacial Injuries and Concussions in Sports: Systematic Review and Meta-Analysis



Sport activities can account for up to one-third of all orofacial injuries. Mouthguards (MGs) have been proposed as a way to reduce these injuries.


To present a systematic review and meta-analysis of the effectiveness of MGs for the prevention of sports-related orofacial injuries and concussions.


Using specific search terms, PubMed, Ovid Embase, and the Cumulative Index to Nursing and Allied Health Literature were searched to find studies that (1) contained original quantitative data on MGs and orofacial injuries and/or concussions, (2) included groups involved in sports or exercise activities, (3) included MG users and non-MG users, and (4) provided either risk ratios (RRs) and 95% confidence intervals (95% CIs) comparing injuries among MG users and non-MG users, or data that could be used to calculate RRs and 95% CIs.


Twenty-six studies met the review criteria. Investigations employed a variety of study designs, utilized different types of MGs, used widely varying injury case definitions, and had multiple methodological weaknesses. Despite these limitations, meta-analyses indicated that the use of MGs reduced the overall risk of orofacial injuries in 12 cohort trials (summary RR [nonusers/users] = 2.33, 95% CI 1.59–3.44), and 11 trials involving self-report questionnaires (summary RR [nonusers/users] = 2.32, 95% CI 1.04–5.13). The influence of MGs on concussion incidence in five cohort studies was modest (summary RR [nonusers/users] = 1.25, 95% CI 0.90–1.74).


These data indicate that MGs should be used in sports activities where there is significant orofacial injury risk.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5


  1. 1.

    Oral health in America: a report of the Surgeon General. 2000 [cited 2018 27 August]; https://www.nidcr.nih.gov/research/data-statistics/surgeon-general. Accessed 27 Aug 2018.

  2. 2.

    Kumamoto DP, Maeda Y. A literature review of sports-related orofacial trauma. Gen Dent. 2004;52:270–80.

    PubMed  Google Scholar 

  3. 3.

    Kvittem B, Hardie NA, Roetger M. Incidence of orofacial injuries in high school sports. J Pub Health Dent. 1998;58:288–93.

    Article  CAS  Google Scholar 

  4. 4.

    Andrade RA, Evans PLS, Almeida ALS, et al. Prevalence of dental trauma in Pan American Games athletes. Dent Traumatol. 2010;26:248–53.

    Article  PubMed  Google Scholar 

  5. 5.

    Dursun E, Harslan YD, Ozgul O, et al. Prevalence of dental traumqa and mouthguard awareness among weekend warrior soccer players. J Oral Sci. 2015;57(3):191–4.

    Article  CAS  PubMed  Google Scholar 

  6. 6.

    Tiryaki M, Saygi G, Yildiz SO, et al. Prevalence of dental injury and awareness regarding mouthguards among basketball players and coaches. J Sports Med Phys Fitness. 2017;57(11):1541–7.

    PubMed  Google Scholar 

  7. 7.

    Ma W. Basketball players’ experience of dental injury and awareness about mouthguard in China. Dent Traumatol. 2008;24:430–4.

    Article  PubMed  Google Scholar 

  8. 8.

    Levin L, Friedlander LD, Geiger SB. Dental and oral trauma and mouthguard use during sport activities in Israel. Dent Traumatol. 2003;19:237–42.

    Article  PubMed  Google Scholar 

  9. 9.

    Vucic S, Drost RW, Ongkosuwito EM, et al. Dentofacial trauma and players’ attitude toward mouthguard use in field hockey: a systematic review and meta-analysis. Br J Sports Med. 2016;50:298–304.

    Article  PubMed  Google Scholar 

  10. 10.

    Hendrick K, Farrelly P, Jagger R. Oro-facial injuries and mouthguard use in elite female field hockey players. Dent Traumatol. 2008;24:189–92.

    Article  PubMed  Google Scholar 

  11. 11.

    Emerich K, Nadolska-Gazda E. Dental trauma, prevention and knowledge concerning dental first-aid among Polish amateur boxers. J Sci Med Sports. 2013;16:297–301.

    Article  Google Scholar 

  12. 12.

    Marshall SW, Spencer RJ. Concussion in rugby: the hidden epidemic. J Athl Training. 2001;36(3):334–8.

    Google Scholar 

  13. 13.

    Koh JO, Cassidy JD, Watkinson EJ. Incidence of concussion in contact sports: a systematic review of the evidence. Brain Inj. 2003;17(10):901–17.

    Article  PubMed  Google Scholar 

  14. 14.

    Zuckerman SL, Kerr ZY, Yengo-Kahn A, et al. Epidemiology of sports-related concussions in NCAA athletes from 2009–2010 to 2013–2014. Am J Sports Med. 2015;43(11):2654–62.

    Article  PubMed  Google Scholar 

  15. 15.

    Marar M, Mcllvain NM, Fields SK, et al. Epidemiology of concussions among United States high school athletes in 20 sports. Am J Sports Med. 2012;40(4):747–55.

    Article  PubMed  Google Scholar 

  16. 16.

    DePadilla L, Miller GF, Jones SE, et al. Self-reported concussions from playing a sports or being physically active among high school students–United States, 2017. Morb Mortal Wkly Rep. 2018;67(24):682–5.

    Article  Google Scholar 

  17. 17.

    Mayer C. Tooth protectors for boxers. Oral Hyg. 1930;20:298–9.

    Google Scholar 

  18. 18.

    Watts G, Woolard A, Singer CE. Functional mouth protectors for contact sports. J Am Dent Assoc. 1954;49(1):7–11.

    Article  CAS  PubMed  Google Scholar 

  19. 19.

    Knapik JJ, Marshall SW, Lee RB, et al. Mouthguards in sport activities: history, physical properties, and injury prevention effectiveness. Sports Med. 2007;37:117–44.

    Article  PubMed  Google Scholar 

  20. 20.

    American Society for Testing and Materials (ASTM). Standard practice for care and use of athletic mouth protectors. Report: American Society for Testing and Materials; 2000. Report No.: F697-00.

  21. 21.

    Parker K, Marlow B, Patel N, et al. A review of mouthguards: effectiveness, types, characteristics and indications for use. Br Dent J. 2017;222(8):629–33.

    Article  CAS  PubMed  Google Scholar 

  22. 22.

    Tuna EB, Ozel E. Factors affecting sports-related orofacial injuries and the importance of mouthguards. Sports Med. 2014;44:777–83.

    Article  PubMed  Google Scholar 

  23. 23.

    Dhillon BS, Sood N, Sood N, et al. Guarding the precious smile: incidence and prevention of injury in sports: a review. J Int Oral Health. 2014;6(4):104–7.

    PubMed  PubMed Central  Google Scholar 

  24. 24.

    Bergman L, Milardovic-Ortolan S, Zarkvic D, et al. Prevalence of dental trauma and use of mouthguards in professional handball players. Dent Traumatol. 2017;33:199–204.

    Article  PubMed  Google Scholar 

  25. 25.

    Cetinbas T, Sonmez H. Mouthguard utilization rates during sport activities in Ankara, Turkey. Dent Traumatol. 2006;222:127–32.

    Article  Google Scholar 

  26. 26.

    Chapman PJ. The pattern of use of mouthguards in rugby league (a study of the 1986 Australian rugby league touring team). Br J Sports Med. 1988;22:98–100.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  27. 27.

    Gould TE, Piland SG, Caswell SV, et al. National Athletic Trainers Association position statement: preventing and managing sports-related dental trauma. J Athl Training. 2016;51(10):821–39.

    Article  Google Scholar 

  28. 28.

    Lloyd JD, Nakamura WS, Maeda Y, et al. Mouthguards and their use in sports: report of the 1st International Sports Dentistry Workshop, 2016. Dent Traumatol. 2017;33:421–6.

    Article  PubMed  Google Scholar 

  29. 29.

    Using mouthguards to reduce the incidence and severity of sports-related oral trauma. J Am Dent Assoc. 2006;137:1712–20.

  30. 30.

    2013–14 NCAA Sports Medicine Handbook (24th Edition): Indianapolis, IL: National Collegiate Athletic Association 2013.

  31. 31.

    Sports Medicine Handbook (4th Edition). Indianapolis IN: National Federation of State High School Associations; 2011.

  32. 32.

    Mills SC. Mandatory mouthguard rules for high school athletes in the United States. Gen Dent. 2015;63(6):35–40.

    PubMed  Google Scholar 

  33. 33.

    Quarrie KL, Gianotti SM, Chalmers DJ, et al. An evaluation of mouthguard requirements and dental injuries in New Zealand rugby union. Br J Sports Med. 2005;39(9):650–1.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  34. 34.

    Hawn KL, Visser MF, Sexton PJ. Enforcement of mouthguard use and athlete compliance in National Collegiate Athletic Association men’s collegiate ice hockey competition. J Athl Training. 2002;37(2):204–8.

    Google Scholar 

  35. 35.

    American Dental Association. Statement on athletic mouthguards 2009 [cited 2018 3 September]; https://www.ada.org/~/media/ADA/Science%20and%20Research/Files/SCI_Statement%20on%20Athletic%20Mouthguards_2016Oct24.pdf?la=en. Accessed 3 Sept 2018.

  36. 36.

    Kerr IL. Mouth Guards for the prevention of injuries in contact sports. Sports Med. 1986;3:415–27.

    Article  CAS  PubMed  Google Scholar 

  37. 37.

    Newsome PR, Tran DC, Cooke MS. The role of the mouthguard in the prevention of sports-related dental injuries: a review. Int J Pediatr Dent. 2001;11:396–404.

    Article  CAS  Google Scholar 

  38. 38.

    Green JI. The role of mouthguards in preventing and reducing sports-related trauma. Prim Dent J. 2017;6(2):27–34.

    PubMed  Google Scholar 

  39. 39.

    Daneshvar DH, Baugh CM, Nowinski CJ, et al. Helmets and mouthguards: the role of personal equipment in preventing sports-related concussions. Clin Sports Med. 2011;30(1):145–63.

    Article  PubMed  PubMed Central  Google Scholar 

  40. 40.

    Emery CA, Black AM, Kolstad A, et al. What strategies can be used to effectively reduce the risk of concussion in sports? A systematic review. Br J Sports Med. 2017;51:978–84.

    Article  PubMed  Google Scholar 

  41. 41.

    Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLOS Med. 2009;6(7):e1000097.

    Article  PubMed  PubMed Central  Google Scholar 

  42. 42.

    Marshall SW, Loomis DP, Waller AE, et al. Evaluation of protective equipment for prevention of injuries in rugby union. Int J Epidemiol. 2005;34:113–8.

    Article  PubMed  Google Scholar 

  43. 43.

    Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomized and non-randomized studies of health care interventions. J Epidemiol Community Health. 1998;52:377–84.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  44. 44.

    Dean AG, Sullivan KM. Open Source Epidemiologic Statistics for Public Health, Version 3.01. 2013 [cited 2018 10 August]; http://www.openepi.com/Menu/OE_Menu.htm.

  45. 45.

    Fleiss J. Statistical methods for rates and proportions. New York: Wiley; 2003.

    Google Scholar 

  46. 46.

    Huedo-Medina T, Sanchez-Meca J, Marin-Martinez F, et al. Assessing heterogeneity in meta-analysis: Q-statistic or I 2 index? Psychol Methods. 2006;11(2):193–206.

    Article  Google Scholar 

  47. 47.

    Sterne JAC, Egger M. Funnel plots for detecting bias in meta-analysis: guidelines on choice of axis. J Clin Epidemiol. 2001;54:1046–55.

    Article  CAS  Google Scholar 

  48. 48.

    Begg CB, Mazumdar M. Operating characteristics of a rank order correlation test for publication bias. Biometrics. 1994;50(4):1088–101.

    Article  CAS  Google Scholar 

  49. 49.

    Duval S, Tweedie R. Trim and fill: a simple funnel-plot-based method of testing and adjusting for publication bias in meta-analysis. Biometrics. 2000;56(2):455–63.

    Article  CAS  PubMed  Google Scholar 

  50. 50.

    Simmonds M. Quantifying the risk of error when interperting funnel plots. Syst Rev. 2015;4:24.

    Article  PubMed  PubMed Central  Google Scholar 

  51. 51.

    Tang JL, Liu JLY. Misleading funnel plot for detection of bias in meta-analysis. J Clin Epidemiol. 2000;53:477–84.

    Article  CAS  PubMed  Google Scholar 

  52. 52.

    Cohen A. A five year comparative study of various mouth protectors. Pennsylvania Dent J. 1962;29(7):6–12.

    Google Scholar 

  53. 53.

    Cohen A, Borish AL. A four year comparative study of various mouth protectors. Bull Nat Assoc Secondary Sch Princ. 1961;45:145–8.

    Google Scholar 

  54. 54.

    Cohen A, Borish AL. Mouth protector project for football players in Philadelphia high schools. J Am Dent Assoc. 1958;56(6):863–4.

  55. 55.

    Dunbar D. Report on reduction in mouth injuries. J Mass Dent Soc. 1962;11(31):34–5.

    Google Scholar 

  56. 56.

    Schoen G. Report on reduction in mouth injuries. Bull Naussau Cty Dent Soc. 1956;30:12–4.

    Google Scholar 

  57. 57.

    Moon DG, Mitchell DF. An evaluation of a commercial mouthpiece for football players. J Am Dent Assoc. 1961;62:568–72.

    Article  CAS  PubMed  Google Scholar 

  58. 58.

    Blignaut JB, Carstens IL, Lombard CJ. Injuries sustained in rugby by wearers and non-wearers of mouthguards. Br J Sports Med. 1987;21:5–7.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  59. 59.

    LaBella CR, Smith BW, Sigurdsson A. Effect of mouthguards on dental injuries and concussions in college basketball. Med Sci Sports Exerc. 2002;34:41–4.

    Article  PubMed  Google Scholar 

  60. 60.

    Benson BW, Meeuwisse WH. The risk of concussion associated with mouthguard use among professional hockey players. Br J Sports Med. 2005;39(6):374–5.

    Google Scholar 

  61. 61.

    Kemp SPT, Hudson Z, Brooks JHM, et al. The epidemiology of head injuries in English professional rugby union. Clin J Sports Med. 2008;18(3):227–34.

    Article  Google Scholar 

  62. 62.

    Zadik Y, Levin L. Does a free-of-charge distribution of boil-and-bite mouthguards to young adult amateur sportsmen affect oral and facial trauma? Dent Traumatol. 2009;25:69–72.

    Article  PubMed  Google Scholar 

  63. 63.

    Cohenca N, Roges RA, Roges R. The incidence and severity of dental trauma in intercollegiate athletes. J Am Dent Assoc. 2007;138:1121–6.

    Article  PubMed  Google Scholar 

  64. 64.

    BoD Education. Evaluation of mouth protectors used by high school football players. J Am Dent Assoc. 1963;66:430–42.

    Google Scholar 

  65. 65.

    McNutt T, Shannon SW, Wright JT, et al. Oral trauma in adolescent athletes: a study of mouth protectors. Pediatr Dent. 1989;11:209–13.

    CAS  PubMed  Google Scholar 

  66. 66.

    Maestrello-deMoya MG, Primosch RE. Orofacial trauma and mouth-protector wear among high school varsity basketball players. ASDC J Dent Child. 1989;56(1):36–9.

    CAS  PubMed  Google Scholar 

  67. 67.

    Tulunoglu I, Ozbek M. Oral trauma, mouthguard awareness, and use in two contact sports in Turkey. Dent Traumatol. 2006;22:242–6.

    PubMed  Google Scholar 

  68. 68.

    Frontera RR, Zanin L, Ambrosano GMB, et al. Orofacial trauma in Brazilian basketball players and level of information concerning trauma amd mouthguards. Dent Traumatol. 2011;27:208–16.

    Article  PubMed  Google Scholar 

  69. 69.

    Tiwari V, Saxena W, Tiwari U, et al. Dental trauma and mouthguard awareness and use among contact and noncontact athletes in central India. J Oral Sci. 2014;56(4):239–43.

    Article  PubMed  Google Scholar 

  70. 70.

    Liew AKC, Abdullah D, Noorina WAW, et al. Factors associated with mouthguard use and discontinuation among rugby players in Malaysia. Dent Traumatol. 2014;30:461–7.

    Article  PubMed  Google Scholar 

  71. 71.

    Vucic S, Drost RW, VanWijk AJ, et al. Patterns of orodental injury and mouthguard use in Dutch field hockey. Br J Sports Med. 2016;50:661–8.

    Article  PubMed  Google Scholar 

  72. 72.

    Galic T, Kuncic D, Poklepovic-Pericic T, 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. Dent Traumatol. 2018;34:175–81.

    Article  PubMed  Google Scholar 

  73. 73.

    Finch C, Braham R, McIntosh A, et al. Should football players wear custom fitted mouthguards? Results from a group randomised controlled trial. Inj Prev. 2005;11(4):242–6.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  74. 74.

    Aubry M, Cantu R, Dvorak J, et al. Summary and agreement statement of the first International Conference on Concussion in Sports, Vienna 2001. Br J Sports Med. 2002;36(1):6–10.

  75. 75.

    Higgins JPT. Commentary: heterogeneity in meta-analysis should be expected and appropiately quantified. Int J Epidemiol. 2008;37:1158–60.

    Article  PubMed  Google Scholar 

  76. 76.

    Shrier I, Boivin JF, Steele RJ, et al. Should meta-analysis of interventions include observational studies in addition to randomized controlled trials? A critical examination of underlying principles. Am J Epidemiol. 2007;166(10):1203–9.

    Article  PubMed  Google Scholar 

  77. 77.

    Faraoni D, Schaefer ST. Randomized controlled trials vs. observational studies: why not just live together? BMC Anesthesiol. 2016;16:102.

  78. 78.

    Podsakoff PM, MacKenzie SB, Lee JY, et al. Common method biases in behavioral research: a critical review of the literature and recommended remedies. J Appl Psychol. 2003;88(5):879–903.

    Article  PubMed  Google Scholar 

  79. 79.

    Furnham A. Response bias, social desirability and dissimulation. Pers Individ Diff. 1985;7(3):385–400.

    Article  Google Scholar 

  80. 80.

    Chisholm DA, Romanow NT, Schneider KJ, et al. Mouthguard use in youth ice hockey and the incidence of concussion and dental injury. Clin J Sports Med. 2015;25(1):e13–4.

    Google Scholar 

  81. 81.

    Mihalik JP, McCaffrey MA, Rivera EM, et al. Effectiveness of mouthguards in reducing neurocognitive deficits following sports-related cerebral concussion. Dent Traumatol. 2007;23:14–20.

    PubMed  Google Scholar 

  82. 82.

    Winters JE. Commentary: role of properly fitted mouthguards in prevention of sports-related concussion. J Athl Training. 2001;36(3):339–41.

    Google Scholar 

  83. 83.

    Boffano P, Boffano M, Gallesio C, et al. Rugby athletes’ awareness and compliance in the use of mouthguards in the North West of Italy. Dent Traumatol. 2012;28:210–3.

    Article  PubMed  Google Scholar 

  84. 84.

    Matalon V, Brin I, Moskovitz M, et al. Compliance of children and youngsters in the use of mouthguards. Dent Traumatol. 2008;24:462–7.

    Article  PubMed  Google Scholar 

  85. 85.

    Tanaka V, Maeda Y, Tang TC, et al. Prevention of orofacial injury via the use of mouthguards among young male rugby players. Int J Sports Med. 2015;36:254–61.

    CAS  PubMed  Google Scholar 

Download references


We would like to thank Mr Kristin Goel, Ms Claudia Coleman, and Ms Patricia Brennen for assisting us with finding many of the references cited here.

Author information



Corresponding author

Correspondence to Joseph J. Knapik.

Ethics declarations


No sources of funding were used for this work.

Conflict of interest

Joseph Knapik, Blake Hoedebecke, Georgia Rogers, Marilyn Sharp, and Steven Marshall declare that they have no conflicts of interest relevant to the content of this work.


The opinions or assertions contained herein are the private views of the author(s) and are not to be construed as official or as reflecting the views of the Army or the Department of Defense.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Knapik, J.J., Hoedebecke, B.L., Rogers, G.G. et al. Effectiveness of Mouthguards for the Prevention of Orofacial Injuries and Concussions in Sports: Systematic Review and Meta-Analysis. Sports Med 49, 1217–1232 (2019). https://doi.org/10.1007/s40279-019-01121-w

Download citation