Mouth guard use among children: Has the GAA policy made a difference?
David S. Evans, Department of Public Health, HSE West, Galway, Margaret O’ Malley, HSE West Dental Services, Castlebar
In 2014 the Gaelic Athletic Association (GAA) in Ireland made mouth guard use mandatory. The study aimed to assess the impact of the policy on mouth guard use among schoolchildren. We replicated a 2011 study of mouth-guard use. A questionnaire was sent to parents of children attending 4th-6th class in a random sample of 25 schools across HSE West. A total of 298 questionnaires were returned for analysis. A total of 68 per cent of children were reported as wearing mouth guards (22 per cent in 2011). Mouth guard use has increased in all sports with Gaelic football experiencing the largest increase (16-87 per cent).
The main type of mouth guard used is ‘boil and bite’ with 2 per cent using a mouth guard from a dentist. Mouth guard use was significantly greater where schools and sports clubs that children attended had policies on mouth guard use. The number of sports accidents involving teeth reduced from 52 per cent in 2011 to 15 per cent in the current study. Rugby and Gaelic football were perceived to have the highest risk of injury to teeth if a mouth guard is not worn. The study suggests that the GAA policy has made a difference in the promotion of mouth guard use. Policies on mouth guards and their promotion need to be undertaken to increase usage in other sports and to promote the use of custom-made mouth guards.
Although participation in sport plays a key role in the promotion of child health, there are risks that sports activities may lead to injuries, particularly to the teeth. Studies have found that sporting activities are linked to over a third of dental injuries (US Department of Health and Human Services, 2000). Such injuries can be very upsetting for children, requiring extensive long-term treatment. Dental injuries can be significantly reduced by wearing a mouth guard.
However, prior to 2012, the only sport in Ireland where mouth guards were mandatory was boxing. Some other sports promoted mouth guard use, but did not have mandatory regulations. The Irish Rugby Football Union, for example, advised clubs to adopt a ‘no guard, no game’ rule.
In 2011, we undertook a survey of mouth guard use among national schoolchildren and found that they were only worn by 22 per cent (O’Malley et al, 2012, 2015). In addition, injuries to permanent teeth represented 87 per cent of all sports injuries. Without mandatory regulations, it appeared that the majority of children, for whatever reason, were not motivated to use mouth guards. In April 2012, the Gaelic Athletic Association (GAA) made mouth guard use mandatory for all ages up to under 21 years, which was extended to adults in 2014.
This represented a significant development in the prevention of dental injury. As with any policy, it is important to determine if it has been effective in promoting mouth guard use in Gaelic football. It is also important to see if mouth guard use in other sports has increased. We therefore conducted a follow-up study to assess its impact on mouth guard use, perceptions of mouth guards in terms of reducing the risk of injury, and school and club policy.
To assess changes in mouth guard use among schoolchildren since becoming mandatory for Gaelic football, we replicated our 2011 study of mouth guard use among schoolchildren. A random sample of 25 schools in HSE West (stratified by county) was selected. School principals sent parents of children in 4th-6th class a confidential self-completion questionnaire for each child attending these classes. The questionnaire sought information from the parents about their child(ren), including sporting activities, policies on mouth guards, mouth guard use, barriers to mouth guard use and history of dental trauma and treatment.
A total of 298 completed questionnaires were received from 25 selected national schools. More than half (54 per cent) were boys with a mean age of 11 years (range 9 to 13 years). On average, children played two sports with Gaelic football (32 per cent), soccer (25 per cent), basketball (31 per cent) and hurling (25 per cent) being the main sports played. The respondent profile is broadly similar to our original research.
Mouth guard use
Overall, 68 per cent of children were reported as wearing mouth guards while playing sport. The corresponding figure was 22 per cent in 2011. Significantly more parents whose children wore mouth guards were aware of the GAA rules for mouth guard use for Gaelic football (83 per cent compared to 54 per cent). For those that wore mouth guards, figure 1 shows the sports where mouth guards were used. It can be seen that of the sports they played, the main sports that a mouth guard was used was for rugby (88 per cent) and Gaelic football (87 per cent). Compared to 2011, the proportion using their mouth guard for each sport has increased, with Gaelic football experiencing the largest increase (from 16 per cent to 87 per cent).
Type of mouth guard
The main type of mouth guard used was ‘boil and bite’ (64 per cent) with 14 per cent using other types of mouth guards and 2 per cent using a mouth guard from a dentist. This pattern is broadly similar to that found in 2011 (64 per cent, 12 per cent, and 4 per cent respectively with 19 per cent not knowing the type of mouth guard). Half (50 per cent) of parents did not know if the mouth guard from a dentist was safer while 40 per cent reported it was safer or much safer.
School and club mouth guard policy
Table 1 (0verleaf) shows over half the parents reported (51 per cent) that their child’s (children) school had a policy on mouth guards. Only 2 per cent of schools had a policy in 2011. In addition, 63 per cent reported that all or most of the sports clubs children attended had a policy on mouth guards (10 per cent in 2011). Mouth guard use was significantly greater where schools and sports clubs that children attended had policies on their use.
Accidents to children during sport in the last year were reported by 15 per cent of parents (10 per cent in 2011). Of these, 15 per cent involved teeth (52 per cent in 2011). Of those that had accidents involving teeth, 23 per cent were wearing a mouth guard for the last accident. All of these children (n=3) were using ‘boil and bite’ mouth guards. Injuries to teeth were to both permanent (63 per cent) and deciduous (80 per cent) teeth. Teeth were broken for almost a third (30 per cent) while over a quarter of parents stated that teeth were pushed out of place (27 per cent) and in need of repair. A quarter visited the dentist straight away, while half visited within one week.
Risk of injury to teeth
Parents were asked to rate the risk of injury to teeth if a mouth guard is not worn while playing a number of sports. Figure 2 shows that for each sport, parents whose children wear mouth guards give a higher risk rating. Overall the sports given the highest risk rating are rugby (86 per cent) and Gaelic football (80 per cent).
Gaelic football, as with most team sports, involves physical contact. This increases the risk of dental injury, which can be reduced by wearing a mouth guard. Our study has found that since 2011 mouth guard use by children during sport has increased by 209 per cent. Mouth guard use for all sports has increased, but the most dramatic increase is for Gaelic football which rose by 444 per cent. Parents who are aware of the GAA mandatory mouth guard policy are more likely to report that their children use mouth guards. These findings suggest that the introduction of the policy in 2014 is promoting mouth guard use in Gaelic football with a knock-on effect on other sports. This is a positive development, particularly as Gaelic football is the most popular sport played by children in our study.
Although there has been a knock-on effect on other sports, with the exception of rugby, mouth guard use for other sports remains considerably lower. Rugby does not have a mandatory rule, but mouth guard use is strongly promoted and many clubs have mandatory rules. Parents perceive the risk of dental injury to be lower for sports that do not emphasise mouth guard use. Other sports need to consider promoting mouth guard use and also introducing mandatory rules. There is a risk of dental injury associated with all contact sports. Both soccer and basketball for example have a risk of dental injury from other players, the ground, the ball, and posts.
Without greater promotion and regulation by sports organisations, it is unlikely that other sports will reach the usage levels achieved in Gaelic football and rugby. The importance of promotion and regulation is also demonstrated by the fact that mouth guard use was significantly greater where schools and sports clubs that children attended had policies on mouth guard use. School and club policies have significantly increased since 2011 which appears to be promoting mouth guard use. Parents of children that were in schools or clubs that had mouth guard policies were more aware of the risks of injury to teeth if mouth guards were not worn during sport. There remains considerable scope to introduce more policies, particularly in schools where half did not have a policy in place.
Customised mouth guards from the dentist are the most effective mouth guards, but disappointingly these were only used by 2 per cent of mouth guard users, with this pattern being broadly similar to that experienced in 2011. Half the parents in the study did not know if the mouth guard from a dentist was safer. Parents need to be aware of the safety benefits of customised mouth guards. The GAA do provide information on mouth guards (GAA, 2013) but they do not make recommendations in terms of the preferred type. The use of custom made mouth guards should be promoted and this should be incorporated into policies on mouth guards. As customised mouth guards are more expensive, the GAA suggest that clubs liaise with dental practitioners to enable customised mouth guards to be constructed for players in their club at reduced cost. The GAA should ensure that there are mechanisms in place to facilitate this process. All adults and children that play Gaelic football should be able to have customised mouth guards made by a dentist at a reduced cost.
Accidents involving teeth have reduced from 52 per cent to 15 per cent of all sports accidents. Although the number of accidents is small (suggesting caution in interpretation), it may be that the protection provided by mouth guards is helping to reduce dental injuries. This is also supported by the fact that anecdotal evidence suggests that the GAA have experienced a reduction in dental injury claims, and the HSE has experienced a reduction in sports related dental injury traumas. Interestingly, the three people that had a dental injury that were wearing mouth guards were wearing the ‘boil and bite’ type, which are less protective compared to customised mouth guards.
The GAA have to be heralded for introducing their mouth guard policy. Our study suggests that it is having a positive impact in terms of promoting mouth guard use among children, both in Gaelic football and other sports. We need to build on this success to increase usage in other sports and to promote the use of custom made mouth guards. Parents need to be made aware of the importance of wearing mouth guards for contact sports. This can be achieved with a combination of policy and promotion by schools, clubs, and the HSE.
GAA, GAA mouth guard Information. Information for clubs, coaches,
players, and parents, 2013. Available here
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O Malley, Evans, D.S. M. Hewson, A. Owens, J. Speaking out on mouth guards, Ireland’s Dental magazine, April 2015
US Department of Health and Human Services, Oral Health in America, A Report of the Surgeon General, Rockville, M.D. 2000. Available here