Sports mouthguards and orthodontics: Current evidence and clinical perspectives - a narrative review

INTRODUCTION

Contact sports are one of the most common reasons for orofacial injuries. Adolescents undergoing orthodontic treatment represent a high-risk group due to combined developmental and treatment-related factors. Fixed orthodontic appliances increase this susceptibility by both aggravating soft-tissue trauma and complicating the injury profile if dental trauma occurs.^[1-3] Mouthguards offer the dual benefits of risk reduction and help decrease injury severity.^[4-7] Despite endorsement by professional organisations and growing public awareness, uptake of high-quality, well-fitted mouthguards remains scarce in the orthodontic population, mainly due to factors such as cost, convenience, and poor comfort with generic and commonly available devices.^[8,9] This review examines the current evidence on mouthguard effectiveness, wearability, and design considerations in athletes undergoing orthodontic treatment with fixed appliances.

MATERIAL AND METHODS

A structured literature search was performed using PubMed, Scopus, and Google Scholar for studies published between 2000 and 2025. Search terms included “mouthguards,” “orthodontics,” “sports injuries,” “dental trauma,” and “fixed appliances,” combined using Boolean operators (AND/OR).

A total of 120 articles were initially identified, of which 90 were screened after removal of duplicates. Based on relevance and eligibility criteria, 25 studies were included in the final review. Duplicate removal and screening were performed manually based on title and abstract relevance.

Although this is a narrative review, a simplified PRISMA-based approach was followed for study selection [Figure 1].

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Figure 1: PRISMA flow diagram for search strategy

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PREVALENCE OF OROFACIAL INJURY AND RISK FACTORS

The literature consistently identifies adolescents as being at the highest risk of sports-related dental trauma, with fixed orthodontic appliances acting as amplifiers for worsening of the risk profile.^[10] The incidence of reported injuries ranges from 10% to 39% among youth involved in sports-related activities, with up to 80% involving the maxillary incisors.^[11] Class II Division 1 malocclusions with increased overjet, which are common indications for fixed appliance therapy, further magnify the associated risk.^[12]

TYPES OF MOUTHGUARDS

WEARABILITY AND COMPLIANCE

Several clinical trials and cross-sectional studies focused on orthodontic patients report that comfort, retention, ease of breathing, and the ability to speak while wearing a mouthguard are important for compliance. Custom-made mouthguards have regularly outperformed both modified and unmodified mouth-formed mouthguards on these criteria.^[27] Adolescents and parents mainly discuss cost, inconvenience, bulk, and the need for repeated refitting as the primary barriers to consistent use.^[14,15]

In addition to patient-related factors, external influences such as coach reinforcement, school-level policies, and parental awareness play a crucial role in improving compliance. Studies have shown that mandatory enforcement in school sports programs significantly increases mouthguard usage.

From a cost perspective, although custom-made mouthguards are initially more expensive, they may be cost-effective in the long term by preventing complex dental trauma and reducing treatment costs.

Emerging models such as insurance coverage, institutional subsidies, and school-based distribution programs may help improve accessibility and adoption among adolescents.

REGULATORY CONSIDERATIONS

In United Kingdom and European Union, mouthguards are classified as personal protective equipment (PPE) and must carry Conformité Européenne (CE) marking; this designation mandates biocompatibility, appropriate manufacturing standards, and compliance with fit and performance criteria.^[5] Professional bodies, such as the British Orthodontic Society, unequivocally recommend custom-made mouthguards as the standard for patients with fixed appliances, while allowing for mouth-formed designs as a temporary solution during active treatment.^[7]

Practical clinical recommendations

• All orthodontic patients engaging in contact sports should be advised to wear a mouthguard.

• Custom-made mouthguards with orthodontic adaptations are the gold standard, especially for those involved in high-impact or stick sports.

• Mouth-formed guards with specialised orthodontic channels may be used temporarily, but practitioners should monitor for retentiveness and thickness over time.

• Stock mouthguards should be discouraged.

• Education on mouthguard use, fit, and replacement is critical for improving adolescent compliance.

• Regular re-assessment is necessary, and new mouthguards may be needed to accommodate ongoing orthodontic movement.

EVIDENCE QUALITY ASSESSMENT

The included evidence comprised a mix of in vitro laboratory studies, clinical trials, cross-sectional surveys, and systematic reviews. Laboratory studies provided valuable insights into material properties and shock absorption, but may not fully replicate intraoral conditions. Clinical studies and surveys offered real-world data on wearability and compliance, though many were limited by small sample sizes and short follow-up durations. Systematic reviews and meta-analyses provided higher-level evidence; however, heterogeneity in study design and outcome measures limits direct comparison. Overall, while the evidence consistently supports the superiority of custom-made mouthguards, further high-quality longitudinal clinical studies are needed.

CLINICAL IMPLICATIONS AND UNRESOLVED CHALLENGES

Evidence supports the use of custom-made mouthguards, those constructed by qualified dental professionals for orthodontic patients engaged in sports.^[28] Their superior fit, comfort, and ability to accommodate orthodontic movement outweigh the higher cost and periodic need for replacement.^[29] Nonetheless, real-world compliance remains low, with surveys indicating that only around 35% of orthodontic patients wear mouthguards consistently during risky activities.^[16] This gap is attributed to multifactorial barriers: cost, inconvenience, and the discomfort or bulk associated with ill-fitting devices.^[15]

Despite advancements in material science, translation of evidence into routine clinical practice remains suboptimal. Even with technical progress in design (e.g., pressure-laminated EVA using multi-layered construction; flexible inner linings with customised external geometry), there is a persistent need for realistic solutions that combine protection with day-to-day practicality in the context of ongoing orthodontic adjustments. Future research should focus on novel materials, rapid in-office fabrication, self-adapting designs, and effective educational interventions to improve uptake and retention of best-practice devices.

CONCLUSION

Mouthguards remain a core preventive strategy for reducing orofacial injuries in athletes undergoing orthodontic treatment with fixed appliances. Custom-made, pressure-laminated EVA mouthguards provide the best balance of fit, comfort, and protective effect. Despite clear professional guidance, compliance is undermined by practical barriers, emphasising the importance of clinician-patient communication, continued innovation in mouthguard design, and policy efforts to expand access to high-quality devices. Ongoing research, education, and enforcement of standards will be vital in transforming effective evidence into routine sports safety behaviour among orthodontic patients.

From a public health perspective, implementation of school-level mandatory mouthguard programs, policy-driven enforcement in organised sports, and incorporation of mouthguard counselling into the orthodontic consent process are critical steps toward improving compliance. Collaborative efforts between orthodontists, educators, sports authorities, and policymakers are essential to translate evidence into preventive practice.