They can all leave you with a chipped front tooth or, worse, no front tooth at all.

Drinking soda through a mouth guard can be rough going, and a face guard makes it next to impossible to enjoy kisses from the one you love. But it simply makes good sense to shield your face and head with protective gear when you play contact sports and sports where balls, bats, pucks, and other "missiles" fly in your face.


The standard head and face protection for football players includes a helmet and a mouth guard.

"Sports and recreational injuries are easily prevented," says Ruth Nowjack-Raymer, coauthor of a recent report on the use of protective head gear -- mouth guards and helmets -- in organized sports (1). The strongest proof of this, she says, comes from the example of football. In the 1950s, a faculty member in the dental school at Ohio State University wrote a series of articles about mouth guards and their cushioning effects.

Some mouth guards are sold over-the-counter in sporting goods stores and drug stores. Others, like the one shown here, are made by dentists and precisely fit the mouth of the wearer. A dentist takes an "impression" of the athlete's teeth and then molds the mouth guard to that shape. The mouth guard is made of plastic. This one is on display in the dentist's office. Photo courtesy of Leslie Ann Rye, D.D.S.

Not only could a mouth guard protect the teeth and jaw but the custom-made style molded by dentists could even prevent a concussion, a form of brain injury. In the early 1960s, before rules and regulations governed the use of football gear, 50% of all injuries to high school football players involved their faces and heads. Then, guidelines were established for shielding those parts of the body, and football players suited up with helmets and mouth guards. Today, only 1.4% of all football injuries involve the head and face.


Football players at Walt Whitman High School in Bethesda, Maryland demonstrate how head gear protects their faces.

It is strange that the example set by football players has not been adopted by athletes who participate in other potentially dangerous sports. Fans and athletes alike readily accept and even admire the "armored" appearance of football players. Football players are, in fact, among the most popular athletes in high schools and colleges in the United States: the annual homecoming dance is always associated with a fall football game, the school's band and cheerleaders perform more often at football games than at other sporting events, and graduates typically return to their schools to see football games. There is no stigma attached to helmets, mouth guards, and padding in this sport.

But, for some reason, there is great resistance among athletes in other sports to wearing protective gear. Nine million students in the United States play baseball and softball (three million play football). But it is rare to see baseball and softball players sporting protective head gear in the field and not even all at-bat players wear helmets. Nowjack-Raymer found that only 35% of kids wear helmets most or all of the time when they play baseball and softball and only 7% wear mouth guards. In Little League ball games, 86% of injuries involve athletes in the field, and most of the injuries affect heads and faces (2).

A young batter wears "the right stuff" -- a helmet and a mouth guard -- even during backyard batting practice. Photo courtesy of Leslie Ann Rye, D.D.S.

As students get older, says Nowjack-Raymer, they are more likely to wear protective gear. This may, in part, reflect their growing understanding of the physical risks they face. It may also have something to do with who sponsors and pays for a sport. Organized sports programs for little children are often run by community centers, parents chip in money to support them, and the organization is relatively low key. As kids grow, she says, more of the programs are coordinated by schools and governed by "rules and regs."
The survey documented some disturbing gender differences. "Girls are injured in sports too," notes Nowjack-Raymer, "and the injuries can be expensive and painful and cause problems that last a lifetime." But girls and women are much less likely to wear protective gear than are boys and men. Is this because they rarely see famous women athletes wearing mouth guards and helmets?

Nowjack-Raymer points to an example in her own family. Her sister, she says, is still dealing with problems that started years ago when she fractured her front teeth during a field hockey game. Field hockey, she notes, is a sport in which the disparity in safety practices between female and male athletes is striking. Male field hockey players at all levels wear head gear. Female hockey players typically do not, and whether they should is the subject of a raging debate. One group has been lobbying strongly for equal protection for female athletes. Another group is strongly opposed, arguing that, if girls and women wear protective gear, the nature and culture of the game will change toward more aggressive, violent play.


Girls who play field hockey are not required to wear protective head gear, but this girl uses a mouth guard when she plays. Photo courtesy of Robert Selwitz, D.D.S., M.P.H.

The data that Nowjack-Raymer analyzed were collected in a national health survey that was conducted in 1991. Nearly 10,000 parents and guardians of children in the 7 to 17 year old age range answered questions about the use of head gear and mouth guards in a number of organized sports. Nowjack-Raymer and her colleagues -- epidemiologists, social scientists, health educators, behavioral scientists and others -- are now beginning to look at the research that has already been done to address the problems that exist and define what research should be conducted next. They are trying to determine what coalitions of students, parents, coaches, trainers, organizations, and others could actually establish educational programs and binding rules that will support the use of protective gear. They are assessing what approaches work best to get student athletes to protect themselves. They are considering looking at the design of protective gear -- is it comfortable, well made, effective? -- and what makes a product acceptable.

In the United States, says Nowjack-Raymer, the strategies that have proved most effective are those based on establishment of and compliance with regulations, and often these have been instituted at local levels. This country has "no overarching authority" that makes rules, as is true in other countries. In Australia, for example, public health agencies provide information about injuries and also develop rules and guidelines for enhancing the safety of sports.
Will head gear ever become stylish? It hasn't yet, notes Nowjack-Raymer, but it has come a long way. "When a new sport comes along," she says, "it is important to think about what gear really makes sense." For example, in-line skating is a relatively new sport in which both beginners and more experienced skaters routinely wear lots of protective gear. Why this has occurred is unclear; perhaps it stems from good training from the beginning, the ready availability of colorful gear, a general acceptance of protective equipment, or some combination of these.


Dazzling young in-line skaters: they are well protected and make strong fashion statements! Photo courtesy Ruth Nowjack-Raymer, R.D.H., M.P.H.

Accidents happen not only during official games but also during informal play, so, warns Nowjack-Raymer, it is important for athletes to wear their gear even when they are just practicing at home. Over 14 million children and teens in the United States participate in at least one organized sport, and injuries are on the rise. Teeth are knocked out in basketball games by the elbows of other players; eye injuries are common for badminton and squash players not wearing protective goggles (3); 144,000 children in the United States suffer annually from head injuries in bicycle accidents, and 85% of these injuries would not have occurred had the child worn a helmet (4). Getting athletes to readily don their helmets and mouth guards may involve major changes in the "cultures" of some sports.

And yet, some cultures have really valued helmets and other protective gear, which have been around as long as people have participated in sports and engaged in battles. Some 5000 years ago, a prince of Ur named Meskalamdug apparently valued his gold and silver helmet so fully that he was buried in it. He also was buried with his bodyguards, all of whom were wearing helmets of copper (5).


Nowjack-Raymer and her children. Photo courtesy of Ruth Nowjack-Raymer, R.D.H., M.P.H.

References:

1. Public Health Reports 1996, 111:82-86.
2. Pediatrics, 1996, 98(3):445-448.
3. J. R. Coll Surg, Edinb, 1993 38(3):127-133.
4. Public Health Reports 1995, 110(3):251-259.
5. Aust. N.Z. J. Surg. 1996, 66:314-324.