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In 2009, the National Football League (NFL) instituted its concussion protocol [11] . Since then, researchers have invested countless hours conducting neurologic studies. These studies have made the public more aware of the long-term consequences associated with head trauma and have influenced the NFL to update the concussion protocol with the aim to help protect its athletes from long-term head injuries. Although the vast majority of us will never become professionals in a contact sport, athletes playing at the amateur level (childhood, through adolescence, and into adulthood) are also susceptible to cranial (head), facial, and oral (mouth) injuries.

Fiscally, orofacial (mouth and face) injuries from sports-related activities are estimated to cost ~$1.8 billion each year [1] ... And, the most common orofacial injuries from athletics are those involving the teeth! In fact, a 1995 study showed that over 5 million teeth are avulsed (dislodged from their bony housing) annually [6,12] . From an emotional standpoint, orofacial and dental injuries can cause problems that money alone cannot fix. Statistically, published results have shown that up to one-third (~33%) of dental-related injuries will occur during sporting events [1,4] , and it is estimated that athletes neglecting to wear a mouthguard are ~60 times more likely to sustain a dental-related injury [10,12] . These numbers may make you question if you should even consider playing...but remember there are countless athletes among us who will (at some point during life) play for the love of the game!

While some athletes may opt to not participate in contact sports, those of us who choose to play should (at a minimum) know which options are available to help minimize the risks of head, face, and mouth-related injuries. To summarize (or to put it in a nutshell)... The best preventive habit, to minimize the risk of head- & mouth-related injuries, is to wear properly fitting athletic equipment! A well-fitted helmet protects the head and brain, a facemask protects the facial structures (eyes, nose, jaw, and skin), and a mouthguard SHOULD protect the teeth and gums [4] . The NFHS (the equivalent to the NCAA for high school athletics) mandates that players be equipped with proper protective equipment. Sizing guides and salespeople are available to inform players about which helmets best suit their needs; however, less information is readily available regarding mouthguards. So which mouthguard is the right choice for you?

That answer is contingent upon your age, dental development, and desired level of protection. Currently, the available mouthguard options are categorized into three (3) main types: stock, self-adapting (aka "boil & bite), and custom-made [1,4,7] . While, the NFHS mouthguard requirement does not dictate which type of mouthguard an athlete must use, the organization does mandate that it be a visible color (other than white). So unless you are a wrestler, a clear mouthguard does NOT meet NFHS requirements and a white colored mouthguard is not permissible for any NFHS sanctioned sport [8] . Club sports often use a high school's name, but may have different interpretations of the rules so inquire with your organization on its particular mouthguard rules.

Types of Mouthguards Available

Stock Mouthguards

Stock mouthguards can be purchased at sporting goods stores usually for < $25 and are available in standard sizes (small, medium, large), Athletes MUST retain this style in the mouth by biting into its rubbery material. Due to the fact this style guard is prefabricated, they cannot be altered to better fit your mouth. While they may be the most attractive to your pocketbook, their inexpensive price tag offers the least amount of protection. However, this style is often the most comfortable fit for athletes undergoing orthodontic treatment because the mouthguard will fit over braces.

Self-adapting (aka “Boil & Bite) Mouthguards

Another frequently purchased mouthguard style are those that have self-adapting capabilities (commonly referred to as "boil & bite" mouthguards). They are prefabricated by the manufacturer, but the special rubber material composition allows their shape to be altered to better fit your mouth. This style can be purchased in many sporting goods stores or online (typically for less than $50). While this mouthguard is not the ideal option for athletes who have completed their dental growth, they may offer the most economical option for elementary-school and middle school athletes as they often have a mixture of primary ("baby") & secondary ("adult") teeth.Like stock guards, "boil & bite" mouthguards are retained in the mouth by occlusal (biting) pressure from the user. Newer versions of self-adapting mouthguards are available in flavors and some even offer a limited dental warranty of over $30,000 [2] Always review the fine print if a warranty is offered because several exclusions will apply including, but not limited to:

• teeth with pre-existing dental work
• mouthguards that are not properly formed to the user's mouth
• the injury must occur during a coach- or official-supervised sporting activity and be properly documented.

Custom Mouthguards

Lastly, there are custom-made mouthguards that are best suited for athletes who are involved in contact sports, have lost all of their baby (primary) teeth, and have completed any orthodontic treatment. When compared to the other options, a custom guard will carry the largest price tag, but in exchange offers the best protection and most comfortable fit in the mouth. The term "custom mouthguard" originates from the process by which it is fabricated. An impression is made of the user's mouth and a cast is poured to replicate the mouth's anatomy. Next, specialized dental equipment is used to adapt the mouthguard's thermoplastic material to the replica cast. These steps are critical to allow the mouthguard to specifically and comfortably fit your mouth. Unlike the other types, a custom mouthguard is retained by the shape of the teeth which allows athletes to speak with it in place. This style is popular and recommended for those playing football (especially quarterbacks), hockey, rugby, softball, lacrosse, and basketball. You can frequently see professional athletes (NFL, NBA, NHL) inserting and removing this style of mouthguard during stoppages of play.

Mouthguard styles are a personal choice, what is preferred by one player may not be the
preference of another player. The information above is intended to help you make an educated decision. Although the research does not demonstrate that a mouthguard will prevent concussions [3] , research does show their ability to reduce the severity of an orofacial injury [9,12] . Remember, the American Dental Association (ADA), several dental specialty organizations, and athletic governing bodies ALL support the use of a mouthguard to protect YOUR oral health. Which mouthguard is right for you?

Fitting a Self-adapting ("boil & bite") Mouthguard

Since the majority of us will use a "boil & bite" style guard, it is important to know how to properly mold one to your mouth. Each manufacturer will have its own specific guidelines that should be followed to properly fit their product to your mouth. The general formula is as follows [5] :

(1) Bring a container of water to a boil (either via stove top or microwave).

(2) To avoid injury, allow the water to cool for ~30 seconds and then submerge the mouthguard in the water for ~60-90 seconds.

*** Many mouthguard's have an ethylene-vinyl acetate (EVA) composition, so this step is needed to soften the material

(3) After ~60-90 seconds, remove the mouthguard from the container of water with a spoon (preferably slotted) to prevent scalding your hand

(4) Quickly apply tap water (~2 seconds) to cool the exterior surface.

*** This step will prevent you from burning your lips & mouths

(5) Use a mirror to help insert the guard into your mouth & make sure it is centered.

(6) Use your thumbs to compress the material onto your back teeth and then work forward.

(7) Bring your lower jaw up into contact with the material & simultaneously use your fingers to mold the guard against the sides of the upper teeth & gums for ~ 30secs.

(8) Remove the guard & rinse under cool water to allow the material to fully set.

(9) Check the guard for proper fit. If changes are required, repeat steps 1-8.

Works Cited

1) Altschuler C. "Sporting mouthguards." AGD Impact 2014 Aug;42(8):20-25.

2) Bite Tech Custom Dental Warranty. Under Armour. revised Aug 2015. <https://www.bitetech.com/wp-content/uploads/Bite-Tech-Custom-Dental-Warranty-AUG-2014.pdf>

3) Daneshvar DH, Baugh CM, Nowinski CJ, McKee AC, Stern RA, Cantu RC. "Helmets and Mouth Guards: The Role of Personal Equipment in Preventing Sport-Related Concussions." Clin Sports Med . 2011 Jan;30(1):145–163.

4) Giglio G. "Mouthguard Use in Sports." ACP position statement 2015.

5) Gel Max and Gel Max Lip guard fitting instructions. Shock Doctor. 2008. <https://www.shockdoctor.com/media/pdfs/mouthguards/fitguides/SD_GelMax_GelMaxLipGuard_FitGuide.pdf>

6) Gutmann JL, Gutmann MS. “Cause, incidence, and prevention of trauma to teeth”. Dent ClinNorth Am . 1995;39:1-13

7) Mantri SS, Mantri SP, Deogade S, Bhasin AS. "Intra-oral mouth-guard in sports relatedoro-facial injuries: Prevention is better than cure!" J Clin Diag Res 2014 Jan;8(1):299302.

8) Position statement and recommendations for mouthguard use in sports. Sports Medicine Advisory Committee. National Federation of State High School Associations. 2014 Oct. <https://www.nfhs.org/media/1014750/mouthguard-nfhs-smac-position-statement-october-2014.pdf>

9) Ramagoni NK, Singamaneni VK, Rao SR, Karthikeyan J. "Sports dentistry: A review." IntSoc Prev Community Dent. 2014 Dec; 4(Suppl 3): S139–S146.

10) Sports Dentistry Facts. National Youth Sports Foundation for Safety fact sheet. <http://www.qualitydentistry.com/dental/sdentistry/s-dent.html>.

11) Stites, Adam. “How Does the NFL's Concussion Protocol Work?” SBNation.com , 18 Sept. 2016, www.sbnation.com/nfl/2016/9/18/12940926/nfl-concussion-protocol-explained.

12) Vastardis. "Athletic Mouthguards: Indications, Types, and Benefits." Dent Today 2005;21(12):52-55.

Our Scheduling Coordinator Adriana recently spent her vacation visiting family and friends in Florida. The precious moments spent with her family included renting a boat and spending the entire day on a private island with friends feasting on snacks, swimming, basking in the sun, and enjoying each other!

For Adriana, It’s important to travel for the enjoyment of the experience but most importantly for the educational aspect!  Adriana is very interested in learning about different cultures and sites. Though traveling is full of newness and excitement, Adriana loves coming home from traveling the most. Being home after traveling reminds her of how blessed she is and also has so much new appreciation after she returns!

The furthest place Adriana has traveled is Brazil. Its approximately a 9-hour flight direct but can be as long as 14 hours if you have a stop along the way. Arriving in Brazil, she was greeted by family and has countless memories of their time together. Other faraway places Adriana would love to visit are Ireland, Hawaii, and Italy.  Her reasons are simple; the beautiful sites and incredible tasting food!

Adriana is an over-packer! She always travels prepared, perhaps a little too prepared as each and every item she takes is equally important to her. Traveling forces Adriana to slow down from her normally very hectic schedule, and she looks forward to "ME" time while reading a good book.

One funny travel moment Adriana will never forget was when she wore a jumpsuit to the airport and being repeatedly searched and frisked. She swears she will never wear a one-piece jumpsuit traveling again, as while she can laugh about it now, it was not funny at the time!!

Princeton Restorative enjoys celebrating our patients every month by our staff each picking a patient to send a thoughtful thank you card to. We also celebrate a patient once a week by picking "patient of the week" and thanking them for their loyalty with 2 movie tickets!  Adriana is always thrilled to see their reactions and enjoys seeing our patients smile!

Summer is a wonderful time to enjoy the outdoors with our family and share our experiences with our staff and patients!

Our hygienist Amy is very excited to welcome in Summer 2019! It’s always great to be able to get out and enjoy the nice weather once it arrives. As the days get longer, Amy has more time to challenge herself and explore new activities. A motto Amy lives by is “work hard, play hard.” Some of Amy’s favorite activities are things like hiking, running, rock climbing, and generally being outside. Amy is excited to have the time to go on new adventures!

Speaking of adventures, we love to celebrate our patients by offering free movie tickets! Once a week, we will give out movie tickets as a way to say “thank you” for trusting our practice. We are so happy to take care of our patients’ dental health, and this is our opportunity to give back to the wonderful community at our Princeton office.

How will you celebrate the start of summer? Share in the comments below! We can’t wait to see you at your next appointment.

Dental anxiety is a very common experience: people postpone checkups, live with tooth pain, or suffer anxiety all through each appointment. Knowing that you share this problem with many others might be comforting, but it isn’t very helpful. If you suffer from mild to moderate anxiety, talk to Dr. Hudis! Nitrous oxide sedation might be the answer.

• What is nitrous oxide?

Often referred to as “laughing gas,” nitrous oxide has been used since the 1800’s in dental procedures. Today, it is a safe and common form of inhalation sedation, and we are trained in its uses and administration. Our equipment is designed to provide a precise mixture of nitrous oxide and oxygen gases inhaled through a face mask that you will wear throughout the procedure. Just breathe normally, and you will feel calmer within minutes.

• Relaxed and Aware

Nitrous oxide provides the lightest form of dental sedation. This type of anesthesia is called “conscious sedation” because you will remain awake, relaxed, and able to respond to instructions. We can control the timing of the sedation easily, as it takes effect right away and leaves your system quickly when you stop inhaling the gas. We can also control the level of sedation as needed, so it will not wear off during longer procedures.

• Convenient Recovery Time

One of the biggest advantages of choosing nitrous oxide sedation is its remarkably quick recovery time. With pills or IV sedation, you might need several hours before and after the procedure both to allow these sedatives to take effect and for recovery time when you’re done. You should also have someone available to drive you to and from the appointment. Nitrous oxide, on the other hand, is used only at the time of the procedure and begins leaving your system as soon as you finish inhaling it. You will be able to resume your normal activities almost immediately.

We believe your dental experience should be as relaxing and stress-free as possible. Talk to us about the types of dental sedation available at our Princeton, NJ office, and we will work with you to decide on the best possible option. If you have mild to moderate levels of anxiety, wish to remain awake and relaxed throughout your visit, and want a brief recovery time from sedation, nitrous oxide could be the ideal sedation choice for you.