December 1, 2010
by George Freedman, DDS, FAACD, FACD; Cam Stewart and Troy Stephens
Dentists have long advocated that protective mouthpieces be worn during active, and particularly contact sports. The mouth guard separates the arches by inserting a secured cushioning device around the teeth. Not only the does the mouth guard protect the integrity of the teeth from inadvertent crushing occlusal forces, but also acts as a shock absorber that minimizes trauma to the cranium, and hence protects the brain. Now the function and utility of mouthpieces has been extended to that of enhancing performance at play, exercise, and work. Historically and anecdotally, “biting on the bullet” to relieve pain during surgery, placing a strap between the teeth to increase strength during fighting, and biting on a stick during childbirth have been recognized to relieve pain and improve performance. A sports study at the University of Tennessee demonstrated that men can improve their grip performance by as much as 67 percent and women by 93 percent simply by inserting an occlusal wedge between their teeth that functions to interrupt clenching. Both mouthguards and mouthpieces effectively insert an occlusal wedge in between the posterior teeth (Fig. 1).
Stress, whether from sports or other activities, causes people to subconsciously clench their teeth. Clenching is a means whereby the body attempts to minimize or eliminate stress. This response is involuntary, although it can be controlled to some extent by certain individuals. The clenching cycle that is commonly observed during stress and strenuous activity releases cortisol (the stress hormone) and lactic acid in the human body. The presence of cortisol has both positive and negative effects on the human body, largely depending on whether the amount released is appropriate or excessive.
Cortisol: The Stress HormoneCortisol is the major corticosteroid in the human body. It is responsible for about 95 percent of all glucocorticoid activity and is essential for the stimulation of gluconeogenesis (creation of glucose) to ensure an adequate fuel supply. It increases the mobilization of free fatty acids, increasing their availability as an energy source and stimulates protein catabolism, releasing amino acids for use in energy production, tissue repair, and enzyme synthesis. Cortisol also acts as an anti-inflammatory agent and can increase epinephrine vasoconstriction.
However, excess cortisol can decrease strength, endurance and performance. The many effects of stress-related cortisol on the human body include: migraines, sleep deprivation, chronic fatigue, hypertension, depression, decreased metabolism and a weakening of the immune system. Thus, it makes eminent sense to limit the stress that the individual is exposed to; this, however, may be difficult or impossible to achieve. In situations where stress cannot be sufficiently reduced, it is imperative to reduce the cortisol production. Limiting the “stress hormone” is often a reasonable, or sole, alternative. The least invasive method for decreasing cortisol production in the presence of stress is to interrupt the clenching cycle.
Interrupting The Clenching CycleAs mentioned above, biting on an object such as a stick, bullet or a strap reduces the ability of the jaws to clench at full force. During clenching, the teeth fully intercuspate, and the airway opening is reduced, limiting the flow of air to the lungs (Fig. 2). With the ArmourBite in place as a power wedge between the teeth, the molars are separated, bringing the condyles out of the fossae (Fig. 3). As the mouth is opened, the airway is made more patent, enhancing air intake and pulmonary oxygen exchange. This, in turn, reduces lactic acid formation and fatigue, improving concentration, strength and endurance. The individual biting on a clench interrupter tends to be calmer, more focused on the task at hand, and able to exert greater force for a longer period of time. Many individuals, without knowing the rationale or the physiology, find it comforting to chew gum when under stressful conditions; this activity works to some extent, but the gum does not have a minimum thickness to keep the teeth apart, and often, the repeated exaggerated masticatory motions overtire the muscles involved, causing additional problems.
In addition to the obvious health applications, there are numerous benefits to interrupting the clenching cycle. It allows the wearer of a suitably designed mouthpiece to function more effectively, more efficiently, more comfortably, and for a longer period of continuous time.
In a working environment, the performance mouthpiece offers the wearer stress relief that allows better concentration and greater efficiency and effectiveness. The shape, position and size of the performance mouthpiece are negligible, encouraging its utilization at any stressful time. The wearer can talk, breathe, and function normally; the appliance is virtually invisible, and can be innocuously inserted and removed.
In a sports environment, the mouthpiece acts as a performance enhancer; increased focus on the activity yields greater precision, calms the wearer, combats fatigue, and improves success. In contact sports, a mouthguard is more appropriate, but in non-contact athletic endeavors such as golf, tennis, cycling, squash, skiing, etc., performance mouthwear interrupts the clenching cycle to enhance performance.
Whose Responsibility Is The Mouthwear Appliance?It is important to determine who among health professionals is most qualified to provide de-stressing and performance enhancing appliances. The best place to de-stress the occlusion is intra-orally; this makes mouthwear the responsibility of the dentist. Certain physicians, general practitioners and specialists, may be generally aware of the mouth but certainly do not have the day-to-day experience with the oral cavity, impressions and appliances. In addition, members of the public are far more likely to see a dentist than a physician in any given year, and tend to view the dental profession as the default source of expertise in all things related to the oral cavity.
When should dental performance mouthwear be utilized? Contact and active sports are definitely indications for protective mouthwear rather than just performance enhancing appliances. The indications for performance mouthwear include exercises where additional strength is helpful, better focus and concentration are necessary, and to alleviate stress-related clenching. The safety of these appliances is well established and their contribution to performance has been documented. Continuing studies are assembling comprehensive data that consistently validates the beneficial performance effects of performance mouthwear appliances. From a clinical perspective, the indications for performance mouthwear in the dental practice include patients who are interested in improving their golf, tennis, or other non-contact games as well as individuals who brux or exhibit similar parafunctional activities.
Patients who self-identify as frequent and/or excessive gum chewers are typically highly stressed, and are well served with a mouthwear appliance.
How Is Dental Performance In-Office Mouthpiece Fabricated?The boil-and-bite Armourbite Mouthpiece is relatively easy to fit to the patient’s mouth. In fact, most patients can readily create the appliance by themselves. The advantage of professional guidance cannot be overestimated, however. Patients may have difficulty in positioning the mouthpiece correctly, particularly when they are trying to read and follow instructions while operating in the unfamiliar territory of mirrored images. For the dental professional, this technique is simple, straightforward, and familiar. It takes little chair time, and provides a well-fitting appliance for the patient. The following photographs demonstrates a self-fitting sequence; the third party fabrication is exactly the same.
Trial FittingFirst, grip
the middle of the labial bar of the Armourbite Mouthpiece with the thumb and middle fingers of both hands (Fig. 4). The Mouthpiece is inserted into the mouth at a slight upward angle. Push the labial bar against the labial surfaces of the lower anterior teeth (Fig. 5). Using a mirror, (Fig. 6) align the notch in the center of the labial bar with the embrasure between the lower centrals and verify the positioning with a mirror.
BoilingOnce the trial fitting is complete, the Mouthpiece is snapped into the end of the fitting tool (Fig. 7). Then the Mouthpiece is inserted into boiled water that is deep enough to entirely submerge the Mouthpiece. The fitting tool, of course, should be out of the water and therefore unheated (Fig. 8). The Armourbite Mouthpiece is kept in the hot water for 60 seconds (Fig. 9) when the fitting tool is used to carefully lift it out of the bath. The Mouthpiece is detached from the fitting tool (Fig. 10). It is important to avoid touching the softened tray material with the fingers (Fig. 11).
Mouth Insertion And Bite FittingHolding the appliance as before with thumbs and forefingers (Fig. 12), the Mouthpiece is inserted into the mouth at the same position and angulation as the trial fitting (Fig. 13). Viewing in a mirror, the center notch is aligned with the embrasure of the lower central incisors and the labial bar is pressed tightly against the lower anterior teeth and held there (Fig. 14). The index fingers are used to press the bite plates down over the lower posterior teeth (Fig. 15). At this stage, the fingers can be slowly removed from the Mouthpiece as the teeth are clamped together to keep the appliance secure between the upper and lower teeth.
ContouringThe fingers can now be used to mold the softened material against the lower teeth and over the soft tissues. This contours the tray material and increases the fit and retention. It is a good idea for the patient to suck against the product, creating a lingual vacuum, to improve its adaptation. As the tray material is cooling and hardening, the teeth should be closed and the patient should be sucking in for approximately 1 minute (Fig. 16).
FinishingAfter the contoured Mouthpiece has been removed from the mouth, place the appliance in ice water (Fig. 17) for approximately 15 minutes to set the soft material (Fig. 18). The mouthpiece is now ready to use.
Performance mouthpieces are available in custom (laboratory-made) and boil-and-bite delivery configurations. While the custom appliance fits better, functions more effectively, and is more comfortable, the boil-and-bite approach is a relatively quick and inexpensive means (for both dentist and patient) whereby patients can be introduced to the concept of intraoral stress relief and its benefits. Just imagine whether the patients whose golf games have been improved by intraoral performance appliances will become more committed and loyal patients and whether they are likely to refer others (except their golf partners) for similar treatment!OH
Dr. George Freedman is a founder and past president of the American Academy of Cosmetic Dentistry, a co-founder of the Canadian Academy for Esthetic Dentistry and a Diplomate of the American Board of Aesthetic Dentistry. Dr. Freedman sits on the Oral Health Editorial Board (Dental Materials and Technology) is a Team Member of REALITY and lectures internationally on dental esthetics and dental technology. A graduate of McGill University in Montreal, Dr. Freedman maintains a private practice limited to Esthetic Dentistry in Markham, ON, Canada.
Cameron Stewart played in the NHL with the Boston Bruins, Florida Panthers, and was an original member of the Minnesota Wild. He retired from hockey due to problems arising from an on-ice concussion. His unique and personal perspective is instrumental in his role as Vice President of Bite Tech Canada and his leadership in the introduction of innovative performance mouthwear to the Canadian sports community.
Troy Stephens is Canadian Manager of Bite Tech Inc. His sporting life includes three seasons in the OHL, highlighted by a trip to the Memorial Cup, Varsity hockey at the University of Waterloo, several years in the minor leagues throughout the US and capped off with nine seasons in Europe.
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References1. J Sports Med Phys Fitness. 1997 Mar;37(1):7-17. Training and overtraining: an overview and experimental results in endurance sports.2. Lehmann MJ, Lormes W, Opitz-Gress A, Steinacker JM, Netzer N, Foster C, Gastmann U.3. Int J Sports Med. 1996 Nov;17(8):554-8. Pepsinogens and gastrointestinal symptoms in mountain marathon runners. Banfi G, Marinelli M, Bonini P, Gritti I, Roi GS.
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