ORIGINAL RESEARCH
Mouthguard Use and Awareness of Junior Rugby League
Players in the Gold Coast, Australia: A Need for
More Education
Jeroen Kroon, PhD,* Julie A. Cox, BOralH,† Jamelle E. Knight, BOralH,† Pia N. Nevins, BOralH,†
and William W. Kong, BOralH†
Objective: To investigate knowledge, attitude, and awareness of
appropriate mouthguard use, as well as the management of traumatic
dental injuries (TDIs).
Design: Cross-sectional survey.
Setting: Community survey.
Participants: Four hundred ninety-four junior rugby league play-
ers and their coaches in the Gold Coast, Australia.
Interventions: Data were collected anonymously during training
sessions by means of a survey questionnaire, followed by a pre-
sentation on mouthguards and the management of TDIs.
Main Outcome Measures: Descriptive statistics on the fre-
quency distribution of the demographic characteristics, knowledge,
and use of mouthguards as well as the relationships between the type
of mouthguard worn and questions related to mouthguard use.
Results: The majority of players surveyed reported wearing
a mouthguard (68.2%). Cost (40.1%) and not believing that they
work (35.7%) were listed as the main reasons for not doing so. The
boil-and-bite type was the most used by players (64.7%). Almost
44% of coaches and 50% of players responded that only a dentist can
manage an avulsed tooth, that a tooth had to be reinserted within
15 minutes (40.6% and 21.9%, respectively), and that either water or
milk can be used to transport an avulsed tooth to the dentist (100%
and 82.2%, respectively).
Conclusions: Education related to the correct use of mouthguards
and the management of TDIs should be ongoing for players, their
caregivers, and their coaches and should be required as part of the
training of coaches to prevent injury in rugby league.
Submitted for publication May 4, 2014; accepted December 2, 2014.
From the *School of Dentistry and Oral Health, Menzies Health Institute of
Queensland, Griffith University, Gold Coast, Australia; and †School of
Dentistry and Oral Health, Griffith University, Gold Coast, Australia.
The authors report no conflicts of interest.
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF
versions of this article on the journal’s Web site (www.cjsportmed.com).
Corresponding Author: Jeroen Kroon, PhD, School of Dentistry and Oral
Health, Gold Coast Campus, Griffith University, Queensland 4222,
Australia (j.kroon@griffith.edu.au).
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Clinical Relevance: This study found that although the over-
whelming majority of junior rugby league coaches encourage the
wearing of mouthguards, only two-thirds of the players do so.
Players’ compliance to wear mouthguards is largely influenced by
their perception of efficacy and its comfort. Educational campaigns
with involvement of dental practitioners, related to the correct use of
mouthguards and the management of TDIs, should be ongoing for
players, their caregivers, and their coaches and should also be
required as part of the training of coaches.
Key Words: awareness, education, mouthguards, rugby league,
sports clubs, dental injuries, trauma
(Clin J Sport Med 2016;26:128–132)
INTRODUCTION
Traumatic dental injuries (TDIs) in Australia are mainly
related to falls, sports, bicycle injuries, assaults, and fights
with the prevalence of dental injuries reported to be
approximately 6% and occurring mostly outdoors, at home,
or at school.1
The American Dental Association (ADA) recommends
that athletes of all ages should use a properly fitted mouth-
guard in any activity that poses a risk of dental injury and
suggests that a custom mouthguard provides patients with the
most precise fit and the best retention.2 The Australian Dental
Association similarly promotes the wearing of a custom-fitted
mouthguard above the boil-and-bite (or mouth-formed) and
ready to wear (or stock) types.3 A review of the role of mouth-
guards in the prevention of sport-related dental injuries
confirmed that custom-made mouthguards offer better protec-
tion than the boil-and-bite type.4 The ADA partially attributes
the underuse of mouthguards to the lack of regulations and
education provided by coaches.2
Although organized sport is recognized as a major
cause of TDIs, incidence as reported in the literature varies
from 2% to 33%.4 This is determined by the type of sport
played, age of the athlete, the level of competition, whether
the data were collected from coaches, hospital emergency
departments or dental clinics, and the use of protective equip-
ment.5 The protective effect of mouthguards was confirmed in
a meta-analysis, where the overall risk of TDIs was found to
be 1.6 to 1.9 times higher when a mouthguard is not worn.6
Soccer, Australian rules football, rugby union, rugby
league, cycling, basketball, hockey, cricket, and baseball are
Clin J Sport Med  Volume 26, Number 2, March 2016
 Clin J Sport Med  Volume 26, Number 2, March 2016 Mouthguard Awareness in Junior Rugby League Players

all popular sports played in Australia, all of which pose a risk of the survey. Parents were given an “opt-out” option if they
for dental trauma.7 Although some studies have reported on did not wish their child to participate.
injuries and mouthguard use of Australian children participat-
ing in rugby union, Australian rules football and basketball,8–11
none have reported on junior rugby league players. In these RESULTS
studies, mouthguard wear in juniors varied from 30% to 60%. None of the parents/caregivers chose for their child to
A Canadian study reported that only 20.2% of children wore “opt-out” of the study. Of the 499 junior rugby league players
mouthguards during sport.12 and 32 coaches surveyed, 5 player surveys had to be excluded
The objectives of this study were to investigate the because of incompleteness. The final sample of 494 players
baseline knowledge, attitude, and awareness of appropriate were from the age groups under 8 to under 15, with almost
mouthguard use, as well as the management of TDIs, in 53% from the under 11 to under 13 age groups. All the
a sample of junior rugby league players and their coaches in participants were male and the mean age of players was
the Gold Coast, Australia. 11.2 years (SD 1.84). The mean number of years that the
coaches had been involved in coaching rugby league was
9.2 years with a median of 5 years.
METHODS Data on the use of mouthguards by players and the
Gold Coast is the sixth largest city in Australia and the awareness of coaches are presented in Table 1. Although
second largest in Queensland after Brisbane. Gold Coast 68.2% of players reported wearing a mouthguard, this
Junior Rugby League supports 17 clubs with approximately increased from 54.5% for the under 8 to 73.9% for the under
5200 members in 2013.13 This study was undertaken during 15, except for the under 13 and under 14 age groups where
the 2012 rugby league season in the 3 largest junior rugby only 68.8% and 46.4% of players reported wearing a mouth-
league clubs in the Gold Coast, Australia. Before the survey, guard. The highest reported use was recorded for the under 12
the questionnaire was piloted in a rugby league club not age group (74.8%). For those not wearing a mouthguard
included in this study. Inclusion criteria for the study were
players in the age groups under 8 to under 15 who is a playing
member of the junior rugby league club included in the study,
was present for practice on the day of the survey, and held TABLE 1. Use of Mouthguards by Junior Rugby League Players
informed consent. Information sheets explaining the study and Awareness of Coaches
were distributed to the parents and coaches before the survey. Sample %
As part of the informed consent for the project, the informa- Players
tion sheet provided parents with an “opt-out” option if they Do you wear a mouthguard during training or
did not wish their child to participate. Data were collected games?
anonymously during training sessions by means of a survey Yes 337 68.2
questionnaire (Supplemental Digital Content 1, http://links. No 157 31.8
lww.com/JSM/A71), which took approximately 10 to 15 mi- What type of mouthguard do you wear?
nutes to complete. Members of the research team were present Custom made 78 23.1
to assist children with clarifying any questions. After com- Boil and bite 218 64.7
pletion of the survey, a short standardized presentation, fol- Ready to wear 41 12.2
lowed by an opportunity for questions about how to manage If you do not wear a mouthguard, why not?
an avulsed tooth and the importance of mouthguards, was Too expensive 63 40.1
provided at each club by a member of the research team, to No time to visit the dentist 35 22.3
address questions from parents, coaches, and players on any I have braces 3 1.9
aspect related to the study. Clubs were also provided with I don’t believe it works 56 35.7
informative posters, produced by the Australian Dental Asso- Coaches
ciation on mouthguards and the management of TDIs,3 to be Do you encourage the use of mouthguards?
displayed in prominent areas of the club. Yes 30 93.7
Data were entered into an SPSS (IBM Corp, Armonk, No 2 6.3
New York) database and descriptive statistics were prepared. What type of mouthguard do you recommend?
The frequency distribution of the demographic characteristics, Custom made 24 75.0
knowledge, and use of mouthguards in players and coaches Boil and bite 7 21.9
was initially analyzed. The relationships between the type of Ready to wear 1 3.1
mouthguard worn and questions related to mouthguard use When do you encourage that the mouthguard
were assessed using the x2 test. A P value #0.05 was should be worn?
considered as statistically significant. Training only 0 0
Games only 10 31.3
Ethical Considerations Training and games 22 68.7
Approval was granted by the Griffith University Human Do you encourage the use of headgear?
Research Ethics Committee to conduct the study (DOH/25/ Yes 22 68.7
11/HREC) after all clubs provided written approval to be part No 10 31.3

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 Kroon et al Clin J Sport Med  Volume 26, Number 2, March 2016

(31.8%), cost (40.1%), and not believing that they work
(35.7%) were listed as the main reasons for not doing so.
The majority of coaches (93.7%) encouraged the use of
mouthguards with 75% recommending the custom-made type,
although the boil-and-bite type was the most used type of
mouthguard worn (64.7%) by players, followed by the custom-
made type (23.1%). An increase was found in the wearing of
custom-made mouthguards by age (Table 2) with 41.2% of
under 15 reporting wearing this type. Age, and when a mouth-
guard is worn, was significantly related to the type of mouth-
guard used (P = 0.05), whereas whether wearing a mouthguard
when injured was found to be highly significantly when related
to the type of mouthguard worn at the time (P , 0.01) (Table
2). No significant association was found between TDIs and
how often a player trained, and if the player also wore pro-
tective headgear when playing rugby league. The ready to wear
mouthguard was mostly worn in the younger age groups,
except for the under 14, where 23.1% of players reported
wearing this type. The majority of players reported wearing
their mouthguards during games (55.2%). Of those who re-
ported never wearing their mouthguard, 50% of players
reported owning a ready to wear type. For players who re-
ported that they only wore a mouthguard when told to do so
by their parents or coaches, 63.6% were using the boil-and-bite
type. Although the nature of the injuries sustained was not
investigated in this study, of the players who reported having
been hurt on the face or teeth when playing sport, 24.4% were
wearing a custom-made mouthguard, 65.3% a boil-and-bite,
and 36% a ready to wear type at the time of the survey.
Table 3 presents data on knowledge of players and
coaches in the management of TDIs. The majority of players
(53.8%) reported having experienced an injury to the face or
teeth when playing sport, whereas 90% of coaches indicating
that they had to deal with such injuries, 41.4% more than 5
times. The majority of players and coaches were of the opinion
that only a dentist can manage an avulsed (knocked out) tooth,
40.6% of coaches, and 21.9% of children indicated that a tooth
had to be reinserted within 15 minutes if they had to do so
themselves. Almost 82% of players and all coaches indicated
either water or milk as a solution to transport an avulsed tooth
to the dentist. Sports drinks were selected by 16% of players
and 6.3% of coaches as a suitable medium of transport.

TABLE 2. Percentage Use of Mouthguards and Percentage Distribution of Mouthguard Type

Do You Wear If You Wear a
a Mouthguard? Mouthguard, Which Type?
Yes (n) No (n) Custom Made Boil and Bite Ready to Wear x2 P
Age group (n) 0.05*
Under 8 (11) 54.5 (6) 45.5 (5) 0 100 0
Under 9 (48) 64.6 (31) 35.4 (17) 25.8 54.8 19.4
Under 10 (96) 71.9 (69) 28.1 (27) 17.4 69.9 13.0
Under 11 (56) 73.2 (41) 26.8 (15) 17.1 73.2 9.8
Under 12 (111) 74.8 (83) 25.2 (28) 24.1 61.4 14.5
Under 13 (93) 68.8 (64) 31.2 (29) 21.9 73.4 4.7
Under 14 (56) 46.4 (26) 53.6 (30) 38.5 38.5 23.1
Under 15 (23) 73.9 (17) 26.1 (6) 41.2 52.9 5.9
Total (494) 68.2 (337) 31.8 (157) 23.1 64.7 12.2
How often do you train (h/wk)? (n) 0.27
1-2 (177) 66.7 (118) 33.3 (59) 20.3 63.6 16.1
3-5 (269) 68.4 (184) 31.6 (85) 23.4 67.4 9.2
More than 5 (48) 72.9 (35) 27.1 (13) 31.4 54.3 14.3
When do you wear your mouthguard? (n) 0.05*
Training only (4) 0 66.7 33.3
Games only (201) 21.9 67.2 10.9
Training and games (87) 28.9 65.1 6.0
All contact sports (32) 24.1 72.4 3.4
Only when told by parent/coach (13) 27.3 63.6 9.1
Never (29) 16.7 33.3 50.0
Do you wear protective headgear? (n) 0.08
Yes (162) 79.0 (128) 21.0 (34) 29.7 59.4 10.9
No (332) 63.0 (209) 37.0 (123) 19.1 67.9 12.9
If ever you have been hurt on your face or 0.006*
teeth when playing sport, did you wear
a mouthguard at the time of the injury? (n)
Yes (135) 88.1 (119) 11.9 (16) 24.4 65.3 36.0
No (131) 52.7 (69) 47.3 (62) 14.5 34.7 64.0
*P # 0.05.

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 Clin J Sport Med  Volume 26, Number 2, March 2016 Mouthguard Awareness in Junior Rugby League Players

not think that they work. Other studies have also confirmed
TABLE 3. Knowledge of Players and Coaches on the
a low level of knowledge in both active participants, care-
Management of TDIs
givers, and spectators of sport.16 Results from our study sup-
Sample % port recommendations that only through the education and
Players increased awareness of all of those involved in sports where
Have you ever been hurt on your there is a risk of orofacial injury, will participants be able to
face or teeth when playing make an informed decision on mouthguards.16,17 It has also
sport?
been suggested that educational posters displayed prominently
Yes 266 53.8
in sports clubs are a clear and low-cost method of presenting
No 228 46.2
the appropriate procedures to follow after TDIs occur.16,17 This
Coaches
principle was applied in this study as part of our duty of care
Have you ever had to deal with an
injury to the face or teeth during where after the survey was completed, informative posters,
your time as a coach? produced by the Australian Dental Association on mouth-
Yes 29 90.6 guards and the management of TDIs,3 were left with clubs to
No 3 9.4 display in the first aid and dressing rooms, and information
If yes, how many times? leaflets handed to all players and their coaches. It has also been
Once 8 27.6 suggested that routine dental visits be used to further educate
2-5 time 9 31.0 the patients regarding the risks of injury, guidance on mouth-
More than 5 times 12 41.4 guards, cost and benefits, and the prevention of TDIs.2,18 A
review of first-aid textbooks has shown a severe lack of infor-
Players Coaches
mation on the management of TDIs and strongly suggests that
Sample % Sample % this be included to promote greater awareness on this topic.19
If a tooth gets knocked out, how Time is a critical factor in the management of TDIs with
much time do you think you have a general acceptance that an avulsed tooth should be
to put it back in?
reimplanted as soon as possible, with milk being regarded
15 min 108 21.9 13 40.6
as the best and most readily available solution to store a tooth
30 min 84 17.0 1 3.1
until reimplantation can occur.20–22 A review of the education
1h 44 8.9 4 12.5
of professional caregivers and lay people in the management
Only a dentist can put it back 249 50.4 14 43.8
of TDIs concluded that the majority of physical education
Do not know 9 1.8 0 0
personnel, teachers, or lay people would not be willing to
If a tooth gets knocked out what
would you put it in? (respondents
attempt to reimplant an avulsed tooth, and would rather refer
could select more than 1 answer) the patient to a dentist or emergency department.23 A review
Water 240 48.6 13 40.6 of dentists’ knowledge in managing dental trauma found that,
Milk 166 33.6 19 59.4 in general, their knowledge was inadequate because
Sports drink 52 10.5 2 6.3 of minimal experience, with their knowledge increasing if
Nothing 79 16.0 4 12.5 they attended further education courses, or were used in group
Do not know 10 2.0 0 0 practices.1 The majority of participants in surveys on how to
manage dental trauma were also not aware that milk would be
the best storage medium for an avulsed tooth.23 Similar results
were found for children in a survey of sixth grade primary
DISCUSSION school children in Brazil,24 as well as this study.
Parents, officials, and coaches have been identified as The Sports Medicine Australia Web site has several
being influencing forces, with coaches being the most resources and fact sheets on the prevention of injuries for
influential, when investigating the motivation behind mouth- different sports, including rugby league.25 The fact sheet on
guard use.14 The results of this study show that although dental injuries recommends custom-fitted mouthguards for all
93.8% of junior rugby league coaches on the Gold Coast, contact sport participants because they are well fitting, can
Australia, encourage the wearing of mouthguards, only accommodate the unique arrangement and number of teeth
68.2% of the players do so, mostly during games. The boil- and ensures adequate thickness of material in vulnerable
and-bite type is the most used (87.8%) among under 8 to areas. It also states that the boil-and-bite type does not meet
under 15 players, although the use of a custom-made mouth- these criteria.
guard increases with age. This study of a sample of the junior rugby league
Players’ perception of efficacy and the comfort of the community on the Gold Coast, Australia, developed an
mouthguard largely determine the compliance of players to insight into the knowledge and practices of coaches and
wear mouthguards.15 Although not investigated in this study, players on the subject of preventive care measures related to
comfort might have been a factor associated with 50% of TDIs, and aimed to educate caregivers, coaches, and children
players with a ready to wear, and 33.3% with a boil-and- involved in the sport on the benefits of mouthguard use and
bite type, reporting never wearing their mouthguard, com- emergency treatment of an avulsed tooth.
pared with only 16.7% for the custom-made type. Just over This study was conducted in the 3 largest junior rugby
35% of players in this study who do not wear mouthguards do league clubs on the Gold Coast, Australia. Not selecting

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 Kroon et al
a representative sample from some of the other clubs might be
perceived as a limitation of this study. Not including “I don’t
know” as an option in the questionnaire might have resulted
in participants guessing one of the other options, which might
have skewed the results, although a member of the research
team was always at hand to address any uncertainties when
the questionnaires were completed. A lack of clarification
whether the mouthguards players were wearing at the time
of a TDI was identical to the type they were currently wearing
was a limitation of this study, as this prevented comparisons
of efficacy of the different mouthguard types.
CONCLUSIONS
The results of this study indicate that although coaches
seem to be aware of the need and benefits of mouthguard use,
this is not reflected in what is practiced by players. Results
further indicate that knowledge on the management of TDIs is
lacking in both coaches and players. It is therefore strongly
recommended that education related to the importance of
mouthguards and the management of TDIs should be ongoing
for players, their caregivers, and their coaches and should be
required as part of the training of coaches to prevent injury in
rugby league.
ACKNOWLEDGMENTS
The authors acknowledge the assistance of Saba Arora,
Monica Bassal, James Carrigy, Gloria Chang, Jong Hur,
Yashoma Lalla, Helen Leung, Sterling Rebeil, Neeraj Vyas,
and Clancy Williamson in this project.
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