Sex-Based Differences in Symptoms With Mouthguard Use After Pediatric Sport-Related Concussion
Authors: van Ierssel Jacqueline , Ledoux Andrée-Anne , Tang Ken , Zemek Roger 
Published: April 2021

Context
Current evidence regarding the protective effect of mouthguard use on symptom severity in children and adolescents who sustain sport-related concussions is insufficient to make clinical recommendations.

Objective
To compare the association between mouthguard use and symptoms stratified by sex in the first 4 weeks after pediatric sport-related concussion. We hypothesized that mouthguard use would be associated with less severe symptoms.

Design
Prospective cohort study.

Setting
Nine Canadian pediatric emergency departments (EDs).

Patients or Other Participants
Children aged 5 to 18 years who were assessed within 48 hours of concussions sustained during a collision or contact sport.

Main Outcome Measure(s)
Injury characteristics were collected using the Acute Concussion Evaluation. The primary outcome measure was symptom score (range = 0–6), measured using age-appropriate versions (5–7, 8–12, or 13–18 years) of the Post-Concussion Symptom Inventory. The independent variable was time postconcussion (initial assessment and 1, 2, and 4 weeks).

Results
Of 1019 children (73% male; median [interquartile range] age = 13.43 years [11.01–15.27 years]), 42% wore a mouthguard at the time of injury. No significant group-by-sex-by-time interaction was present for symptoms (\(\def\upalpha{\unicode[Times]{x3B1}}\)\(\def\upbeta{\unicode[Times]{x3B2}}\)\(\def\upgamma{\unicode[Times]{x3B3}}\)\(\def\updelta{\unicode[Times]{x3B4}}\)\(\def\upvarepsilon{\unicode[Times]{x3B5}}\)\(\def\upzeta{\unicode[Times]{x3B6}}\)\(\def\upeta{\unicode[Times]{x3B7}}\)\(\def\uptheta{\unicode[Times]{x3B8}}\)\(\def\upiota{\unicode[Times]{x3B9}}\)\(\def\upkappa{\unicode[Times]{x3BA}}\)\(\def\uplambda{\unicode[Times]{x3BB}}\)\(\def\upmu{\unicode[Times]{x3BC}}\)\(\def\upnu{\unicode[Times]{x3BD}}\)\(\def\upxi{\unicode[Times]{x3BE}}\)\(\def\upomicron{\unicode[Times]{x3BF}}\)\(\def\uppi{\unicode[Times]{x3C0}}\)\(\def\uprho{\unicode[Times]{x3C1}}\)\(\def\upsigma{\unicode[Times]{x3C3}}\)\(\def\uptau{\unicode[Times]{x3C4}}\)\(\def\upupsilon{\unicode[Times]{x3C5}}\)\(\def\upphi{\unicode[Times]{x3C6}}\)\(\def\upchi{\unicode[Times]{x3C7}}\)\(\def\uppsy{\unicode[Times]{x3C8}}\)\(\def\upomega{\unicode[Times]{x3C9}}\)\(\def\bialpha{\boldsymbol{\alpha}}\)\(\def\bibeta{\boldsymbol{\beta}}\)\(\def\bigamma{\boldsymbol{\gamma}}\)\(\def\bidelta{\boldsymbol{\delta}}\)\(\def\bivarepsilon{\boldsymbol{\varepsilon}}\)\(\def\bizeta{\boldsymbol{\zeta}}\)\(\def\bieta{\boldsymbol{\eta}}\)\(\def\bitheta{\boldsymbol{\theta}}\)\(\def\biiota{\boldsymbol{\iota}}\)\(\def\bikappa{\boldsymbol{\kappa}}\)\(\def\bilambda{\boldsymbol{\lambda}}\)\(\def\bimu{\boldsymbol{\mu}}\)\(\def\binu{\boldsymbol{\nu}}\)\(\def\bixi{\boldsymbol{\xi}}\)\(\def\biomicron{\boldsymbol{\micron}}\)\(\def\bipi{\boldsymbol{\pi}}\)\(\def\birho{\boldsymbol{\rho}}\)\(\def\bisigma{\boldsymbol{\sigma}}\)\(\def\bitau{\boldsymbol{\tau}}\)\(\def\biupsilon{\boldsymbol{\upsilon}}\)\(\def\biphi{\boldsymbol{\phi}}\)\(\def\bichi{\boldsymbol{\chi}}\)\(\def\bipsy{\boldsymbol{\psy}}\)\(\def\biomega{\boldsymbol{\omega}}\)\(\def\bupalpha{\bf{\alpha}}\)\(\def\bupbeta{\bf{\beta}}\)\(\def\bupgamma{\bf{\gamma}}\)\(\def\bupdelta{\bf{\delta}}\)\(\def\bupvarepsilon{\bf{\varepsilon}}\)\(\def\bupzeta{\bf{\zeta}}\)\(\def\bupeta{\bf{\eta}}\)\(\def\buptheta{\bf{\theta}}\)\(\def\bupiota{\bf{\iota}}\)\(\def\bupkappa{\bf{\kappa}}\)\(\def\buplambda{\bf{\lambda}}\)\(\def\bupmu{\bf{\mu}}\)\(\def\bupnu{\bf{\nu}}\)\(\def\bupxi{\bf{\xi}}\)\(\def\bupomicron{\bf{\micron}}\)\(\def\buppi{\bf{\pi}}\)\(\def\buprho{\bf{\rho}}\)\(\def\bupsigma{\bf{\sigma}}\)\(\def\buptau{\bf{\tau}}\)\(\def\bupupsilon{\bf{\upsilon}}\)\(\def\bupphi{\bf{\phi}}\)\(\def\bupchi{\bf{\chi}}\)\(\def\buppsy{\bf{\psy}}\)\(\def\bupomega{\bf{\omega}}\)\(\def\bGamma{\bf{\Gamma}}\)\(\def\bDelta{\bf{\Delta}}\)\(\def\bTheta{\bf{\Theta}}\)\(\def\bLambda{\bf{\Lambda}}\)\(\def\bXi{\bf{\Xi}}\)\(\def\bPi{\bf{\Pi}}\)\(\def\bSigma{\bf{\Sigma}}\)\(\def\bPhi{\bf{\Phi}}\)\(\def\bPsi{\bf{\Psi}}\)\(\def\bOmega{\bf{\Omega}}\)\({\rm{\chi }}_3^2\) = 0.27; P = .965). Male mouthguard users reported similar symptom scores in the ED (difference in Post-Concussion Symptom Inventory Δ scores [diff] = −0.07; 95% CI = −0.23, 0.09) and at weeks 1 (diff = −0.02; 95% CI = −0.18, 0.14), 2 (diff = −0.03; 95% CI = −0.19, 0.13), and 4 (diff = −0.13; 95% CI = −0.29, 0.04) compared with males who did not wear a mouthguard. Female mouthguard users described minimally higher symptom scores at week 1 compared with non-mouthguard users (diff = 0.29; 95% CI = 0.01, 0.56). In the ED, symptom scores were not different for females who wore a mouthguard and those who did not (diff = 0.22; 95% CI = −0.04, 0.48) or at weeks 2 (diff = 0.22; 95% CI = −0.06, 0.51) or 4 (diff = 0.08; 95% CI = −0.20, 0.36).

Conclusions
Wearing a mouthguard at the time of injury was not associated with reduced acute or subacute symptoms after sport-related concussion in either males or females who were treated in the ED compared with those who did not wear a mouthguard. Athletes are still encouraged to wear mouthguards during sports because overwhelming evidence supports their use in preventing dental injuries.