Microbiota Found in Protective Athletic Mouthguards

Protective athletic mouthguards (PAM) or mouthpieces provide protection for the teeth during contact sports.4,12-14,16,18,19 These results have prompted the American Dental Association to support the use of PAM for all contact sports. Football teams at all levels have been among the most compliant with the association’s recommendations. However, the best practices for sanitization and changing these devices are unknown.2 Many teams allow players to store and replace their PAM as they deem necessary.1,3,5,15 Recent studies of hockey players,8 football players, and medical students6 have shown that PAM harbor a range of pathogenic and opportunistic bacteria, yeasts, and molds.17 Ultrastructural analyses by scanning electron microscopy reveal that the microorganisms can be found both on the surfaces and in the porosities of the polymerized PAM material (Figures 1 and ​and22). Figure 1. Scanning electron microscopy of a typical protective athletic mouthguard. Note the large crevices that allow for deep penetration of microorganisms and produce difficulties in the mechanical removal of the microbes. Original magnification, 1000×. ... Figure 2. Scanning electron microscopy of a protective athletic mouthguard demonstrating large accumulations of a variety of microorganisms forming a complex network (biofilm), as well as areas that appear completely free of any microbes (no biofilm). Original ... In previous studies of PAM, the 2 most frequently isolated gram-positive cocci (Staphylococcus aureus and Staphylococcus epidermidis) were not only prominent skin pathogens but also associated with endocarditis, pericarditis, pneumonia, osteomyelitis, food intoxication, and athletic equipment contamination.6,8 Other species of bacteria and fungi isolated from the football and hockey PAM were associated with myriad diseases, such as meningitis, urinary tract infections, peritonitis, periodontal disease, wound infections, and exercise-induced asthma.9,10 While both football and hockey PAM studies do not represent the total microbial population found on PAM, they are sufficient to warrant genuine concern. Also, the condition of PAM after wear may facilitate disease transmission.6,8-10 The jagged, sharp areas of the posterior regions of typical PAM are in close proximity to the pterygoid plexus of veins and, therefore, the entire circulatory system (Figure 3). A recent study over the course of a season confirmed that football mouthguards increased the number and severity of oral mucosal injuries.9 Previous studies found that some commercially available PAM were contaminated before use.6,8 Figure 3. Typical protective athletic mouthguard after a season of wear. Note the rough, jagged edges capable of creating a microbial portal of entry into the tissues. PAM storage is also an important factor to consider. Rules dictate that the football and hockey PAM be in the players’ mouths during play; a typical location of the PAM between plays is often extraoral (Figure 4). These tendencies facilitate the contamination of the device with a range of environmental microbes. Figure 4. Typical position of the protective athletic mouthguard in between plays (arrow), allowing for substantial environmental contamination. PAM are porous and can become contaminated, emphasizing the need to evaluate the in vivo spectra of microorganisms that may be found within such devices. The following study was performed to address these questions: (1) Do PAM become contaminated by a range of microorganisms with wear? (2) Can the microorganisms found on and in PAM be either eliminated or significantly reduced (103 reduction) using a sanitizing formulation (NitrAdine, MSI Laboratory, Vaduz, Liechtenstein)?