The Concussion Blog

If you have not been following the comment section you have missed a debate on mouth gear and concussions (Please feel free to enter into the conversation).  I believe that the information about how there is no current evidence that any oral device can attenuate concussions or help with symptoms related to the injury of concussions.  Here is a statement from the National Federation of State High School Associations (NFHS) Sports Medicine Handbook – 4th Edition;

“The effectiveness of mouthguards for preventing or reducing the risk of sustaining a concussion remains controversial. Research continues to be done on the different mouthguards and their properties to answer this question, but there is currently no reproducible evidence supporting the use of any mouthguard to protect against concussion in any sport.”

For a health care professional dealing with sports injuries this should be a telling statement.  However there are those out there trying to push a product and make money on the misinformation about concussions.  Below you will see some of the exchange and the prime example of why there continues to be a problem.  (The commenter “Mark” represents a company that is trying to sell a product that may help with tempromandibular issues, but is wading into the concussion realm and delivering improper information, bordering on fraudulent claims, we have highlighted more of this in two previous posts – 1 & 2).

Here are the most recent claims and responses from more than just me;

Mark

Clearly part of Vicks injury was from a blow to the jaw/ chin, it was reported that part of his tongue was on the field after biting off. He should be evaluated to see if the cartilage (meniscus) was also damaged due to this or a past injury. Why not, knowing that the symptoms of temporal mandibular joint dysfunction can be similar to pcs, it makes sense, since it is simply diagnosed. In fact the Eagles already have access to this technology. A corrective ortho retainer like mouth guard, already used in the NFL has no plastic on the front teeth and allows for clearer speech and breathing. It’s made of a hard acrylic material so they fit tightly and you can’t even see it the the players who wear them. Several NFL quarterbacks are already using these medically constructed appliances, worn by the majority of N.E. Patriot players. At least with these types of guards there is some medical oversight, unlike boil and bite or custom made products that ignore this diagnosable factor.

My Response;

Fine someone can look at the things you mention… BUT!!! It remains that none of what you are saying played a role in his injury. He was concussed due to the rotational/deceleration forces to his head, period.

Was Arrington, Woodhead and Wright wearing your product at the time of their concussions for New England? Does Asante Samuel continue to wear your mouth product after being concussed last year, heck was he even wearing?

I continue to let you comment because, one this is an open site and two it is rather enjoyable to watch you hang yourself with all the rope I give you…

I am not the only one that comments in response to you, there is a mom that finds your information laughable, as well as a respected MD… Just sayn’

VtRace Mom

Mark with all due respect, your comments (tone of which is unprofessional) on this blog has only cast more doubt in my mind as to this question of whether or not mouthgear can reduce the rate of concussions involving impact to the jaw. Old thought was that mandible vs skull contact due to a misaligned jaw could cause a concussion due to the force applied to the jaw. I thought that this outdated 2006 argument was proven inconclusive as, if there is force sufficient to the jaw to cause a concussion then the force in and of itself jaw or no jaw is enough to cause the brain to move within the skull causing a concussive event. Perhaps I have misunderstood the basic dynamic of injury?

I have become wary of any research based on “reported concussions” we are all very well aware of the pitfalls there!

Another comment from Mark;

In a recent comment you stated, “of course you get a concussion from a blow to the jaw”, he bit part of his tongue off, no question he got hit in the chin. The amount of force needed to cut of a piece of the tongue, would without doubt damage cartilage in the jaw joint, just like a boxer. While not all concussion, as previously stated, comes from jaw trauma, we are saying the “risk factor” is elevated if temporal mandibular joint dysfunction is diagnosed. Symptoms of TMD can be confused with concussion, If your going to make a mouth guard for someone who has a concussion history and TMD, the experts agree, evaluating for this key risk factor is crucial. Dr. Jeffery Shaefer of Harvard MGH has written a research recommendation to U.S. Army research, who are now moving forward with a $2 million dollar initiative. Boil and bite and common custom tooth protectors cannot achieve this, they arbitrarily position the jaw, they don’t adapt to the physiology, there is no standard of care. Changing this random positioning of the end of the jawbone has been found to be effective in preliminary data, peer reviewed by Shaefer. For now, Mom’s, have no standard to look for in educating themselves about the different types of oral appliances, mouth guards and there limitations. There is so much snake oil and non medical marketing out there, it’s easy to see why there is much skepticism.

My very simple response;

Mark,
Yes wearing any mouth gear would have prevented hid tongue injury. If MG can only help wth TMD and oral injuries (which I agree with), then market yours that way and stay out of the concussion issue.

Thank you, PS: Oh, what about the NE players I listed?

Mark

Dustin,
Symptoms of TMD are nausea, headache, paricurarly after night grinding, facial numbness, jaw pain, blurred vision. Sound familiar. This type of jaw trauma can be misconstrued as concussion symptoms. Many athletes with pcs exihbit these same symptoms and many have found relief with this procedure. It is a medical approach, backed by diagnosis, addressing risk factors.
Players may wear our guards one week, then another week may have something else in. Most Patriot players who have concussion, are given the details of our procedure, since there is no mandate or universal standards, they make there own decision on what they use. I know Woodhead had a concussion and has been crushed since, whether he was fitted or not, I don’t know. I have seen Wright and Arrington wearing two dollar boil and bites, even today with Arrington. Samuals was quoted on our web site of his success using our product, once traded to the Eagles, who knows what he is wearing, even though I have spoken with Burkholder about their dentist being certified in the procedure, there is no continuity because their is no universally accepted standard. Only division, such as what we have here with you. Identifying “risk factor” in those with concussion history and TMD needs to be backed by a larger independent study, only then will we be recognized as a standard of care by insurers and neurologists. You have not voiced your opinion on the fact that a Harvard MGH expert has peer reviewed our preliminary published data and has initiated military research.
Shaefer states in peer reviewed literature, the Patriots have the lowest concussion rate annually. Why aren’t you and the experts scrutinizing this and the fact that this Harvard cranial facial expert peer reviewed this linked published data accepted by military research and the Pentagon.

http://www.ncbi.nlm.nih.gov/pubmed/19614931

http://www.bu.edu/cste/our-research/academic-articles/

Before I had a chance to respond a commenter name “Tad” had this to say;

That 2nd study cited is almost laughable. Multiple issues: company founder is study author, small sample size, self-reported symptoms, and no control? This is a fairly good example of how not to do a study. I smell nothing but placebo response here.

Then my response;

Mark you really going to let me SHRED this information that you provide??? First I have not commented on TMJ/TMD information because I do not know about such things…

Second, are you saying that concussions are actually just TMJ/TMD issues? You present it that way in the above comment…
Third, making statements that NE Patriots wear your product then say in one comment later that you don’t know if they wear it from week to week is telling…
Fourth, so what if it has been peer-reviewed, a lot of crap is reviewed later to be found just that crap…
Fifth, the Patriots DO NOT have the lowest concussion rate annually, it is impossible to discern that because those numbers were never released until our work here and certainly they were not last year and are not this year either…
Sixth, the article you link lost all relevance when I saw who a publisher was of the study, Maher, the owner and designer of the orthodic, HARDLY independent, shame on anyone who thinks this is a good idea…
Seventh, the second link is just a list of articles, but if you get into the one about MG you will find that they SHREDDED the work you continue to cite on here. Here are some quotes from the article http://www.bu.edu/cste/files/2011/07/Daneshvar-et-al.-Helmets-and-Mouth-Guards.-2011.pdf (thanks for providing more information to us that makes you look both irresponsible and foolish);

study of 28 high school and college football players suggested a decrease in the rate of concussion after the use of customized mandibular orthotics; however, this study was marked by several design flaws. Concussion rate before customized mandibular orthotics was measured by self-report, whereas concussion rate following orthotic use was calculated only based on concussions diagnosed by athletic trainers and coaches. Also, because all athletes were given orthotics, the observed decrease in the concussion rate could simply be an artifact of different styles or age of play; all athletes were necessarily older when using the custom orthotics than they were when using standard mouth guards. Finally, calculation of the rate of concussion before the use of custom orthotics was not limited to games, whereas only concussions occurring during games were counted after the use of custom orthotics.86 No large study has been able to demonstrate a significant difference in the concussion rate depending on the type of mouth guard used. One study recruited 87 of a total of 114 Division 1 teams to participate in a study evaluating 154 Daneshvar et al the effect of various mouth guard types on the rate of concussion. There was no statistically significant result between the different mouth guards.87 These findings have since been replicated by other large, multicenter cohort studies.88

Wait there is more…

Although mouth guards have been shown to be effective in preventing dental and orofacial injury, there is currently no evidence that standard or fitted mouth guards decrease the rate or severity of concussions in athletes.85 The bulk of the evidence indicating a potential protective effect of mouth guards on concussion incidence has been based on a limited case series studies and retrospective, nonrandomized, cross-sectional surveys.91 There is also evidence that mouth guard use does not result in any difference in neurocognitive test performance after concussion.109 In sports such as hockey, there is no evidence that visors play a protective role in preventing or mitigating concussions.91–94

Keep going and you ALONE will be responsible for dismantling all thoughts on MG as it relates to concussion… Like shooting fish in a barrel. (OK, perhaps I am getting a little curt)

Then there was this comment from “Tina”;

Mark,
You may think that Dustin is alone in his professional opinions of the mouthgear, but, you would be sorely mistaken. Every collegue I have come in contact with has repeatedly told coaches and parents, “No mouthguard will protect against a concussion.” Dustin has explained repeatedly why we make this statement, so, I won’t bore you with repeating it. Just so you know, the same goes with helmet manufacturers…you’re not alone.
Tina

Mark then has this comment;

The B.U. group is funded by the NFL, nuff said.

This is what it is all about, the rest is just B.S. and politics: Independent researchers like Guskewicz must recognize this new initiative.

While the specific cause of concussions is part of ongoing medical research efforts; facial and skull injuries experienced by soldiers can be reduced with the use of an appliance device which helps reduce concussion risks and protects the face and jaw. Currently, professional athletes are
fitted with a customized dental appliance to prevent concussions. Hence, a soldier could utilize this same technology in the battlefield to prevent facial injuries and reduce event related concussions. Research on this appliance, indicates a relationship between the jaw and skull at the temporomandibular joint (TMJ) that better enables players to dissipate the force that originates from a violent blow to the chin. Without the shock absorber in place, a concussion and/or other neurological damage can occur when the jaw slams into the skull.1 In addition, a peer review hypothesis presented by Massachusetts General Hospital/ Harvard School of Dental Medicine Oral Maxillofacial Surgery Department indicated that “tight helmet chin strap worn by troops places increased pressure on the temporomandibular joint with the result of enhanced force transmission and/or decreased resistance within the cervical musculature to oblique forces to the head”.2 The thrust of this effort is to develop an appliance system for soldiers to wear as an orthotic type splint and mouth guard that will absorb and dissipate high energies due to blast over pressures or blunt impacts being exposed to the skull and TMJ region while protecting the soldier jaw and teeth.

To which I had this response;

My response to this weak information is in ()’s and italicized…

The B.U. group is funded by the NFL, nuff said. – (AND??? BTW, not wholly funded… AND YOU WERE THE ONE USING THEM AS A POSITIVE SOURCE FOR YOUR CLAIMS, maybe you should read the article first….)

This is what it is all about, the rest is just B.S. and politics: Independent researchers like Guskewicz must recognize this new initiative. –( They have and said MG has no diff in testing…)

While the specific cause of concussions is part of ongoing medical research efforts;(Serious?)facial and skull injuries experienced by soldiers can be reduced with the use of an appliance device(Correct)which helps reduce concussion risks and protects the face and jaw.(How?) Currently, professional athletes are
fitted with a customized dental appliance to prevent concussions (no such device exists and if someone is claiming that it is fraudulent). Hence, a soldier could utilize this same technology in the battlefield to prevent facial injuries and reduce event related concussions. Research on this appliance, indicates a relationship between the jaw and skull at the temporomandibular joint (TMJ) that better enables players to dissipate the force that originates from a violent blow to the chin(chin contact is just one variable, which is low on the scale compared to acceleration/deceleration/rotatoinal forces). Without the shock absorber in place, a concussion and/or other neurological damage can occur when the jaw slams into the skull(show me the evidence, independent and not called into question).1 In addition, a peer review hypothesis presented by Massachusetts General Hospital/ Harvard School of Dental Medicine Oral Maxillofacial Surgery Department indicated that “tight helmet chin strap worn by troops places increased pressure on the temporomandibular joint with the result of enhanced force transmission and/or decreased resistance within the cervical musculature to oblique forces to the head” (no research suggests this has anything to do with concussions or mTBI).2 The thrust of this effort is to develop an appliance system for soldiers to wear as an orthotic type splint and mouth guard that will absorb and dissipate high energies due to blast over pressures or blunt impacts being exposed to the skull(how can any of what you claim protect the skull as a whole? Perhaps you meant that it just protects the area of the skull where the TMJ could make contact) and TMJ region while protecting the soldier jaw and teeth(I have told you your device can do this).

Mark continues;

Dustin, until this and any other research on orthotics is complete, there is only preliminary research, but that does not mean it doesn’t or can’t help those with TMD. Military research has data that is not made public, they will find out for sure if this helps and you or any other sources will not be able to criticize. I guess your fixed on condemning this and nothing I show you will change your mind, you’ve made it personal. You said it yourself, you don’t know much about TMJ/TMD. Hopefully the educational material that comes from this initiative, such as an accredited NATA training seminar, will help you and others understand the importance of evaluating prior to play, to make sure athletes with TMD are screened for risk factors and fit with the correct oral appliance. Your anger is misplaced. You should be angry that nobody has investigated this. The evidence is there, why has it not been researched.

And me;

Mark,
For the umpteenth time, I don’t discount that your MG can help with TMJ/TMD, that is not my area… I am simply stating your MG cannot and will not help in attenuating the injury of concussion, that you keep claiming… Stay on a subject… I am not angry, I am stating facts and shredding your information…

Your product cannot attenuate concussion of concussive forces, PERIOD!!!

Mark once again;

Just like the Staal injury with the Rangers, the “mystery” factor around recurring symptoms may be clarified in some cases. If the TMD factor is present, a simple evaluation will plot a course of action. While not all concussion is jaw related, some are. If we can help 10% of those in need, that is what we are focused on. Like I said, the fact that no real independent researchers have taken this on is insane given the road signs.

My response;

I think the correct statement would be; not all symptoms of concussions are jaw related… Concussions are not created by jaw movement, well research tells us that (so does physics and biomechanics)… Headache is a symptom of concussion but HA could be from TMJ/TMD, low blood sugar, adrenaline, environment, tension, etc… The crux of the matter remains oral protective devices will not prevent concussions… Can they attenuate symptoms that are similar to concussion symptoms, sure if there is a separate etiology…

Mark;

So, there you go. If these types of appliances are used in those who are candidates and we can target who is a candidate by a medically accepted evaluation protocol, thus determining risk factors. Why not? The research connecting them to other types of concussion, Shaefer suggests whiplash concussion is in play, will come later. For now understanding the limitations boil bite, custom made guards compared to jaw positioning devices is the key. If it helps 10% of the athletes, that’s a huge number. Part of our initiative is to teach trainers these tools, through a NATA accredited homestudy dvd and classroom seminar. This training would consist of educational material on what’s available on the market and what those products can achieve, including helmets and pschye testing. Most importantly, trainers will be shown how to evaluate the head neck and jaw to determine the risk factor from TMD.

“No oral device has been found to reduce or decrease the chance of concussion” Cantu makes this same statement, then follows with. Just because the research has not been done, does not mean a corrective appliance can’t help, it’s just an area that has not been researched using an orthotic appliance. Studies show, common tooth protecting guards are ineffective in any real change in those prone to concussion. The Eagles team dentist is certified to make the same adaptive mouth guard used by the Patriots. Whether Burkholder saw the need to fit Vick, that is another question. If on his first concussion, Vick damaged his jaw cartilage resulting in TMD and symptoms of temporal mandibular joint dysfunction, or the boxers “Glass Jaw”, there is a chance one of these appliances could reduce tmd symptoms that can be similar to pcs. Yet, we wait for the research to clear the air, until then we can only hope trainers will see the benefit of orthotically aligning the jaw in those prone athletes with tmd. Common guards cannot correct or align the jaw, but they are better than nothing at all.

My response;

Mark,
Re: Cantu; I can say the same about a band-aid on the forehead… Why don’t you add that your product was out and “established” when Cantu made the comment, therefore your technology would be included in on the original statement. Meaning if you connect the dots, just like the articles you provided, your device WILL NOT do anything for concussions… You need to stop the facade, you are bordering on fraudulent claims.

Stop trying to equivocate concussions with symptoms of concussions… Your product does nothing for the injury of concussion…

And Mark’s most recent comment;

Dustin, you just admitted you know nothing of tmj, crainal facial issues, don’t disregard the experts in the field. How can you close the door just like that when we have a history of use in the NFL for over two decades, preliminary data approved by the Pentagon for research and a Peer reviewed published study with high school kids. Dr. Shaefer, a Harvard MGH specialist and other tmd experts agree. Yet you dismiss, when you admit openly your not qualified to make that judgment, what’s up with that. Seek and expert opinion please.

And my simple response;

Apparently you are the expert Mark… You claim to be, or have people who are, yet you KEEP ON telling us your product can help with concussions, and I KEEP ON telling you it cannot, period… Then you back track and say it can help with symptoms that are similar to concussions, and I tell you that if there is some other etiology – like TMD – then it could be possible…

STAY ON TOPIC…

Keep on researching it, I have never said you should stop that, I have only stated CLEARLY that you should not make claims that are factually incorrect…

===========

I am not, nor do I claim to be a dentist/”jaw guy”.  I happen to know a lot about concussions and the mechanisms that cause concussions.  Current evidence tells us CLEARLY that any thing placed in the mouth is great for oral/facial/possibly jaw injuries, but has ZERO effect on attenuating concussions.  Until there is new research, that is not in dispute, this should be a closed case…