We received a comment on the Montana and Bradshaw post from Maureen Kilcullen, one of the webmasters of a site called NFL Former Players, suggesting that readers visit that site for more information on the hardships faced by some NFL retirees. I encourage our readers to read Ms. Kilcullen's comments and visit her website.
If you want to get a sense for how angry these retirees are about the way the NFL and the NFLPA have ignored their plight, read Nick Buoniconti's letter to Gene Upshaw that is posted on the site.
I'm adding a link to the retirees' website, and I encourage everyone to learn more about these issues and to let the league and union know that fans don't want the retired players to be overlooked during negotiations on the new collective bargaining agreement.
Wednesday, February 08, 2006
NFL Retirees' Website
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NFL won't bite on dentist's concussion deviceBy Peter Keating
ESPN The Magazine
Shaun Alexander is one of the fortunate. Some 20 minutes after being leveled by Redskins linebacker LaVar Arrington, the league MVP wandered the Seattle sideline, unable to find his guards or tackles. Not until he spotted Matt Hasselbeck on the jumbo screens at Qwest Field did he realize he had been knocked cold and removed from the field.
ESPN The Magazine
This story appears in the Feb. 13, 2006, edition of ESPN The Magazine, available online to subscribers.
• ESPN The Magazine
Alexander recovered his smile and his moves in time to torch the Panthers a week later in the conference championship game. But Priest Holmes is still trying to recover from multiple hits to the head and spine, including a helmet-to-helmet shot he took against the Chargers four months ago. Wayne Chrebet's career ended in November after what was at least his ninth concussion. And the Rams, Jets and Browns had starting QBs sidelined during the season because of blows to the head.
Even as the NFL changes rules and helmet makers improve their designs, the league says concussion rates have stayed level at about 0.4 incidents per game in recent seasons -- about 100 per year. But teams report only half of these. In the four seasons between 2000 and 2003, clubs listed a total of 203 concussions on weekly injury reports, according to data compiled by the Pittsburgh Tribune-Review. Not all teams suffer equally. Some clubs reported multiple head injuries in each of the years. The Colts listed 20 concussions.
The Patriots listed zero.
And a small-town New England dentist, who literally has been inside Patriots players' heads for 25 years, says he knows why.
* * *
"This is Curtis Martin," says Gerald Maher, as he extends his hand. His palm reveals a plaster model of the 2004 rushing champion's teeth and jaw.
Maher is 59, with receding white hair, a compact build and the flinty, but jovial, features of the Yankee Irish. Lined with striped wallpaper and dental hygiene posters, his office in South Weymouth, Mass., is unremarkable -- except for one wall that is covered with photos of athletes who have been his patients. One shows super-middleweight Scott Pemberton leveling an opponent, Omar Sheika, amid a spray of sweat. "If Sheika had one of your mouthpieces," reads Pemberton's inscription, "he might have taken this shot better."
It's a comforting thought for Maher's devotees, a group that includes more than 60 active NFLers. Maher has been working with the Patriots since 1979. In addition to taking X-rays and performing root canals, he has custom-fit hundreds of players with mouthpieces that both he and many of them believe protect against football's scariest blows, hits that average 98 times the force of gravity.
From the back room where he has stored dental molds of dozens of players, Maher produces a skull to demonstrate how its parts, and his mouthguard, work. The lower jaw, or mandible, extends up from the chin, ending in a knuckle-like knob called a condyle. The skull, or temporal bone, makes up the rest of the head and houses the brain. In between the jaw and skull, at the temporomandibular joint, a dime-size disk of cartilage sits atop the condyle.
According to Maher, 64 percent of adults have misaligned mandibles. When someone who is "off his disk" is struck with sufficient force, the top of the jaw can be driven smack into the skull, causing a concussion. Maher says he can realign a patient's mouth to center the jaw and make sure the cartilage disk, not the brain, absorbs a hit to the chin, mouth or cheek. "The disk is like an air bag in a car," he explains. "It makes sure you don't go through the windshield."
Maher has been working on mouthpieces since the late 1970s, when he first started to talk with local legend (and patient) Marvin Hagler about why some boxers can take a punch while others have glass jaws. In adapting mouthguards for football players over the years, Maher has developed a protective device that looks and feels like a retainer. Two small pieces of acrylic, joined by stainless steel bands, fit securely onto to the lower molars. That leaves more room to talk and breathe than traditional "bite-and-boil" upper mouthpieces.
“ The best thing it does for you is that you know when the blow comes, it's going to be there. With other mouthpieces, there's a mental process you go through where you have to figure out whether to bite down or hold it in place. This just clicks right onto your teeth. ”
— Matt Chatham, Patriots linebacker
"The best thing it does for you is that you know when the blow comes, it's going to be there," says Patriots linebacker Matt Chatham. "With other mouthpieces, there's a mental process you go through where you have to figure out whether to bite down or hold it in place. This just clicks right onto your teeth."
Other Pats and ex-Pats, from Vincent Brisby to Dan Koppen to Lawyer Milloy to Asante Samuel, offer similar testimonials. Each suffered at least one concussion before they began using Maher's mouthguard; none has since. "These guys are human beings, not pieces of meat," says Maher, who wrestled and played rugby at Holy Cross and who has served on his local board of health since 1987. "But so many get concussions and don't tell anybody, because they're afraid somebody will take their job."
Maher is not the first person to suggest that mouthguards can prevent head injuries in football. In 1963, a team of dentists outfitted Notre Dame with custom-made pieces and reported a dramatic decrease in concussions. Today, the NCAA mandates mouthguards for all its football players. The American Dental Association and the American Academy of Pediatrics recommend them for high school players, too, in part because they "may reduce the severity and incidence of concussions." Last season, more than 2,000 football players in the Philadelphia school system wore "Brain-Pads," mouthpieces that are not custom-fitted but are designed to be clenched between the upper and lower teeth.
No biomechanical studies support the commonsense theory that keeping the jaw and skull separated helps reduce shock to the brain. For example, nobody has yet conducted controlled experiments to measure the difference in the force absorbed by skulls fitted with mouthguards and by those that are not. "The jury is still out, although, anecdotally, many people have said it makes a difference to have that shock absorption," says Kevin Guskiewicz, director of the Sports Medicine Research Laboratory at the University of North Carolina at Chapel Hill. "I think Dr. Maher's idea should get some time and attention."
If the evidence for Maher's mouthguards is anecdotal, some of the anecdotes are pretty good. Like the one about Steve Trapilo, the Boston College guard who became famous for catching Doug Flutie when Flutie jumped into his arms after making his miracle pass against Miami in 1984. Trapilo went to see Maher as a high school freshman, after he'd been knocked out by a hit to the side of the head. Maher fit him for a mouthguard. Over the rest of his career, which included five years with the Saints, Trapilo broke or bent 26 face masks. He never suffered another concussion.
Or the one about the Duxbury (Mass.) High School football team, whose coaches consulted Maher before the start of last season after suffering a rash of head injuries. Maher custom-designed mouthpieces for 11 players. "Our returning players had had 44 concussions over the three prior years," says coach Dave Maimaron. "This year, we had only three. One was our freshman quarterback, and the other two were not wearing the mouthguards when they got hit." The squad went 13-0 and won the state championship.
The NFL, however, doesn't require mouthguards, and 40 percent of players don't wear them. Elliot Pellman, the league's medical liaison and head of its committee on mild traumatic brain injury, has yet to be impressed by the claims that link mouthpieces to the prevention of brain trauma. "I can give you 100 dentists who say they've got the best method for reducing concussions," he says. "Many times I've had them in my office. One brought me a box of cookies. My response to that person and to 20 others is that I'm intrigued, but it's your job to prove to me your idea does what you say it does."
One of Maher's earliest patients, Hall of Fame cornerback Mike Haynes, continued to consult Maher after being traded to the Raiders. On Oct. 15, 1984, Haynes wrote Maher a note that read in part: "Thanks to the mouthpiece, I can't remember when I had my last concussion, and I have had plenty of situations where I could have had one." Haynes retired in 1989 and has been the NFL's vice president for player development since 2002. He and Maher met up at Super Bowl XXXVIII in Houston. Over a Mexican dinner, they discussed Maher's mouthguard.
"Mike, you never sent any Raiders to me," Maher recalls saying.
"That's because I knew I had an edge, and I didn't want to share it," Haynes replied. But, Haynes added, now that he was "on the other side of the fence," he wanted to get the word out. So the two men scheduled a conference call with Pellman, and Maher sent Pellman material on mouthguards and concussions. But Pellman canceled the call, and another, and a third, the last only five minutes before it was to take place. "It was extremely unprofessional, a total slap in the face," says Maher.
"I have many things going on," says Pellman, who doesn't recall setting up or canceling the calls. "There's nothing personal. I have no grudge against him." According to Maher, Haynes later suggested the dentist apply for a grant from NFL Charities, through which a committee, including Pellman, disburses research funds once a year. In June 2004, Maher submitted a request for $30,000 to fit 60 NFL players with mouthguards.
He never heard back from the league.
* * *
By training, Pellman is a rheumatologist -- a specialist in the treatment of joints and muscles -- not a neurologist. So when Paul Tagliabue named him to chair the NFL's concussions committee in 1994, it raised some eyebrows. (It didn't help that last March, The New York Times reported that Pellman, who is also the Jets team doctor, had inflated his résumé.)
Pellman has spearheaded the NFL's first serious study of concussions, which has led to significant changes in helmet design. But he also has reached -- and aggressively promoted -- controversial conclusions about how concussions are managed. One of his papers reported that NFL players who had three or more concussions performed no differently from other players on neuropsychological tests, and that the same was true of players who were out for more than a week after a head injury. Another paper concluded that players who suffered concussions, then returned to play later in the same game, were not at "significant risk of a second injury, either in the same game or during the season."
Pellman uses these studies to defend league policy and team decisions. Clubs use neuropsychological tests to evaluate injured players, and some keep a neurosurgeon on the field, but the NFL doesn't mandate either. In practice, 15 percent of players who suffer concussions return to play immediately; another 34 percent later go back into the game. "If there's normal testing and a player feels good, what's the contraindication to letting him play?" Pellman says. "There really is none."
Studies at other levels of football, though, show that if you get your bell rung once, you're more likely to get it rung again, and that those future blows will do even more damage. "There aren't a lot of people in this field who think NFL players who suffer concussions aren't predisposed to future injuries," says Guskiewicz. "How does Elliot Pellman explain Troy Aikman, Steve Young, Stan Humphries, Al Toon, Chris Miller, Wayne Chrebet?" Guskiewicz's research shows NFL players who have had three or more concussions are, in fact, much more likely to suffer from depression or Alzheimer's disease after they retire from the game than players who have had no head injuries. "The league hasn't even begun to study long-term effects of concussions," he says.
“ You're asking the fox if there's a particular problem with hanging around the henhouse. Pellman works for the NFL. Until there's definitive evidence otherwise, he's going to take the tack that managing concussions isn't a problem. ”
— Arthur Day, Neurological Sports Injury Center director
"You're asking the fox if there's a particular problem with hanging around the henhouse," says Dr. Arthur Day, director of the Neurological Sports Injury Center at Brigham and Women's Hospital in Boston. "Pellman works for the NFL. Until there's definitive evidence otherwise, he's going to take the tack that managing concussions isn't a problem. Will Mercedes tell you they're not the best car?"
Pellman says the league has begun a study involving mouthguards and is considering another to look at the long-term impact of head injuries. Maher, meanwhile, recently heard again from Haynes, who advised him to reapply for an NFL research grant. Maher is putting together a new package of materials to send to the league. "It's like Groundhog Day," he says.
In some ways, this is a tale of two doctors at opposite ends of the spectrum of power in sports. Maher and his supporters believe Pellman has blocked them at every turn; Pellman says he doesn't even remember Maher's name. But it's also a story about the frontiers of sports science -- about how discoveries can come from any place, and about where the planet's biggest league will put its dollars and attention.
The hits will keep coming in the NFL (ask Panthers running back Nick Goings what he recalls about his collision with Seahawks linebacker Lofa Tatupu). And it can't hurt the league to find out whether Maher is right.
But it might hurt someone if they don't.
www.mahercor.com
Abstract: The Use of a Custom Mandibular Athletic Mouthguard in the Prevention of Concussions in NFL Football Players
Jeffry R Shaefer DDS MS MPH
Objective: Observe the benefit of a mandibular appliance for the control of concussions among football players. Concussions in contact sports are an ongoing problem. In relation to football, Pellman, funded by the NFL, showed that oblique blows to the head causing head acceleration are the most dangerous, while quarterbacks, wide-receivers and linebackers are the type of players most at risk for concussions (1-3). Blows to the chin are dangerous as there is no protection from such a blow to prevent direct transmission of the force to the brain, while forces from other directions can be controlled by the player’s helmet and facemask (4). Various studies have examined the benefit of mouth guards to prevent force transmission through the mandible from blows under the chin (5-13). The consensus from these studies is that mouth guards are successful in protecting oral structures but that their benefit in controlling concussions is unclear. Methods: A case series report. Results: Maher reports excellent compliance, satisfaction, and control of concussions in a case series of 22 New England Patriot football players who used a concussion prevention mouth appliance he constructed (14). Eleven of the Patriots had a prior history of concussions and controlled their potentially career-ending concussions with Maher’s appliance. The use of Dr Mayer’s patented appliance has allowed the New England Patriots football team players to have the lowest number of concussions in the league (14). Conclusion: a retrospective analysis of NFL football players use of athletic mouth guards and the corresponding rate of orofacial injuries and concussions and a prospective study to measure the affect of this appliance on concussion rates in players with and without a prior history of concussion is warranted.
1. Pellman EJ: Background on the National Football League’s research on concussion in professional football. Neurosurgery 53: 797–798, 2003.
2. Pellman EJ, Viano DC, Tucker AM, Casson IR: Concussion in professional football: Location and direction of helmet impacts–Part 2. Neurosurgery 53: 1328–1341, 2003.
3. Pellman EJ, Viano DC, Tucker AM, Casson IR, Waeckerle JF: Concussion in professional football: Reconstruction of game impacts and injuries. Neurosurgery 53: 799–814, 2003.
4. Williams ED. Jaw joint disorders in contact sports athletes: diagnosis and prevention head and neck injuries in sports. In: Hoerner EF, ed. Jaw Joint Disorders in Contact Sports Athletes; Diagnosis and Prevention: Head and Neck Injuries in Sports. Philadelphia, Pa: ASTM STP 1229, American Society for Testing and Materials; 1994.
5. Chapman PJ. The bimaxillary mouthguard: increased protection against orofacial and head injury in sport. Aust J Sci Med Sport. 1985;17:25-28.
.
6. Hodgson VR. Standard Method of Impact Testing and Performance Requirements for Football Faceguards and Mouthguards Impact Test, 7 Load Ring Triaxial Accelerator Model May 13, 1993.
7. Barth JT, Freeman JR, Winters JE. Management of sport related concussions. Dent Clin North Am. 2000;44:67-83.
8. Barth JT, Freeman JR, Winters JE. Management of sport related concussions. Dent Clin North Am. 2000;44:67-83.
9. Proctor MR, Cantu RC. Head and neck injuries in young athletes. Clinics in Sports Medicine. 2000;19:693-715.
.
10. Torg JS, Truex R Jr, Quedenfeld TC, et al. The national football head and neck injury registry: report and conclusions, 1978. J Am Med Assoc. 1979;241:1477-1479.
11. Woodmansey KF. Athletic mouthguards prevent orofacial injuries: a review. Gen Dent. 1999;Jan-Feb:64-69.
12. Francis KT, Brasher J. Physiologic effects of wearing mouthguards. Br J Sports Med. 1991;25:227-231.
13. Tomotaka Takeda, Keiichi Ishigami, Sanae Hoshina, Toru Ogawa, Jun Handa, Kazunori Nakajima, Atsushi Shimada, Tsuneya Nakajima, Connell Wayne Regner Can mouthguards prevent mandibular bone fractures and concussions? A laboratory study with an artificial skull model Dental Traumatolog 21( 3 )Pg 134, June 2005
14. Maher: personnal communication; publication pending
Purpose:
To present to the Academy a case series of subjects using a single arch mandibular appliance to prevent concussion.
Background and discussion:
The claim that athletic mouthpieces worn during contact sports are helpful in the prevention of concussions is controversial. Two trials that have been commonly used to support this claim; Stenger’s study on Notre Dame footballers and Hickey’s cadaver study have methodological problems. In fact McCrory (Br J Sports Med 2001) states that only anecdotal evidence points to a dental appliance effect against concussion. He summarizes:
Although the use of correctly fitting mouthguards can reduce the rate of dental, orofacial, and mandibular injuries, the evidence that they reduce cerebral injuries is largely theoretical, and no clinical evidence for a beneficial effect in reducing concussion rates has yet been demonstrated clinically.
A recent study of the incidence of concussions in college basketball players showed no statistical difference (.35 vs .55 per 1000 exposures) between wearers and non mouthguard wearers (Labelle 2002). Wisniewski (Dent Trauma 2004) found no positive affect for a custom-made mouthguard compared to a “boil and bite” type appliance for the prevention of orofacial injuries or concussions in a study of Division I football players. Barbic observed the effect of the dual arch Brain-Pad appliance worn for one season by Canadian college athletes playing contact sports. Although the Brain-Pad is recommended by the American Boxing Association to prevent concussion, Barbic found it to provide no greater protection when compared to a non-custom mouthpiece in a randomized trail. These studies can explain why many experts in Sports Medicine discount the potential affect of blows to the jaw in the etiology of concussion.
In comparison, Benson’s investigation of hockey players wearing full vs half face shields points to a role of forces directed against the mandible as contributing to the incidence of concussions (1.71 vs 4.71 missed practices). He also found the increased potential for concussion in those players wearing half face shields could be reduced significantly if they wore a mouth guard (5.57 vs 2.71 missed practices). In a laboratory study using lateral blows to the jaw on a skull model, Takeda (Clin J Sports Med 2005) found that wearing a mouth guard decreased (P < 0.01) the distortion to the mandibular bone and the acceleration of the head significantly compared with not wearing a mouth guard (54.7%: to the mandible, 18.5%: to the head).
Gusenbauer proposes three explanations for a positive benefit for the prevention of concussions from the use of a dental appliance:
Dissipation of forces directed to the jaw
Stabilization of neck muscles when clenching on a mouthpiece so as to resist head acceleration
Distraction of the condyle from the glenoid fossa decreasing force transfer via the temporal bone
Conclusion: Concussions in contact sports are a great concern, especially among adolescents. Athletes whom have had a concussion are 4-6 times at greater risk for a second concussion. Powell and Barber-Foss report that 3.9-7.7% of high school and college athletes sustain a MTBI (minor traumatic brain injury) each year. Many of these athletes will continue to play despite these increased risks and feel protected by appliances such as the Maher mouthpiece (see Boston Globe story). The effectiveness of this appliance might or might not be substantiated by a randomized clinical trial to measure it’s affect but such data will allow athletes and parents to make informed decisions about the continued participation in a contact spot. Possibly the positive effect from a dental appliance is limited to a subset of athletes such as those with TMJ disk displacement, forward head posture, children under the age of 14, females, or athletes with a prior history of MTBI. Clearly further study with a randomized clinical trial to answer these questions is indicated.
Purpose:
To present to the Academy a case series of subjects using a single arch mandibular appliance to prevent concussion.
Background and discussion:
The claim that athletic mouthpieces worn during contact sports are helpful in the prevention of concussions is controversial. Two trials that have been commonly used to support this claim; Stenger’s study on Notre Dame footballers and Hickey’s cadaver study have methodological problems. In fact McCrory (Br J Sports Med 2001) states that only anecdotal evidence points to a dental appliance effect against concussion. He summarizes:
Although the use of correctly fitting mouthguards can reduce the rate of dental, orofacial, and mandibular injuries, the evidence that they reduce cerebral injuries is largely theoretical, and no clinical evidence for a beneficial effect in reducing concussion rates has yet been demonstrated clinically.
A recent study of the incidence of concussions in college basketball players showed no statistical difference (.35 vs .55 per 1000 exposures) between wearers and non mouthguard wearers (Labelle 2002). Wisniewski (Dent Trauma 2004) found no positive affect for a custom-made mouthguard compared to a “boil and bite” type appliance for the prevention of orofacial injuries or concussions in a study of Division I football players. Barbic observed the effect of the dual arch Brain-Pad appliance worn for one season by Canadian college athletes playing contact sports. Although the Brain-Pad is recommended by the American Boxing Association to prevent concussion, Barbic found it to provide no greater protection when compared to a non-custom mouthpiece in a randomized trail. These studies can explain why many experts in Sports Medicine discount the potential affect of blows to the jaw in the etiology of concussion.
In comparison, Benson’s investigation of hockey players wearing full vs half face shields points to a role of forces directed against the mandible as contributing to the incidence of concussions (1.71 vs 4.71 missed practices). He also found the increased potential for concussion in those players wearing half face shields could be reduced significantly if they wore a mouth guard (5.57 vs 2.71 missed practices). In a laboratory study using lateral blows to the jaw on a skull model, Takeda (Clin J Sports Med 2005) found that wearing a mouth guard decreased (P < 0.01) the distortion to the mandibular bone and the acceleration of the head significantly compared with not wearing a mouth guard (54.7%: to the mandible, 18.5%: to the head).
Gusenbauer proposes three explanations for a positive benefit for the prevention of concussions from the use of a dental appliance:
Dissipation of forces directed to the jaw
Stabilization of neck muscles when clenching on a mouthpiece so as to resist head acceleration
Distraction of the condyle from the glenoid fossa decreasing force transfer via the temporal bone
Conclusion: Concussions in contact sports are a great concern, especially among adolescents. Athletes whom have had a concussion are 4-6 times at greater risk for a second concussion. Powell and Barber-Foss report that 3.9-7.7% of high school and college athletes sustain a MTBI (minor traumatic brain injury) each year. Many of these athletes will continue to play despite these increased risks and feel protected by appliances such as the Maher mouthpiece (see Boston Globe story). The effectiveness of this appliance might or might not be substantiated by a randomized clinical trial to measure it’s affect but such data will allow athletes and parents to make informed decisions about the continued participation in a contact spot. Possibly the positive effect from a dental appliance is limited to a subset of athletes such as those with TMJ disk displacement, forward head posture, children under the age of 14, females, or athletes with a prior history of MTBI. Clearly further study with a randomized clinical trial to answer these questions is indicated.
Purpose:
To present to the Academy a case series of subjects using a single arch mandibular appliance to prevent concussion.
Background and discussion:
The claim that athletic mouthpieces worn during contact sports are helpful in the prevention of concussions is controversial. Two trials that have been commonly used to support this claim; Stenger’s study on Notre Dame footballers and Hickey’s cadaver study have methodological problems. In fact McCrory (Br J Sports Med 2001) states that only anecdotal evidence points to a dental appliance effect against concussion. He summarizes:
Although the use of correctly fitting mouthguards can reduce the rate of dental, orofacial, and mandibular injuries, the evidence that they reduce cerebral injuries is largely theoretical, and no clinical evidence for a beneficial effect in reducing concussion rates has yet been demonstrated clinically.
A recent study of the incidence of concussions in college basketball players showed no statistical difference (.35 vs .55 per 1000 exposures) between wearers and non mouthguard wearers (Labelle 2002). Wisniewski (Dent Trauma 2004) found no positive affect for a custom-made mouthguard compared to a “boil and bite” type appliance for the prevention of orofacial injuries or concussions in a study of Division I football players. Barbic observed the effect of the dual arch Brain-Pad appliance worn for one season by Canadian college athletes playing contact sports. Although the Brain-Pad is recommended by the American Boxing Association to prevent concussion, Barbic found it to provide no greater protection when compared to a non-custom mouthpiece in a randomized trail. These studies can explain why many experts in Sports Medicine discount the potential affect of blows to the jaw in the etiology of concussion.
In comparison, Benson’s investigation of hockey players wearing full vs half face shields points to a role of forces directed against the mandible as contributing to the incidence of concussions (1.71 vs 4.71 missed practices). He also found the increased potential for concussion in those players wearing half face shields could be reduced significantly if they wore a mouth guard (5.57 vs 2.71 missed practices). In a laboratory study using lateral blows to the jaw on a skull model, Takeda (Clin J Sports Med 2005) found that wearing a mouth guard decreased (P < 0.01) the distortion to the mandibular bone and the acceleration of the head significantly compared with not wearing a mouth guard (54.7%: to the mandible, 18.5%: to the head).
Gusenbauer proposes three explanations for a positive benefit for the prevention of concussions from the use of a dental appliance:
Dissipation of forces directed to the jaw
Stabilization of neck muscles when clenching on a mouthpiece so as to resist head acceleration
Distraction of the condyle from the glenoid fossa decreasing force transfer via the temporal bone
Conclusion: Concussions in contact sports are a great concern, especially among adolescents. Athletes whom have had a concussion are 4-6 times at greater risk for a second concussion. Powell and Barber-Foss report that 3.9-7.7% of high school and college athletes sustain a MTBI (minor traumatic brain injury) each year. Many of these athletes will continue to play despite these increased risks and feel protected by appliances such as the Maher mouthpiece (see Boston Globe story). The effectiveness of this appliance might or might not be substantiated by a randomized clinical trial to measure it’s affect but such data will allow athletes and parents to make informed decisions about the continued participation in a contact spot. Possibly the positive effect from a dental appliance is limited to a subset of athletes such as those with TMJ disk displacement, forward head posture, children under the age of 14, females, or athletes with a prior history of MTBI. Clearly further study with a randomized clinical trial to answer these questions is indicated.
With mouthpiece, dentist tackles concussions
NFL says more evidence needed
By Keith Reed, Globe Staff | March 30, 2006
If New England Patriots wide receiver Deion Branch never has another
concussion, he can thank former boxing champ ''Marvelous" Marvin Hagler and Gerald Maher, his Weymouth dentist.
In 1980, the Brockton-bred pugilist called Maher, a specialist in jaw
structure and facial pain, to ask why his crushing punches floored some
opponents, while others walked away from them.
Maher's answer was that the alignment of the jaw made some people
susceptible to concussions -- catch somebody with his mouth in the wrong position, and it's lights out. He created a mouthpiece that kept Hagler's jaw in the right spot, preventing Hagler -- and many other professional athletes since then -- from suffering the injury, which results from a violent jarring of the head that renders the victim unconscious and in some cases induces vomiting or permanent
memory loss.
Now Maher, who has filed for a patent, is pushing the National Football
League, which doesn't require its players to wear mouthpieces, to study
whether his device or others like it could protect athletes from concussions that might end their careers -- or worse.
''For safety reasons, I think it would help every player, and I'm interested in the safety of every player in the NFL," Maher said.
He has fitted about two-thirds of the Patriots for the devices, and
hand-delivered a mouthpiece to former Patriots nose tackle Ted Washington in Houston on the day of the 2004 Super Bowl.
None of the players Maher has outfitted have suffered concussions using the equipment, he said. The Patriots reported no concussions last season.
That's not enough to convince league officials to change their policy,
though.
Elliot Pellman, football's medical liaison and chairman of its concussion committee, said a few athletes' success stories can't supplant the hard medical research the league requires before it endorses a piece of equipment. Maher is not the first dentist to claim that a mouthpiece prevents concussions, but none has offered scientific evidence to back it up, he said.
Morever, other devices have had unintended consequences for players who wore them for safety. Pellman recalled that in the 1990s, players began wearing ProCaps, an apparatus that slipped over their helmets and was supposed to prevent concussions. The league responded to the product's growing popularity among players and tested ProCaps. It found no evidence that ProCaps reduced concussions, but did find an increased risk of neck injury.The league recommended that players cease using them.
''The New England Patriots might be wearing this mouthpiece, but can anyone guarantee me that there may not be an incidental component that occurs that is not desirable?" Pellman said.
A Patriots spokesman declined to comment.
But scores of athletes, from high school footballers to professional
basketball stars, have pushed Maher's device between their teeth, convinced it will help protect them.
Maher said he has applied for a $125,000 grant from the NFL to fit a team other than the Patriots -- perhaps a college football squad -- with his mouthpieces so their effectiveness can be objectively studied. Pellman said he's unaware of the status of that application, but that the league, along with Wayne State University, is building a sophisticated model to study the effectiveness of several mouthpieces, including Maher's, in preventing concussions.
If the NFL wants more evidence, Duxbury High School's football coach might be worth calling. Eleven of the team's players had previously suffered concussions, some three or four times. After hearing about Maher's mouthpieces, the coach, Dave Maimaron, asked the dentist to fit the players who had suffered concussions. There were no concussions last season, and Duxbury went undefeated, taking a state championship.
''I almost feel like we had an advantage this season," Maimaron said.
''Everybody should be wearing this thing. I'd be very surprised if that
doesn't happen."
Concussions are common in volatile sports like boxing, whose very object is to hit your opponent harder than your opponent hits you, and football, where 200- to 300-pound men collide and send each other into the ground over and over.
Maher's mouthpieces are designed on the principle that keeping an athlete's jawbone and temporal mandibular joint properly aligned absorbs the force of blows that would otherwise literally rattle their skulls and cause a concussion. The most susceptible position, he argues, is when the mouth is tightly closed. Then, the force of a blow can travel unobstructed up the jawbone and into the skull. Helmets protect against concussions and other injuries caused by blows to the crown of the head, but their chin straps keep players' jaws in precisely the position that Maher argues puts them at risk.
His mouthpieces separate the jawbone from the joint slightly, helping to absorb the blows. They also fit tightly over the bottom row of teeth, letting football players talk to each other. Besides Branch, Patriots Asante Samuel, Vince Wolfolk and Daniel Graham wear the mouthpieces.
Maher said he doesn't think he can eradicate concussions, but he thinks many are preventable.
''You would never say to an athlete that they're not going to get a
concussion," he said. ''But I want to put them in the best position to try and prevent that."
Keith Reed can be reached at reed@globe.com.
© Copyright 2006 Globe Newspaper Company.
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