Craniofacial Injuries: Community-Based Interventions to Encourage Use of Helmets, Facemasks, and Mouthguards in Contact Sports

The CPSTF finding is based on evidence from a systematic review of 8 studies (search period 1946-November 2012). The systematic review was conducted on behalf of the CPSTF by a team of specialists in systematic review methods, and in research, practice, and policy related to oral health. This finding updates and replaces the 2000 CPSTF finding on Population-Based Interventions to Encourage Use of Helmets, Facemasks, and Mouthguards in Contact Sports to Prevent Oral and Facial Injuries.

There is evidence to support the efficacy of mouthguards and facemasks in preventing craniofacial injuries in contact sports (Knapik et al., 2007; Benson et al, 2009; Asplund et al, 2009). There is also a large body of evidence to support the efficacy of helmets in non-contact sports such as cycling and skiing (Thompson et al, 2009; Benson et al, 2009).

Detailed results from the systematic review are available in the CPSTF Finding and Rationale Statement

Eight studies were included in the review.

• Study results were inconsistent.
• The diversity in sports, potential injuries, and population characteristics across the studies limited the ability to pool data and draw any general conclusions about intervention effectiveness.

An economic review of this intervention was not conducted because the CPSTF did not have enough information to determine if the intervention works.

Applicability of this intervention across different settings and populations was not assessed because the CPSTF did not have enough information to determine if the intervention works.

The CPSTF identified several areas that have limited information. Additional research and evaluation could help fill remaining gaps in the evidence base. (What are evidence gaps?)

• More research is needed on the efficacy of various protective equipment devices in preventing injuries in different contact sports.
• Further research is required to establish the effectiveness of community-based interventions that provide and promote the use of protective equipment. Ideally, researchers will use consistent outcome measures and definitions.
• Finally, research should examine potential harms of the intervention, especially with regard to risk compensation behavior.

• Included studies were associated with six different contact sports.
• Studies evaluated three broad categories of interventions including legislative mandates, provision of safety equipment, and health promotion and education.
  • Legislative mandates attempt to ensure compliance by removing choice.
  • Provision of equipment attempts to improve access, empower, and provide additional choice.
  • Health promotion and education interventions aim to educate and raise awareness of the benefits of sports safety equipment.
• Seven of the included studies were conducted in high-income countries.

Effectiveness Review

Analytic Framework

When starting an effectiveness review, the systematic review team develops an analytic framework. The analytic framework illustrates how the intervention approach is thought to affect public health. It guides the search for evidence and may be used to summarize the evidence collected. The analytic framework often includes intermediate outcomes, potential effect modifiers, potential harms, and potential additional benefits.

Effectiveness Review

Summary Evidence Table – Effectiveness Review

The number of studies and publications do not always correspond (e.g., a publication may include several studies or one study may be explained n several publications).

Effectiveness Review

Barbic D, Pater J, Brison RJ. Comparison of Mouth Guard Designs and Concussion Prevention in contact sports: a multicenter randomized controlled trial. Clin J Sport Med 2005;15:294 8.

Benson BW, Mohtadi NG, Rose MS, Meeuwisse WH. Head and neck injuries among ice hockey players wearing full face shields vs half face shields. JAMA 1999;282(24):2328-32.

de Wet FA, Badenhorst M, Rossouw LM. Mouthguards for rugby players at primary school level. J Dent Assoc S Afr 1981;36(4):249-53.

Eime R, Finch C, Wolfe R, Owen N, McCarty C. The effectiveness of a squash eyewear promotion strategy. Br J Sports Med 2005;39:681 5.

Finch C, Braham R, McIntosh A, McCrory P, Wolfe R. Should football players wear custom fitted mouthguards? Results from a group randomised controlled trial. Injury Prevention 2005;11:242 6.

Jolly KA, Messer LB, Manton D. Promotion of mouthguards among amateur football players in Victoria. Aust N Z J Public Health 1996;20(6):630-9.

McIntosh AS, McCrory P, Finch CF, Best JP, Chalmers DJ, Wolfe R. Does padded headgear prevent head injury in rugby union football? Med Sci Sports Exerc 2009;41(2):306 13.

Webster DA, Bayliss GV, Spadaro JA. Head and face injuries in scholastic women’s lacrosse with and without eyewear. Med Sci Sports Exerc 1999;31(7):938-41.

Effectiveness Review

In 2012, electronic searches of the literature were conducted by a public health librarian in the databases listed below. Search strategies were adjusted to each database, based on controlled and uncontrolled vocabularies and search software. The types of documents searched in the databases included journal articles, books, book chapters, reports, conference papers, and dissertations. In addition, the bibliographies of all reviewed articles were used to identify any further literature.

OHG Trials Register (Whole database through Nov 2012)

1. ((skull* or head* or face* or facial* or forehead* or fore-head or occipital or parietal or temporal or brain* or scalp* or cheek* or cheek-bone* or nose* or nasal or lip* or gum* or frontal*)) AND (INREGISTER) [REFERENCE][STANDARD]
2. ((craniocerebral or cranio-cerebral or craniofacial or cranio-facial or eye* or jaw* or mandib* or maxill* or orbital* or zygomatic* or mouth* or cranium)) AND (INREGISTER) [REFERENCE][STANDARD]
3. ((tooth or teeth)) AND (INREGISTER) [REFERENCE][STANDARD]
4. (#1 or #2 or #3) AND (INREGISTER) [REFERENCE][STANDARD]
5. ((injur* or trauma* or fractur* or dislodg* or luxat* or sublux* or concuss* or disloc* or mTBI)) AND (INREGISTER) [REFERENCE][STANDARD]
6. (sport* or athletic*) AND (INREGISTER) [REFERENCE][STANDARD]
7. ((baseball* or basketball* or boxing or boxer* or football* or soccer or hockey or “martial art*” or karate or judo or juijitsu or “ju jitsu” or “tae kwon do” or taekwondo or kendo or sumo or aikido or “kung fu” or acrobatic* or gymnastic* or bobsleigh* or dodgeball* or “dodge ball*” or handball* or softball* or racquetball* or squash or “shot put*” or kendo or wrestl* or puroresu or surfing or polocrosse or “figure skat*” or “inline skat*” or “water polo” or kabbadi or kabaddi or “jai alai” or wushu)) AND (INREGISTER) [REFERENCE][STANDARD]
8. ((cricket* or rugby or “track and field” or volleyball* or kickbox* or fenc* or lacrosse)) AND (INREGISTER) [REFERENCE][STANDARD]
9. ((helmet* or mouthguard* or mouth-guard* or “mouth guard*” or headgear* or head-gear* or “head gear*” or facemask* or “face mask*” or face-mask* or visor* or shield* or faceshield* or face-shield* or toothguard* or “tooth guard*” or tooth-guard* or teethguard* or “teeth guard*” or teeth-guard* or gumshield* or “gum shield*” or gum-shield* or gumguard* or “gum guard*” or gum-guard* or “scrum cap*” or goggle*)) AND (INREGISTER) [REFERENCE][STANDARD]
10. #6 or #7 or #8
11. #4 and #5 and #10 and #9

CENTRAL (to Issue 10, 2010)

1. MeSH descriptor: [Skull] explode all trees
2. MeSH descriptor: [Head] explode all trees
3. (skull* or head* or face* or facial* or forehead* or fore-head* or occipital* or parietal* or temporal or brain* or scalp* or cheek* or cheek-bone* or nose* or nasal or lip* or gum* or frontal*)
4. (craniocerebral or cranio-cerebral or craniofacial or cranio-facial or eye* or jaw* or mandib* or maxill* or orbital* or zygomatic* or mouth* or cranium*)
5. (tooth or teeth)
6. #1 or #2 or #3 or #4 or #5
7. MeSH descriptor: [Athletic Injuries] this term only
8. MeSH descriptor: [Craniocerebral Trauma] explode all trees
9. (injur* or trauma* or fractur* or dislodg* or luxat* or sublux* or concuss* or disloc* or mTBI)
10. MeSH descriptor: [Tooth Injuries] explode all trees
11. #7 or #8 or #9 or #10
12. MeSH descriptor: [Sports] explode all trees
13. (sport* or athletic*)
14. (baseball* or basketball* or boxing or boxer* or football* or soccer or hockey or “martial art*” or karate or judo or juijitsu or “ju jitsu” or “tae kwon do” or taekwondo or kendo or sumo or aikido or “kung fu” or acrobatic* or gymnastic* or bobsleigh* or dodgeball* or “dodge ball*” or handball* or softball* or racquetball* or squash or “shot put*” or kendo or wrestl* or puroresu or surfing or polocrosse or “figure skat*” or “inline skat*” or “water polo” or kabbadi or kabaddi or kabadi or “jai alai” or wushu)
15. (cricket* or rugby or “track and field” or volleyball* or kickbox* or kick-box* or fenc* or lacrosse)
16. #12 or #13 or #14 or #15
17. MeSH descriptor: [Protective Devices] explode all trees
18. (helmet* or mouthguard* or mouth-guard* or “mouth guard*” or headgear* or head-gear* or “head gear*” or facemask* or “face mask*” or face-mask* or visor* or shield* or faceshield* or face-shield* or toothguard* or “tooth guard*” or tooth-guard* or “teethguard*” or “teeth guard*” or teeth-guard* or gumshield* or “gum shield*” or gum-shield* or gumguard* or “gum guard*” or gumguard* or “scrum cap*” or goggle*)
19. protect*
20. #17 or #18 or #19
21. #6 and #11 and #16 and #20

MEDLINE via OVID (1946 to Nov 5, 2012)

1. exp Skull/
2. exp Head/
3. (skull$ or head$ or face$ or facial$ or forehead$ or fore-head$ or occipital$ or parietal$ or temporal or brain$ or scalp$ or cheek$ or cheek-bone$ or nose$ or nasal or lip$ or gum$ or frontal$).tw.
4. (craniocerebral or cranio-cerebral or craniofacial or cranio-facial or eye$ or jaw$ or mandib$ or maxill$ or orbital$ or zygomatic$ or mouth$ or cranium$).tw.
5. (tooth or teeth).tw.
6. or/1-5
7. Athletic injuries/
8. exp Craniocerebral Trauma/
9. (injur$ or trauma$ or fractur$ or dislodg$ or luxat$ or sublux$ or concuss$ or disloc$ or mTBI).tw.
10. exp Tooth injuries/
11. or/7-10
12. exp Sports/
13. (sport$ or athletic$).tw.
14. (baseball$ or basketball$ or boxing or boxer$ or football$ or soccer or hockey or “martial art$” or karate or judo or juijitsu or “ju jitsu” or “tae kwon do” or taekwondo or kendo or sumo or aikido or “kung fu” or acrobatic$ or gymnastic$ or bobsleigh$ or dodgeball$ or “dodge ball$” or handball$ or softball$ or racquetball$ or squash or “shot put$” or kendo or wrestl$ or puroresu or surfing or polocrosse or “figure skat$” or “inline skat$” or “water polo” or kabbadi or kabaddi or kabadi or “jai alai” or wushu).tw.
15. (cricket$ or rugby or “track and field” or volleyball$ or kickbox$ or kick-box$ or fenc$ or lacrosse).tw.
16. or/12-15
17. exp Protective devices/
18. (helmet$ or mouthguard$ or mouth-guard$ or “mouth guard$” or headgear$ or head-gear$ or “head gear$” or facemask$ or “face mask$” or face-mask$ or visor$ or shield$ or faceshield$ or face-shield$ or toothguard$ or “tooth guard$” or tooth-guard$ or “teethguard$” or “teeth guard$” or teeth-guard$ or gumshield$ or “gum shield$” or gum-shield$ or gumguard$ or “gum guard$” or gumguard$ or “scrum cap$” or goggle$).tw.
19. protect$.tw.
20. or/17-19
21. 6 and 11 and 16 and 20
22. Comment/
23. Letter/
24. Editorial/
25. or/22-24
26. 21 not 25

EMBASE via OVID (1980 to Nov 5, 2012)

1. exp Skull/
2. exp Head/
3. (skull$ or head$ or face$ or facial$ or forehead$ or fore-head$ or occipital$ or parietal$ or temporal or brain$ or scalp$ or cheek$ or cheek-bone$ or nose$ or nasal or lip$ or gum$ or frontal$).tw.
4. (craniocerebral or cranio-cerebral or craniofacial or cranio-facial or eye$ or jaw$ or mandib$ or maxill$ or orbital$ or zygomatic$ or mouth$ or cranium$).tw.
5. (tooth or teeth).tw.
6. or/1-5
7. Sport injury/
8. exp Head injury/
9. (injur$ or trauma$ or fractur$ or dislodg$ or luxat$ or sublux$ or concuss$ or disloc$ or mTBI).tw.
10. exp Tooth injury/
11. or/7-10
12. exp Sport/
13. (sport$ or athletic$).tw.
14. (baseball$ or basketball$ or boxing or boxer$ or football$ or soccer or hockey or “martial art$” or karate or judo or juijitsu or “ju jitsu” or “tae kwon do” or taekwondo or kendo or sumo or aikido or “kung fu” or acrobatic$ or gymnastic$ or bobsleigh$ or dodgeball$ or “dodge ball$” or handball$ or softball$ or racquetball$ or squash or “shot put$” or kendo or wrestl$ or puroresu or surfing or polocrosse or “figure skat$” or “inline skat$” or “water polo” or kabbadi or kabaddi or kabadi or “jai alai” or wushu).tw.
15. (cricket$ or rugby or “track and field” or volleyball$ or kickbox$ or kick-box$ or fenc$ or lacrosse).tw.
16. or/12-15
17. exp Protective equipment/
18. (helmet$ or mouthguard$ or mouth-guard$ or “mouth guard$” or headgear$ or head-gear$ or “head gear$” or facemask$ or “face mask$” or face-mask$ or visor$ or shield$ or faceshield$ or face-shield$ or toothguard$ or “tooth guard$” or tooth-guard$ or “teethguard$” or “teeth guard$” or teeth-guard$ or gumshield$ or “gum shield$” or gum-shield$ or gumguard$ or “gum guard$” or gumguard$ or “scrum cap$” or goggle$).tw.
19. protect$.tw.
20. or/17-19
21. 6 and 11 and 16 and 20
22. exp Animals/
23. exp Human/
24. 22 not 23
25. 21 not 24

Asplund C, Bettcher S, Borchers J. Facial protection and head injuries in ice hockey: a systematic review. Br J Sports Med 2009;43(13):993-9.

Benson BW, Hamilton GM, Meeuwisse WH, McCrory P, Dvorak J. Is protective equipment useful in preventing concussion? A systematic review of the literature. Br J Sports Med 2009;43 Suppl 1:i56-67.

Knapik JJ, Marshall SW, Lee RB, Darakjy SS, Jones SB, Mitchener TA, delaCruz GG, Jones BH. Mouthguards in sport activities: history, physical properties and injury prevention effectiveness. Sports Med 2007;37(2):117-44.

Thompson DC, Rivara FP, Thompson R. Helmets for preventing head and facial injuries in bicyclists. Cochrane Database of Systematic Reviews 2009; 1.

Despite the finding of insufficient evidence, the following are considerations for implementation drawn from studies included in the evidence review, the broader literature, and expert opinion.

• The use of of helmets, facemasks, and mouthguards may raise players’ concerns regarding comfort and athletic performance.
• Helmets, facemasks, and mouthguards vary in quality, fit and comfort, and their individual properties have the potential to inhibit or facilitate their use as well as affect their protective properties.
• The wider literature includes concerns about potential harms associated with the use of helmets, facemasks, and mouthguards, such as impaired breathing, speech, peripheral vision, and hearing.
• An additional concern is risk compensation, meaning players using protective equipment may take greater risks because they perceive themselves to be better protected.