A coach and athletic-trainer playbook
Mouthguard Player Compliance: Why Athletes Pull Mouthguards Out, and What Actually Fixes It
The equipment-and-coaching playbook for the athletes who won't keep a mouthguard in: the ten-year-old who spits it out between plays, the fighter who pulls a bulky guard before every round.
The guard an athlete won't keep in protects nothing. Lower-jaw design is what fixes it.
The one line behind this whole page.The mouthguard an athlete refuses to wear protects nothing, and the two reasons they pull it out, breathing and talking, both trace to one design choice: which arch the guard sits on. NeuroGuard+ sits on the lower jaw (the bottom teeth), leaving the roof of the mouth and the airway path clear, so a ten-year-old can call the play and a fighter can talk to his corner without spitting it out3. Custom lower-jaw appliances are associated with an 8.4% reduction in respiratory rate during exercise with no loss of oxygen, and custom guards do not impair VO2max or VEmax while boil-and-bite guards measurably reduce both2.
For a program, that same design choice is the difference between the protection you budgeted and half of it: a mouthguard associated with a 26% lower concussion rate at full compliance delivers roughly a 13% reduction at 50% compliance1. A guard on the bench protects no one. This is the coach-and-AT playbook for fixing the silent failure mode, and the buyer's guide for the athlete who keeps taking it out.
Compliance is the silent failure mode of every mouthguard program, and most programs don't audit it
Every coach and every athletic trainer who has ever run a youth, high school, or collegiate athletic program knows the pattern. The program buys mouthguards at the start of the season. Compliance is approximately 100% in the first two weeks. By week four, athletes have started leaving them on the bench between drills, then between plays, then more or less permanently. By midseason, a meaningful fraction of the team is on the field without the mouthguard the program paid for, and the program-level protective effect that was budgeted at the start of the season has effectively halved.
This is the silent failure mode. It is silent because no athletic department audits compliance the way they audit attendance or eligibility: there is no formal compliance log, there is no in-game compliance enforcement beyond the visible-color rule in some sports, and the conversation between an AT and a coach about a specific athlete's compliance is informal and infrequent. It is silent because the athletes who remove the mouthguard are generally not the athletes who report it; they are the athletes who quietly stop wearing it and move on. And it is silent because the protective-effect cost of low compliance does not surface on a single concussion event. It surfaces as an elevated concussion rate over a multi-year program horizon, which most programs do not track at the granularity that would make the failure mode visible.
The cost of the silent failure mode is captured in the compliance × efficacy math below. The 2023 BJSM meta-analysis found a 26% reduction in concussion incidence in collision sports for mouthguard wearers1; the protective effect is intrinsically tied to actually wearing the mouthguard. A program with 100% compliance gets the full 26% reduction. A program with 50% compliance (which is the realistic compliance rate for many retail mouthguard programs by midseason) gets approximately half the reduction. The cost of low compliance is therefore not abstract; it is the differential concussion incidence that the program was budgeting to avoid. Auditing compliance is the part of the program-level decision that retail-grade mouthguard purchases skip.
The four reasons athletes pull mouthguards out: each has a mechanism, each has a fix
Mouthguard non-compliance is not a single behavior; it is four behaviors driven by four separate failure modes. A coach or AT who wants to improve program-level compliance has to address all four. Asking "why are athletes not wearing their mouthguards?" without distinguishing the four modes generally produces a generic answer ("they don't like them") that doesn't lead to a fix.
Failure mode 1: Breathing restriction. Athletes describe a sense that the mouthguard is restricting airflow, especially during high-output anaerobic efforts. This sensation is real with stock and boil-and-bite mouthguards: the 2017 Caneppele meta-analysis of 14 studies found that mouthguards in general reduce VO2max and VEmax, but custom-made mouthguards specifically do not have a significant effect on either measure2. The mechanism is partly physical (bulk in the oral cavity, particularly around the airway and palate) and partly psychological (athletes who have associated mouthguard use with breathing sensation generalize the association even when wearing a better-fitted appliance). The fix is custom fit. Caneppele's data shows the breathing restriction is essentially eliminated with a properly fitted custom appliance. For lower-jaw custom appliances specifically, Garner & Lamira 2020 measured an 8.4% reduction in respiratory rate during steady-state exercise with no change in oxygen consumption3, meaning the appliance changes breathing efficiency, not breathing capacity.
Failure mode 2: Speech and communication interference. Athletes, especially in helmet sports, describe difficulty calling plays, signaling to teammates, and communicating with coaches with a mouthguard in. The failure mode is sport-specific: football quarterbacks, hockey centers, lacrosse middies, and basketball point guards experience it more acutely than skill positions with less verbal load. The mechanism is mouthguard bulk in the anterior oral cavity (where tongue articulation happens) and palate (where vowel formation happens). The fix is mouthguard design that minimizes anterior and palatal bulk while preserving posterior occlusal thickness, which is exactly what custom pressure-laminated and custom mandibular appliances are designed to do, vs OTC mouthguards which often cover the upper teeth and palate with material that interferes with articulation. Athletes report substantially better speech with custom appliances, though the improvement varies with mouthguard design.
Failure mode 3: Gagging or jaw fatigue from poor fit. Athletes describe nausea, gagging, or jaw soreness from holding a mouthguard in place over a long practice or game. The mechanism is poor occlusal contact and inadequate retention: when a mouthguard does not seat naturally, the athlete must consciously hold it with jaw musculature, which produces fatigue and gag responses. This failure mode is particularly common with stock mouthguards and inadequately-fitted boil-and-bite mouthguards. The fix is a custom impression-based fit that distributes occlusal contact across the dental arch and retains by friction with the teeth, rather than by jaw muscle clamping. Custom mouthguards generally eliminate the gagging-and-fatigue failure mode entirely, which is why custom-fit retention is much higher.
Failure mode 4: Fit fall-out from material degradation. Even a mouthguard that fits well at the start of the season degrades over time. Winters & DeMont 2014 measured average OTC mouthguard thickness dropping from 1.65 mm at season start to 1.34 mm at time of injury4. That is the material literally chewing down across the season. As the mouthguard degrades, retention falls, athletes start adjusting it, the athlete-mouthguard fit relationship breaks down, and removal becomes easier and more frequent. The fix is custom pressure-laminated material thickness (Winters specifies ≥3mm posterior occlusal thickness) that resists chewing degradation across an active season, plus an annual replacement cycle that resets the fit. This is also why retail OTC mouthguards have the worst program-level compliance: even when the initial fit is acceptable, the material does not survive the season.
Why lower-teeth design improves compliance (and lets athletes breathe and talk)
Lower-teeth design improves compliance because it moves the guard off the palate, the one place bulk blocks breathing and speech at the same time. The most common compliance complaint is not "it hurts." It is "I can't breathe" and "I can't talk." A ten-year-old spits the guard out between plays because it is in the way of calling the play and catching his breath. A fighter pulls a bulky guard before every round because he needs to talk to his corner and breathe through his mouth. Both are describing the same two failure modes from the section above, breathing restriction and speech interference, and both trace back to one design decision most mouthguards get wrong: where the guard sits in the mouth.
Almost every retail mouthguard sits on the upper teeth and covers the palate, the roof of the mouth. That is the worst place to put bulk for an athlete who has to breathe hard and communicate. The tongue forms words against the palate and the front teeth, and the airway sits just behind them, so material on the upper arch lands directly in the breathing-and-speech zone. This is why upper-arch and boil-and-bite guards draw breathing and articulation complaints more often, and why the fix for both failure modes is the same: get the bulk off the roof of the mouth.
NeuroGuard+ is built on the opposite premise. It is a custom mandibular appliance that covers the lower arch, the bottom teeth, and leaves the palate and the front of the mouth clear. There is nothing on the roof of the mouth to gag against and less material in the path of the airway. The peer-reviewed mechanism evidence lines up with the design: a custom lower-jaw appliance was associated with an 8.4% reduction in respiratory rate during exercise with no loss of oxygen uptake3, custom-made mouthguards do not impair VO2max or VEmax while stock and boil-and-bite guards measurably reduce both2, and mouthpiece use has been associated with a 9% increase in upper airway width5. The result an athlete actually feels is that they can breathe under load and talk without pulling the guard out.
The design does not trade protection for comfort. The lower-arch appliance still carries the protective posterior thickness the impact research depends on, the same ≥3mm pressure-laminated thickness used in the custom arm of the Winters trial4. So the answer for an athlete who "won't wear a bulky guard" is usually not a thinner guard with less protection. It is moving the guard to the lower arch so the palate and airway stay clear while the protective thickness stays where the impact is. The performance side of this same lower-jaw mechanism, airway and neuromuscular output, is covered on jaw alignment and athletic performance.
Lower-teeth vs upper-arch, including SISU and Under Armour: the design comparison
The lever most buyers reach for is thinness. It is the wrong axis. A 1.6 mm guard that still sits on the upper arch covers the palate, so the athlete is still talking and breathing around material in the speech-and-airway zone. Which arch the guard sits on matters more than how thin it is. That is the single variable this table isolates.
| Design factor | NeuroGuard+ (lower-arch) | SISU Aero (upper-arch, ultra-thin) | Boil-and-bite / Under Armour (upper-arch) |
|---|---|---|---|
| Arch the guard sits on | Lower teeth (mandibular) | Upper teeth (maxillary) | Upper teeth (maxillary) |
| Roof of the mouth (palate) | Left clear | Covered | Covered |
| Profile thickness | ≥3 mm protective posterior thickness, pressure-laminated4 | About 1.6 mm (SISU's thin-profile spec) | About 1.65 mm, degrading to 1.34 mm at time of injury4 |
| Talk and call plays | Front of the mouth stays clear; athletes report talking and calling plays without removing it | Thinner, but palate coverage still interferes with articulation | Palatal and anterior bulk interfere with articulation |
| Breathing under load | 9% wider upper airway5; 8.4% lower respiratory rate, no VO2 loss3 | Thin, but sits on the upper arch in the airway-and-speech zone | Boil-and-bite reduces VO2max and VEmax2 |
| What drives "keep it in" | Removes the top two removal triggers at the design level | Reduces bulk, but not palate coverage | Bulk plus mid-season material degradation drive removal |
SISU's Aero is a genuinely comfortable, thin guard, and for pure dental protection it does its job. The point here is narrower: for the athlete who has to breathe hard and talk, thinness on the upper arch does not clear the palate, and clearing the palate is what stops the guard from coming out. That is why NeuroGuard+ is built on the lower arch. The performance side of this same lower-jaw design is on jaw alignment and athletic performance.
What the peer-reviewed evidence says about custom-fit compliance mechanisms
The case for custom-fit mouthguards rests partly on concussion-incidence trials and partly on mechanism-and-physiology studies that explain why custom fit changes the athlete's experience. The mechanism evidence is what makes the compliance argument credible at the program level. Coaches and ATs need to know not just that custom mouthguards have better compliance, but why. Below is the full study-by-study evidence. Open it for the numbers, or skip to the practical playbook.
See the five peer-reviewed studies behind the compliance mechanisms
Cardiopulmonary capacity (Caneppele 2017 meta-analysis). The strongest single source on the breathing question is the 2017 Caneppele systematic review and meta-analysis of 14 cross-over studies in Sports Medicine International Open2. Overall mouthguard effect on VO2max favored no mouthguard (p=0.0001, 95% CI: −2.638 to −1.728), and VEmax similarly favored no mouthguard (p=0.0001, 95% CI: −4.103 to −1.354), confirming that mouthguards in general reduce both measures. The critical sub-finding is that custom-made mouthguards specifically did not show a significant effect on VO2max or VEmax compared to control. The authors' verbatim conclusion: "Custom-made MGs seem to have no effect on these parameters" and "the evidence collected from the present meta-analysis support the use of custom-made MGs." This is the FTC-defensible aerobic-performance claim, and it directly explains why the breathing-restriction failure mode is concentrated in stock and boil-and-bite mouthguards rather than custom appliances.
Respiratory rate and ventilation (Garner & Lamira 2020). The 2020 randomized cross-over study in 17 healthy subjects measured an 8.4% reduction in respiratory rate (28.35 BPM without OA vs 25.97 BPM with OA, p<0.01) and a 5.3% reduction in minute ventilation (50.34 l/min vs 47.66 l/min, p<0.01) during steady-state aerobic exercise with a custom lower-jaw genioglossal-effecting oral appliance, with no significant change in VO23. The authors' interpretation: the appliance engages the genioglossus muscle, lowering respiratory rate and ventilation without compromising oxygen uptake. The implication for compliance is that a properly designed custom lower-jaw appliance changes the breathing pattern in a way athletes generally describe as more efficient, not more restricted, the opposite of the breathing-restriction failure mode for OTC mouthguards.
Airway dimensions (Garner & McDivitt 2009). CT imaging measurements in 10 healthy college males found a 9% increase in upper airway width during mouthpiece use (28.27 mm vs 25.93 mm, P=0.029), with a corresponding 31.6% reduction in post-exercise lactate (1.86 mmol/L vs 2.72 mmol/L)5. Small N, healthy non-athletes, self-adapted mouthpiece: caveats acknowledged. The mechanism context is what matters: the appliance is physically opening the airway, not narrowing it, which is the opposite of the bulk-restriction story that drives the breathing-restriction failure mode in OTC designs.
Performance physiology (Haughey & Fine 2020). A within-subjects study of 15 elite athletes (Gaelic football, field hockey, boxing) compared habitual bite vs physiological-rest-position bite (created by a custom thermoformed mouthguard at TENS-derived neuromuscular position) and found 5.8% improvement in lower-body power, 10% in upper-body power, 14% in hamstring flexibility, and 4.8% in balance (all p<0.05)6. The authors note the findings are preliminary given the small sample. The compliance implication: athletes who associate a custom appliance with a positive performance feel (even subjectively, without measured improvement) are substantially more likely to keep it in.
Material durability (Winters & DeMont 2014). The 412-player HS football randomized trial measured average OTC mouthguard thickness falling from 1.65 mm at season start to 1.34 mm at time of injury4, while custom pressure-laminated mouthguards retained ≥3mm thickness across the season. The implication for the fit-fall-out failure mode is direct: OTC mouthguards do not survive the season as well as custom pressure-laminated mouthguards, and the fit deterioration drives compliance erosion in the back half of the season.
We cite the counter-evidence on every page that touches a concussion claim: Daneshvar 20117 and Benson 20098 both concluded the evidence for mouthguard-mediated concussion reduction was insufficient at the time they published. The literature has clearly evolved with the 2023 BJSM meta-analysis1 and the controlled trials on custom mandibular designs4, but the older reviews remain in the record. The compliance argument is not separate from the efficacy argument. They are linked through the compliance × efficacy math below.
Compliance comparison: custom mandibular vs OTC boil-and-bite
The table below pulls the compliance failure modes against the peer-reviewed evidence base for each type of mouthguard. The comparison is not meant to read as "custom is better at everything." It is meant to surface which failure modes each design addresses and which it doesn't.
| Compliance Failure Mode | Custom Mandibular (NeuroGuard+ family) | Custom Pressure-Laminated | OTC Boil-and-Bite |
|---|---|---|---|
| Breathing restriction | Custom-made mouthguards do not significantly reduce VO2max or VEmax2; lower-jaw appliance associated with 8.4% reduced respiratory rate without VO2 impact3 | Custom-made mouthguards do not significantly reduce VO2max or VEmax2 | Mouthguards in general reduce VO2max and VEmax (p=0.0001, Caneppele 20172); athletes describe breathing restriction more frequently |
| Speech and communication | Minimal anterior/palatal bulk in custom lower-jaw appliances; athletes generally report substantially better articulation | Lower anterior bulk than OTC; depends on lab design | Upper-arch coverage often includes palatal bulk; articulation interference more common |
| Gagging or jaw fatigue | Custom impression-based fit distributes occlusal contact; retention by friction rather than jaw clamping | Same: custom impression and pressure-lamination distribute contact | Variable fit from boil-and-bite process; gag responses and jaw fatigue more common when fit is imperfect |
| Fit fall-out from material degradation | Custom pressure-laminated material ≥3mm thickness retains across the season4; annual replacement cycle | Same: Winters trial used pressure-laminated ≥3mm in the custom arm4 | Average OTC thickness drops 1.65 mm → 1.34 mm at time of injury4; fit deterioration drives compliance erosion |
| Concussion-incidence in HS football (controlled trial) | Mechanism family supported by Hutchison 2018 (4,010-cohort, 0.224% rate)9 and Eliason 2023 meta-analysis1 | 3.6% concussion rate in Winters RCT4 | 8.3% concussion rate in Winters RCT4 |
| Counter-evidence acknowledged | Daneshvar 20117 and Benson 20098 cited on every page that touches a concussion claim | Same standard if the vendor adopts it | Rarely cited in retail marketing |
The pattern: custom-fit appliances address the four compliance failure modes more directly than OTC mouthguards, and the compliance × efficacy compounding means the program-level concussion-incidence delta in actual use is wider than the controlled-trial delta. Programs that buy OTC mouthguards for budget reasons should plan for the compliance failure modes explicitly. The silent failure mode is what makes the up-front budget advantage smaller than it looks.
The compliance × efficacy math: why half your compliance halves your protective effect
The compliance × efficacy math is the load-bearing piece of arithmetic in any program-level concussion-protection conversation. The headline meta-analytic finding is the 26% concussion-incidence reduction in collision sports for mouthguard wearers from the 2023 BJSM meta-analysis1. That figure is a per-wearer, per-impact figure. It assumes the mouthguard is in the athlete's mouth at the moment of impact. At 100% compliance, the program-level reduction is approximately the meta-analytic reduction. At 50% compliance, the program-level reduction is approximately half.
This is not a quirky observation; it is intrinsic to how the efficacy of any wearable protective equipment generalizes from the trial setting (where compliance is generally near 100% under research-grade supervision) to the field setting (where compliance is variable and typically lower). For a 60-athlete high school football roster at the CDC baseline 6.9% youth TBI incidence10, the math runs as follows:
- Baseline expected events per year: 60 × 0.069 ≈ 4 concussions per roster-year.
- At 100% mouthguard compliance with 26% reduction1: 60 × 0.069 × (1 − 0.26) ≈ 3 events per year (approximately 1 event avoided).
- At 50% compliance (50% wearing × 26% reduction + 50% not wearing × 0% reduction): 60 × 0.069 × (1 − 0.13) ≈ 3.6 events per year (approximately 0.5 events avoided).
Half your compliance halves your protection. The equipment decision and the "will they actually keep it in" decision are the same decision.
The cost of low compliance is the difference between approximately 1 event avoided per year and approximately 0.5 events avoided per year. At a roster-level, that is the difference between 1 athlete-season disrupted and 1.5, and the difference compounds across multi-year cohorts. The same math runs at any roster size and any baseline incidence; what changes is the absolute event count, not the proportional sensitivity to compliance. The full risk-mitigation walkthrough is on the cost of concussions in youth sports.
A second piece of the math: for the custom-vs-OTC sub-question specifically, Winters & DeMont 2014 reported 3.6% vs 8.3% concussion incidence in 412 randomized HS football players4. That delta is observed under typical mid-season compliance, meaning the controlled-trial figure already includes some compliance attrition for both arms. The implication is that the custom-vs-OTC delta in real-world use is at least as large as the trial delta, because OTC compliance attrition (driven by the four failure modes above) is faster than custom compliance attrition.
The honest caveats: meta-analytic effect sizes pool across many study contexts; compliance rates vary by program, age group, sport, and coaching staff; and the relative-risk reduction is not a guarantee of avoided events at the individual-athlete level. We cite the counter-evidence78 honestly because both sides of the literature belong in the program decision.
The coach + AT compliance playbook: five practices that move compliance rates materially
Compliance is partly an equipment problem and partly a culture problem. The equipment side is addressed by buying a mouthguard design that minimizes the four failure modes. The culture side is addressed by program-level practices that head coaches and head athletic trainers can implement directly. Five practices have the highest leverage.
Practice 1: Audit compliance, don't assume it. A coach or AT who is not auditing compliance has no basis for assessing program-level protective effect. Audit can be lightweight: visual check across the first 15 minutes of every practice, periodic spot-checks during scrimmages and games, conversation with positional coaches about their athletes. The point is to put a compliance figure on the program, share it with the AD, and track it over time. Most programs that start auditing discover compliance is lower than they assumed.
Practice 2: Distinguish the four failure modes when athletes complain. When an athlete says "I don't like the mouthguard," ask which of the four failure modes they are experiencing: breathing, speech, gagging, or fit fall-out. The conversation goes differently depending on the answer. Breathing complaints on a custom appliance often respond to coaching ("the breathing is normal. Try it through the next two practices and tell me what you notice"); breathing complaints on an OTC mouthguard generally don't and indicate the equipment needs to change. Speech complaints on the QB or center indicate a design issue that should go to the vendor. Gagging or jaw fatigue indicates a fit problem that needs an AT or dentist intervention. Fit fall-out is a material-degradation indicator and a signal that mid-season reorder or replacement is needed.
Practice 3: Make compliance a team-culture marker, not an individual call-out. Programs with strong compliance generally have built compliance into team identity: the mouthguard is "what we do," reinforced by captains and veterans rather than enforced by the AT in 1:1 conversations. The shift is from "we tell athletes to wear it" to "veterans show new athletes how the program works." This is a slow culture change, but it is the single highest-leverage compliance lever once the equipment side is sound.
Practice 4: Tie compliance to athletic performance, not just to safety. Athletes respond to performance arguments more reliably than to safety arguments. The peer-reviewed evidence supports a modest performance-physiology case for custom mandibular appliances (Haughey & Fine 20206; Garner & Lamira 20203; Caneppele 20172): small samples, preliminary findings, but real and citable. Coaches who frame the mouthguard as performance equipment rather than safety equipment generally see higher compliance, particularly in the back half of the season. The deeper performance case is on jaw alignment and athletic performance.
Practice 5: Replace mouthguards on the program's schedule, not on the athlete's request. A custom pressure-laminated or custom mandibular appliance retains ≥3mm thickness across an active season4 but should still be replaced annually as part of program operations. An athlete who has to ask for a replacement generally doesn't, and the fit degradation drives compliance erosion. A program-level annual replacement cycle is the equipment-side version of practice 3. It builds compliance into program operations rather than into individual decisions.
What this means for program design, and where it fits in a concussion-prevention stack
A team-level mouthguard program is one layer of a CISG Amsterdam 2022-aligned11 concussion-prevention stack. Equipment selection is a procurement decision; compliance management is a coaching and culture decision; return-to-play protocol management is a clinical decision. All three layers belong in the program manual, and a program that has done one of them well and the others poorly is incomplete in a way that surfaces during a state regulatory review or a litigation discovery process.
The implication for program design is that compliance management is not a side concern; it is the variable that determines whether the equipment-layer investment produces the protective effect the budget conversation assumed. A custom mouthguard program with strong compliance management is meaningfully different from a custom mouthguard program with no compliance management. The equipment is the same, but the program-level protective effect is approximately twice as large. The procurement framework on the team mouthguard program buyer's guide is the equipment layer; this page is the coaching-and-culture layer; the risk-mitigation budget math on the cost of concussions in youth sports is what ties them together for the AD or program director.
A program that wants to take this seriously builds the compliance audit into the same operational cadence as eligibility checks, equipment inspections, and standard-of-care file reviews. The compliance figure is presented at the same coaching staff meetings that look at injury rates, practice intensity, and academic eligibility. The mouthguard is treated as program equipment with a defined operational lifecycle, not as a personal item the athlete is responsible for replacing. The cost of building this into program operations is small; the cost of not building it in is the protective-effect erosion that the compliance × efficacy math surfaces.
Why a dentist built a lower-jaw appliance
"I'm a dentist, and I'm a dad. I watched my own son leave his mouthguard on the bench because he couldn't breathe or call the play with it in. A guard on the bench protects nothing. So I built one that sits on the lower teeth and leaves the roof of the mouth clear, because the guard that stays in is the only one that does anything."
Dr. Michael Hutchison, Founder, NeuroGuard+ · inventor of the mandibular appliance studied in the 2018 cohort of 4,010 athletes
Frequently asked questions
How big is the compliance problem in mouthguard programs?
Compliance rates vary widely across programs and have not been systematically measured at the population level in the published literature. Anecdotal reports from athletic trainers and coaches consistently describe a pattern where compliance is approximately 100% at the start of the season, drops to 50–70% by midseason, and continues to erode in the back half, particularly for OTC mouthguards where material degradation drives fit fall-out. The Winters & DeMont 2014 measurement of average OTC mouthguard thickness dropping from 1.65 mm at season start to 1.34 mm at time of injury4 is the closest direct measurement of the equipment-side compliance failure mode; the coaching-and-culture side is less well measured but widely observed.
Why do custom mouthguards have better compliance?
Custom mouthguards address all four documented failure modes more directly than OTC mouthguards. The 2017 Caneppele meta-analysis found that custom-made mouthguards specifically do not impair VO2max or VEmax, while stock and boil-and-bite mouthguards measurably reduce both2. Custom lower-jaw appliances are associated with reduced respiratory rate during exercise without changing oxygen consumption (Garner & Lamira 20203). Custom pressure-laminated material retains ≥3mm thickness across an active season4. Custom impression-based fit distributes occlusal contact and retains by friction with the teeth, reducing the gagging-and-fatigue failure mode. The combination of mechanisms explains why custom appliances generally have higher compliance retention across a season.
What's the compliance × efficacy math in plain numbers?
For a representative 60-athlete high school football roster at the CDC baseline 6.9% youth TBI incidence10, the program expects approximately 4 concussions per year. At 100% mouthguard compliance with the 26% meta-analytic incidence reduction1, expected events drop to approximately 3 (approximately 1 event avoided). At 50% compliance, the program-level reduction is approximately 13% (half of 26%), and expected events drop to approximately 3.6 (approximately 0.5 events avoided). The difference between 100% compliance and 50% compliance is approximately half of the program's protective effect.
Should the program audit compliance?
Yes. A program that does not audit compliance has no basis for assessing whether the equipment investment is producing the protective effect the budget conversation assumed. Audit can be lightweight: visual check across the first 15 minutes of practice, periodic spot-checks during games, conversation with positional coaches. The point is to put a compliance figure on the program, track it over time, and surface failure modes early. Most programs that start auditing find compliance is lower than assumed.
Does the design of the mouthguard matter for breathing during high-output efforts?
Yes. The 2017 Caneppele systematic review and meta-analysis of 14 studies found that mouthguards in general reduce VO2max (p=0.0001) and VEmax (p=0.0001), but custom-made mouthguards specifically did not have a significant effect on either measure2. The implication for breathing-restriction compliance complaints is that the failure mode is concentrated in stock and boil-and-bite mouthguards rather than custom appliances. For a custom lower-jaw appliance specifically, Garner & Lamira 2020 measured an 8.4% reduction in respiratory rate during steady-state exercise with no change in oxygen consumption3, meaning custom lower-jaw appliances change breathing pattern in a direction athletes generally describe as more efficient.
What about speech and play-calling for quarterbacks and centers?
Speech and communication interference is a documented compliance failure mode and is particularly acute for high-verbal-load positions: football quarterbacks, hockey centers, lacrosse middies, basketball point guards. The fix is mouthguard design that minimizes anterior and palatal bulk. Custom pressure-laminated and custom mandibular appliances are generally designed with less anterior bulk than OTC mouthguards, which often cover the upper teeth and palate with material that interferes with articulation. Athletes report substantially better speech with custom appliances, though the improvement varies with mouthguard design. A coach evaluating a vendor for a high-verbal-load position should ask specifically about anterior bulk and palatal coverage.
My kid keeps spitting his mouthguard out because he can't breathe or talk. What are the options?
Those are the two most common removal reasons, breathing restriction and speech interference, and they usually come from the same source: a guard that sits on the upper teeth and covers the roof of the mouth, which is exactly where the tongue forms words and the airway sits behind. The options that address the cause are custom appliances that keep the palate and the front of the mouth clear. NeuroGuard+ does this by covering the lower arch (the bottom teeth) instead of the upper teeth, so there is nothing on the roof of the mouth to gag against and less material in the airway path. The mechanism evidence supports the direction: custom lower-jaw appliances are associated with an 8.4% reduction in respiratory rate during exercise with no loss of oxygen uptake3, and custom-made mouthguards do not impair VO2max or VEmax while boil-and-bite guards measurably reduce both2. For a young athlete, moving the bulk off the palate is usually what turns "I keep spitting it out" into a guard he will actually keep in.
What is the best low-profile mouthguard for an athlete who won't wear a bulky guard?
Reframe "low-profile" before shopping on thickness alone. The discomfort athletes call "bulky" is usually not raw millimeters, it is where the material sits. A guard on the upper arch puts bulk on the palate and behind the front teeth, in the breathing-and-speech zone, which is what makes it feel intrusive. A custom lower-arch appliance keeps the roof of the mouth clear while holding the protective posterior thickness the impact research depends on, the ≥3mm pressure-laminated thickness used in the custom arm of the Winters & DeMont 2014 trial4. So the better question is not "how thin can I go" but "can I move the guard off the palate," because thinning a guard to solve comfort usually costs the protective thickness that matters most. NeuroGuard+ is built on the lower arch for exactly this reason: palate clear, airway path clear, protection intact.
SISU vs Under Armour for a fighter who needs to talk and breathe without taking the guard out?
Both SISU and Under Armour are upper-arch guards, so both sit on the roof of the mouth in the exact zone a fighter uses to talk to his corner and breathe between rounds. SISU's Aero is thinner (around 1.6 mm), which helps, but thinness does not clear the palate; the material is still on the upper arch. Under Armour's guards carry more anterior and palatal bulk. For an athlete whose complaint is "I have to pull it to talk and breathe," the fix is not a thinner upper guard, it is moving the guard to the lower arch. NeuroGuard+ covers the bottom teeth and leaves the palate and airway path clear, which is why athletes can talk and breathe without removing it3. It also holds the ≥3 mm protective thickness the impact research depends on4, where a guard thinned for comfort gives that up.
Where does the player-compliance layer fit in a CISG-aligned program?
Equipment compliance is the coaching-and-culture layer that sits between the equipment-procurement decision and the CISG Amsterdam 202211 return-to-play protocol. The procurement layer decides what equipment the program uses; the compliance layer determines whether the equipment is actually in the athlete's mouth at the moment of impact; the return-to-play protocol manages post-injury return. All three layers belong in the program manual. A program that has good procurement and a CISG-aligned RTP protocol but no compliance management is incomplete. The equipment-layer protective effect is being eroded silently by the compliance failure mode.
What does NeuroGuard+ provide for compliance management?
The NeuroGuard+ team program includes a coach-and-AT compliance playbook structured around the five practices above: compliance auditing cadence, failure-mode-distinguishing conversation framework, team-culture compliance framing, performance-physiology messaging, and annual replacement cycle on the program's schedule. The mechanism (custom lower-jaw appliance, mandibular physiologic rest position) addresses the four equipment-side failure modes (breathing, speech, gagging, fit fall-out) via the peer-reviewed mechanisms in Caneppele 20172, Garner & Lamira 20203, Garner & McDivitt 20095, and Winters & DeMont 20144. The procurement framework that this compliance playbook sits inside is on the team mouthguard program buyer's guide; the risk-mitigation budget math is on the cost of concussions in youth sports; the performance-physiology case for the mechanism is on jaw alignment and athletic performance.
References
- 1. Eliason PH, Galarneau JM, Kolstad AT, et al. Prevention strategies and modifiable risk factors for sport-related concussions and head impacts: a systematic review and meta-analysis. British Journal of Sports Medicine. 2023;57(12):749-761. doi:10.1136/bjsports-2022-106656
- 2. Caneppele TMF, Borges AB, Pereira DM, et al. Mouthguard Use and Cardiopulmonary Capacity – A Systematic Review and Meta-Analysis. Sports Medicine International Open. 2017;1(5):E172-E182. doi:10.1055/s-0043-117599
- 3. Garner DP, Lamira J. Respiratory outcomes with the use of a lower custom fit genioglossal-effecting oral appliance. Clinical and Experimental Dental Research. 2020;6(1):100-106. doi:10.1002/cre2.254
- 4. Winters JE Sr, DeMont R. Role of mouthguards in reducing mild traumatic brain injury/concussion incidence in high school football athletes. General Dentistry. 2014;62(3):34-38.
- 5. Garner DP, McDivitt E. Effects of mouthpiece use on airway openings and lactate levels in healthy college males. Compendium of Continuing Education in Dentistry. 2009;30 Spec No 2:9-13. PMID:19774773
- 6. Haughey JP, Fine P. Effects of the lower jaw position on athletic performance of elite athletes. BMJ Open Sport & Exercise Medicine. 2020;6:e000886. doi:10.1136/bmjsem-2020-000886
- 7. Daneshvar DH, Baugh CM, Nowinski CJ, McKee AC, Stern RA, Cantu RC. Helmets and Mouth Guards: The Role of Personal Equipment in Preventing Sport-Related Concussions. Clinics in Sports Medicine. 2011;30(1):145-163. doi:10.1016/j.csm.2010.09.006
- 8. Benson BW, Hamilton GM, Meeuwisse WH, McCrory P, Dvorak J. Is protective equipment useful in preventing concussion? A systematic review of the literature. British Journal of Sports Medicine. 2009;43(Suppl 1):i56-i67. doi:10.1136/bjsm.2009.058271
- 9. Hutchison DD, Madura C, Hutchison MC. Impact of an improved mandibular rest position via custom mouth guard on the incidence of concussions in athletes. Michigan State University College of Human Medicine; Helen DeVos Children's Hospital; 2018. Note: corresponding author Dr. Michael Hutchison invented the studied appliance. manuscript PDF
- 10. Centers for Disease Control and Prevention. HEADS UP: Data on Sports and Recreation Activities. Updated 2024. cdc.gov/heads-up
- 11. Patricios JS, Schneider KJ, Dvorak J, et al. Consensus statement on concussion in sport: the 6th International Conference on Concussion in Sport, Amsterdam, October 2022. British Journal of Sports Medicine. 2023;57(11):695-711. doi:10.1136/bjsports-2023-106898
