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.
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.
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"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," 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.
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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," 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.