Game changers: Many factors put athletes at increased risk for oral health complications

We see many patients at high risk for decay and periodontal disease, and we know that those with diabetes, heart conditions, polypharmacy, and cancer may need special treatment plans. However, dental professionals need to be aware that athletes should be added to the list of patients at high risk.

Studies reveal that athletes are at risk

The high prevalence of untreated oral problems in athletes was first reported at the 1958 FIFA World Cup in Sweden. Dental consultations at the London 2012 Summer Olympic Games comprised 30% of all medical visits seen.¹ Oral health screenings performed on Dutch elite athletes before the 2016 Rio Olympics revealed that almost 50% required dental treatment to ensure healthy participation in the games.^2,3

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Studies done by Azeredo, Guimaraes, and Gallagher have shown athletes have poor oral health. Athletes studied showed 46% had dental caries.^4,5 Gingival inflammation was common, at 58%–85%, and 5%–41% of athletes had periodontitis.^4,5 Erosion affected nearly every second athlete.^6,7

Oral health affects more than just the mouth

Athletes may be unaware that periodontal disease is associated with many systemic diseases and conditions. Cardiovascular diseases (e.g., atherosclerosis, stroke, acute myocardial infarction) and respiratory diseases (e.g., pneumonia, bronchitis, emphysema) have a relationship with periodontal disease.⁸ Thus, athletes’ oral health can impact both their performance and overall health.

Supplements and sports drinks exacerbate the problem

Intense training for athletes such as marathoners, Ironman triathletes, 30K/50K racers, and swimmers can involve daily or twice a day workouts. Energy replacement is crucial to continue the activity, maintain, and improve athletic performance.⁸ To achieve peak performance, athletes consume foods, sports/energy drinks, energy bars, gels, and gummies high in carbohydrates and sugar.² Many mineral salt replacements are highly acidic in composition.⁸ Athletes consume energy replacement not only during competitions, but also during training. There are many different sports drinks and supplements on the market today to use for pre-training, during training, and post-training. Sport/energy drinks are highly acidic, with a pH of 2.4–4.5 (figure 1).⁸

Many athletic supplements and sports drinks are also high in sugar.² In a study done by Khan on sports drink consumption, he found a high prevalence (66.7%) of usage among elite athletes. Other studies show an even higher prevalence among college athletes.² The frequent acid attacks from these supplements raise the athlete’s risk for caries and erosion (figure 2).

Dehydration is also a common issue with athletes, and it can lead to dry mouth. The use of supplements and sports drinks to hydrate instead of water and not having the correct amount of protective saliva puts athletes at risk for caries and erosion. The problem can be further complicated with endurance athletes because intense exercise can lead to immune suppression which alters saliva composition, reducing the protective properties of saliva.^1,2 Intense physical activity produces a high concentration of CO2 in the bloodstream, which is transferred to saliva, decreasing the pH.⁹

Chlorinated water a concern for swimmers

Swimmers are at risk of erosion from not only sports/energy drinks, but constant exposure to chlorinated water. This is especially true if a swimming pool is not kept at the optimal pH of 7.4.¹⁰ Swimmers can experience tooth sensitivity and notice tooth transparency on the edges of their front teeth. Swimmers who spend more than six hours a week in chlorinated water are at risk of developing “swimmer’s mouth.”¹¹ Swimmer’s mouths results in a brownish stain and calculus on the teeth. It accumulates where the water passes through the teeth while swimming.¹²

In 2017, a study showcased that swimmers, on average, ingest 32 mL of water per hour.^12,13 This high exposure to chlorine affects the saliva rate and composition, lowering the flow of saliva and phosphate composition. The exposure also increases calcium and fluoride levels.¹¹ These changes in the oral cavity led to an exaggerated formation of calculus.¹²

Educating athletes to avoid long-term adverse affects

A study by Nascimento et al revealed that of 254 athletes surveyed, most did not floss or use any interdental cleaners, only 186 had seen a dentist in the last two years, and most had a lack of knowledge about the relationship between oral health maintenance and sport practices.⁷ Poor oral health among elite athletes can have short- and long-term effects. Short-term effects can be pain, distress, and difficulties in eating and sleeping.¹ Pain from decay or periodontal disease can be a deterrent for training sessions and workouts, affecting performance. Long-term effects include tooth loss, increased treatment times, and loss of oral function. Oral disease can also affect performance with the inflammation that can occur.¹ Inflammation can increase the level of cytokines.⁷ These cytokines play a role in the origin of muscle fatigue and oxidative stress. Muscle fatigue can cause muscular cramps when associated with exercise and leads to a reduction in capacity of energy absorption.⁷ This can leave muscles more susceptible to injury.

Education is important to prevent oral problems. Athletes should be aware of the high sugar and acidic content of many supplements and consider replacing them with water or rinsing with water after consuming supplements to decrease the caries rate. Brushing and interproximal cleaning is essential, and some athletes would benefit from seeing their dentist and hygienist more frequently. Fluoride treatments in the dental practice and at home should be implemented.

Dental hygienists have a responsibility to guide athletes, and athletes should be able to perform without the complications that come from poor oral health.

Editor's note: This article appeared in the January/February 2024 print edition of RDH magazine. Dental hygienists in North America are eligible for a complimentary print subscription. Sign up here.

References

1. Needleman I, Ashley P, Fine P, et al. Oral health and elite sport performance. Br J Sports Med. 2015;49(1):3-6. doi:10.1136/bjsports-2014-093804
2. Khan K, Qadir A, Trakman G, et al. Sports and Energy Drink Consumption, Oral Health Problems and Performance Impact among Elite Athletes. Nutrients. 2022;14(23):5089. Published 2022 Nov 30. doi:10.3390/nu14235089
3. Kragt L, Moen MH, Van Den Hoogenband CR, Wolvius EB. Oral health among Dutch elite athletes prior to Rio 2016. Phys Sportsmed. 2019;47(2):182-188. doi:10.1080/00913847.2018.1546105
4. Azeredo FN, Guimarães LS, Luís W, Fialho S, Alves Antunes LA, Antunes LS. Estimated prevalence of dental caries in athletes: An epidemiological systematic review and meta-analysis. Indian J Dent Res. 2020;31(2):297-304. doi:10.4103/ijdr.IJDR_764_18
5. Gallagher J, Ashley P, Petrie A, Needleman I. Oral health and performance impacts in elite and professional athletes. Community Dent Oral Epidemiol. 2018;46(6):563-568. doi:10.1111/cdoe.12392
6. Merle CL, Richter L, Challakh N, et al. Orofacial conditions and oral health behavior of young athletes: A comparison of amateur and competitive sports. Scand J Med Sci Sports. 2022;32(5):903-912. doi:10.1111/sms.14143
7. de Queiroz Gonçalves, P.H.P., Guimarães, L.S., de Azeredo, F.N.A. et al. Dental erosion’ prevalence and its relation to isotonic drinks in athletes: a systematic review and meta-analysis. Sport Sci Health 16, 207–216 (2020). https://doi.org/10.1007/s11332-020-00624-8
8. Nascimento BL, Zen IR, Demench LS, Mazzetto NC, Spada PP. Knowledge of triathlon athletes about the relationship between oral health and performance. RSBO. 2015:12(4),352-355.
9. Athletes and their oral health. Century Dental. September 20, 2022. www.centurydental.org/athletes-and-their-oral-health
10. Tanabe-Ikegawa M, Takahashi T, Churei H, Mitsuyama A, Ueno T. Interactive effect of rehydration with diluted sports drink and water gargling on salivary flow, pH, and buffering capacity during ergometer exercise in young adult volunteers. J Oral Sci. 2018;60(2):269-277. doi:10.2334/josnusd.17-0183
11. Moore AB, Calleros C, Aboytes D. Risks to oral health posed by swimming. Dimensions of Dental Hygiene. 2018;16(8):45-48.
12. Race R. Study finds swimmers six times more likely to see stained teeth. Swim Swam. August 11, 2021. swimswam.com/study-finds-swimmers-six-times-more-likely-to-see-stained-teeth
13. Straus R. Frequent swimmer? Your oral health may be grimmer. Oral Health Group. December 23, 2022. www.oralhealthgroup.com/features/frequent-swimmer-your-oral-health-may-be-grimmer
14. Dufour AP, Behymer TD, Cantú R, Magnuson M, Wymer LJ. Ingestion of swimming pool water by recreational swimmers. J Water Health. 2017;15(3):429-437. doi:10.2166/wh.2017.255

Sherry Basham, MSDH, RDH earned her degrees at Northern Arizona University and Old Dominion University. Sherry is an active member of the Virginia Dental Hygienist Association and works as the liaison for the VDHA to the Virginia Association of Free and Charitable Clinics. She is an advocate for public health and passionate about building community health awareness. She and her husband are avid runners and enjoy traveling to different races.