Subject: Caries And Dental Erosion In Athletes
The development of caries and dental erosion is in many respects
related to lifestyle factors. Many athletes can be considered
to be
at high risk for both these type of lesions. In order to gain
sufficient amounts of energy and liquid, an increased intake
of foods
with a high calorie value, particularly those containing sugars,
are
often consumed by athletes. In addition, sports drinks are
used for
rehydration and electrolytic replacement during or directly
after
highly aerobic sports.
Caries is related to the intake of fermentable carbohydrates.
These
can be broken down by oral microorganisms to different organic
acids,
which results in a pronounced pH fall below the critical pH
for
enamel (pH 5.5) and dentine (pH 6.2). Dental erosion on the
other
hand is defined as a loss of dental hard tissue by a chemical
process
without involvement of bacteria. It is the net result of an
exposure
to an acidic source. This may be extrinsic, such as the intake
of
acidic food and drinks, or related to intrinsic factors, for
example
regurgitation and reflux disorders. While dental caries prevalence
has decreased during recent decades worldwide, the prevalence
of
erosion is increasing.
A deterioration in oral health of athletes has been suggested
1, 2,
which is believed to be related to a high intake frequency
of both
sugar and acid-containing products. In addition to a high intake
frequency, products are often consumed during or directly after
intense exercise, resulting in breathing hard through the mouth
and
reduced salivary secretion rate. pH on the tooth surface may
reach
even lower levels and the duration of a low pH is prolonged
during
such dry mouth conditions. The risk for dental erosion is believed
to
be particularly high as acidic drinks are most often consumed
during
this physical condition. The site specificity of dental erosion
in
relation to type of exposure is still under debate, but during
extreme conditions all surfaces will be affected, as well as
enamel
and dentine. The method of drinking will influence the impact
of a
drink on the dentition. Prolonged consumption increases the
risk.
Risk Evaluation
Many athletes can be expected to have an increased risk of
developing
dental caries and dental erosion, but this risk in not evenly
distributed within this population. This means that some athletes
can
have a high and some a low or even no risk. For the dentist
it is
therefore important to carry out an individual risk evaluation.
The clinical examination of the buccal, lingual and occlusal
surfaces
is very important in order to find early signs of both dental
caries
and dental erosion. Bitewing radiographs should also be taken.
With
regard to dietary habits, the interview should focus on the
frequency
of consumption of relevant products. In this context, the dentist
should ask the athlete about eating and drinking habits both
when
exercising and when not exercising, i.e. the rest of the day.
The
patient's oral hygiene habits should be discussed in detail.
One way
to better get information about the athlete's brushing habits,
rather
than just interviewing, is to ask him or her to brush with
toothpaste
in the clinic and to observe the `toothpaste technique'. Thus,
the
amount of toothpaste, the spreading of the paste in the dentition
and
the post-brushing water rinsing should be registered and if
necessary
improved.
As a supplement to clinical examination and interview, a saliva
and
microbiological test is of great value for risk evaluation.
A low
saliva secretion rate and a low salivary buffer capacity implies
a
high risk of developing both dental caries and dental erosion.
In
addition, high counts of mutans streptococci and lactobacilli
are
often associated with high caries risk.
Prevention of Caries and Dental Erosion
The prevention programme for an athlete should include the
following
three parts:
1. Dietary advice including appropriate use of sugar-free products.
2. Fluoride treatment both at home and at the clinic.
3. Oral hygiene instruction - in some cases professional
toothcleaning.
Dietary advice
The athlete should avoid unnecessarily frequent intake of products
such as snacks and sport drinks and not to keep the products
too long
in the mouth. A long retention time will increase the risk
both for
dental caries and dental erosion. The possibility of using
sugar-free
chewing gums and sugar-free lozenges after eating or drinking
occasions should be discussed. These products stimulate saliva,
shorten the oral clearance time of sugar and acids in the mouth
and
increase the pH on the tooth surfaces. In relation to erosion,
the
use of chewing gum should not be exaggerated because of risk
for
abrasion.
Fluoride treatment
Independent of the caries and erosion risk, all athletes should
be
informed to increase their daily use of fluoride. Thus, toothbrushing
twice a day with fluoride toothpaste and with an improved `toothpaste
technique' should be stressed. Daily mouthrinsing with 0.05
percent
NaF can also be recommended to all athletes. For high risk
patients,
the dentist may encourage the athlete to brush the teeth with
fluoride toothpaste at one extra occasion during the day and
to
increase the daily rinsing with 0.05 percent NaF to two to
three
times per day. Fluoride chewing gums and fluoride tablets are
available in some countries. These products can be used several
times
per day, both after and between the meals. For very high risk
patients (regarding both dental caries and dental erosion),
fluoride
gel application will give the teeth extra protection. The dentist
may
also apply fluoride varnish two to four times per year.
Oral hygiene
In order to improve oral hygiene, an electric toothbrush can
be
recommended to some athletes. It is important, however, that
the
brushing is combined with fluoride toothpaste. The toothbrushing
should be carried out after breakfast and just before bedtime
with no
eating or drinking up to one to two hours afterwards. In order
to
avoid tooth abrasion, brushing should not be carried out directly
after using an acid product, like a sport drink. If the oral
hygiene
is poor, professional tooth cleaning using a rubber cup, a
mild
polishing fluoride-containing paste and dental floss is carried
out
two to four times per year followed by fluoride varnish application.
References
1 Ljungberg G, Birkhed D. Dental caries in players belonging
to a
Swedish soccer team. Swedish Dental Journal 1990;14:261-266.
2 Milosevic A, Kelly MJ, McLean AN. Sport supplement drinks
and
dental health in competitive swimmers and cyclists. British
Dental
Journal 1997;182:303-308.
This article first appeared in Dental Digest, volume 5, issue
2
