It would be safe to say, that to become truly remarkable at anything in this life takes a significant amount of effort. It takes routine, commitment, drive, and passion. The above description sounds to me like the makings of an ideal dental client. Someone who is dedicated enough to achieve athletic greatness, could also be motivated to maintain optimal oral health. If I am correct, then this would mean that an athlete, someone who has achieved greatness through blood, sweat and tears, would be our dream patient. Unfortunately, my assumption is precisely the issue that has led to a demographic in need. Some of our physically healthiest clients need our help, yet their needs have fallen under the radar. Over the next few pages, I hope to bring to your attention the unique opportunity we have to partner with a formidable group of people. To educate them towards optimal oral health, and to prevent against physical trauma and disease.
During the 2018 EuroPerio meeting held in Amsterdam, one of the world’s leading conferences in Periodontology, some new information came out related to our athletes. The question at hand was, why are there higher rates of decay and missing teeth in our athletes when they are so determined to be the best in other areas?
How the team started to gather information on this was actually through studying Olympic athletes. During the Olympics, athletes from across the globe are offered free dental care. It is here that they began to see, treat and collect data on their findings with athletes and oral care. Some in the study were also coaches and former athletes, so they had even more years of training in their sport to experience the impacts on their oral health. Many of these coaches were missing over half their teeth. This was a shocking revelation. Socio-economic factors and access to care did have a large impact on the athletes coming from so many different places around the world, but the overall synopsis revealed an underlying issue within the group.
Let’s take a look at the potential reasons and risk factors associated with various sports and training programs, and then have a discussion around how we, as dental professionals, can create change.
As mentioned previously, athletes tend to be hard working, dedicated and committed. These qualities will serve to assist the dental professional in motivating their client towards positive changes needed for their oral health and protection from disease and injury.
Additionally, physical exercise decreases the risk of suffering inflammatory factors that exacerbate the appearance of diseases such as periodontitis. This is simply because practising sports improves the corporal response to stress and inflammation in a general sense, and therefore, to periodontal disease.
Risk factors for athletes
There are many risks to explore in this group, and we will discuss the following:
- Facial trauma
- Mouth breathing during sport and the association with xerostomia
- High carbohydrate diets and frequent consumption
- Performance pressure
- Socioeconomic factors
- Busy schedules
Many athletes are not aware of the health implications of a traumatic injury to the head, mouth or orofacial structures. As dental professionals, we need to partner with our clients to educate them on the potential for traumatic injury as well as the resources available to help prevent them.
The face is arguably the most vulnerable area of the body during sports, and yet, it is usually the least protected. Approximately 11-40% of all reported sports injuries involve the face.
A study done involving a total of 750 patients with maxillofacial injuries was analyzed to shed light on the types of injuries given the specific sport practiced. From this group, of the reported maxillofacial fractures, 27% were sustained during skiing and snowboarding, 22% during team sports such as soccer or ice hockey, and 21% were from cycling accidents. It was shown that 68% of the cyclists, 50% of the ice hockey players and soccer players, and 48% of the skiers and snowboarders had isolated fractures of the midface. Fractures of the mandible were found primarily in contact sports.
The three causes of the majority of these orofacial injuries come from:
- Impact with another player
- Impact with the ground of floor
- Impact with the sports equipment
The most common and readily available preventive measures we have for tooth trauma include helmets with cages and mouthguards. Fortunately, many countries have made sports mouthguards mandatory for school teams and extracurricular activities. This is largely due to the educational efforts by us as dental professionals across the globe. It should be stressed to our clients that sports mouthguards should be worn when there is a possibility of body-to-body or body-to-equipment contact. Sports mouthguards are the easiest way to help prevent injuries to the teeth, lips, gingiva, tongue, and mucosa. In addition to these benefits, it has been found that sports mouthguards help to cushion possible traumatic forces that could produce jaw fractures, dislocations, and trauma to the temporomandibular joint. According to one study, sports mouthguards have also helped to reduce the likelihood of concussion by maintaining a separation between the head of the mandibular condyle and the base of the skull.
Sports mouthguard considerations:
When educating our clients on the options available for sports mouthguards, the areas we need to focus on should be the fit, function, and cleansability of the appliance.
If a sports mouthguard is ill fitting, the temptation will be to use it as a chew toy. Athletes have been known to carry their guards in their teeth, rather than on their teeth. For this reason, the ideal sports mouthguard is custom fit, in the dental office, by a professional. Good alginate impressions and models are also important here. Once made, they should be inserted and inspected, not simply handed to the client. Look to see if there is any tissue impingement, or excess material. Have the client run their tongue over all surfaces to feel for any sharp areas and understand that even a slight irritation will be enough to tempt the athlete to spit the sports mouthguard out. Recommend that they clean it regularly with non-toxic soap and water, denture cleaner or non-toxic cleaner such as Force of Nature available through Bisco Canada.
We have a responsibility to our clients to educate them on the options available to them. We should be aware of the pros and cons of the options available as well as the financial considerations involved in the decision. Although a custom fit guard is our preference, we need to be compassionate and understanding of their decision after we have offered our knowledge. Here is a brief summary you can use to help the client see and understand the options available.
- Available over the counter
- Made of rubber
- Limited number of sizes
- Cannot be altered to improve fit
- Offer the least amount of protection
- Interfere with breathing and speech
- The least expensive ($3-$35)
Boil and Bite:
- Made of a thermoplastic material called ethylene-vinyl acetate (EVA)
- Formed to the teeth with pressure from the mouth and fingers
- Offers more protection than stock guards
- Tend to be bulky and uncomfortable
- May interfere with breathing and speech
- Difficult to fit around orthodontics and can damage, or cut lips and cheeks if player is hit in the mouth
Custom fit guards:
- Superior fit
- Increased comfort
- Increased protection
- Increased compliance
- More durable
- Won’t interfere with breathing and speaking
- $50 +
Saliva is a much-underrated bodily fluid. Nothing happens to the tooth until it happens to the saliva. Saliva helps to prevent acid erosion and has a buffering capability. During athletic performance and training, this underrated fluid is in short supply largely due to reduction of nasal breathing and increase and reliance on mouth breathing. There are three significant ways we can help.
Hydration – Appropriate hydration should be encouraged. Water would be the ideal choice, although some may not be willing to part with their highly acidic sports drinks. If we cannot change our clients, we should focus on changing their tools. This leads me to my next two suggestions.
Stabilized Stannous Fluoride – Consider suggesting a toothpaste that contains stabilized stannous fluoride such as Crest Gum Detoxify. It is important to note that not all fluoride is created equal. This type of fluoride will offer a level of protection that is superior. Unlike the stannous fluoride of the past, stabilized stannous fluoride will not cause stain. Stabilized stannous fluoride will offer our patients caries prevention and antimicrobial activity. It is considered to be anti caries, anti-plaque, and anti-gingivitis because it is both bacteriostatic and bactericidal. This means it not only kills bacteria, but it also inhibits growth. It is important that the toothpaste used is capable of both. Essentially, it inhibits both protein and carbohydrate metabolism of various bacteria by impeding sugar transport and utilization of sugar. In this way, it is not only preventing the transport through the cell wall but also inhibiting its use. This ability slows replication leading to plaque growth and reduces the metabolization of sugar leading to disease and decay.
Xylitol – One of the amazing functions of saliva is its role in protecting the mouth and teeth. Stimulated saliva in particular contains all the components needed to repair early areas of decay. Research has shown that the use of xylitol helps repair damage to the enamel; however, in addition, these same studies have revealed that the dental benefits of xylitol also include benefits to the saliva quality itself. Saliva that contains xylitol becomes more alkaline in nature than saliva stimulated by other sugar products. After consuming a xylitol containing product, the concentration of basic amino acids and ammonia in both the saliva and plaque may rise. In response, the plaque pH rises as well. When pH is above 7, calcium and phosphate salts in saliva start to move into weakened portions of the enamel structure. Subsequently, soft, calcium-deficient enamel sites begin to harden again. Xylitol cannot be metabolized by oral bacteria, which results in an absence of lactic acid and polysaccharides production. Over time, with regular use of xylitol, less plaque forms and the level of acids attacking the tooth surface is lowered.
High carbohydrate or frequent carbohydrate consumption
Athletes expend a great deal of energy. Many of them need to eat frequently throughout the day to stay replenished. As we know, we would rather our clients sit and eat an entire cake in one sitting than to take small bites throughout the day. Perhaps not the best advice for weight management but would actually be a better scenario for preventing tooth decay. If sugar is only taken a couple of times a day, the saliva can do the job alone. Unfortunately, most people, and athletes in particular, consume simple sugars so often that the mouth’s own defensive tools are not enough.
As dental health professionals, we need to partner with our clients and take their goals and values into consideration. For the vast majority, they want to do what is necessary to compete and function at a high, almost superhuman level. For this reason, they may need frequent small meals throughout the day, or even sports specific energy supplements that can help fuel them through their athletic requirement. Many runners, for instance, use sugary gels during a marathon to maintain energy and electrolytes. This may provide the energy required, but given the xerostomic state, these simple carbohydrates put them in a high-risk category on the CAMBRA charts.
We need to be prepared to meet them where they are at, and value their goals and agendas rather than our own. Lecturing on carbohydrate consumption and the need to stop may be met with resistance. The use of stannous fluoride, xylitol supplements and power toothbrushes will help reduce their risk of decay and inflammation while they are training and performing.
Athletics are a great way to build self-esteem, promote physical conditioning, and demonstrate the value of teamwork, but not all athletic stressors are positive. The pressure to win and an emphasis on body weight and shape can create a toxic combination. Athletic competition can also be a factor contributing to severe psychological and physical stress. When the pressures of athletic competition are added to an existing cultural emphasis on thinness, the risks increase for athletes to develop disordered eating.
In a study of Division 1 National Collegiate Athletic Association (NCAA) athletes, it was revealed that over one-third of female athletes reported attitudes and symptoms placing them at risk for anorexia nervosa. Though there is a higher percentage of females with eating disorders, male athletes are also at risk—especially those competing in sports that tend to place an emphasis on the athlete’s diet, appearance, size, and weight requirements. Some examples could include sports such as wrestling, bodybuilding, crew, and running. For both genders, sports that are considered more aesthetic sports such as dance, figure skating and gymnastics also have higher incidences of disordered eating.
Current statistics related to eating disorders in sports suggest that athletes are also at a higher risk than the rest of the population to suffer the harsh consequences of eating disorders. This is largely due to the fact that they already exercise heavily, so their bodies are depleted sooner.
The suggestions for these clients are similar to those listed above. Lecturing clients of the effects of their eating habits, binging and or purging habits and dehydration may not be the motivating factors we are aspiring for. Be a safe place. Offer education over judgement every time. Power brushes will help to reduce the bacterial load, stannous fluoride will help create protection from the effects of possible binging and/or purging, and xylitol will create a more alkaline environment. This last recommendation is especially appropriate following an episode of purging where the pH of the oral cavity plummets.
This is not always an issue. In fact, in North America there are wealthy athletes who are able to be competitive because they have had the resources to afford multiple dance classes a week, Rep hockey, expensive equipment, personal trainers, travel, etc. But what about the others? The parents who work overtime to afford new hockey equipment for their growing child with potential, for example. The Mom or Dad who had to go down to part time to accommodate their busy lifestyle. The food bills to feed active children, or teenagers who have rigid diets or are just hungry all the time from the activity. This issue is not an easy one and is a whole topic in and of itself. Our takeaway should be to never assume. Also, we should never assume we know what they are willing to do as far as prevention and treatment are concerned in spite of their financial situations. Sensitivity and compassion are our best line of defense here. For this reason, prevention and home care need to be a strong focus. Given the higher risk category for decay, a three-month hygiene interval may be indicated. Power brushes, high quality toothpaste containing stabilized stannous fluoride, and the best options for protection such as custom fit sports mouthguards should be presented as options regardless of socio-economic standing. Present your educated treatment plans and allow the client and/or caregiver to make an informed decision.
Have you ever tried to schedule a coffee date with a hockey parent, or dance parent?
It is safe to say that the life of working parents today in general are extremely demanding. Combine a busy training schedule with both parents working full time, or a single parent or caregiver working full time, dinner to make, a house to clean, dog to walk, laundry to do, yard work to complete, the Jones’ next door to compete with. Life is challenging! Additionally, for the athletes themselves, keeping physically fit and maintaining a competitive training schedule while keeping up with their studies, social lives, and their part-time or full-time jobs, can seem impossible.
We need to support each other wherever we can. Advocating for our clients and partnering with them towards achieving their oral health goals may be our best line of defense. I have already presented the idea that I believe many athletes should be on a 3-month interval. This is not always possible. This is even more reason why they need the right tools in their hands as we discussed earlier. Work with them. Ask them what their ideal time might be. Ask if it would be helpful to have all family members on the same day, or different days, so they can focus on one child at a time. Ask the athlete or caregiver what their travel schedule looks like for the year and how you can help to schedule dental hygiene visits around it. When your client feels like you are their partner they will be more willing to schedule the time needed and commit to it. You become a safe place.
In conclusion, orofacial injuries that occur during sports activities are largely preventable. Our extensive knowledge on the options available for protection for athletes is one of dentistry’s contributions to sports medicine. Additionally, the higher rates of decay and erosion are also preventable through sharing our understanding and insight on the ways we can protect from and reduce exposure to the contributing factors at play. With the help and partnership of the dental team, our athletes can continue to thrive on their journey to greatness and accomplishment with the assurance that we are behind them and supporting their goals. Sports and athleticism are simply one of the many areas where we as dental professionals have the opportunity to have an impact and be agents of change.
- Sporting Mouthguards Preventing Sports-Induced Orofacial Injuries BY CLAIRE ALT. https://www.academyforsportsdentistry.org/assets/docs/aug14_sportingmouthguards.pdf
- Dental Hygiene Facts: Xylitol and Oral Care, ODHA. https://odha.on.ca/wpcontent/uploads/2016/08/ODHA-Facts-xylitol.pdf
- Dental Complications of Eating Disorders, National Eating Disorder Association. https://www.nationaleatingdisorders.org/dental-complications-eating-disorders
- Re-examining the Plaque-Gingivitis Connection and the Role of Stannous Fluoride, Sherri M Lukes, RDH, MS, FAADH. https://www.dentalcare.ca/en-ca/professional-education/ce-courses/ce579
- Sport, Periodontal Consequences and Athletic Patients, Siobhan C. Budd Jean Christophe Egea. https://link.springer.com/chapter/10.1007/978-3-319-53423-7_12
About the Author
Beth Parkes is an engaging presenter who has been a Registered Dental Hygienist for 16 years. Beth has practised clinical dental hygiene in both Ontario and British Columbia. She graduated with honours in 2005 and has since worked in general practice, independent dental hygiene practice, mobile dental hygiene, orthodontics and periodontics. She is the VP of rdhu in Burlington, Ont. Her vision is to help create leaders in the dental hygiene profession.