The Importance of Oral Health in High Performance Athletes: A Brief Review

Abstract

The purpose of this review is to present the reality of oral health among high performance athletes. All data collected and pertinent information to construct this review was retrieved from the indexed scientific literature. The results observed enhanced that the oral health among high elite athletes has been neglected. There is a necessity to apply the previous knowledge about preventive oral medicine and its benefits to improve the performance of this population in prospective studies with long term follow-up.

Full text

Remedy Publications LLC.
Journal of Dentistry and Oral Biology
2017 | Volume 2 | Issue 4 | Article 1037
1
Introduction
Some studies [1-3] have consistently reported poor oral health in elite athletes since the rst
report from Berlin Olympic Games in 1936. e ndings is consistent both across selected samples
attending dental clinics at major competitions and more representative sampling of teams and has
led to calls from the International Olympic Committee for more accurate data on oral health. Poor
oral health is an important issue directly as it can cause pain, negative eects on appearance and
strong eects on condence and quality of life and may have long-term consequences for treatment
burden. Self-reported evidence also suggests an impact on training and performance of athletes
[2,4]. ere are many potential challenges to the oral health of athletes including nutritional, oral
dehydration, exercise-induced immune suppression, lack of awareness, negative health behaviors
and lack of prioritization [2]. e aim of this review is to show what has been happening in high
performance athletes’ oral health. All data collected and pertinent information was retrieved from
the scientic papers in relevant indexed journals.
What have we already known about the Interaction between
Systemic Disease and Oral Health?
e 8th World Congress on Preventive Dentistry emphasized that oral health is an integral
part of general health and wellbeing and a basic human right. e participants and Associations
support the eorts of the World Health Organization (WHO) Oral Health Programme which
aims at coordinating and supporting inter-country sharing of experiences in health promotion
and oral disease prevention. e good news is that oral diseases are preventable, easy to treat at
the beginning and considerable improvements can be made if appropriate public health programs
are established [5]. Periodontitis or periodontal disease (PD) is characterized by alveolar bone
and clinical attachment loss, gingival inammation and increased tooth mobility. Most forms of
PDs are chronic inammation however, there are acute forms and both of them are related with
specic bacterial infection accumulated around teeth [6]. Approximately 90% of the world’s
population experiences mild to advanced PD and increased inammatory markers had been found
among patients. Activation of systemic inammatory processes can be linked to increase the risk
of cardiovascular disease, diabetes mellitus, pulmonary disease, rheumatoid arthritis, cerebral
vascular disease, adverse pregnancy outcomesand cancer [7,8]. It has been suggested that active
PD can disseminate bacterial species via bloodstream and, in this way, impact on systemic health
inuencing the host response factors [7,9]. e treatment of PD should be simple and cheap as
cleaning the teeth above and below the gingival line, termed “scaling and root planning”, which
is sometimes, can be improved by use of mouth rinse, patient education, training in oral hygiene,
and counseling on control of risk factors. In more advanced cases, periodontal surgery may also
be required. Such procedures aim to reduce gingival inammation, thereby reducing bacterial bio
The Importance of Oral Health in High Performance
Athletes: A Brief Review
OPEN ACCESS
*Correspondence:
Paulo SG Henriques, Department of
Periodontics, Faculty of Dentistry São
Leopoldo Mandic, Rua Dr. José B. C.
Nogueira, 214, sala 125, Jd. Madalena,
Cep 13091-611, Campinas, São Paulo,
Brazil, Tel: +55-19-32550288; Fax: +55-
19-32944815;
E-mail: phenriques@mpc.com.br
Received Date: 09 Jan 2017
Accepted Date: 06 Feb 2017
Published Date: 09 Feb 2017
Citation:
Henriques PSG, Sukekava F. The
Importance of Oral Health in High
Performance Athletes: A Brief Review. J
Dent Oral Biol. 2017; 2(4): 1037.
Copyright © 2017 Henriques PSG.
This is an open access article
distributed under the Creative
Commons Attribution License, which
permits unrestricted use, distribution,
and reproduction in any medium,
provided the original work is properly
cited.
Review Article
Published: 09 Feb, 2017
Abstract
e purpose of this review is to present the reality of oral health among high performance athletes.
All data collected and pertinent information to construct this review was retrieved from the indexed
scientic literature. e results observed enhanced that the oral health among high elite athletes has
been neglected. ere is a necessity to apply the previous knowledge about preventive oral medicine
and its benets to improve the performance of this population in prospective studies with long term
follow-up.
Keywords: Oral health; Periodontal disease; Elite athletes; Olympic games
Paulo SG Henriques1* and Flávia Sukekava2
1Department of Periodontics, Faculty of Dentistry São Leopoldo Mandic, Brazil
2Division of Periodontics, School of Dentistry University of São Paulo, Brazil

Paulo SG Henriques, et al., Journal of Dentistry and Oral Biology
Remedy Publications LLC. 2017 | Volume 2 | Issue 4 | Article 1037
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lms on the tooth and root surface, ultimately leading to a reduction
of both bacterial populations and transmission of bacteria and toxins
through the gingival tissue [7,10]. Tooth decay/dental caries is a tooth
disease exhibiting clinical features like cavities and darkened teeth.
e active lesion is initiated by bacterial plaque accumulation around
teeth, as the same way PD. So, both diseases are, essentially, caused
by a lack of oral hygiene. Streptococcus mutans, a major pathogen of
dental caries, is also considered to be one of the causative agents of
infective endocarditis (IE), which is an infection of either the heart’s
inner lining (endocardium) or the heart valves can be serious or even
sometimes fatal illness [10,11]. e treatment of tooth decay can be
simple and cheap as treatment to PD, including patient education,
training in oral hygiene, counseling on control of risk factors and
lling and more advanced cases, endodontic treatment or even tooth
loss.
What are the Real Benets from Oral Care to
the High Performance Athletes?
e mechanisms behind negatively aects from oral diseases
over the training and performance of elite athletes might include
distress, pain, reduced well-being and quality of life and increased
systemic inammation [1-3] published a systematic review about the
epidemiology of oral disease and trauma in the high performance
athlete’s population and the impact of their oral health on sporting
results. e data depicted that: i) despite the excellent systemic health,
the oral health is poor among various sports; ii) dental caries, erosion
and PD are the most frequent oral disease and nally; iii) poor oral
health can impact directly on the elite athlete’s performance. e
search strategy found data since 1950 and showed the negligence
around oral health. Even though the most part of athletes in included
papers were from developed countries with a well-organized oral
health system. e British Cycling Federation (BCF) has established a
preventive medical program screening for its athletes during the “o
season” period to avoid physical injuries and decreasing performance
during the competitive months since 1990. In 1996 they published
the results and it was demonstrated again, among high performance
athletes the oral health is neglected: 21% of all cyclists examined
needed some sort of dental treatment [12]. Poor oral health can cause
pain and distress episodes, aesthetical negative aspects, psychological
eects, and diculties in eating and sleeping and muscles/tendons
reinjures. All these situations can present short-term consequences,
for example decreasing the athletes’ performance in the day of the
nal competition, as well as long-term eects [1-3,12-14].
Eating Habits and Oral Disease
Unhealthy eating habits, which can induce overweight, may
be involved in the development of this PD in young people [15]
conducted a cross-sectional study of 801 university students that
aims to examine the relationships among overweight, eating habits,
and the periodontal condition in university students. Patients were
classied as underweight, normal weight, and overweight. Students
completed a questionnaire including items related to eating habits
and underwent oral health examinations. Patients with a community
periodontal index (CPI) of 0 to 2 were considered no-disease and
patients with a CPI >2 were considered to have PD. e prevalence
of underweight, normal weight, and overweight patients was 21%,
62%, and 17%, respectively. In overweight patients, the PD risk
was increased by the frequent consumption of fatty and reduced
by the frequent consumption of vegetables. In underweight and
normal-weight groups, eating habits did not dier signicantly
according to the presence of PD.In overweight students, the frequent
consumption of fatty foods and infrequent consumption of vegetables
were associated with an increased risk of PD. Obesity and exercise
are important elements associated with lifestyle-relateddiseases, and
studies suggested that these factors may also be related to PD. A study
investigates the relationship between obesity and physicaltnessand
PD in 1160 Japanese subjects.Periodontalconditions were evaluated
using the CPI and subjects with > or =3 sextants of CPI code 3 or 4
were dened as having severe PD. e authors used the body mass
index (BMI) and percentage of body fat as indicators of obesity and
estimated the maximal oxygen consumption during exercise as an
indicator of physical tness. e examination evaluated the single
eect and interactions of the obesity index and maximal oxygen
consumption on severe PD. e lowest quintile in BMI and the
highest quintile in maximal oxygen consumption were inversely
associated with severe PD. Subjects with the combined lowest quintile
in BMI and the highest quintile in maximal oxygen consumption had
a signicantly lower risk of severe PD compared to subjects with other
combined quintiles in BMI and in maximal oxygen consumption.
ese results suggest that obesity and physicaltnessmay have some
interactive eect on periodontal health status [16]. Rich diets in
vegetables and vitamin C also appear to associate positively with better
periodontal health and negatively with PD progressing more rapidly
in undernourished populations [17]. In recent years, strong evidence
has emerged that diets rich in rened carbohydrates and saturated
fats are pro-inammatory, whereas those rich in polyunsaturated fats
(sh oils), antioxidant micronutrients (fruits, berries and vegetables)
and certain nuts (cashews) are anti-inammatory, like a “stone-age”
diet [18,19].
What Are the Complications from Elite
Athlete’s Preparation on Oral Health?
Elite athletes follow demanding training regimes to achieve
optimal performance in taking dietary supplementation, sports
drinks, multivitamin and mineral preparations, carbohydrate sports
bars, protein powder, and meal-replacement. e important role of a
disease-free oral cavity for peak performance is oen overlooked and
oral health may be compromised [12,13,20] tried to answer which are
the risk factors for tooth decay/erosion among elite triathletes, using
questionnaires regarding training, diet and oral health, and clinical
examination performed in 10 athletes randomly selected. Sports
drinks were consumed by 83.9% of the triathletes while training; for
48.4% consumption of both sports drinks and water. Eating during
training sessions was reported by 93.5% of participants; of those 62.1%
ate only during cycling training. Only 3.2% perceived training as high
risk to oral health. All clinical examination cases were assessed as high
risk for developing caries. e elite triathletes’ diet is consistent with
a high risk prole for tooth decay and erosion as well observed [20].
Piccininni & Fasel observed that sports beverages can be harmful for
athletes’ dentition causing tooth erosion/dental caries and this event
can be preventable if the athletes and their sta were properly educated
to change habits and minimize the eects. ere are some evidences
that elite athlete is more susceptible to eating disorders than the
average member of society. e need to particularly reduce weight in
some specic sports can lead to eating disorders being prevalent [21].
Nutrients, such as vitamin E, vitamin C, carotenoids, polyphenols,
glutathione and trace elements, can contribute directly and indirectly
to the robustness of antioxidant defenses of the host. Oxidative stress
is involved in the pathogenesis of a number of diseases, including PD.
An adequate intake of antioxidants may be important for preventing

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oxidative stress syndrome [22]. Protection of the athletes' health is
a clearly objective of the International Olympic Committee, during
preparation period as well during competitions. Longitudinal
surveillance of injuries and illnesses can provide valuable data that
may identify high-risk sports and disciplines. During the XXIX
Summer and XXI Winter Games, comprehensive injury and illness
recording through the medical sta of the participating National
Olympic Committees and the sports medicine clinics revealed that
between 7% and 11% of all athletes incurred an injury or suered from
at least one occurrence of illness during the Games. e incidence
of injuries and illnesses varied substantially between sports [23].
Callaghan MJ had an important example of preventive action. ey
followed-up for 6 years the bikers from BCF and observed that more
than 20% needed dental care and neglected the most basic treatment.
So, the BCF provided all the treatment necessary previous the
competitive season and consequently to obtain the better results from
these athletes. e London 2012 Summer Olympic Games involved
10568 elite athletes from 204 dierent countries. To manage and
control the varied healthcare needs of this diverse population, a huge
Polyclinic was constructed in the athletes' village and all treatments
were entered into a database to cover the rst to last full day of
competition. ere were a total of 3220 encounters, and 2105 medical
consultations; musculoskeletal comprised the greatest number (52%),
followed by dental (30%) and ophthalmic (9%). Overall, oral health
was consistently poor across these studies, especially considering
the young age of the participants. Dental caries, periodontal disease,
dental erosion and pericoronitis/impacted third molars were widely
reported. e range of proportion of athletes aected by these
conditions was: dental caries 15–75%, moderate-to-severe PD up to
15%, dental erosion 36–85% and pericoronitis/impacted third molars
5–39%. Dental trauma was reported by 14–57% of athletes in at-risk
sports. Africa provided the largest proportion of athletes attending
the Polyclinic (44%) and Europe the least (9%). Peak usage of all
facilities was seen around days 9 and 10 of competition, reecting the
busiest time of the competition and the largest number of athletes in
the village [24]. In the same population, Needleman observed more
accurately 55% of calls presented dental caries, 45% dental erosion
and PD (gingivitis 76%, periodontitis 15%). Almost half of athletes
were concerned with their oral health and his impact on quality of
life and on training and performance. e maintenance treatment as
examination or hygiene care was performed only nearly half of the
participants during the previous year.
What can we do now?
As mentioned [3,13,23,24], using a similar structure of facilities
and available expertise from previous Olympic Games, future research
of risk factor; injury mechanism; oral health and periodic health
evaluations of athletes should be perform and injury-prevention; oral
health strategies should be built to optimize health protection.
All studies above could be a reference to the future Olympics and
mainly to high performance athletes involved in these competitions
and their sta implicated. e Olympic Committee from each
country registered for Tokyo 2020 can, at least six month before the
next games, to perform in their athlete’s complete examination in
systemic health interrelationships, the necessity to produce a custom
made mouth guard, intraoral examination to detect tooth decay,
periodontal diseases, endodontic lesions, and periocoronitis and
to manage specic treatment needs, when appropriate. In this way,
control of risk factors, patient education in health promotion and
training in oral hygiene under supervision can reverberate in athletes’
best performance.
Conclusion
Oral health is an integral part of general health. Self-reported
evidence suggests that poor oral health have an impact on training
and performance of athletes. e important role of a disease-free
oral cavity for peak performance is oen overlooked and oral health
may be compromised. e protection of the athletes' health is a
clearly articulated objective of the International Olympic Committee
and consensus statement aims to raise awareness of the issues of
oral health in elite sport and recommends strategies for prevention
and health promotion in addition to future research strategies that
can reverberate in athletes’ best performance. ere is a lack of
information from prospective studies about the benets of preventive
and also outpatient oral health care on elite athlete’s performance.
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