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Oral health related behaviours reported by elite and professional athletes
In elite sport, protection of an athlete’s health is a priority, however research indicates a substantial
prevalence of oral disease in elite and professional athletes. The challenges to oral health from
participation in sport require investigation to identify effective strategies and mitigate risk.
To explore athlete-reported oral health behaviours, risks and potential for behaviour change in a
representative sample of elite athletes based in the UK.
This was a cross sectional study. We provided oral health screening for 352 elite and professional
athletes from June 2015-September 2016; 344 athletes also completed a questionnaire.
Median age was 25 years (range 18 - 39) and 236 (67%) were male. 323 (94.2%) said they brush twice
daily. 136 (40%) said their most recent dental attendance was within the previous 6 months. 97 (28%)
would be assessed as high consumers of sugar in their regular diet. Use of sports nutrition products
was common; 288 (80%) reported using sports drinks during training or competition but were positive
about behaviour changes.
Despite reporting positive oral health related behaviours, athletes have substantial amounts of oral
disease. Athletes are willing to consider behaviour change related to daily plaque removal, increased
fluoride availability and regular dental visits to improve oral health.
Oral diseases and athlete-reported negative performance impacts are common in elite and
Advises dentists that elite athletes are willing to adopt oral health related behaviours to
mitigate the risks to oral health associated with sport
Dentists should be aware of the need for enhanced prevention for sports people
In elite sport, protection of an athlete’s health is a priority, however dental caries, periodontal diseases
and erosive tooth wear (ETW) remain prevalent. 1-4 Furthermore, athletes with poor oral health report
negative impacts on wellbeing, quality of life, training and performance.1-4 Severe events such as acute
dental infections or oro-facial trauma, leading to time lost from training and even competition, occur
infrequently. However chronic impacts which may not lead to time loss, but rather a reduction in
quality of training, are commonly reported, and at elite level may have important consequences. 4,5
Likely challenges to oral health in sport include increased risk of dental caries due to increased and/or
inappropriate consumption of dietary carbohydrates within usual diet or sports nutrition products
such as sports drinks, and energy bars or gels. 6,7 These products are marketed with no accompanying
guidance related to oral health. Sports drinks tend to be acidic, therefore may also contribute to ETW.8
Lack of awareness or prioritisation may also be a factor in elite sport.9 The risks of oral disease may
be further increased due to alterations in saliva composition during exercise10 and immune
suppression following intense effort.11 Effective oral health promotion strategies may minimise
performance impacts from poor oral health.4 Although there is good evidence for oral health
promotion and prevention outside of sport ,12 the challenges to oral health from sport and those
related to implementation in this environment, confer unique characteristics that require
investigation to identify effective strategies and mitigate risk.13
The aim of this study was to explore athlete-reported oral health behaviours, risks to oral health and
potential for behaviour change in a representative sample of elite athletes.
This was a cross-sectional study, conducted at UK elite athlete training centres between June 2015
and August 2016. We provided oral health screening for 256 athletes on podium potential/ placement
programmes for the 2016 Rio Olympic Games and 96 professional athletes (352 in total) across 11
sports which we categorised as “endurance”, “strength and power”(events lasting less than two
minutes) or “mixed” (e.g. team sports). The methods and results are reported in a previous paper.4
The athlete-reported data presented in this paper were collected with a self-administered
questionnaire, completed at the screening appointment.
Member of elite (Olympic or professional) training/development squad
Aged 18 years or over
Able to understand the consent process with the aid of a translator if required
Able to understand and complete the questionnaire with the aid of a translator if required
Ethical approval was received from University College London research ethics committee (Project ID
6388/001). Informed written consent was obtained. Participation in the study was entirely voluntary
and with no obligation.
Athlete-reported oral health behaviours, risks to oral health and potential for behaviour change
The questionnaire was developed with input from our advisory group which included academics,
athletes, and dentists with an interest in sport. Items to explore self-reported oral health related
behaviours were based on those used in the Adult Dental Health (ADH) Survey 2009.14 They included:
frequency of tooth brushing, use of additional oral hygiene methods, most recent dental attendance,
type of service used, most important factor when making a dental appointment and previous dental
advice received. Use of additional oral hygiene aids included electric toothbrush (ETB),fluoride
mouthwash, interdental cleaning and sugar free chewing gum (SFG). Risks to oral health included
tobacco use and consumption of sugar in usual diet. The Scientific Advisory Committee on Nutrition
(SACN) advises that the maximum free sugar consumption for the UK diet should be 5%.15 Using the
method described in ADH 2009, athletes who indicated that they consumed a serving of cakes, or
sweets, or soft drinks six or more times a week were categorised as high sugar consumers.14 We also
explored knowledge of risks to oral health of sports nutrition products (SNPs). We also asked about
athletes’ use of SNPs before, during and after training and competition. Finally, we asked which
behaviours athletes would consider adopting if it would improve their oral health. The research
advisory group reviewed the questionnaire which was piloted before use.
We used a standard statistical package (IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY).
For data analysis. Counts and percentages summarised the categorical data. This report was guided
by the STROBE statement of observational studies16.
Median age was 25 years (range 18 - 39) and 236 (67%) were male. The demographic characteristics
of the group are presented in Online table 1. There were 50 (14.2%) athletes in the strength and power
(S&P) category, 143 (40.6%) in the endurance category and 159 (45.2%) in the mixed category. Table
1 summarises the prevalence of oral disease in each category and sport. Questionnaire data were
available for up to 344 athletes (50 (14.5%) S&P, 140 (40.7%) endurance and 154 (44.8%) mixed). Eight
questionnaires were not returned due to time constraints and some athletes omitted some response
Oral health behaviours (Online Tables 2, 3 and 4)
Overall, 323 (94.2%, 95% CI 91.8-96.7) reported brushing their teeth at least twice daily. Regarding
use of additional methods for oral hygiene, 190 (55.9%, 95% CI 49.9 -60.4) said they used an ETB, 148
(43.7%, (95% CI 37.9-48.3) said they used dental floss or interdental brushes, 139 (40.9%, 95% CI 35.4-
45.6) said they used fluoride mouthwash and 120 (35.1%, 95% CI 30.32-40.3) reported using sugar
free chewing gum (SFG). Three hundred and twelve (90%, 95% CI (87.1 -93.4) athletes reported
drinking water on at least six days or more per week.
Risks to oral health (Online Tables 5, 6 and 7)
One (0.3%) athlete reported current use of smokeless tobacco. We categorised 97 (28.2%, 95% CI
23.7-33.2) of athletes as high consumers of sugar in their regular diet. Regarding the use of sports
nutrition products, 288 85.7% (95% CI 81.5-89.1) of the 336 athletes who provided this information
reported using sports drinks at least sometimes during training/competition, 198 (58.8%, 95% CI 53.4-
63.9) energy bars and 239 (70.3%, 95% CI 65.9 -75.5) energy gels.
Dental service considerations (Online Tables 8, 9, 10 and 11)
We asked how recently athletes had attended a dentist. Fewer than half (136, 39.5%, 95% CI 34.5-
44.8) of the athletes said they had attended for a dental visit within the previous 6 months. Three
quarters (262, 76.2%, 95% CI 71.4-80.4) said they recalled receiving oral hygiene advice from a dental
professional at some time and just over half (206, 59.9%, 95% CI 54.6-64.9) said they recalled receiving
advice about diet. When asked what type of dental service they used for their most recent dental visit
141 (41%, 95% CI 35.9-46.3) said an NHS dentist, 147 (45.6%, 95% CI 40.5-50.9) said a private dentist
and 34 (9.9%, 95% CI 7.13-13.52) said a private dental hygienist. Athletes were asked which single
factor was the most important when arranging a dental appointment. However, twenty indicated
more than one factor. Of the remaining 314, 195 (62.1%, 95% CI 56.6-67.3) said convenience, 85
(27.1%, 95% CI 22.5-32.3) reputation of the dentist and 34 (10.8%, 95% CI 6.9-13.2) cost.
Oral health beliefs and potential for behaviour change
The majority of athletes recognised that smoking and sugary foods and drinks including sports
nutrition products could damage oral health (Table 2). The potential for behaviour change options
and athlete responses are listed in Table 3. With the exception of reducing snacking between meals
most athletes were positive about potential for behaviour change.
This is the first study to investigate self- reported oral health behaviour and challenges to oral health
in representative samples of elite and professional athletes from different sports. In general, athletes
report favourable oral health behaviours including toothbrushing before bed and in the morning but
fewer than half had attended a dentist within the previous six months. Overall, we categorised 28.2%
of athletes as high consumers of sugar in their regular diet, however 58.8% reported using energy bars
and 70.3% energy gels during training and competition and fewer than half (46%) athletes said they
could or probably could reduce snacking between meals. Although 85.7% reported using sports drinks
at least sometimes during training/competition, 80.4% said they could or probably could reduce
sugary drinks including sports drinks between meals. Athletes said that they would consider regular
dental visits, use of additional oral hygiene aids and increasing fluoride availability to improve oral
Strengths and limitations of the data
The strength of this study is the number of participants and completeness of the sample screened in
each sport. Conducting studies in elite sport is difficult due to the competing pressures for time on the
athletes and their support teams. However, self-reported measures can be unreliable and only serve
as a proxy measure for oral hygiene and dietary habits. The questionnaire was completed
independently and anonymously for convenience and to limit responder bias. However, it provided
limited information regarding whether the athletes used sports drinks, energy bars and gels on the
advice of coaches and/or nutritionists, or if they used them in response to marketing/ availability.
Information on the content of the snacks consumed by athletes was also limited. Use of qualitative
methods such as interviews or focus groups would have yielded a much greater depth of information
but would have required a greater time commitment from the athletes which was not possible during
Comparison with other studies
Few studies have investigated oral health behaviours and risks to oral health in this relatively young
adult group.17-19 A cautious comparison may be made with adults of a similar age in the general
population in England, Wales and Northern Ireland. 19 Elite athletes report more favourable oral health
behaviours; 94% compared to 74% say they brush morning and night and 43% compared to 18% say
they use dental floss or interdental brushes. Only one athlete reported currently using smokeless
tobacco (the proportion of smokers in the general population is around 28%) and 28.2% compared to
55% would be classed as high consumers of sugar in their general diet. The findings from this study
support those from one study of Nigerian college athletes17 and another study limited to triathletes18
which concluded by recommending “raising athletes’ awareness of their specific increased risk for
dental caries and erosion and demonstrating how to optimize their oral hygiene and advice”.
Evidence-based interventions to improve oral health
We found differences in prevalence of oral diseases between different sports. However the document
“Delivering better oral health; an evidence-based toolkit” (DBOH) recommends that everyone should
be given the benefit of advice and support to change behaviour regarding their general and dental
health, not just those thought to be ‘at risk’.12 Therefore strategies identified in this paper are
appropriate to all sports
Reducing risks to oral health from lifestyle
Athletes reported high consumption of energy gels and bars during training and competition despite
believing that they can damage oral health. However fewer than half felt they could reduce snacking.
Hydration is an important consideration in sport20 and most athletes reported using sports drinks
however, many felt that they could reduce their intake of sports drinks. The use of beverages and
supplements containing sugars should be discouraged. 7 Many rowers regularly drink sugar free
squash, however this is not associated with increased caries or ETW in this group, therefore could be
a useful alternative to proprietary sports drinks for hydration. For post-event hydration, milk could be
substituted for proprietary sports drinks, and plain water is adequate if combined with electrolyte and
carbohydrate-containing foods such as those normally eaten during the recovery period. 7,21,22 Many
athletes (83.2%) would consider the use of SFG but DBOH does not recommended it as a preventive
adjunct. There is however some evidence that it may have a potential role in caries prevention.23
Athletes reported receiving oral hygiene advice and advice about diet from a dental professional at
some time and dental professionals are well placed to identify potential lifestyle problems such as
eating disorders. 13 Sport nutrition is one of the cornerstones for athlete preparation and therefore
well placed to deliver benefits across performance, general health, oral health and wellbeing. It would
therefore make sense for strategies incorporating oral health to be jointly developed by registered
sport nutritionists, oral health experts and other athlete support team members.7
Improving oral health through oral health screening and coaching
Oral health promotion in sport is most likely to be successful if it is embedded within overall athlete
general health and performance promotion24 but most members of the athlete support team are not
expert in this area and therefore specialist input is needed. Coaches, nutritionists and those who work
with athletes should have robust training to ensure that athletes balance performance with their oral
and general health. Dental recall intervals are based on risk25 and regular attendance for dental checks
does not necessarily predict better oral health. 26 However regular checks are important, not only to
identify oral diseases at an early stage but also as an opportunity to enhance motivation towards a
high standard of oral health. 27 Most athletes said they would attend for regular dental checks if it
would improve their oral health, but convenience is an important consideration. Oral diseases such as
caries, ETW and periodontal diseases do not present with pain in their early stages and athletes may
delay a dental check or even treatment until they perceive that they have a problem. Athletes may
not be brushing effectively as most had evidence of gingival inflammation or risk factors present.
Interdental cleaning using dental floss or other methods is important for optimum oral health.12,28
Although less than half currently do this, most athletes said they would consider cleaning interdentally
if it would improve oral health. However practical instruction is required to improve oral hygiene skills.
Our high recruitment rate of athletes underlines the importance of providing screening and simple
oral health promotion/preventive advice at athletes’ training centres, preferably combined with
education and coaching in practical oral hygiene skills.
Opportunities to mitigate risk through increased fluoride availability
The most important behavioural factor affecting both caries and periodontal health is routinely
performed oral hygiene with fluoride. 29 When normal strength fluoride toothpaste (1000-1450ppm)
is used, fluoride mouthwash used at a different time to brushing can be advised30. Many athletes said
they could use a fluoride mouthwash, at a different time to brushing, therefore this could be an
opportunity to increase fluoride availability but requires a new behaviour. Where caries risk is
increased, higher strength prescription fluoride (2800ppm) is indicated31. Very high strength fluoride
toothpaste (5000ppm) may also have a protective effect against erosion32. Nearly all athletes said they
brushed in accordance with the widely recognised oral health advice of twice daily12, therefore using
prescription strength fluoride toothpaste would increase fluoride availability without requiring change
in current behaviour.
Enhancing oral health related behaviour through behaviour change techniques
To date, there is no evidence show which behaviour change technique (BCT) is best for enhancing
health behaviours related to oral health.33 However, the current dominant approach to understanding
health behaviour is the COM-B model 34 and it has been suggested that interventions based on this
behaviour change theory may be successful.35 Further research including consultation with all
stakeholders including sports nutritionists, sport and exercise medicine practitioners and dental
professionals is needed to ensure quality and relevance within elite athlete care.
Elite and professional athletes report more favourable oral health behaviours but still have similar
levels of oral disease to the general population. Athletes say they would consider simple behaviour
change including reduction in the use of sports drinks, attendance for regular screening and adoption
of additional oral hygiene methods. These findings help inform on the design of interventions to
improve/maintain oral health and reduce performance impacts.
Declaration of interests
This project was jointly funded by a grant from GSK and UCL IMPACT (award number 157871). The
authors declare no conflict of interest. The Centre for Oral Health and Performance is part of the UK
IOC Research Centre for Prevention of Injury and Protection of Athlete Health with the Institute of
Sport Exercise and Health (ISEH) and the National Centre for Sport and Exercise Medicine (NCSEM).
We wish to acknowledge the input from our advisory group, the athletes and support staff from all
the sports who so generously gave of their time to contribute to this research project. Thank you also
to Miss Sarah Needleman and Mrs Karen Wigmore for data entry and to Mrs Karen Wigmore, Mrs
Alison O’Neil and Miss Laura Wigmore for assistance during data collection. We are grateful to
Professor Susan Michie and Professor Robert West of the UCL Centre for Behaviour change for advice
regarding the design of the behaviour change elements of the questionnaire.
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