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

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

Study shows athletes at risk

The high prevalence of untreated oral problems among athletes was first reported at the 1958 FIFA World Cup in Sweden. At the 2012 Summer Olympics in London, dental consultations accounted for 30% of all medical visits.1 Before the 2016 Rio Olympics, an oral health examination of elite Dutch athletes showed that nearly 50% of the athletes needed dental treatment to ensure healthy participation in the Olympics.2,3

You might be right too. What elite athletes can teach us about dry mouth

Research by Azeredo, Guimarães, and Gallagher shows that athletes have poor oral health. Studies show that 46% of athletes suffer from tooth decay.4,5 Gum inflammation is common, occurring in 58%–85% of athletes, and 5%–41% of athletes have periodontitis.4,5 Almost every two athletes are eroded.6,7

Oral health affects more than just the mouth

Athletes may not be aware that periodontal disease is associated with many systemic diseases and conditions. Cardiovascular diseases (such as atherosclerosis, stroke, acute myocardial infarction) and respiratory diseases (such as pneumonia, bronchitis, emphysema) are associated with periodontal disease.8 Therefore, an athlete's oral health can impact their performance and overall health.

Supplements and sports drinks exacerbate the problem

High-intensity training for athletes such as marathoners, triathletes, 30K/50K runners, and swimmers can include daily or twice-daily exercise. Energy replenishment is essential for continued activity, maintenance and improvement of athletic performance.8 To achieve peak performance, athletes consume carbohydrate- and sugar-rich foods, sports/energy drinks, energy bars, gels, and gummies.2 Many mineral salt substitutes are highly acidic in their ingredients.8 Athletes consume energy not only during competition but also during training. There are many different sports drinks and supplements on the market today that can be used before, during and after training. Sports/energy drinks are highly acidic, with a pH of 2.4–4.5 (Figure 1).8

Many sports supplements and sports drinks are also high in sugar.2 In a study of sports drink consumption, Khan found high rates of sports drink use among elite athletes (66.7%). Other studies show the prevalence among college athletes is even higher.2 Frequent acid attacks caused by these supplements increase the risk of dental caries and erosions in athletes (Figure 2).

Dehydration is also a common problem among athletes and can lead to dry mouth. Using supplements and sports drinks instead of water to rehydrate and not having the right amount of protective saliva puts athletes at risk for cavities and erosions. For endurance athletes, the problem may be compounded because strenuous exercise can cause immunosuppression, which changes saliva composition and reduces the protective properties of saliva.1,2 Strenuous physical activity produces high concentrations of carbon dioxide in the blood, which is transferred to the saliva, lowering the pH.9

Chlorinated water a concern for swimmers

Swimmers are not only at risk from sports/energy drink erosion, but also from ongoing exposure to chlorinated water. This is especially true if the pool is not maintained at an optimal pH of 7.4.10 Swimmers can experience tooth sensitivity and notice tooth transparency at the edges of their front teeth. Swimmers who spend more than six hours a week in chlorinated water are at risk of “swimmer's mouth.”11 Swimmer's mouth can cause brown spots and tartar to appear on your teeth. It accumulates where water flows over the teeth while swimming.12

A 2017 study showed that swimmers consume an average of 32 milliliters of water per hour.12,13 High exposure to chlorine affects salivary rate and composition, reducing the flow of salivary and phosphate components. Exposure also increases calcium and fluoride levels.11 These changes in the mouth lead to excessive tartar buildup.12

Educate athletes to avoid long-term adverse effects

A study by Nascimento et al showed that of the 254 athletes surveyed, the majority did not floss or use any interdental cleaners, only 186 had seen a dentist within the past two years, and most were concerned about oral health maintenance. There is a lack of understanding of the relationship with oral health.7 Poor oral health in elite athletes can have both short- and long-term effects. Short-term effects may be aches, pains, and difficulty eating and sleeping.1 Pain caused by tooth decay or periodontal disease can hinder training and exercise, affecting performance. Long-term effects include tooth loss, increased treatment time, and loss of oral function. Oral disease can also affect performance due to inflammation that may occur.1 Inflammation can increase cytokine levels.7 These cytokines play a role in the origin of muscle fatigue and oxidative stress. Muscle fatigue during exercise can lead to muscle spasms and a decrease in energy absorption.7 This makes the muscles more susceptible to injury.

Education is important in preventing oral problems. Athletes should be aware of the high sugar and acid content of many supplements and consider replacing them with water or rinsing with water after consuming supplements to reduce tooth decay rates. Brushing and interproximal cleaning are vital, and some athletes will benefit from more frequent visits to the dentist and hygienist. Fluoridation treatments should be performed in dental offices and at home.

Dental hygienists have a responsibility to coach athletes, who should be able to compete without complications from poor oral health.

Editor’s note: This article appeared in the January/February 2024 print edition RDH Magazine. Dental hygienists in North America are eligible for a free print subscription. Register here.

refer to

  1. Needleman I, Ashley P, Fine P, et al. Oral health and elite sports performance. British Journal of Sports Medicine. 2015;49(1):3-6. doi:10.1136/bjsports-2014-093804
  2. Khan K, Qadir A, Trakman G, et al. Effects of sports and energy drink consumption, oral health problems, and performance in elite athletes. Nutrients. 2022;14(23):5089. Published on November 30, 2022.
  3. Kragt L, Moen MH, Van Den Hoogenband CR, Wolvius EB. Oral health status of elite Dutch athletes before the Rio 2016 Olympic Games. sports medicine. 2019;47(2):182-188. Number: 10.1080/00913847.2018.1546105
  4. Azeredo FN, Guimarães LS, Luis W, Fialho S, Alves Antunes LA, Antunes LS. Estimating the prevalence of dental caries in athletes: an epidemiological systematic review and meta-analysis. indian dental journal. 2020;31(2):297-304. doi:10.4103/ijdr.IJDR_764_18
  5. Gallagher J, Ashley P, Petrie A, Needleman I. Community Dental Oral Epidemics. 2018;46(6):563-568. doi:10.1111/cdoe.12392
  6. Merle CL, Richter L, Challakh N, et al. Orofacial conditions and oral health behaviors in young athletes: A comparison of amateur and competitive sports. Scandinavian Journal of Medical Sciences and Sports. 2022;32(5):903-912. Number: 10.1111/sms.14143
  7. de Queiroz Gonçalves, PHP, Guimarães, LS, de Azeredo, FNA et al. Prevalence of dental erosion in athletes and its association with isotonic beverages: a systematic review and meta-analysis. exercise science health 16, 207–216 (2020).
  8. Nascimento BL, Zen IR, Demenchi LS, Mazzetto NC, Spada PP. Triathletes' understanding of the relationship between oral health and performance. RSBO. 2015: 12(4), 352-355.
  9. Athletes and their oral health. Century Dental. September 20, 2022.
  10. Tanabe-Ikekawa M, Takahashi T, Churei H, Mitsuyama A, Ueno T. journal of oral science. 2018;60(2):269-277. doi:10.2334/josnusd.17-0183
  11. Moore AB, Calleros C, Aboytes D. Dimensions of dental hygiene. 2018;16(8):45-48.
  12. Race R. Swimmers are six times more likely to see stained teeth than other people, study finds. swimming swimming. August 11, 2021.
  13. Straus R. Swim a lot? Your oral health could be worse. Oral Health Group. December 23, 2022.
  14. Dufour AP, Behymer TD, Cantú R, Magnuson M, Wymer LJ. Recreational swimmers ingest swimming pool water. Water Health Magazine. 2017;15(3):429-437. doi:10.2166/wh.2017.255

Shirley Basham, MSDH, RDH degrees from Northern Arizona University and Old Dominion University. Sherry is an active member of the Virginia Dental Hygienists Association and serves as VDHA's liaison to the Virginia Association of Free Charitable Clinics. She is a public health advocate with a passion for increasing community health awareness. She and her husband are avid runners and enjoy competing in different races.

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