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Diet & Associated Pathologies

Lyndon Meehan

Sports dentistry is a rapidly growing area within modern day sport. Over the course of two papers the challenges an athlete’s dentition may face, as a result of competing and training for sport, shall be outlined. These risks will be true for athletes whether competing at school, club, national or international levels.

This paper will consider an athlete’s dietary intake and oral hygiene which may bring associated dental pathologies. An athlete’s dietary requirement will be completely different from normal dietary requirements and may have a deleterious impact on their dentition. Prevention regimes and advice that can be adopted shall also be outlined.

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DENTAL CARE OF THE SPORTSPERSON Many sports teams will have an associated team dentist who may form part of a larger professional sports medicine team and club staff that will be responsible for total athlete care. It is vital that good lines of communication exist within the team. This ensures any dental treatment or dental problems that exist, do not affect performance or cause training to be missed.

We may need to adopt a potentially slightly different approach to dental care when treating the sporting patient. The timing of dental treatment or dental pathologies may also hinder an athlete’s specific sports diet regime or hydration programme as set out by a nutritionist. Post treatment anaesthesia, swelling or trismus as a result of dental abscess /pericoronitis or toothache will also all influence nutrition regimes.

ATHLETES DIET AND HYDRATION NEEDS Russell’s study on professional youth soccer players diet analysis, found their total carbohydrate intake was inadequate, representing around 56%. It was suggested soccer players should ideally maintain a total dietary intake comprising of 60-70% carbohydrate.1

Athletes need to be optimally hydrated for maximum performance. With prolonged and sustained periods of exercise large volumes of fluid are lost. This results in decreased blood glucose levels and depleted muscle glycogen stores, leading to dehydration, a decreased performance and increased fatigue. Usually carbohydrates/electrolyte drinks and energy bars are ingested to maintain blood glucose as high rates of carbohydrate oxidation provide increased endurance capacity.

In certain sports, for example rugby basketball and soccer, due to the changeable nature of the game and exertion, an athlete’s metabolic demands will vary during game time. They will interchange between running, walking and sprinting many times over the course of a game.

Ideally soccer players are advised to consume daily baseline of 2.5 Litres of fluid. Additional consumption of between 0.15-0.25 Litres is recommended every 15 minutes during intermittent exercise, which may last over a period of two hours daily. This could bring the ideal target intake up to approximately 4.5 Litres depending on the amount of exercise daily. Russell found that the total fluid intake of youth soccer players was inadequate being 3.3Litres daily. He concluded that increased consumptions of carbohydrate beverages will be of benefit to youth players to increase their volume of fluid and total carbohydrate intake.1

The best possible nutrition is essential for powering young athletes involved in sport, but also to achieve maximum growth and development. As teeth develop in children, the quality of their development is determined by nutritional demands and their dietary nutritional adequacy will have a role to play.2

EXERCISE EFFECTS ON THE ORAL CAVITY With increased competition, and energy expenditure, dehydration, and a decrease in salivary flow is an issue. Many of the high carbohydrate sports drinks consumed are acidic in nature having a relatively low pH and drop

the intraoral pH value (Fig 1 the Stephan curve shows this relationship). Over a time period frequent ingestion of food and drinks of a lower pH means the oral cavity remains at a lower pH for longer. The crucial destructive pH range for enamel dissolution is between 4.5 - 5.5.3

Salivary clearance rates vary considerably between sites in the mouth. Upper anterior buccal surfaces receive the slowest rate of clearance, whilst lingual surfaces of lower anteriors receive the greatest.3

If rich carbohydrate beverages are consumed regularly over multiple daily training sessions, to maintain adequate nutritional and hydration intake, this is the perfect breeding ground for a multitude of dental pathologies. Considering this, the potential challenge the dental professional faces to maintain a neutral pH to prevent demineralisation and destruction is therefore massive.

ASSOCIATED DENTAL PATHOLOGIES The hours of investment and struggle to achieve a heightened level of fitness and readiness to compete should in no way be compromised by preventable oral health problems occurring before or during competition. Therefore dietary advice and oral health education and prevention will have a vital role to play in athletes.

Many embark upon sport at a very young age having lengthy careers be it professionally, semi professionally or purely for recreation. In the young athlete, multiple games/ events and training sessions can be attended per week. If the appropriate advice and prevention is not outlined in the infancy of a sporting career regarding diet and nutrition to instil good habits, multiple irreversible dental problems may be seen.

There is evidence to suggest that professional sportspersons have high caries rates and are at an increased risk of dental erosion with a greater dental treatment need.4-12 This may be due in part to the relatively high carbohydrate and acidic beverage intake often used for energy and rehydration during training and playing 1,5,13-15

Pathologies manifest as tooth wear mainly through erosion, and also dental caries which can severely compromise the longevity and

S P O RT S D E N T I S T RY “...involves the prevention and treatment of orofacial athletic injuries and related oral diseases, as well as the collection and dissemination of information on dental athletic injuries and the encouragement of research in the prevention of such injuries.”

www.academyforspor tsdent istr y.org

Fig 1 - Relationship between acid levels (pH) at the tooth surface and time following intake of food and drink is shown by the Stephan Curve.

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restorative status of a patient’s dentition in later life.

TOOTHWEAR This is the gradual loss of tooth surface due to repetitive physical contacts or due to chemical dissolution. It can be caused by abrasion, abfraction, attrition and erosion and is usually multifactorial.

Abfraction This is the pathological loss of tooth structure due to biomechanical forces such as flexure, compression, or tension. It can be seen as V-shaped notching cervically in a tooth.

Attrition This is the loss of tooth tissue by means of friction caused by tooth contact or from restorations during biting and chewing. Flattened incisal and occlusal surfaces are classically seen.

Abrasion The loss of tooth tissue by means of friction caused by the contact of teeth with objects other than teeth. The most common cause of dental abrasion is overzealous brushing on exposed dentine with high abrasivity toothpastes.16 Yet the greatest threat is brushing in combination with erosion. Cervical notching and occlusal cupping are seen.

Erosion This is the chemical dissolution of dental hard tissue not involving bacteria. Labial surfaces or maxillary palatal surfaces are shiny and glassy with rounded edges. Incisal edges may appear translucent and incisal and occlusal pitting can be seen. Amalgams may stand proud with the absence of staining on teeth. The source can be intrinsic or extrinsic which shall be outlined further.

Studies have shown erosion amongst adults and children is estimated to occur between 2-18% of the population and is on the increase.14

Common symptoms and clinical findings from toothwear may include the following

Commonly there is a combination of erosion and abrasion or attrition. This is due to the initial softening and morphological change of the tooth’s surface by erosion from an acidic challenge making it in turn more susceptible to wear from abrasion and attrition.

Sensitivity Shortened tooth height

Sharp edges on teeth Decreased Facial height

Soft tissue trauma and ulceration

Altered dietary regime /abrasive elements

Pulpitis Altered ability on masticatory function

Habitual bruxism /nail chewing

Iatrogenic damage from opposing porcelain crowns

Fig 2 – shows occlusal pitting on lower premolars and molars from erosion

Fig 3 - shows shiny palatal surface toothwear of maxillary anterior teeth from erosion

Fig 4 - shows cervical notching and dentine exposure with gingival recession through abrasion

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THE ACIDIC CHALLENGE

Extrinsic Sources

Many fruits will contain several organic acids mainly a combination of citric, malic and oxalic acid. Citric acid is this most destructive with the highest potential for dental erosion. High citric acid contents are found in oranges lemons and grapefruits which is likely to form part of an athlete’s diet.16

Extrinsic sources of acidic challenges will include any athlete’s dietary habits which may include drink swishing and also lifestyle factors and the nature of their sport. Sirimaharaj found that running and ball and field sports had the greatest frequency of consumption of fruit juices, soft drinks and sports drinks between meals due to their high energy expenditure and high carbohydrate need. Those athletes consuming fruit juices more than twice daily were more likely to report erosion than those not consuming fruit juices.14

It is common place also to see dental erosion affecting the labial aspect of maxillary teeth in swimmers who spend lengthy training periods in chlorinated swimming pools.17,18 In a comparative study between swimmers and cyclists, more maxillary palatal tooth wear was seen in cyclists with a greater consumption of sports drinks.5

The greatest effect on performance from sports drinks occurs with prolonged intense exercise over one hour. An interesting study on athletic performance and metabolic balance showed that both water and sports drinks in equal volumes were effective in maintaining water electrolyte and mineral balances and resulted in equal levels of performance. Therefore individuals not involved in prolonged sport or exercise have no benefit from sports drinks over water. 14

Enamel dissolution from sports drinks and energy drinks is shown to be 3-11 times greater than that from cola drinks.13 Rees found that herbal teas had an erosive effect on enamel that is five times that of traditional teas.17 Dentine is far more susceptible to acid erosion than enamel with dissolution rate three times greater than enamel at pH 5.

INTRINSIC SOURCES In the modern day sporting world there are pressures of body perfection or in certain sports weight restrictions apply. Therefore intrinsic sources of acidic attack in athletes may be seen as intentional gastric reflux and vomiting, giving re-entry of gastric acid into the oral cavity. Prolonged periods of strenuous exercise may also induce vomiting, which again can be destructive on enamel in a dehydrated mouth. Conditions such as alcoholism, anorexia, bulimia and anorexia athletica should be borne in mind when encountering sportspersons for dental treatment. They all will have a drastic effect on young athletes in that their body mass growth and development will be affected as well as performance.

Anorexia athletica signs and symptoms may include the following2

DENTINE HYPERSENSITIVITY Sensitivity is a common complaint as a result of

FACTORODDS RATIO

Citrus fruits consumed more than twice daily 37

Vomiting 31

Low salivary flow rates 5

Soft drink daily consumption 4

Sports drinks weekly consumption 4

Fear of weight gain in a lean person Excess fatigue

Increase in exercise and reduction of food intake Dehydration

Anxiety Binge eating

Delayed puberty High smokeless tobacco use to suppress appetite

Gastrointestinal complaints Energy intake below high training needs

Beverage pH

Isostar Sports drinks 2.38

Coke 2.49

Powerade 2.75

Gatorade 3.12

Herbal Teas 3.2

Red Bull 3.41

Orange juice 3.4

Lucozade Original 3.5

Maxim Sports drinks 4.46

Water 7.00

Fig 5 - Table above shows the typical pH values for several beverages

About the Author:

Dr Lyndon Meehan is a general practitioner working in South Wales splitting his working week between Morriston Hospital Swansea, as a Staff grade Restorative Dentist, and private and NHS dental practices. He has a passion for sports dentistry dental trauma and pre competition dental screening for sportspersons.

Lyndon has supported many sports organisations and teams over the last 6 years. This has included being a tournament Dentist for the U20 Junior Rugby World Cup and role of a sports dentist to the UK school sports games on an annual basis. He currently is team dentist to Cardiff City FC and Pontypridd RFC and has supplied mouthguards to the Welsh Rugby Union senior squad for their Six Nations and Rugby World Cup 2011 campaigns. He currently provides advice on Dental trauma to the England and Wales cricket board and national county cricket sides. Most recently he has completed and played his part in providing dental treatment and advice in the athlete’s village polyclinic during the London 2012 Olympic and Paralympic games.

Address for correspondence: Lynddent@yahoo.co.uk

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toothwear. The frequency of sensitivity in athletes when consuming hot and cold drinks or foods is strongly correlated with a pattern of dental erosion.15

It is characterised by a short sharp pain arising from exposed dentine in response to thermal stimuli. Typically thermal, evaporative, tactile, osmotic or chemical which cannot be ascribed to any other form of dental defect or pathology. The hydrodynamic theory of fluid movement within dentinal tubules is postulated to elict symptoms recognised with sensitivity.16, 21

The clinical diagnosis of dentinal hypersensitivity strongly suggests exposure and patency of a number of dentinal tubules. The main causes of exposure of dentinal tubules and the removal of the overlying enamel are dental trauma, erosion abrasion attrition combinations and gingival recession bucco cervically. Acid erosion has been shown to promote lesion formation and initiation.

Clinical investigations have indicated that in particularly hypersensitive regions there is a greater density of patent tubules and the tubules have significantly greater diameters than in non sensitive regions.16

Diet modification tooth brushing advice and the use of specific toothpastes, in conjunction with resin desensitizers and restorations will form part of the treatment armoury in controlling areas of exposed sensitive dentine.

DENTAL CARIES Carbohydrates are the ideal energy source for the active athlete. In sportspersons oral hygiene may be poor with the add on of plaque deposits, frequent sugar intake and reduced saliva flow. This will enhance the bacterial degradation of carbohydrates providing acid which causes tooth surface demineralisation and carious lesion formation. This may initially present as a white spot lesion.

The important factors in caries assessment are the following 21 • The number of active lesions that are cavitated or non cavitated • The history of new lesions filled in past 2-3 years and how many lesions are present • Multiple active lesions in areas of rapid salivary flow (lower incisor and buccal surface of molars shows high caries activity) • A yearly increment of two or more lesions indicates a high rate of lesion activity and progression

An athlete who may consume a high carbohydrate diet before, during and after exercise, in addition to transitional meals, is classed as a high caries risk.

Gay Esconda’s 2011 study on Fc Barcelona soccer players showed they had higher DMF scores and mean active carious lesions when compared to students of the same age.23 Ljungberg also showed a higher DMF score in Swedish soccer players.8 Bryant’s study on Triathletes dietary habits showed frequent high sugar snack and sport drink intake. Only 3.2% of the athletes in this study associated training as a high risk to their oral health and the rest were unaware that the frequency of sports drink intake posed a problem to their dental health5.

In 2007 UK Department of Health published an evidence based guide on prevention advice entitled “Delivering better oral health an evidence based toolkit for prevention”. This toolkit encourages prevention action in form of professional intervention giving tabular advice on caries prevention for children and young adults and is worth considering given the age of the patient.

PERICORONITIS This is the inflammation of the flap of gingival tissue around a partially erupted molar tooth. It is commonly associated to the third molars and seen mainly in the late teens and early twenties. It is the result of food and plaque trapping, poor oral hygiene or mechanical trauma to this flap of gingiva (operculum) around the partially erupted tooth.

Common complaints are painful swollen gingival tissue in the area, a bad taste in the mouth and potentially a purulent discharge. Further heightened symptoms can include lymphadenopathy, swelling and trismus associated on that side which may require antibiotics. Local debridement of any food packing around the gingival tissue may need to be undertaken in conjunction with Chlorhexidine or hot salt water mouth rinses.

Pericoronitis in an athlete can again compromise nutrition, training and competition schedules. Therefore recognition and adequate oral hygiene instruction are essential around partially erupted teeth.

PREVENTION AND CONSIDERATIONS FOR CARE Without appropriate education intervention and prevention an athlete may not be aware of the potential dental destruction which may be quiescently ongoing in their mouth until too late. Dental health and attendance may also be a low priority for athletes until a problem arises. Toothache at the wrong moment can sacrifice years or months of training and preparation for competition time. For those athletes who do present for treatment, careful consideration may have to be given to how appointments are scheduled. Athletes may also decline treatment days before competition for mental fear of problems post dental visit. Therefore it is essential athletes are screened and declared dentally fit in an off season period. This will attempt to avoid the need for dental treatment in season. Many sporting bodies are now advocating dental screens and dental fitness to compete prior to seasons starting or embarking on overseas tours or major competitions.

PRESCRIBING As health care professionals we also need to be wary in our prescription and advice of any drugs and remedies to athletes who are regularly drug tested. Certain drugs can be checked for their prohibition status on the UK and world antidoping agency websites (www.globaldro.com/uk-en , www.wada-ama.org) before recommendation. Again it may be prudent to document clearly in the patient’s records any advice given and any online reference numbers obtained for checks. Liaison with any club medical staff on prescriptions given is essential to avoid overlapping administration of drugs.

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PREVENTION ADVICE

Common widely known prevention advice that should be encouraged in this group of patients includes the following:

1. Question dietary habits and beverage intake frequency and consumption method (immediate, swallowing, swishing, sipping or through a straw). The use of a week long athlete diet diary can also be an effective way of diet assessment.

2. Encourage reduction in the frequency of intake and substitute for less erosive PH drink if feasible and rinsing with water.

3. The use and placement of a wide bore straw (long sports nozzle on bottles) to the back of mouth so no swishing is undertaken. Thereby ensuring immediate swallowing of any sport giving minimal tooth contact. Anecdotally interproximal caries patterns have been seen in athletes due to the retention and swishing of drinks.

4. Cooling sports drinks decreases their acidity. Yet the patient may complain of increased sensitivity due to existing tooth wear and exposed dentine.

5. Fluoride prevention therapy through regular use of high fluoride toothpastes and mouthwashes. 21, 24, 25

6. Fissure sealing programmes for athletes and short recall intervals for high risk cases.

7. Enhanced oral hygiene instruction and plaque disclosure regimes.

8. Chewing sugar free gum post meals enhances remineralisation preventing demineralisation. It should be chewed 5 minutes after eating for a 20 minute post meal period.2

9. A fluoride rinse to balance the intra oral pH post competition and training where a prolonged intake of sports drinks and carbohydrates may have been undertaken lowering pH posing a higher erosive and caries risk. A period of time should be left before brushing (1hour) after acid attack as the enamel is soft and prone to wear.

10. Asthmatics through steroid inhaler use maybe more prone to oral thrush and cross infection maybe an issue within team water bottles. This also applies for patients with herpetic episodes. Rinsing after steroid inhaler use and personal water bottle use during contagious periods is encouraged.

11. Being vigilant on issues such as alcoholism, anorexia athletic and bulimia and look for warning signs which may prompt further discussion. The dentition and intra oral structures will provide clues on this which may alert the dental team to the patient’s habits outside of the surgery. Frequent vomiting episodes may also cause xerostomia and parotid gland enlargement.

12. As has been seen in the USA in certain sports such as baseball and American football athletes habitually chew tobacco and maybe totally unaware of the risk of oral cancer. This fashion is being increasingly seen in UK sports. Questioning, education and advice on tobacco use should be undertaken. Commonly tobacco is placed high in the buccal or labial sulci and left in situ. Any abnormal soft tissue lesions such as red/white patches or non healing ulcerations warrant further urgent investigation. Chewing tobacco due to its acidic nature and coarseness can also be erosive.13

The role of the Dental Hygienist and Dental Hygienist-Therapist is expanding and will continue to do so. It is the responsibility of the dental profession to embrace sports dentistry and become more proactive in prevention and education. DCPs will come to the fore with their prevention advice and care for athletes regarding their diet and nutritional needs. Of course we cannot prevent all eventualities yet with favourable promotion of dental health and prevention regimes and education to sports persons we can hope to keep disruption to athletes from dental problems to a minimal. The dental surgery gives a perfect and unique setting for access to athletes to allow nutritional evaluation inform educate and instil good life long oral health habits in young children participating in their chosen sport.

In the second paper in this series we will consider dental trauma and its impact on an athlete and the role of mouthguards.

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2. Studen-Pavlovich D, Bonci L, Etzel KR. Dental implications of nutritional factors in young athletes. Dent Clin North Am. 2000; 44(1): 161-78, vii.

3. Chander S ,Rees JS. Strategies for the prevention of erosive tooth surface loss. Dent Update 2010; 37(1): 12-4.

4. Soler Badia D, Batchelor PA , Sheiham A. The prevalence of oral health problems in participants of the 1992 Olympic Games in Barcelona. Int Dent J. 1994; 44(1): 44-8.

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6. de Sant’Anna GR, Simionato MR, Suzuki ME. Sports dentistry: buccal and salivary profile of a female soccer team. Quintessence Int. 2004; 35(8): 649-52.

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11. Yang XJ, Schamach P, Dai JP et al. Dental service in 2008 Summer Olympic Games. Br J Sports Med. 2011; 45(4): 270-4. doi: 10.1136/bjsm.2010.075283. Epub 2010 Nov 3.

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14. Sirimaharaj V, Brearley Messer L, Morgan MV. Acidic diet and dental erosion among athletes. Aust Dent J. 2002; 47(3): 228-36.

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17. Buczkowska-Radlińska J, Lagocka R, Kaczmarek W et al. Prevalence of dental erosion in adolescent competitive swimmers exposed to gas-chlorinated swimming pool water. Clin Oral Investig. 2013; 17(2): 579-83. doi: 10.1007/s00784-012-0720-6. Epub 2012 Apr 3.

18. Geurtsen W. Rapid general dental erosion by gas-chlorinated swimming pool water. Review of the literature and case report. Am J Dent. 2000; 13(6): 291-3.

19. Addy M. Tooth brushing, tooth wear and dentine hypersensitivity- -are they associated? Int Dent J. 2005; 55(4 Suppl 1): 261-7.

20. Glassman P, Anderson M, Jacobsen P et al. Practical protocols for the prevention of dental disease in community settings for people with special needs: the protocols. Spec Care Dentist. 2003; 23(5): 160-4.

21. Kidd E Caries control from cradle to grave. Dent Update. 2010; 37(10): 651-2, 654-6.

22. Page J ,Kidd E. Practical suggestions for implementing caries control and recall protocols for children and young adults. Dent Update 2010; 37: 422-432

23. Gay-Escoda C, Vieira-Duarte-Pereira DM, Ardèvol J et al. Study of the effect of oral health on physical condition of professional soccer players of the Football Club Barcelona. Med Oral Pathol Oral Cir Bucal. 2011; 16(3) : e436-9.

24. Lawson S. Practical suggestions for implementing caries control and recall protocols for children and young adults. Dent Update. 2010; 37(10): 709; author reply 709.

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