SPORTS NUTRITION
ATHLETES AND ORAL HEALTH Claire Chaudhry NHS Community Diabetes Dietitian/ Private Sports Dietitian, BCUHB/ Claire Sports Nutrition
Poor oral health, i.e. our teeth and gums, can negatively influence an athlete’s ability to bite, chew and swallow food and thus can lead to pain, swelling and inability to eat properly to meet individual nutritional requirements.
In Claire’s 14 years of experience she has worked in acute and community NHS settings. Claire has taught Nutrition topics at universities and colleges and regularly provides talks to groups; NHS and private. www. dietitianclaire.com.
The research into the oral health of athletes/sports people is limited; nevertheless, studies have consistently reported poor oral health in elite athletes since the first report from University College London during the 1968 Olympic Games.1 At the time of writing, the Rugby Six Nations is in full swing and Wales will play Ireland this weekend. The players strength and ability to sprint for a try when needed throughout the 80 minutes, is amazing. After writing this article I am somewhat curious to know if each player’s oral health is as good as their physical health. Poor oral health can lead to dental caries, acid erosion and in extreme cases loss of teeth. What exactly is poor oral health? And what do we know already about the prevalence amongst athletes? Tooth decay, or dental caries, results from the breakdown, by bacteria on the hard tissue, of the teeth called tooth enamel. This occurs due to food left over in the mouth or sugar left on the tooth surface and can eventually cause holes in the teeth. Acid erosion is the erosion of the tooth’s enamel and also gums. Acidic drinks and foods lower the pH level of the mouth leading to acid erosion of the teeth. Drinks that cause acid erosion include acid-based drinks such as fruit juices and sports drinks. Dental trauma is teeth being removed or knocked out, jaw fracture, damage to
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Claire would like to thank Elizabeth Gronnow RDN (Registered Dental Nurse) for her contribution on this article.
gums, tongue, lips and frenulum; which is the fold of skin beneath the tongue, or between the top lip and gum. Other oral conditions include: • Gingivitis - an inflammation of the gums usually caused by plaque build-up; • Periodontal disease - inflammation of the tissues that surround and support the teeth; • Mouth ulcers, cold sores, swollen tongue; • Burnt mouth through hot or cold food/drink The most recent studies look at oral health in elite/professional athletes: London 2012 and Rio 2016. London 2012 had data from 278 elite/professional athletes from the continents of Africa, America and Europe; and included data from 25 different sports. The results showed high levels of poor oral health including dental caries in 55% of athletes, acid erosion in 45% of athletes, gingivitis in 76% of athletes and periodontal disease in 15% of athletes. They also found that more than 40% of athletes were ‘bothered’ by their oral health and 18% reported a negative impact on their training and performance. Nearly half of the athletes had not undergone a dental examination or hygiene check in the previous year.2 Out of 116 Olympic and Paralympic Dutch athletes participating in Rio 2016, www.NHDmag.com April 2017 - Issue 123
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SPORTS NUTRITION a dental screen prior to Rio found that 43% of them needed a direct referral to a general dentist due to poor oral health.3 WHY ARE ATHLETES AT RISK OF POOR ORAL HEALTH?
There are many factors which contribute in the development of poor oral health of athletes including nutrition, dehydration, exercise-induced immune suppression, lack of awareness among athletes, negative health behaviours and a lack of prioritisation in relation to their training schedule. Nutrition and frequency of nutrition, in particular carbohydrates Carbohydrates, like glucose and fructose, in foods, are mouth bacteria’s first food source and, therefore, a diet high in these increases the risk of dental caries. Although every individual is different, in Sports Nutrition, up to 70% of an athlete’s overall diet is likely to come from carbohydrates.4 Due to the energy demands of athletes, they are more likely to consume a high amount of carbohydrates throughout their day; during training and whilst competing. The athlete must also consume a greater amount of carbohydrate intake and fluid intake with greater frequency, i.e. glucose and fructose in foods and or gels and/or isotonic drinks. For both dental caries and acid erosion to occur, it is the frequency rather than the total intake of sugar and acidic foods and fluids that is the contributing factor, thus putting the athlete at greater risk of poor oral health. Dry mouth and imbalance of pH in the mouth from exercising regularly During exercise, our heart rate increases resulting in an increased rate of breathing, which again increases as the intensity of the exercise increases. With increased breathing through the mouth, the mouth becomes drier; when the mouth is dry less saliva is produced. Our saliva helps to neutralise the harmful bacteria in our mouth and also maintains a normal pH balance; therefore, having a dry mouth can lead to dental caries. Dehydration during exercise also causes a dry mouth as well as fatigue and reduced energy levels. Regular swimming in incorrectly chlorinated pools can also lower the pH balance in a swimmer’s mouth, leading to less saliva being produced. 44
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The risk of sports-related oral injuries causing dental trauma All sports have some risk for dental injury, but ‘contact sports’ incur more risk. Contact sports like boxing, rugby, hockey, football and martial arts all carry an increased risk of dental trauma, i.e. teeth removal, gum damage, split lips, split frenulum, bitten tongues and fractured jaws. A study of insurance claims for sports-related dental trauma showed that rugby was the contact sport most responsible, which ranged from 22%-33% of claims.5 HOW CAN ATHLETES IMPROVE THEIR ORAL HEALTH?
Frequency and amount of sugars in the diet are undoubtedly the most important dietary factors in the development of dental caries and poor oral health.6 There is much debate about the burden of dental caries throughout the world and studies highlight the need for a very low sugar intake throughout our lives, with some dental experts suggesting that only 2-3% of our daily energy intake should come from free sugars.7 The majority of dental experts would discourage the frequent use of high fructose and glucose foods and drinks. Current SACN recommendations for free sugar consumption in the UK state that we should be eating no more than 5% of our total daily energy intake.8 According to the most recent National Dietary survey, as a population we are consuming double this daily amount across the age ranges.9 However, to reduce the glucose and fructose intake, as well as frequency in an athlete, will greatly affect their training schedule, stamina, performance and ability to recover. Whatever sport your athlete participates in; whether they are a professional/elite athlete, or an athlete who enjoys keeping fit as a hobby, a dietitian can provide individual dietary advice and education to help achieve optimal oral health, which is an important factor in maintaining good general health and wellbeing. IMPROVING POOR ORAL HEALTH
Running, cycling, gym sessions, gymnastics, dancing, walking etc Educate the athlete to know what fluids they require and when during their exercise schedule.
Table 1: Practical tips for maintaining good oral health aimed at athletes Brushing
Ensure that teeth are brushed twice a day with a soft toothbrush; this can help to minimise gums receding. Avoid brushing teeth straight after an acidic food or fluid, wait about 30 minutes.
Fluoride toothpaste
Use an appropriate fluoride containing toothpaste. Adults and children over the age of six years require 1450ppm fluoride in toothpaste. Always ensure the toothpaste contains no sugar or ingredients ending in ‘ose’, yes surprisingly they do exist!
Xylitol
Use xylitol containing products such as chewing gum between training schedules and after meals and snacks.
Flossing
Floss the teeth once a day as flossing teeth gets in between the hard-to-reach areas in the mouth and helps with gum health. There are huge ranges of floss products available. It is advisable to try a few different ones to see which one suits an individual’s mouth structure best.
Mouthwash
Use alcohol-free mouthwash up to twice a day. Mouthwashes are not to be used straight after brushing but in between brushing teeth throughout the day.
Dental checkups
Have regular dental checkups every six to 12 months with a dentist or hygienist. Ask them to check teeth brushing technique. Concerns regarding oral health in relation to a particular training, nutrition and hydration regime should be discussed with the dentist.
Ensure athletes are always kept well hydrated throughout their training. Keeping well hydrated helps to avoid a dry mouth and thus avoids reduced salivary flow. For most sporting activities under 45 minutes, plain water is adequate to prevent dehydration. If sports drinks or isotonic liquids are used, aim to reduce contact with the teeth by using the following strategies: • Avoid swishing/rinsing the drink around your mouth. • Avoid holding the drink in the mouth. • Use a squeegee bottle to help minimise contact with teeth by directing fluids to the back of mouth. If the athlete uses jelly sweets, gels or isotonic drinks, or any other foods high in carbohydrate, advise them to always carry water with them and if possible that they rinse their mouth out with water after eating or drinking. Scuba diving, swimming (synchronised/lengths) If swimming in chlorinated pools check that the pool’s pH is tested regularly and that the chlorination is correct. Advise the athlete to try not to open the mouth too much underwater and advise against swishing the pool water around the mouth. If a regular scuba diver, either in the
pool or in the sea, ensure the mouthpiece fits correctly to avoid rubbing. Contact sports: rugby, boxing, martial arts Contact sport participants must always use a mouth guard and ensure the guard fits correctly. The benefits of preventing dental trauma in contact sports with a mouth guard are well documented.10 In certain boxing and Taekwondo associations, as well as a mouth guard, head gear which protects the jaw area, must also be worn when sparring.11 CONCLUSION
Regular dental screening must be incorporated into the general preventive healthcare of all professional/elite athletes. Due to the increased risk of poor oral health amongst athletes, it is necessary that any educator coming into contact with athletes (i.e. coaches, dietitians, personal trainers, physiotherapists and sports nutritionists), should ideally also be offering advice on preventing poor oral health as part of their education on maintaining optimal health. As for my rugby team, Pob lwc Cymru, cadwch ar brwsio dannedd! - Good luck Wales, keep on brushing those teeth! www.NHDmag.com April 2017 - Issue 123
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