|Caries And Dental Erosion
The development of caries and dental erosion is in many respects
related to lifestyle factors. Many athletes can be considered to
be at high risk for both these type of lesions. In order to gain
sufficient amounts of energy and liquid, an increased intake of
foods with a high calorie value, particularly those containing
sugars, are often consumed by athletes. In addition, sports drinks
are used for rehydration and electrolytic replacement during or
directly after highly aerobic sports.
Caries is related to the intake of fermentable carbohydrates. These
can be broken down by oral microorganisms to different organic
acids, which results in a pronounced pH fall below the critical pH
for enamel (pH 5.5) and dentine (pH 6.2). Dental erosion on the
hand is defined as a loss of dental hard tissue by a chemical
process without involvement of bacteria. It is the net result of an
exposure to an acidic source. This may be extrinsic, such as the
intake of acidic food and drinks, or related to intrinsic factors,
for example regurgitation and reflux disorders. While dental caries
prevalence has decreased during recent decades worldwide, the
erosion is increasing.
A deterioration in oral health of athletes has been suggested
which is believed to be related to a high intake frequency of both
sugar and acid-containing products. In addition to a high intake
frequency, products are often consumed during or directly after
intense exercise, resulting in breathing hard through the mouth and
reduced salivary secretion rate. pH on the tooth surface may
reach even lower levels and the duration of a low pH is prolonged
during such dry mouth conditions. The risk for dental erosion is
believed to be particularly high as acidic drinks are most often
consumed during this physical condition. The site specificity of
dental erosion in relation to type of exposure is still under
debate, but during extreme conditions all surfaces will be affected,
as well as enamel and dentine. The method of drinking will influence
the impact of a drink on the dentition. Prolonged consumption
increases the risk.
Many athletes can be expected to have an increased risk of
developing dental caries and dental erosion, but this risk in not
evenly distributed within this population. This means that some
athletes can have a high and some a low or even no risk. For the
dentist it is therefore important to carry out an individual risk
The clinical examination of the buccal, lingual and occlusal
surfaces is very important in order to find early signs of both
dental caries and dental erosion. Bitewing radiographs should also
be taken. With
regard to dietary habits, the interview should focus on the
frequency of consumption of relevant products. The athlete is to
asked about eating and drinking habits both when exercising and when
not exercising, i.e. the rest of the day. Oral hygiene habits should
be discussed in detail. Ask him or her to brush with toothpaste in
the clinic and to observe the `toothpaste technique'. Thus, the
amount of toothpaste, the spreading of the paste in the dentition
and the post-brushing water rinsing should be registered and if
As a supplement to clinical examination and interview, a saliva and
microbiological test is of great value for risk evaluation. A low
saliva secretion rate and a low salivary buffer capacity implies a
high risk of developing both dental caries and dental erosion. In
addition, high counts of mutans streptococci and lactobacilli are
often associated with high caries risk.
Prevention of Caries and Dental Erosion
The prevention program for an athlete should include the following
1. Dietary advice including appropriate use of sugar-free products.
2. Fluoride treatment both at home and at the clinic.
3. Oral hygiene instruction - in some cases professional
The athlete should avoid unnecessarily frequent intake of
products such as snacks and sport drinks and not to keep the
products too long in the mouth. A long retention time will increase
the risk both for dental caries and dental erosion.
The possibility of
using sugar-free chewing gums and sugar-free lozenges after eating
occasions should be discussed. These products stimulate saliva,
shorten the oral clearance time of sugar and acids in the mouth and
increase the pH on the tooth surfaces. In relation to erosion, the
use of chewing gum should not be exaggerated because of risk for
Independent of the caries and erosion risk, all athletes should be
informed to increase their daily use of fluoride. Thus,
toothbrushing twice a day with fluoride toothpaste and with an
improved `toothpaste technique' should be stressed.
Daily mouthrinsing with 0.05
percent NaF can also be recommended to all athletes. For high risk
patients the athlete should brush their teeth with fluoride
toothpaste at one extra occasion during the day and to increase the
daily rinsing with 0.05 percent NaF to two to three times per day.
Fluoride chewing gums and
fluoride tablets areavailable. These products can be used several
per day, both after and between the meals. For very high risk
patients (regarding both dental caries and dental erosion), fluoride
gel application will give the teeth extra protection. And fluoride
varnish can be applied two to four times per year.
In order to improve oral hygiene, an electric toothbrush can be
recommended to some athletes. It is important, however, that the
brushing is combined with fluoride toothpaste. The toothbrushing
should be carried out after breakfast and just before bedtime with
no eating or drinking up to one to two hours afterwards. In order to
avoid tooth abrasion, brushing should not be carried out directly
after using an acid product, like a sport drink.
If the oral hygiene is poor,
professional tooth cleaning by a dental professional is to be
two to four times per year followed by fluoride varnish application.
Peter Lingström and
DowenBirkhed, from the Faculty of Odontology at Göteborg University
Sweden, discuss the oral health of athletes and the impact
ofconsuming high energy products.
1 Ljungberg G, Birkhed D. Dental caries in players belonging to a
Swedish soccer team. Swedish Dental Journal 1990;14:261-266.
2 Milosevic A, Kelly MJ, McLean AN. Sport supplement drinks and
dental health in competitive swimmers and cyclists. British Dental
This article first appeared in Dental Digest, volume 5, issue 2