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Caries And Dental Erosion In Athletes

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 other
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 prevalence of
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.

Risk Evaluation
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 evaluation.

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 necessary improved.

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 three parts:

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 toothcleaning.

Dietary advice
    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 or drinking
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 abrasion.

Fluoride treatment
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 times
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.

Oral hygiene
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 carried out
two to four times per year followed by fluoride varnish application.


Peter Lingström and DowenBirkhed, from the Faculty of Odontology at Göteborg University in
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 Journal 1997;182:303-308.

This article first appeared in Dental Digest, volume 5, issue 2

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