Dental Care and Injury Prevention in Athletes – Part 2
Most athletes don’t give their teeth a second thought - until a dental injury occurs. This is Part 2 of the article in which an expert panel of dentists provide their opinions on the topic. The information generated by this discussion should help athletes maintain good oral hygiene and help prevent injuries to teeth.
3. What are some considerations in choosing a mouth-guard to prevent such injuries?
Dr. Johnsen: Mouth-guards are recommended in situations where the teeth can be struck during the sport. Specifically, the activities include the collision sports (e.g., boxing, football, lacrosse, and ice hockey) and contact sports (basketball, wrestling, and soccer). High school athletic associations require mouth-guards for many sports. While there are differences among types of mouth-guards, the most important factor is the wearing of some type of mouth-guard.
Dr. Douglas: Even participation in activities such as weight lifting and rollerblading has the potential for injury to teeth. The clenched jaws mentioned by Dr. Moss frequently occur in weight lifters; this is an example of where a mouth-guard would offer protection. Merely because an athletic activity is considered non-contact doesn’t mean that mouth-guard protection is not needed. Mouth-guards not only protect the teeth and gums, but, perhaps most importantly, they reduce the risk of concussion.
There are three types of mouth-guards: The stock, the mouth-formed, and the custom-made mouth-guards. Specific advantages and disadvantages of each are outlined in the supplement. The most important consideration in choosing a mouth-guard is whether the athlete will wear it. The better the fit and comfort, the more likely the compliance. As you can imagine, the custom-made mouth-guard is recommended for most any activity.
Dr. Cameron: Many dentists will attest to a large number of dental injuries sustained off the sports field during “noncontact” activities such as cycling, and in sports that we normally don’t consider as contact sports, e.g., baseball, softball, and even gymnastics. It has been our experience in Australia to see fewer traumatic dental injuries during the traditional contact sports because more participants are wearing mouth-guards. Custom-fitted mouthpieces work the best, but it should be pointed out that even the best mouth-guard will not prevent all dental injuries. However, injuries that are sustained are usually less severe if a mouth-guard is worn.
Dr. Moss: To reiterate, it is wise to use a mouth-guard for any activity that could potentially result in oral injury. Technology today enables dentists to craft custom-fitted and highly comfortable mouth-guards that allow the wearer to breathe and talk easily. Once the wearer becomes accustomed to the mouth-guard, normally requiring a very brief time, he or she will not even notice it anymore. The classic case in which a mouth-guard is a must, particularly to protect the soft lip tissue, is in an athlete wearing an orthodontic appliance such as a brace, lip bumper, or retainer. In this way, orthodontics should never be a hindrance to participation in sports, whether competitive or recreational.
Dr. Till: Athletes with orthodontic appliances have the potential for a significantly greater incidence of mouth injuries, including cuts to the lips, cheeks, and tongue. Although some cuts may be considered as minor nuisance injuries, most sports organizations now require that bleeding be controlled before the athlete is allowed to participate again. Orthodontic patients can participate safely in the sports where there is a risk for dental injuries; however, there are three precautions to be considered. First, a mouth-guard should be fabricated to allow for changes in teeth movement that can occur over a period of several months. Second, both upper and lower jaw mouth-guards may be necessary; and third, the mouth-guard should be checked by the orthodontist routinely to ensure that it is functioning properly.
For those athletes without orthodontic appliances, an appropriately fitting mouth-guard should hold the cheeks and lips away from the teeth, cover all the upper teeth, and cushion anterior teeth to redistribute forces from a direct frontal blow, as well as protect the lower jaw and joints in the event of a blow to the chin. It also should fill in spaces of missing teeth, fit comfortably, and not inhibit breathing or speech.
4. Compared to the general population, are athletes at increased risk for dental events such as caries (cavities) or erosion?
Dr. Moss: While the diets of athletes are not incompatible with good dental health, athletes do need to be vigilant with dental care because of the way that they may eat throughout the day. Fluoride, a key protective mineral, is washed out of the mouth over time as we eat and drink. The main source of daily fluoride is from toothpaste, making it critical to brush with a fluoride toothpaste in the morning (after breakfast) and just before bed. Establishing such a routine helps maintain the protective fluoride reservoir in the mouth for longer periods of time, enabling the fluoride to enhance the remineralization of the tooth surface. But fluoride is only effective when it remains in the mouth. Just as many athletes put in “two-a-day” training sessions, “two-a-day” brushing habits are needed to boost the fluoride level while also helping the athletes clear food remnants from the mouth.
Caries and erosion differ in several fundamental ways, but the end result of the destruction of teeth in erosion and caries is similar. Caries is far more prevalent than erosion. Rarely do both occur simultaneously at the same site on a tooth. With true erosion, the tooth enamel is demineralized by direct contact with acids, whereas caries is a disease that occurs by the action of acids produced by plaque biofilm microorganisms. In most cases, our saliva, with its buffering action, protects our teeth from erosion. While the caries process is well understood today, the etiology of true dental erosion is not well understood. It is difficult, even for some dentists, to distinguish among tooth erosion, attrition, abrasion, and wear from habits such an chewing on pencils or fingernails. A knowledgeable and cautious dentist needs to make the correct diagnosis.
Dr. Cameron: The causes of dental caries and erosion are multifactorial. No single factor - the carbohydrate content of food, the acid content, the frequency of eating, or decreased salivary flow - can be isolated to the exclusion of other potential causes. To Dr. Moss’s recommendation, I speculate that people should not brush teeth immediately after eating. It might be better to wait 20 to 30 minutes before brushing; at this point a protective protein film is sure to be re-established on the teeth. We have our saliva to thank for this protection.
Dr. Johnsen: I am not aware of significant incompatibilities between athletes’ diets and dental health. The recommendations for athletes are the same as for non-athletes, i.e., exposure to fluoride, regular dental checkups, and restriction of sugary sweets between meals.
The risk for erosion is minimal under normal athletic conditions. There have been infrequent reports of swimming pool pH low enough to contribute potentially to erosion. But as Dr. Cameron indicates, it is impossible to isolate one factor as the cause. Other causative factors such as the occurrence of gastric reflux, bulimia, or unusual eating habits (e.g. sucking on lemons) should also be investigated.
Dr. Till: To elaborate on caries, or cavity formation, bacteria present in the mouth use dietary carbohydrates as a substrate from which acid production is an inevitable byproduct. This holds for the non-athlete and athlete alike. This acid lowers the pH of the dental plaque to a level that makes enamel susceptible to decay. If consumption of carbohydrate-containing foods is frequent, the pH can be lowered to demineralizing levels for several hours per day. This frequent demineralization causes the calcium, phosphate, and other minerals to diffuse out of enamel, thus creating a carious lesion.
Technically, athletes should be at no greater risk for caries and erosion than the general population. This statement must be tempered by the fact that increased exposure to cariogenic substances, without the necessary precautions, could result in an increase in oral disease. I concur with Dr. Moss that athletes must practice the same, or even greater levels of oral hygiene, than persons who are not frequently consuming large amounts of carbohydrate.
5. Are there any oral health implications for the athletes who use chewing tobacco?
Dr. Till: Smokeless tobacco, snuff, and chewing tobacco are not safe alternatives to smoking. Snuff and chewing tobacco contain greater amounts of cancer-causing substances than are found in cigarettes. “Spit tobacco” can cause a number of mouth problems, including leukoplakia (white patches), that can lead to cancer. It also leads to other dental and medical problems such as gingival (gum) recession, stained teeth, bad breath, increased heart rate, and high blood pressure. Spit tobacco contains high levels of nicotine just as cigarettes do. It does not take long to become addicted to nicotine. The dipping and chewing habit is very hard to kick.
Oral health professionals are in an excellent position to help smokeless tobacco users who are interested in quitting. The results of using spit tobacco can be pointed out, and information about its effects on health and the benefits of quitting can be discussed. The dental office can help a tobacco user plan “quit strategies” and alternatives.
Dr. Johnsen: In light of the association between tobacco and cancer, the American Cancer Society recommends that people not chew tobacco. I believe strategies that can be effective include discouragement by coaches, other athletes, and parents.
Dr. Moss: Experts point out that in athletes particularly, there is a strong psychological dependency established in those who use chewing tobacco and snuff. Athletes, however, do not perform better under any circumstances through the use of smokeless tobacco products. The influence of professional athletes on children who idolize them is powerful. Many young baseball players, for example, admit that they took up the smokeless tobacco habit because they had seen many of their baseball heroes use such products for many years. Major League Baseball, in fact, is now a partner in a national effort to stem the use of smokeless tobacco in children and adults. Many prominent major leaguers have done public service announcements to discourage smokeless tobacco use among children and young adults, including players who have tried, and failed, to quit this highly addictive drug. The best advice to athletes: Don’t start. Chewing tobacco will not help you; it can only hurt.
Roundtable: Dental Care and Injury Prevention in Athletes
RT# 29 / Volume 8 (1997), Number 3
By Angus C. Cameron, B.D.S., M.D.Sc., F.R.A.C.D.S., Michael Till, D.D.S., D. Stephen Douglas, D.M.D., P.T., A.T.C., Stephen J. Moss, D.D.S., M.S., David C. Johnsen, D.D.S.
Angus C. Cameron, B.D.S., M.D.Sc., F.R.A.C.D.S., Department Head, Pediatric Dentistry, Westmead Hospital Dental Clinical School, Clinical Senior Lecturer, Pediatric Dentistry, The University of Sydney, Australia
Michael Till, D.D.S. Dean, School of Dentistry, University of Minnesota, Minneapolis, MN
D. Stephen Douglas, D.M.D., P.T., A.T.C., Private Practice, Arlington Heights, IL, Chicago Bulls’ Dentist
Stephen J. Moss, D.D.S., M.S., Professor Emeritus, New York University School of Dentistry, New York, NY
David C. Johnsen, D.D.S., Dean, School of Dentistry, The University of Iowa, Iowa City, IA
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