RGUHS Nat. J. Pub. Heal. Sci Vol No: 17 Issue No: 3 pISSN:
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1Dr. Deepa N Shetty, Reader, Department of Periodontics, The Oxford Dental College, Bangalore, Karnataka, India.
2Department of Periodontics, Farooqia Dental College & Hospital, Mysore, Karnataka, India
*Corresponding Author:
Dr. Deepa N Shetty, Reader, Department of Periodontics, The Oxford Dental College, Bangalore, Karnataka, India., Email: deepanshetty@gmail.com
Abstract
Physical exercise is known to have a positive effect on overall health. It has been observed that periodontal health also benefits from regular moderate exercise. However, due to intense workout routines, sportspersons form a population of special interest; despite constant physical activity, a high prevalence of periodontal disease has been found among them. This occurs due to the impact of sports on periodontium through immunomodulatory effects, hormonal and physiological changes, nutrition, and stress. Certain sports like swimming can increase calculus formation, referred to as swimmer’s calculus. Improper use of mouthguards has also been shown to increase bacterial accumulation in the mouth. Similarly, the presence of periodontal disease has been shown to negatively influence sports performance, with 30-40% of athletes self-reporting an adverse impact of oral disease on their performance. This complex relationship between sports and periodontal health demands a thorough understanding of the underlying pathophysiology, along with appropriate recommendations for preventive measures and treatment.
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Introduction
Sports dentistry, first introduced in 1958 in Brazil during the Soccer World Cup, is a specialized branch of dentistry.1,2 The International Academy for Sports Dentistry defines it as ‘the branch of sports medicine that deals with the prevention and treatment of dental injuries and related oral diseases associated with sports and exercise”.3-5 It has been primarily concerned with sports-related injuries in the maxillofacial area.
In recent times, the association between periodontal disease and overall health has emerged, highlighting its effect on overall well-being. Studies have shown that individuals with severe marginal bone loss due to periodontal disease have a poor quality of life compared with those who have no or minimal marginal bone loss.6 This has led to the emergence of a new dimension in sports dentistry- oral diseases that may affect an individual’s physical and psychological well-being, negatively impact quality of life, and ultimately impair sports performance.7
Thus, the aim of this literature review was to summarize the effects of periodontal disease on the sports performance of athletes and to discuss the possible health care measures that can be recommended.
Physical Activity and Periodontal Health
The World Health Organization (WHO) defines physical activity as “any bodily movement produced by skeletal muscles that requires energy expenditure.”8 Regular physical exercise has been shown to reduce periodontitis risk by 23%, while overweight or obese individuals are 1.86 times more likely to have periodontitis.9
Mechanisms by which moderate physical activity decreases the risk of periodontitis are as follows:
a) Inflammatory mediator regulation: Physical activity leads to a reduction in proinflammatory mediators such as tumour necrosis factor-alpha (TNF-α), interleu-kin 6 (IL-6), C-reactive protein, and other related mediators.10-13 Consequently, the inflammatory response in the periodontium decreases, reducing the risk of periodontitis.
b) Vascular changes: Regular physical activity has been shown to prevent age-induced endothelial dysfunction in older subjects by improving peripheral blood flow.14,15 It produces a significant reduction in serum soluble ICAM- 1, soluble VCAM-1, and other peripheral inflammatory markers in chronic heart failure patients.16 Thus, the vascular changes induced by exercise lead to improved blood flow, endothelial function, and suppression of vascular inflammatory markers, thereby aiding in the cessation of periodontal disease progression.
c) Obesity: Physical exercise reduces the percentage of intra-abdominal fat, which in turn combats overweight/ obesity, factors associated with various metabolic diseases, and an increase in inflammatory mediators.9,10,12
d) Insulin resistance: Physical activity lowers glycated haemoglobin (HbA1C) levels and improves diabetic control. A two-way relationship between diabetes and periodontal disease has already been established.17,18 Thus, physical activity protects against the progression of periodontitis by reducing the associated risk factors.
e) Health promoting behaviour: Healthy lifestyle habits (physical exercise, healthy diet, or maintaining optimal weight) are associated with a lower probability of developing periodontitis. Individuals who engage in physical activity may also be more motivated to adopt self-care behaviours that promote a healthier lifestyle, such as maintaining good oral hygiene, and following a nutritious diet.19
Sports and Periodontal Health
Sportspersons are known to follow an active regimen, towards maintaining physical fitness. As a result, they engage in extensive physical activity and generally adhere to a healthy nutritional diet. Based on the evidence that physical activity reduces the risk of periodontitis, it could be assumed that athletes would exhibit good periodontal health. However, existing evidence contradicts this assumption. Table 1 shows a high prevalence of gingival and periodontal diseases among sportspersons.
Influence of Sports on Periodontal Health
Although physical activity has been shown to provide a protective effect against periodontitis, the high prevalence of periodontal conditions among athletes can be attributed to the influence of sports and associated regimens on periodontal health, as discussed below.
Immunomodulatory effect: The relationship between exercise and susceptibility to infection follows a “J-shaped” curve.26 Moderate physical activity performed regularly has been shown to improve immune function compared to minimal or no physical activity. However, intense physical activity for longer period may impair immune function.27 Intense exercise is accompanied by an increase in circulating leukocytes and plasma concentrations of various inflammatory cytokines, such as macrophage inflammatory protein-1, TNF-α, and IL- 1; anti-inflammatory cytokines IL-6, IL-10, and IL-1- receptor antagonist (IL-1ra); and acute phase proteins, including C-reactive protein (CRP).28 A drastic increase in plasma IL-6 concentration observed during exercise is entirely attributed to the release of this cytokine from contracting muscle fibers.29
This immunomodulatory effect may increase the risk of periodontitis in sportspersons, as they undergo intense bouts of exercise.
Hormonal changes: Intense exercise has been shown to increase plasma concentrations of several hormones, e.g., epinephrine (adrenaline), cortisol, growth hormone, and prolactin. Muscle-derived IL-6 also contributes to elevated levels of cortisol during prolonged exercise.27 Increased values of these hormones have been detected in patients with periodontitis.30 Catecholamines have also been shown to promote the expression of virulence factors in periodontal pathogens such as Porphyromonas gingivalis.31
Salivary changes: Athletes during training may acquire the habit of mouth breathing, which, accompanied with fluid loss, results in decreased salivary flow and a dry oral environment.7 Salivary cortisol levels, known to be associated with periodontitis, are also elevated during intense workouts.32
Psychological stress: Most of the competitive sports and championships are associated with tremendous stress, which is one of the risk factors of periodontitis.
Nutrition: Though athletes generally try to maintain a healthy nutritional diet, the frequent consumption of carbohydrate-rich sports drinks is associated with higher periodontal scores.33
Behavioural: Regular dental maintenance appointments and individual oral hygiene practices are often insufficient, particularly with respect to interdental care and adequate fluoride use.20,22,23,25
Gingival hypertrophy: Athletes usually use anabolic steroids which may cause gingival hypertrophy.34
Swimmer’s calculus: Swimmers are exposed to chlorinated water for extended periods, which can lead to calculus formation.34 The pool water, having a higher pH than saliva, accelerates the breakdown of salivary proteins and promotes the formation of organic deposits on the anterior teeth.35
Impact of Periodontal Disease on Sports Performance
Systemic diseases: Cumulative evidence does show causal association between periodontal infection and atherosclerotic cardiovascular disease.36 A decline in lung function is seen with increasing periodontal attachment loss.37 Chronic elevation of cytokine levels, as seen in periodontal disease, can damage or destroy the cells responsible for insulin production, potentially inducing type 2 diabetes in otherwise healthy individuals.38 In individuals with diabetes, periodontal disease progression can further impair glucose tolerance.39 Therefore, the association between periodontitis and other systemic diseases can adversely affect the performance of the athlete.
Increased risk of muscle injuries: Studies have shown an increased risk of soft tissue injuries and muscle protein damage with elevated levels of circulating inflammatory cytokines.40,41 Therefore, periodontal disease may serve as a contributory factor to the increased incidence of soft tissue injuries in athletes.
Tooth loss: Untreated active periodontal disease can eventually cause loss of tooth. Tooth loss can impact the social and psychological wellness by impairing speech and appearance, while also compromising physical health through its effect on nutritional status, thereby affecting overall well-being of the individual.42
Periodontal disease can therefore affect an individual’s overall physical capacity and, consequently, their performance. Approximately 30-40% of athletes have self-reported an oral health-related impact on sports performance.21,23 Furthermore, reduced vital capacity of lungs in periodontitis patients has been shown to impair the performance of athletes.43
Periodontal Care in Sports
A complex, two-way relationship exists between sports and periodontal health. Considering the impact of periodontal disease on sports performance and the prevalence of poor periodontal health due to the sports regimen, it becomes extremely essential to take preventive measures, closely monitor periodontal health of athletes, and provide appropriate treatment.
Regular examination and monitoring: The demanding schedule of athletes is often the primary reason for irregular dental check ups. Therefore, sports committees should ensure that athletes undergo routine dental examinations.
Saliva serves as a valuable diagnostic tool and can be utilized to examine exercise-related physiological status, training load, and susceptibility to oral or general diseases.
Preventive measures: World Dental Federation (FDI) published the first ever sports dentistry guidelines in 2019. Apart from regular examination and monitoring, they emphasize on following preventive measures.44
Oral hygiene maintenance: It is recommended that individuals brush twice daily for at least two minutes using a toothbrush and fluoride toothpaste. The use of floss/interdental brushes is advised for effective plaque removal, and rinsing with water after meals and snacks is suggested when brushing is not possible.
Tabacco: It has been recommended to avoid both smoking and the use of smokeless tobacco.
Nutrition: It is recommended to follow a healthy diet. Athletes should be aware of acidic nature of sports drinks they often consume and take necessary precautions. It is also recommended to stay hydrated by drinking water regularly.
Mouthguard: The use of a mouthguard is mandatory in sports with an increased risk of dentofacial injuries, such as boxing. It is also recommended in sports with a moderate risk, like martial arts, and rugby. The use of custom made mouthguard is preferred over store-bought one, as it provides optimal comfort and a better fit.
Long-term use of mouthguard increases plaque formation and hampers the protective effect of saliva by reducing its pH and buffering capacity.45
This can be prevented by proper hygiene maintenance of the device, including regular cleaning after each use and storing them in a well-ventilated environment.
Conclusion
The importance of periodontal health in sports dentistry is evident from its impact on athletes’ performance. Intensive sports training schedules and other sports associated factors can also impede periodontal health, indicating a possible association. Future research should be carried out in this direction to support the development of recommendations for maintaining the periodontal health of the athletes and integrating these measures into sports dentistry.
Conflict of Interest
Nil
Supporting File
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