Simple oral health steps help improve elite athletes' performance

Elite athletes who adopted simple oral health measures, such as using high fluoride toothpaste and cleaning between their teeth, reported significantly reduced negative effects on performance related to poor oral health, finds a study led by UCL.

The new research, published in BMJ Open Sport & Exercise Medicine, is the latest in a series of studies* led by the UCL Centre for Oral Health and Performance (COHP), based at UCL Eastman Dental Institute, which have found that elite athletes have substantial rates of oral disease**, including tooth decay and gum inflammation, and these symptoms negatively affected their wellbeing and sporting performance.

To help address this, researchers at UCL COHP designed a behavioural change programme aimed at better educating elite athletes about oral health and providing some simple interventions to improve their daily oral health routines.

Explaining the study, lead author, Dr Julie Gallagher (UCL Eastman Dental Institute), said: "Poor oral health of elite athletes is common and is associated with negative performance. However, compared with other health and training pressures, oral health care is not a high priority in elite sport.

"We therefore wanted to develop a programme which was aligned with the existing high-performance culture of the athletes and their teams. Underpinning the study was health behaviour psychology, which included education, self-motivation, goal setting, and an easy to use toolkit, ensuring the athletes had a readily available opportunity to improve."

In total, 62 athletes from two Great Britain Olympic Teams, rowing and cycling, and one Premiership Rugby Club, Gloucester Rugby, were recruited to the study.

Athletes and support teams were asked to watch a 10-minute presentation which focussed on building motivation to improve oral health, and three 90-second information films, featuring GB rower Zak Lee-Green, which focussed on increasing oral health knowledge and skills to perform optimum oral health behaviour.

In addition, each athlete received an oral health screening to check for diseases such as caries (tooth decay) and gingivitis (gum inflammation). They were then given a bespoke follow up report with tailored advice and an oral health toolkit, containing a manual toothbrush, prescription fluoride toothpaste and flosspicks. As a minimum, they were also asked to brush their teeth for two minutes twice a day, to include brushing before training in the morning and before bed in the evening.

In total 89% of athletes completed the four-month study. On completion athletes were asked to fill in an oral health knowledge questionnaire, undergo a follow-up gingival (oral disease) assessment and evaluate the oral health kit.

Results

The study found that the behaviour change model was associated both with reductions in self-reported negative performance impacts and in improvements in oral health behaviours.

Athlete use of prescription strength fluoride toothpaste increased from 8 (12.9%) to 45 (80.4%), use of interdental cleaning aids at least two to three times per week increased from 10 (16.2%) to 21 (34%). Bleeding (gums) score remained unchanged. A desire to avoid inflammation in the body resulting from poor oral health was cited by 93% of athletes as the key motivator to make changes to their oral health routine. ]

Improvements in sporting performance were measured using the Oslo Sports Trauma Research Center Overuse Injury Questionnaire (OSTRC-O), developed to monitor illness and injury in elite athletes. UCL COHP adapted the questionnaire to focus on oral health, asking the extent to which the oral health problem affected 1) sports participation, 2) training volume; 3) sporting performance; and 4) the extent to which the individual has experienced oral pain.

As a result of the behavioural change programme the mean OSTRC score across athletes reduced from 8.73 (out of 100) to 2.73, which while low at the outset, does indicate a statistically significant reduction in problems associated with oral health and sporting performance.

In addition the number (proportion) of athletes who reported a 0 (zero) score, meaning they had no negative sporting impact from oral health conditions, increased from 32 (51.6%) at baseline to 54 (98.2%) at the end of the study

Dr Gallagher added: "Through our previous research and focus group sessions, we established that athletes' motivations for taking part in the study were both appearance and athletic performance, with many keen to avoid gum inflammation affecting other parts of their bodies, which can happen in serious cases.

"We believe that bringing behaviour change science together with an understanding of the athletes' and teams' priorities is key to making changes stick." There are a number of reasons athletes are more likely to have poor oral health: physical activity causes a dry mouth, which in the long-term increases risk of tooth decay and gum diseases, along with frequent sugar intakes from normal diet and energy supplements.

Co-author and UCL Centre for Oral Health and Performance lead, Professor Ian Needleman, said: "To compete at the top level elite athletes need to make the most of marginal gains and maintaining good oral health has been proven to have real performance benefits.

"With so many other competing interests, such as training, nutrition, sleep and mental health, it is remarkable to see such great rates of adherence to the new routines in a high-performance environment."

Zak Lee-Green, a member of the GB Rowing Team and a dentist who took part in the study, said: "As athletes we are acutely aware of the marginal gains required to achieve peak performance and maintaining good oral health is a prime example of an area often overlooked.

"This programme has gone a step further than showing the positive effect of excellent oral health on everyday life and has shown the potential benefits for improved performance, helping us reach the highest levels of sport. It can only be a step in the right direction if the sporting role models of the present and future are managing their oral health in the same way that they do their elite training."

Dr Nigel Jones, Head of Medical Services at British Cycling, said: "The topic of oral health amongst athletes is an important one, especially as it can be linked to performance. My role with the Great Britain Cycling Team is to ensure the holistic well-being of our cyclists, and as oral health can have a big impact on immune function as well as being important in its own right, I wanted to support this project. The learnings which the riders took from the study have been invaluable and will be deployed across the whole team as we ramp up our preparations for the Tokyo Olympic and Paralympic Games next year."

This behavioural change study was based on the COM-B model, which identifies sources of behaviour that could provide opportunities for intervention.

Capability (C) that is, the person having the physical skills and knowledge to perform the behaviour, Opportunity (O), that is, access to the necessary materials and social environment such that the person feels able to undertake the new behaviour, while Motivation (M) refers to a person deciding to adopt the behaviour

Researchers believe the bespoke model they have developed could be used for other health promotion needs in elite sport.

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*Previous UCL studies

* Elite athletes have poor oral health despite brushing twice daily, published August 2019.

* High levels of oral disease among elite athletes affecting performance, published June 2018

* Better oral health for footballers is needed: https://www.ucl.ac.uk/eastman/news/2015/nov/new-research-better-oral-health-footballers-needed, published November 2015

* London 2012 athletes had 'bad teeth' https://www.ucl.ac.uk/news/headlines/2013/sep/london-2012-athletes-had-bad-teeth, published September 2013

** In 2018 researchers at UCL COHP found nearly half (49.1%) of the athletes had untreated tooth decay, 77% had gingivitis, an early indicator of gum disease, and 39% self-reported having bleeding gums while cleaning their teeth, a sign of gum inflammation. Only 1.1% of the participants had 'excellent' periodontal health. In addition, more than a third (32%) reported that these conditions had impacted negatively on their sporting performance, along with their ability to eat (34.6%), relax and sleep (15.1%) and smiling and self-confidence (17.2%).

A probiotic derived from Chinese pickles prevents cavities

Can a probiotic derived from Chinese pickles prevent cavities? That seems to be the case, according to a study by researchers at Ben-Gurion University of the Negev and Chengdu University in China.

Pickles are an integral part of the diet in the southwest of China. When fruits and vegetables are fermented, healthy bacteria break down the natural sugars. These bacteria, also known as probiotics, not only preserve foods but offer numerous benefits, including immune system regulation, stabilization of the intestinal microbiota, reducing cholesterol levels, and now inhibiting tooth decay.

According to the study published in Frontiers in Microbiology, a strain of Lactobacilli (L. plantarum K41) found in Sichuan pickles reduced S. mutans by 98.4%. Dental caries (cavities) are caused by Streptococcus mutans, (S. mutans) commonly found in the human oral cavity as plaque and is a significant contributor to tooth decay.

Prof. Ariel Kushmaro of the BGU Avram and Stella Goldstein-Goren Department of Biotechnology Engineering and the Chinese research team evaluated 14 different types of Sichuan pickles from southwest China. They extracted 54 different strains of Lactobacilli and found that one, L. plantarum K41, significantly reduced the incidence and severity of cavities. K41 was also highly tolerant of acids and salts, an additional benefit as a probiotic for harsh oral conditions. It also could have potential commercial value when added to dairy products.

According to Doug Seserman, chief executive officer of American Associates, Ben-Gurion University of the Negev based in New York City, "the researchers currently have no plans to evaluate Jewish deli pickles."

Largest study to date of electronic dental records reviews understudied populations

Data is from solo and small practice dentists where most Americans receive dental care

REGENSTRIEF INSTITUTE

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IMAGE: THE LARGEST STUDY TO DATE OF ELECTRONIC DENTAL RECORDS (EDRS) DELVES INTO BOTH PREVIOUSLY INACCESSIBLE DATA AND DATA FROM UNDERSTUDIED POPULATIONS WITH THE ULTIMATE GOAL OF IMPROVING ORAL TREATMENT OUTCOMES.... view more 

CREDIT: REGENSTRIEF INSTITUTE

INDIANAPOLIS - The largest study to date of electronic dental records delves into both previously inaccessible data and data from understudied populations with the ultimate goal of improving oral treatment outcomes. The work presents a learning health system - a mechanism for dentists to learn from their own experience and the experiences of fellow practitioners.

Researchers led by Regenstrief Institute Research Scientist Thankam Thyvalikakath, DMD, PhD, associate professor and director of the Dental Informatics Core at Indiana University School of Dentistry, evaluated de-identified data from the electronic dental records (EDRs) of 217,887 patients of 99 solo or small dental practices across the United States. These EDRs contained more than 11 million observations, with observation periods as long as 37 years.

The study determined that it is feasible to mine and utilize enormous amounts of EDR data to learn which dental therapies work and which do not, empowering quality improvement by individual dentists. EDR data is sufficiently reliable for purposes beyond the clinical care of individual patients.

Learning from aggregating data across practices gives each dental practitioner the opportunity to acquire knowledge not only from his or her own patient data but also the opportunity to compare their practice with their peers. Information obtained during each patient's visit thus contributes to improved care for all, creating a true learning health system.

Now that the they have completed the proof of concept; the researchers will use the data to evaluate of the long-term effectiveness of two common dental procedures performed on permanent teeth -- root canal therapy and tooth-colored fillings in rear teeth. Data analysis for that portion of the study, which will determine how well and how long root canal treated teeth and back teeth filled with tooth-colored fillings continue to function, will help both dentists and the patients make evidence-based care decisions. Data analysis is currently nearing completion and the findings will be published in the future.

"Here in the real world of the dentist's office we are seeing patients with all kinds of real-world conditions - pain, underlying medical conditions, lack of adequate past oral health care -- so this large data set provides a unique insight into the treatments offered in the type of dental offices where most Americans receive care," said Dr. Thyvalikakath, the founding director of Regenstrief-IU School of Dentistry dental informatics program.

Information on demographics, reason for visit, medical and dental history, social history, tooth characteristics and treatment, as well as practice and practitioner characteristics was collected for each patient visit.

Dr. Thyvalikakath describes the work as groundbreaking in four areas:

1. Dentists were able to share their data for research in an anonymized process with their EDR vendors' help, because a typical solo dentist or even small practice does not have dedicated IT staff.
2. Data from two electronic dental record systems with varying formats and operating systems were combined. Interoperability has proved difficult with data from electronic medical record systems.
3. It is the largest study to evaluate data quality in a regular patient setting.
4. It looked at the oral health and treatment options of both insured and uninsured patients. Past studies have relied on insurance records and thus have provided no information on uninsured patients.

"Findings derived from patient data in real-world conditions is typically less difficult for clinicians to translate at the point of care than studies performed in large health systems which often represent a patient population that does not mirror the community dentists see in their practices," said Dr. Thyvalikakath. "We are presenting a mechanism for dentists, many of whom practice by themselves or with only one or two others, to learn from their own experience and from the experiences of their peers to assist in improving skills and facing problems."

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"Leveraging Electronic Dental Record Data for Clinical Research in the National Dental PBRN Practices" is published in the peer-reviewed journal, Applied Clinical Informatics