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

Electronic Cigarettes Trigger an Inflammatory Response That May Set the Stage for Gum Disease

The oral microbiomes of 25 otherwise healthy participants who use e-cigarettes daily closely match those seen in patients with gum disease, a new study shows. The results suggest that e-cigarettes trigger a proinflammatory response, coating commensal bacteria in the mouth with a layer of slime that makes them unrecognizable to the body and prevents the sequential colonization of other bacteria that form a healthy community. Sukirth Ganesan and colleagues conclude that the glycerol/glycol vehicle in e-cigarettes appears to drive these changes. 

E-cigarettes have grown wildly popular among Americans, with six percent of the country's population - including 2.5 million high schoolers - puffing on the products nine years after their introduction to the United States. But while these e-cigarettes contain potentially toxic substances, including volatile organic compounds and metals, much remains unknown their long-term effects on human health. 

To gain insight into how e-cigarettes affect the oral microbiome, Ganesan et al. recruited 123 otherwise healthy individuals, including 25 smokers, 25 nonsmokers, 20 e-cigarette users, 25 former smokers currently using e-cigarettes, and 28 smokers who also use e-cigarettes. They created a catalog of bacterial genes in the microbial communities of e-cigarette users based on plaque samples collected from their teeth, finding that variations arose based on the duration of e-cigarette use, but were not tied to variations in the concentration of nicotine or the type of flavoring. 

The researchers also observed that while both smoking and e-cigarette use cause inflammation, they do so through different molecular pathways. 

"I am hoping this research will drive some level of policymaking about the harm we are seeing," said Purnima Kumar, a coauthor of the study, in an interview, challenging the popular perception that e-cigarettes provide a safer alternative to smoking. "If we can see changes in people who are otherwise healthy and have nothing wrong with them, then we should start seriously considering why would you put their lives and their wellbeing at risk."

Dental opioids study points to need for better prescribing

Though non-opioid painkillers can be just as effective, patients having dental procedures just before weekends and holidays are more likely to fill prescriptions for opioids

MICHIGAN MEDICINE - UNIVERSITY OF MICHIGAN

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IMAGE: KEY FINDINGS FROM A STUDY OF MORE THAN 2 MILLION AMERICANS WHO HAD DENTAL PROCEDURES IN THE PRE-COVID19 ERA view more 

CREDIT: UNIVERSITY OF MICHIGAN/JADA

As dentists and their teams across America get back to their regular schedules after a sharp COVID-19-related reduction, a new study shows a key opportunity to reduce the use of opioid painkillers by their patients.

The analysis of four years' worth of datafrom two million patients show that those who had dental procedures on a Friday or a day before a holiday were much more likely to fill a prescription for an opioid than other patients.

Teens and young adults were the most likely to get opioids, which were likely prescribed in order to get them through the weekend or holiday break without needing to contact the dentist for pain care.

One in five of the patients, all between the ages of 13 and 64, filled a prescription for an opioid, even though non-opioid pain medications are equally effective at controlling pain and have lower risks.

Those who had pre-weekend or pre-holiday procedures were 27% more likely to pick up an opioid prescription. If they were teens or young adults, they were 43% more likely than older patients to do so.

The new findings, reported in the Journal of the American Dental Association by a team from the University of Michigan, build on prior work showing overprescribing of opioids by dentists with no increase in pain relief or patient satisfaction .

The rate of weekend and holiday opioid prescription-filling by young people is especially troubling because of previous work showing that those who get opioids after getting their wisdom teeth out are nearly three times as likely to keep refilling the prescription long after their mouths should have healed.

"Variation in opioid prescription fills may put some patients at increased risk," says Caitlin Priest, the U-M Medical School student who led the analysis as part of the Michigan Opioid Prescribing Engagement Network team. "Now that we understand that dental opioid prescription fills were increased on Fridays and before holidays, we can create and disseminate best practices to avoid unnecessary prescribing."

Just over half of the patients whose records were analyzed had their dental procedure on an emergency basis. But the rest were scheduled - one-fifth of them on Fridays and the days before holidays.

Half of the patients who filled an opioid prescription had had scheduled surgical tooth extractions, but the pre-weekend and pre-holiday increase was seen across all 11 dental procedures studied.

This suggests multiple opportunities to reduce unneeded opioid prescribing, says Romesh Nalliah, M.H.C.M., D.D.S., the associate dean for patient services at the U-M School of Dentistry and a member of the study team. He notes that patients may seek Friday and pre-holiday appointments for their scheduled procedures to avoid missing work as they recover.

"The significance of our study is that, with the help of big data, it begins to unpack potentially harmful opioid prescribing trends that were not previously understood," he says. "In the event that we have particular concerns about a given case or patient, we can more deliberately book surgeries when we are available to follow-up."

The senior author of the paper, Chad Brummett, M.D., co-directs Michigan OPEN, which has published evidence-based guidelines for opioid prescribing for acute pain caused by many types of procedures and operations. He is also director of pain research in the Department of Anesthesiology at Michigan Medicine, U-M's academic medical center.

The guidelines say that for dental extractions, non-steroidal anti-inflammatory medications and over-the-counter pain relievers should be sufficient for pain control.

Cavity-causing bacteria assemble an army of protective microbes on human teeth

Examining bacteria growing on toddlers' teeth, a team from the University of Pennsylvania and Georgia Tech found that the microbes' spatial organization is crucial to how they cause tooth decay

UNIVERSITY OF PENNSYLVANIA

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IMAGE: RESEARCHERS FROM THE UNIVERSITY OF PENNSYLVANIA FOUND THAT THE BACTERIA RESPONSIBLE FOR TOOTH DECAY "SHIELDS " ITSELF UNDER BLANKETS OF SUGARS AND OTHER BACTERIA IN A CROWN-LIKE ARRANGEMENT, HELPING IT EVADE... view more 

CREDIT: DONGYEOP KIM

Studying bacteria in a petri dish or test tube has yielded insights into how they function and, in some cases, contribute to disease. But this approach leaves out crucial details about how bacteria act in the real world.

Taking a translational approach, researchers at the University of Pennsylvania School of Dental Medicine and the Georgia Institute of Technology imaged the bacteria that cause tooth decay in three dimensions in their natural environment, the sticky biofilm known as dental plaque formed on toddlers' teeth that were affected by cavities.

The work, published in the journal Proceedings of the National Academy of Sciences, found that Streptococcus mutans, a major bacterial species responsible for tooth decay, is encased in a protective multilayered community of other bacteria and polymers forming a unique spatial organization associated with the location of the disease onset.

"We started with these clinical samples, extracted teeth from children with severe tooth decay," says Hyun (Michel) Koo of Penn Dental Medicine, a co-senior author on the work. "The question that popped in our minds was, how these bacteria are organized and whether their specific architecture can tell us about the disease they cause?"

To address this question, the researchers, including lead author Dongyeop Kim of Penn Dental Medicine and co-senior author Marvin Whiteley of Georgia Tech, used a combination of super-resolution confocal and scanning electron microscopy with computational analysis to dissect the arrangement of S. mutans and other microbes of the intact biofilm on the teeth. These techniques allowed the team to examine the biofilm layer by layer, gaining a three-dimensional picture of the specific architectures.

This approach, of understanding the locations and patterns of bacteria, is one that Whiteley has pursued in other diseases.

"It's clear that identifying the constituents of the human microbiome is not enough to understand their impact on human health," Whiteley says. "We also have to know how they are spatially organized. This is largely under studied as obtaining intact samples that maintain spatial structure is difficult."

In the current work, the researchers discovered that S. mutans in dental plaque most often appeared in a particular fashion: arranged in a mound against the tooth's surface. But it wasn't alone. While S. mutans formed the inner core of the rotund architecture, other commensal bacteria, such as S. oralis, formed additional outer layers precisely arranged in a crownlike structure. Supporting and separating these layers was an extracellular scaffold made of sugars produced by S. mutans, effectively encasing and protecting the disease-causing bacteria.

"We found this highly ordered community with a dense accumulation of S. mutans in the middle surrounded by these 'halos' of different bacteria, and wondered how this could cause tooth decay," Koo says. "

To learn more about how structure impacted the function of the biofilm, the research team attempted to recreate the natural plaque formations on a toothlike surface in the lab using S. mutans, S. oralis, and a sugar solution. They successfully grew rotund-shaped architecture and then measured levels of acid and demineralization associated with them.

"What we discovered, and what was exciting for us, is that the rotund areas perfectly matched with the demineralized and high acid levels on the enamel surface," says Koo. "This mirrors what clinicians see when they find dental caries: punctuated areas of decalcification known as 'white spots.' The domelike structure could explain how cavities get their start."

In a final set of experiments, the team put the rotund community to the test, applying an antimicrobial treatment and observing how the bacteria fared. When the rotund structures were intact, the S. mutans in the inner core largely avoided dying from the antimicrobial treatment. Only breaking up the scaffolding material holding the outer layers together enabled the antimicrobial to penetrate and effectively kill the cavity-causing bacteria.

The study's findings may help researcher more effectively target the pathogenic core of dental biofilms but also have implications for other fields.

"It demonstrates that the spatial structure of the microbiome may mediate function and the disease outcome, which could be applicable to other medical fields dealing with polymicrobial infections," says Koo.

"It's not just which pathogens are there but how they're structured that tells you about the disease that they cause," adds Whiteley. "Bacteria are highly social creatures and have friends and enemies that dictate their behaviors."

The field of microbial biogeography is young, the researchers say, but extending this demonstration that links community structure with disease onset opens up a vast array of possibilities for future medically relevant insights.

Journal of Dental Research study: Fluoridation is not associated with increase in osteosarcoma

Study published in the Journal of Dental Research demonstrates that community water fluoridation is not associated with increased risk of osteosarcoma

INTERNATIONAL & AMERICAN ASSOCIATIONS FOR DENTAL RESEARCH

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May 11, 2020, Alexandria, Va., USA--The Journal of Dental Research published today the results of a study that demonstrated that community water fluoridation is not associated with increased risk of osteosarcoma.

More than sixty percent of the U.S. population have access to community water fluoridation, considered to be one of the most important public health policies of the twentieth century due to its reduction of tooth decay at the population level. Fluoride ingestion has been suggested as a possible risk factor for osteosarcoma based on a 1990 animal study. Six of the seven subsequent case-control studies in humans reported that fluoride in drinking water was not associated with osteosarcoma.

This study assessed whether living in a fluoridated community was a risk factor for osteosarcoma by performing a secondary data analysis using data collected from two separate, but linked studies. Patients for both Phase 1 and Phase 2 were selected from U.S. hospitals using a hospital-based matched case-control study design. For both phases, cases were patients diagnosed with osteosarcoma and controls were patients diagnosed with other bone tumors or non-neoplastic conditions.

In Phase 1, cases (N=209) and controls (N=440) were patients of record in the participating orthopedic departments from 1989-1993. In Phase 2, cases (N=108) and controls (N=296) were incident patients who were identified and treated by orthopedic physicians from 1994-2000. This analysis included all patients who met eligibility criteria on whom we had complete data on covariates, exposures, and outcome. Conditional logistic regression was used to estimate odds ratios (OR) and 95% confidence intervals (CI) for the association of community water fluoridation with osteosarcoma.

The adjusted OR, for osteosarcoma and ever-having lived in a fluoridated area for non-bottled water drinkers was 0.51(0.31 - 0.84), p=0.008. The same comparison adjusted OR for bottled water drinkers was 1.86 (0.54 - 6.41), p=0.326.

"These results indicate that residence in a fluoridated community is not related to an increase in risk for osteosarcoma after adjusting for race, ethnicity, income, distance from the hospital, urban/rural living status, and drinking bottled water. This should not be surprising given that ingestion of fluoridated water is a common exposure and osteosarcoma remains a rare disease," said Chester Douglass; Harvard School of Dental Medicine, Department of Oral Health Policy and Epidemiology.

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View the complete paper at https://journals.sagepub.com/doi/full/10.1177/0022034520919385 or contact IADR at media@iadr.org.