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Strive-the Student View Endurance Athletes at Increased Risk for Caries
It has always been a joy for me to return to school after a summer vacation and talk about what I did over the break. It wasn’t until I returned to school in the fall of 2004, when I received the comment “You did what?! Are you out of your mind?” that I realized that my activities over the break were not universally perceived as “fun.” I had completed my first Ironman triathlon in Coeur d’Alene, Idaho, that summer. Endurance events such as the Ironman (consisting of a 2.4-mile swim, 112-mile bike ride, and a 26.2-mile run) and ultramarathons are increasingly popular, so we can expect to see an increasing number of patients becoming interested and/or involved. What some do not realize, however, is that this type of lifestyle can increase the risk of decay for these individuals. The Diet The strenuous efforts that endurance athletes train in can take a tremendous toll on their bodies if energy expenditures are not compensated for with an equal amount of energy, or calories, consumed by the athlete. For this reason, the diet of the endurance athlete consists mostly of carbohydrates. Athletes consume carbohydrates at a rate of 6 - 10 g/Kg body weight per day, which represents about 60% of their calories.1 This type of diet is crucial to the health of the athlete throughout the training period because “diminished energy intake can compromise nutrition intake and exercise performance while decreasing both body fat and muscle mass.”1 Perhaps an even more detrimental effect of the endurance athlete’s diet occurs during a race. It is then that the athlete must consume a greater amount of carbohydrates with greater frequency. The Ironman triathlon, for example, can last anywhere from 8 to 17 hours. During this period, the athlete needs not only to consume the amount of calories she/he would on a day with no exercise, but also to compensate for the calories burned during the event. The American Dietetic Association, Dietitians of Canada, and the American College of Sports medicine suggest that “during exercise [it is necessary to] replace fluid losses and provide carbohydrate (approximately 30 - 60g per hour) for the maintenance of blood glucose levels.”1 This means that up to 1020g of carbohydrates must be consumed. Dental professionals know that a diet high in carbohydrates provides more nutrient content in the mouth for Streptococcus mutans to flourish. Research states that “biofilm formed in the presence of sucrose presents low concentrations of calcium, phosphorus, and fluoride”2 and that “frequent drinking or sipping of sugary drinks provides an abundant food supply for the caries-causing bacteria on tooth surfaces.”3 Sugary drinks include sports drinks commonly used during strenuous activity. Taking a look at the nutritional supplements that are available on the market, we can see a source of potential problems. The assortments of bars, gels, drinks and chews all contain large amounts of sugar. With the amount and frequency of fermentable carbohydrate consumed on a daily basis and during an event, we can see that oral cariogenic bacteria will have adequate time to establish themselves. In a study by Luke, Gough, Beeley, and Geddes, it was found that “carbohydrate residues… were still present in the mouth even 1 hour after ingestion.”4 James P. Dorosh DDS of Spokane, Wash., competed in Ironman races in 2004 and 2005. His race diet consisted of energy gel every 2 - 3 miles (approximately every 30 minutes), fruits such as bananas and energy drinks with water. Chad P. Collins, DMD, of Spokane, Wash., while racing in the Portland and Seattle Marathons, consumed energy gel about every 45 minutes and water or energy drinks every mile. James Hoppe, DDS, of Spokane, Wash., while training for the Madrid Marathon in Spain, would drink 2 oz. of energy drink or water every mile and, when drinking water, would eat a gel pack every four or five miles. With consumption of carbohydrates as frequent as this, the activity of bacteria in the mouth can be nearly constant. Current literature explains how the sports nutrition diet can accelerate demineralization and the caries process, and deserves attention from the dental professional. After volunteering in the medical tent during Ironman races in 1994, Kathy Conlin, RDH, RN, of Spokane, Wash., recalled that she “would see the European and Australian participants with obvious class V and interproximal caries when they would smile.” Conlin added that the acidity of sports drinks may affect the progression of decay, a relationship that has also been reported in literature.5 The anterior teeth are the ones most exposed to sports drinks and most likely to become dehydrated, which is the next risk factor. Dry Mouth: A Catalyst for Decay As an athlete trains and races, the rate of breathing increases along with the level of intensity of the exercise. With increased respiration, the mouth tends to become drier due to the large amounts of air passing through it. Collins, Dorosh and Hoppe all report having experienced dry mouth during racing, and Conlin observed the trend in participants as well. In a study by Kalan, Kenyon, Seemungal and Wedzicha, the side effect of dry mouth was more common with increased flow rate in the presence of nasal positive pressure ventilation used to alleviate sleep apnea.6 Where there is less saliva flow, and thus a lower concentration of neutralizing enzymes, the caries process is accelerated. Zussman, Yarin and Nagler concluded early this year that elderly and otherwise xerostomatic individuals have oral cavities that are more susceptible to caries due to the compromised lubrication.7 Xerostomia has further been associated with an increased number of lactobacilli and S. mutans.8 The many benefits of saliva have been well catalogued (e.g., acid buffering, a solvent for carbohydrates, lubricant, etc.) and with its decreased activity during sporting events, a cariogenic environment is more likely. Call for Education Athletes are typically health-oriented individuals and will thus be open to making healthier decisions. It is our responsibility to illustrate the dangers that are involved in dental decay. These are some simple suggestions that we can make as dental professionals that will fit well into a high-intensity lifestyle: 1. Suggest the use of xylitol-containing products such as chewing gum between workouts and meals to attempt to generate remineralization. In a study by Simons, Kidd, Beighton and Jones, not only was the chewing gum found to inhibit S. mutans, but it also provided relief from dryness in 55% of subjects by increasing salivary output.9 Sports drinks companies are starting to use xylitol for a sweetener; educating our athlete patients on what to look for in a drink or gel can help them make better decisions for their oral health. 2. Recommend that the athlete carry a bottle of water while racing and working out to rinse the mouth after consumption of gels, drinks and bars. This can also help relieve dry mouth. Dorosh stated that, during races, he “used a bottle for water only and drank every few minutes…[and] during the run carried a cup of ice.” 3. Recommend the appropriate fluoride. In 2001, Duggal, Toumba, Amaechi et al. studied enamel demineralization accompanying various frequencies of carbohydrate consumption with and without the use of fluoride. They concluded that an individual would need to consume carbohydrate at a much higher frequency if using fluoridated toothpaste in order for demineralization to occur as compared to those using fluoride-free toothpaste.10 4. Reinforce the need for pit and fissure sealants where appropriate, and explain the benefits of sealing areas where bacteria can flourish. 5. Reinforce the importance of proper home care. Brushing well and flossing regularly are the best defense we have against caries, along with visits to the dental office as needed to check up on and maintain a state of oral health conducive to overall health. Hoppe reported, “I treat a few presently active endurance athletes and more who were very good past endurance athletes and may not be presently training. Many of these older athletes have had severe dental problems leading to many dental procedures including dentures, root canals, crowns, etc. I have attributed this to poor dental habits and inconsistent dental treatment. However, possibly these dental problems could have been initiated when they were training in younger years.” While endurance events are usually pursued by the generally health-conscious individual, there are still those who are unaware of the effects the oral environment can have on overall health. By modifying education, home care and nutritional instructions to fit the athlete’s personal needs, we can help to decrease the incidence of caries in this higher risk population.
Amanda Bergquist is a recent graduate of the dental hygiene program at Eastern Washington University. She has been involved in endurance sports for over four years and has an increasing passion for the hobby. She plans to begin her career in eastern Washington as a general practice dental hygienist as well as to continue learning about endurance sports as a serious and committed competitor.
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By
Amanda Bergquist
