1. Introduction
Success in sport depends on multiple factors that combine to achieve optimal performance. Neglecting any aspect involved in the training processes could lead to sports failure [
1]. Maintaining proper oral hygiene is considered an important variable in maintaining a general health status [
2,
3].
Recent studies have highlighted the growing interest that dental health is currently achieving in sports, especially when dealing with professional and elite sports [
4,
5,
6]: usually, athletes tend to have many oral problems like frequent intake of carbohydrates and acidic sports drinks, dry mouth, and little knowledge about oral health are some of the reasons that explain the high prevalence of oral diseases in this group [
7].
Dental health may play a relevant role in sports performance, so adequate prevention could allow athletes to maintain their training and competition routines, without suffering interference in their sports planning due to the occurrence of some dental discomforts [
1,
7]. For this reason, the improvement of dental status assessments should be highly recommended in the medical follow-up of athletes [
8].
Research conducted at top-level international competitions highlights the importance that oral health monitoring is gaining in elite sport. During the Olympic Games, the care and maintenance of oral health has become increasingly important: in Athens 2004, dental care was the second most demanded health service [
9], while during the Olympic Games of Beijing 2008, close to 1600 dental treatments were carried out [
10]. Additionally, during the London 2012 Olympic Games, 30% of all medical emergencies presented by athletes were induced by oral diseases [
11,
12].
Interest in oral health in sport has increased, due to the significant prevalence of oral disorders among athletes, acquiring a more preventive approach [
13,
14]. As a consequence, oral examinations and oral health status are taken into account in athletes eligible to participate in the Olympic Games, with the purpose of creating dental awareness and avoiding possible problems during competition [
6].
In the field of professional sports, the evaluation of oral health has increased due to its relationship with athletes’ general physical condition: both caries and periodontal disease can be infectious foci and may degenerate into heart problems due to the huge number of bacteria that are located at the gingival level and can access the bloodstream, affecting other body regions [
15,
16].
Many joint and muscle injuries are the consequence of dental foci and/or periapical infections: if this happens, athletes may suffer asthenia expressed as muscle fatigue, joint inflammation, joint pain, or tendon injuries with late recovery [
17,
18].
On the other hand, the absence of teeth due to trauma and/or diseases entail other consequences, such as digestive disorders with a higher energy expenditure and slower digestion, being a disadvantage in sports competition [
19]. Craniomandibular disorders are also frequent among elite athletes due to the habit of bruxism usually induced by stress during competition or training: bruxism not only affect the temporomandibular joint (TMJ) or teeth (wear), but may also cause head, neck, and back muscle pain [
20].
In an experiment with highly proficient marksmen, performance was found to be significantly better when the mandible was in symmetric centric relation, as compared with intercuspal or lateral occlusion, an effect primarily attributed to postural stabilization [
21]. In this context, recent studies investigated the performance of golf professionals while using stabilizing splints: Kwon et al. (2010) and Pae et al. (2013) observed significant improvements in driving distance and club head speed when the oral appliances were being used [
22,
23]. Professional soccer and volleyball teams reported significant oral health problems associated with reduced performance [
24,
25,
26]. Moreover, previous studies reported differences in oral status between athletes and the control group [
24,
27,
28].
However, to our knowledge, there are no studies that have analyzed differences in oral health between team and individual sports. It may be speculated that a more institutionalized attention to dental status is paid by the medical service of sport teams in comparison with athletes who train individually: sometimes the athlete voluntarily decides to visit or to not visit the dentist, but this is often overlooked, due to many factors such as fear, lack of time, training schedules, etc. The features of the different sports modalities could also influence the athlete’s oral status. In this sense, long-term endurance sports duration may present the highest risk, since they require large carbohydrate intake due to the extraordinary degree of glycogen breakdown during exercise. This intake, which is done throughout the day and during exercise in the form of gels, bars, or energy drinks may significantly increase the risk of tooth decay and erosion [
29]. In this respect, the objective of this study was to evaluate the state of oral health and oral health habits in elite athletes according to the type of sport practiced, evaluating different individual and team sports.
4. Discussion
The purpose of this study was to evaluate the state of oral health and oral health habits in elite athletes according to the practiced sports modality. There is increasing evidence that elite or professional athletes present a poor oral health status, with consequences in well-being, training, and performance [
1,
13,
26,
28].
The OHIP-14 was aimed at capturing the impacts that oral conditions have on the athletes’ quality of life. All the impacts measured by OHIP-14 were conceptualized as adverse outcomes and therefore the instrument measured the negative aspects of oral health [
39]. The results achieved revealed that there were no significant differences in the score obtained in the OHIP-14 questionnaire according to the sport type: athletes considered that their oral status had no negative impact on their quality of life or performance, being quite satisfied with their oral situation. However, this self-perception was not completely in accordance with the results achieved by the clinical examination.
One of the most relevant results highlighted in this study regards the number of teeth present in the oral cavity, which differs depending on the sport type: a higher number of teeth have been found in athletes who compete in team disciplines. Likewise, a greater number of healthy teeth were found in athletes who practice team sports. It may be due to the fact that athletes who train individually often decides to visit or not the dentist without specific and institutionalized medical guidelines, and many factors such as fear, training schedules, geographical limitations/distance (i.e., for athletes training in rural areas, like climbers, trail runners, etc.), lack of economical support, etc., may negatively affect their awareness about oral health. The results obtained in the present study regarding team sports athletes are similar to those reported by Needleman et al. [
11] in Olympic athletes and Gallagher et al. [
13] in elite and high-performance athletes. In a recent survey on the oral health status of the Spanish population, the cohort between 35 and 44 years old presented an average of 25.3 teeth in arch (on a maximum of 28, since the third molar was excluded from the analysis) [
32]. These findings confirm the importance of monitoring, detecting, and promptly treating dentition in elite athletes, since its alteration can negatively affect chewing. Although many studies support the concept of reduced dental arch suggesting that a full dentition may not be necessary or desirable for all patients (thus questioning the need for replacement of missing molars, which are the most commonly affected by tooth decay and periodontal disease), other authors suggest that incorrect chewing, as a result of a deficit in the oral health status, can induce facial muscle overload and therefore produce an alteration in the digestion and absorption of nutrients, which may require higher nutritional energy expenditure [
19,
40,
41,
42].
Oral health status differed between groups and the number of decayed and missing teeth and DMFT index were higher in individual sports athletes. Previous studies reported that the incidence of caries in elite athletes was 75% [
1] and 49.1% [
13]. Likewise, Needleman et al. [
11] reported that more than half of the athletes had dental caries (55.1%). A study carried out in soccer players revealed that 37% of them had active tooth decay [
26]. Regarding the DMFT index, previous authors observed higher values in competitive soccer players compared to the inactive population [
24,
43]. However, Juliá-Sánchez et al. [
44] obtained a lower DMFT index in anaerobic athletes compared to the control group. In a sample with characteristics similar to those of the present study, DMFT values ranging from 2.8 to 16.8 were reported [
45]. Regarding individual endurance athletes, values of 6.2 were observed for swimmers and 11.6 for cyclists [
46]. It should be noted that the results obtained in the present study achieved DMFT indexes superior to those reported in the Spanish youth population [
47,
48]. When comparing the restoration indexes (IRs), the sample analyzed presented lower values than the Spanish population (56.1%) [
32].
Regarding periodontal plaque, it was observed that the prevalence was higher in athletes of individual sports modalities. Dental plaque accumulation may reflect a reduced awareness about oral health status and may be associated with the development of more destructive forms of periodontal diseases in later life. Different studies report a close relationship between exercise and physiological changes in the immune system: exercise may reduce the immune response depending on its type, duration, and intensity thus increasing susceptibility to certain infections, including periodontal disease [
46,
49,
50].
Ashley et al. [
1] reported that the prevalence of moderate irreversible periodontal disease was up to 15% and gingivitis up to 76% in elite athletes. Kragt et al. [
6] reported a Dutch periodontal screening index score of 1.71 ± 0.73 in Olympic athletes, which was equivalent to the presence of dental plaque. Moreover, Gay Escoda et al. [
24] reported an association between periodontal plaque and gingivitis. When comparing these results with the 2015 Spanish Oral Health Survey, it is evident that there is more prevalence of gingival/periodontal disease in athletes than in the general population [
32].
Nutritional intake, including regular diet, sports drinks, and supplements, is an important determinant of oral health [
7]. Athletes present a high risk of developing dental caries due to high and frequent carbohydrate intake [
51]. Frequent consumption of sports drinks has been reported by 55–91% of athletes [
28,
51]. Long-term endurance sports require a large intake of carbohydrates, water, and electrolytes due to the high degree of glycogen breakdown and increased sweating during physical exercise. Currently, in all endurance sports, most of them practiced individually, such as for cycling or a triathlon, the consumption of gels and energy bars is highly extended, due to their easiness and rapid assimilation. These foods are characterized by their adherence to the tooth surface and they are rich in carbohydrates and citric acid [
52]; their intake, which is carried out throughout the day and during exercise in the form of gels, bars, or energy drinks, may significantly increase the risk of tooth decay and erosion [
51,
53]. Therefore, Frese et al. [
28] found a significant correlation between the incidence of caries and the hours of weekly training. Frequent consumption of carbohydrates causes a drop in pH in the oral environment that could lead to prolonged tooth demineralization and subsequent caries development [
28,
53]. Commercially available sports drinks have a low pH and a buffering capacity of 43.0–56.5 (mmol/OH) [
54]: dehydration and dry mouth during sports can increase the impact of carbohydrates on oral health by reducing the amount of saliva and, therefore, impairing its protective function [
55].
Knowledge of food composition, the amount and frequency of food intake, and the way in which sugary drinks are consumed, can be an important factor for the development of preventive programs aimed at improving oral health status [
56,
57,
58]. Regarding the intake of sugary drinks, all athletes confirmed using them, being more frequent among those who practice team sports during the recovery phases. The amount and frequency of ingestion constitute a moderate risk factor for the development of carious lesions [
7,
59]. Theoretically, the use of low-sugar or sugar-free bars or sports drinks should be advisable, although few data on their effectiveness on sport performance are available in the literature. Low-glycemic index versus a high-glycemic index sport nutrition bars consumed before a simulated soccer match were recently investigated revealing a lower carbohydrate oxidation rate and a modest improvement in performance (i.e., better agility and heading performance late in a simulated soccer match) [
60]. However, other authors found no relationship between sports drink intake and oral health [
61]. To reduce risk factors for developing oral diseases, it is essential to introduce preventive measures like promoting periodic oral assessment programs and the learning of correct oral hygiene procedures. In the present study, the mean with respect to the last visit to the dentist was around 19 months, far from what is recommended by the health authorities [
31]. The better oral health results found in team athletes could be due in part to the fact that sports teams, having their own medical services, could predispose athletes to better access to primary care centers and induce greater awareness in the maintenance of oral health [
62].
Regarding the prevalence of malocclusions, the present study highlighted a significant relationship between sports modality and malocclusion. Athletes in individual sports modalities presented a higher prevalence of classes II and III. The presence and influence of dental malocclusion has been studied in individual and team sports [
24,
63,
64,
65]. Using a similar methodology, Souza et al. [
63] evaluated players between 13 and 20 years old classifying 89% of them in class I, 8% in class II, and 3% in class III. Similarly, after evaluating the Barcelona Football Club players, Gay Escoda et al. [
24] reported that the prevalence of class I was 60%, while class II and III were 20%. Alterations in occlusion could significantly compromise performance, as they may interfere with chewing effectiveness and subsequent food digestion, impairing nutrient absorption. Other factors that may depend on occlusal alteration have also been proposed: loss of muscle balance, headache, temporomandibular joint problems, discomfort, or stress [
66].
The training of an athlete necessarily implies the acquisition of coordinative abilities that allow him/her to control his/her motor actions. Balance participates in the proper execution of complex sports actions, being influenced by numerous factors including the stomatognathic system. A dental occlusion seems to differentially affect postural control depending on static versus dynamic conditions and on whether the eyes are open or closed. The main impact was previously observed to occur in dynamic conditions and with closed eyes. Maintaining balance (static and dynamic) is essential for an athlete, for a two reasons: first of all because athletes tend to have better balance and then because it seems to decrease the risk of sports injuries [
67,
68,
69]. The influence of dental occlusion on body posture appears more pronounced in professional athletes than in the general population [
65].
The present study presented the following limitations: (1) no distinction was made between sexes; (2) the nutritional intake of the participants was not analyzed; (3) there was no control group to compare results. The methodology of the present study should be repeated in a larger sample of athletes. Future research should also focus on the influence of oral status on athletes’ performance and on the effect of preventive oral health examinations.