Simple Oral Health Interventions Improve Elite Athlete Performance

Dentistry Today
Martin Bennett/Gloucester Rugby


Martin Bennett/Gloucester Rugby

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, according to the University College London (UCL) Centre for Oral Health and Performance (COHP).

Previous UCL studies have found that elite athletes have substantial rates of oral disease, including tooth decay and gum disease, and these symptoms have negatively affected their well-being and athletic performance.

Researchers at UCL COHP then designed a behavioral change program aimed at better educating elite athletes about oral health and providing simple interventions to improve their daily oral health routines.

“Poor oral health of elite athletes is common and is associated with negative performance. However, compared with other health and training pressures, oral healthcare is not a high priority in elite sport,” said lead author Dr. Julie Gallagher of the UCL Eastman Dental Institute.

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

The study recruited 62 athletes from two Great Britain (GB) Olympic teams, rowing and cycling, and one Premiership Rugby club, Gloucester Rugby. Athletes and support teams watched a 10-minute presentation on building motivation to improve oral health and three 90-second information films featuring GB rower Zak Lee-Green about increasing oral health knowledge and skills to optimize oral health behavior.

Each athlete also received an oral health screening to check for diseases such as caries and gingivitis. They then received a bespoke follow-up report with tailored advice and an oral health toolkit including a manual toothbrush, prescription fluoride toothpaste, and floss picks. As a minimum, they were asked to brush their teeth for two minutes twice a day before training in the morning and before bed in the evening.

According to the researchers, 89% of the athletes completed the four-month study. On completion, athletes were asked to complete an oral health knowledge questionnaire, undergo a follow-up gingival assessment, and evaluate the oral health kit. The study found that the behavior change model was associated both with reductions in self-reported negative performance impacts and in improvements in oral health behaviors.

Athlete use of prescription strength fluoride eight (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) scores 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 oral health problems affected sports participation, training volume, athletic performance, and the extent to which the individual has experienced oral pain.

As a result of the behavioral change program, the mean OSTRC-O score across athletes reduced from 8.73 (out of 100) to 2.73. While the score was low at the outset, the researchers said, the change does indicate a statistically significant reduction in problems associated with oral health and sporting performance.

Also, the number of athletes who reported a 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.

“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,” Gallagher said.

“We believe that bringing behavior change science together with an understanding of the athletes’ and teams’ priorities is key to making changes stick,” said Gallagher.

There are multiple reasons why athletes are more likely to have poor oral health, the researchers said. For example, physical activity causes a dry mouth, which in the long term increases risk of tooth decay and gum diseases, along with frequent sugar intake from normal diet and energy supplements.

“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,” said study coauthor and UCL COHP lead professor Ian Needleman.

“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,” said Needleman.

“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,” said Zak Lee-Green, a dentist and member of the GB Rowing Team who took part in the study.

“This program 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,” said Lee-Green. “It can only be a step in the right direction of the sporting role models of the present and future are managing their oral health in the same way that they do their elite training.”

“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,” said Dr. Nigel Jones, head of medical services at British Cycling.

“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,” Jones said.

This behavioral change study was based on the COM-B model, which identifies sources of behavior that could provide opportunities for intervention. Capability (C) represents the person’s physical skills and knowledge in performing the behavior. Opportunity (O) is access to the necessary materials and social environment such that the person feels able to undertake the new behavior. Motivation (M) refers to a person deciding to adopt the behavior.

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

The study, “Implementation of a Behavioral Change Intervention to Enhance Oral Health Behaviors in Elite Athletes: A Feasibility Study,” was published by BMJ Open Sport & Exercise Medicine.

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