Implementation of a behavioural change intervention to enhance oral health behaviours in elite athletes: a feasibility study

Disadvantage starts early: academy football has high levels of oral disease

ABSTRACT

Objectives

We have previously reported high levels of oral disease in professional senior team footballers in England and Wales. In this study, we aimed to determine the prevalence of oral disease in professional academy footballers, to identify if problems start earlier and to inform health promotion strategies.

Method

Professional academy football clubs in England (footballers aged 16-18 years) were invited to participate. Questionnaires were used to collect oral health behaviours and self-reported impacts and validated clinical outcomes to assess oral health.

Results

160 academy footballers were recruited from 10 English academy football clubs, of whom 86.8% (n=139) were men and 13.2% (n=21) were women, with a median age of 16.9 years. We identified high levels of oral disease: 31.2% (n=50) had dental caries requiring treatment; 76.8% (n=123) had gingivitis; and 22.5% (n=36) had periodontitis. Tooth wear affecting up to at least 50% of tooth structure was present in 15.5% (n=25) of participants. While 76.2% (n=122) self-reported brushing their teeth twice a day, 15.5% (n=25) brushed once or less a day and 21% (n=34) had not attended the dentist for >2 years. There was a general perception that oral health issues impacted the sporting performance of participants.

Conclusion

In this study, the prevalence of oral diseases among professional academy footballers in England was high and greater than found in national surveys of a similar age demographic. Urgent action is needed to embed oral health promotion in development and youth football, to reverse and prevent the disadvantages that will have lifelong consequences for treatment burden, quality of life and sporting performance.

Association between periodontitis and physical fitness in law enforcement workers

OBJECTIVES

Oral and periodontal health have been linked to systemic health, cardiovascular disease and inflammation markers. Physical fitness has been linked to increased inflammatory response, but only few studies have investigated the association between oral health with physical activity. The aim of this study was to evaluate the association between oral and periodontal health status and physical fitness in British law enforcement workers.

METHODS

89 subjects were recruited between November and December 2019. Cardiopulmonary fitness was measured by Maximal Oxygen Uptake (VO2max) (ml/kg/min) and Maximum Load (Loadmax) (W) generated at the end of the Bruce incremental treadmill test; physical activity levels through accelerometers; functional strength tests by Countermovement Jump (CMJ) Power (W) and Height (cm) average. Oral variables included percentage of sites with PPD > 4 mm (% PPD > 4), full-mouth bleeding score (FMBS) and Decayed, Missing, and Filled Teeth (DMFT) index. Linear regression models were adjusted for age, gender and fat %.

RESULTS

Mean age was 41.5 years (range 23-61; 71.9% male). Higher % PPD > 4 was consistently correlated with lower Loadmax (-4.96; p = 0.092), CMJ Height average (-0.39; p = 0.064), and press-ups in 60 s (-0.85; p = 0.052) though the associations were not statistically significant. FMBS was associated with the % of a day spent in sedentary (0.78; p = 0.030) and light activities (-0.75; p = 0.022).

CONCLUSIONS

Periodontitis may be negatively associated with certain components of physical performance.

CLINICAL RELEVANCE

Oral health status may be associated with physical fitness and functional strength.

Concordance and Clinical Outcomes Improvement Following Oral Hygiene Motivation: A Systematic Review and Report of the Workshop of the Italian Societies of Dental Hygiene

Aim: A workshop on concordance and oral hygiene was held in February 2024. To address the topic, a systematic review aimed at investigating the effectiveness of motivational interventions in improving oral hygiene and focusing on periodontal clinical indices outcomes was designed. Materials and Methods: A comprehensive literature search was conducted across PubMed and Scopus electronic databases to identify relevant articles published up to 2024. Inclusion criteria encompassed studies comparing motivational interventions targeting oral hygiene behaviours, with a focus on periodontal clinical indices. Twelve articles meeting the eligibility criteria were selected for analysis. Quality assessment and data extraction were performed systematically. Results: The synthesis of findings from the selected studies revealed a consistent positive effect of motivational interventions on periodontal clinical indices. These interventions encompassed various strategies, including educational sessions, personalized feedback and motivational interviewing. Improvement in indices such as plaque index (PI), gingival index (GI) and periodontal probing depth was observed following motivational interventions, despite the variety of motivational protocols employed. Conclusion: Motivational interventions are effective in enhancing oral hygiene practices and improving periodontal clinical indices. Tailored motivational approaches can serve as valuable tools in promoting oral health behaviours among individuals, potentially reducing the risk of periodontal diseases. Further research is warranted to explore the long-term sustainability and scalability of motivational interventions in diverse populations and settings.

Periodontal disease and sports performance: a systematic review and meta-analysis

This systematic review and meta-analysis aimed to assess the association between athletic performance and periodontal disease (PD). Observational studies published up to April 2022 were searched in online databases (PubMed, Scopus, Web of Science, The Cochrane Library, LILACS, OpenGrey, and Google Scholar). PECO statement focused on studies with professional athletes (Participants) with PD (Exposition) compared to those with healthy periodontium (Comparison) and its effects on sports performance (outcome). Searches were conducted according to the PRISMA guidelines (registration protocol: 10.17605/OSF.IO/7ADH6) and risk of bias evaluation according to the Joanna Briggs Institute checklist. A total of 793 references were retrieved, of which eight were considered eligible. Two studies did not show an association between clinical PD parameters and performance. A meta-analysis with 396 participants suggested a relationship between PD and self-reported reduction in sports performance (odds ratio [OR] = 1.55; 95% confidence interval [CI] 1.04-2.31; p = 0.03; I2 = 0%) with moderate quality of evidence accordingly GRADE analysis. Despite the differences in performance evaluations between studies, PD was associated with reduced self-reported sports performance. Additional studies assessing confounding factors and objective assessment of PD and performance are needed to clarify the real effect of both conditions.

Evaluation of Oral and Dental Health Results and Competition Stress Levels of Adolescent Athletes in Different Winter Sports Branches

BACKGROUND

 The aim of the present study was to examine the findings of the intraoral examinations of the 12-16 years old novice (control) and elite athletes across the winter sports branches, which were alpine discipline skiing, snowboarding, biathlon, ski jumping, and ice hockey. Besides, the study aimed to determine the intra- and inter-group relationships by comparing the athletes salivary stress biomarker levels at precompetition, during-match, and post-competition stages.

METHODS

 Ninety-one athletes (71 elite, 20 novice) participated in our study. Oral health status of the athletes were evaluated. In addition, cortisol levels in the saliva samples obtained at pre-competition (rested before the competition), during-match (just before the start), and post-competition (competition ending moment) stages were measured. The data were analyzed statistically with a significance level of 0.05.

RESULTS

 Ice hockey athletes were the most affected by untreated dental caries (27.3%). No signs of dental trauma caused by sports activities were found in the winter sports branches. Basic erosive wear examination scores of the ice hockey athletes were similar to the ski jumping athletes and lower than other groups (P=.034). The mean cortisol values between sports branches were listed as: biathlon alpine skiing < ice hockey < ski jumping (P < .001). Test results of the winter sports athletes' saliva samples revealed that their salivary stress levels might vary in accordance with the sports branches, and there was a negative relationship between the levels of salivary stress biomarkers in competitions and oral health.

CONCLUSION

 In winter sports activities, measures for improving oral health should be disseminated.

Sports Diet and Oral Health in Athletes: A Comprehensive Review

Food and fluid supply is fundamental for optimal athletic performance but can also be a risk factor for caries, dental erosion, and periodontal diseases, which in turn can impair athletic performance. Many studies have reported a high prevalence of oral diseases in elite athletes, notably dental caries 20-84%, dental erosion 42-59%, gingivitis 58-77%, and periodontal disease 15-41%, caused by frequent consumption of sugars/carbohydrates, polyunsaturated fats, or deficient protein intake. There are three possible major reasons for poor oral health in athletes which are addressed in this review: oxidative stress, sports diet, and oral hygiene. This update particularly summarizes potential sports nutritional effects on athletes' dental health. Overall, sports diet appropriately applied to deliver benefits for performance associated with oral hygiene requirements is necessary to ensure athletes' health. The overall aim is to help athletes, dentists, and nutritionists understand the tangled connections between sports diet, oral health, and oral healthcare to develop mitigation strategies to reduce the risk of dental diseases due to nutrition.

Theoretical and methodological approaches in designing, developing, and delivering interventions for oral health behaviour change

Oral health behaviour change interventions are gaining momentum on a global scale. After lagging behind other disciplines, oral health behaviour change is becoming an area of fast and important development. Theories used in medicine and healthcare more generally are now being applied to oral health behaviour change with varying results. Despite the importance of using theories when designing and developing interventions, the variety and variation of theories available to choose from create a series of dilemmas and potential hazards. Some theories, like the COM-B (Capability, Opportunity, Motivation-Behaviour) model, and frameworks, like the Behaviour Change Wheel might represent areas of opportunity for oral health behaviour change interventions with careful consideration vital. Different methodological approaches to intervention development are actively utilized in oral health with a wide host of potential opportunities. The issue of co-designing and co-developing interventions with intended users and stakeholders from the start is an important component for successful and effective interventions, one that oral health behaviour change interventions need to consistently implement. Oral health behaviour change interventions are utilizing technology-based approaches as a major vehicle for intervention delivery and, innovative solutions are implemented across a wide host of oral health behaviour change interventions. With multiple options for designing, developing, and delivering interventions, careful selection of appropriate, user-inclusive, and adaptable approaches is essential. With a lot of available information and evidence from other disciplines, oral health behaviour change interventions need to reflect on lessons learned in other fields whilst also maximizing the potential of the wide variety of theories, frameworks, methodologies, and techniques available at present.

Theory-based behavioral change interventions to improve periodontal health

Periodontal disease is a significant global health burden affecting half of the world's population. Given that plaque and inflammation control are essential to the attainment of periodontal health, recent trends in preventive dentistry have focused on the use of behavioral models to understand patient psychology and promote self-care and treatment compliance. In addition to their uses in classifying, explaining and predicting oral hygiene practices, behavioral models have been adopted in the design of oral hygiene interventions from individual to population levels. Despite the growing focus on behavioral modification in dentistry, the currently available evidence in the field of periodontology is scarce, and interventions have primarily measured changes in patient beliefs or performance in oral hygiene behaviors. Few studies have measured their impact on clinical outcomes, such as plaque levels, gingival bleeding and periodontal pocket reduction, which serve as indicators of the patient's disease status and quality of oral self-care. The present narrative review aims to summarize selected literature on the use of behavioral models to improve periodontal outcomes. A search was performed on existing behavioral models used to guide dental interventions to identify their use in interventions measuring periodontal parameters. The main models were identified and subsequently grouped by their underlying theoretical area of focus: patient beliefs (health belief model and cognitive behavioral principles); stages of readiness to change (precaution adoption process model and transtheoretical model); planning behavioral change (health action process approach model, theory of planned behavior and client self-care commitment model); and self-monitoring (self-regulation theory). Key constructs of each model and the findings of associated interventions were described. The COM-B model, a newer behavioral change system that has been increasingly used to guide interventions and policy changes, is discussed with reference to its use in oral health settings. Within the limitations of the available evidence, interventions addressing patient beliefs, motivation, intention and self-regulation could lead to improved outcomes in periodontal health. Direct comparisons between interventions could not be made due to differences in protocol design, research populations and follow-up periods. The conclusions of this review assist clinicians with implementing psychological interventions for oral hygiene promotion and highlight the need for additional studies on the clinical effects of behavioral model-based interventions.

The Significance of Oral Inflammation in Elite Sports: A Narrative Review

Recently, there has been intense discussion about sports dentistry and potential interactions between oral health and athletes' performance. This narrative review aims to provide a comprehensive overview of the available literature about oral inflammation in sports. For this purpose, it presents the most common types of oral inflammation (gingivitis, periodontitis, pericoronitis, apical periodontitis), and their prevalence in athletes. Both the impact of oral inflammation on performance and causes for oral inflammation in athletes are discussed by presenting current literature. Finally, international recommendations for dental care in sports are presented. Several studies stated a high prevalence of oral inflammation in athletes, especially of gingivitis (58-97%) and periodontitis (41%). Also, many athletes report oral pain (17-30%) and a negative impact of oral health on training (3-9%). Besides this, a systemic impact of oral inflammation is discussed: In periodontitis patients, blood parameters and physical fitness are changed. In athletes, associations between muscle injuries and poor oral health are reported. There are deficits in oral health behavior. Furthermore, systemic changes due to physical stress could influence oral tissues. Overall, complex bidirectional interactions between competitive sports and oral inflammation are possible. Regular dental examinations and prevention strategies should be implemented in sports.

'It's their mouth at the end of the day': dental professionals' reactions to oral health education outcomes

Introduction Research has established varying levels of efficacy of oral health education (OHE) efforts. However, little is known regarding how outcomes impact dental professionals and their OHE practice. This study explores dental professionals' reactions to varying OHE outcomes and their motivations to persist with their efforts.Methods Qualitative, semi-structured interviews were conducted with dental team members working in mainly NHS general dental practices in South Wales, UK. Interviews were conducted face-to-face pre-COVID-19 and then by telephone, transcribed and analysed thematically.Results In total, 30 interviews were conducted (17 dentists, 6 dental therapists and 7 dental nurses). Pleasure was gained from improved patient oral health. Responses to non-adherence included disappointment, frustration and acceptance. Acceptance centred around a shared responsibility for oral care between clinician and patient and reassurance that they had 'done their job'. The unpredictability of patient adherence aided OHE motivation; efforts might eventually inspire patient action or might align with patient readiness to change.Conclusions This study reveals how OHE outcomes impact on dental professionals' perceptions of their role and personal motivations for continued educational efforts with patients. Greater emphasis on both preventative dentistry and self-care, coupled with understanding of the complex factors influencing oral health behaviour, would aid motivation for OHE.

Developing the role of the sports dentist

Sports dentistry has traditionally focused on orofacial trauma. There is now increasing evidence that participation in sport, particularly at elite level, may significantly increase the risks to oral health. The negative impact of poor oral health on athlete-reported wellbeing and performance is clear. The risks to athlete oral health can and should be mitigated and the role of the sports dentist is evolving to meet these new challenges. Custom-made mouthguards provide protection against orofacial trauma and potentially, concussion. Oral health screening should be included in athlete pre-season preparation. As integrated members of the athlete support team, dentists and dental care professionals can provide sport-specific oral health advice, encouraging athletes to take ownership of their oral health. The potential for translational health and wellbeing benefits to the wider population is also substantial, particularly with youth groups and recreational athletes. Sports dentistry requires distinctive skills. A UK-wide network of dentists and other oral health professionals with an interest in sport is important, to ensure that both appropriate advice and treatment is evidence-based and to further develop the research and clinical foundations.

Understanding behaviour change to promote regular dental attendance

Regular dental attendance is a key oral health behaviour. Behaviour change interventions are increasingly being used to promote positive oral health behaviours. A systematic approach to understanding behaviour has led to the development of frameworks which aim to guide the process of designing behaviour change interventions. One such framework is the Behaviour Change Wheel (BCW). This article aims to explore and identify barriers to regular dental attendance which may be targeted using behaviour change interventions based on the Capability, Opportunity and Motivation Behaviour model (COM-B) and the BCW, and suggests potential behaviour change techniques which could be utilised into a behaviour change intervention with the aim to promote regular dental attendance.

The Impact of Sport Training on Oral Health in Athletes

Athletes' oral health appears to be poor in numerous sport activities and different diseases can limit athletic skills, both during training and during competitions. Sport activities can be considered a risk factor, among athletes from different sports, for the onset of oral diseases, such as caries with an incidence between 15% and 70%, dental trauma 14-70%, dental erosion 36%, pericoronitis 5-39% and periodontal disease up to 15%. The numerous diseases are related to the variations that involve the ecological factors of the oral cavity such as salivary pH, flow rate, buffering capability, total bacterial count, cariogenic bacterial load and values of secretory Immunoglobulin A. The decrease in the production of S-IgA and the association with an important intraoral growth of pathogenic bacteria leads us to consider the training an "open window" for exposure to oral cavity diseases. Sports dentistry focuses attention on the prevention and treatment of oral pathologies and injuries. Oral health promotion strategies are needed in the sports environment. To prevent the onset of oral diseases, the sports dentist can recommend the use of a custom-made mouthguard, an oral device with a triple function that improves the health and performance of athletes. During training, the sports dentist must monitor the athletes and the sports examination protocol must be implemented with the inclusion of the clinical examination, quantitative and qualitative analysis of saliva and instructions on the use, cleansing and storage of the mouthguard.