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SHOOTING WIDE? OR STRAINING MUSCLES? THEN OPEN WIDE! FEATURE / DR SUNNY SHARMAN Introduction The oral health of athletes, specifically footballers, has been gaining international attention over the last few years due to excellent research confirming its link with the musculoskeletal system and the performance of elite athletes. A quick Google search of teeth and footballers’ injuries will give you lots of quotes from Jamal Musiala, Arjen Robben, Clarence Seedorf, Steven Gerrard, and Cesc Fàbregas, to the great Arsene Wenger, who requested his players have wisdom teeth removed. They all accredited a link between soft tissue injuries and rotten teeth. Hansi Flick hired a dentist with the Germany national team and again at Barcelona. Footballers have an increased risk of poor oral health due to1 • Decreased saliva production during training and matches • Increased carbohydrate intake through nutritional supplements • Dehydration • Increased airflow through the mouth • Impaired immune system function with high training load Is this an overlooked part of the body with regard to performance? We will delve into the connections.
Teeth The largest representative sample of footballers by UCL2 found that 37% of players had active dental caries (decay) and 53% had dental erosion (loss of enamel or dentine).
• gait biomechanics • postural control among elite football athletes16
A very recent study of academy players identified high levels of oral disease: 31.2% had dental caries requiring treatment; 76.8% had gingivitis; and 22.5% had periodontitis. Tooth wear affecting up to at least 50% of tooth structure was present in 15.5% of participants.15
Players who have malocclusions and an asymmetrical biting force tend to have asymmetrical gait.
Dental decay will cause pain and often players learn to chew differently, avoiding certain triggers and this can affect nutrition intake. Dental erosion can cause sensitivity which can be disruptive. Both can contribute to poor sleep.3 Impacted wisdom teeth can limit jaw opening and lead to silent chronic infections, leading to lower energy levels. The most common reason I have seen players as emergencies are for infected wisdom teeth. Gums Gum diseases are among the most common of chronic human diseases, affecting between 20 to 50% of people worldwide.4 Footballers have been shown to have 5% moderate-severe irreversible periodontal disease.2 7 out of 10 athletes with multiple injuries suffer from periodontitis.10 It has been linked to Cardiovascular disease,5 Alzheimer’s,6 Type 2 Diabetes7 and Cancers.8 Oral pathogens can enter the systemic circulation with chronically higher levels of IL-6 and other cytokines. Chronically higher levels of IL-6 are associated with fatigue, and fatigue is a significant risk factor for (re)injuries.9-10 The margins are so small with athletes, yet many have normalised bleeding gums. TMJ and Dental Occlusion The infamous Milan lab was one of the pioneers in establishing a link between how dental occlusion affects: • hamstring/quadriceps isokinetic performance
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The studies and evidence since the 90’s have only strengthened this hypothesis.
Clinical studies show that once asymmetry is corrected with a mouth-wearing appliance or adjustment of the teeth, athletes have a more symmetrical posture and lower risk of injury11 due to more balance in their gait. Performance-enhancing mouthguards are increasingly being used across all sports. David Beckham once wore a small appliance to cover a missing tooth to help his gait.13 Wataru Endo also wears one to help his balance. We can now demonstrate a significant link between jaw repositioning, airway volumetric change, and performance enhancement in both aerobic and anaerobic performances.12 Treatments to correct can vary from simple adjustment of fillings and crowns to wearing a splint or to orthodontics.