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).
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
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
• gait biomechanics
• postural control among elite football athletes16
The studies and evidence since the 90’s have only strengthened this hypothesis.
Players who have malocclusions and an asymmetrical biting force tend to have asymmetrical gait.
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.
Recommendations for
Food for thought
Sports dentistry is gaining traction. In the USA, NFL, NBA, NHL, MLS, and MLB teams are required to have a certified sports dentist.
Our advice would be to introduce pre-season dental screening and to consider a players bite.
Pre-season screening with a sports dentist would normally take place on the same day as cardiovascular and musculoskeletal medical day. The dentist would need 4-5 minutes for a rapid screen on a massage table to be able to triage them into a red, amber or green zone. A report will be then sent to the club doctor for further investigations.
An assessment of a player’s bite in relation to gait, posture and hamstring/quadriceps isokinetic performance should be explored with players who have recurrent soft tissue injuries in the season.
References
1. https://www.ucl.ac.uk/eastman/file/2195 Infographic
2. Poor oral health including active caries in 187 UK professional male football players: Clinical dental examination performed by dentists. Ian Needleman1 , Paul Ashley2 , Lyndon Meehan3, Aviva Petrie4, Richard Weiler5,6,7, Steve McNally8, Chris Ayer9, Rob Hanna10, Ian Hunt11 Steven Kell12, Paul Ridgewell13, Russell Taylor14
3. Association between sleep duration and dental caries in a nationally representative U.S. population
4. Prevalence of periodontal disease, its association with systemic diseases, and prevention - Muhammad Ashraf Nazir 1 ,
5. Periodontitis Increases the Risk of a First Myocardial Infarction: A Report From the PAROKRANK Study - Lars Rydén 1, Kåre Buhlin 2 , Eva Ekstrand 2, Ulf de Faire 2, Anders Gustafsson 2, Jacob Holmer 2, Barbro Kjellström 2, Bertil Lindahl 2, Anna Norhammar 2, Åke Nygren 2, Per Näsman 2, Nilminie Rathnayake 2, Elisabet Svenungsson 2, Björn Klinge 2
6. Association between chronic periodontitis and the risk of Alzheimer’s disease: a retrospective, population-based, matched-cohort study - Chang-Kai Chen, Yung-Tsan Wu & Yu-Chao Chang
7. A systematic review and meta-analysis of epidemiologic observational evidence on the effect of periodontitis on diabetes An update of the EFP-AAP review - Filippo Graziani, Stefano Gennai, Anna Solini, Morena Petrini
8. Periodontal Disease, Tooth Loss, and Cancer Risk - Dominique S Michaud *, Zhuxuan Fu, Jian Shi, Mei Chung
9. Miller KC, Stone MS, Huxel KC, Edwards JE. Exercise-associated muscle cramps causes, treatment, and prevention. Sports Health. 2010;2:279–83.
10. Mair SD, Seaber AV, Glisson RR, Garrett Jr WE. The role of fatigue in susceptibility to acute muscle strain injury. Am J Sports Med. 1996;24:137–43.
11. Associations of Masticatory Muscles Asymmetry and Oral Health with Postural Control and Leg Injuries of Elite Junior Soccer PlayersHenny Solleveld!, Bram Slaets!, Arnold Goedhart!, Luc Vanden Bossche²
12. Physiological Responses of a Jaw-Repositioning Custom-Made Mouthguard on Airway and Their Effects on Athletic PerformanceRicardo Schultz Martins 1, Patrick Girouard, Evan Elliott, Said Mekary
13. https://www.independent.ie/sport/soccer/beckhams-career-blooming-with-a-little-help-from-milan-fitness-lab/26542573.html
14. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4520673/
15. Konviser SN, Nurek M, Needleman I, Fine P. Disadvantage starts early: academy football has high levels of oral disease. BMJ Open Sport & Exercise Medicine. 2025;11:e002245. https://doi.org/10.1136/bmjsem-2024-002245
16. Solleveld H, Slaets B, Goedhart A, VandenBossche L. Associations of Masticatory Muscles Asymmetry and Oral Health with Postural Control and Leg Injuries of Elite Junior Soccer Players. J Hum Kinet. 2022 Nov 8;84:21-31. doi: 10.2478/hukin-2022-0086. PMID: 36457464; PMCID: PMC9679175.