FE v19n3 artigo 9 Nvu


Association between oral health and changes in athlete’s routine and physical condition: systematic review

Associação entre a saúde bucal e as mudanças na rotina dos atletas e condição física: revisão sistemática


Jullian Josnei de Souza1, Juliana Squizatto Leite1, Ricardo Bahls2, Rodrigo Stanislawczuk Grande3, Bárbara Capitanio de Souza4, André Luiz Lopes5, Fabio André Santos1


1Department of Dentistry, Ponta Grossa State University, Ponta Grossa, Paraná, Brazil.

2Private practice, Ponta Grossa, Paraná, Brazil.

3Department of Dentistry, Campos Gerais Higher Education Center, Ponta Grossa, Paraná, Brazil.

4Postgraduate Program in Physiology at the Federal University of Rio Grande do Sul, Porto Alegre, Brazil. Department of Morphological Sciences, Federal University of Rio Grande do Sul, Porto Alegre, Brazil.

5Physical Education Professional. Master and Doctor in Movement Sciences, Federal University of Rio Grande do Sul, Porto Alegre, Brazil.


Receipt on: February 29, 2020; Accepted on: June 8, 2020.

Corresponding author: Fábio André Santos, Department of Dentistry, Ponta Grossa State University, Av. Carlos Cavalcanti, n.4748, 84030-900 Ponta Grossa PR, Brazil


Jullian Josnei de Souza: jukajs@hotmail.com

Juliana Squizatto Leite: jsl.squile@gmail.com

Ricardo Bahls: ricardo@odontopontaonline.com

Rodrigo Stanislawczuk Grande: rodrigozuk1@hotmail.com

Bárbara Capitanio de Souza: barbara.capitanio@gmail.com

André Luiz Lopes: andregym23@hotmail.com

Fabio André Santos: fasantos@uepg.br



Objectives: Oral health can affect athlete’s training routine negatively impacting their performance. Therefore, the objective of this review was to evaluate the influence of oral health on the physical condition of athletes. Design: Systematic review. Methods: A systematic search of multiple databases was conducted to identify studies that reported the association between oral health and the physical performance of athletes. The inclusion criteria were observational studies that evaluated the impact of oral health on the physical performance of athletes in English, Portuguese and Spanish. Results: Twelve papers were included, and most of the relevant papers evaluated the influence of oral health conditions on physical performance, using self-assessment type questionnaires, with heterogeneous methodology. The association between oral health and physical performance varied from 7% to 88%. Conclusion: We observed an association between oral health in physical performance of athletes, however, there is still insufficient evidence to quantify this influence.

Keywords: oral health, athletic performance, athletes, observational study.



Objetivo: A saúde bucal pode afetar a rotina de treinamento dos atletas de forma a impactar negativamente no seu desempenho físico. Sendo assim, o objetivo dessa revisão sistemática foi de avaliar a influência da saúde bucal na condição física dos atletas. Desenho da pesquisa: Revisão sistemática. Métodos: Realizou-se uma busca sistemática de múltiplas bases de dados para identificar estudos que reportassem associação entre a saúde bucal e o desempenho físico dos atletas. Foram incluídos estudos observacionais que avaliavam o impacto da saúde bucal no desempenho físico dos atletas escritos em inglês, português e espanhol. Resultados: Doze artigos foram incluídos, e a maioria dos artigos relevantes avaliaram a influência da condição de saúde bucal no desempenho físico por meio de questionários de autoavaliação, cuja metodologia era heterogênea. A associação entre a condição de saúde bucal e o desempenho físico variou de 7% a 88%. Conclusão: Observou-se associação entre a condição de saúde bucal e o desempenho físico dos atletas, entretanto, ainda não há evidência científica suficiente para quantificar essa influência.

Palavras-chave: saúde bucal, desempenho atlético, atletas, estudo observacional.




Athletes are commonly regarded as completely healthy individuals, even though studies in the literature have shown that they often are not [1]. Oral health may be closely linked to systemic health; a great example of this is the periodontal disease, which is the second leading cause of dental pathology, is presented as a risk factor for some systemic complications such as respiratory disease, heart complications and diabetes control [2-5].

The last systematic review of the oral health of athletes showed a 75% occurrence of caries among the studied athletes, who also presented several other oral problems such as periodontal disease, dental erosion and facial trauma [6]. It has been reported in the literature that the oral health of athletes can impact on their well-being and in the development of their physical activities; a negative effect on their daily life was observed in 41% of athletes and 5% reported changes in their activity routine [7]. In the case of elite athletes, one study found an even higher level of impact on physical condition, about 18% [8]. Given the investment that is made in the careers of high-performance athletes it is important to consider the impact of oral health conditions, which can potentially have a huge effect on athletes' health and in the development of training activities and competitions.

Thus, the aim of this systematic review was to evaluate the influence of oral health status on the physical condition of athletes, as well as analyzing the methodologies of those studies. The central research question of this review was to answer the following question: can poor oral health influence in the development of training activities and competitions of athletes compared to the performance of athletes with good oral health?




Protocol and registration


This study was registered at the International Prospective Register of Systematic Reviews (CRD42018096935) and followed the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement [9].


Eligibility criteria


The electronic search strategy was based on the following PECO categories:


  • Population (P): athletes;
  • Exposure (E): poor oral health;
  • Comparison (C): good oral health;
  • Outcome (O): changes in the development of sports activities


No date restrictions were applied to the search; there was a limitation in terms of language because the assessed studies were in English, Spanish and Portuguese. Observational studies were included if they contained any variable to measure the impact of oral health on athletic physical activities. In which the development of sports activities could be assessed by questionnaires. The questionnaires were assessed either self-reported association between oral health and physical condition of athletes.


Information sources and search strategy


The search was performed using the following databases: CAPES Periodic Portal; Cochrane Library; Google Scholar; Lilacs; PEDro; PubMed; SciELO; Scopus and Web of Science (Table I). Grey literature was also searched via the Catalogue of Theses and Dissertations of CAPES; the Grey Literature Report; Open Grey; and Penn Libraries. The reference lists of all the primary studies were manually searched for additional relevant studies.

When using Pubmed the search strategy used the following MeSH terms: athletes; athletes/medical; athletes/sports; athletes amateurs; athletes care sports; athletes elite; athletes physical activity; athletes population; plaque index; gingival bleeding; dental calculus; tooth loss; gingivitis; inflammation; dental mobility; periodontal bleeding index; probing depth; bleeding on probing; plaque control; oral hygiene; periodontal health; clinical attachment level; oral health and preventive dentistry; oral health/education; oral health; oral hygiene; toothbrushing frequency; interdental cleaning; oral home care; oral health promotion and any changes in the routine of physical activities.

The data extraction started with dividing the keywords and adjusting them for each specific database. For example, in PubMed we used MeSH (medical subject heading), and in Lilacs we used DeCS (health science descriptors).The search strategy was not solely restricted to the key-words subject; entry terms were added in Medline, such as text words, synonyms, acronyms, related words, spelling variations, previous indexing or derivations of the subject, which contributed to the efficacy of the strategy.


Risk of bias


The search and the quality assessments of the selected trials were carried out by two independent reviewers SJJ and LSJ. During the data selection and quality assessment, any disagreements between the reviewers were resolved through discussion and, if needed, consultation with a third reviewer SFA.

Three evaluations were performed. First, we checked if the selected articles complied with the STROBE guidelines. Then, we evaluated the quality of the articles by using the Newcastle Ottawa Scale and Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies (National Heart, Lung and Blood Institute, National Institute of Health, USA).

During the analysis of the studies regarding STROBE, if the recommendations from the guidelines were followed completely the study was represented as “+” in the topic; if the recommendations were only partially followed than it was represented as “+-”; and if the recommendations were not followed at all than it was represented as “-”. Consequently, studies with more “+-” and “-” did not follow the STROBE guidelines.

The Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies was adjusted and the questions that involved follow-up were removed because this systematic review analyzed cross-sectional studies. Therefore, questions 6-10, and 12-13 were not included in this quality assessment. Each question could be answered with either “yes”, “no”, “cannot determine” (CD), “not applicable” (NA) or “not reported” (NR). If the answer was “no”, “cannot determine” or “not reported” the risk of bias increased.

The Newcastle-Ottawa Scale was also adjusted, and the questions that involved follow-up and control groups were removed because this study reviewed cross-sectional studies only. In the selection domain, if the sample size was justified it was graded 1 point, if not 0; if the sample was homogenous it was graded 1 point, if not 0; and if the data was obtained from structured questionnaire or clinical evaluation it was graded 1 point, if it was from non-structured questionnaire it was graded 0. In the outcome domain, if the data was assessed by clinical evaluation, it was graded 1 point; if it was assessed by self-report it was graded 0 point.

The quality rating for each analysis could be either “poor” (0-50%), “fair” (51-70%) or “good” (71-100%).




Study selection


The search was conducted in June 2018 by two reviewers. The following 2386 records were identified through searching the databases: 200 articles from Google Scholar; 117 from Lilacs; 18 from PEDro; 519 from CAPES Periodic Portal; 764 from PubMed; 27 from Scielo; 370 from Scopus; 303 from Web of Science; six from Cochrane Library; and 62 from Grey Literature. During the database search, articles identified through the database searching that were related to the PECO question were hand-searched; therefore, an additional 64 titles were screened. After removing the duplicates, which was carried out with the support of Endnote Studies software, as well as the articles without the outcomes evaluated in this systematic review, 49 articles remained for full-text assessment for eligibility. Eleven articles were included for the quality analysis (Figure 1).



Figure 1 - Flow diagram of literature searches and selection, according to the PRISMA statement.


Study characteristics


The articles were mostly from Brazil (45%) and were published from 2011- 2018. The influence of oral health on physical performance was mostly evaluated from questionnaires; only in three studies was this evaluation not self-reported, and in the latter three studies, the data were analysed from clinical evaluations. Soccer was the most frequent sport in which the influence of oral health on physical activities was evaluated (Table 1).


Risk of bias within studies


The compliance of the articles with the method domain of the STROBE guidelines was fair to good in most articles (56 to 100%) (Table II), although this was not the case with the result domain (25 to 50%) (Table III).


Table I - Characteristics of the studies. (see annexe in PDF)


Table II - Compliance of the studies included in the qualitative analysis with the method domain of the Strobe guidelines. (see annexe in PDF)


Table III - Compliance of the studies included in the qualitative analysis with the result domain of the Strobe guidelines. (see annexe in PDF)



In most studies the quality rating in terms of the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies was fair to good (57 to 71%) (Table IV). In Newcastle-Ottawa Scale the rating was mostly poor, from 25 to 50% (Table V).


Table IV - Quality assessment tool for observational cohort and cross-sectional studies. (see annexe in PDF)


Table V - Newcastle-Ottawa Scale or assessing the quality of nonrandomized studies. (see annexe in PDF)



Results of individual studies


All studies showed an association between oral health and physical activities; however, this association was assessed by questionnaires in most studies. Among the observed and self-reported changes were the modifications of the sports routine suffered. The influence by self-assessment ranged from 7-88%.




The main outcome was that all the studies reported the influence of oral health conditions on difficulties in developing training routines and competitions. The data source from most studies were questionnaires [8,13-22], therefore the results were obtained by self-report answers from the athletes. One limitation of this review is that the results were self-assessed, however, the biggest issue was since the questionnaires used were not validated, generating a lack of standardization and an increased risk of bias since each study applies its own questionnaire. The best suggestion is the conduct of clinical trials that perform the treatment of these conditions associated with physical performance evaluation tests.

Other way to obtain more reliable data could be by the evaluation of oral clinical parameters associated with physical parameters of performance. Three studies tried to that, by assessing periodontal clinical parameters with muscle injuries or serum creatin kinase levels, these studies work with the physiological microlesions that occur with the physical activity itself, suggesting an important potential action of the oral health condition on the muscular inflammatory reaction [11,12,16]. Gay-Escoda et al. [11] observed a statistically significant correlation between plaque index and probing pocket depth with muscle injuries (p<0.05). Souza et al. [12] found that depth of probing and bleeding probing were associated with changes in serum creatin kinase levels during training. Alshail et al. [16] found that soccer players with periodontal complication exhibited raised serum creatin kinase levels compared to those without this disease.

There are some animal studies that have found a relationship between oral health and changes in muscle recovery [23], which justifies their inclusion. The data suggested that the association between the pro-inflammatory state induced by periodontal disease and exercise load may play an important negative role in muscle hypertrophy. Another study conducted in animals found that a group that was with immobilized, and with periodontal disease, presented greater degeneration of muscle tissue and increased inflammatory cells compared to other groups. This was due to decreased capillaries and increased connective tissue, which may be indicative of the fact that muscle recovery may be affected by problems of oral origin such as periodontal disease [24]. Hence, periodontal disease may also be a risk factor for a decrease in functional performance of the musculature, since the elevation of pro-inflammatory systemic cytokines can modify the muscular metabolism, leading to the loss of mass and decrease in strength, which is an important factor of physical performance [25].

There are other factors which are important to consider, such as the fact that professional athletes are constantly exposed to maximum stress and recovery situations, which may consequently impact on athlete's activities.

Most of the studies included in this review were performed in Brazil. There was also a higher percentage of studies regarding soccer players. Which can be explained by the fact that it is one of the sports with a greater number of athletes and due to the huge popularity of soccer, which is the most practiced sport worldwide [26]. The sample size of the studies also revealed a lack of standardization, knowing the specific characteristics of each study; we noticed a high rate of sample variation from 15 to 352 athletes, which may indicate a limitation for these observational studies. This can be explained because most samples are convenience samples due to the difficulty of working with athlete patients, considering that the interventions cannot interfere with the training routine. However, more important than the standardization of the sample size, would be to do follow-ups in these athletes, before and after dental treatment to evaluate in the same population if the oral health really impacts on physical performance.

A systematic review prior to the present study showed four studies assessed this association in which 5 to 18% of the athletes reported negative impact of poor oral health or dental trauma and changes in the development of sports activities [6]. Their methodological quality analysis, Newcastle-Ottawa Scale adjusted, was mostly poor, which was also observed in this review.




Oral health influences in the development of the sportsman's routine, which may impair his adaptation to training of athletes. We suggest that further studies should be conducted with qualitative and quantitative variables to better measure this influence.




The authors wish to thank Dr. Sean Stroud for reading this manuscript an offering his valuable comments.


Conflict of interests


The authors declare that they have no conflicts of interest.


Authors' contributions


Study conception and design: JJS, JSL and FAS. Acquisition of data: JJS, JSL and RB. Analysis and interpretation of data: JJS, JSL and RB. Drafting of manuscript: BCS, ALL, and RGS. Critical revision: BCS, ALL, RGS and FAS.




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