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Table of Contents   
SYSTEMATIC REVIEW  
Year : 2020  |  Volume : 31  |  Issue : 2  |  Page : 297-304
Estimated prevalence of dental caries in athletes: An epidemiological systematic review and meta-analysis


1 Postgraduate Program, School of Dentistry, Fluminense Federal University, Niterói, RJ, Brazil
2 Postgraduate Program, School of Dentistry, Fluminense Federal University, Niterói; Department of Specific Formation, School of Dentistry, Fluminense Federal University, Nova Friburgo, RJ, Brazil

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Date of Submission10-Oct-2018
Date of Decision24-Jan-2019
Date of Acceptance07-Jun-2019
Date of Web Publication19-May-2020
 

   Abstract 


Background: Dental caries is a dysbiotic polymicrobial disease that can cause damage to an individual's successful, elite sporting performance. Aims: This study aimed to realize a meta-analysis to calculate a worldwide, pooled estimated prevalence of dental caries in athletes. Methods and Materials: This systematic review and meta-analysis was registered in PROSPERO (n° CRD42017068127). A systematic search was conducted in the electronic databases Pubmed, Scopus, Web of Science, Virtual Health Library (Lilacs) and Grey literature from inception up to April 2017. The MeSH terms “Sports,” Athletes,” and “Dental Caries” were used. The inclusion criteria used in this review were observational cross-sectional studies, longitudinal retrospective, and prospective studies that presented the prevalence of dental caries in athletes without intellectual disabilities. From selected articles, the risk of bias tools were assessed. After considering the qualitative heterogeneity among studies, a meta-analysis was conducted. Results: A total of 1,376 abstracts were initially retrieved, with only five meeting the inclusion criteria. Of these, one was considered to have a low risk of bias and four were considered to have a moderate risk of bias. The overall estimated prevalence of dental caries in athletes was 46.25% (95%CI 28.73-64.27). Conclusion: The estimated prevalence of dental caries in athletes, and particularly in athletes from developing countries is considered to be high. The pooled prevalence estimates have important implications in regard to preventive measures and research planning around the world.

Keywords: Athletes, caries, decay, players, sports

How to cite this article:
Azeredo FN, Guimarães LS, Luís W, Fialho S, Alves Antunes LA, Antunes LS. Estimated prevalence of dental caries in athletes: An epidemiological systematic review and meta-analysis. Indian J Dent Res 2020;31:297-304

How to cite this URL:
Azeredo FN, Guimarães LS, Luís W, Fialho S, Alves Antunes LA, Antunes LS. Estimated prevalence of dental caries in athletes: An epidemiological systematic review and meta-analysis. Indian J Dent Res [serial online] 2020 [cited 2020 Aug 11];31:297-304. Available from: http://www.ijdr.in/text.asp?2020/31/2/297/284585



   Introduction Top


Dental caries is defined as a dysbiotic polymicrobial disease caused by pathobionts.[1] Evidences from the decayed, missing, filled index (DMF), published by FDI (Federation Dental International), showed that carious lesions are highly prevalent in many countries[2] and considered to be higher in underdeveloped countries when compared to developed countries.[3],[4],[5],[6] Therefore, dental caries represents a major public health problem[7] and it remained the most prevalent health condition across the world in 2010, affecting 2.4 billion people.[8]

There is, according to literature, relevant data demonstrating the impact of poor oral health on quality of life.[9] Oral diseases can induce a systemic inflammatory response; and the weight of evidence from some studies supports an association between periodontitis and cardiovascular disease, and between periodontitis and diabetes.[10],[11] No study has yet proved the association between dental caries and induction of systemic disease. However, this condition, poor oral health, in athletes, can affect well-being, training and their performance.[12],[13],[14]

The risk of dental caries has been reported to be high in athletes.[3],[5],[6],[13],[15],[16],[17] This finding might result from the use of sports drinks,[18],[19],[20] diet,[21] exercise-induced immune suppression,[22] the level of knowledge related to oral health, and decreased salivary flow during exercise.[23]

As indicated in the literature, the prevalence of dental caries in athletes varies from 8.57% to 84%.[4],[6] Therefore, the main purpose of this study was to conduct an extensive and systematic review of the literature to calculate a worldwide-pooled estimated prevalence of dental caries in sports athletes.


   Materials and Methods Top


This systematic review and meta-analysis of the estimated prevalence of dental caries in sports athletes was conducted in accordance with the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA statement - www.prismastatement.org), and was registered in the PROSPERO database (http://www.crd.york.ac.uk/PROSPERO/), CRD42017068127.

Focused question

The present systematic review was conducted to answer the following focused question: “What is the estimated prevalence of dental caries in athletes”.

Inclusion and exclusion criteria

The inclusion criteria used in this review were observational cross-sectional studies; longitudinal retrospective and prospective studies that presented the prevalence of dental caries in athletes without intellectual disabilities; or studies that permitted the calculation of these numbers. The data should have been taken from clinical oral evaluations.

Editorial letters, pilot studies, historical reviews, book chapters, theses, guidelines, laboratory studies, animal studies, descriptive studies (such as case reports and case series), and studies that were not in the proposed theme were excluded. Studies that used only questionnaires and interviews were also excluded.

Literature search strategy

A systematic search using electronic databases including PubMed, Scopus, Web of Science (WOS), and Virtual Health Library (Lilacs) was performed for articles published since inception up to April 28, 2017. There were no restrictions that were placed on the publication date. The grey literature was consulted using the database System for Information on Grey Literature in Europe (SIGLE) (http://www.opengrey.eu). The searches were complemented by hand searching and screening the references of selected studies to find any study that did not appear in the database search. The terms for the search strategies were obtained through discussion between an information specialist and the review group, by scanning the background literature. The MeSH (Medical Subject Headings) terms (www.nlm.nih.gov/mesh/meshhome.html) used in the search were “Sports,” “Athletes,” and “Dental Caries”. Furthermore, it included MeSH synonyms, related terms, and free terms. The Boolean operators “AND” and “OR” were applied to combine the keywords [Table 1].
Table 1: Search strategy

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Study selection

Two investigators (FNAA and LSG) individually assessed relevant articles by title, and abstract to identify studies to be included according to the inclusion and exclusion criteria. Disagreements were discussed and resolved by consensus of the authors or third-party arbitration (LSA). The articles that appeared in more than one database were considered only once. All full text of studies potentially meeting the inclusion criteria (or when the inclusion was unclear) were obtained and reviewed in full text by the two reviewers (FNAA and LSG). This was done independently to minimize the possibility of overlooking important articles. Again, disagreements were discussed and resolved by consensus or by third party arbitration (LSA).

Quality assessment of included studies

The authors assessed the risk of bias for each included study using a modified tool, developed by Hoy et al.[24] for assessing this variability in prevalence studies as shown in [Table 2]. The risk of bias tool consisted of ten High Risk/Low Risk and Not Applicable (NA) items, including four measures of external validity and six measures of internal validity. Studies were classified as having a low risk of bias when eight or more of the ten questions were answered as “low risk,” a moderate risk of bias when six to seven of the questions were answered as “low risk” and a high risk of bias when five or fewer questions were answered as “low risk.”
Table 2: The risk of bias tool developed by Hoy et al.[24] for assessing this variable in prevalence studies

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Data extraction

The data of the included articles were compiled and organized according to: 1) the first author of the article, year of publication; 2) country; 3) study design; 4) examination place; 5) sample; 6) sample calculation; 7) sports; 8) mean age (SD); 9) training and calibration; 10) risk factors for dental caries; 11) conditions for diagnosis; 12) dental caries index evaluated; 13) radiography.

Meta-analysis

The estimated global prevalence of dental caries was calculated using a fixed and a random model. When heterogeneity was statistically significant (P < 0.05), the random model was adopted. All analyses were performed using the software MedCalc 17.2 (MedCalc Software bvba, Ostend, Belgium).

Results

[Figure 1] presents a flowchart of the systematic review process. Initially, 1,376 studies were identified through their abstracts in the following electronic databases: 371 studies from PubMed, 434 from Web of Science, 407 from Scopus, and 164 from VHL. After disregarding the duplicated studies, 922 remained. Of these, 903 studies were excluded after reading the title and abstract due to obvious irrelevance toward the proposed theme. Papers that did not present clear information were included for a complete analysis. At this level, 19 articles were assessed. There were about 14 studies that were excluded as 12 assessed dental caries in a population of athletes with intellectual disabilities, and two studies did not include dental caries data. The authors were also contacted to obtain detailed information about methods and results. After the electronic search, the references of the selected studies were hand searched, but no further articles were found. A total of five articles were included in the final analysis.
Figure 1: Preferred Reporting Items for Systematic Reviews and Meta-Analyses: Prisma 2009 Flow Diagram

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The risk of bias scores in this systematic review ranged from six to eight out of ten possible points. Out of the five studies that underwent a risk of bias assessment, one (20%) was considered to have a low risk of bias;[4] and 4 (80%) were considered to have a moderate risk of bias.[3],[5],[6],[13] Data for risk of Bias Assessment Outcomes for included studies are shown in [Table 3].
Table 3: Risk of bias assessment for included studies

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A population sample of 559 individuals was enrolled in this review, ranging from 25 to 278 athletes. All articles were cross-sectional studies. There were about three studies that came out with information about soccer players,[3],[5],[6] one showed information about triathlon participants,[4] and one brought information about 25 types of sports.[13] All of the participants were professional players. In all these studies the exam of the oral health of the athletes, and diagnosis of dental caries was made by dentists; and in two studies, there were training and calibration of these professionals.[4],[13] Only two studies used a standardized diagnosis form decayed missing filled teeth (DMFT) index to assess caries prevalence.[4],[6] Among the five articles, just one[3] used panoramic radiography to help the diagnosis of dental caries [Table 4].
Table 4: Data extraction of all included studies

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The estimated combined prevalence of dental caries in athletes was 46.25% (95%CI 28.73-64.27) in the random model [Figure 2]. This analysis showed significant heterogeneity across studies (P < 0.000).
Figure 2: Meta-analysis evaluation and forest plot showing the combined prevalence rates of dental caries of all included studies

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   Discussion Top


Generally, the oral health of athletes is poor, substantially affecting the athletes' performance, training and well-being.[3],[13] About knowing of the prevalence rates of dental caries suggests that health promotion and disease prevention measures should be adopted. These actions are necessary to optimize and improve athletic performance.[13] Therefore, the aim of this review was to search all available literature reporting the estimated prevalence of dental caries in athletes.

After an exhaustive search, only five articles pertaining to athletes without intellectual disabilities were included to answer the focused question. This inclusion criteria avoid selection bias, increasing the certainty of the evidence.

The quality of evidence in the selected studies was classified as moderate, with the majority of the studies achieving a moderate risk of bias. All studies[3],[4],[5],[6],[13] were not representative of the national population as it is an important issue for Global Burden of Disease Study and indeed for any attempt to describe disease patterns in a country.[24] Only one study performed a true or close representation of the target population.[4]

The oral health of professional athletes participating in different types of sports was evaluated by dentists. Only in the studies of Needleman et al.[13] and Frese et al.[4] were the professionals who performed the diagnosis trained and calibrated. This detail may directly interfere in the number of cases of dental caries in other studies, since a wrong diagnosis could have been made, as the concept of caries disease may be relative from professional to professional.

Another factor that may interfere with evaluation of the prevalence of dental caries is the variability of the conditions in which the diagnosis was made. In both studies in which the process of assessment was reported,[3],[4] plain mirrors and exploratory probes were used on clean and dry teeth. Needleman et al.[5] additionally used photographs and, Randell[3] used the X-ray evaluation. Only two articles[4],[6] used a standardized diagnosis index (DMFT).

Clinical examination and intraoral radiographs are the most used methods for the diagnosis of carious lesions,[25] and underestimation of this disease may occur where the X-ray exam is not used.[26] In a single study,[3] panoramic radiography was performed for diagnostic purposes. However, for a routine evaluation of dental caries, intraoral radiographs are used - the bitewing technique being the first choice, since it provides a significant diagnosis for caries lesions in the proximal and occlusal sides.[27],[28],[29],[30]

Poor oral health of athletes may have a negative influence on training, performance and well-being in daily life. In this regard, carious lesions may have a negative impact on the athlete's performance, as it has been shown in three studies[5],[6],[13] corroborating with Ashley et al.[14] Among the effects of poor oral health are tooth loss, reduced function, and psychological damage,[31] demonstrating a need for a rigorous and time-consuming treatment. The estimated prevalence of dental caries in athletes (46.25%) is considered to be high. This is a surprising finding, since athletes are much too worried about their bodily health and do not give equal attention to oral health. This is also surprising because the disease can be prevented with proper oral hygiene.

The poor hygiene of the oral cavity is a risk factor for the emergence of diseases.[32] Causes of poor oral health include unfavorable individual health habits,[33] nutrition,[34],[35] and cultural, and structural factors such as access to oral health promotion and the value of oral health in the support system for sports.[5] Two studies have shown the precariousness of this condition in athletes[5],[6] even though all athletes brushed their teeth twice a day,[6] and 73.4% of them had gone to the dentist in the past 12 months.[5] The duration of physical exercise may be associated with a higher frequency of nutritional intake and reduction of salivary flow in athletes. Consequently, it may have a significant influence on the prevalence of caries.[4],[13] Risk factors for the development of dental caries in athletes should be studied more rigorously. Thus, prevention methods, adopted correctly, could positively contribute to decrease in the prevalence of caries in athletes.

This study presents relevant strengths as the statistical approach used for combined prevalence rates. The authors used the prevalence rate itself to obtain a combined prevalence rate among all studies. This provides useful data for estimating the actual prevalence of dental caries in athletes worldwide. These results will be useful to support future research intending to investigate this disease in athletes, since it is possible to detect which factors are influencing the prevalence rates among all included studies.

Our findings should be considered in the context of some limitations. The diagnostic method should be improved, especially regarding the location to the athlete. It must be a specific environment that allows the use of equipment for the correct diagnosis, such as the X-ray apparatus. All examiners must be experienced, trained and calibrated dentists, so that there is minimal inconsistency at the examination time. It is important to perform a calculation to obtain a representative sample. The index for disease evaluation should be standardized to increase the reliability of the results. These aspects may positively influence the reliability of the findings regarding the prevalence of carious lesions in athletes.

The issue should also be broadly addressed for dissemination of information. Planning and prevention measures should be taken by the athletes to minimize the risks of dental caries. It is very important to have the presence of a specialized professional in the sports center. The dentists are the professionals indicated to give instructions regarding oral hygiene and to carry out procedures of prevention against the diseases that can appear in the oral cavity. They can assist in improving the oral health of the athlete, maintaining good conditions and, consequently, not allowing poor dental health to negatively affect the athletic performance.

According to the data from low and moderate risk studies included in this systematic review and meta-analysis, the estimated prevalence of dental caries in athletes (46.25%) is considered to be high.

Acknowledgements

Kathleen Burk revised the manuscript for Grammar and style.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Correspondence Address:
Dr. Leonardo Santos Antunes
Department of Specific Formation, School of Dentistry, Fluminense Federal University, Rua Doutor Silvio Henrique Braune, 22 Centro, Nova Friburgo, Rio de Janeiro - 28625-650
Brazil
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijdr.IJDR_764_18

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