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Year : 2019  |  Volume : 44  |  Issue : 4  |  Page : 390-393

Prevalence of dentinal hypersensitivity and dental erosion among competitive swimmers, Kerala, India

Department of Public Health Dentistry, Government Dental College, Kottayam, Kerala, India

Date of Submission23-May-2019
Date of Acceptance03-Oct-2019
Date of Web Publication12-Nov-2019

Correspondence Address:
Dr. K Arun Rao
Department of Public Health Dentistry, Government Dental College, Kottayam - 686 008, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijcm.IJCM_213_19

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Background: Professional swimmers face a hidden occupational hazard due to improper maintenance of pool. Ill maintained pools can lead to erosive effects on dental health and thus needs to be evaluated. Methodology: Fifty-six competitive swimmers from two training centers were contacted and surveyed for swimming exposure and oral health. A visual analog scale was used to rate the tooth sensitivity. Dental erosion and dental caries were recorded according to WHO oral health assessment criteria (2013). The dentinal hypersensitivity experience was assessed using the dentine hypersensitivity experience questionnaire - 15 (DHEQ-15). Data were analyzed using Chi-square test and multivariate analysis. Results: The prevalence of dentinal hypersensitivity and dental erosion was found to be 69.6% and 48.2%, respectively. The common surfaces affected by dental erosion were palatal surfaces of maxillary anterior, followed by lingual surfaces of mandibular anterior. There was a direct association between duration of the stay in pool and dental erosion. The DHEQ-15 questionnaire revealed that more than 80% of the participants never felt these sensations had any serious long-term effects on oral health. Conclusions: Oral health professional must understand dental erosion among competitive swimmers as an occupational oral health hazard and provide early counseling and necessary invasive and noninvasive care.

Keywords: Dentin sensitivity, oral health, swimming, swimming pools, tooth erosion

How to cite this article:
Rao K A, Thomas S, Kumar JK, Narayan V. Prevalence of dentinal hypersensitivity and dental erosion among competitive swimmers, Kerala, India. Indian J Community Med 2019;44:390-3

How to cite this URL:
Rao K A, Thomas S, Kumar JK, Narayan V. Prevalence of dentinal hypersensitivity and dental erosion among competitive swimmers, Kerala, India. Indian J Community Med [serial online] 2019 [cited 2021 Oct 24];44:390-3. Available from: https://www.ijcm.org.in/text.asp?2019/44/4/390/270802

   Introduction Top

Swimming is one of the most popular sports with multiple physical and mental health benefits. Chlorination of swimming pools helps to oxidize matter and kill microorganisms. The recommended pH range of chlorine in pool water is 7.4–7.6, below which it might lead to irritation of eyes and mucous membranes. Improperly maintained pools may lead to acute diffuse otitis externa (swimmer's ear) and asthma.[1],[2]

Competitive swimmers, who often swim for a longer time, expose their teeth to large amounts of chemically treated water. Organic deposits due to breakdown of salivary proteins are noted on swimmer's teeth as a result of a higher pH due to addition of antimicrobial agents.[3]

Tooth wear such as tooth erosion has drawn increasing attention as a risk factor for tooth loss. Erosion is the progressive loss of tooth surface by acid from a nonbacterial source. The causes of erosion can be intrinsic as seen in gastroesophageal reflex, dietary erosion, and extrinsic such as environmental and occupational factors; such occupational factors may lead to erosion and thus hypersensitivity in professional swimmers.[4]

Among professional swimmers, the most common dental noncarious destructive lesion is dental erosion.[5] Pathogenic mechanism of dental erosion is based on the dissociation of hydroxyapatite and on impaired mineralization of the dental hard tissue due to long and frequent effect of acids. For the erosion to progress, the solution pH level has to be below 5.5 for enamel and below 6.0 for dentine.[6] Early diagnosis of dental erosion is difficult but critical to implement preventative measures and preserve tooth tissue. The paucity of diagnostic devices for the assessment of dental erosion leads to difficulties in early diagnosis. Clinical signs and carefully elicited history including patient's occupation are critical for early detection and deciding treatment options.[7] Clinical features of dental erosive lesions include broad concavities within smooth tooth enamel or loss of enamel surfaces with dentine exposure.[8]

The oral and systemic effects of swimming in ill-maintained pools have been studied in multiple high-income countries,[9],[10],[11] but the status with respect to low- and middle-income countries is yet to be uncovered; this dearth of knowledge about the prevalence of erosion among competitive swimmers in India could be traced using a professional swimming establishment with interregional trainees.

The objective of the current study is to find the prevalence of dentinal hypersensitivity and associated oral health symptoms among competitive swimmers in Kottayam district of Kerala, India.

   Methodology Top

A cross sectional study was conducted among competitive swimmers from two training centers at Kottayam, India. A pilot study was conducted, and the sample size was calculated as 48. Swimmers with <1 year of training were excluded. Written consent was obtained from each participant before their examination, and the study was approved by an institutional review board.

Data were collected from each participant regarding their years of swimming, average duration of training per day, and consumption of acidic beverages. Caries and dental erosion status were recorded using the WHO Oral Health Assessment Criteria (2013).[12] Participants completed the dentine hypersensitivity experience questionnaire-15 (DHEQ-15)[13] with five domains: restrictions, coping, social, emotions, and identity.

A portable dental unit equipped with light (Transport II portable dental unit-Aspetico Inc, WA, USA) and compressed air was used for clinical oral examination. A single examiner conducted the oral inspection on all the tooth surfaces using mouth mirror and #23 explorer to clinically identify dental erosion. Dentinal hypersensitivity was measured using a visual analogue scale.[14] A stream of air was blown onto the teeth surfaces using an air–water syringe, and the level of sensation was recorded on the scale.

The data were analyzed usingStatistical software package SPSS (version 16.0; SPSS Inc., USA). Chi-square test and multivariate analysis were applied to find any association, and statistical significance was considered if P ≤ 0.05. Chi-square analysis was done to find any association between dental erosion and swimmers experience in years, duration of swimming, dental caries, dentinal hypersensitivity, and frequency of consumption of fizzy drinks. Those variables for which a significant association was found were further analyzed to generate a multivariate model, and adjusted odds ratios were estimated.

   Results Top

A total of 56 competitive swimmers with a mean age of 15 ± 2.8 years consisting of higher proportion of males (62.5%) participated in this study. Dentinal hypersensitivity was experienced among 69.6% and dental erosion among 48.2% participants. The prevalence of dental caries was found to be 39.3%. Among the participants having dentinal hypersensitivity, 61.5% were noted to have dental erosion.

[Table 1] shows the associated factors for dental erosion among competitive swimmers. There was no gender predilection for dental erosion (P > 0.05). With increase in years of swimming experience, the prevalence of dental erosion increased from 26% to 69%. In this study, swimmers spent an average of 2 h in each training session. An increase in dental erosion was found among those who spent more than 2 h during a training session, although 61% had a habit of consuming acidic beverage, no association was found between the frequency of consumption of fizzy drinks and dental erosion. The odds of developing dental erosion were found to be 5.3 times among swimmers who have more than 3 years of swimming experience.
Table 1: Associated factors for dental erosion among competitive swimmers

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[Table 2] shows the participant responses to the DHEQ-15. Among the participants with dentinal hypersensitivity, 41.2% agreed that they have had problems while eating cold foods like ice cream. Less than 40% reported these sensations to be very annoying to them. More than 44% of the participants with hypersensitivity disagreed to have any associated emotional problems; also, more than 80% did no't think these sensations were of health concern even though these sensations were not holding them back from visiting a dentist.
Table 2: Dentinal hypersensitivity experience questionnaire-15

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   Discussion Top

Dental erosion is the loss of tooth surface due to the chemical etching which results in dissolution of the hard tissue. The presence of acidic external environment, which is not bacterial in origin, can result in dentin sensitivity. Tooth wear in a young patient would be seen as pathological rather than physiological problem.[15]

The prevalence of dentinal hypersensitivity and dental erosion among the competitive swimmers in the present study is 69.6% and 48.2% respectively. These values are higher compared to a similar study conducted by Buczkowska-Radlińska et al.[10] in Poland Zebrauskas et al.[11] in Lithuania reported higher prevalence of dental erosion among competitve swimmers aged 18–25 years(50%) compared to 12 - 17 years (25%). Further, this present study showed an increase in prevalence of dental erosion with the swimmer's experience. Eroded anterior tooth in swimmers is characterized by increased incisal translucency, incisal chipping, and in moderate to severe cases, cupping out of the incisal edges.[8]

Majority complained that the hypersensitivity aggravated on consuming citrus or cold foods, with most common site of discomfort being maxillary and mandibular anterior region as shown in [Figure 1]. There was no probable link noted between dentinal hypersensitivity in relation to dental caries and consumption of fizzy drinks along with a significant relationship elucidated between dental erosion and dentinal hypersensitivity (P< 0.05); this suggests the hypersensitivity among this population could be a good indicator of dental erosion.
Figure 1: Dental erosion on palatal surface of maxillary upper anteriors

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Dental erosion was noted to be more frequent on palatal surface of maxillary anterior followed by mandibular anteriors, similar to the findings reported by Buczkowska-Radlińska et al.[10] Majority of swimmers who were experiencing dentinal hypersensitivity restricted certain food items such as citrus fruits and ice creams, as with the study population in a research conducted by Bekes et al. in Germany.[16]

More than 80% of these swimmers did not perceive dentinal hypersensitivity as a health problem and demand any treatment. The low demand for dental services was noted by 75% of participants in a study by Gillam et al.[17]

This study reports a prevalence of dental erosion 5 times higher compared to another study conducted among school children of similar age in India[18]. This raises a tangible public health concern regarding oral health among the young competitive swimmers.

Consumption of sports drink is an added exposure to dental erosion among athletes. However, no significant relationship has been established between consumption of soft drinks and dental erosion;[19] the present study also failed to establish any such relationship.

Dental caries and dental erosion share some common risk factors; furthermore, the acidic environment which leads to erosion is found to encourage the growth of Streptococcus mutans.[20],[21] Multivariate analysis revealed no significant relationship in this study.

   Conclusions Top

Professional maintenance of swimming pools with emphasis on balancing the pH of pool water is vital to avoid health risks for swimmers. Oral health professionals need to understand this oral health hazard and provide early counseling

It is impossible to avoid potentially erosive agents from contact with the tooth during a lifetime; therefore, the emphasis should be on early diagnosis and prevention. Awareness about the harmful effects of overchlorinating the pool water among employees must be improved. Oral health professionals can play a key role in promoting customized mouth guards among professional swimmers. Enamel repair commences within 2 h of an acidic exposure. Brushing teeth immediately after swimming can be harmful as the surface of the teeth is softened by the acidic chlorine. Rinsing of oral cavity with water, baking soda, or fluoride mouthwash after each swimming practice and usage of soft tooth brush must be encouraged among competitive swimmers.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Wang MC, Liu CY, Shiao AS, Wang T. Ear problems in swimmers. J Chin Med Assoc 2005;68:347-52.  Back to cited text no. 1
Fernández-Luna Á, Burillo P, Felipe JL, del Corral J, García-Unanue J, Gallardo L. Perceived health problems in swimmers according to the chemical treatment of water in swimming pools. Eur J Sport Sci 2016;16:256-65.  Back to cited text no. 2
Buzalaf MA, Hannas AR, Kato MT. Saliva and dental erosion. J Appl Oral Sci 2012;20:493-502.  Back to cited text no. 3
Johansson AK, Omar R, Carlsson GE, Johansson A. Dental erosion and its growing importance in clinical practice: From past to present. Int J Dent 2012;2012:632907.  Back to cited text no. 4
D'Ercole S, Tieri M, Martinelli D, Tripodi D. The effect of swimming on oral health status: Competitive versus non-competitive athletes. J Appl Oral Sci 2016;24:107-13.  Back to cited text no. 5
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Joshi M, Joshi N, Kathariya R, Angadi P, Raikar S. Techniques to evaluate dental erosion: A systematic review of literature. J Clin Diagn Res 2016;10:ZE01-7.  Back to cited text no. 7
Paryag A, Rafeek R. Dental erosion and medical conditions: An overview of aetiology, diagnosis and management. West Indian Med J 2014;63:499-502.  Back to cited text no. 8
Centerwall BS, Armstrong CW, Funkhouser LS, Elzay RP. Erosion of dental enamel among competitive swimmers at a gas-chlorinated swimming pool. Am J Epidemiol 1986;123:641-7.  Back to cited text no. 9
Buczkowska-Radlińska J, Łagocka R, Kaczmarek W, Górski M, Nowicka A. Prevalence of dental erosion in adolescent competitive swimmers exposed to gas-chlorinated swimming pool water. Clin Oral Investig 2013;17:579-83.  Back to cited text no. 10
Zebrauskas A, Birskute R, Maciulskiene V. Prevalence of dental erosion among the young regular swimmers in Kaunas, Lithuania. J Oral Maxillofac Res 2014;5:e6.  Back to cited text no. 11
World Health Organization | Oral Health Surveys: basic Methods – 5th ed. Available from: https://www.who.int/oral_health/publications/9789241548649/en/. [Last accessed on 2019 Apr 10].  Back to cited text no. 12
Machuca C, Baker SR, Sufi F, Mason S, Barlow A, Robinson PG, et al. Derivation of a short form of the dentine hypersensitivity experience questionnaire. J Clin Periodontol 2014;41:46-51.  Back to cited text no. 13
Heaton LJ, Barlow AP, Coldwell SE. Development of labeled magnitude scales for the assessment of pain of dentin hypersensitivity. J Orofac Pain 2013;27:72-81.  Back to cited text no. 14
Wang X, Lussi A. Assessment and management of dental erosion. Dent Clin North Am 2010;54:565-78.  Back to cited text no. 15
Bekes K, John MT, Schaller HG, Hirsch C. Oral health-related quality of life in patients seeking care for dentin hypersensitivity. J Oral Rehabil 2009;36:45-51.  Back to cited text no. 16
Gillam DG, Seo HS, Bulman JS, Newman HN. Perceptions of dentine hypersensitivity in a general practice population. J Oral Rehabil 1999;26:710-4.  Back to cited text no. 17
Kumar S, Acharya S, Mishra P, Debnath N, Vasthare R. Prevalence and risk factors for dental erosion among 11- to 14-year-old school children in South India. J Oral Sci 2013;55:329-36.  Back to cited text no. 18
Mathew T, Casamassimo PS, Hayes JR. Relationship between sports drinks and dental erosion in 304 university athletes in Columbus, Ohio, USA. Caries Res 2002;36:281-7.  Back to cited text no. 19
Hunter PB. Risk factors in dental caries. Int Dent J 1988;38:211-7.  Back to cited text no. 20
Lussi A, Jaeggi T. Erosion – Diagnosis and risk factors. Clin Oral Investig 2008;12 Suppl 1:S5-13.  Back to cited text no. 21


  [Figure 1]

  [Table 1], [Table 2]

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