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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 17  |  Issue : 1  |  Page : 51-58

Awareness of dental health in competitive and recreational swimmers: A comparative survey-based study


Department of Oral and Maxillofacial Pathology and Microbiology, D. Y. Patil University School of Dentistry, Navi Mumbai, Maharashtra, India

Date of Submission18-Dec-2021
Date of Decision10-Jan-2022
Date of Acceptance06-Feb-2022
Date of Web Publication25-Jul-2022

Correspondence Address:
Dr. Sandhya Tamgadge
Department of Oral and Maxillofacial Pathology and Microbiology, D. Y. Patil University School of Dentistry, Nerul, Navi Mumbai - 400 706, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_469_21

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  Abstract 


Background: Swimming is an exercise globally popular due to its beneficial effects. It is a well-known fact that chlorine is added to pool water for disinfection, although the repercussion of the same is not prominently described in the literature. Aims: (1) This study aims to establish the presence of symptoms of dental erosion in swimmers who swim competitively as well as recreationally and (2) to compare the gradient of symptoms experienced by the two groups. Materials and Methods: This cross-sectional prospective study was carried out to establish the correlation between dental erosion in swimmers who swim competitively (n = 250) – 6 or more than 6 h a week and recreationally (n = 250) – lesser than 6 h a week. A questionnaire was distributed both online and manually across India and feedback was received. All the findings were correlated and statistically analyzed. Observation and Results: The results showed the distinct presence of the phenomenon among a majority of swimmers who experienced an array of symptoms of dental erosion such as chalkiness of teeth in 58.2% of subjects, roughness of teeth in 54.4%, generalized sensitivity in 38.2%, sensitivity to hot and cold foods/drinks in 52%, discoloration in 37.6%, and staining in 36.6% subjects. A remarkable finding of this study was the lack of generalized awareness with respect to the phenomenon among competitive and recreational swimmers Conclusion: This study highlights the prevalence of the phenomenon and the general lack of awareness among swimmers with respect to dental erosion associated with exposure to the chlorinated pool water.

Keywords: Chlorine, competitive, oral health, recreational, swimmer's erosion, Swimmers


How to cite this article:
Engineer S, Tamgadge S, Rijhwani N, Choudhary N, Shukla G. Awareness of dental health in competitive and recreational swimmers: A comparative survey-based study. J Datta Meghe Inst Med Sci Univ 2022;17:51-8

How to cite this URL:
Engineer S, Tamgadge S, Rijhwani N, Choudhary N, Shukla G. Awareness of dental health in competitive and recreational swimmers: A comparative survey-based study. J Datta Meghe Inst Med Sci Univ [serial online] 2022 [cited 2022 Aug 16];17:51-8. Available from: http://www.journaldmims.com/text.asp?2022/17/1/51/352247




  Introduction Top


As one of the most popular modes of physical activity, swimming/aquatic exercise confers significant physical health benefits for both healthy individuals and those with the disease.[1] Although what people often are oblivious to, are the adverse effects it may have on the dentition. It is a well-known fact that chlorine is added to pool water for disinfection, although the repercussion of the same is not prominently described in the literature.[2]

In 1982, Savad first reported that swimmers who swim in improperly maintained swimming pools may be susceptible to acid erosion of enamel.[3]

Centerwall et al. also described the erosion of enamel among competitive swimmers at a gas chlorinated pool in Charlottesville, Virginia – a study of 747 club members.[4]

Rapid and severe tooth erosion from swimming in an improperly chlorinated pool – was also reported by Colin Dawes with reference to a 72-year-old woman.[5]

Mehdipour concluded through his study that there was no relation between swimming time and dental erosion.[6]

Although studies in the literature provide relevant insight into the presence of the phenomenon, existing literature has very few studies with comparatively smaller sample sizes, with few sets of questions in their survey. However, the current study is a consolidation of multiple parameters put together in a concise, relevant, and detailed manner. The sheer diversity of subjects, which were chosen at random from well-renowned swimming pools across the country, is a distinct feature of this study. Furthermore, the number of subjects was a considerable size and hence provided significant/substantial data to arrive at a conclusion.

Therefore, the aim of the study was (1) to establish the presence of symptoms of dental erosion in swimmers who swim competitively as well as recreationally and (2) to determine the variability and compare the gradient of symptoms experienced by the two groups.


  Materials and Methods Top


This cross-sectional prospective study was carried out from December 2018 to September 2019 to establish the correlation between dental erosion called “swimmer's erosion” in swimmers (n-250) who swim competitively (6 or more than 6 h a week) and recreationally (n-250) for fun or health-related reasons (lesser than 6 h a week). A questionnaire was distributed both online and manually across India and the feedback received was recorded [Figure 1]. The total number of subjects in this study consisted of 500 swimmers (competitive + recreational category) from a random selection of swimming pools and clubs present across India.
Figure 1: Questionnaire

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  1. Inclusion criteria comprised swimmers who have swam 6 or more than 6 h a week regardless of age and sex
  2. Exclusion criteria comprised swimmers who entered themselves as competitive swimmers but did not meet the criteria of swimming more than 6 h a week and any individual who entered themselves as recreational swimmers but did not meet the criteria of swimming < 6 h a week.


The competitive swimmer group comprised 250 subjects (149 males, 101 females), whereas the recreational group comprised 250 subjects (99 males, 151 females). All the subjects received a standard questionnaire. The questionnaire comprised 21 questions and targeted five parameters, which are as follows:

  1. Swimming habits based on: Competitive – 6 or more than 6 h a week and recreational – <6 h a week
  2. Swimming habits based on: Time in years spent swimming, number of sessions per week, and duration of each session
  3. Symptoms of dental erosion experienced by the subjects: Generalized sensitivity, sensitivity to air/hot or cold food substances, chalkiness and roughness of enamel surface, discoloration, and staining
  4. General dental health awareness and preventive strategies such as scaling, use of mouthguard devices, and fluoride treatments undertaken
  5. Awareness among the subjects with respect to preventive modalities and familiarity of the subjects with the phenomenon of “swimmers erosion”
  6. Ethical approval was not considered as the participant's identity was not disclosed.


Data were tabulated and analyzed using software IBM SPSS 20.0 (IBM Corp, Armonk, NY).


  Observation and Results Top


When all the observations were made and compared in both groups, results were found as follows:

The mean age group of the subjects was 24.5 years. The competitive subjects had a mean age group of 21.71 years and recreational subjects were 27.29 [Figure 2].
Figure 2: Age distribution of subjects (in years)

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Swimming habits

Among competitive swimmers, 33.2% of swimmers have been swimming for 10+ years, followed by 30.8% for 6–10 years, 27.6% for 1–5 years, and 8.4% for lesser than a year.

About 38.8% of swimmers have swum recreationally for over 10 years, followed by 24% for 1–5 years, 21.6% for 6–10 years, and 15.6 for lesser than 1 year.

Duration of session

Among competitive swimmers, 43.2% of them claimed to spend 1–2 h per session of training. About 30.8% swam for 30 min to 1 h and 20.4% for more than 2 h. About 5.6% of the subjects claim to be competitive swimmers who spend 15–30 min per session in the pool but do not qualify as per the inclusion criteria. A statistically highly significant difference (P < 0.001) with respect to hours of swimming per session among both study groups was observed.

Most of the competitive participants trained more than five times a week – 38.4% followed by 31.2% who trained 4–5 times a week and 16%, 2–3 times a week (highly significant difference [P < 0.001]).

Recreationally the majority claimed to swim lesser than once every month 24.8%, followed by 22.8% of the group swam once every week.

Competitive swimmers who claimed to swim lesser than once every month (n = 19), once a month (n = 5), once in 2 weeks (n = 2), and once a week (n = 10) have been added to the exclusion criteria.

Combining data from the two groups, 22.2% swam more than five times a week, followed by 18.2% who swam 4–5 times a week. In a close contest, 16.2% swam lesser than once a very month and 15.2% swam 2–3 times a week, followed by 13.4% who swam once a week [Figure 3] and [Figure 4].
Figure 3: Swimming habits: (a) Swimming time in years, (b) hours spent per session, (c) number of sessions per week, and (d) quantity of ingested water

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Figure 4: Graphical description of swimming habits: (a) Swimming time in years, (b) hours spent per session, (c) number of sessions per week, and (d) quantity of ingested water

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Water ingestion while swimming

95 subjects swam competitively and 99 swam recreationally; Overall, the majority (38.8%) of the total number of subjects claimed to have ingested 1–2 mouthfuls of water during a swim session (highly significant difference [P < 0.001]) [Figure 3] and [Figure 4].

Symptoms

Chalkiness

291 subjects had chalkiness when upper and lower teeth touch each other after a swim of which competitive were 69.2% and recreational were 47.2% (highly significant difference [P < 0.001]).

Roughness

272 subjects had roughness when the teeth were touched/came in contact with the tongue and other teeth of which 64.4% were competitive and 44.4% were recreational (highly significant difference [P < 0.001]).

Generalized sensitivity

One-hundred and ninety-one subjects claim to have generalized sensitivity timed around exposure to the swimming pool water/training, of which 55.4% are competitive and 44.5% are recreational swimmers (no statistically significant difference [P > 0.05]).

Sensitivity to hot and cold food and drinks

Two hundred and sixty subjects reported having sensitivity to hot and cold food and drinks timed post their workouts, out of which 48.8% swam competitively and 55.2% swam recreationally (no statistically significant difference [P > 0.05]).

Discoloration

A surprising 188 subjects reported discoloration of their teeth, of which 51.5% swam competitively and 48.4% recreationally (no statistically significant difference [P > 0.05]).

Staining

One hundred and eighty-three subjects reported staining of teeth, of which 54% swam competitively and 45.9% swam recreationally [Figure 5] and [Figure 6] (no statistically significant difference [P > 0.05]).
Figure 5: Symptoms experienced by subjects: (a) Chalkiness, (b) roughness, (c) sensitivity to hot and cold food and drinks, (d) sensitivity of teeth when in contact with air (e) discoloration of teeth, and (f) staining of teeth

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Figure 6: Graphical description of symptoms experienced by subjects: Chalkiness, roughness, sensitivity when teeth come in contact with air, sensitivity to consuming hot or cold food and drinks, discoloration of teeth, staining of teeth, subjects who think that the symptoms they are experiencing could be due to swimming

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An overwhelming, 33.4% of subjects (167/500), of which competitive were 106 and recreational were 61 felt that the symptoms they were experiencing were timed around their workouts and could be due to swimming [Figure 6] and [Figure 7] (highly significant difference [P < 0.001]) [Figure 5] and [Figure 6].
Figure 7: Description of subjects who think that the symptoms they are experiencing could be due to swimming

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Awareness

Chlorine added for disinfection purposes

Fifty-four subjects were unaware of the fact that chlorine is added to the water for sanitization purposes, of which 42.5% were competitive and 57.4% were recreational (no statistically significant difference [P > 0.05]).

Inquiry about technicalities of pool water

415 subjects have never inquired about technicalities of pool water such as pH and temperature of pool water, of which 51.3% are subjects who swam competitively and 48.6% are those who swam recreationally.

Use of mouthguard

Four hundred and sixty subjects do not wear a protective device such as a mouthguard for protection. Of the remaining 40 subjects who use a mouthguard, 26 subjects swam recreationally and 14 recreationally (significant difference [P < 0.05]).

Aware of any preventive modality

Three hundred and seventy-nine subjects are unaware of the fact that there exists a preventive modality to combat dental erosion, of which a higher percentage exists among competitive swimmers (no statistically significant difference [P > 0.05]).

Frequency of dental visits

One hundred and sixty-three subjects claim to go every 1.5–6 months for checkups which comprise the majority (32.6%). This is followed by subjects who go lesser than once a year annually (28.2%), subjects who visit every 6.5 months–1 year (26.4%), and finally, subjects who visit once every month (12.4%).

Fluoride treatment benefits awareness

Three hundred and twelve subjects are unaware of the fact that fluoride application has beneficial effects of the tooth structure. Of the 188 subjects aware 69 swam competitively and 119 swam recreationally (highly significant difference [P < 0.001]).

Undergone preventive care

Three hundred and seventy-nine subjects have not undergone any preventive care. Of the 121 subjects who have recreational swimmers marginally exceeded competitive swimmers by 0.9% (no statistically significant difference [P > 0.05]).

Read articles about the phenomenon of “swimmer's erosion” or other such related articles: four hundred and forty-seven of the total number of subjects have never come across in their lifetime any article that makes them aware of the existence of the phenomenon of “swimmer's erosion.” Among the number of people who have recreational swimmers exceed competitive ones [Figure 8] (no statistically significant difference [P > 0.05]).
Figure 8: Awareness among subjects and precautionary measures taken up by them: (Clockwise) (a) awareness of chlorine as a pool water disinfectant, (b) inquiry made with respect to pool water technicalities, (c) use of mouthguard, (d) awareness of preventive modality, (e) frequency of clean up/regular checks ups, (f) awareness of fluoride treatments, (g) patients who have undergone preventive care, (h) awareness with regard to the phenomenon of swimmer's erosion

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Consumption of energy drinks containing high amount of sugars, color additives, etc., synergizes the effect of acid on the tooth. Competitive exceed the use of energy drinks when compared with recreational swimmers by 26.9% [Figure 9].
Figure 9: Consumption of energy drinks by subjects

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  Discussion Top


It is an established fact that tooth enamel does not decalcify unless the pH falls below 5.5 (critical pH). High levels of chlorine in pool water cause a decrease in pool water pH.[7] Recommended pH of the pool water should be maintained at 7.2–7.8.[8]

In general, when both the groups are taken into consideration, results depicted a distinct presence of the phenomenon among a significant number of swimmers who experienced an array of symptoms of dental erosion such as chalkiness, roughness, and general sensitivity when in contact with air of teeth in more than half the subjects and the more graver symptoms such as discoloration and staining in almost 40% of the subjects.

Competitive swimmers consume a higher quantity of sports drinks. This consumption along with a physiological decrease of saliva flow which is caused due to dehydration from exercise would possibly produce additive erosive damage to teeth.[9]

When swimming habits were compared between the two groups, for example, competitive and recreational, it was observed that most parameters were dominated by competitive swimmers. They have also claimed to experience symptoms of dental erosion in higher magnitudes than recreational swimmers. Hence, we can positively confirm that the symptoms experienced by swimmers are directly proportional to time spent in the pool. A similar conclusion was established in a pilot study by Baghele et al.[10] In contrast, a study by Mehdipour concluded otherwise.[6]

Furthermore, where the ingestion of water is concerned, surprisingly 14.4% of competitive swimmers claimed to ingest 7–8 mouthfuls during a session which could be the result of aggressive nature and more time spent in the pool. Generally speaking, the amount of water ingested by swimmers and pool users will depend on a range of factors, including experience, age, skill, and type of activity. Thus, there appears to be no data which state the exact amount of water which is harmful when ingested.[11]

Symptoms

All the symptoms of dental erosion experienced are seen more in competitive swimmers than in recreational, chalkiness by 22%, roughness by 20%, and generalized sensitivity by 10.9%. Here, physiologic wear-related sensitivity is an inconsequential criterion as the mean age of subjects of this study is 24.5 years and that of the competitive swimmers is even lesser, 21 years, who in a comparison with recreational swimmers experience more sensitivity when in contact with air. Discoloration and staining are seen more in competitive than recreational by 3.1% and 8.1%, respectively. This difference could be less due to the fact that most sportspersons follow a moderately strict, nutritious diet regimen with less frequent consumption of foodstuff considered unhealthy and containing color additives.

A note can be made that the only case where the symptoms in recreational swimmers are more than competitive is sensitivity to hot and cold food and drinks by 6.4%. The reason could be that recreational swimmers might be eating/consuming foodstuff directly after their workouts or within a short time after coming out of the pool.

When awareness is considered, recreational swimmers show enhanced awareness as compared to competitive (which is opposite of what one would generally perceive) when factors such as inquiry in relation to pool technicalities, availability of preventive modalities, benefits of fluoride application, undertaking of preventive procedures, and having read articles based on swimmers erosion/related phenomenon are concerned. Competitive are only more aware of the fact chlorine is added to pool water for disinfection purposes. There are very few studies in the literature which focus on the evaluation of awareness of the harmful effects of pool water on teeth. Francesca Gallè conducted a study but the awareness was focused on extraoral effects.[12]

Poor knowledge of dental health among Indian societies; lack of awareness of preventive measures; disregard toward the maintenance of the pool water; lack of regular monitoring of the pool water by the managing authorities or state/central government bodies; improper and cheap equipment; overcrowding of pools; lack of seriousness and accountability; poor water quality; and the use of certain chemicals in higher quantities than is recommended by the World Health Organization, and the Centers for Disease Control and Prevention.[9]

The drawback of the study was that swimmers with a history of gastric reflux, hyperacidity, bulimia, or an occupation in a chemical factory; those with adverse/abrasive teeth-cleaning habits; and those with a diet including citrus fruits might also have erosion which was not considered exclusion criteria as there was no personal interaction with the participants. Therefore, in future studies, such parameters should be asked and excluded.

Advances in knowledge

Swimming is the best excursion but is quite harmful to teeth. The amount of time spent in the pool is directly proportional to the symptoms experienced by subjects. A highlight of this study is the generalized lack of awareness among subjects.

Application to patient care

On a professional front, dentists must advise and administer fluoride treatments to high-risk patients and ensure regular follow-ups.


  Conclusion Top


From these results, we can definitively state that the amount of time spent in the pool is directly proportional to the symptoms experienced by subjects. A highlight of this study is the generalized lack of awareness among subjects. We must target our efforts toward enlightening people about this rampant phenomenon and lay down strict laws and criteria to maintain the pH of pool water. We must also provide rigorous training to staff/personnel such as pool managers/coaches in the maintenance of the same as a preventive strategy. On a professional front, dentists must advise and administer fluoride treatments to high-risk patients and ensure regular follow-ups.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Łubkowska W, Paczyńska-Jędrycka M, Eider J. The significance of swimming and corrective exercises in water in the treatment of postural deficits and scoliosis. Centr Eur J Sport Sci Med 2014;6:93-101.  Back to cited text no. 1
    
2.
Geurtsen W. Rapid general dental erosion by gas-chlorinated swimming pool water. Review of the literature and case report. Am J Dent 2000;13:291-3.  Back to cited text no. 2
    
3.
Savad EN. Enamel erosion.multiple cases with a common cause (?). J N J Dent Assoc 1982;53:32, 35-7, 60.  Back to cited text no. 3
    
4.
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. 4
    
5.
Dawes C, Boroditsky CL. Rapid and severe tooth erosion from swimming in an improperly chlorinated pool: Case report. J Can Dent Assoc 2008;74:359-61.  Back to cited text no. 5
    
6.
Mehdipour M. Evaluation the effect of swimming time on dental erosion among swimmers. J Islam Dent Assoc Iran 2013;25:76-9.  Back to cited text no. 6
    
7.
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. 7
    
8.
Chuenarrom C, Daosodsai P, Benjakul P. Erosive potential of low PH swimming pool water on dental enamel. J Health Res 2010;24:91-4.  Back to cited text no. 8
    
9.
Tooth damage linked to public pool by Center for Disease Control. Fla Dent J 1983;54:12-3.  Back to cited text no. 9
    
10.
Baghele ON, Majumdar IA, Thorat MS, Nawar R, Baghele MO, Makkad S. Prevalence of dental erosion among young competitive swimmers: A pilot study. Compend Contin Educ Dent 2013;34:e20-4.  Back to cited text no. 10
    
11.
World Health Organization. Water, Sanitation and Health Team. Guidelines for Safe Recreational Water Environments. Volume 2, Swimming Pools and Similar Environments. World Health Organization; 2006.  Back to cited text no. 11
    
12.
Gallè F, Dallolio L, Marotta M, Raggi A, Di Onofrio V, Liguori G, et al. Health-related behaviors in swimming pool users: Influence of knowledge of regulations and awareness of health risks. Int J Environ Res Public Health 2016;13:E513.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]



 

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