FACT SHEET - Dental Health : Vol. 2 No. 5 February 1999
Risk Factors on Dental Erosion among Swimmers
Chantana Ungchusak Dentist,
Surat Mongkolchai-arunya Dentist,
Kanit Rattanarungsima Public Health Technical Officer
Dental Health Division, Department of Health, Tel : 5904213
The most effected surface were facial surface of anterior teeth. It was found, by crude analysis of each factors , that swimming athletes had dental erosion 4.68 times more than general swimmers.

Introduction

Dental erosion is described as the loss of tooth surfaces which can be caused by exposure to acidic chemical agent. (1,2) The aetiology of dental erosion can either be intrinsic or extrinsic factors. Intrinsic causes include recurrent vomiting, extrinsic causes include exposure to acidic foods and drinks, inhalation of corrosive industrial fumes, or exposure to any acidic substances. The tooth surface is eroded generally in the pH range below five.(3,4,5) When different acids were compared for their eroded potential, citric acid was found to be the most damaging to tooth structure.(3) The tooth structure is much dissolved during prolonged or repeated exposure to acidic environment.
The dental erosion among swimming athletes were reported in 1986 and 1994, in the gas chlorined swimming pools. (6,7) Recently there were some reports on dental erosion among the swimming athletes in Thailand.(8,9) The objective of this study is to identify risk factors associated to dental erosion among swimmers. The hypotheses were that some chlorine compound used in the pools and long exposure time had effect upon dental erosion.

Material and method

Six pools in Bangkok were purposive selected according to the chlorine compound used and their willingness to participate. Sample of all swimmers (athletes and non-athletes) in the survey date from these pools were enrolled. Cases were those having dental erosion, while controls were those who has no dental erosion. Being matched by gender and age between cases and controls, there were 70 cases and 214 controls, at the age of 7-15 years old.
Sample were interviewed about swimming practice and other possible risk factors known to cause dental erosion. Twelve anterior teeth of each sample were examined to detect dental erosion using Linkosalo & Markkanen's criteria. The pools were inspected, chlorine compound used were reviewed, pH of pool water were measured and the pool caretakers were interviewed about maintenance practices .

Results

Almost half of the cases had 1-5 eroded teeth surface (range 1-27). The most effected surface were facial surface of anterior teeth. It was found, by crude analysis of each factors , that swimming athletes had dental erosion 4.68 times more than general swimmers ( 95 % CI = 2.35-9.31). The swimmers who swam in pools using Trichloroisocyanuric acid had dental erosion 2.78 times more than those who swam in pools using calcium or sodium hypochlorite (Table1). The risk was increased to 13 times if the swimming athletes swam in Trichloroisocyanuric acid pools (table 2).

Discussion

The result of this study is consistent with some other studies which showed the association of frequent swimming or swimming athletes and dental erosion. (6,7,8,9,10) There was also experimental study showed that dental enamel can be destroyed by low acidic solution.(3,11) In the swimming pool, chlorine products are known to change the water pH. (12) There are 4 major types of chlorine products; gas, sodium hypochlorite (liquid), calcium hypochlorite (granular) and trichloroisocyanuric acid or sodium dichloroisocyanuric acid (stabilized). When chlorine gas or trichloroisocyanuric acid is used, the resulting solution is acidic. A buffering substance such as sodium bicarbonate is recommended for increasing the pH. When sodium hypochlorite or calcium hypochlorite is added to water, the pH of the pool water is increased, and the use of acids such as hydrochloric acid is needed. In this study, there were three common chlorine chemical used for the purpose of cleaning the water in the pools namely, sodium hypochlorite, calcium hypochlorite and trichloroisocyanu- ric acid. Only trichloroisocyanuric acid was identified as a rick factor since the chemical compound produced a strong acid condition in the swimming pool. Trichloroiso-cyanuric acid is widely used because it is cheaper and can prevent algae proliferation in the water at the same time.
To eliminate this risk, the Department of Health along with the Bangkok Metropolitan Authority had conducted meetings and had held training courses for the managers of the swimming pools in the Bangkok area. Daily monitor of water pH and adjust the acidity by using Sodium bicarbonate are strongly recommended. Swimming atheletes might also need to use some personal mouth guard for the purpose of protection.

Conclusion.

This study has identified the association of dental erosion caused by long practice session, particularly the swimming athletes, in pools using trichloroisocyanuric acid. The problem can be further prevented by educating the pool managers and caretakers to be ware of the risk, help eliminating by daily monitor with care and adjust the appropriate water acidity.
Reference
  1. Bernstein M.L. Physical and Chemical Oral Injury, In Miller R.L., Gould A.R., Bernstein M.L., Read C.J. General and Oral Pathology. Mosby-Year Book, Missouri.1995, pp 215-235.
  2. Jarvinen V, Rytomaa I.I., Meurman J.H. Location of Dental Erosion in a Refered Population. Caries Res, 26: 391-396, 1992.
  3. Gilmore H.W., Lund M.R. Operative Dentistry Second Edition. The C.V. Mosby Company Saint Louis 1973 pp 401-407.
  4. Johnson G.K., Silvers J.E. Attrition, Abrasion, and Erosion: Diagnosis and Therapy. Clin Prev Dent , 9: 12-16, 1987.
  5. Jarvinen V.K., Rytomaa I.I, Heinonen O.P. Risk Factors in Dental Erosion. J Dent Res , 70: 942-947, 1991.
  6. Centerwall, B.S. Armstrong,C.W., Funkhouser, L.S. and Elzar,R.P. Erosion of Dental Enamel among Competitive Swimmers at a Gas Chlorined Swimming Pool Am. J. Epidemiol 123:, 641-647, 1986.
  7. Filler S.J., Lazarchik D.A. Tooth Erosion : An Unusual Case. Gen Dent ,Nov-Dec,:568-569, 1994.
  8. Warapun Limsintaropas, Srisuda Leelasitorn, Chantana Ungchusak. Dental Erosion among Swimming Athletes in Phitsanulok Province. J. Dent. Assoc. Thai, Vol 45 No 2 Mar-Apr 1995.
  9. Boonyanit Thaweboon, Thanomwong Kritpet, Waranun Buajeeb, Sroisiri Thaweboon. Prevalence of Enamel Erosion in Thai Swimmers and the Related Factors. J. Dent. Assoc. Thai, Vol 48 No 3 May-Jun. 1998.
  10. Bevenius, L'Estrange, Angmar-Mansson. Erosion: Guidelines for the General Practitioners. Aus Dent J , 33: 407-411, 1988.
  11. Gabai Y, Fattal B , Rahamin E, Gedalia I. Effect of pH Levels in Swimming Pools on Enamel Human Teeth. Am J Dent , 1 : 241-243, 1988.
  12. Manual of Pool and Spa Water Chemistry. In Apply Biochemists,Inc. Mequon, Wisconsin, U.S.A. pp 1-11.
Go back to the top | Go back to main menu