We are often told that our permanent teeth are meant to last a lifetime, and therefore they deserve the best possible care. This is achievable through a healthy and balanced lifestyle. However, there are situations where this delicate balance is disrupted.
In this brief literature review, we focus on dental erosion – the progressive loss of tooth surface caused by non-bacterial acidic sources – in swimmers.
Dental Erosion: Triggering Causes
The primary trigger lies in the excessive acidity of the environment: for erosion to progress, the pH level must be below 5.5 for enamel and 6.0 for dentin.
This can occur due to intrinsic sources (such as gastroesophageal reflux or vomiting) and extrinsic sources (caused by medications and dietary supplements). A third category includes those exposed to acidic environments for professional reasons – swimmers being a prime example.
It is worth noting that according to the latest WHO guidelines from 2006, the pH of swimming pool water using chlorine-based disinfectants should be maintained between 7.2 and 7.8, well above the 5.5 threshold mentioned earlier.
Not all swimmers or pools are under the same conditions, and ideally, swimmers should be in perfect dental health. Oral diseases negatively impact quality of life and can reduce performance during training and competition, causing pain, anxiety, lack of focus, and ultimately suboptimal results.
Dental Erosion: Professional vs. Amateur Swimmers
An important distinction exists between professional and amateur swimmers. Competitive swimmers, who spend more hours training in the water, show a higher incidence of dental trauma and discoloration compared to non-competitive swimmers. This may be due to the chemicals used to disinfect pool water and the prolonged exposure of teeth surfaces to water. Generally, more than six hours of training per week increases the risk of dental staining.
Some studies report cases where inconsistent pool pH control caused dental erosion – even severe cases within just two weeks. If this exposure is combined with the consumption of sports drinks, the risk of developing erosive lesions increases, although this remains debated in the literature.
The pathogenic mechanism of dental erosion is based on the dissociation of hydroxyapatite and the reduced mineralization of the dental hard tissue due to prolonged and frequent acid exposure.
In fact, our body neutralizes the effects of acid attacks by relying on the buffering capacity of saliva, which restores the proper pH in the oral cavity in approximately 30-40 minutes.
However, this ideal scenario is rarely reflected in daily sports practice, as exposure to the chemical agent can be prolonged, and salivary flow may also be reduced during intense physical exercise due to dehydration.
In fact, the likelihood of developing dental erosion was found to be 5.3 times higher among swimmers with more than three years of swimming experience.
The serious concern here is that over 80% of the surveyed swimmers did not consider these conditions to be a health risk and therefore did not think a dental check-up was necessary. The only reason a swimmer typically visits a dentist is due to dentin hypersensitivity caused by excessive erosion; this suggests that hypersensitivity could be a reliable early indicator of dental erosion.
Therefore, those responsible for monitoring oral health – the dental community – have the task of proactively managing the onset of erosive lesions. The natural consequence is effective erosion management through early screening for signs of erosion and a thorough assessment of all contributing factors.
Dentists and dental hygienists must carefully evaluate the erosive potential of the various foods and beverages consumed by the patient, as well as ask targeted questions regarding sports activities, which, as we have seen, play a crucial role.
How to counteract dental demineralization and erosion
What alternatives do we have today?
First of all, the worst thing to do is to recommend brushing teeth immediately after swimming: this can be harmful because the tooth surface is softened by the acidic chlorine.
There are several alternatives, and as we’ll see, not all of them are practical in a competitive training setting.
The literature primarily suggests to take advantage of the remineralizing properties of milk and cheese as both contain higher concentrations of calcium and phosphate ions compared to saliva. A variation of this approach involves the use of fluoridated milk, which has been shown to provide protective effects against enamel erosion caused by low‑pH swimming pool water. Applying fluoridated milk both before and after erosive exposure yields the strongest protective benefits. Another option is fluoride itself, though its effectiveness against erosion remains somewhat controversial. Promising results have been observed only with high concentrations of fluoride found in varnishes and foams, rather than in everyday toothpastes.
Fluoride is well known for enhancing remineralization and significantly reducing demineralization in mildly acidic environments.
Finally, the use of a sodium bicarbonate spray such as Cariex® has proven to be one of the most convenient and rapid solutions. It helps control the drop in salivary pH following carbohydrate intake, thereby contributing to the prevention of both caries and dental erosion.
Recommendation: Brush your teeth thoroughly with a soft toothbrush before entering the pool, spray Cariex® onto the mucosa and dental surfaces, and repeat the application every 40 minutes during training.
– Dr. Simone Bergomi –
For questions, please contact: simone.bergomi93@gmail.com
References
Rinsing with antacid suspension reduces hydrochloric acid-induced erosion
Maria do Socorro Coelho Alvesa Taís Fonseca Mantillab Enrico Coser Bridia Roberta TarkanyBastingaFabiana Mantovani Gomes Françaa Flávia Lucisano Botelho Amarala Cecilia Pedroso Turssia
The effect of swimming on oral health status: competitive versus non-competitive athletes
Simonetta D’ERCOLE, Marco TIERI, Diego MARTINELLI, and Domenico TRIPODI
The Effect of Swimming on Oral Ecological Factors
Prevalence of Dentinal Hypersensitivity and Dental Erosion among Competitive Swimmers, Kerala, India
Arun Rao, Susan Thomas, Jishnu Krishna Kumar, and Vivek Narayan
Author information Article notes Copyright and License information Disclaimer
Saliva and dental erosion
Marília Afonso Rabelo Buzalaf 1 , Angélicas Reis Hannas, Melissa Thiemi Kato
The Status of Mineralized Dental Tissues in Young Competitive Swimmers
Rapid General Dental Erosion by Gas-Chlorinated Swimming Pool Water. Review of the Literature and Case Report
The Effect of Bicarbonate/Fluoride Dentifrices on Human Plaque pH
J C Blake-Haskins 1 , A Gaffar, A R Volpe, J Bánóczy, Z Gintner, C Dombi
The Erosive Effects of Saliva Following Chewing Gum on Enamel and Dentine: An Ex Vivo Study
E M Paice 1 , R W Vowles, N X West, S M Hooper
Prevention of Erosive Tooth Wear: Targeting Nutritional and Patient-Related Risks Factors
M A R Buzalaf 1 , A C Magalhães 1 , D Rios 1
Consensus Report of the European Federation of Conservative Dentistry: Erosive Tooth Wear–Diagnosis and Management
T S Carvalho 1 , P Colon, C Ganss, M C Huysmans, A Lussi, N Schlueter, G Schmalz, R P Shellis, A B Tveit, A Wiegand
Chapter 9: Acidic Beverages and Foods Associated With Dental Erosion and Erosive Tooth Wear
Thiago Saads Carvalho 1 , Adrian Lussi 2
Salivary pH After a Glucose Rinse: Effect of a New Mucoadhesive Spray (Cariex) Based on Sodium Bicarbonate and Xylitol
G M Abbate, L Levrini, M P Caria
Effects of tannin-fluoride and milk-fluoride mixture on human enamel erosion from inappropriately chlorinated pool water
Sumalee Boonviriya, Sissada Tannukit, Suwanna Jitpukdeebodintra
Rapid and Severe Tooth Erosion from Swimming in an Improperly Chlorinated Pool: Case Report
Colin Dawes, BSc, BDS, PhD; Carey L. Boroditsky, DMD
Guidelines for Safe Recreational Water Environments: Swimming pools and similar environments
SItI Working Group – Motor Sciences, Italian Society of Hygiene, Preventive Medicine and Public Health.
Evidence for biofilm acid neutralization by baking soda
Domenick T. Zero, DDS, MS ROLE