Physical preparation is not the only thing an elite athlete needs to do before an event. Preparing for the highest level of competition is complex. This is well known to champion Shannon Boxx, who spent two decades playing at the highest levels of American soccer, including the United States women’s national soccer teams, which won three Olympic gold medals, followed by a FIFA Women’s World Cup win in 2015. Shannon is the elite of elite.
Shannon started playing soccer at the age of four, yet it was only in more recent years that she noticed she had a white film around her mouth after a match. She had concerns about bad breath and some changes in her sense of taste and ability to chew or swallow pills. Even so, her symptoms were not enough to realize there was a medical problem until after she had been diagnosed with Sjögren’s syndrome,2 with her greatest symptom being extremely dry eyes.
As is the case with many autoimmune conditions, Shannon’s diagnosis took a long time. In Sjögren’s syndrome, the immune system attacks the glands that make tears and saliva.
Dry mouth is not unusual for elite athletes, whatever the sport. There are both physiological and behavioral explanations. Physiologically, there can be a decrease or even interruption of saliva secretion in the oral cavity during athletic effort. It is linked to stress, thermogenesis (heat formation), and buccal respiration. The behavioral explanation lies in the fact that the athletes, who are used to dealing with physical discomfort, might merely choose to cope with the dryness. Specific oral consequences can include cervical caries, periodontal disease, and opportunistic infections.
Dry mouth is common
We take saliva for granted, but when this natural function is diminished or stops, quality of life can drastically change. Have you ever had such a dry mouth that you drank gallons of water a day and it didn’t help? One of my patients described her dryness as her tongue and palate feeling like two halves of Velcro. Saliva, that tasteless liquid mixture produced by the salivary glands, is something most patients never think about—and sometimes dental professionals don’t either.
Dry mouth is a very common problem and is far more prevalent than many clinicians think. Reported rates of dry mouth vary, but one large study of more than 3,000 patients estimated the prevalence to be about 21% for men and 27% for women. Elderly patients have higher rates of dry mouth (about 30%), but don’t let that lull you into thinking dry mouth is something that is just part of the aging process.3 Over 60% of symptoms can be attributed to polypharmacy, the use of three or more medications, including over-the-counter medications.4
Dry mouth at all ages
We are also likely to see an increase in dry mouth due to the aging of the US baby boomer population. Oral health conditions likely to be associated with the boomer or “new” elderly are apt to be complicated by a lifetime of wear and tear and possible dry mouth. A common misconception is that normal aging directly causes dry mouth. The incidence of xerostomia does increase as we grow older, but that trend is primarily due to use of multiple medications or another medical condition that causes dry mouth. Dry mouth is also not limited to older adults. The American Academy of Allergy, Asthma, and Immunology reminds us about the link between childhood obesity and asthma.5 Asthma, breathing issues, and sleep apnea all lead to dryness and are other important aspects to look for in a medical history discussion.
Diagnosis and coping habits
Clarity of terminology is needed here. Hyposalivation is a clinical diagnosis that is made based on health history and examination. This includes evaluation for reduced salivary flow rates with a stimulated saliva flow rate less than 0.5 ml per gland in 5 minutes, or less than 1 ml per gland in 10 minutes. This is not the same as xerostomia, which is the patient’s perception of dry mouth symptoms. Dry mouth symptoms may not appear until salivary flow rate is reduced to 50% of normal.6
The behavioral aspect of oral dryness can be related to unhealthy coping habits. A 2019 study showed elite athletes have poor oral health despite their efforts to care for their teeth; this new study found that 94% reported brushing their teeth at least twice a day, and 44% reported regular interdental cleaning.1 The researchers found that the athletes regularly used sports drinks (87%), energy bars (59%), and energy gels (70%).1 As an oral health professional, you see the problem.7
Oral health professionals have a duty
Since being diagnosed, Shannon Boxx has become a true partner with her dentist and dental hygienist. She now wants to help increase awareness of the need for early identification of this condition and effective symptom management.
“As a high-performing athlete on the soccer field and now a busy mother and soccer coach, I’ve learned to deal with the symptoms and lessen their impact on my quality of life. The role of dentists and hygienists is key. Early identification of this condition and appropriate management of the symptoms with effective products can make a real difference in the lives of patients like me,” said Shannon.
Just as Shannon committed fully to soccer and achieving the highest levels of success, she has a new mission: she is now partnering with oral care leader Sunstar Americas, the makers of GUM Hydral Dry Mouth Relief, to increase awareness among dental professionals of the prevalence of dry mouth, often not recognized by sufferers until they have lost more than half of their saliva production.
“It took at least six years for me to be diagnosed,” says Shannon. “Like many patients, I suffered for years without knowing what was wrong. Managing the symptoms and lessening their impact on quality of life is important.” She has found real symptom relief with the GUM Hydral Dry Mouth Relief line from Sunstar (gumhydral-pros.com), which includes:
- GUM Hydral oral rinse: instant and long-lasting relief, up to four hours, for all-day use and as part of a daily oral hygiene routine
- GUM Hydral oral spray:on-the-go relief that leaves little aftertaste and requires no rinsing
- GUM Hydral oral gel:ideal for nighttime relief
- GUM Hydral anticavity toothpaste: a gentle formulation with soothing ingredients such as aloe vera and bisabolol, a natural constituent of chamomile
She reports that these products are cooling, soothing, and moisturizing, with a light flavor. Shannon added that the oral gel helped her to finally get a good night’s sleep. Before trying the gel, she had kept water at her bedside and woke up numerous times a night with dryness.
Interrupted sleep can have negative consequences on overall health, as we have seen and learned with the growth of sleep dentistry. During the night, the body progresses through different stages of sleep. If one stage is interrupted, the body has to reset and start going through the stages again, meaning the person may never get to the deep, restorative sleep that occurs during later stages. Sleep is essential for athletes, both to prepare for—and recover from—training and competition. This is no less true for those of us who are not elite athletes.
About a third of the population is estimated to have dry mouth.3 If you are not treating about a quarter to a third of your patients for this condition, than you may be underdiagnosing. Most routine dental assessments lack questions that specifically help to identify or diagnose dry mouth. Most health questionnaires do not include specific questions about dry mouth. The condition may go unnoticed if the patient doesn’t mention anything about it. The sidebar offers a few simple questions that can be asked of every patient. A positive response is an important indication that a patient may have dry mouth.8
If you don’t ask questions during routine dental exams, you may not uncover patients who have dry mouth and may be suffering in silence or who have less-than-healthy coping strategies. Chronic dry mouth is strongly and independently associated with a reduction in a patient’s quality of life. Diminished quality of life can result in loss of self-esteem and other social problems.
Early recognition and intervention
Early diagnosis and intervention are key to managing dry mouth and helping to control the consequences of this condition. Although most dental professionals treat dry mouth, we often wait until dental caries have gone into cavitation and complications arise. Early diagnosis and intervention can help mitigate consequences and improve a patient’s quality of life.
Shannon continues to influence the next generations. She is a mother and coach and still gets out on the field as academy clinic director for Bridge City Soccer. She works with the US U-17 Women’s National Team and coaches her daughter’s recreational soccer team in Portland, Oregon. Shannon urges dental professionals to consider the GUM Hydral Dry Mouth Relief products from Sunstar as important tools to help manage dry mouth for those who trust you with their health and wellness.
Questions to identify people with, or at risk of developing, salivary gland hypofunction
- Do you have any difficulty swallowing?
- Does your mouth feel dry when eating a meal?
- Do you sip liquids to aid in swallowing dry food?
- Does the amount of saliva in your mouth seem to be too little, too much, or do you not notice?
- Gallagher J, Ashley P, Petrie A, Needleman I. Oral health-related behaviours reported by elite and professional athletes. Br Dent J. 2019;227(4):276-280. doi:10.1038/s41415-019-0617-8
- What is Sjögren’s? Sjögren’s Foundation. https://www.sjogrens.org/understanding-sjogrens/frequently-asked-questions
- Orellana MF, Lagravère MO, Boychuk DG, Major PW, Flores-Mir C. Prevalence of xerostomia in population-based samples: a systematic review. J Public Health Dent. 2006;66(2):152-158. doi:10.1111/j.1752-7325.2006.tb02572.x
- Humphrey SP, Williamson RT. A review of saliva: normal composition, flow, and function. J Prosthet Dent. 2001;85(2):162-169. doi:10.1067/mpr.2001.113778
- Asthma statistics. American Academy of Allergy, Asthma, and Immunology. https://www.aaaai.org/about-aaaai/newsroom/asthma-statistics
- Turner MD. Hyposalivation and xerostomia: etiology, complications, and medical management. Dent Clin North Am. 2016;60(2):435-443. doi:10.1016/j.cden.2015.11.003
- Dawes C. How much saliva is enough for avoidance of xerostomia? Caries Res. 2004;38(3):236-240. doi:10.1159/000077760
- Plemons JM, Al-Hashimi I, Marek CL; American Dental Association Council on Scientific Affairs. Managing xerostomia and salivary gland hypofunction: executive summary of a report from the American Dental Association Council on Scientific Affairs. J Am Dent Assoc. 2014;145(8):867-873. doi:10.14219/jada.2014.44