Impact of physical activity on oral health: A systematic review

ABSTRACT

Physical activity and overall health are directly related. Physical inactivity has significant detrimental health effects over the course of a lifetime. World Health Organization (WHO) defines oral health as the absence of mouth and facial pain, oral diseases, and disorders that restrict a person’s ability to bite, chew, smile, talk, and maintain their mental health. Poor oral health has been linked to lower quality of life (QOL) and well-being, increased risk of several noncommunicable diseases (for example, hypertension, dementia, depression etc). This systematic review was registered in PROSPERO. Articles from three electronic databases PubMed, Scopus, and DOAJ, using Boolean operator from January 2013 until May 2023, were searched. Quality assessment of all studies was assessed using the NIH and JBI tool. 1909 articles were identified from e-databases, and after inclusion and exclusion criteria, a total of 17 studies were included in this literature. The systematic review suggests that whether or not physical activity generally influences overall oral health outcomes. The results of this systematic study show a relationship between people who exercise regularly and their oral health and oral health practices. People who are physically active have been found to have lower levels of inflammatory biological markers, which is linked to better oral health.

“Reading is to the mind what exercise is to the body”

-Joseph Addison

Introduction

It is a well-known truth that physical activity and overall health are directly related. Physical inactivity has significant detrimental health effects over the course of a lifetime, and it is a crucial part of a comprehensive plan for preventing chronic diseases and promoting health, according to the body of scientific knowledge that has developed over the last 50 years. The term “physical activity” encompasses to any skeletal muscle-related movement that involves more energy intake than while at rest. Furthermore, there are many distinct kinds of physical activity, such as work, sports, and active transportation. Regular exercise enhances a variety of physical functions in relation to human health in general. Numerous studies have demonstrated that exercise has anti-inflammatory effect: compared to more sedentary people, those who lead an active lifestyle have lower CRP levels and white blood cell counts. On the other side, increased levels of this protein have been linked to a variety of systemic and dental diseases, particularly periodontal disease. The degree of oral cavity inflammation is caused by both local and systemic factors.[1] The World Health Organization (WHO) defines oral health as the absence of mouth and facial pain, oral diseases, and disorders that restrict a person’s ability to bite, chew, smile, talk, and maintain their mental health. Poor oral health has been linked to lower quality of life (QOL) and well-being, as well as an increased risk of several noncommunicable diseases (for example, hypertension, dementia, depression etc). According to statistics, dental caries can range from 20% to 90% in young children around the world, and about one-third of persons between the ages of 65 and 74 are missing all of their natural teeth.[2] Glycaemic control was not linked to oral bacteria and the oral microbial composition of obese and nonobese patients differs, which may indicate a relationship between oral bacteria and obesity.[3] Cross-sectional and prospective studies demonstrated that vigorous exercise is inversely encompassing periodontal disease. Physical activity has been considered to enhance insulin sensitivity, diminish inflammation, and counteract obesity in order to improve periodontal health. Numerous studies point out that regular walking mitigates internal inflammation.[4] Exercise and physical activity are crucial components of human agility. Despite the foregoing information, the systematic review suggests that whether or not physical activity generally influences overall oral health outcomes.[1]

This systematic review aims to demonstrate these following.

1. Following periods of severe physical training, the nature and characteri stics of saliva will be measured according to their importance degree and categorized as follows: saliva flow rate, saliva pH, levels of C-reactive protein and inflammatory bio markers.

2. To demonstrate the relation between physical activity and periodontitis.

3. Effects of regular exercise on dental caries burden.

4. Evaluate whether physical training effects oral musculature.

5. Effects of sports drink on teeth structure and its relation with dental caries.

Methodology

Protocol development

The systematic review was recorded in PROSPERO, an international prospective registry for systematic reviews, registration ID CRD42023403721.

Search strategy

Articles from three electronic databases PubMed, Scopus, and DOAJ, from January 2013 until May 2023, were searched. The articles were identified according to Medical subject heading (MeSH) terms “Physical activity”[MeSH Terms], “exercise”[MeSH Terms], “Physical fitness”[Mesh], (“periodontitis”[Mesh]) AND “saliva”[Mesh], “Mouth disease”[Mesh] which were searched from PubMed using Boolean operators (AND, OR) to combine searches and entry terms for DOAJ and Scopus.

Eligibility criteria

Article related to physical activity and oral health which are available in full text format in the database according to observational, experimental, clinical and randomized controlled trial studies published within 2013 to 2023 was included. Secondary reports that were followed by original publication, studies that had no access to full text, studies in unpublished format and articles unrelated to the topic were excluded from this review.

Population: Anybody taking part in intense physical exercise, recreational athletes, runners, cyclists, swimmers, participants taking part in school/university sports events.

Intervention: How physical activity affect the oral health?

Comparison: Person does not involve in intense physical activity as well as any kinds of sports.

Outcome: The nature and properties of saliva after periods of intense physical training will be measured according to their significance level and will be categorized as follows: saliva flow rate saliva total proteins (STP) including statherins, cystatins, mucins, immunoglobulins IgA, enzymes carbonic anhydrases, saliva pH, dental pellicle structure (Thickness, adsorption), pellicle proteins.

Study selection

The titles and abstracts of studies yielded from the aforementioned databases were retrieved and screened for relevance by two separate review authors independently. Any possible disagreements were addressed by consulting a third reviewer. Data were extracted and tabulated for quality assessment.

Data extraction

The data recorded included the title, authors, journal and year of publication, place of study, study design, sample size, results, and conclusion.

Quality assessment

Quality assessment of Figures 1 and 2 of all studies was assessed using the NIH tool developed by NHLBI following the criteria derived from the reporting checklist observational cohort and cross-sectional studies and the parameters based on the checklist for reporting controlled intervention studies. Scores are as follows:

Figure 1.

Quality assessment of observational studies using the NIH checklist

Figure 2.

Quality assessment of randomized control trials using NIH checklist

• YES-✓

• NO-✗

• NA/NR/CD

JBI is a globally recognized research institution located within the Faculty of Health and Medical Sciences at the University of Adelaide in South Australia. On the basis of the criteria, four experimental study included is shown in Figure 3.

Figure 3.

Quality assessment of experimental studies using the JBI checklist

Result

The study’s methodology followed the flowchart outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [Figure 4].

Figure 4.

PRISMA flowchart of literature search and selection criteria

Selection of articles for review

After initial search, 1909 articles were identified from e-databases, as given in Figure 4. Following the elimination of duplicate entries, 1152 articles were left for screening based on their titles and abstracts. Those articles that did not meet the inclusion criteria were excluded from further consideration. Subsequently, 234 articles underwent eligibility screening, from which 17 were identified as meeting all inclusion criteria.

Table 1 provides an overview of the descriptive data characteristics from the cross-sectional studies included, while Table 2 outlines those from experimental studies. In total, seventeen studies met the inclusion criteria and underwent qualitative synthesis. Among these studies, ten adopted a cross-sectional design, one followed a cohort design, four were interventional studies, and two were randomized controlled trials.

Table 1.

Observational studies included (n=11)

Author and Year	Type of study	Journal	Place	Sample size	Mean age	Result
Moya AT et al.[3] (2021)	Descriptive observational study	International Journal of Environmental Research and Public Health.	Barcelona, Spain	230	37.1 years	Physically active patients exhibited fewer apical lesions (20.25-27.77%) and higher OPGI and TDI indices. (OPGI=Orthopantography index. TDI=Total Dental Index).
Han SJ. et al.[4] (2019)	Cross-sectional study	Nature	Korea	11921	19 Years and older	After adjusting for various factors, the odds ratio for periodontitis in regular walkers was 0.793 (95% CI: 0.700–0.898). Nonregular walkers showed similar social gradients, but low socioeconomic status was not significant in the regular walking group. The study found that regular walking is linked to a lower prevalence of periodontitis and can weaken the association between periodontitis and low socioeconomic status.
Anderson AP et al.[5] (2018)	Cross-sectional study.	J. periodontol	USA	5,611	40 years and older	When compared to sedentary individuals, physical activity was positively associated with the Orange-Blue antibody cluster in both insufficiently and sufficiently active individuals, but not with any other antibody groups. The adequately active group had a higher prevalence of males (49.6% vs. 32.2%), a greater proportion of whites (79.5% vs. 62.8%), a lower average BMI (26.5 kg/m² vs. 27.3 kg/m²), a lower prevalence of blacks (7.8% vs. 17.0%), and fewer current smokers (16.3% vs. 25.6%) compared to the inactive group.
Kim S. et al.[6] (2018)	cross-sectional study	Annals of S Geriatric Medicine and Research	Korea	2378	65 Years or older	In both sexes, subjects with NRT had higher ASM and SMI levels than those without NRT. SMI and NRT were correlated in both men (r=0.018, P<0.001) and women (r=0.007, P<0.001).
Huttunen m et al.[7] (2022)	Cross-sectional study.	Odontology	Finland	Research pool comprised 13,564 Finnish male conscripts. The sample size was not calculated.	19.6 years	According to DT and DMFT values, conscripts who frequently exercised had significantly better dental health than those who skipped workouts. The greatest difference was observed among conscripts who exercised more than four times per week. The proportion of conscripts with DT=0 gradually increased with higher levels of physical activity (from 39.0% to 59.4%). Post hoc tests revealed that the proportion of conscripts with DT >3 was higher among those who exercised less, and lower among those who exercised more.
Botelho J et al.[8] (2021).	Observational study	Nutrients	Portugal	22	27±5.4 years.	Most (n=9) had stage 1 periodontitis, with two cases at stages 2 and 3. Overall, 40.9% had the condition, with an average of 0.8 missing teeth. Nontraumatic muscle injuries were more common in professionals with periodontitis (55.6%) than in those without (38.4%).
Miettinen O et al.[9] (2021).	cross-sectional study.	International Journal of Environmental Research and Public Health.	Finland	The research pool comprised 13564 Finnish male conscripts. The sample size was not calculated.	19.6 years.	Conscripts who were physically inactive had a significantly higher prevalence of all TMD symptoms compared to those who were physically active.
Jang JH. et al.[10] (2021)	cohort study	Nature	Korea	(n=10,254)	45 Years and above	Of the 1,941 participants, 18.95% passed away over a 12-year follow-up of middle-aged/older Koreans. Denture users had a mortality rate of 31.4%, with 813 deaths. The mortality rate was higher in the non-REG group compared to the REG group (35.8% vs. 26.9%; P<0.001). Masticatory discomfort was inversely correlated with mortality (P=0.01).
Cho HJ et al.[11] (2020)	Cross-sectional study	Community Dentistry and Oral Epidemiology.	South Korea	16941	19 Years and older	Moderate-intensity physical activity is associated with more TMD pain. Patients with TMD should avoid high-intensity level exercises and continue low-intensity exercises to prevent pain aggravation.
Ostensjo V. et al.[12] (2017)	Prospective cross-sectional study	Pain Research and Management	Norway	560	17 years	TMD sufferers were less likely to engage in regular exercise than controls. The prevalence of TMD-P was not affected by sitting in front of a computer for more than three hours a day.
Inui A et al.[13] (2016)	Cross-sectional study	Dovepress	Japan	607	40-79 years	The timed 10m walk test, particularly in females, showed a negative correlation with the number of teeth present. Reduced tooth density and poor occlusal support may contribute to slower walking speeds in the timed walk test.

Table 2.

Experimental studies included (n=6)

Author and Year	Type of study	Journal	Place	Sample size	Mean age	Result
Pacheco VB et al.[14] (2022)	Clinical trials	Hindwi	Brazil	10	65 or over	Participants in the NPE group had more severe dental caries over their lifetime. The PE group had a total of 317 proteins, while the NPE group had 367 proteins. There were differences in the salivary proteome between older adults who exercised regularly and those who didn’t.
Kim HJ et al.[15] (2019)	Interventional study	Dovepress	Korea	84	74.43 years	The simple oral exercise group (SOE group) had a quick beneficial effect on oral functions and the enhancement persisted for a period of one week.
Frese C et al.[16] (2018)	Randomized control trial.	Nature	Germany	54	36.53±9.49 years	There was no effect of stannous fluoride products, although there was a significant difference for the period of the examination (P 0.0001).
Rutherfurd- Markwick K et al.[17] (2017)	Randomized control trial.	Journal of the International society of sports Nutrition.	New Zealand	20	27±5.9 years	Under steady-state exercise stress, females showed a stronger response than males, with significant increases in osmolality (P<0.001), amylase activity (P=0.001), secretion rate (P=0.023), and SIgA secretion rate (P=0.023), along with trends towards increased K+ (P=0.053) and decreased Cl- (P=0.067).
Edmonds R et al.[18] (2015)	clinical trial	Plos one	Not mentioned clearly	8	15-29 years	During the observation period, significant negative correlations were found between weekly mean HR and both RMSSD (-0.738, P<0.05) and SD1 (-0.720, P<0.05). Weekly sAA also negatively correlated with SD1, while a strong positive correlation was observed between weekly sAA and mean HR.
Gillum T et al.[19] (2014)	Clinical trial	Exercise Immunology review	California	18	Men=(21.1±1.1) Women=(22.4±2.4)	Osmolality and salivary flow rate were not gender-specific. Saliva osmolality increased from preexercise to immediately after exercise, while saliva flow rate increased from preexercise to one-hour postexercise.

Discussion

This systematic review describes the relation between physical activity and oral health systematically. They are as follows: effect of physical activity on periodontal health and periodontitis, effect of physical activity on dental caries, effect of physical activity on temporomandibular disorders, effect of physical activity on salivary flow, protein and antibodies, effect of physical activity on natural remaining tooth and its ability effect of lifestyle factors to maintain a positive oral health and effect of oral exercise on oral function.

Living an active lifestyle may be beneficial for maintaining good periodontal health. By enhancing insulin sensitivity and preventing the establishment of type II diabetes, a known risk factor for periodontal disease, exercise may help to prevent periodontal disease.[3] In another study conducted by Han SJ in Korea among adult population reported, regular walkers significantly reduced their likelihood of developing periodontitis.[4] Anderson AP et al.[5] studied relationship between physical activity and periodontal antibodies among US population; they find out there was a marginally favorable correlation between physical activity and the orange–blue cluster antibodies which formed against E. nodatum; A. naeslundii shows a connection between systemic and good periodontal health. According to reports, there is a significant relationship between dental health and factors like age, race, family income and status, smoking, metabolic disorders, and physical activity.[6] Pacheco VB and team discovered that, in the physical exercise group, the expression of four salivary proteins—Alpha-2-macroglobulin, complement C3, serotransferrin, and protein soluble in brain acid 1—was reduced. Conversely, six proteins—lactotransferrin, alpha-amylase 1, S100-A8, S100-A9, lactoperoxidase, and galectin-3 binding protein—showed increased expression in the exercise group compared to data observed in nonpractitioners.[14]

Among individuals aged 30 to 39, engaging in moderate-intensity exercise was strongly correlated with increased symptoms of TMD pain, while low-intensity exercise was notably linked to fewer TMD pain symptoms. These associations remained significant even after adjusting for variables known to influence TMD pain,[11] whereas simple oral exercise increases mastication, salivation, and swallowing function reported by Kim HJ.[15]

Frese C et al.[16] conducted a 4-year randomized control trial, and this is the first study to provide insight into management tactics for the prevention of caries in athletes over a 4-year period is this 4-year randomized controlled clinical experiment.

Males and females exhibit significantly different responses to steady-state exercise stress, as measured by unstimulated whole saliva.[17]

Østensjø V et al.[12] also investigate on the same concern, and he found that in Rogaland County, TMD-P was 7% prevalent. TMD patients exercised less frequently than controls did on average. Inui A and colleagues have seen that reduced tooth density and the occlusal support region may be risk factors for slower walking speed in the timed 10 m walk test.[13]

Edmonds R and colleagues carried out an experimental investigation involving paralympic swimmers. Over the course of 14 weeks leading up to the 2014 Commonwealth Games in Glasgow, Scotland, and the Pan Pacific Para-swimming Championships in Pasadena, California, the researchers closely monitored each athlete to assess the enduring effects of training on both heart rate (HR) and saliva indicators. The current study demonstrated that intense national competition lowers HRV (SD1) and raises salivary stress biomarkers (sAA).[18] Gillum T and his team investigate the effects of exercise, sex and menstrual phase on salivary antimicrobial proteins, and he found that Women’s IgA levels were greater before exercise, whereas men’s Lys values were consistently higher than those of women. Both sexes’ lactoferrin values increased after exercise, but men’s values remained high.[19]

Conclusion

This systematic review reveals an association between oral health, oral health behaviors, and physical activity. Reduced inflammatory biomarkers were observed in physically active individuals, which is associated with improved periodontal health. Physical activity has positive effect on salivary antigens, flow rates, as well as oral musculature. There is significant lower risk of temporomandibular pain in physically active group of individuals.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.