Sports, travel and leisure, and pets
Exercise has clear benefits to both health and quality of life (Ch. 36). However, there are occasional sudden deaths (Table 33.1) and there may be risks from trauma, such as in sports, sometimes from other issues such as travel, and occasionally from associated disordered eating, menstrual disturbances and supplement use.
Endogenous causes of sudden death in athletes
|Cardiac causes||Other causes|
|Anomalous origin of coronary artery||Alcohol|
|Aortic rupture (Marfan syndrome)||Amphetamine|
|Coronary artery disease||Erythropoietin (EPO)|
|Electrical conduction system abnormalities||Head trauma|
|Hypertrophic cardiomyopathy||Vascular event|
|Long QT syndrome|
|Right ventricular dysplasia|
See also Chapter 24 and www.aans.org/ (Sports-related head injury is under the Patient information/Conditions and Treatments tabs; accessed 30 September 2013).
Head, orofacial, ocular and other injuries are a risk in many sports; therefore the wearing of helmets and eye, face, jaw and mouth protection is often indicated, along with other protection.
Head injuries and maxillofacial and dental trauma are all too common in any sport involving fast movement, including those involving vehicles, roller-blading, skateboarding, snowboarding and skiing. Indeed, trauma is possible in all motion sports and as new types of sports become popular, the injuries associated with them also increase. Helmets are mandatory and, in some instances, protection for eyes, jaws, hands, knees, elbows and wrists is indicated.
Contact sports include football (soccer and rugby), boxing, martial arts (e.g. wrestling, karate and judo), gymnastics and hockey; to a degree, there is contact in some other sports such as baseball and basketball. Injuries to the teeth and orofacial soft tissues are common, particularly in football, boxing, martial arts and hockey.
Most sports injuries affect the maxillary incisors and involve young males. In soccer and rugby, players have about a 10% chance of injury per season. This may include head injury, cerebral concussion and neck injuries, which can be fatal or lead to paraplegia. Maxillofacial and dental injuries account for about 13% of the costs of all soccer injuries.
Prevention and adequate preparation are the key elements in minimizing injuries from such sports. Teaching skills such as tackling, use of appropriate equipment, safe playing areas and the wearing and utilization of properly fitted protective equipment like helmets and mouthguards are essential. A properly fitted mouthguard may also reduce the chances of sustaining a concussion from a blow to the jaw. Mouthguards are usually made of vinyl or acrylic, and three main types are available (Box 33.1).
Non-contact sports, such as tennis and volleyball, can also be dangerous. Custom-made protectors could offer the best protection against dental damage.
Athletes who swim more than 6 hours per week in pools chemically treated to maintain safe water quality standards may develop tooth stains mistermed ‘swimmer’s calculus’ and/or tooth erosion. The stains can usually be removed with professional cleaning.
Scuba divers depend on air in the form of compressed air from a tank, transmitted to the mouth by way of a regulator held in the mouth by the teeth, so that there is an airtight seal between the teeth and lips. Inability to hold the mouthpiece because of missing teeth poses a contraindication to scuba diving. Dental concerns in divers include temporomandibular joint (TMJ) and muscle pain from holding the regulator (‘diver’s mouth syndrome’), barotrauma and barodontalgia (from the effects of pressure changes), and the management of prostheses. Many divers experience TMJ and/or facial muscle pain or headache from the continuous jaw clenching. Mouthpieces are usually made of neoprene or silicone rubber and are held in place by bite tabs that fit into the dentition at the canine and premolar area. The average dive lasts 30–60 minutes and requires constant jaw muscle effort. Extending the bite tabs to cover the molar teeth balances the weight of the regulator and can relieve stress on the TMJ.
Barodontalgia (pain in the tooth caused by pressure changes) can arise in divers (or people in aircraft or at high altitude) if there are pulp lesions, abscesses or sinusitis. Antral pain may have a similar cause. Teeth that have been opened for endodontic treatment and temporarily sealed have been known to explode from air trapping and expansion on surfacing – mainly in deep divers using a helium–oxygen mixture. Full porcelain crowns can also shatter from relatively shallow dives of 65 feet. Raised pressure in the middle ear can occasionally cause facial palsy (baroparesis) but this typically resolves spontaneously over a few hours.
Divers cannot wear full or partial dental prostheses while diving, as they may be dislodged and aspirated. To eliminate the possibility of dislodgment completely, a custom mouthpiece to obviate the chance of aspiration of the prosthesis can be made. Full arch impressions are taken with the patient holding silicone putty in the roof of the mouth until it is set; they are then mounted in a hinge articulator and sent to the laboratory with the silicone putty impression.
Drug Use in Sports
Further information is available at: sportsanddrugs.procon.org/ (accessed 30 September 2013).
Sports people may wish to take drugs as medication for disease; to improve their performance (performance-enhancing drugs; PEDs) and, in doing so, to gain an unfair advantage; or for ‘recreational’ reasons. Some substances are banned only during competition, while others depend on the method of administration (e.g. inhalation versus tablet or injection form). The list of prohibited substances is updated annually to keep up with advances in science and technology, a new list being issued on 1 January. A substance is added to the list if it meets two of the three criteria listed:
■ The potential for enhanced performance
■ The potential for being detrimental to health
The International Olympic Committee permits or prohibits the use of various drugs (Table 33.2). A comprehensive list of banned substances from the World Anti-Doping Agency (WADA) is available at: www.wada-ama.org/en/World-Anti-Doping-Program/ (under ‘International Standards/Prohibited List’; accessed 30 September 2013).
Substances and methods not permitted for use by athletesa
|Prohibited at all times||Prohibited in competition||Prohibited in certain sports|
|S1 Anabolic agents||S6 Stimulants||Alcohol|
|S2 Peptide hormones, growth factors and related substances
S3 Beta agonists
|S4 Hormone and metabolic modulators|
|S5 Diuretics and other masking agents|
|M1 Manipulation of blood and blood components|
|M2 Chemical and physical manipulations|
|M3 Gene doping|
aThe World Anti-Doping Agency (WADA) is responsible for maintaining and updating this list. See www.wada-ama.org/en/World-Anti-Doping-Program/ (under ‘International Standards/Prohibited List’; accessed 30 September 2013).
Some drugs are banned at all times; others are permissible when not competing but not during competition; and some are banned in some sports but not others. Banned substances can include alcohol and caffeine above a certain level. Some agents are permitted for use for certain complaints (Table 33.3). In some cases, an athlete may have a pre-existing medical condition that requires them to take medication that is listed. In this case, the athlete can apply to their international federation for a Therapeutic Use Exemption (TUE), which must be verified by their physician. In order for their request to be accepted, the following must be true:
■ The athlete would suffer significant health problems if they do not take the medication
■ There is no suitable alternative that is not listed
Examples of agents permitted for use by athletes for certain complaintsa
|Allergies||Astemizole, cetirizine, chlorphenamine, loratadine, terfenadine|
|Bacterial infections||Antibiotics (all)|
|Fungal infections||Amphotericin, fluconazole, nystatin, miconazole, terbinafine|
|Viral infections||Aciclovir, idoxuridine|
|Asthma||Cromoglicate, theophylline, fluticasone (under specific conditions), beclometasone, salbutamol, formoterol, terbutaline, salmeterol|
|Coughs and colds||Antihistamines, dextromethorphan, guaifenesin, pholcodine|
|Oral or ear, nose and throat problems||Sprays or drops containing: betamethasone, dexamethasone, docusate, hydrocortisone, beclometasone, fluticasone, tramazoline|
|Eye problems||Ointments or drops containing: antazoline, betamethasone, hydrocortisone, beclometasone, chloramphenicol|
|Pain and inflammation||Aspirin, paracetamol (acetaminophen), non-steroidal anti-inflammatory drugs (NSAIDs), codeine, dextropropoxyphene|
|Nausea and vomiting||Cimetidine, cinnarizine, domperidone, metoclopramide, prochlorperazine|
aCheck with governing bodies, as regulations may vary, or apply under specific circumstances/conditions.
Anabolic steroids are available legally by prescription only, for conditions in which the body produces abnormally low amounts of testosterone, such as delayed puberty and some types of impotence. They are also used to treat body wasting in, for example, patients with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS). Athletes (and others) may misuse anabolic (androgenic) steroids (AAS) – synthetic substances related to male sex hormones – to enhance performance (and also to improve physical appearance); these are taken orally or injected, typically in cycles of weeks or months (‘cycling’), rather than continuously. There are two types of AAS:
■ Exogenous: synthetic versions of testosterone. Common examples include nandrolone and danazol.
■ Endogenous: naturally occurring substances involved in the metabolic pathways of testosterone. For testing of drug use, all endogenous steroids have a normal range. Results outside of this normal range are deemed positive.
Due to the enhancement of testing procedures in the detection of anabolic steroids, ‘designer steroids’ such as tetrahydrogestrinone (THG) have been developed. THG breaks down during the preparation method used for normal steroid testing procedures. A test specifically for the detection of THG has since been developed.
Anabolic steroids given to adolescents may accelerate pubertal changes and cause premature skeletal maturation, halting growth. The major toxic effects include kidney and liver tumours (and jaundice), fluid retention and hypertension, increases in low-density lipoprotein (LDL) and decreases in high-density lipoprotein (HDL), severe acne, trembling, hostility and aggression, and other psychiatric effects. Gender-specific adverse effects include: for men – testicular atrophy, low sperm count, infertility, baldness, breast development and prostate cancer; and for women – facial hair growth, baldness, menstrual changes, clitoris enlargement and deepened voice. Injecting anabolic steroids is also associated with the risk of contracting or transmitting HIV or viral hepatitis.
Blood doping is the process of artificially increasing the amount of erythrocytes in an attempt to improve athletic performance. In the past this was accomplished by autologous transfusion, a practice now outlawed. Erythropoietin (EPO) stimulates erythrocyte production and is also illegal. It increases blood viscosity, may lead to thromboses and is one of the causes of the ‘sudden death syndrome’ seen in occasional athletes (see Table 33.1 and www.uksport.gov.uk; accessed 30 September 2013).
There are major side-effects associated with erythropoietin use, which have proven to be fatal in previous cases:
Human growth hormone
Human growth hormone (hGH), sometimes known as somatotropic hormone or somatotropin, is credited with having the following effects:
Many small studies, however, have shown no increases in muscle size or strength following injection with hGH. A common practice among body-builders and weightlifters is to combine hGH and anabolic steroids, with recent research demonstrating beneficial effects.
The side-effects of hGH are vast and some are serious:
■ Gigantism (pituitary gigantism or giantism) in younger athletes (abnormally excessive growth in height, considerably above average)
■ Acromegaly in adult athletes (a condition in which the pituitary gland produces too much hGH, resulting in the growth and swelling of body parts, typically hands, feet, nose but possibly progressing to brow and jaw protrusion and swelling of internal organs)
■ Hypothyroidism (low production of thyroid hormone, which disrupts metabolic rate and protein production)
■ Cardiomyopathy (disease of the cardiac muscle, increasing the risk of arrhythmia and sudden cardiac death)
■ Hypercholesterolaemia (presence of high levels of cholesterol in the blood)
■ Ischaemic heart disease (a lack of blood to the heart, often due to coronary artery disease)
■ Myopathies (neuromuscular diseases affecting the function of muscle fibres)
■ Menstrual irregularities in women
■ Creutzfeldt–Jakob disease (CJD or mad cow disease; transmission is possible when hGH is obtained from cadavers).
Insulin-like growth factor
Due to its perceived anabolic effects, athletes use insulin-like growth factor (IGF)-1 to increase muscle mass and strength, although clinical studies have not proven that it does so. It is thought that it is actually IGF binding protein-3 that is responsible for growth, rather than the growth factor itself. IGF-1 does, however, inhibit cell death and so may have a role in reducing recovery times.
Human chorionic gonadotrophin
hCG is mainly used by male athletes, as it increases the production of both testosterone and epitestosterone, so keeping the testosterone-to-epitestosterone ratio unchanged from normal values (vital in avoiding detection of the presence of other prohibited substances). It is also used to maintain testicular volume in males who are using anabolic steroids. However, it is now thought that it is follicle-stimulating hormone (FSH) that is responsible for maintaining testicular volume and so hCG use would be entirely ineffective; in females there would be no beneficial effect at all.
Side-effects associated with hCG use are rare and non-serious:
■ Gynaecomastia (the development of abnormally large mammary glands in males due to increased levels of the oestrogen).
Gamma hydroxybutyrate (GHB) is also used by some body-builders. Drugs such as modanifil have been used to help alertness. Other banned substances not described above include:
Smokeless tobacco is associated with some sports in the USA, and is potentially dangerous in terms of oral keratoses and malignant change.
Eating Disorders in Sports
Some athletes, mainly women, in cross-country, track and field, gymnastics, dancing, figure skating, volleyball and basketball, may be prone to develop eating disorders (Ch. 27). Tooth erosion may then be seen.
In endurance sports, such as long-distance running, triathlons or cycling, athletes may consume a high amount of refined carbohydrates (‘carbo-load’), as well as carbohydrate gels or drinks (sports drinks – often containing carbohydrates, electrolytes, B vitamins and an acid such as citric, malic, tartaric or phosphoric).
Further information is available at: www.uksport.gov.uk/publications/eating-disorders-in-sport (accessed 30 September 2013).
Dental Aspects in Sports
Preventive dental care and prevention of caries and erosion are important. Operative care for athletes under local anaesthesia (LA) is permitted. Analgesics such as aspirin, NSAIDs and paracetamol (acetaminophen) are permitted but opioids are banned and opiate-related analgesics are problematical. Codeine is not on the WADA list of banned substances, and combinations such as co-codamol and co-proxamol appear acceptable, but as screening does not always differentiate adequately between the various narcotic or codeine-related compounds, they are best avoided.
Anxiolytics may sometimes be banned. Alcohol and beta-blockers are illegal in certain sports, and therefore alcohol-containing oral health-care products are also best avoided. Some vitamin, herbal and nutritional supplements are banned.
Antimicrobials of all types are generally permitted. Therapeutic preparations used for topical oral use are also generally permitted; for example, topical corticosteroids are permitted but systemic corticosteroids are best avoided, or a TUE is required.
Travel and Leisure
International travel is undertaken by ever-growing numbers of people for social, recreational, professional and humanitarian purposes, and can result in a variety of health risks in unfamiliar environments that present variable levels of risk and standards of health care, as well as the transmission of infectious agents and the appearance globally of diseases hitherto confined to certain areas. Most problems can be minimized by common sense, with suitable precautions taken before, during and after travel (see UK Department of Health booklet Health advice for travellers [T7.1], Fig. 33.1; available at www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4123441, accessed 30 September 2013).
The countries to be visited and the duration of the visit are important in determining the likelihood of exposure to many problems, such as violence and infectious agents, and will influence decisions on the need for protection and certain vaccinations or antimalarial or other medication. The behaviour of the traveller is also important: exposure to the risk of assault or accidents, or to insects, rodents or other animals, infectious agents and contaminated food and water, is often a lifestyle choice. A business trip to a city in the high-income world, for instance, typically involves far fewer risks than a visit to remote rural areas in the tropics. For example, going outdoors in the evenings in a malaria-endemic area without using precautions, such as wearing protective clothing, applying repellents and taking antimalarials, is highly risky. The duration of the visit may also determine whether the traveller may be subjected to wide changes in temperature and humidity, or to other environmental factors.
Travellers are far more likely to be killed or injured in accidents or through violence than to be struck down by an exotic infectious d/>