Oral radiological findings in a population of athletes at the III Para-Pan American Games, Rio de Janeiro, Brazil

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1 Journal of Disability and Oral Health (2010) 11/ Oral radiological findings in a population of athletes at the III Para-Pan American Games, Rio de Janeiro, Brazil Patricia Luise Scabell Evans DDS MS 1, Aurelino Machado L Guedes DDS PhD 1, Rafaela De Andrade DDS MS 1, Fabio R Guedes DDS PhD 1, Anne Luise Scabell De Almeida DDS 1, Juliana De Jesus Rodrigues-Da-Silva DDS 1 and Eduardo Muniz Barretto Tinoco DDS PhD 1,2 1 Faculty of Dentistry, State University of Rio de Janeiro, Rio de Janeiro, Brazil; 2 School of Health Sciences, UNIGRANRIO, Duque de Caxias, Brazil Abstract Objective: This cross-sectional study aimed to assess the oral health status in a population of para-athletes competing at the III-Para-Pan American Games, Rio de Janeiro, using Digital Panoramic Radiographs (DPR). Method: The study was approved by the appropriate institutional review board. Over 1,500 contestants and medical staff received printed invitations before and during the Games. DPR were taken from 118 recruited para-athletes, mean age 32.3(sd±9.53), 92(77.97%) males. A trained practitioner assessed all DPRs, observing/ registering teeth conditions as known: Erupted/Sound (S); Absent (A); Non-erupted/impacted (NE); Partly-erupted (PE); Extensive carious lesion (EC); Extensive carious lesion w/periapical lesion (EC+PL); Restored (R); Cyst (C); Residual roots (RR); Implant (I); Fracture (F); Orthodontic Band (OB); Anomalous lateral incisor (ALI); Endodontic treatment w/periapical lesion (ET+PL). Results: Number of observations(n)/average per athlete: S:n=2451/20.77; A:n= 401/3.40; NE:n=52/0.44; PE:n=20/0.17; EC:n= 62/0.52; EC+PL:n= 50/0.42; R:n= 670/5.67; C:n=4/0.03; RR:n= 22/0.18; I:n=5/0.04; F:n=3/0.02; OB:n=11/0.09; ALI:n=12/0.10; ET+PL:n= 13/0.11. Conclusions: Oral health preventive programmes should be encouraged within this special population. DPR is a useful method for screening large populations with special needs during major sports events. Key words: Athletes, digital panoramic radiographs, Pan American Games, oral health status Introduction In general, studies show that people with physical or intellectual disabilities have poorer oral health than does the general population (National Institute of Dental and Craniofacial Research, 2000). Some individuals with different degrees of impairments or disabilities may even need special support to clean their teeth. One way of integrating people with disabilities into the society is to encourage their participation in games and sports events (Jackson and Fredrickson, 1997; Gold 2007). The Para-Pan American Games gather professional athletes from the American Continent every four years. The games are awarded to a host city, and this city is responsible for creating an Organizing Committee to take charge of all the aspects of the competitions, including the preparation of the appropriate medical assistance. Rio de Janeiro held the III Para-Pan American Games in August 2007, embracing 10 different sports. The Brazilian Para-Olympic Committee (CPOB) arranged general and medical facilities for all the contestants, temporarily living at the Pan American Village during the Games. The facilities of the Village and Medical Polyclinic were fully adapted to receive para-athletes with different impairments and disabilities, and offered free medical services, including dental care, physiotherapy, pharmacy, massage therapy, and medical imaging. Trained volunteers were available throughout the Games to assist the contestants whenever required. It is worth noting that athletes need be as healthy as possible in order to be able to train and achieve their best performance when representing their countries during major sports events. Acute dental pain might force an athlete to drop out of an official game. Similarly, chronic asymptomatic lesions, which may go unnoticed, can impair the health status of a contestant, thus jeopardising the training capacity and performance during the competitions.

2 188 Journal of Disability and Oral Health (2010) 11/4 Surprisingly, over the last few decades, only a few articles have reported on oral health conditions among Special Athletes (intellectually impaired) competing worldwide. Those sparse studies did not focus on athletes with physical impairments or disabilities (Feldman et al., 1997; White et al., 1998; Perlman, 2000; Reid et al., 2003). To our knowledge, specific epidemiological data on the prevalence and the distribution of general oral health conditions among Para-Pan American athletes are non-existent. The lack of data makes it hard to develop customised oral health programmes for this population with special needs. This cross-sectional study aimed to assess the oral health status in a population of para-athletes competing at the III Para-Pan American Games that took place in Rio de Janeiro, using digital panoramic radiographs (DPRS). Materials and methods Approximately 1,500 contestants from different countries from the American Continent, including North America, Central America, Caribbean Islands, and South America, were received at the Para-Pan American Village for the Games. Written invitations (printed letters) in the three official languages of the Games - English, Portuguese and Spanish; were previously approved by the Brazilian Para-Olympic Committee (CPOB). These letters were firstly distributed to the medical staff of each participant country, explaining the purpose of the study. The survey protocol was approved by the Research Ethics Committee of the University of the State of Rio de Janeiro (UERJ). Recruitment and examination happened only during the official period of the competitions (8 days). The team in charge of the recruitment, worked daily from 9 AM to 6 PM, with the facility to speak the three official languages of the Games. The area for recruitment was strategically located between the International Zone of the Village and the Restaurant entrance where all the para-athletes had to go for their meals. At the time of the recruitment process, written invitations with explanations about the study were randomly distributed, and Para-athletes were included in the study if they accepted to be examined. Visual impaired athletes would get assistance to reach the examination area if necessary. The forms containing personal data and the informed consent for contestants under the age of 18 had to be filled out by the coach in charge of the athlete. Athletes with visual impairment or hand impairment, who were not able to read or write, were assisted by volunteers or by the examination team, to fill up the form with their personal data and informed consent. The facilities for the study, were located inside the Polyclinic, at the ground level, and were previously inspected and approved by the Rio de Janeiro Nuclear Energy Committee (CNEN/RJ) to ensure the safety of all the radiological procedures. The facilities included: A waiting room prepared to register the para-athletes, helping them to fill up the appropriate forms written in English, Spanish, or Portuguese A room properly prepared for the radiological examination A side room which was prepared for the data recording process. The following equipment was used: Digital radiograph equipment (Kodak 8000C, Kodak/ Carestream Health, CA) A desk computer - Pentium IV ( Dell Inc. - USA) Specific installed software - Carestream Health Dental Imaging Software v6.7, Chicago, U.S.- PACS (PACS - Picture Archiving and Communication System, Kodak/ Carestream Health, CA). Six practitioners were previously calibrated, trained to participate in this study and had fluency in all the three official languages of the Games. The appropriate arrangements for the study, such as contacting the Organization of the Games and obtaining appropriate authorisations, took place one year before the event. All contestants went through the following examination protocol: 5 minutes for registration and explanation about the resources of exam, reading and signing the informed consent 3 minutes to fill up the software registration form, radiological barrier protection, positioning on the machine, and to take the x-ray 3 minutes for explanations about important radiological findings and possible existing risk factors for sudden pain during the training or competitions 1 minute to send the image to PACS (Picture Archiving Computerized System, Carestream Health, Chicago, U.S.) and to record it on a CD-Rom. All the digital panoramic radiographs were taken by two experienced radiologists. The records from each contestant athlete were inserted in the software registration form (Carestream Health Dental Imaging Software v6.7, Chicago, U.S.), including: date of attendance, name, age, gender, country, and the modality of the sport. The preparation of each athlete included: removal of all metal garnishing (necklaces, piercings, and earrings), proper radiological barrier clothing, and positioning for radiological examination. Digital radiograph equipment (Kodak 8000C, Kodak/ Carestream, CA) was adjusted for the exam according to the special needs of each para-athlete. Some individuals underwent the radiological examination sitting in their wheelchair. Visually impaired para-athletes had to be assisted for the procedure.

3 Evans et al.: Oral radiological findings at the III Para-Pan American Games 189 Upon request, a brief explanation about the radiological findings was given to each athlete. The image was then sent to the PACS (Picture Archiving Computerized System) and a CD-Rom with the recorded image was prepared, so that each athlete could have access to their digital panoramic radiography. Analysis of the radiographs was done by one previously calibrated professional. All 118 radiographs were screened with the aid of appropriate specific software (Carestream Health Dental Imaging Software v6.7, Chicago, U.S.). The following dental conditions were observed and registered for each individual: Erupted/sound teeth (S); Absent teeth - excluding third molars (A); Non-erupted/impacted teeth (NE); Partly erupted teeth (PE); Teeth with extensive carious lesion (EC); Teeth with extensive carious lesion and periapical lesion (EC+PL); Restored teeth (R); Cyst (C); Residual roots (RR); Dental Implants (I); Fractures (F); Orthodontic Bands positioned on molars (OB); Anomalous lateral incisor with a cone shape (ALI); Teeth that were endodontically treated with periapical lesion (ET+PL). Results The study population consisted of 118 recruited individuals, representing 7.86% of the total number of contestants, mean age 32.3 (sd±9.53), 92 (77.97%) were males. The individuals participated in 8 of the 10 different sport modalities. Tables 1 and 2 show the records of the individuals examined. The total number of each oral radiological finding and the average of each condition per individual are shown in Table 3. Figure 1 illustrates a DPR of a 30-year-old male athlete showing teeth with extensive carious lesions, periapical lesions, and several residual roots. It is worthy of note that the findings also identified two athletes with radiological images indicative of a unilateral maxillary sinus retention cyst, although neither reported any symptoms. Discussion Disparities in oral health are common among people with physical and/or mental disabilities. Depending on the type of impairment or disability these individuals may require assistance from other people to perform normal oral hygiene procedures. There are no data indicating that para-athletes are representative of this group, although they are certainly part of it. Para-athletes are individuals who show enormous reserves, enough to break through barriers and compete in different kinds of sports despite their impairments. Whether or not para-athletes show the same oral health conditions as people with disabilities not participating in sports is not known at the moment. Epidemiological studies focusing on oral health of this special population are rare and the Para-Pan American Games represent a unique opportunity to screen these individuals from several countries for several conditions which may go unnoticed. On the other hand, it is important to point out that this study had some limitations and the results have to be interpreted with caution. The study population was recruited among para-athletes who positively responded to invitations made in the Village. An attempt was made to minimise potential biases, by not including individuals who were seeking dental treatment. The number of females (22.03%) in this study was relatively low, probably reflecting the low number of participating women in the Games. It is not known if women s participation in major sport events for para-athletes in various countries, for instance in some Central and South-American countries, is encouraged. We are aware of the existing disparities in oral health status and access to oral care among nations in the American Continent. Grouping the data made the comparisons between countries impossible. However, we decided to group the data from the different countries because some countries had only a few athletes who were examined and the data could not therefore be used for appropriate statistical analysis. An average of 15 individuals per day were recruited and examined in eight days only, which was the duration of the Games. This represents approximately 8% of the contestants. Recruitment and examination of individuals with special needs requires considerably more time and specially trained staff, but it is worthy of note that most of the recruited contestants were very receptive and grateful for our initiative towards their health. Digital panoramic radiography is a quick and useful method to screen and detect asymptomatic pathologies and conditions, which may go unnoticed during clinical examination. Reports by Special Olympics and the U.S. Surgeon General have shown unmet health needs and significant disparities of people with learning and other developmental disabilities (Fenton et al., 2003). Studies on the oral health status of people with intellectual disabilities and adults with disabilities also emphasise that they have poorer oral health than does the general population (Ohito et al., 1993; Pieper et al., 1986; Pezzementi and Fischer, 2005). Among possible causes are failure to ensure access to dental care and inadequate numbers of professionals with appropriate training to treat this population with special needs. Limited mobility and access to transportation, especially in underdeveloped or developing countries, with positioning problems, behavioural difficulties, dental fears, and limited ability to provide oral self-care are some of the potential barriers encountered by this vulnerable population. Reid presented a survey comparing the oral health status of United States and international Special Olympics athletes, athletes with intellectual disabilities (Reid et al., 2003). This study was based on self- reported information about dental pain and oral hygiene, and also a clinical inspection. The author considered that the data on treatment needs was reflected in untreated caries, and the evidence of past oral health care was evident from the prevalence of restorations, sealants and extractions. Direct comparison between their results and the results from the present study is

4 190 Journal of Disability and Oral Health (2010) 11/4 Table 1. Total number of athletes examined, according to their country and gender COUNTRY OF ORIGIN GENDER TOTAL Males Females n % n % N % Argentina % % % Bolívia % % Brazil % % % Chile % % Colômbia % % Costa Rica % % El Salvador % % Equador % % Guatemala % % Jamaica % % % Mexico % % % Nicaragua % % % Peru % % Puerto Rico % % Uruguai % % Venezuela % % % Total 92 77,97% 26 22,03% ,00% Table 2. Para-athletes examined, according to their sport and gender Sport of Competition Gender Total Males Females n % n % n % Track and Field % % % Basketball % % % Soccer % - 0% % Judo % - 0% % Weight Lifting % % % Swimming % % % Table Tennis % % % Volleyball % - 0% % Total % % % Table 3. Total number and mean of each radiological observations per individual among males and females in the III Para-Pan American Games RADIOLOGICAL FINDINGS ATHLETES Males N=92 Females N=26 Total N=118 n Mean per athlete n Mean per athlete n Mean per athlete Totally erupted / Sound teeth Absent teeth Non-erupted / impacted teeth Partly erupted / sound teeth Teeth with extensive carious lesions Teeth with extensive carious lesion + periapical lesions Restored teeth Dental Cysts Residual roots Dental implants Fractures Molars with orthodontic band Anomalous lateral incisors Teeth with root canal treatment and periapical lesion

5 Evans et al.: Oral radiological findings at the III Para-Pan American Games 191 Figure 1. Digital Panoramic Radiograph of a 30-year-old male contestant showing teeth with severe destruction, extensive carious lesions, periapical lesions and several residual roots not possible, because digital panoramic radiographs only were used as the screening method. It is probable that the number of carious lesions is underestimated due to the low sensitivity of the panoramic radiographs in detecting them. However, the chosen method had the advantage of detecting conditions, for example, periapical lesions, cysts, impacted teeth, which could not be seen in a clinical examination. The current focus on eliminating health disparities and the need to integrate special needs populations, raise issues for discussion regarding preventive and treatment services for these individuals. Conclusions Preventive programmes in oral health should be encouraged within this special population. Digital panoramic radiography is a useful method for screening large populations with special needs during major sports events. Acknowledgements The authors wish to thank the officials, the staff, and the volunteers involved in the organisation of the III Para Pan American Games. The authors also wish to thank Carestream Health for providing the necessary equipment for this study, and creating the appropriate conditions for the digital radiological screening. References Feldman CA, Giniger M, Sanders M, Saporito R, Zohn HK, Perlman SP. Special Olympics, Special Smiles: Assessing the Feasibility of Epidemiologic Data Collection. J Am Dent Assoc 1997; 128: Fenton SJ, Hood H, Holder M, May PB, Mouradian WE. The American Academy of Developmental Medicine and Dentistry: Eliminating Health Disparities for Individuals with Mental Retardation and Disabilities. J Dent Educ 2003; 67: Gold MM. Access for all: the rise of the Paralympic Games. J R Soc Health 2007; 127: Jackson RW, Fredrickson A. Sports for the physically disabled: the 1976 Olympiad (Toronto). Am J Sports Med 1979; 7: National Institute of Dental and Craniofacial Research. Oral health in America: a report of the Surgeon General. Rockville, MD: U.S. Public Health Service, Department of Health and Human Services; Ohito FA, Opinya GN, Wang Ombe J. Dental caries, gingivitis and dental plaque in handicapped children in Nairobi, Kenya. East Afr Med 1993; 70: Perlman S. Helping Special Olympics Athletes Sport Good Smiles. Dent Clin North Am 2000; 44: Pezzementi ML, Fischer MA. Oral Health Status of people with intellectual disabilities in the southeastern United States. J Am Dent Assoc 2005; 136: Pieper K, Dirks B, Kessler P. Caries, oral hygiene and periodontal disease in handicapped adults. Community Dent Oral Epidemiol 1986; 14: Reid BC, Chenette R, Macek MD. Prevalence and predictors of untreated caries and oral pain among Special Olympic athletes. Spec Care Dentist 2003; 23: White JA, Beltrán ED, Malvitz DM, Perlman SP. Oral Health Status of Special Athletes in the San Francisco Bay Area. J Can Dent Assoc 1998; 26: Address for correspondence: Patricia Luise Scabell Evans Rua Visconde de Sepetiba, 935 salas 909 & 910 Centro Niterói Rio de Janeiro - CEP: pat.scabell@gmail.com