and television breaking news reports abound with alarming evidence of the
increasing misuse and abuse of performance-enhancing (ergogenic) substances by
today’s athletes. This crisis is neither confined to professional sports
figures nor to international world-class amateur athletes, but has expanded to
include collegiate, high school, and even middle school students, both males and females.1-5 Youngsters
are participating at earlier ages in increasingly competitive sports, and often
multiple sports simultaneously.6 One overarching factor in today’s sports
equation is the allure of societal incentives and rewards for personal athletic
In addition to the
potential for future fame and fortune, several other reasons have been
postulated for the initiation of
performance-enhancing substance abuse patterns by adolescent athletes.6,7
These include, among others,
emulation of their favorite professional sports stars, improving personal
strength and body build, gaining a
competitive edge against opponents, or succumbing to peer-pressure.8,9
regardless the reason, such practices are illegal, unethical, and unhealthful,
placing these young athletes at increased risks for acute or chronic adverse
systemic health outcomes.10
As current widespread
abuse patterns continue to expand, it becomes even more critical for practicing dental
professionals to be knowledgeable about the performance-enhancing substance history of their
understanding of the effects and side effects of these substances will not
only better prepare practitioners with information to advise their adolescent athlete/patients more
effectively, but also may enable the dental team to reduce the associated risks for adverse
systemic outcomes during or after dental treatment.
It is the intent of
this article to provide an overview to practicing dentists of the adverse
outcomes associated with the abuse of performance-enhancing substances by their
patients who are adolescent athletes, with particular emphasis on
chemicals or substances to boost athletic performance is known as doping, and usually refers to
those substances that have been banned by sports governing bodies. The 2007
Prohibited List published by the World Anti-Doping Agency is an international
standard code that identifies substances and methods prohibited in competition,
out-of-competition, and in particular sports.12 Substances
and methods are classified by categories. The use of prohibited substances by
an athlete is a violation of the code. However, the code does provide a
therapeutic use exemption for identified medical reasons. Readers interested in
detailed information regarding the international standard may wish to
visit the World Anti-Doping Agency web site at http://www.wada-ama.org/en/prohibitedlist.ch2.
Performance-Enhancing Substances: Selective Categories
A brief review of some
of the major categories of banned performance-enhancing substances seems
warranted prior to undertaking a more detailed review of anabolicandrogenic
steroids. These selected categories include the following: beta blockers,
diuretics, stimulants, narcotics, growth hormones, and blood doping.
Drugs such as
atenolol, metoprolol, and propanolol are used to slow heartbeat and reduce
tremors. The calming effects produced by beta blockers have been used illicitly
by participants in shooting sports such as archery and rifle events, as well as
in fencing. Beta blockers slow cardiac response time, make running difficult,
and increase skin sensitivity to sun and temperature extremes.4, 6-7, 12-16
Drugs such as
acetazolamide, hydrochlorothiazide, and triamterene are used to increase urine
flow and volume. Increased
urinary output produced by diuretics has been used illicitly by athletes in
weight limit sports such as boxing and wrestling, as well as by participants in
ballet, cheerleading, and gymnastics. Diuretics contribute to rapid weight
loss, dehydration, ionic imbalance, and exhaustion.4, 6-7, 11-16
Drugs such as
amphetamine, methamphetamine, pseudoephedrine, and albuterol are used to
increase metabolic activity to reduce fatigue and enhance endurance. The
effects of increasing alertness and improving reaction times produced by
stimulants have been used illicitly by baseball players, skiers, and soccer
players. Stimulants increase heart rate, blood pressure, nervousness, and
irritability. They alter cardiovascular cooling and predispose athletes to heat
exhaustion.2, 4,6-7, 11-12, 14-16
Other stimulants of
concern include smokeless tobacco and cocaine. Increased salivary flow and the nicotine buzz
associated with smokeless tobacco are factors for its traditional use in
baseball. In addition, athletes in weight category sports such as wrestling use
smokeless tobacco as an appetite suppressant. Dentists should be alert to any
intraoral soft tissue changes for possible biopsy of leukoplakia or
excision and follow-up management of oral carcinoma in their adolescent
athlete-patients who dip snuff.17, 18
The intense euphoria
produced by cocaine reinforces its habitual use. In addition to perceived
performance enhancement, the abuse of cocaine by professional basketball and
football players often has
become a part of the persona and lifestyle of addicted athletes. Sudden deaths
due to cardiac arrhythmias have been reported. Cocaine users, therefore, are of
particular concern to dentists because of the potential for dangerous
interactions that may result from the injection of local anesthetics that
contain epinephrine.4, 6-7, 12, 15
Drugs such as heroin,
hydrocodone, methadone, and morphine are used to mask pain. The analgesic
effects produced by narcotics have been used illicitly by boxers, football
players, and participants in the martial arts. Consequences associated with
pain masking include overuse injuries or more serious traumatic
brain damage. The addiction to narcotics also should alert the dentist to the
ever-present and life-threatening dangers of drug overdosing.4, 6-7, 11-12,
Human growth hormone
(hGH), human chorionic gonadotropin (hCG), and adrenocorticotropic hormone (ACTH) elevate
testosterone in men and decrease fat mass. The effects of increased muscle mass
and strength enhancement produced by these hormones have been used illicitly by
athletes in baseball, swimming, and track and field. Misuse of hGH and hCG can
cause fatal neurological disorders, and misuse
of ACTH may cause enlargement of the heart muscles.2, 4, 6, 11-12, 13-16
erythropoietin (EPO), autologous blood transfusions, and homologous blood
transfusions elevate the hematocrit
and hemoglobin concentrations in the circulating blood to boost the level of
oxygen delivered to muscles and enhance aerobic endurance. Blood doping
techniques have been used illicitly by athletes
in cycling, skiing, swimming, tennis, and track. EPO increases red blood cell
concentration and blood viscosity similar to polycythemia. These athletes are
subject to higher sweating rates and increased risk for dehydration during
competition. High concentrations of red blood cells could lead to clot
formation, stroke, hypertension, and congestive heart failure. The misuse of blood transfusions
increases the risk for transmission of blood-borne pathogens such as HBV and
HIV infections.4, 6, 11-13, 15
Steroids (AAS) are synthetic derivatives of the male sex hormone testosterone.
AAS build muscle tissue and body mass, and they increase strength and
aggression. Users include body builders and weight lifters, track and field
athletes, and professional athletes in sports such as baseball, football,
and wrestling. Users refer to AAS by various names such as ‘roids, juice, hype,
or pump. Adolescents, in their quest for status through athletic success, place
themselves at increased risks for acute and chronic adverse systemic episodes
by illegally and unethically misusing AAS.2, 10, 14, 19
AAS: Scope of the Problem
The illegal use of AAS
athletes has been reported to range from one to three million
individuals. Perhaps even more alarming are
the estimates of steroid use by high school students ranging from four percent
to 11% for boys, and up to 3.3% for girls. Other studies have documented childhood steroid use
at two percent to three percent for students from nine years of age to young
teens. Admittedly, while the incidence of AAS use by athletes of all ages represents
a serious health risk for the individual, the extent of the problem represents
an enormous and escalating public health issue.1, 2, 3, 5, 14
AAS: Routes of Administration
AAS are prepared in
three forms based on the route of administration and include the oral route,
the injection route, and the newer transdermal route.2
Oral preparations must undergo
hepatic conversion into testosterone to activate the drug’s effects. Oral AAS
are short-acting and eliminated over several days. Injectable steroids are more
potent and consequently more dangerous than the oral preparations. Injectable steroids
do not require hepatic conversion and have a longer-lasting effect than do the
oral preparations. Users of injectable steroids are more likely to be identified
through positive drug testing as these substances remain detectable for months
after administration.2, 10, 14
Transdermal delivery recently has become
available. The steroid cream may be rubbed gently on the skin or a transdermalpatch may be applied. Generally,
athletes tend to use AAS in the off-season during conditioning and strength training
sessions. This is due in part to the decreased risk of being detected. AAS are
used in cycles lasting from four to twelve weeks. Taking multiple steroids at
one time is referred to as “stacking”, and the term “pyramiding” is used for a dosing
schedule in which the highest amounts are taken during the middle of cycles.2,
AAS: Desired Effects
Athletes who succumb
to the allure of AAS are seeking substantial gains in muscular strength and
fat-free muscle mass. Strength enhancement has been recorded for both
isokenetic and isometric strength. Gains in muscle mass have been attributed to
muscle hypertrophy as well as to the formation of new muscle fibers. AAS have
not been documented to enhance aerobic effects.2, 14, 19
AAS: Adverse Effects
Despite the gains in
muscle mass (anabolic effect) and strength associated with AAS, the misuse and
abuse of these performance-enhancing substances is not without substantial risks
to the health and well being of the athlete. While some of the adverse effects
of AAS are reversible, others are not. These substances have the potential for
devastating and life-threatening adverse effects on multiple systems, including
deleterious effects on the cardiovascular, musculoskeletal, genitourinary, hepatobiliary,
dermatologic, and psychological functioning of the user-athlete.
cardiovascular effects of AAS include reversible elevations in blood pressure
and total cholesterol, as well as reduction in high density (good) lipoprotein
levels. Electrolyte disturbances, coagulation disorders, and cardiac
dysrhythmias are potential adverse side effects. AAS increase the risk for
cardiovascular diseases such arteriosclerotic heart disease and cardiomyopathy.
Acute thrombosis, myocardial infarction, and stroke also have been reported.2,
10, 14-16, 19
Although one of the
desired effects of AAS is to increase muscle strength, the correlative negative
effect is the increased frequency of musculoskeletal injuries. Often these are
tendon sprains based on muscle-strength gains that exceed the related strength
of the tendon. An irreversible effect of AAS is that continued use may stunt linear
growth by premature epiphyseal closure in skeletally immature individuals.2,
10, 14-16, 19
The adverse effects of
AAS on genitourinary function are multiple. Males may actually experience a decrease in the
production of endogenous testosterone as well as decreased size and firmness of
the testes with
fluctuations in sex drive. Gynecomastia in males is another associated condition.
Female user-athletes gradually develop masculine secondary sexual
characteristics (androgenic effects) that appear to be nonreversible such as
deepening voice and clitoromegaly. Reversible negative effects in females include
menstrual irregularity or cessation, and increased libido.2, 10, 14-16, 19
From the perspective of
hepatobiliary function, AAS precipitate transient increases in liver function
such as elevation in liver enzymes and bilirubin. There is an increased risk
for liver tumors both benign and malignant. Blood-filled cysts (peliosis
hepatis) are subject to traumatic rupture that may result in fatal
hemorrhage. Sharing of needles for the injection route of administration of AAS
has the potential to be
the port of entry for Hepatitis B and HIV infectious diseases.2, 10, 14, 16, 19
encountered by male users of AAS include severe acne on the face and back as well
as male-pattern hair loss on the scalp. Female users also encounter increased
acne in addition to skin coarseness and increased facial and body hair.10, 14,
psychological effects of AAS are many and often unpredictable. While some may
view increased aggression
as a positive factor in the athlete’s approach to training and competition, the
risks include increases in
anti-social “’roid rage” behaviors such as fighting or destroying property.
Severe mood swings fluctuate from anger, hostility, and irritability to anxiety
with panic attacks or depression with thoughts of suicide.
Hypomania, schizophrenia, and psychotic episodes have been reported. Users may
succumb to physical and psychological dependence to AAS.2, 10, 14, 16, 19
AAS: Dental Considerations
The key factor in providing
safe and effective dental treatment to athletes who illicitly use AAS is a
thorough understanding of the actions, interactions, and adverse effects that
can result from the abuse of these performance-enhancing substances. It is
worth noting, however, that patients may not readily divulge their use of
these substances or recognize the dentist’s need to know. These patients are
particularly vulnerable in the dental situation.
For those patients who
do admit to using AAS, it becomes incumbent upon the dentist to be prepared to question
and interpret patient self reported information and to integrate that
information with the known adverse effects as outlined above to formulate a
safe and effective dental treatment plan. It should be noted that from the
perspective of evidence based scientific literature there is a paucity of
information available on this topic.
The oral examination
for athletes on AAS should include a thorough evaluation of the gingival
tissues. A recent study identified significant levels of gingival enlargement
in a group of body builders and weight lifters who used AAS on a prolonged basis.20
While there were no statistical differences for scores on either plaque or
gingival indices between the study group of users and the control group of non-users, AAS
users did demonstrate statistically higher scores for gingival thickness,
extent of gingival encroachment, and total gingival enlargement scores compared
to the non-user control group.20
Other possible oral
manifestations that may be associated with AAS abuse have been suggested. These include xerostomia,
cervical decay, susceptibility to oral candidiasis, and trigger bruxism leading
complications that might arise in the dental office for athletes on AAS require
a cautious preparatory approach
prior to the administration of local anesthetics and the initiation of oral
surgical procedures.21, 22
most significant concern related to procedures such as third molar extractions
or surgical placement of dental implants in patients on AAS is the potential
A complete blood cell count including a differential count and
a platelet count should be ordered to identify
polycythemia and thrombocytopenia. A prothrombin time also should be ordered to
determine any deficiencies in the various clotting factors. Although these
blood studies will identify potential coagulopathy risks and pre-surgical
therapy can be directed toward correction of these problems,23
the potential for slow healing of the soft tissues at the surgical site.21
A further complication
that may arise during surgical procedures is shock in those AAS abusers with suppressed adrenal gland function.21
In some instances it may be advisable to recommend a delay in the
surgery until after the AAS use has been discontinued and a sufficient period
of time has elapsed to clear the system. While the primary focus of this report
has centered on the adverse side effects of performance-enhancing substances as
well as the implications for providing safe and effective dental treatment to
user-athletes, dentists also need to be aware of several cautions to avoid
inadvertently causing a positive drug test in their athlete/ patients related
to medications that we might administer or prescribe in the routine course of
For example, local
anesthetics containing epinephrine should be avoided immediately prior to or during competition.22
post-operative opioid analgesics should be avoided in favor of non-steroidal anti-inflammatory
The use of dental medicaments that contain corticosteroids for
the treatment of oral ulcerations or for sedative dressings should not be prescribed.22
AAS: Legal Considerations
The acquisition of AAS
and other banned performance-enhancing substances for other than prescribed medical conditions is
an illegal act, and the use of these substances is unethical behavior in
athletics. A conviction for the illegal possession of AAS is punishable by a
minimum fine of $1,000 and/or a one-year prison term. A conviction for selling
or the intent to sell AAS carries with it a fine of $25,000 and/or sentence of
five years in prison.2
attitude and achievement of personal athletic
success, while viewed by many as motivational, may, conversely, promote
unethical behaviors and illegal
use of performance-enhancing substances such as AAS by an increasingly broad spectrum of athletes
from professional and world-class amateur athletes down to impressionable
pre-teenage youth, regardless of gender.
The purpose of this
article was to provide practicing dentists with an overview of information
related to the adverse
outcomes associated with the abuse of performance enhancing substances, with emphasis
on anabolic-androgenic steroids by their patients who are adolescent athletes.
Knowledgeable dentists are in a unique
position to observe clinical signs of potential substance abuse and to ask their
adolescent athlete/ patients appropriate questions, in a non-judgmental manner,
regarding their use of performance-enhancing substances. Educational materials
identifying the serious and life-threatening side effects associated with the
abuse of these substances can be provided to enhance the
awareness of athletes. Appropriate guidance and referrals can be made for those
who elect to make a quit attempt.
Drug testing of adolescent
athletes remains a controversial issue. While the issue of drug testing is
beyond the scope of this article, suffice it to say that rules and drug testing
alone cannot resolve the problem of performance-enhancing substance abuse by
adolescent athletes. Education is one fundamental ingredient to facilitate interventions
for both individual and public health strategies. It seems evident that dental
practitioners, as health care providers, have a professional responsibility to
be prepared to address the various clinical challenges presented by today’s
1. Buckley WE, Yesalis
CE, Friedl et al. Estimated prevalence of anabolic steroid use among male high
school students. JAMA 1988; 260(23): 3441-3445.
2. Calfee R, Fadale P.
Popular ergogenic drugs and suppliments in young athletes. Pediatrics 2006;117(3):e577-e589. Available at:
3. Faigenbaum AD,
Zaichkowsky LD, Gardner DE et al. Anabolic steroid use by male and female middle
school students. Pediatrics 1998;101(5):e6. Available at:
4. Koch JJ:
Performance-enhancing substances and their use among adolescent athletes.
Pediatrics in Review 2002;23(9):311-317.
5. vanden Berg P, Neumark-Szainer
D, Cafri G et al. Steroid use among adolescents: Longitudinal findings from
Project EAT. Pediatrics 2007;119(3):476-486.
6. Ranalli DN, Rye LA.
issues for women athletes. Dent Clin North Am 2001;45(3):523-539.
7. Ranalli, DN,
Elderkin DL. Oral health issues for adolescent athletes. Dent Clin North Am 2006;50(1):523-539.
8. Ungerleider, S. Faust’s
Gold: Inside the East German Doping Machine. Thomas Dune Books (St. Martin’s Press) 2001.
9. Pope HG. Unraveling
the Adonis complex. Psychiatric Times 2001;18(3). Available at: www.psychiatrictimes.com/p010353.html
of Pediatrics. Steroids: Play safe, play fair. Available at:
11. Dawson RT. Drugs
in sport — the role of the physician. J Endocrinol 2001;170:55-61.
12. The World
Anti-Doping Agency. The World Anti-Doping Code: The 2007 Prohibited List International
Standard. Available at: www.
13. Escher S. Advising
the athlete on nutrition and supplements. In Sports Medicine in Primary Care,
Johnson R, editor. Philadelphia:
WB Saunders,2000, pages 61-67.
14. Griesmer BA:
Performance enhancing substances. In Care of the Young Athlete, Sullivan
JA, Anderson SJ, editors. Rosemont (IL): AmericanAcademy of Orthopaedic Surgeons and AmericanAcademy of Pediatrics 2000; 95-104.
15. Strauss RH,
Yesalis CE. Drugs in sports. In Sports Medicine, Strauss RH, editor. Philadelphia: WB Saunders
1991, pages 255-272.
16. Zorpette G: The
chemical games. In Scientific American Presents. Building the Elite Athlete.
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17. Guggenheimer J.
Implications of smokeless tobacco use in athletes. Dent Clin North Am 1991;
18. Guggenheimer J.
Tobacco and athletes: update and current status. Dent Clin North Am 2000;44(1):179-187.
19. Johnson MD.
Anabolic steroid use in adolescent athletes. Pediatr Clin North Am 1990;37(5):1111-1123.
20. Ozcelik O, Haytac
MC, Seydaoglu G. The effects of anabolic androgenic steroid abuse on gingival
tissues. J Periodontol 2006;77:1104-1109.
21. Bida D. Sports
dentistry’s role in preventing steroid abuse. Twelfth Night 1999;38(1):8.
22. Gizzarelli G.
Point of Care: As a team dentist, what issues in doping control and banned substances
do I need to be concerned about? J Can Dent Assoc
23. Smith BK, Haug RH,
Shepard L et al. Management of the oral and maxillofacial surgery patient on
anabolic steroids. J Oral Maxillofac Surg 1991;46:627-632.
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Studen-Pavlovich D. High risk substance behaviors in adolescent athletes. J Ped
Dent Care 2005;11(2):37-38.
It’s Not Supposed to Happen This Way… A Cautionary Tale
Mark A. Roettger, D.D.S., F.A.S.D.*
A number of years ago,
a young man growing up in the suburbs of Saint
Paul was feeling the pressure of transitioning from
childhood to adulthood. These pressures can be quite intense, and even moreso
if you are a frail young
kid dealing with the ever-present bullies found in every school. After dealing with
an abundance of abuse, this young man decided that enough was enough, and began
to work out with his friends to transform his body from frail to buff. But the workouts weren’t fast enough, so he
started using FDA-approved protein supplements and vitamins. This helped some,
but still the progress was too slow, and the memories of ridicule persisted.
The young man then turned to the use of anabolic androgenic steroids to enhance
his workouts even more. He was able to purchase these illicit drugs online, without
a prescription and without the knowledge of family or friends.
The use of these
steroids went on for some time, and the young man’s behavior began to change.
When his father became suspicious of his activities and confronted him, a
steroid-induced rage escalated the confrontation, and when it was over, the
young man was no longer welcome in his father’s home.
A year passed. More
steroid use, and also some narcotic use began, and life was deteriorating for
the young man. He turned to the most consistent comfort he had known, his
father. During their reconciliation, it came out that the young man’s third molars
were causing pain, and his father agreed to help him with his dental bills. The
dentist evaluated the teeth, and likely an incomplete medical history, and
recommended extraction, and the appointment was scheduled. At the consultation appointment, the
dentist wrote a prescription for a narcotic pain medication so it could be
filled prior to the extraction appointment, as is often done.
The dental appointment
never happened. The third molars were never extracted, because, you see, the
young man died suddenly the night before the appointment.
Discussing the tragic
death with the young man’s father, we were told this death was not ruled a
suicide, and that the autopsy found five different steroids in his son’s
system, as well as narcotics. The narcotics were found to be in non-lethal
concentrations by the medical examiner, but in concert with the steroids the
combination produced a toxic poison that likely contributed to his death.
It isn’t supposed to
happen this way. This is a tragic story, and we should all take something away
from this sad tale. First, it happened in our backyard. We can’t say that this could
only happen elsewhere. It could have happened in your practice. The dentist in
this case did nothing wrong, but the fact remains,
a young man is dead.
In the future, we in
dentistry must be more vigilant so we can avoid similar situations in our
We need to realize
that steroid abuse continues to rise, and in younger and younger kids. It can
be star athletes lured by the fame and fortune of professional athletics, or,
as in this case, simply a young man trying to build his body to escape the
ridicule of “bullies”. Simply, it can be anyone in your practice.
In light of this
information, don’t be afraid to ask your patients about steroid use, and if you
suspect abuse even if the patient denies it, consider postponing treatment or
altering your prescribing regimens. Educate yourselves on the implications of
steroid abuse on dental treatment to know the dangers that exist in treating
these patients. Let’s all work to make sure there are no more of these tragic stories,
because it really isn’t supposed to happen this way.
*Dr. Ranalli is Professor of
PediatricDentistry and Senior Associate Dean at the University
of Pittsburgh, School of Dental Medicine.
He a past president of the Academy for Sports Dentistry and is a team dentist for
the University of
E-mail is email@example.com
*Dr. Roettgeris a general dentist in private practice
in Stillwater, Minnesota. He is a charter member and past
president of the Academy for Sports Dentistry, and has served on the Medical
Advisory Committee of the MinnesotaStateHigh School League, the ADA task force on mouth protectors, the Minnesota
Vikings mouthguard program, as a dental consultant for the University of Minnesota Athletic Department,
and as a representative on the Joint Commission of Sports Medicine and Science.
E-mail is firstname.lastname@example.org.