Recent research coming from Boston University suggests our traditional one-on-one behavioral interventions with patients may not be the best for long-term preventive behaviors. In fact, researcher Brenda Heaton, an assistant professor of health policy and health services research at Boston University’s Henry M. Goldman School of Dental Medicine offers information that may change the way information is dispersed throughout communities in order to have larger, long-term effect.
Heaton specializes in social epidemiology with a focus on oral health. In 2008, she, along with other members of BU’s Center for Research to Evaluate & Eliminate Dental Disparities, began a new line of research, focused on understanding oral health and disease among residents in Boston public housing. The majority of the work to date has focused on whether or not “motivational interviewing” can influence how women care for their children’s diet and oral health—specifically, the impact on kids with dental caries (also known as tooth decay). There is mounting evidence that one-on-one behavioral interventions, like motivational interviewing, may change short-term behavior, but the effects don’t last long. “We started to get a sense that there may be more influences that we need to acknowledge beyond just the individual,” says Heaton. She found that social networks—not Facebook and Twitter, but networks of friends, family, and acquaintances—may play an overlooked role in oral health care.
Since 2008, her team has interviewed close to 200 women living in Boston public housing and identified nearly 1,000 individuals who were influential. Heaton is using those network maps to find similarities about how information flows through these communities.
The ultimate goal, she says, is to use the map to introduce health information and resources into a community in ways that change long-term behaviors.
“You can’t design those interventions until you actually have a really strong grasp of the network structure,” says Heaton. For instance, if you want to make an impact, should you look for community members with the most personal connections or for people with large influence but fewer personal ties? Should you take advantage of existing connections or seed new ones?
The power of this approach is that it focuses on prevention rather than cures, says Heaton. It might take a village, but tooth decay “is an entirely preventable health outcome.”
To read the full article go here
What do you think? Is social mapping a positive move for oral health practitioners who want to prevent tooth decay?
Have you ever had a young patient come to your office with strange black staining? Something we see from time to time are children who present with superficial black stains on the teeth. Parents will always ask what causes it, and usually we discuss things like water and vitamins, but often we throw our hands in the air because the answer seemed elusive. Well, this recent study might shed some light on what is going on:
Assess prevalence, familial predisposition and susceptibility to caries of Black Stains (BS). Evaluate the microbiological composition of BS, saliva and subgingival plaque.
MATERIALS AND METHODS:
Sixty nine subjects with BS (test group) and 120 subjects without BS (control group) were analysed for oral status. For each BS-patient, a BS-deposit, 1 ml of saliva and subgingival plaque were collected and microbiologically analysed. Five deciduous teeth with BS were observed under SEM.
This study showed a BS prevalence similar to that of the Mediterranean area and a familiality. The microbiological origin of BS was confirmed by SEM and culture method and the BS flora differ from that of supragingival plaque.
Predominance in BS and saliva of Actinomycetes and the low salivary prevalence of S. mutans and L. acidophilus may be related with low caries incidence in BS patients. The high presence of Actinomyces spp can be a causative factor for BS.
(Tripodi D, Martinelli D, Pasini M, Giuca MR, D’Ercole S. Black Stains: a microbiological analysis and a view on familiarity and susceptibility to tooth decay of patients in childhood. Eur J Paediatr Dent. 2016 Dec;17(4):261-266. 69+BS, 120 –BS, 5 Decid teeth.)
So what can we tell our patients when they are concerned about their children? Patients with black stains typically have low caries incidence and high presence of the bacteria Actinomyctes causing the black coloration. It turns out the black stain is a bacterial origin issue, and seems to not be anything serious.
What about you? Have you seen patients with black stain? If so, what did you tell them?
It was an interesting year in Dental Caries research. For this update series we started with about 100 articles, and pared it down to 50 that we believe broaden our knowledge and will help us better diagnose and treat our patients. Over the next several weeks we will walk through the research, feel free to ask questions or provide your experience in the comments section.
The series will be organized by unpacking what we refer to as the “Usual Suspects” or patterns we have identified as being the common reasons patients suffer from dental caries. Our ability to recognize and identify these patterns allow us to focus our diagnosis and treatment of the disease. The first we will tackle is saliva flow. Low saliva flow is the number one self-reported risk factor in our data base of nearly 13,000 patients. 63% of these patients self-report dry mouth or low saliva. When beginning the conversation with patients, starting with saliva is smart.
An interesting study that came out in December looked at saliva flow and its relationship to dental caries and periodontal disease:
This study examined the relationship between stimulated salivary flow rate and oral health status in an adult population. Multinomial multivariate logistic regression analysis was used to examine the associations of salivary flow rate with dental caries status and periodontal status at the individual level among 2,110 Japanese adults with ≥10 teeth. Then, a spline model was used to examine the nonlinear relationship between salivary flow rate and teeth with dental caries or periodontal disease in multilevel analysis. Odds ratios were calculated for a 1.0-mL/min reduction in salivary flow rate at a point.
After adjusting for confounding variables, participants with a flow rate ≤3.5 mL/min had significantly higher odds ratios for high caries status, and participants with a flow rate ≤1.4 mL/min had a higher odds ratio for broad periodontal disease, than did those with a flow rate >3.5 mL/min. In spline models, the odds ratio for teeth with dental caries or periodontal disease increased with reduced saliva secretion. The present findings suggest that decreased saliva secretion affects both dental caries and general periodontal health status. (Shimazaki Y, Fu B, Yonemoto K, Akifusa S, Shibata Y, et al. Stimulated salivary flow rate and oral health status. J Oral Sci. 2016 Dec 28. 2110 Japan Ad >10 teeth).
So, not only does decreased saliva flow impact risk for dental caries, but also risk for periodontal disease. How does this information impact how you assess your patients?
What do you think? Have you noticed dry mouth as a usual suspect in dental caries and/or perio in your patients?
Tonight Dr. Kim Kutsch offers an update on the science of dental caries. Sign up for this free event by clicking the link below.
In other news…
We had an excellent question by a reader on last week’s post Q & A With Dr. Kim Kutsch: Saliva and Brushing
Q: What is the evidence that there is a significant reduction in salivary flow in older adults?
PUBMED Format: Abstract
J Am Geriatr Soc. 2015 Oct;63(10):2142-51. doi: 10.1111/jgs.13652. Epub 2015 Oct 12.
Meta-Analysis of Salivary Flow Rates in Young and Older Adults.
Affoo RH1, Foley N2, Garrick R3, Siqueira WL4, Martin RE1,5,6,7.
To determine whether salivary flow decreases as a function of aging.
Individuals aged 18 and older reported to be free of major systemic disease.
Relevant studies were identified through a literature search of several databases, from their inception to June 2013. Studies were included if saliva had been collected on at least one occasion in subjects aged 18 and older and if the data were presented in a manner that enabled comparisons of younger and older participants. Differences in salivary flow rates between age groups were calculated for each salivary source and condition and reported as standardized mean differences (SMDs), standard errors (SEs) and 95% confidence intervals (CIs). The results were pooled using a random effects model. A separate analysis examining medication use was also conducted.
Forty-seven studies were included. Whole (SMD = 0.551, SE = 0.056, 95% CI = 0.423-0.678, P < .001) and submandibular and sublingual (SMSL) (SMD = 0.582, SE = 0.123, 95% CI = 0.341-0.823, P < .001) salivary flow rates were reduced significantly in older participants and in unstimulated and stimulated conditions. In contrast, parotid and minor gland salivary flow rates were not significantly reduced with increasing age. Additionally, unstimulated and stimulated SMSL, and unstimulated whole salivary flow rates were significantly lower in older adults, regardless of medication usage.
The aging process is associated with reduced salivary flow in a salivary-gland-specific manner; this reduction in salivary flow cannot be explained on the basis of medications. These findings have important clinical implications for maintaining optimal oral health in older adults.
Please join the webinar tonight and get all the latest science on dental caries!
Here are some questions posed recently to Dr. Kutsch and his responses:
Q: What is your baseline approach to a saliva compromised patient?
For the patient with reduced salivary flow, which may be a result of age and or medication use, my approach is to make sure they understand the importance of keeping the mouth hydrated and the impact of snacking throughout the day. They need to understand how snacking compromises their saliva flow and pH. I would discuss changing dietary habits to achieve the least amount of negative impact. Also, it would benefit them to replace their saliva with a pH neutral or elevated pH product in order to protect and buffer their pH. I would have them on the CTx4 Gel 5000 for life. Also, after they eat, I tell them to rinse with tap water.
Now, for the patient that is completely saliva compromised, like a radiation patient or one that has Sjogren’s syndrome, it is a whole different approach. If their bacteria levels are high, I would put them on an antimicrobial for 3 months-2 years. I may use SDF to arrest any root surface caries while we figure out a treatment plan. I have put many Sjogren’s patients into trays with the CTx4 Gel 5000 to wear during the day or at night. You need to do everything for this patient and know that it is a lifetime treatment as their saliva is forever compromised.
Q: Do you approach a saliva compromised patient differently based on their ‘why’? (i.e Sjogren’s vs. medication or radiation induced xerostomia)
With exception of the radiation patient, the patient who has Sjogren’s or is on many medications I use the approach above. Now, for the radiation patient, short term they lose a lot of saliva, but long term it can go from totally dry to just a hyposalivation situation. You can prescribe Pilocarpine, and it will help with secreting saliva, but it will also produce more tears and sweat. There is a lollipop and sucker version that is an OK short-term solution for some patients.
Q: Are there any benefits of brushing with a toothpaste that do not contain remineralization agents?
A: Yes, even dry brushing is better than not brushing at all. Disrupting the biofilm on the teeth and cleaning it off the teeth everyday is beneficial. Do you get as good a benefit as using a gel with nano-hydroxyapatite or fluoride? Probably not. But, brushing every day will be helpful. The simple answer is: yes. However, in my mind, if you are going to do it anyway, use something alkaline (like saliva or CTx4 Gel 5000 with Nano HA) to reap additional benefits.
Have a question for Dr. Kutsch? Leave it in the comments below and you may be featured on a future blog post!
My approach to talking to patients about their dental health has changed dramatically over time. I have moved away from telling patients what they ‘have’ to letting them know ‘what I find’. It has made all the difference in the world. Specifically, when discussing caries risk, I have adopted the scripted statements and questions below:
Here are the risk factors that are causing your cavities
Which one do you want to work on first?
What is your plan?
What support would you like from me?
When we talk about these things, we talk about it objectively and without judgement. Remember we can only make one behavioral change at a time. Don’t try and do too much at once. I used to be invested in telling the patient ‘my way'; telling them what to work on first, second etc. Now, I let them choose. They are far more successful that way. Ask them where they want to start. When it comes to restorations, of course there is a logical order however, when it can be up to the patient, let it be up to them. Let the patient come up with the plan and let YOU know what it is.
What about intervention?
Intervention and treatment needs to target and be specific to the patient’s risk factors. When the patient has decided they are ready to move forward with treatment, let them know the appropriate level of intervention based on your assessment.
Suspects (Risk Factors) Drive the Treatment Strategies
Bacteria: Antimicrobial and/or Behavior
Diet: Limit sweets versus Limit snacking
Saliva: Hydration, Neutralize support the pH
Genetic: Minimize acid exposure, support wellness
Treatment Strategies per risk level
Dr. Kutsch’s Protocol for Low Caries Risk
Caries Risk Assessment with Biometric
Offer 12 month Fluoride Varnish
Offer pH, Xylitol, Nano-HA, Fluoride
Educate about Risk Factors
Dr. Kutsch’s Protocol for Moderate Caries Risk
Caries Risk Assessment with Biometric
Recommend 6 month Fluoride Varnish
Recommend pH, Xylitol, Nano-HA, Fluoride
Behavioral Coaching targeted to Risk Factors
Dr. Kutsch’s Protocol for High Caries Risk
Caries Risk Assessment with Biometric
3 month Fluoride Varnish (Always)
pH, Xylitol, Nano-HA, Fluoride (Always)
+/- Antimicrobial strategy
+/- Silver Diamine Fluoride
Behavioral Coaching for Risk Factors
At the end of the day it all comes down to balance. A healthy balance in your mouth comes from healthy saliva, healthy diet and healthy home care. Your body cannot be healthy if your mouth is not in balance.
What about you? How do you approach treatment?
We know counseling patients can be challenging. Today we offer a few reasons why it can be so hard, and a few strategies that work to help patients really make change.
One of the greatest forces working against us (and our patients) is called proactive interference. Old habits are a significant force keeping us from forming new habits. In essence you don’t just have to learn something new, you have to also unlearn old habits.
Proper tooth brushing is a seemingly simple motor activity that can promote oral health. Applying health theories, such as the Information-Motivation-Behavioral Skills (IMB) model, Motivational Interviewing (MI) and Integrated Health Coaching (IHC), may help optimize tooth brushing technique in those with suboptimal skills. Some motor activities, including tooth brushing, may over time become rote and unconscious actions, such that an existing habit can inhibit new learning, i.e., exert proactive interference on learning the new skill. Proactive interference may impede the acquisition of new tooth brushing skills; thus, in this report, we: (1) Review how the habit of tooth brushing is formed; (2) Postulate how proactive interference could impede the establishment of proper tooth brushing retraining; (3) Discuss the merits of this hypothesis; and (4) Provide guidance for future work in this topic within the context of an approach to behavior change that integrates IMB, MI and IHC methodology.
“Some motor activities, including tooth brushing, may over time become rote and unconscious actions, such that an existing habit can inhibit new learning, i.e., exert proactive interference on learning the new skill. Proactive interference may impede the acquisition of new tooth brushing skills.”(Thavarajah R, Kumar M, Mohandoss AA, Vernon LT. Drilling Deeper into tooth brushing skills: Is proactive interference an under-recognized factor in oral hygiene behavior change? Curr Oral Health Rep. 2015 Sep;2(3):123-128)
One consistent message we convey to all doctors is that changing someone’s behavior surrounding sugar consumption is harder than changing their behaviors surrounding alcohol. This is a significant challenge. If alcohol treatment requires a 12 step program, changing sugar habits may be a 13-14 step process. We mention this to hammer home just how difficult behavior change around diet can be.
The Cochrane Oral Health Group Trials Register CENTRAL, Medline, Embase, PsycINFO, CINAHL, Web of Science conference proceedings (IADR and ORCA), reference lists and Dissertations Abstracts were searched.
Randomised controlled trials assessing the effectiveness of 1:1 dietary interventions in a dental care setting were included. This could be brief advice, skills training, self help materials, counselling or lifestyle strategies delivered by any member of the dental team.
DATA EXTRACTION AND SYNTHESIS:
Two reviewers independently screened and abstracted data with disagreements resolved by discussion and a third review author. The Cochrane risk of bias assessment tool was used.
Five studies were included; two were at high risk of bias, three were at unclear risk of bias. Two were multi-intervention studies where the dietary intervention was one component of a wider programme of prevention, but where data on dietary behaviour change were reported. One of the single intervention studies concerned caries prevention. The others concerned general health outcomes. No studies were aimed at preventing tooth erosion. Four out of five studies found a significant change in dietary behaviour in at least one of the primary outcomes.
“There is some evidence that one-to-one dietary interventions in the dental setting can change behavior, although the evidence is greater for interventions aiming to change fruit/vegetable and alcohol consumption than for those aiming to change dietary sugar consumption.”(Evans D. Some evidence that one-to-one dietary interventions in the dental setting can change behaviour. Evid Based Dent. 2012 Jun;13(2):42. Sys Rev. 5 trials.)
Ask open ended questions
So what do we do? One of the greatest strategies I have learned to implement is asking open ended questions. These are questions that cannot be answered ‘yes’ or ‘no’.
Instead of asking: Do you floss? How many times per day?
What would you like to focus on?
How has this affected your life?
One of the best non-judgmental statements is:
Tell me more about…
Telling (selling) vs. Asking
Another trap we fall in is telling patients what they need instead of asking what they want.
Are we telling them what they “should” do?
Or are we asking them what they want?
Are we selling or are they purchasing?
These are just a few of the strategies I find helpful in counseling my patients. What strategies do you find helpful?
Wellness Coaching helps the patient understand why they have a problem and empowers them to do something about it.
Wellness Coaching helps the patient develop their own answers.
The Baraka Institute and Feroshia Knight
This myth came from a plastic surgeon who determined that it took patients about 21 days to get used to their rhinoplasty. It has nothing to do with real behavior change.
“There’s no shortage of apps out there designed to help you form a habit, and many of those are built on the assumption that all you need is 21 days. This number comes from a widely popular 1960 book called Psycho-Cybernetics by Maxwell Maltz, a plastic surgeon who noticed his patients seemed to take about 21 days to get used to their new faces.”(SIGNE DEAN. Here’s how long it takes to break a habit, according to science: You’re gonna need more than will power. Science Alert 24 SEP 2015)
New habits take 66-254 days
“In conclusion, repeating a behavior in response to a cue appeared to be enough for many people to develop automaticity for that behavior. Although consistency in repetition is required, the degree of consistency is not yet known. There was variation both in the maximum automaticity reached and the time taken to plateau.”(Lally p, Van Jaarsveld CM, Potts HWW, Wardle J. How are habits formed: Modelling habit formation in the real world. European Journal of Social Psychology Eur. J. Soc. Psychol. 40, 998–1009 (2010))
Patients change at their pace. We need to know how to help them change. It also takes daily reinforcement.
Our attitude affects the outcome
Front line providers of care are frequently lacking in knowledge on and sensitivity to social and structural determinants of underprivileged patients’ health. Developing and evaluating approaches to raising health professional awareness and capacity to respond to social determinants is a crucial step in addressing this issue. McGill University, in partnership with Université de Montréal, Québec dental regulatory authorities, and the Québec anti-poverty coalition, co-developed a continuing education (CE) intervention that aims to transfer knowledge and improve the practices of oral health professionals with people living on welfare. Through the use of original educational tools integrating patient narratives and a short film, the onsite course aims to elicit affective learning and critical reflection on practices, as well as provide staff coaching.
A qualitative case study was conducted, in Montreal Canada, among members of a dental team who participated in this innovative CE course over a period of four months. Data collection consisted in a series of semi-structured individual interviews conducted with 15 members of the dental team throughout the training, digitally recorded group discussions linked to the CE activities, clinic administrative documents and researcher-trainer field notes and journal. In line with adult transformative learning theory, interpretive analysis aimed to reveal learning processes, perceived outcomes and collective perspectives that constrain individual and organizational change.
The findings presented in this article consist in four interactive themes, reflective of clinic culture and context, that act as barriers to humanizing patient care: 1) belief in the “ineluctable” commoditization of dentistry; 2) “equal treatment”, a belief constraining concern for equity and the recognition of discriminatory practices; 3) a predominantly biomedical orientation to care; and 4) stereotypical categorization of publically insured patients into “deserving” vs. “non-deserving” poor. We discuss implications for oral health policy, orientations for dental education, as well as the role dental regulatory authorities should play in addressing discrimination and prejudice.
Humanizing care and developing oral health practitioners’ capacity to respond to social determinants of health, are challenged by significant ideological roadblocks. These require multi-level and multi-sectorial action if gains in social equity in oral health are to be made.(Lévesque MC, Levine A, Bedos C. Ideological roadblocks to humanizing dentistry, an evaluative case study of a continuing education course on social determinants of health. Int J Equity Health. 2015 Apr 30;14:41).
We must be non-judgmental
“Briefly, this health coaching approach is based on an interactive assessment (both physical and psychological), a non-judgmental exploration of patients’ knowledge, attitudes, and beliefs, a mapping of patient behaviors that may contribute to disease progression, gauging patient motivation, and tailoring health communication to encourage health-promoting behavior change.”(Vernon LT, Howard AR. Advancing Health Promotion in Dentistry: Articulating an Integrative Approach to Coaching Oral Health Behavior Change in the Dental Setting. Curr Oral Health Rep. 2015 Sep;2(3):111-122.)
There is a lot of shame, guilt and emotional baggage associated with dental caries. We must tell them that we believe in them and they are capable of making the change. They need the positive reinforcement in order to be successful. Next time we will look at some strategies I have learned to help patients change.
How about you? Do you implement wellness coaching strategies with your patients?
Saliva is nature’s most effective protective strategy for your mouth. Resting saliva has a pH of about 6.75 and stimulated saliva has a pH of 8.0. When we begin to look at things that threaten this protection there are several that come to mind.
1. Medication Induced Xerostomia
70% of Americans take at least one medication daily, across all age demographics. Unfortunately I can’t take my patients off of their medications. So my job is to help them understand how it relates to their caries risk. I also let them know how much more susceptible they are when eating and drinking. I encourage them to keep their mouth moist and stay hydrated.
Adolescents with psychiatric conditions may be at risk for xerostomia. In this preliminary study, we estimated xerostomia prevalence in adolescents ages 9 to 17 years from an inpatient psychiatric clinic (N = 25) and examined whether: (1) gender and age were associated with xerostomia and (2) xerostomia was associated with self-reported cavities.
We used a modified 11-item Xerostomia Index to identify xerostomia (no/yes) and asked if adolescents ever had or currently have cavities (no/yes).
The mean age was 14 years (SD = 2.3) and 72% were male. Sixty percent reported xerostomia (SD = 50). There were no significant associations between xerostomia and gender (p = 0.99) or age (p = 0.66), or between xerostomia and past (p = 0.26) or current cavities (p = 0.11). Larger proportions of adolescents with xerostomia reported previous and current cavities.
“Sixty percent of adolescents from an inpatient psychiatric clinic reported having xerostomia, which may lead to increased caries risk over time. Additional research should examine the prevalence and consequences of xerostomia in high-risk adolescents.”(Kaur M, Himadi E, Chi DL. Prevalence of xerostomia in an adolescent inpatient psychiatric clinic: A preliminary study. Spec Care Dentist. 2015 Dec 21. doi: 10.1111/scd.12154. [Epub ahead of print])
2. Sjogren’s Syndrome
The photo is of a patient who was averaging 2 new caries a year, yet had impeccable home care. Her issue was she had virtually no saliva.
As North Americans live longer, have more chronic conditions and take more medications, adverse oral events are likely to increase and aggravate the symptoms of Sjögren syndrome (SS).
A total of 151 adults who self-reported having SS and who had a mean (standard deviation [SD]) age of 65.8 (11.5) years completed a survey that included questions about basic demographic information, current medical conditions, medications used (prescription and over the counter [OTC]) and the use of oral products to manage SS symptoms. Owing to the self-reporting process in our survey, the term “SS” in our study population represented a mixture of people with SS and people with dry mouth symptoms.
The mean (SD) number of daily medications recorded as prescription, OTC and oral care products were 4.9 (3.5), 4.5 (2.8) and 4.6 (1.4), respectively. Participants with four or more comorbid medical conditions (n = 74; 49.0 percent) had significant differences (P < .05) in oral symptoms compared with those who had fewer than four (n = 75; 49.7 percent). Participants who were taking fewer than four prescription and OTC medications daily (n = 61; 40.4 percent) has significant differences (P < .05) in voice hoarseness compared with those taking four or more prescription and OTC medications daily (n = 54; 35.8 percent).
The survey results indicated that medication use and comorbid medical conditions demonstrated significant differences and may have had a substantial impact on the oral symptoms in adults who self-reported having SS.
Given the prevalence of SS, obtaining an accurate and complete medical and pharmacological history has implications for dental practitioners because medication use and comorbid medical conditions have a significant impact on oral symptoms in patients with SS.(Donaldson M, Epstein J, Villines D. Managing the care of patients with Sjögren syndrome and dry mouth: Comorbidities, medication use and dental care considerations. J Am Dent Assoc. 2014 Dec;145(12):1240-7. 151 Ad, >4 Rx)
The authors used a large community sample of methamphetamine (MA) users to verify the patterns and severity of dental disease and establish a hierarchy of caries susceptibility by tooth type and tooth surface.
Using a stratified sampling approach, 571 MA users received comprehensive oral examinations and psychosocial assessments. Three calibrated dentists characterized dental and periodontal disease by using National Health and Nutrition Examination Survey protocols. The authors also collected data on substance use history and other attributes linked to dental disease.
On all dental outcome measures, MA users evidenced high dental and periodontal disease, with older (≥ 30 years) and moderate or heavy MA users disproportionately affected. Women had higher rates of tooth loss and caries, as well as a greater prevalence of anterior caries. Current cigarette smokers were more likely to manifest 5 or more anterior surfaces with untreated caries and 3 or more teeth with root caries. Nearly 3% were edentulous, and a significant percentage (40%) indicated embarrassment with their dental appearance.
MA users have high rates of dental and periodontal disease and manifest a dose-response relationship, with greater levels of MA use associated with higher rates of dental disease. Women and current cigarette smokers are affected disproportionately. The intraoral patterns and hierarchy of caries susceptibility in MA users are distinctive.
The prevalence and patterns of dental and periodontal disease could be used to alert dentists to possible covert MA use and to plan treatment. Concerns about dental appearance have potential as triggers for behavioral interventions. (Shetty V, Harrell L, Murphy DA, Vitero S, Gutierrez A, Belin TR, Dye BA, Spolsky VW. Dental disease patterns in methamphetamine users: Findings in a large urban sample.J Am Dent Assoc. 2015 Dec;146(12):875-85.)
Special needs individuals truly have special needs when it comes to dental caries. Under the direction of Drs. Steve Perlman and Allen Wong, CariFree has donated materials to begin studying these individuals and their caries needs at Special Olympics events. We are gaining the best ever data on this under served and often neglected and forgotten population.
“The subjects in this study had a high prevalence of dental caries and need for restorative care. They would benefit from parental education on diet modification, improvement of oral hygiene practices and regular dental visits.”(Oredugba FA, Akindayomi Y. Oral health status and treatment needs of children and young adults attending a day centre for individuals with special health care needs. BMC Oral Health October 2008. 22(8):30.)
How do we help patients modify their behaviors when it comes to dry mouth? What do you suggest?
Of course sugar consumption plays a large role in our patients caries risk. However even practicing 30+ years, I am still surprised to find new places sugar is showing up in my patients’ diets.
Over the years people have begun to understand the link between sugary soda and poor oral and systemic health. Many, in an effort to make healthier choices have migrated from soda to sports drinks, thinking they are doing themselves a favor. However, drinking sports drinks or supplements like GU are doing themselves a disservice.
For optimal athletic performance, an athlete requires good oral health to reduce the risk of oral pain, inflammation, and infection and thereby minimize the use of analgesics and antimicrobial agents. Increased intake, frequency, and dental contact time of carbohydrate-rich foods, sports nutrition products, and acidic carbohydrate-containing sports and energy drinks may contribute to risks of dental erosion, caries, and inflammatory periodontal conditions in the athlete, especially when he or she also exhibits dehydration and poor oral hygiene habits. Examining the athlete before he or she begins participating in a sport allows the dental care provider to determine the patient’s existing oral health, hygiene, and susceptibility to risk factors for erosion, caries, and inflammatory periodontal disease. This oral profile, in conjunction with the individual athlete’s dietary needs, can be used to establish a treatment and preventive program, including oral health education. Good oral hygiene practices and application of topical fluoride, especially via fluoridated toothpastes and topical fluoride varnishes, must be available to the athlete. Rinsing with water or a neutral beverage after exposure to carbohydrates or acidic sports nutrition products may reduce carbohydrate contact time and bring oral pH levels back to neutral more quickly, reducing the risk of caries and erosion. Finally, the dentist should encourage the athlete to consult with an experienced sports dietitian to ensure that principles of sports nutrition are being appropriately applied for the type, frequency, and duration of exercise in consideration of the individual’s oral health needs.(Broad EM, Rye LA. Do current sports nutrition guidelines conflict with good oral health? Gen Dent. 2015 Nov-ec;63(6):18-23)
“Rinsing with water or a neutral beverage after exposure to carbohydrates or acidic sports nutrition products may reduce carbohydrate contact time and bring oral pH levels back to neutral more quickly, reducing the risk of caries.”
What do we know about Sugar Sweetened Beverages?
What about 100% fruit juice?
This study that hit the NY Times and stated that 100% fruit juice would NOT contribute to dental caries. However, in the study it was a 4-6 oz can. it was consumed one time with a meal. People took the idea and ran with it. We need to be very careful about our recommendations with regard to juice. The below image shows how much juice was consumed in the study.
The results of several studies conducted in the United States show no association between intake of 100 percent fruit juice and early childhood caries (ECC). The authors examined this association according to poverty and race/ethnicity among U.S. preschool children.
The authors analyzed data from the 1999-2004 National Health and Nutrition Examination Survey (NHANES) for 2,290 children aged 2 through 5 years. They used logistic models for caries (yes or no) to assess the association between caries and intake of 100 percent fruit juice, defined as consumption (yes or no), ounces (categories) consumed in the previous 24 hours or usual intake (by means of a statistical method from the National Cancer Institute).
The association between caries and consumption of 100 percent fruit juice (yes or no) was not statistically significant in an unadjusted logistic model (odds ratio [OR], 0.76; 95 percent confidence interval [CI], 0.57-1.01), and it remained nonsignificant after covariate adjustment (OR, 0.89; 95 percent CI, 0.63-1.24). Similarly, models in which we evaluated categorical consumption of 100 percent juice (that is, 0 oz; > 0 and ≤ 6 oz; and > 6 oz), unadjusted and adjusted by covariates, did not indicate an association with ECC.
Our study findings are consistent with those of other studies that show consumption of 100 percent fruit juice is not associated with ECC.
Dental practitioners should educate their patients and communities about the low risk of developing caries associated with consumption of 100 percent fruit juice. Limiting consumption of 100 percent fruit juice to 4 to 6 oz per day among children 1 through 5 years of age should be taught as part of general health education.
“Dental practitioners should educate their patients and communities about the low risk of developing caries associated with consumption of 100% of 100% fruit juice to 4 to 6 oz. per dayfruit juice. Limiting consumption among children 1 through 5 years of age should be taught as part of general health education.”(Vargas CM, Dye BA, Kolasny CR, Buckman DW, McNeel TS, et al. Early childhood caries and intake of 100 percent fruit juice: Data from NHANES, 1999-2004. J Am Dent Assoc. 2014 Dec;145(12):1254-61. 2,290 2-5 yo) SSB/Medications
Another important area to consider is sugary medication.
AIM:An investigation was conducted in a population of pediatric patients with a high risk of caries in order to assess the association between caries history (CH) and the number of early carious lesions (ECLs) and the frequency and timing of cariogenic food and beverage intake, sugar-containing medication, the frequency and efficacy of tooth brushing, and the use of topical fluorides.
MATERIALS AND METHODS:
Study design: descriptive study. One hundred children aged 6-15 years with≥ ECL of a permanent tooth and not enrolled in any dental health educational or preventive programme were selected. For diagnosis it was used an explorer according to the ICDAS II criteria. The participants completed a closed-list questionnaire on the frequency and timing of cariogenic food intake.
There was a nonsignificant tendency to present more ECLs and a greater CH among patients who consumed cariogenic foods and beverages. A significant relationship (p<0.05) was observed between cariogenic beverages and the number of ECL or CH. Using the number of ECLs as dependent variable, regular fluoridated rinses (p=0.003), frequent sugar-containing medication (p=0.007), and cariogenic beverage consumption (p=0.024) were identified as explanatory parameters in the linear regression model.
The Student t-test was used to compare ECL and CH with dietetic factors, fluoridated rinses, sugar- containing medicines, and the frequency and efficacy of tooth brushing. Linear regression analysis correlated the number of ECLs to the mentioned explanatory variables.
The frequent consumption of sugary beverages and medications, and failure to regularly use fluoridated rinses, were positively correlated to an increased number of ECLs in patients with a high prevalence of caries.
“The frequent consumption of sugary beverages and medications, and failure to regularly use fluoridated rinses, were positively correlated to an increased number of early caries lesions (ECL)s in patients with a high prevalence of caries.”(Llena C, Leyda A, Forner L, Garcet S. Association between the number of early carious lesions and diet in children with a high prevalence of caries. Eur J Paediatric Dent. 2015 Mar;16(1):7-12. 100 6-15 yo)
In my experience, both amount and frequency of sugar consumption contribute to dental caries–not one or the other. We as practitioners need to be vigilant in our risk assessment to determine if there are sugary substances being consumed that may be putting our patients at risk.