New Age, New Meals, Old Problem

Dentistry Today


Whether it’s in a cup or a can, today’s “meals-on-the-go” are risky. As adults we are constantly trying to squeeze 25 hours into a 24-hour day. Not only is our health suffering, but in conjunction so are our teeth.

 though we are a generation obsessed with health, we are constantly seeking the quick fix. From diet drinks to power drinks, and diet bars to power bars, we eat on the go. As we pump ourselves up, we load our mouths with sugars and carbohydrates. A civilization fluoridated has become a civilization inundated. Steps need to be taken and awareness increased. Should we brush first, rinse after, or chew gum? These are the questions that we need to answer.
The challenge to the dental community is to become passionate about what our patients are consuming. Ask what, how much, and how often. Get involved. Monitor. Formulate nutritional diaries. Let’s take a closer look at dental disease, why it is on the rise, and what you can do about it.

The Facts
We all know that dental decay is a disease of the teeth resulting in damage to the tooth structure. Bacteria, normally present in the mouth, convert all foods—especially sugars and starches—into acids. The combination of bacteria, acid, food debris, and saliva in the mouth forms plaque. The acids in the plaque cause cavities. Within 20 minutes after eating or drinking, plaque and bacteria begin to accumulate. If left untouched, decay can be the result. Intake of sugars and starches (carbohydrates) increases this risk and multiplies destruction. The frequency of ingestion, timing, and type of carbohydrates are more important than the amount.


Childhood Decay
Dental decay in children remains a significant problem even with the proven benefits of fluoridated water in many municipalities and fluoride-containing products. How is this happening in spite of parents having such a heightened awareness of nutrition, health, and fitness?

A quick glance into our childrens’ school cafeterias may be a surprise. In exchange for donations to school systems, athletic departments, and associated programs, the “fruit drink” machine is promptly displayed for all to see (called “pouring rights”). For a mere 75 cents any child can enjoy a refreshing drink. As the name implies it is all fruit, right? Not exactly. Soda, fruit juices, and power drinks, to name a few, all have an average of 8 teaspoons of sugar per can. 
Dried fruits, granola bars, and gummy bears are also some of the items our children are consuming throughout the day. Their teeth do not stand a chance with all these soft, sweet, sticky goods lodged on and between them.
Sugars and caffeine are both addictive as well as unhealthy. The more one consumes the more one craves, like a hamster on that never-ending wheel. Large soft-drink companies are targeting children and teenagers in their promotions and advertisements. This has the potential to directly increase the consumption of foods and beverages high in decay-enhancing carbohydrates. As parents, we need to be advocates for our children. We must pass bills to get these machines out of our cafeterias. We need to be aware of subtle messages urging our children to snack, drink, and eat what we know is not good for them. 
Let’s unite and cut down on high-sugar snacks. Offer vegetables, cheese, or pretzels as snack alternatives. Reduce the frequency of snacking if a child cannot brush. Avoid soft, sticky, sweets that can lodge on and between tooth surfaces. Watch how often children are consuming sugar-rich foods like gum, lollipops, and hard candies. Monitor and educate. Allow occasional poor snacking as long as the child can brush immediately after eating. Awareness is the key.

Young Adult Decay (Ages 17 to 25)
Caries is still the most common dental disease seen in adults. Soft drink consumption has increased significantly in the last 50 years. Frequency of consumption between meals seems to be the major factor.

I recently had a college student return for her 6-month recare appointment. She had been caries free for 20 years. As per her past history, I only took bite-wing x-rays every 18 to 24 months, which meant she was due at this visit. Her mouth was devoid of plaque, and to the naked eye appeared healthy as usual. A quick glance at her radiographs revealed a totally different picture. She had 10 interproximal areas of decay. As she sat with tears in her eyes all she could mutter was, “How could this happen?” 
She and I took some time right then to evaluate her dietary habits. As the conversation progressed, together we learned that her diet consisted of a diet drink and coffee for breakfast, power bars and soda for lunch, chips with more soda for snack, and a sensible dinner washed down with a coke.
As a young adult devoid of any decay, she thought she was invincible. She had made it through her teens untouched. Everyone knows adults don’t get cavities, or so she thought. She agreed to write a nutritional diary for 1 week. I gave her a small notebook and asked her to register the date, time, and amount of every entry. After 1 week we would get together and evaluate.
At our nutritional counseling visit, I shared some basic information with her. As we know, every 4 grams of sugar is equivalent to 1 teaspoon. Her diet drink contains 35 grams of sugar, which equals approximately 8 teaspoons of sugar per can. “But it’s supposed to me good for me,” she said.
Yogurt has 38 grams of sugar, a power bar has 24 grams, a can of soda has 44 grams—these were just some of the items listed in her food diary. When made aware, my patient was astonished at how much sugar she was actually ingesting. All along she was trying to eat quickly and in a healthy way. Only now, after the damage was done, was she aware of what she actually had been consuming. 
In addition to the sugar content we must also be aware of the amount of carbohydrates consumed. Sticky versus nonsticky plays a key role. Take notice when reading labels. 
My patient cried the day her cavities were filled. Some days I believe she is still angry with me for finding the decay. She was duped into believing that her diet was okay and not harmful. My patient is and could be any of your patients, totally unaware of the true consequences of “you are what you eat/drink.” 
In this age group, it is also important to be aware of eating disorders and their manifestations, which your younger patients may not be willing to reveal. Frequent exposures of the teeth to stomach acids, carbohydrates, or induced vomiting place these patients at high risk for caries.

Adult Decay (Ages 35 to 44)
With the eating habits of adults in this age group, it should not be surprising that a significant number have lost at least one tooth from decay. However, it should be alarming with what we know today.

As mentioned previously, both caffeine and sugars are addictive. Caffeine, besides having absolutely no nutritional value, is an appetite suppressant. This causes one to eat less of the nutritional foods we require. Our bodies are then forced to snack when the levels of caffeine diminish. Unfortunately, we end up grabbing that quick fix loaded with sugars and high carbohydrates. Caffeine has been linked to breast cysts, depression, tremors, and increased heart rate. It has also been a contributor to ulcers and irritation of the digestive system. Moderation should be the key when consuming any items with high levels of caffeine.

Older Adults (Ages 65 and up)
With this age group, eating habits are just one obstacle to overcome. Our patients consistently return for recare appointments with recurrent, rampant, root, or xerostomia caries.

Because of many medications these patients may be taking, they may be further compromised. Hundreds of drugs can result in the infamous dry mouth. The decrease in salivary flow causes a drop in the natural “wash” effect. This dryness in turn increases the consumption of liquids and sugars.
The dry mouth is constant. This results in increased consumption of soda, coffee, juices, and bottled water as well as sucking on mints, hard candies, and chewing gum. With so many medications causing dry mouth, it will be an uphill battle to compensate. 
Besides medications, there are other causes of dry mouth. Mouth breathing, age-induced dryness, diabetes, leukemia, and pernicious anemia are just a few. Other contributing factors include chemo- and/or radiation-therapy. If this therapy is in the vicinity of the salivary glands, one could experience reductions of their pre-irradiated saliva flow rate.
Need we wonder why adult decay is on the rise? In addition, our more mature population has more risk management factors. Their dexterity is not what it once was. The physical challenges related to loss of manual dexterity also place this category of adults at high risk for caries. Loss of sight, arthritis, stroke, Parkinson’s disease, and cerebral palsy are just some afflictions that place these patients in this high-risk category. 

Other challenges for older adults could be acid reflux or digestive disorders. The constant use of sugar-containing antacids poses a problem.

Our first course of action as healthcare providers is to increase awareness: educate, educate, educate. We must ask our patients about their dietary habits and encourage them to take notice of what they are consuming. Can we be more proactive? What about having patients e-mail you a 1-week dietary intake log? We assume our patients are aware of nutrition, but are they aware of what they are consuming?
Comprehensive exams should consist of but not be limited to:
(1) DIAGNOdent (KaVo) for virgin teeth.
(2) Radiographs every 12 months.
(3) Use of loupes for clinical evaluation.
(4) Review and updating of medical histories.
(5) Evaluation of any risk factors.
(6) Plaque control.
Consider reviewing risk assessment and management strategies for the different types of dental decay. Evaluate such items as risk factors, medical history, dietary habits, social/cultural history, fluoride exposure, plaque control, and clinical evidence. Recommend the proper strategies according to the needs of the patient.

Does the patient have poor oral hygiene, low dental IQ, medication-induced dry mouth, and/or frequent consumption of high-sugar drinks and carbohydrates? Or does the patient have effective plaque control, high dental IQ, no medications, and low to infrequent consumption of sugar drinks and carbohydrates? The answers to these questions will determine your management strategies.
If we are not asking the questions, how can we provide the best oral hygiene regimen and instructions to our patients? The patient with poor dental hygiene and low dental IQ may require reinforced home care, maintenance every 3 to 4 months, bite-wing x-rays every 12 months, in-office fluoride rinse, as well as a take-home fluoride rinse or gel. Dietary counseling needs to be provided and recommendations made for nutritional snacking. Some suggestions might include nuts and seeds, popcorn, fruits, vegetables, plain yogurt, or cheese, and switching from high-sugar drinks to water. If bottled water is preferred then perhaps it will be necessary to incorporate a home fluoride regimen.
A quick review of the fluorides available might be helpful. Over-the-counter (OTC) rinses include ACT (Johnson & Johnson) and Fluorigard (Colgate) for low-risk cases. Gel-Kam (Colgate) is now OTC as well. Moderate- to high-risk cases should use prescription strengths. Choose among gel, rinse, or toothpaste, and recommend the necessary type for each individual situation. Gel-Kam and Perfect Choice (Biotrol) are examples of the 0.4% stannous fluorides available. For cosmetic patients, a 1.1% neutral sodium fluoride is suggested. Fluoridex Daily Defense (Discus) and PreviDent 5000 (Colgate) are two dentifrice fluorides. 
With dry mouth syndrome, which can disrupt the patient’s natural defense, our awareness of products must be broadened. Again, the use of in-office and take-home fluoride is necessary. Laclede, Inc has done some extensive research on dry mouth syndrome. Their products are designed specifically to help protect the mouth from harmful bacteria. This protection is the same as the body’s own saliva. The combination of toothpaste, mouthwash, and moisturizing gel seems to be very helpful. The gel can be used throughout the day when needed. 

Laclede, Inc. has also developed a xylitol gum that is sugar free and helps when brushing between meals is not possible.

The gauntlet has been placed. Your mission, should you choose to accept it, will be to increase your awareness of patients’ dietary intake. Take this mission to heart and become passionate about “you are what you eat/drink.”

Take responsibility for educating and instructing your patients. Whether it is providing adult fluoride rinses in the office, take-home prescription fluorides, or nutritional counseling, make a commitment and select the proper regimen for each individual patient.

Ms. Lorah is a coach with Hygiene Mastery. For a complimentary analysis of your hygiene department, including therapeutic fluoride programs, call (888) 347-4785 or e-mail