Ohio Dentist and Dental Hygienist Ebook Continuing Education

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OHIO Dental Continuing Education

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CARIES-PRONE PATIENTS: PREVENTION, ASSESSMENT, AND INTERVENTIONS, 3RD EDITION [4 CE hours] The impact of nutrition on the caries process is known in the dental field, but dental professionals need to continue to convey the importance of this relationship to patients. Working as partners with patients, dental professionals can aid in the prevention of dental caries and help maintain patients’ overall health by offering nutritional counseling and behavior modification techniques. The incidence of caries in the United States could decrease significantly as dental professionals implement the advances available for early caries detection, recommend anticaries treatments, and offer nutritional analysis and counseling.

CULTURAL COMPETENCE: AN OVERVIEW

[2 CE hours] Culture serves as a lens through which patients and practitioners filter their experiences and perceptions. Patients will bring their unique life stories and concerns to the practitioner, and their cultural values and belief systems will inevitably shape how the problem is defined and their beliefs about what is effective in solving the problem. However, the cultural backgrounds and values of patients are not necessarily scripts that define behavior, and when practitioners view culture as a strength and not a pathology, practitioners will be able to more effectively join with patients to mobilize change.

INFECTION CONTROL FOR DENTAL PROFESSIONALS

[5 CE hours] Effective infection control techniques are critical to reducing the incidence of infections in dental facilities. Antiseptic techniques and antibiotics will kill micro-organisms, while proper hand hygiene will block their transmission. Gloves, gowns, and masks remove dental professionals from the transmission cycle by protecting them from contact with micro-organisms. Contact Precautions and isolation techniques help patients avoid being vectors of transmission. Lastly, ensuring that dental professionals are immune or vaccinated can help decrease the availability of potential hosts.

ORAL CANCER AND COMPLICATIONS OF CANCER THERAPIES

[5 CE hours] Millions of people are diagnosed with a variety of malignant neoplastic lesions each year. Oral cancer, in which the primary malignancy arises within the oral cavity, is the 8th most common cancer in men and the 14th most common cancer in women. The common element among this diverse patient group are the problems encountered post-surgically when chemotherapy and or radiotherapy are used to destroy malignant cells, which can remain after the completion of surgery. Malignant lesions in the oral cavity are usually treated by surgical removal and several weeks of radiotherapy. The latter modality can cause severe changes in the mucosal tissues, bone, salivary glands, and the teeth, most of which are irreversible. Proper management before, during, and after both modes of therapy will have a positive impact on the quality of life and decrease the morbidity associated with these treatment regimens. This course will discuss the changes experienced within the oral environment during and after the treatment for oral and systemic cancers. Methods to mitigate these problems and to decrease the morbidity and the mortality which afflict these patients will be reviewed.

TREATING THE APPREHENSIVE DENTAL PATIENT

[4 CE hours] Many people have varying degrees of apprehension related to various aspects of dental treatment. Even patients who obtain regular dental care can have trepidation about dental procedures, especially those that are surgical in nature, those for which anesthetic injections are required, and restorative dentistry in which use of a high-speed hand-piece is required. Most people are able to obtain and complete proposed dental procedures despite their fears. However, some patients have levels of apprehension about dental treatment that make it difficult for them to schedule dental appointments and complete treatment that has been planned, and this course will focus on this group of patients. Highlights will include an exploration of the terminology used to describe the varying levels of dental apprehension and behavioral and/or pharmacological techniques that can be used to assist patients to complete dental treatment. Treatment modifications to decrease patients’ fear about procedures, the most common dental situations which patients find stressful, the origins of many dental-based fears, and the adverse effects of stress on the dental staff will also be discussed.

DENTAL CONTINUING EDUCATION

ANTIBIOTICS REVIEW

[5 CE hours] Choosing an antibacterial agent can be challenging, given the wide array of drugs available. Learning the important properties and uses of these drugs is made easier by the fact that they are grouped in classes based on their biochemical structure. Members of a drug class share characteristics such as clearance, mechanism of action, absorption, and side effects; knowing these shared properties makes it easier to choose the appropriate agent for a particular patient. In addition, it is easier to quickly grasp the strengths and weaknesses of a newly marketed antibiotic if you understand the general pharmacology of its class. A good grasp of the use of specific agents to target specific bacteria leads to improved clinical response to treatment and a decrease in the likelihood of the development of microbial resistance. This course is intended as an overview of the general characteristics of the major antibiotic classes, with a brief discussion of the individual agents and indications, giving greater perspective to the actions and characteristics of antibiotics. Due to the large number of antibiotics available, this course focuses on eight major classes of antibiotics: the penicillins, cephalosporins, other beta-lactams, aminoglycosides, macrolides, quinolones, sulfonamides, and tetracyclines. A brief discussion of vancomycin and the newer glycopeptide analogues is also included.

MEDICAL MARIJUANA AND OTHER CANNABINOIDS

119

[5 CE hours] A large body of clinical trials has now been published on cannabis and other cannabinoids in the treatment or management of a wide range of diseases and conditions. This course will review the body of research on medicinal cannabis to provide the learner with the most recently available information on potential indications, pharmacology and mechanism of action, acute and chronic side effects, and patients for whom medicinal cannabis is contraindicated. Also discussed will be a comparison between medicinal and recreational cannabis users, and how differences between the two groups in background characteristics and patterns of cannabis ingestion may differentially influence the development of side effects such as cannabis abuse and dependence. An evaluation of the strength and the quality of the research evidence will also be provided, as well as a discussion of how the cannabinoid mechanism of action may interact with disease pathogenesis to produce clinical benefit. The use of cannabis for medicinal purposes throughout recorded human history will also be presented.

FINAL EXAM ANSWER SHEET

147

©2025: All Rights Reserved. Materials may not be reproduced without the expressed written permission or consent of Colibri Healthcare, LLC. The materials presented in this course are meant to provide the consumer with general information on the topics covered. The information provided was prepared by professionals with practical knowledge in the areas covered. It is not meant to provide medical, legal or professional services advice. Colibri Healthcare, LLC recommends that you consult a medical, legal or professional services expert licensed in your state. Colibri Healthcare, LLC has made all reasonable efforts to ensure that all content provided in this course is accurate and up to date at the time of printing, but does not represent or warrant that it will apply to your situation or circumstances and assumes no liability from reliance on these materials.

DENTAL CONTINUING EDUCATION

Frequently Asked Questions What are the requirements for license renewal? Licenses Expire CE Credit Hours

Mandatory Subjects

Dentists - 30 Dental Hygienists - 20 (All hours are allowed through home study)

Licenses expire December 31 in odd-numbered years

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Caries-Prone Patients: Prevention, Assessment, and Interventions, 3rd Edition

4 1 5 5 4 5 5

4 1 5 5 4

$36 $18 $45 $45 $36 $45 $45

Cultural Competence: An Overview Infection Control for Dental Professionals

Oral Cancer and Complications of Cancer Therapies

Treating the Apprehensive Dental Patient

Antibiotics Review

Medical Marijuana and Other Cannabinoids

Dentist 30-Hour CE Package

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Is my information secure? Yes! We use SSL encryption, and we never share your information with third parties. We are also rated A+ by the National Better Business Bureau. What if I still have questions? What are your business hours? No problem, we have several options for you to choose from! Online at EliteLearning.com/Dental you will see our robust FAQ section that answers many of your questions. Simply click FAQs at the top of the page, email us at office@elitelearning.com , or call us toll-free at 1-866-344- 0972, Monday - Friday 9:00 am - 6:00 pm and Saturday 10:00 am - 4:00 pm EST. Important information for licensees Always check your state’s board website to determine the number of hours required for renewal, mandatory topics (as these are subject to change), and the amount that may be completed through home study. Also, make sure that you notify the board of any changes of address. It is important that your most current address is on file. Licensing board contact information: Ohio State Dental Board 77 South High Street, 17th Floor

Are you an Ohio board-approved provider? NetCE is an ADA CERP Recognized Provider.

ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP at www.ada.org/cerp.

NetCE Nationally Approved PACE Program Provider for FAGD/MAGD credit. Approval does not imply acceptance by any regulatory authority or AGD endorsement. 10/1/2021 to 9/30/2027 Provider ID #217994.

Are my hours reported to the Ohio board? No. The board performs random audits at which time proof of continuing education must be provided. What information do I need to provide for course completion and certificate issuance? Please provide your license number on the test sheet to receive course credit. Your state may require additional information such as date of birth and/or last 4 of Social Security number; please provide these, if applicable.

Columbus, OH 43215 Phone (614) 466-2580 Website: https://dental.ohio.gov/

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DENTAL CONTINUING EDUCATION

How To Complete This Book For Credit

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• Go to EliteLearning.com/Book and enter the code that corresponds to the course below, then click GO . Each course will need to be completed individually, and the specified course price will apply. • Proceed to your exam. If you already have an account, sign in with your username and password. If you do not have an account, you’ll be able to create one now. • Follow the online instructions to complete your exam and finalize your purchase. Upon completion, you’ll receive access to your completion certificate. ONLINE FASTEST AND EASIEST!

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If you are only completing individual courses in this book, enter the code that corresponds to the course below online. Caries-Prone Patients: Prevention, Assessment, and Interventions, 3rd Edition 4 4 $36 DOH04CP Cultural Competence: An Overview 2 2 $18 DOH02CC Infection Control for Dental Professionals 5 5 $45 DOH05IC Oral Cancer and Complications of Cancer Therapies 5 5 $45 DOH05OC Treating the Apprehensive Dental Patient 4 4 $36 DOH04AD Antibiotics Review 5 $45 DOH05AR Medical Marijuana and Other Cannabinoids 5 $45 DOH05MM

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DENTAL CONTINUING EDUCATION

__________________________ Caries-Prone Patients: Prevention, Assessment, and Interventions, 3rd Edition DOH04CP — 4 CE CREDIT HOURS R elease D ate : 07/01/24 E xpiration D ate : 06/30/27 Caries-Prone Patients: Prevention, Assessment, and Interventions, 3rd Edition

Audience This course is designed for dental professionals involved in the prevention and treatment of caries. Course Objective The purpose of this course is to equip all members of the dental team with the skills needed to implement the advances available for early caries detection, recommend anticaries treat- ments, and offer nutritional analysis and counseling. Learning Outcomes Upon completion of this course, you should be able to: 1. Describe the caries process and methods for its detection. 2. List the oral care habits recommended by the American Dental Association. 3. Identify the dietary choices of patients and the factors that influence the diets of patients. 4. Recognize populations at increased risk for caries and describe caries prevention products and procedures for this population. 5. Explain the use of personalized patient care and nutritional counseling to decrease incidence of caries. Faculty Mark Szarejko, DDS, FAGD , received his dental degree from the State University of New York at Buffalo School of Dentistry in 1985 and Fellowship in the Academy of General Dentistry in 1994. He has been an examiner for the State of Florida Dental and Dental Hygiene Licensure Examinations since 1994. He has also served as an expert witness for the state of Florida and for private companies. He has authored and edited many dental continuing education courses and has given presentations on varied dental topics to local, regional, and national audiences. He has served as a dentist in the county correctional system for nearly half of his career, where the incidence of HIV/AIDS is much higher relative to that of the general population. The surgical and nonsurgical dental

treatment of HIV/AIDS patients is a common occurrence in this setting, allowing him to have a unique perspective of the oral manifestations of HIV/AIDS patients and of their dental treatment. Faculty Disclosure Contributing faculty, Mark Szarejko, DDS, FAGD, has dis- closed no relevant financial relationship with any product manufacturer or service provider mentioned. Senior Director of Development and Academic Affairs Sarah Campbell Director Disclosure The Director of Development and Academic Affairs has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned. Accreditations & Approvals NetCE is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP at www.ada.org/cerp. NetCE Nationally Approved PACE Program Provider for FAGD/MAGD credit. Approval does not imply acceptance by any regulatory authority or AGD endorsement.

10/1/2021 to 9/30/2027 Provider ID #217994.

Designations of Credit NetCE designates this activity for 4 continuing education credits. AGD Subject Code 250.

Mention of commercial products does not indicate endorsement.

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About the Sponsor The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare. Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice. Disclosure Statement It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distrib- uting or providing access to this activity to learners.

HOW TO RECEIVE CREDIT • Read the entire course online or in print. • Complete a mandatory test (a passing score of 75 percent is required). Test questions link content to learning objectives as a method to enhance individualized learning and material retention. • Provide required personal information and payment information. • Complete the mandatory Course Evaluation.

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__________________________ Caries-Prone Patients: Prevention, Assessment, and Interventions, 3rd Edition

Infants are not born with pathogenic oral bacteria but can acquire them from the skin or vaginal area during delivery or from family members with whom they are in close contact [8]. It has been determined that these bacteria can be transmitted between individuals through kissing, sharing eating utensils or cups, and other interactions. Studies have demonstrated that the mouth of the neonate is colonized by bacteria that resemble those from the oral cavity of the mother [9]. Women of childbearing age, parents, and caregivers of young children should be educated about the potential to transmit the bacteria contributing to dental caries. SUSCEPTIBLE TOOTH SURFACE All erupted teeth have the potential to develop caries lesions. However, teeth with optimal fluoride content are more resis- tant to caries lesion development than are teeth lacking in fluoride, as fluoride has an essential role in protecting enamel from demineralization [10]. Patients with recession (exposed root surfaces) are at increased risk for dental caries because roots do not have enamel, the extremely hard and most caries- resistant material surrounding the crown of the tooth. DIET A diet high in sugar, including fermentable carbohydrates, increases the likelihood of developing dental caries. Included are foods that are innately sugary (e.g., juices), those with sugar added (e.g., soda and candy), and starchy foods that break down into sugars in the mouth (e.g., breads and crackers). When fermentable carbohydrates are introduced into the mouth, the sugars begin to be broken down to acid by oral bacteria. This acid lowers the pH of the saliva and oral plaque biofilm and may increase the rate of demineralization of tooth surfaces. Tooth enamel begins to demineralize at a pH of 5.5, and root surface demineralization occurs at an even milder pH of 6.2 [11]. Once the pH dips into these ranges, the outer layer of the tooth loses minerals. This causes a loss in surface hard- ness and increases the possibility of caries lesion progression. TIME/FREQUENCY Time is a contributing factor in the caries process because the probability of caries increases as the frequency of acid formation from fermentable carbohydrate–rich food sources increases [6]. Simply stated, the more often fermentable carbo- hydrates are ingested, the more often salivary pH will decrease, and the greater the likelihood that teeth will experience demin- eralization. The extent of demineralization depends on the length of time the acidic biofilm is in contact with the tooth surface and the frequency of this contact. Caries lesions are the result of repeated or extended periods of demineralization.

INTRODUCTION Dental caries is a preventable disease that affects a majority of the population. According to the 2011–2016 National Health and Nutritional Examination Survey, approximately 90% of adults 20 to 64 years of age had at least one decayed tooth [1]. Data collected between 2017 and 2020 indicate that among children and adolescents 2 to 19 years of age, 46.0% had one or more carious lesions in their primary or permanent teeth [2]. These statistics show the increase in caries incidence over time, making it important for dental professionals to develop strategies for determining caries risk and counseling patients to reduce risk and a future of dental caries. The impact of nutrition on the caries process is known in the dental field, but dental professionals need to continue to convey the importance of this relationship to patients. Work- ing as partners with patients, dental professionals can aid in the prevention of dental caries and help maintain patients’ overall health by offering nutritional counseling and behavior modification techniques. The incidence of caries in the United States could decrease significantly as dental professionals implement the advances available for early caries detection, recommend anticaries treatments, and offer nutritional analysis and counseling. This basic-level course is intended to equip all members of the dental team with the skills needed to realize this over-riding goal. THE CARIES PROCESS Dental caries is a multifactorial disease. It is also preventable. In order for caries disease to occur, a number of factors must be present, including caries-causing microorganisms, a susceptible tooth surface, fermentable carbohydrates, and time. Dental professionals have the obligation to inform adult patients and parents of young patients that they possess the power to prevent and reverse this disease process. In this section, the factors that affect caries development will be addressed. MICRO-ORGANISMS AND DENTAL PLAQUE Untreated dental caries among deciduous (“baby/milk”) teeth is the most prevalent childhood ailment, affecting 514 million children globally. Overall, dental caries affects 97% of the global population at some point in their lives [3; 4]. The accepted theory of caries formation is related to the acids produced by oral bacteria removing tooth surface minerals, eventually causing a cavitation. Streptococcus mutans ( S. mutans ), S. sobrinus , Bifidobacterium species , and Lactobacillus micro- organisms have all been found to aid in caries progression [5; 6]. These same bacteria are associated with root caries, as are the micro-organisms Actinomyces viscosus and A. naeslundii , which are notably present in active lesions [7].

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Caries-Prone Patients: Prevention, Assessment, and Interventions, 3rd Edition __________________________

• Replace the toothbrush every three to four months, or more frequently if bristles are fraying. • Floss or use an interdental cleaner daily to remove bacteria between teeth and under the gum line. • Limit snacking and eat a balanced diet. • Develop a customized at-home oral hygiene regimen that includes the use of prescription- strength fluoride gels or toothpastes. • Establish a dental recall schedule that reflects the patient’s ability to maintain ideal oral hygiene. ORAL HYGIENE INSTRUCTION Since the average patient brushes for less than one minute and few adults floss daily, it is important to review the ADA guidelines with patients at dental visits. To increase patient acceptance and understanding of oral hygiene instructions, it is advantageous for the dental professional to give patients the opportunity to demonstrate oral hygiene techniques. This allows the patient to receive feedback and gain confidence. Power toothbrushes may be advisable for some patients because they are better than manual toothbrushes at reducing dental plaque levels and can be an exceptional oral hygiene tool for orthodontic patients and those with limited manual dexterity [16]. Timers may also be recommended to ensure that patients are brushing for a full two to three minutes. CARIOUS DIETS In order to decrease caries through nutritional counseling, the dental professional must understand the most common caries-promoting behaviors and diet choices among the population. Poor nutrition can promote the development of carious lesions and can also have an adverse effect upon the structural integrity of the gingival tissues, the oral mucosa, and the periodontium [17]. SNACKING Snacking is a common habit in the United States, with 90% of U.S. adults reporting one or more snacks per day—which accounts for approximately 22% of their daily energy intake [18]. Snacking promotes caries for a number of reasons. First, patients do not often brush or floss after eating snacks, leaving food debris and dental plaque biofilm in the mouth for extended periods. Second, most snack foods either have elevated sugar content or—like potato chips and crackers—are high in fermentable carbohydrates, allowing for acid formation from oral bacteria. Third, snacks are usually eaten throughout the day, permitting oral bacteria to produce acid and lower the salivary and plaque biofilm pH multiple times in a relatively short period.

CARIES LESION DETECTION METHODS

Caries lesions are detected a number of ways [3; 12; 13; 14]: • Visual examination is employed for diagnosing large pit and fissure, root surface, and facial and lingual smooth surface caries lesions. • Inspection with a blunt explorer or probe over the surfaces of teeth is the tactile method of detecting caries lesions. This exploration is especially effective around margins of existing restorations. • Using the air/water syringe to visualize teeth wet and dry is helpful. Demineralized surfaces will look dull, chalky, and irregular when dry. • Radiographs can be used to identify interproximal caries before they can be detected visually or tactilely, allowing for diagnosis when they are small or incipient. • Transillumination is the technique of shining light through the teeth with a dental light and mirror or with fiber-optic equipment. Various lasers for caries detection are available from dental equipment manufacturers. These methods allow tooth examination without risking cavitation of decalcified tooth surfaces, as may occur with the use of dental instruments. Employing a combination of these methods increases the prob- ability of finding carious lesions in early stages when restorative treatment can be minimal or may even be avoided. A thorough dental examination helps the dental professional to determine a patient’s caries risk level because any caries activity, including the presence of white spots or demineralization, automatically places a patient at high risk for caries development [15]. ORAL CARE HABITS The role of plaque biofilm in the caries process necessitates the teaching and frequent reviewing of proper oral hygiene with patients. It is possible to distinguish patients who are at increased risk for dental caries by recognizing patients with poor oral care habits. AMERICAN DENTAL ASSOCIATION RECOMMENDATIONS To prevent tooth decay, the American Dental Association recommends the following oral hygiene behaviors [16]: • Brush teeth twice a day. • Brush for two to three minutes. • Use a fluoride toothpaste that is ADA-accepted.

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__________________________ Caries-Prone Patients: Prevention, Assessment, and Interventions, 3rd Edition

FAST FOOD The American population’s consumption of fast food has been growing steadily for many years. Data from the National Health and Nutrition Examination Survey of 2017–2018 indicated that on an average day, 36.5% of American adults consume fast food, which accounted for 13.8% of their daily calories [21]. Children and adolescents vary in their daily caloric intake from fast food consumption. Each day, approximately 36.3% of children and adolescents consume fast food, with 11.4% of children and adolescents obtaining more than 45% of their daily caloric intake from fast food; 13.8% obtaining 25% to 40% of their caloric intake from fast food; and 11.1% obtain- ing less than 25% of their caloric intake from fast food [22]. Clearly, millions of Americans consume fast food on a regular basis, and this is associated with a high caloric intake and poor diet quality. Patients who eat fast food meals or snacks laden with carbohydrates are at increased risk for caries due to the high amounts of sugar and fermentable carbohydrates present in fast food items [23]. Being armed with knowledge of the statistical relationships between fast food and caries may help the dental professional counsel patients on making healthier fast food choices. In addition, there is a correlation between eating fast food on a regular basis and developing insulin resistance, which is a risk factor for type 2 diabetes [24]. To guide patients with diabetes and the general public toward healthier fast food options, the practitioner can refer patients to the American Diabetes Association website (http://www.diabetes.org), their physician, or a nutritionist for guidance specific to the patient’s health condition, keeping in mind that as a dental professional, oral health should remain a focus. SODA/SOFT DRINKS Within the United States, the median annual per capita consumption of sugar-sweetened beverages (SSB) in 2021 was 37.1 gallons, with the annual per capita consumption of SSB the lowest in Hawaii (23.5 gallons) and the highest in Missouri (51.8 gallons) [25]. Most people are unaware of the sugar con- tent of their favorite sugar-sweetened beverage or soda, and they are not aware of the daily recommended maximum amount of sugar. The World Health Organization has recommended that for children the maximum daily consumption of sugar is 3 teaspoons. A 20-ounce bottle of soda contains about 16 teaspoons of sugar, while a 12-ounce can contains about 10 teaspoons of sugar [26]. Many nutritional experts and health organizations believe that soda and SSB in general are a major contributing factor to the escalation of childhood and adult obesity [27]. The consumption of soda doubles the risk of the development of carious lesions in children and increases the potential for the development of carious lesions in adults [26].

Snacking habits have changed over the years, making it important for dental professionals to stay abreast of healthy options and nutritional evaluation techniques. Over a span of 35 years—between 1977 and 2012—there was a significant increase in per capita energy intake from snacking. The snack foods and beverages consumed were typically sugar-sweetened beverages, desserts, sweets, and salty snacks, the consistent consumption of which is not ideal for oral or systemic health [18]. The consumption of such snacks between meals or at a time that is typically not conducive to tooth brushing leads to a cumulative effect of an increased potential for the devel- opment of carious lesions. It is estimated that in the United States, approximately 22% of the daily caloric intake is from snacks that are sweet, salty, or desserts despite dietary guide- lines that these items should comprise a limited portion of the daily caloric intake [18]. Even patients trying to eat healthfully may fall prey to ingesting excessive sugar because many snack foods marketed as “low-fat” have increased sugar per serving to improve taste once the fat is removed. The average American consumes approximately 20 teaspoons of sugar every day via ingredients in foods and beverages such as fructose, dextrose, and high-fructose corn syrup [19]. The amount of sugar in the typical American diet not only pro- motes caries but also underlies the increase in obesity, heart disease, and diabetes in the general population. The American Heart Association recommends that men consume no more than 9 teaspoons (36 grams or 150 calories) of added sugar per day and that women consume no more than 6 teaspoons (25 grams or 100 calories per day) of added sugar per day [20]. The Nutritional Questionnaire and Food Log shown in Table 1 is an example of a dietary questionnaire that clinicians can use to gather nutritional information that is pertinent to oral health. A food log can help the dental professional guide patients to modify snacking habits and include fewer ferment- able carbohydrates and sugars. Some dental providers ask their patients each question, and the questions can be customized depending on previous knowledge. Other dental providers send questionnaires home with patients and assess them at a subsequent appointment. The technique used would depend on the caries risk of the individual and the suspicion that diet plays a role. See the Resources section for websites that contain valuable informa- tion and interactive programs to help patients improve their diets. To decrease caries risk, dental professionals should encourage patients to make changes in the composition and frequency of snacks—moving toward more healthy choices. Even minor changes, such as limiting snacks to a period of 10 to 15 minutes once a day and brushing teeth or chewing sugar-free gum after snacks, may decrease this common habit’s negative effects on patients’ teeth.

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Caries-Prone Patients: Prevention, Assessment, and Interventions, 3rd Edition __________________________

NUTRITIONAL QUESTIONNAIRE AND FOOD LOG This form is intended to gain information about habits that may promote tooth decay. When answering the following questions, please choose the answer that fits best and provide as much information as possible. Feel free to provide any additional information you feel is important. Please bring this completed form to your appointment on _________________________ . 1. What are your favorite drinks and how often do you consume them? ________________________________________ ______________________________________________________________________________________________ 2. How often do you eat fast food?  Daily  2–3 times a week  Less than once a week 3. How often do you skip meals?  Daily  2–3 times a week  Less than once a week 4. Do you chew gum?  Yes  No If yes, how often?  Daily  2–3 times a week  Less than once a week If yes, what kind? _________________________________________________________________________________ 5. Do you consume antacids, breath mints, or hard candies regularly?  Yes  No If yes, how often?  Daily  2–3 times a week  Less than once a week Do you make an effort to choose sugar-free antacids, breath mints, or hard candies?  Yes  No 6. Please list your favorite snacks and how often you eat these items. ___________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ 7. Do you buy food or drinks from vending machines?  Yes  No 8. Is your drinking water fluoridated?  Yes  No  Don’t know Use the following chart to record your food and drink intake for three days. Meals and snacks should be recorded. Choose days that you are eating normally (not dieting) and include at least one weekday and one weekend day. If possible, record the carbohydrate and sugar content of foods eaten. Time Food Eaten Grain Fruit Vegetable Protein Dairy Fat Sugar _______ __________________ ________ _________ __________ _________ _______ _______ _______ _______ __________________ ________ _________ __________ _________ _______ _______ _______ _______ __________________ ________ _________ __________ _________ _______ _______ _______ _______ __________________ ________ _________ __________ _________ _______ _______ _______ _______ __________________ ________ _________ __________ _________ _______ _______ _______ _______ __________________ ________ _________ __________ _________ _______ _______ _______ _______ __________________ ________ _________ __________ _________ _______ _______ _______ _______ __________________ ________ _________ __________ _________ _______ _______ _______

Source: Author

Table 1

The patient education pamphlet “Sip All Day, Get Decay!” produced by the Minnesota Dental Association (available at http://www.sipallday.org) states that the average 12-ounce can of soda has 10 teaspoons of sugar and a pH just over 3. The low pH of soft drinks results from the ingredient phosphoric acid. Sodas also contain carbonic acid, and many contain citric acid. Therefore, even diet sodas are detrimental to oral health due to their acidic pH levels.

Patients who sip soda throughout the day cause their oral pH to plunge due to the acidity of the soda and the acid formed from oral bacteria metabolizing the sugars with this extended exposure a source of an increased risk for the development of dental caries [28]. Sports drinks and fruit juices also tend to be acidic and contain high amounts of sugar [29; 30]. The use of these products should be limited. Milk and water remain the best drink options for healthy teeth. The development of flavored, unsweetened water gives patients another drink option that is not detrimental to their teeth.

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__________________________ Caries-Prone Patients: Prevention, Assessment, and Interventions, 3rd Edition

FACTORS INFLUENCING DIET It is important for dental professionals to study the factors influencing patients’ diet choices to understand the motiva- tions behind them and to offer healthy alternatives. Factors influencing diet include food availability, family structure, con- venience, parental influence, habit, cost, and media [31; 32]. Food Availability and Convenience As the number of Americans who are eating meals prepared outside of the home continues to increase, food availability and convenience have become factors that greatly influence food choices. The majority of foods that are considered “convenient” are high in sugar, refined or fermentable carbohydrates, and fat [17; 18]. These foods are therefore unhealthy choices for oral and systemic health. Examples of convenience foods include hamburgers, chips, vending machine snacks, and candy bars. The prevalence of vending machines gives people access to many low-nutrient, energy-dense snacks on a daily basis [33; 34]. The Smart Snacks school nutrition standards became effective at the beginning of the 2014–2015 school year and established limits on the amount of fat, sugar, sodium, and calories in foods that are sold in vending machines within school settings [35]. The Smart Snacks school nutrition stan- dards have specific nutritional requirements for food items sold in vending machines, student stores, and snack bars [36]. However, simply not having these options available is not the complete answer. Hungry teens need to understand the ben- efits of high-nutrient snack options and learn to seek them out. Within the United States, vending machines are present in 43% of elementary schools, 74% of middle schools, and 98% of high schools [37]. Though Congress has mandated a reduc- tion of foods and snacks in schools that are correlated with obesity and dental caries, schools continue to struggle with replacing these items with more nutritional, low-fat options as do hospitals and workplaces [38]. Many schools gain some rev- enue from vending machine sales, which adds to the complexity of changing food items. Schools, food vendors, and families continue to struggle with balancing nutrition, funding, and adolescents’ food preferences. Vending machines are found in many places besides schools, and the low nutritional quality of vending machine foods is generally consistent throughout the different locations [38]. Increasing the nutritional value of foods available through vending machines would have a positive impact on various groups. Dental professionals should educate patients about the healthiest and least caries-promot- ing vended items, such as sunflower seeds, nuts, crackers with cheese, and sugar-free gum. Many fast food chains have added more nutritious options to their menus in an effort to appeal to health-conscious consum- ers. Dental professionals can promote patients’ oral health by educating them about the impact of common convenience foods on the caries process and guiding them toward more healthful choices.

Parental Influence Parental influence also plays a role in diet choices, especially those of children and adolescents [39]. Because parents gener- ally purchase the foods available for snacking and family meals, they have a high level of control over what foods are eaten by their children. Children tend to emulate their parents’ food choices [39; 40]. Parents’ food choices and nutritional guidance can be driven by habits, myths, misinformation, weight control efforts or problems, availability, and their own nutritional knowledge [17; 41]. Other factors that influence dietary choices include cultural preferences, parenting styles, and family dynamics [17]. Dental professionals should guide parents to not buy sodas and low-nutrient foods in an effort to discourage the formation of habits such as snacking and soda consumption that can contribute to caries. Parents may need to be guided to make healthy, affordable choices for themselves and their families. Also, parents can limit snacking by not allowing children to eat while watching television or playing video games. Educating parents about their influence and guiding them toward healthy food choices can benefit the entire family. Habit Eating habits start early and may be difficult to change, espe- cially as time solidifies these behaviors [39; 42]. Habits such as eating at the table, having a healthy breakfast, and eating fruits and vegetables can and should start in childhood; however, it is never too late to start these beneficial habits [40; 43]. Through discussing habits with patients, dental professionals can encourage behaviors that will promote oral health and identify caries-promoting practices that need to be altered. Cost The cost of food is a factor that influences dietary choices for many people. Foods with low nutritional value are often more affordable and more easily accessible than foods with high nutritional value. Fresh fruits, vegetables, and lean proteins are more costly per serving than alternatives that are higher in sugar and fermentable carbohydrates [44]. In addition, there is an inverse relationship between calories and cost per serving: Nutritionally deficient foods such as those with high sugar, fermentable carbohydrate, and fat content are among the most affordable dietary choices [45]. When recommending diet modifications to patients, dental professionals need to consider food costs for many reasons. Studies show that persons of low socioeconomic status tend to live in neighborhoods known as food deserts , where good quality, nutritional foods are scarce and transportation and the time needed to get to nutritional food sources factor into the cost of food [46]. Due to the higher costs associated with healthier foods, people with low incomes incur the highest risks of diet-related conditions [47].

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Caries-Prone Patients: Prevention, Assessment, and Interventions, 3rd Edition __________________________

Media Media have an impact on diet in two ways. Children ages 8 to 18 spend approximately 7.5 hours every day with media, includ- ing television, the Internet, music, magazines, cell phones, and tablets. Marketing of foods and snacks to children tends to be geared toward low-nutrition foods and beverages [48]. Media influence diet choices, especially those of children, by the sheer number of food-related advertisements found on television, in print, and on cell phones and tablets—which can evade parental monitoring [48]. By realizing the factors that affect patients’ diets, dental profes- sionals are more likely to recommend diet changes to which patients will be willing to adhere. Also, dental professionals can educate patients about these factors to facilitate self-assessment of dietary influences. POPULATIONS AT RISK Certain populations are at increased risk for caries formation due to diet, habits, lack of adequate oral hygiene, and other fac- tors. These populations can especially benefit from nutritional counseling and caries prevention applications and procedures. CHILDREN Because all teeth, once erupted, are susceptible to dental caries, even very young children are vulnerable. Early childhood car- ies (ECC) is defined as the presence of one or more decayed, missing (due to caries), or filled tooth surfaces in the primary dentition of a preschool-age child [49]. This condition is seen throughout the general population but is more common in the poor and near-poor preschool children. In the United States, it is estimated that between 3% and 6% of children have early childhood caries [50]. The National Institute of Dental and Craniofacial Research (NIDCR) has indicated that between the years of 2011–2016 that 23% of children between the ages of 2 and 5 years had carious lesions in their primary teeth and that children from lower-income families were twice as likely to have decay in their primary teeth compared to children from higher-income families [51]. Among children ages 6 to 11 years, 17% had decay in their permanent teeth [51]. To prevent ECC development, the American Academy of Pediatric Dentistry (AAPD) recommends that children have their first dental appointment soon after their first tooth erupts and no later than their first birthday [49]. Educating the child’s primary caregiver about oral hygiene care for the child and proper use of bottles is one of the main objectives of this appointment. Sodas, juices, and other sugared drinks should not be given to children, or they should be given very sparingly, and they should never be dispensed through a bottle. Children using bottles should not be allowed to go to sleep with them unless the bottle contains water. The AAPD also advises eliminating the use of a baby bottle by age 12 months and avoiding foods and drinks that contain sugar for children under 2 years of age [49].

Parents and primary caregivers need to be reminded about the eruption pattern of teeth and the fact that children have new teeth exposed to the oral environment from age 6 months to approximately age 12 years. The enamel of primary teeth is thin- ner and less organized compared to the enamel of permanent teeth, so the former is more susceptible to demineralization and the formation of carious lesions compared to the latter [50]. Therefore, soda, sugar, and fermentable carbohydrate exposure is more detrimental in youth than in adults. ADOLESCENTS The incidence of caries continues to rise as children grow into teenagers. According to the NIDCR, approximately 57% of adolescents between ages 12 and 19 have had carious lesions in their permanent teeth [52]. Adolescence is a time of increased caries risk because teenagers consume diets that are higher in fermentable carbohydrates and sugars, and they often practice poor oral hygiene. Research shows that this age group responds to health behavior change requests through motivational interviewing (MI) tech- niques, rather than the traditional dissemination of informa- tion and dispensing of advice [53]. Motivational interviewing, a collaborative, goal-oriented form of communicating behavior change, has been shown to positively affect adolescents’ change in diet, exercise, and compliance with medications. MI tech- niques that will help professionals better communicate oral healthcare principles with this age group and the mechanisms by which MI works to instill behavioral changes in adolescents is an area of continued research [54]. Among high school stu- dents between 2019–2021, approximately 16.5% of boys and 12.7% of girls had consumed one or more sugar-sweetened soda beverages each day [55; 88]. Soda is included with other sugary products and those made with solid fats in the category of empty calories. Empty calories account for 30.2% to 34.4% of 9- to 13-year-olds’ daily caloric intake and 30.5% to 35.5% of that of 14- to 18-year-olds [56]. Utilizing the principles of MI, the dental professional can work with each teenager to find easily accessible and tasty alternatives to sugar-laden foods. The Resources section contains links to websites that can be shared with young patients and their parents. Many adolescents have braces or other orthodontic appliances that complicate oral hygiene. The combination of susceptible tooth surfaces, a high-sugar diet, and poor oral hygiene is the perfect recipe for caries formation. To decrease caries risk in the adolescent population, medical and dental professionals should inform teenagers about the impact of diet choices on teeth and educate them about healthy eating. Minor changes such as limiting soda consumption to mealtimes and brushing after meals can have a large impact on caries development. In addition, the use of fluoride and sealants is extremely beneficial in preventing caries in the adolescent population.

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