_____________________________________ Caries-Prone Patients: Prevention, Assessment, and Intervention
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. 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]. 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].
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