Oulun ammattikorkeakoulu
ePooki 49/2019

Nutritional Challenges and their Effects in Oral Health among Ninth-Graders

Metatiedot

Nimeke: Nutritional Challenges and their Effects in Oral Health among Ninth-Graders. In A-L. Jussila & M. Oinonen (eds.) Oral Health Promotion

Tekijä: Tasala Laura; Paso Jaana; Lautamo Elina; Ervasti Katja; Kaisto Salla; Iinatti Sanna-Mari; Jussila Aino-Liisa

Aihe, asiasanat: hampaat, syöminen, teeth, nutrition

Tiivistelmä: Tooth erosion and dental caries prevalence in the younger population have raised concern in the dental community. The main reasons for erosion and caries are poor oral hygiene and consumption of carbonated drinks and acidic sweets and snacks. Informing adolescents of these harmful dietary habits are important in promotion of good oral health.

The causes of erosion and caries are multiple and diverse. The main reason is the frequent use of soft drinks. Also, the acidity of the food and irregular mealtimes combined with snacking are significant parts of the problem. Unhealthy diet, in this case especially soft drinks and snacks, are usually containing substantial amount of sugar. Therefore, adolescents’ unhealthy eating and drinking habits are multiplying the caries risk. Third aspect in adolescents’ oral health is irregularity of eating habits and compensation of proper meals with sugary, energy-dense and nutrient-poor snacks.

Yet, in the case of preventive dentistry, one should consider also the environmental, social as well as personal factors such as family’s eating habits and personal attitudes. Because of the diversity of the adolescents’ dental health there is a need for multi-professional work. Only by working together, using comprehensive methods and ways of educating, can we as healthcare professionals meet the challenge of the problem.

Julkaisija: Oulun ammattikorkeakoulu, Oamk

Aikamääre: Julkaistu 2019-06-28

Pysyvä osoite: http://urn.fi/urn:nbn:fi-fe2019061019838

Kieli: englanti

Suhde: http://urn.fi/URN:ISSN:1798-2022, ePooki - Oulun ammattikorkeakoulun tutkimus- ja kehitystyön julkaisut

Oikeudet: CC BY-NC-ND 4.0

Näin viittaat tähän julkaisuun

Tasala, L., Paso, J., Lautamo, E., Ervasti, K., Kaisto, S., Iinatti, S-M. & Jussila, A-L. 2019. Nutritional Challenges and their Effects in Oral Health among Ninth-Graders. In A-L. Jussila & M. Oinonen (eds.) Oral Health Promotion. ePooki. Oulun ammattikorkeakoulun tutkimus- ja kehitystyön julkaisut 49. Hakupäivä 6.12.2019. http://urn.fi/urn:nbn:fi-fe2019061019838.

Tooth erosion and dental caries prevalence in the younger population have raised concern in the dental community. The main reasons for erosion and caries are poor oral hygiene and consumption of carbonated drinks and acidic sweets and snacks. Informing adolescents of these harmful dietary habits is important in promotion of good oral health. This information was brought to group of ninth-graders aiming to make a positive impact in their eating and drinking habits. 

Introduction

Dental caries is the most common oral disease, but dental erosion is a rapidly growing problem, especially among young people. The purpose of this article is to clarify the origin of caries and erosion and how to influence to the prevention of these conditions. Regular eating and healthy drinking choices can help to prevent dental caries as well as erosion, which means the dissolution of dental enamel. Surprisingly a snack or a drink, perceived as healthy, in high doses or inappropriately consumed can cause irreparable damage to teeth. 

On February 2019 a small functional briefing about dental health for the ninth-grade students was organized at the Oulu International School. On our stand we talked about sugar consumption and the effect of acidic drinks on oral health. Our aim was to show how daily choices can make a big difference to one’s oral health. The event was well received among students and we got some good experience of organizing preventive dental care event.

Caries and erosion 

Dental caries is a dynamic process that involves susceptible tooth surfaces, a fermentable carbohydrate source and cariogenic bacteria like Streptococcus mutans or Lactobacillus. All carbohydrates are generally considered cariogenic, but fermentable carbohydrates are primarily sucrose. Other factors such as lack of motivation for maintaining oral hygiene, socioeconomic and cultural differences, genetics, parenting practices and salivary gland hypofunction, play a major role in dental disease development. The risk of dental caries increases due to frequent consumption of carbohydrates in the form of simple sugars. Tungare, S. & Paranjpe, AG. 2018. Diet and Nutrition to Prevent Dental Problems. Referred 12.2.2019. https://www.ncbi.nlm.nih.gov/books/NBK534248/

Dental erosion is an irreversible loss of dental hard tissue that does not involve bacteria and is caused by a chemical process Skalsky Jarkander, M., Grindefjord, M. & Carlstedt, K. 2018. Dental erosion, prevalence and risk factors among a group of adolescents in Stockholm County. Eur Arch Paediatr Dent. 19 (1), 23–31. Referred 12.2.2019. https://doi.org/10.1007/s40368-017-0317-5. There has been considerable interest in the epidemiology of dental erosion during the last 20 years since there is some evidence that its incidence and prevalence are increasing. Margaritis, V., Mamai-Homata, E., Koletsi-Kounari, H. & Polychronopoulou, A. 2011. Evaluation of three different scoring systems for dental erosion: A comparative study in adolescents. Journal of Dentistry 39 (1), 88–93 Referred 5.3.2019. https://doi.org/10.1016/j.jdent.2010.10.014 The presence of non-bacterial acids is related to the nature of tooth erosion in the oral environment. Acids could stem from drinks or food. Salas, M., Nascimento, G., Vargas-Ferreira, F., Tarquinio, S., Huysmans, M. & Demarco, F. 2015. Diet influenced tooth erosion prevalence in children and adolescents: Results of a meta-analysis and meta-regression. Journal of Dentistry 43 (8), 865–875. Referred 12.2.2019. https://doi.org/10.1016/j.jdent.2015.05.012 Dental erosion often occurs together with abrasion caused by any material with abrasive effect, and with attrition caused by contact between teeth Skalsky Jarkander, M., Grindefjord, M. & Carlstedt, K. 2018. Dental erosion, prevalence and risk factors among a group of adolescents in Stockholm County. Eur Arch Paediatr Dent. 19 (1), 23–31. Referred 12.2.2019. https://doi.org/10.1007/s40368-017-0317-5.

In a study among Greek adolescents no significant differences concerning the prevalence of dental erosion were observed between boys and girls. On the other hand, students with higher socioeconomic status appeared to be less prone to develop dental erosion than the other children. Margaritis, V., Mamai-Homata, E., Koletsi-Kounari, H. & Polychronopoulou, A. 2011. Evaluation of three different scoring systems for dental erosion: A comparative study in adolescents. Journal of Dentistry 39 (1), 88–93 Referred 5.3.2019. https://doi.org/10.1016/j.jdent.2010.10.014

Diet and eating habits in relation to oral health

Diet is one of the main factors in oral health as well as in health as a holistic point of view. Diet and nutrients may have effects on caries risk, soft tissue health and response to injury and infection. While the nutrients help maintain good oral health, cariogenic carbohydrates in food and beverages and acidity of the food harm the oral health. Marshall, T.A. 2016. The Impact of Diet and Nutrition On Oral Health.  Referred 12.02.2019. https://dimensionsofdentalhygiene.com/article/the-impact-of-diet-and-nutrition-on-oral-health/ Maliderou, M., Reeves, S. & Noble, C. 2006.The effect of social demographic factors, snack consumption and vending machine use on oral health of children living in London. British Dental Journal 201, 441–444. Referred 12.02.2019. https://doi.org/10.1038/sj.bdj.4814072

Oral health professionals ought to recognize the harmful food consumption habits of their target group. In counselling schoolchildren, we should put our focus on the importance of regular meals, reducing sugar consumption or using sugar with non-fermented sugar substitutes, avoidance of beverages and brushing of the teeth with fluoride toothpaste twice a day. Food and drinks containing added sugar combined with snacking, sipping beverages or pocketing food in the mouth increase the caries risk significantly. Snacking has been identified as a popular habit among schoolchildren. In most cases snacks are unhealthy in many ways: snacks contain sugar, fat and are nutrient-poor. Maliderou, M., Reeves, S. & Noble, C. 2006.The effect of social demographic factors, snack consumption and vending machine use on oral health of children living in London. British Dental Journal 201, 441–444. Referred 12.02.2019. https://doi.org/10.1038/sj.bdj.4814072 Mobley, C., Marshall, T.A., Milgrom, P. & Coldwell, S.E. 2009. The Contribution of Dietary Factors to Dental Caries and Disparities in Caries. Academic Pediatrics 9 (6&, 410–414. Referred 12.02.2019. https://doi.org/10.1016/j.acap.2009.09.008

Eating behavior consists of multiple variables. It has environmental, social as well as personal factors such as family’s eating habits and personal attitudes. Therefore, diet counselling is an important part of the oral health prevention but also a challenging task for oral health professionals. We can provide our patients with adequate knowledge, but that is not probably enough to change their unfavorable eating habits. Restricting availability of and accessibility to sugar-sweetened snacks and beverages in schools are a one solution to reduce schoolchildren’s sugar consumption. Advertising, marketing and low-costs of the cariogenic, energy-dense food are more difficult problems to tackle. Maliderou, M., Reeves, S. & Noble, C. 2006.The effect of social demographic factors, snack consumption and vending machine use on oral health of children living in London. British Dental Journal 201, 441–444. Referred 12.02.2019. https://doi.org/10.1038/sj.bdj.4814072 Mobley, C., Marshall, T.A., Milgrom, P. & Coldwell, S.E. 2009. The Contribution of Dietary Factors to Dental Caries and Disparities in Caries. Academic Pediatrics 9 (6&, 410–414. Referred 12.02.2019. https://doi.org/10.1016/j.acap.2009.09.008

The effects of soft drink consumption on oral health

The term soft drink includes sodas and other sugar-sweetened beverages such as fruit juices, lemonade, iced tea, cola drinks and energy drinks Malik, V., Schulze, M. & Frank Hu, F. 2016. Intake of sugar-sweetened beverages and weight gain: a systematic review. The American Journal of Clinical Nutrition 84 (2), 274–288. Referred 11.3.2019. https://doi.org/10.1093/ajcn/84.2.274. Frequent consumption of soft drinks with acids and sugars causes both caries and erosion. Caries lesion involves bacteria whereas dental erosion is determined as a physical result of acid. In addition of sugars and acids, drinking habits, like holding the soft drink for a long time in the mouth before swallowing, boosts the effect of the pH drop and increases the enamel loss. 

Most soft drinks, especially grape and citric juices, are acidic by nature. Low pH value along with high citrate content increases the surface enamel loss. Carbonated soft drinks usually have lower pH value than fruit juices and are therefore more harmful to the enamel Cheng, R., Yang, H., Shao, M-y., Hu, T. & Zhou, X-d. 2009. Dental erosion and severe tooth ecay related to soft drinks: a case report and literature review*. Journal of Zhejiang University SCIENCE B 10 (5), 395–399. Referred 11.3.2019. https://doi.org/10.1631/jzus.B0820245. In addition to citric acid, carbonated soft drinks also contain phosphoric acid, which increases the risk of acid attack Abou Neel, E., Aljabo, A., Strange, A., Ibrahim, S., Coathup, M., Young, A., Bozec, L. & Mudera, V. 2016. Demineralization–remineralization dynamics in teeth and bone. International Journal of Nanomedicine 11, 4743–4763. Referred 11.3.2019. https://doi.org/10.2147/IJN.S107624. Although yoghurt and other fermented milk products may also have low pH values, they don't erode the enamel. This is because of their high content of calcium and phosphates, which can minimize the demineralisation process Barac, R., Gasic, J., Trutic, N., Sunaric, S., Popovic,J., Djekic, P., Radenkovic, G. & Mitic, A. 2015. Erosive Effect of Different Soft Drinks on Enamel Surface in vitro: Application of Stylus Profilometry. Med Princ Pract 24, 451–457. Referred 11.3.2019. https://doi.org/10.1159/000433435.  

A research made in 2012 studied the beverage consumption among European adolescents aged 12–18. The study showed that the most used beverages in addition to water were fruit juices and sugar sweetened beverages Duffey, K.J., Huybrechts, I., Mouratidou, T., Libuda, L., Kersting, M., DeVriendt, T.,  Gottrand, F., Widhalm, K., Dallongeville, J., Hallström, L., González-Gross, M., DeHenauw, S., Moreno, L.A. & Popkin, B.M. 2011. Beverage consumption among European adolescents in the HELENA Study. European Journal of Clinical Nutrition 66 (2), 244–252. Referred 11.3.2019. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3392586/. The large consumption of soft drinks among young people is showing in their dental health very clearly. A recently published Swedish study revealed that 28,3 % of 15 years old and 34,3 % of 17 years old adolescents in Stockholm were diagnosed with dental erosion. The study pointed out that the result correlated directly to the soft drink consumption among young people as they tend to use sugar sweetened beverages and juices as thirst quenchers. Skalsky Jarkander, M., Grindefjord, M. & Carlstedt, K. 2018. Dental erosion, prevalence and risk factors among a group of adolescents in Stockholm County. Eur Arch Paediatr Dent. 19 (1), 23–31. Referred 12.2.2019. https://doi.org/10.1007/s40368-017-0317-5

Finnish Food Authority has acknowledged the chances in beverage consumption culture. It points out that nowadays’ sipping culture may cause damage to teeth, when the acid attacks are frequent and may last long periods of time. The official recommendation is that the primary thirst quencher should be water. Juices, soft drinks, sweetened milk drinks and yoghurt drinks were intended for occasional use only. The frequent use of soft drinks and especially energy drinks are particularly harmful among under 15 year old children. This is because the enamel of the teeth is still forming and hasn’t reached its final strength yet and is therefore prone to caries and erosion. In addition of acids and sugar, energy drinks contain a large amount of caffeine and therefore are not suitable for children Valsta, L., Borg, P., Heiskanen, S., Keskinen, H., Männistö, S., Rautio, T., Sarlio-Lähteenkorva, S. & Kara, R. 2008. Juomat ravitsemuksessa. Valtion ravitsemusneuvottelukunnan raportti. Helsinki. Referred 11.3.2019. https://www.ruokavirasto.fi/globalassets/teemat/terveytta-edistava-ruokavalio/ruoka-aineet/juomat/juomat_ravitsemuksessa.pdf

The Health Promotion Event for Ninth Graders in Oulu International School

At our stand (photos 1–2) the pupils were asked to estimate the amount of sugar and the pH levels of different products. They also had the opportunity to test the pH levels of milk and of a carbonated beverage. We also answered any possible questions the pupils had concerning oral health.

PHOTOS 1–2. The amount of sugar and the pH levels of different products (photos: Lautamo Elina)

At the end of the event pupils level of knowledge concerning the cause of erosion was tested with a questionnaire. Pupils were given three options to choose the right answer from. The three options given were A) carbonated drinks, B) candy and C) greasy food. Out of 45 pupils one chose all three answers correct, one chose only option B, 13 pupils answered that both A and B are correct and 29 students answered correctly that option A is the cause of erosion. Most of the students chose the right answer but nearly half of them chose another option as well.

Conclusion

Hannu Hausen, Finland’s leading professional of preventive dentistry, brought out dentist’s observations of increasing erosion problems in adolescents' dentition in his column in Finnish Dental Journal Hausen, H. 2018. Hammaseroosio tulee ottaa vakavasti. Suomen Hammaslääkärilehti 3. Referred 4.3.2019. http://www.hammaslaakarilehti.fi/fi/kolumnit/hammaseroosio-pitaa-ottaa-vakavasti. At the moment there aren't any accurate data available about the problem, which has been already recognized on the field. The erosion injuries in small children's and adolescents’ dentition are increasingly common sight in the dental receptions. 

The causes of erosion and caries are multiple and diverse. The main reason is the frequent use of soft drinks. Also, the acidity of the food and irregular mealtimes combined with snacking are significant parts of the problem. Unhealthy diet, in this case especially soft drinks and snacks, are usually containing substantial amount of sugar. Therefore, adolescents’ unhealthy eating and drinking habits are multiplying the caries risk. Third aspect in adolescents’ oral health is irregularity of eating habits and compensation of proper meals with sugary, energy-dense and nutrient-poor snacks. 

Because currently the erosion problem and soft drink use is in the spotlight, we wanted to put the focus on the effect of using soft drinks to oral health in the health promotion event at Oulu International School.

Yet, in the case of preventive dentistry, one should consider also the environmental, social as well as personal factors such as family’s eating habits and personal attitudes. Because of the diversity of the adolescents’ dental health there is a need for multi-professional work. Only by working together, using comprehensive methods and ways of educating, can we as healthcare professionals meet the challenge of the problem. 

References

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