Monday, February 28, 2022
The time constraints of any given dental appointment can make including vital nutritional messages a challenge. Bite-sized messages can convey “user-friendly” ideas for patients to implement that can have profound, positive effects on both oral and systemic health.
Nutritional choices that impact oral health are complex, but any time dental professionals witness demineralization, dental caries, dry mouth, gingivitis, and periodontitis, alarm bells should go off to investigate the patient’s dietary choices. All of these consequences can be strongly influenced positively or negatively by what patients eat and drink.
Much has been published on the subject of nutrition and oral health but perhaps the title of a 2021 study captures this potential best: “Nutrition as a Key Modifiable Factor for Periodontitis and Main Chronic Diseases.”1 This data confirms low-sugar, high-fiber and high omega-3 fatty acid ratio to omega-6 intake reduces the risk of periodontal diseases. These same dietary choices lower the risk of dental caries. So, if you’re not already, carve out a few moments to share bite-sized nutritional messages with your patients during each visit.
Before sharing these messages with your patients, however, try digesting them yourself. As evidenced by the average staff lounge in dental offices today (full of all kinds of sugary snacks, desserts and sodas), a little house-cleaning will enable you to be authentic and persuasive in sharing these health-driven messages.
Bite-sized Message No. 1: Indulge in sweets only for special occasions
More than a decade ago and based on concerns surrounding elevated risks of cardiovascular events, the American Heart Association (AHA) tried sounding the alarm about sugar consumption in this country with recommendations to slash added sugar from our diets.2 The classic Western diet, which is high in added sugars, has been shown to be a contributing factor in the development of cardiovascular diseases and diabetes.
The 2009 AHA recommendation was for Americans to slash added sugar consumption to 9 grams or 36 teaspoons daily for men and 6 grams or 24 teaspoons daily for women. By 2017, the AHA advised cutting added sugar for children to the same recommendation for women (6 grams per day) and to avoid added sugars for children young than 2!3 Why? Here is a quote from the AHA statement:
“Strong evidence supports the association of added sugars with increased cardiovascular disease risk in children through increased energy intake, increased adiposity, and dyslipidemia.”
Slashing the daily sugar indulgence could help protect your heart (not to mention, oral health). But how hard is that? Well, the average soda has 40 grams of added sugar, and added sugar now finds its way into almost all processed foods. Even one sweetened beverage per day sets you up for overconsumption of the AHA guideline with potential oral and systemic consequences as a result.
Most patients are completely unaware of this recommended guideline. One way to engage patients to approach sugar consumption differently is to share this bite-sized message: Indulge in sweets only for special occasions.
To accomplish this, we all need to become label detectives equipped with the AHA guidelines in the back of our minds. Shifting your indulgence in sugary sweets is not easy, but worth it when considering the adverse oral and systemic consequences added sugar can have on our health.
Bite-sized message No. 2: Remember the 3-Bite rule
A successful strategy to help reduce sugar consumption from delectable temptations is to remember the 3-bite rule, because exotic donuts, mile-high chocolate cakes, cinnamon streusel muffins, and endless flavors of ice cream are all loaded with added sugar.
Satisfaction derived from sugary treats does not increase with each bite taken, and in fact one systemic effect over-consumption of fructose from added sugars has in the body is the creation of leptin-resistance.4 This important hormone basically signals when we are full, so over-indulgence of added sugar actually works against leptin triggering our brains to stop eating, which literally becomes a vicious cycle. More sugar equals less effective leptin, which fosters eating more and so on.
The eighth bite of a sugar-laden dessert or snack isn’t any more satisfying than the first three bites, but can alter the oral and gut microbiota substantially favoring dysbiosis.
Using restraint to enjoy only three bites of a special occasion sugary treat can be pleasurable yet doesn’t overload your system with a high-fructose consumption that has the potential to be converted into fat in the liver with significant adverse down-stream systemic effects.5 The 3-bite rule can become a habit just as much as over-indulgence becomes a habit.
The 3-bite rule does not apply to natural fructose found in fruits, however, because they are filled with antioxidants, fiber and essential vitamins. From a weight management perspective, fruits with lower levels of natural fructose such as kiwi, strawberries and blueberries are preferable to high-fructose fruits such as mangos and grapes.
Bite-sized message No. 3: Avoid drinking sugar and acid
Energy drinks, Kombucha, fruit juices, coffee drinks and designer sweet teas have begun to compete with the sugary soda market. Data comparing liquid sugar to solid sugar consumption reveals the sugar in beverages increases the risk of metabolic diseases more than sugar from foods because of the concentration of sugar and how quickly it is absorbed and metabolized.6
While fermentable carbohydrates, such as sugary drinks, have a long history in their role toward caries development, periodontal health can also be influenced by sugar intake. Several studies have confirmed an increase in gingival bleeding that corresponds with an increase in sugar consumption7,8,9 and most clinicians witness this clinically in patients who sip on sweetened beverages every day.
Ask all patients what they like to drink throughout the day. The answers are often surprising. Avoiding sugary beverages is an important step, but the acidic content of many sugary and even sugar-free choices makes them also undesirable for long-term oral health. The critical pH for loss of minerals in enamel is 5.5 and erosion in dentin can happen at a pH of 6.0.10 Most sugary and acidic sugar-free drinks are well below these thresholds, making the bite-sized message to avoid drinking sugar and acid imperative to preserving dentition.
Bite-sized message No. 4: Eat lots of plants with every meal
Antioxidants, fiber, vitamins and minerals are essential to our health. Increasing consumption of plants even to the point of adopting a plant-dominate diet naturally increases these vital components in our bodies. In fact, higher dietary antioxidants are correlated to a reduction in all-cause mortality compared to those at the lowest intake level.11 One must be intentional about plant choices over high-calorie habits, simple carbohydrates and fast foods, so a simple message to eat lots of plants with every meal can be a starting point for patients to shift their food choices.
It is easy to increase the antioxidant capacity daily by adding powerful herbs to food and beverage preparations. Curcumin, cinnamon, oregano and cloves are just a few of the herbs high in antioxidants, and a little goes a long way when used routinely. Did you know polyphenol containing foods and beverages such as green tea, cranberries, pomegranates, blueberries and fruit and vegetable extracts have powerful inhibitory effects against periodontal pathogens such as P. gingivalis, F. nucleatum and A. actinomycetemcomitans?12,13,14
In just four weeks, an anti-inflammatory group of patients who consumed a diet high in antioxidants, fibers and Omega-3 fatty acids, vitamins C and D, and low in carbohydrates significantly reduced gingival and periodontal inflammation compared to controls that did not change their diets.15 Even though this was a small study, the fact all inflammatory parameters decreased in the group that altered their diet to almost half that of baseline values escalates the importance of the bite-sized message to eat lots of plants with every meal.
Bite-sized message No. 5: Vitamin C and D are your friends
An immediate payoff of increasing plants in your diet will be increased amounts of vitamin C found in citrus fruits and green, leafy vegetables. Most dental professionals are aware vitamin C is critical for maintaining the integrity of oral tissue, and in fact a recent systematic review of studies reveals greater progression of periodontitis in patients with a lower dietary intake of vitamin C compared to controls.16
Vitamin D levels run lower than ideal for many Americans. Insufficient vitamin D levels have been implicated in many conditions such as cardiovascular disorders, cancer, chronic pain and psychiatric diseases.17 A recent systematic review also confirms significantly lower vitamin D levels in patients with periodontitis compared to healthy controls.18
Dietary choices that have higher levels of vitamin D are some of the same choices that also have higher levels of omega-3 fatty acids: salmon, herring and sardines are at the top of the list. Cod liver oil, canned tuna, mushrooms and egg yolks are additional foods with high levels of vitamin D, although regular sunshine exposure (even 10 minutes a day a few times a week) can also increase vitamin D easily.19 The simple message that vitamin C and D are your friends can help patients remember to increase these essential vitamins daily.
Improving oral health is an obvious outcome dental professionals want for their patients. The benefits of weaving important nutritional messages into patient education can be far-reaching systemically too. A striking summary to this topic is found in a study published in the Journal of Clinical Periodontology: “Dental caries and periodontal diseases are a sensitive alarm bell for an unhealthy diet, which predicts the future onset of the diseases of civilizations.”20
Bite-sized nutritional messages have never been more important than they are today for all of us to digest.
Karen Davis is founder of her own continuing education company, Cutting Edge Concepts®, and currently practices dental hygiene in Dallas, Texas. Her background as a clinician, consultant, coach, and speaker enables her to identify with challenges facing dentistry and offer innovative solutions vital to success in today’s marketplace. Dentistry Today has consecutively recognized Karen as a “Leader in Continuing Education” since 2006.
Karen received her Bachelor of Science in Dental Hygiene from Midwestern State University. She is an accomplished author, maintains memberships in numerous professional associations, is a key opinion leader to various dental corporations, and currently serves on several advisory boards.
References
1. Martinon P, Fraticelli L, Giboreau A, Dussart C, Bourgeois D, Carrouel F. Nutrition as a Key Modifiable Factor for Periodontitis and Main Chronic Diseases. J Clin Med. 2021 Jan 7;10(2):197. doi: 10.3390/jcm10020197. PMID: 33430519; PMCID: PMC7827391.
2. Johnson RK, Appel LJ, Brands M, Howard BV, Lefevre M, Lustig RH, Sacks F, Steffen LM, Wylie-Rosett J; American Heart Association Nutrition Committee of the Council on Nutrition, Physical Activity, and Metabolism and the Council on Epidemiology and Prevention. Dietary sugars intake and cardiovascular health: a scientific statement from the American Heart Association. Circulation. 2009 Sep 15;120(11):1011-20. doi: 10.1161/CIRCULATIONAHA.109.192627. Epub 2009 Aug 24. PMID: 19704096.
3. Vos MB, Kaar JL, Welsh JA, et al. Added Sugars and Cardiovascular Disease Risk in Children: A Scientific Statement From the American Heart Association. Circulation. 2017;135(19):e1017-e1034. doi:10.1161/CIR.0000000000000439
4. Shapiro A, Mu W, Roncal C, Cheng KY, Johnson RJ, Scarpace PJ. Fructose-induced leptin resistance exacerbates weight gain in response to subsequent high-fat feeding. Am J Physiol Regul Integr Comp Physiol. 2008 Nov;295(5):R1370-5. doi: 10.1152/ajpregu.00195.2008. Epub 2008 Aug 13. PMID: 18703413; PMCID: PMC2584858.
5. Houghton D, Stewart CJ, Day CP, Trenell M. Gut Microbiota and Lifestyle Interventions in NAFLD. Int J Mol Sci. 2016;17(4):447. Published 2016 Mar 25. doi:10.3390/ijms17040447
6. Sundborn, Gerhard, et al. "Are liquid sugars different from solid sugar in their ability to cause metabolic syndrome?" Obesity 27.6 (2019): 879-887.
7. Hujoel, P. (2009) Dietary carbohydrates and dental-systemic diseases. Journal of Dental Research 88, 490–502.
8. Woelber, J. P., Bremer, K., Vach, K., Konig, D., Hellwig, E., Ratka-Kruger, P., Al-Ahmad, A.& Tennert, C. (2016) An oral health optimized diet can reduce gingival and periodontal inflammation in humans – a randomized controlled pilot study. BMC Oral Health 17, 28.
9. Baumgartner, S., Imfeld, T., Schicht, O., Rath, C., Persson, R. E. & Persson, G. R. (2009) The impact of the stone age diet on gingival conditionsin the absence of oral hygiene. Journal of Periodontology 80, 759–768.
10. Warreth A, Abuhijleh E, Almaghribi MA, Mahwal G, Ashawish A. Tooth surface loss: A review of literature. Saudi Dent J. 2020;32(2):53-60. doi:10.1016/j.sdentj.2019.09.004
11. Ivey KL, Jensen MK, Hodgson JM, Eliassen AH, Cassidy A, Rimm EB. Association of flavonoid-rich foods and flavonoids with risk of all-cause mortality. Br J Nutr. 2017;117(10):1470-1477. doi:10.1017/S0007114517001325
12. Ben Lagha A, Dudonné S, Desjardins Y, Grenier D. Wild Blueberry (Vaccinium angustifolium Ait.) Polyphenols Target Fusobacterium nucleatum and the Host Inflammatory Response: Potential Innovative Molecules for Treating Periodontal Diseases. J Agric Food Chem. 2015 Aug 12;63(31):6999-7008. doi: 10.1021/acs.jafc.5b01525. Epub 2015 Aug 4. PMID: 26207764.
13. Basu A, Masek E, Ebersole JL. Dietary Polyphenols and Periodontitis-A Mini-Review of Literature. Molecules. 2018 Jul 20;23(7):1786. doi: 10.3390/molecules23071786. PMID: 30036945; PMCID: PMC6099717.
14. Ben Lagha A, LeBel G, Grenier D. Dual action of highbush blueberry proanthocyanidins on Aggregatibacter actinomycetemcomitans and the host inflammatory response. BMC Complement Altern Med. 2018 Jan 10;18(1):10. doi: 10.1186/s12906-017-2072-x. PMID: 29321009; PMCID: PMC5763534.
15. Woelber, J.P., Bremer, K., Vach, K. et al. An oral health optimized diet can reduce gingival and periodontal inflammation in humans - a randomized controlled pilot study. BMC Oral Health 17;28 (2017). https://doi.org/10.1186/s12903-016-0257-1
16. Tada A, Miura H. The Relationship between Vitamin C and Periodontal Diseases: A Systematic Review. Int J Environ Res Public Health. 2019;16(14):2472. Published 2019 Jul 11. doi:10.3390/ijerph16142472
17. Straube S, Derry S, Straube C, Moore RA. Vitamin D for the treatment of chronic painful conditions in adults. Cochrane Database Syst Rev. 2015;2015(5):CD007771. Published 2015 May 6. doi:10.1002/14651858.CD007771.pub3
18. Machado V, Lobo S, Proença L, Mendes JJ, Botelho J. Vitamin D and Periodontitis: A Systematic Review and Meta-Analysis. Nutrients. 2020;12(8):2177. Published 2020 Jul 22. doi:10.3390/nu12082177
19. Time for more vitamin D. Sept.1, 2008. Harvard Health Publishing. https://www.health.harvard.edu/staying-healthy/time-for-more-vitamin-d. Accessed February 12, 2022.
20. Hujoel PP, Lingström P. Nutrition, dental caries and periodontal disease: a narrative review. J Clin Periodontol. 2017 Mar;44 Suppl 18:S79-S84. doi: 10.1111/jcpe.12672. PMID: 28266117.