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An Effective Oral Health Promoting Message?

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An Effective Oral Health Promoting Message? An effective oral health IN BRIEF • Social inequalities in oral health are a reality today. OPINION promoting message? • Oral health education (OHE) has an important part to play in oral health promotion, particularly in order to reduce W. Richards1 and T. Filipponi2 social inequalities. • A clear, common, unambiguous dietary message is necessary in order to improve effectiveness of OHE. • A message is presented that may facilitate improvements in communication. This paper questions the effectiveness of current oral health promoting activities in reducing social inequalities in oral health. An attempt is made to address the needs of dental professionals and nutritionists in communicating an under- standing of biological aspects of the aetiology of caries and erosion. With a clear understanding of the disease process oral health promoters can possibly reduce social inequalities in oral health. A clear common message which satisfies both dental and nutritional professionals is presented. The issues of commonality and ambiguity are fundamental to effective behavioural/teaching practice. Currently the evidence base suggests that dietary messages are inconsistent and ambigu- ous. Therefore, a clear common and unambiguous dietary message, based on science, could go some way to improving oral health inequalities. INTRODUCTION to the delivery of oral health promo- step towards a healthy diet as carbohydrate Social inequalities in oral health are appar- tion in order to influence behaviour.8,9 is the principal source of energy as well as ent and increasing in the UK.1,2 The determi- In order for this to be effective consist- providing fibre, B vitamins, and to some nants of oral health have been identified as ent nutritional guidelines are essential to extent calcium and iron.13 deprivation, age, gender, ethnicity, environ- improve health.7 Stillman-Lowe stresses ment, psycho-social, poverty and lifestyle.3 that commonality and ambiguity should NUTRITIONAL BACKGROUND Approaches to oral health improvement be addressed in order to improve the effec- The National Diet and Nutrition Survey have been tackled at a collective level tiveness of oral health promotion activi- (NDNS) aims to identify the food con- through dental public health services with ties.10 Inconsistencies are found not only sumption, nutrient intake and nutritional the application of water fluoridation being between healthcare professionals (dental, status of people living in private house- high on the health promotion agenda as dietetic and nutritional students)7 but also holds.15 The result of the first year of the this improves the health of the community among dental professionals.11 national survey of British people aged 1½ regardless of the behaviour of the indi- The common risk factor approach to years and older shows that total carbohy- vidual.3 Strategies aimed at the individual health promotion is a sensible approach. drates provided about 47% food energy in are dependent on behavioural compli- This approach recognises that a host of adults and 51% in toddlers and children ance, and historically these strategies have chronic diseases can be prevented through four to 18 years old.15 The main source of tended to increase social division.4-6 Shah a unified approach towards healthy behav- energy for all age groups was provided by et al. suggest that interventions to change iours. These include a balanced diet and the group listed as cereal and cereal prod- behaviour have enormous potential to alter regular exercise. ucts with bread as the main contributor.15 disease patterns.7 However, the same study The Food Standards Agency’s ‘Eat Well Although the consumption of white bread identified conflicts in dietary messages Plate’ shows the types and proportions of in all ages group was reduced if compared having negative effects on the behaviour, food that are needed to make up a healthy with past surveys, toddlers’ consumption motivation and attitudes of individuals. and well-balanced diet.12,13 The consump- did not show the same reduction.15 The More recently services have embraced tion of bread, especially wholegrain vari- Low Income Diet and Nutrition (LIDN) a wider ‘common risk factor’ approach ety, as well as potatoes, rice and pasta survey also identified that among the should provide about one-third of the cereals food group white bread was total volume of food eaten.12,13 However, the most popular choice (children 90%, 1*,2 Faculty of Health Sport and Science, University of 16 Glamorgan, Pontypridd, CF37 1DL the consumption of non-milk extrinsic adults 83%). *Correspondence to: Professor W. Richards sugars (NMES), the so-called added sugar, Food behaviour and therefore food Email: [email protected] is still above the Dietary Reference Value choices are affected by many factors: Refereed Paper (DRV) of no more than 11% of food energy availability, cost and preferences; cul- Accepted 27 October 2011 14,15 DOI: 10.1038/sj.bdj.2011.1001 intake. The recommendation to base a tural values and cooking skills; eating ©British Dental Journal 2011; 211: 511-516 meal on starchy foods is undoubtedly a patterns; parents’ beliefs and practices; BRITISH DENTAL JOURNAL VOLUME 211 NO. 11 DEC 10 2011 511 © 2011 Macmillan Publishers Limited. All rights reserved. OPINION peers’ influence; food marketing and so understanding of desired behaviours to and spaced meals consumed at regular on.17 Income is one of the major determi- enable improved oral and general health intervals are recommended to maintain nants of children’s eating and drinking outcomes in populations. The paper also energy levels.13 habits.17 Comparison of the NDNS 2003 reports on sugar and salt content in com- The glycaemic index (GI) or glycaemic data with the LIDNS 2007 survey showed monly consumed breads. load (GL) rate the potential of foods to that consumption of non-diet, non-car- raise blood glucose and insulin levels.27 bonated soft drinks was greater in chil- SCIENTIFIC BASIS The GI ranks carbohydrates according to dren and young people four to 18 years The dental perspective their effect on blood glucose levels. Low old in LIDNS in comparison with NDNS.18 GI foods provide low to moderate fluctua- Children in the low income group had a Caries tions in blood sugar stimulating less insu- significantly higher intake of non-milk The biology of the mouth is such that lin release.27,28 Recent studies and Cochrane extrinsic sugars (NMES)16 and obtained a tooth enamel is in a constant state of systematic reviews have shown that low greater amount of energy and nutrients flux with regard to its mineral content. GI or GL diets have been associated with from snacks.17 While the mouth is empty the minerals a lower incidence of cardiovascular dis- Between-meal eating and/or drinking in the saliva are deposited into the tooth ease, diabetes and certain cancers, a reduc- habits are seen as acceptable health behav- enamel; this process is termed reminer- tion of total and LDL cholesterol, a better iours, providing the snack/drink is sugar alisation. However, when the mouth con- management of diabetes and a greater loss free.19 However, it is reported that young tains sugars these are metabolised in the of body fat.28 However, the type of car- people tend to skip ‘proper meals’ and plaque so as to cause the reverse, in that bohydrate, the dietary fibre content, the ‘snacking’ and ‘grazing’ is becoming the the minerals are lost from the enamel into cooking method, the composition of the ‘westernised’ way of eating.20,21 An under- the saliva; this process is termed dem- meal have an effect on the speed of car- standing of food behaviour and choices by ineralisation. Demineralisation occurs bohydrate to glucose conversion.27 Low GI different social sub-groups is important if while the sugar is in the mouth and for a foods such as pulses and apples27 provide any inroads are to be made towards reduc- further period of about 30 minutes. This a slower and steadier release of glucose ing social inequalities in oral health. dynamic state allows the tooth structure to to the bloodstream whereas high GI foods Bread is advised as one of the suitable remain intact providing remineralisation such as white bread produce a much more snacks along with fresh fruit, vegetable exceeds demineralisation.3 rapid increase in blood glucose causing sticks and cubes of cheese, especially for Within this theoretical base, clinicians rapid insulin response.28 children 3-5 years old.13,22 Bread is pro- now understand that dental caries is no As a result regular meals are recom- moted as a suitable between meal snack longer a non-self-repairing disease. In mended by nutritionists in order to main- in an oral health promotion campaign.22 some circumstances early lesions can tain constant blood sugar levels. Bread is used as an example of a food that remineralise without the need for tissue contains hidden sugars. As such there is removal and restoration. Baelum suggests Bread potential for confusion when promoting that the diligent visual-tactile caries exam- Bread can be broadly divided into two sugar free snacks. ination should be the main diagnostic tool categories, ones made without yeast and The evidence suggests that although for assessment, particularly focusing on those made with yeast. The latter includes ground and heat-treated starch is less cari- lesion activity and tooth surface integrity.26 different types from white to wholemeal to ogenic than sugar, it still induces dental brown with or without added fibre or oats. caries.23 The potential of cooked starch to Erosion The bread can be in the form of sliced/ induce caries increases as sugar is added.23 Another form of demineralisation can unsliced loaves, baguettes, bread rolls, cia- Bread is rarely consumed alone but with dif- occur when tooth enamel is bathed directly batta, pitta bread and many more.29 ferent fillings.
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