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JJ ECPD sugar tax v2

Johnson & Johnson is delighted to bring you this article, with the aim of supporting the ongoing CPD needs of dental healthcare professionals in improving and maintaining the oral health of their patients.

This article is equivalent to one hour of Enhanced CPD. To provide feedback on this article, please contact dentalcpd@its.jnj.com

Learning outcomes

A,C,D

Aims and objectives

The aim of this article is to consider the oral health implications of the ‘sugar tax’, as well as looking beyond it to examine what else might help to reduce the high rate of caries in the UK.

On completing this CPD session, the reader will:

• Understand the reasons behind the introduction of the UK’s tax on some sugary drinks

• Understand current levels of caries among adults and children in England, Wales and Northern Ireland

• Understand that a combination of susceptible tooth enamel, plaque biofilm and sugar metabolism contribute to the development of dental caries

• Understand the need to tackle the challenge of caries using a multi-disciplinary approach

• Understand the importance of fluoride in the fight against caries.

Oral health – a taxing issue

This article considers the oral health implications of the ‘sugar tax’, as well as looking beyond it to examine what else might help to reduce the high rate of caries in the UK.

In April 2018, a tax on sugar-sweetened beverages (SBBs) was introduced in the UK. It involved the application of two levy bands – drinks containing 5-8g of sugar per 100ml are now taxed at 18p per litre, whilst beverages with 8g or more of sugar per 100ml are subject to a tax of 24p per litre.1

Its application came shortly after Public Health England’s call for parents to ‘look for 100-calorie snacks, two a day max' to cut children’s sugar intake. Figures suggest that approximately half of children’s sugar intake – roughly 7 cubes a day – comes from unhealthy food and drink choices.2

Data published in the most recent Children's Dental Health Survey (2013) indicated that almost half of 15-year-olds and just over a third of 12-year-olds had ‘obvious decay experience’* in their permanent dentition. In addition, nearly half of 8-year-olds and almost a third of 5-year-olds had ‘obvious decay experience’ in their primary teeth.3

There also appears to be an unmet oral health need in adults as well. The Adult Dental Health Survey of 2009 stated that almost a third of participants had obvious tooth decay in either the crowns or roots of their teeth.4

Despite figures being widely available to indicate the negative impact of sugar consumption on teeth – not least The Faculty of Dental Surgery at the Royal College Surgeons reporting a 24% rise in the number of tooth extractions in children up to 4 years old in hospitals in England over the last decade – the Government’s focus has been on tackling obesity.5

However, that does not mean the dental profession cannot try to make use of these high-profile campaigns in an effort to help improve the nation’s oral health. As Wordley and colleagues (2017) wrote: ‘The new sugar tax was recently announced by Government, aiming to combat obesity through investment in school sports. Dental professionals should seize this rare opportunity to raise awareness of the other adverse effects of sugar; young children continue to suffer alarmingly high rates of dental cavities in the UK.’5

Back to basics

According to Keyes Concept, a combination of susceptible tooth enamel, plaque biofilm and sugar metabolism lead to acid production, which contributes to the development of dental caries. Over the years, this caries model has been expanded to cover modifying factors, including the composition and frequency of dietary choices, as well as behavioural aspects.6

More recently, Pitts and colleagues (2017) proposed that dental caries, ‘[…] is a biofilm-mediated, sugar-driven, multifactorial, dynamic disease that results in the phasic demineralization and remineralization of dental hard tissues’7

It is accepted that: ‘Diet has a direct, local effect on oral health, particularly in regard to the formation of dental caries and dental erosion.’ However, it has been suggested that the content of dietary advice provided by general dentists in the UK varies widely, which is concerning given the link between diet and dental disease.8

No more sugar-coating

Giacaman (2016) advised DHCPs to tackle the challenge of caries using a multi-disciplinary approach, because, ‘It is very difficult to think that people will change or modify sugar consumption because of caries.’ He suggests that bringing other disorders affected by sugar intake, such as diabetes and obesity, into the conversation may help to achieve better results.9

He further recommended: ‘At an individual level, dentists should spend more time explaining to their patients the importance of controlling sucrose consumption, not only in the context of caries control, but also with a systemic health view. Further¬more, the dentist and the dental profession as a whole must be engaged in the interdisciplinary work of the healthcare providers.’9

In terms of offering specific, tailored advice, The Oral Health Foundation offers patient-friendly guidance. It describes in simple terms why sugary foods are potentially damaging to the dentition, as well as listing more tooth-friendly alternatives, such as cheese, raw vegetables, nuts and breadsticks.10

In addition, it is important to ensure patients understand that the timing of consuming sugary foods or drinks is significant, and that they should be confined to mealtimes.10

The F factor

In terms of other factors that may aid in the fight against caries, Pitts and colleagues (2017) commented: ‘The importance of fluoride in modifying disease expression cannot be overemphasized.’7

Adding to this concept, Moynihan (2005) wrote: ‘Research has consistently shown that when consumption of sugars exceeds 15kg/person/year dental caries increases and intensifies […] although exposure to fluoride may increase the safe level of consumption of sugars to approximately 20kg/year.’11

Public Health England’s guidance on ‘Delivering better oral health: an evidence-based toolkit for prevention’ also emphasises the significance of fluoride application, stating: ‘High quality evidence of the caries-preventive effectiveness of fluoride varnish in both permanent and primary dentitions is available and has been updated recently. A number of systematic reviews conclude that applications two or more times a year produce a mean reduction in caries increment of 37% in the primary dentition and 43% in the permanent. The evidence supports the view that varnish application can also arrest existing lesions on the smooth surfaces of primary teeth and roots of permanent teeth.’12

Addressing the challenge on a daily basis, the toolkit also provides a number of recommendations for caries prevention in adults, including:

• Brushing at least twice daily with fluoridated toothpaste

• Brushing last thing at night and on at least one other occasion

• Using fluoridated toothpaste with at least 1,350ppm fluoride

• Spitting out after brushing and not rinsing, to maintain fluoride concentration

• The frequency and amount of sugary food and drinks should be reduced.12

The toolkit further submits that, in some patients, the use of a mouthrinse may offer caries support. For example, people who have obvious current active caries, dry mouth, special needs or other predisposing factors might find the use a fluoride mouth rinse daily (0.05% sodium fluoride) at a different time to brushing beneficial.12

Primary care

Offering an overview of the situation, Pitts (2017) published: ‘Perhaps dental caries can be described best as a complex biofilm-mediated disease that can be mostly ascribed to behaviours involving frequent ingestion of fermentable carbohydrate (sugars such as glucose, fructose, sucrose and maltose) and poor oral hygiene in combination with inadequate fluoride exposure.’7

Picking up on this notion, Bedi (2018) wrote: ‘Reducing sugar consumption will have a significant impact on helping to reduce the global epidemic of noncommunicable diseases. As sugar is the primary factor responsible for the development of tooth decay, any reduction measures will also lower this risk, particularly for children.’13

Offering a final word on the subject, Giacaman (2016) stated: ‘Caries reduction is possible, but it mandates to trigger its main causative factor; sugar.’9

Whether the sugar tax will help to reduce the prevalence of caries in the UK remains to be seen, but it may certainly be used as a lead into discussions with patients about plaque control and other preventive possibilities.5

* Obvious decay experience includes untreated decay requiring fillings or tooth extraction, fillings and teeth lost because of decay, dmft for primary teeth and DMFT for permanent teeth.3

QUESTIONS: 

References

  1. Lean MEJ et al. Sugar taxation: a good start but not the place to finish. Am J Clin Nutr 2018; 108: 435-436

  2. Accessed 5 November 2018

  3. Children’s Dental Health Survey 2013. Health and Social Care Information Centre 2015

  4. Adult Dental Health Survey 2009. Health and Social Care Information Centre 2011

  5. Wordley V et al. The sugar tax – an opportunity to advance oral health. BDJ 2017; 223(1): 11-12

  6. van Loveren C et al. Functional foods/ingredients and dental caries. European Journal of Nutrition 2012; 51 (supplement 2): S15-S25

  7. Pitts NB et al. Dental caries. Nature Reviews Disease Primers 2017; 3(17030): 1-16

  8. Franki J et al. The provision of dietary advice by dental practitioners: a review of the literature. Community Dental Health 2014; 31: 9-14

  9. Giacaman R. Sugar and dental caries: new insights of an old problem and its implication in clinical management. Journal of Oral Research 2016; 5(2): 57-58

  10. Accessed 5 November 2018

  11. Moynihan PJ. The role of diet and nutrition in the etiology and prevention of oral diseases. Bulleting of the World Health Organization 2005; 83(9): 694-699

  12. Delivering better oral health: an evidence-based toolkit for prevention. Public Health England, 3rd edition 2014. Revised 2017

  13. Bedi R. The sugar tax: a leadership issue for the dental profession and an opportunity to demonstrate that oral health is part of general health. Contemp Clin Dent. 2018; 9(2): 149-150