Lifting the lid on hidden sugars

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

Aims and objectives

The aim of this article is to consider the current attitudes and level of awareness of hidden sugars within the UK population, and offer practical guidance to help dental health care professionals communicate with patients – including parents and guardians – as to the subsequent caries risk and how to minimise the potential for damaging oral health.

On completing this CPD session, the reader will:

• Understand the myriad factors involved in the creation of caries

• Understand the current situation regarding sugar consumption among the population

• Understand why there may be confusion as to what constitutes a ‘healthy’ dietary choice

• Understand the significance of a multi-disciplinary approach to patient education

• Understand how oral health messages regarding sugar consumption and caries might be communicated effectively to patients.

Lifting the lid on hidden sugars

This article considers the current attitudes and level of awareness of hidden sugars within the UK population, and offer practical guidance to help dental health care professionals (DHCPs) communicate with patients.

The Keyes Concept indicates that susceptible tooth enamel, plaque biofilm and sugar metabolism leading to acid production all contribute to the development of dental caries. In the intervening years since this caries model was created, it has been developed to take into account the idea that elements such as attitudes to oral hygiene, income and education level also have a role to play.1

van Loveren and colleagues (2012) wrote that a person’s predisposition to caries also depends on the, ‘[…] composition, morphology, location and position […]’ of the teeth, as their shape will affect the degree of plaque retention.1

This alone, however, does not result in caries, also requiring ‘…the presence of acidogenic species for caries to develop. Caries will not develop in the absence of bacteria.’ These acidogenic bacteria then need something to feed on, for example fermentable carbohydrates and sugars.1

Adding to this narrative, ten Cate (2009) stated, ‘Studies have shown that while fluoride usage may counteract tooth destruction caused by sugar consumption, there is a limit to this repair potential.’2

This is especially worrying because, ‘[…] dietary habits in the past decades have developed toward an equal or higher consumption of sugars and, more importantly, a higher frequency of intake of caries-promoting foods.’2

In addition, it is suggested that, ‘Analysis of […] data shows that, with regular fluoride use, caries can still develop when sugar intake occurs too frequently.’2

ten Cate (2009) continued: ‘Our rapidly increasing knowledge about oral biofilms includes sufficient relevant new information to embark on new strategies to limit the deleterious side-effects of dental plaque, while keeping its benign potential.’2

Forbidden fruit

The idea that sugar consumption is linked to caries goes back thousands of years, with Aristotle recording that sweet figs decay teeth.3 Yet the headline findings in the current National Diet and Nutrition Survey indicate that non-milk extrinsic sugars (NMES) (in essence, added sugar) continues to exceed recommendations for all age groups, except in women aged 65 years and older.4,5

One of the main sources of NMES were fruit juices and soft drinks.4 A survey by Boulton and colleagues (2016) into the amount of sugar in fruit juices, juice drinks and smoothies revealed a range from 0g to 16g per 100ml. Mean sugar content was 7g per 100ml, but in fruit juices it was 10.7g per 100ml and for smoothies, 13g per 100ml.6

Considering this in the context of public perception, they wrote: ‘In a recent survey of people’s perception of sugars in drinks, the sugars content of fruit juices and smoothies was underestimated by 48% on average, whereas the sugars content of carbonated drinks was overestimated by 12%. Therefore, it is not surprising that the role of sugar-sweetened drinks and fruit juices in the increase in caries and obesity has recently been at the forefront of public debate. Furthermore, there is increasing public awareness of the negative impact of sugar-sweetened drinks on children’s health. As a result, parents may replace sugar-sweetened carbonated drinks (that are perceived to be unhealthy) with fruit juices, juice drinks and smoothies (FJJDS) (that are perceived to be healthier). However, this can also have a negative health impact if the sugars content of FJJDS is equal to or higher than sugar-sweetened carbonated drinks.’6

In an effort to avoid sweet treats between meals, a number of alternatives, perceived to be healthier in some quarters, are recommended, such as crudités, cheese and bread. However, bread is another good example of the types of foods that contain hidden sugars.5

‘The evidence suggests that although ground and heat-treated starch is less cari¬ogenic than sugar, it still induces dental caries. The potential of cooked starch to induce caries increases as sugar is added. Bread is rarely consumed alone but with dif¬ferent fillings. Surveys carried out by Evans et al and the School Food Trust aiming at accessing the composition and nutri¬tional content of packed lunches showed that the majority of children bringing a packed lunch had a sandwich and of those 20% had a sweet filling (jam, chocolate spread, etc) with a higher average intake of NMES.’5

Placing the potential for sugar in bread in context, the edible portion of flour contains between 1g and 2g of sugar per 100g. Greater amounts of sugar are produced by yeast fermenting during the creation of bread. Meanwhile, some bread manufacturers add sugar to help the crust to brown or to speed up the fermentation process.5

Effecting change

Giacaman (2016) proposed that DHCPs should deal with 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 conditions such as obesity and diabetes into the equation – both influenced by sugar consumption – may help to achieve better results.7

He wrote: ‘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. Caries reduction is possible, but it mandates to trigger its main causative factor; sugar.’7

It has been suggested that intervening to encourage patients to make behavioural changes can affect disease patterns considerable. It has also been indicated, however, that conflicting advice from different quarters can have a negative effect on how people behave, their attitudes, and their level of motivation.5

Addressing this challenge, Richards and Filipponi (2011) wrote: ‘[…] recently services have embraced a wider ‘common risk factor’ approach. In order for this to be effective consist¬ent nutritional guidelines are essential to improve health. Stillman-Lowe stresses that commonality and ambiguity should be addressed in order to improve the effec¬tiveness of oral health promotion activi¬ties. Inconsistencies are found not only between healthcare professionals (dental, dietetic and nutritional students) but also among dental professionals.’5

Looking at the specifics of the diet choices people make, factors that influence food selection include:

• Availability, cost and preferences

• Cooking skills

• Cultural values

• Eating patterns

• Carers’ beliefs and practices

• The influence of peers

• Impactful advertising.5

It would seem that the oral health messages shared by DHCPs would need to transcend these factors, for example: ‘Caregivers must be taught to remove themselves from the mindset that giving their children excess sugar is a sign of reward. High levels of sugar in the diet have an instantly damaging effect on teeth in addition to the myriad of other preventable medical condi-tions that no child should suffer from.’8

The use of a diet diary has also been proposed as a useful tool in dental practices, something that Arheiam and colleagues (2016) explored in their study, in terms of being able to identify sugar-consumption patterns that may predispose a patient to caries.9

The factors that need to be recorded on a template are the type, timing and quantity of foods and beverages consumed, alongside when the patient went to bed, for a defined period of time (often for three days, consisting of weekend and week days).9

Not only does it enable DHCPs to identify cariogenic behaviours, it also helps to start a discussion with the patient about the issues revealed, which can be followed through to create behavioural change goals.9

Diet diaries are recommended as best practice in England, however many DHCPs are not using them, ‘[…] probably because of perceived constraints related to finance and time. Development of a more time efficient tool, which can assess diet and help stimulate behaviour change, is needed to tackle high sugar consumption and other related dietary issues pertinent to the dental health setting.’9

Working together

It is clearly important that patients understand the significance of allowing the oral environment to remineralise. Alongside the need to raise awareness of the importance of mechanical cleaning twice a day, the role of a balanced diet is also an important message to share.5

Whilst it remains the case that conflicting advice may be given to patients as a result of their healthcare provider’s focus, according to Richards and Filipponi (2011), ‘[…] an acceptable ‘common and unambiguous’ message to health care professionals [is] a simple message of leaving the mouth empty for two hours between episodes of food and/or drink is suggested. This fulfils dental, nutritional and educational principles.’5

Explicit in their message regarding the need for health professionals to come together to educate the public about the effects of sugar, Wordley and colleagues (2017) wrote: ‘Ultimately, oral health is an integral part of overall health. We simply cannot delay any further in providing universal oral health pre¬vention for absolutely everybody.’8



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

  2. ten Cate JM. The need for antibacterial approaches to improve caries control. Advances in Dental Research 2009; 21: 8-12

  3. Hujoel PP et al. Nutrition, dental caries and periodontal disease: a narrative review. Clin Periodontol 2017; 44 (Suppl. 18): S79–S84

  4. National Diet and Nutrition Survey. Results from Years 5 and 6 (combined) of the Rolling Programme (2012/2013 – 2013/2014). Public Health, September 2016

  5. Richards W, Filipponi T. An effective oral health promoting message? BDJ 2011; 211(11): 511-516

  6. Boulton J et al. How much sugar is hidden in drinks marketed to children? A survey of fruit juices, juice drinks and smoothies. BMJ Open 2016; 6: e010330

  7. 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

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

  9. Arheiam A et al. The use of diet diaries in general dental practice in England. Community Dental Health 2016; 33: 1–7