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Pouring energy into caries

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 examine the caries ‘epidemic’ in relation to the consumption of sports and energy drinks by children in the UK, as well as explore how to communicate effectively in an effort to help them achieve and maintain a good level of oral health.

On completing this CPD session, the reader will:

• Understand the government’s view that current scientific evidence is insufficient to support a statutory ban on the sale of energy drinks to children

• Understand the difference between ‘energy’ and ‘sports’ drinks, and their potential effect on oral health

 • Understand the level of the problem amongst children in the UK, in terms of free sugar intake and energy / sports drink consumption

• Understand that prevention of childhood dental caries relies on adherence to key behaviours

• Understand how to communicate more effectively with children and their caregivers, in order to offer patients greater support in their oral health care endeavours between appointments.


Pouring energy into caries

This article examines the caries ‘epidemic’ in relation to the consumption of sports and energy drinks by children in the UK, as well as exploring how to communicate effectively in an effort to help them achieve and maintain a good level of oral health.


In early December 2018, government advisors concluded there was insufficient evidence to warrant a ban on sale of energy drinks to children, even though a study by the European Food Safety Authority found that young people in the UK consumed more energy drinks than in other EU countries.1,2

With the possibility of this helping hand off the table, it would seem bridging the subsequent oral health gap is firmly in the hands of dental professionals, to try to motivate patients to minimise and counteract the effects of excess sugar intake.

Perhaps the first issue to tackle is that there is a difference between so-called ‘energy’ and ‘sports’ drinks, although both have the potential to result in caries and erosion due to their high free sugar content (unless sugar-free) and low pH.3,4

Broughton and colleagues (2016) defined the variation as follows: ‘An energy drink is marketed for its mental stimulant effect and contains high levels of substances such as caffeine, taurine and glucoronolactone. Sports drinks do not have a stimulant effect, but concentrate on providing carbohydrates, salts and hydration.’4

A spoonful of sugar…

In 2015, the World Health Organization recommended limiting free sugars for adults and children from the previous maximum of 10% of total energy intake to 5%.5 This was incorporated into a revised version of the ‘Delivering better oral health: an evidence-based toolkit for prevention’ (2017), which recommends that, for all age groups aged over two years old, the average intake of free sugars should not exceed 5% of total dietary energy intake.6

According to Hashem and colleagues (2017), using figures from Public Health England, in children aged between 4 and 10, sugar represented 13% of their daily energy intake, while for those aged 11 to 18 it was 15% .2 This, clearly, is far off the recommended 5%.2

The effect of excessive free sugar intake is clear to see, with the Children’s Dental Health Survey of 2013 revealing that 46% of 15-year-olds and 34% of 12-year-olds suffered from obvious decay experience* in their permanent teeth, while 31% of 5-year-olds and 46% of 8-year-olds had obvious decay experience in their primary teeth.7

How might these problems be addressed by dental professionals? As stated by Duijster and colleagues (2015), ‘The prevention of childhood dental caries relies on adherence to key behaviours, including twice daily tooth brushing with fluoride toothpaste and reducing the consumption of sugary foods and drinks.’8

Communicating with kids

Since we know that sugar is an essential element of caries, a considerable amount of research and professional advice offered to parents involves education to help modify food and drink choices.9

Recognising that parents’ behaviour may affect a child’s oral health, Bozorgmehr and colleagues (2013) wrote: ‘It can be concluded […] that some important health behaviors in parents, such as tooth brushing habits and frequency of consumption of sweet foods, are important determinants of these behaviors in their young children. Children with high-educated mothers had lower plaque index than the others. So, promoting parents’ knowledge and attitude could affect their children oral health behavior and status.’10

Given this concept, Ramos-Gomez and colleagues (2010) suggested that sharing a message similar to the following to both parents and children may help: ‘Reducing the amount of sugary and starchy foods, snacks, and drinks you consume can help to reduce tooth decay. This doesn’t mean that you can never eat these types of foods, just that you should limit the number of times you eat them between main meals. A good rule is three meals per day and no more than three snacks per day.’11

Adding to the communication mix, it has been well publicised that there is more to communication than what is voiced – evidence indicates that 7% is attributable to the words used, 38% to the tone and volume used to impart those words, and 55% is related to body language.12

This is important to bear in mind for patients of all ages, but it has been suggested that children – especially small children – react more significantly to how things are said, rather than what is being said.12

Thus, it may be useful to change the way dental professionals communicate with their younger patients so as to be age appropriate, with the non-verbal aspect of communication (i.e. tone, volume and body language) used to reinforce what is being said. Ideally, this should begin even before the child reaches the dentist’s chair, ensuring the waiting room is a friendly environment and team members present themselves as happy and positive.12

Implementing change

Nonetheless, getting young people to make changes can be a significant challenge, as outlined by Hardy and colleagues (2017): ‘Potential reasons for children's intentional or unintentional non-adherence to health behavior recommendations may include children and parents' lack of awareness, misunderstanding, inadequate knowledge of the consequences of non-adherence, recommendations being too complex, high financial cost and lack of perceived immediate health benefits.’13

Offering practical advice on this issue, Erdemir and colleagues (2016) wrote: ‘Dentists have a duty to their patients to give them instructions on the consumption of drinks or foods which can damage dental health. Most food and drinks have little noticeable effects on dental health. Among the drinks that are most likely to damage teeth and restorative materials are sports and energy drinks which contain sugar to feed oral bacterial, and drinks which have a low pH which can erode teeth and increase their sensitivity. Patients who suffer poor oral health because of their over-consumption of sports and energy drinks need to be made aware of the likely causes of their dental problems.’14

* 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.7

QUESTIONS: 

References

  1. <p>Energy drinks and children. Parliamentary Science and Technology Committee 2018</p>

  2. <p>Hashem KM et al. Cross-sectional surveys of the amount of sugar, energy and caffeine in sugar-sweetened drinks marketed and consumed as energy drinks in the UK between 2015 and 2017: monitoring reformulation progress. BMJ Open 201: 7: e018136. doi: 10.1136/bmjopen-2017-018136</p>

  3. <p>Broad E. Do current sports nutrition guidelines conflict with good oral health? General Dentistry 2015; Special sports dentistry section: 18-23</p>

  4. <p>Broughton D et al. A survey of sports drinks consumption amongst adolescents. BDJ 2016; 220: 639-643</p>

  5. <p>Guideline: Sugars intake for adults and children. World Health Organization 2015</p>

  6. <p>Delivering better oral health: an evidence-based toolkit for prevention. Public Health England. Third edition, revised 2017</p><p>Delivering better oral health: an evidence-based toolkit for prevention. Public Health England. Third edition, revised 2017</p>

  7. <p>Children’s Dental Health Survey 2013. Public Health England 2015</p>

  8. <p>Duijster D et al. Establishing oral health promoting behaviours in children – parents’ views on barriers, facilitators and professional support: a qualitative study. BMC Oral Health 2015; 15: 157-169</p><p>Duijster D et al. Establishing oral health promoting behaviours in children – parents’ views on barriers, facilitators and professional support: a qualitative study. BMC Oral Health 2015; 15: 157-169</p>

  9. <p>Çolak H et al. Early childhood caries update: a review of causes, diagnoses, and treatments. Journal of Natural Science, Biology and Medicine 2013; 4(1): 29-38</p>

  10. <p>Bozorgmehr E. Oral health behavior of parents as a predictor of oral health status of their children. ISRN Dentistry 2013: 741783</p>

  11. <p>Ramos-Gomez F et al. Caries risk assessment, prevention, and management in pediatric dental care. General Dentistry 2010; 505-517</p>

  12. <p>Bellis W. Managing the young child patient. Vital 2013; 10: 26-27</p>

  13. <p>Hardy LL et al. Children's adherence to health behavior recommendations associated with reducing risk of non-communicable disease. Preventive Medicine Report 2017; 8: 279–285</p>

  14. Erdemir U et al. Effects of energy and sports drinks on tooth structures and restorative materials. World J Stomatol 2016; 5(1): 1-7