It is the position of the Academy of Nutrition and Dietetics that nutrition is an integral component of oral health”.1
Dental caries is recognized as one of the most prevalent, yet preventable, chronic diseases in North America, particularly among two to five-year-olds.2 Collaborative partnerships including healthcare professionals, educators, researchers, and others, can help improve and maintain overall oral health.3 There are effective ways that pediatric dentists and nutrition experts can work together to reduce the incidence of dental caries, and thus help to improve the overall health and wellbeing of children.
SETTING THE STAGE: FACTORS CONTRIBUTING TO POOR ORAL HEALTH
“During thousands of years marked by food scarcity, human beings developed efficient mechanisms to store energy as fat. Until recently, we rarely enjoyed the abundance of cheap food that we see today”.4 Dietary choices that we make can have a profound effect in setting the stage for overall health, especially for our children. According to findings from the Canadian Community Health Survey of 2004, only a small percentage of children consume the number of servings of fruits, vegetables, and other nutrient dense foods recommended by governmental guidelines; in addition, many exceed their recommended limit for fat intake.5 In 1978, only 15 percent of Canadian youth were classified as overweight or obese. By 2007, 29 percent of the youth were identified as overweight or obese; and according to the most recent data, approximately 31.5 percent of all five to 17-year-olds in Canada are considered overweight or obese, thus setting the stage for increased risk of many chronic diseases.6
Overweight and obese children are at higher risk for cardiovascular disease, Type II diabetes, asthma, gallbladder disease, gastro-esophageal reflux disease (GERD) and certain cancers.7–9 As children are becoming more overweight, another health relationship has been observed: obesity rates and caries increase together. Hayden and colleagues presented a meta-analysis of obesity and dental caries in children, noting a significant relationship between increased weight and increased incidence of caries.10
As Vipeholm and other studies have demonstrated, carbohydrates, including sugars, have a role in caries formation. Frequency of sugar consumption and duration of carbohydrate exposure have a significant impact on caries incidence. A proper diet (types of foods consumed, the frequency of exposure, and the amount of food eaten) goes a long way toward reducing the risk for dental caries and obesity.11
An often-overlooked contributor to poor dental health includes eating disorders, specifically anorexia nervosa and bulimia nervosa. As DeBate, Tedesco, and Kerschbaum note, the dental professional could actually provide early detection of the oral cavity manifestations.12 Another concern that is not frequently correlated with poor oral health is food insecurity. Families may lack financial resources, knowledge, and/or access to nutrient dense foods, which can significantly increase risk for obesity and poor oral health. Furthermore, parents and/or caregivers of infants and children often receive little guidance about preventive oral health care and nutrition.13,14
In 1995, Nowak recognized the need for pediatric health professionals to work together with parents to form therapeutic alliances that would result in the highest quality healthcare for children. Today, many individuals and organizations are acknowledging the importance of a collaborative approach toward improving the overall health of our children. The report from the Committee on Oral Health Access to Services highlights the value of training healthcare teams to deliver consistent messaging, such that oral health and dietary recommendations go hand-in-hand.15
PLAYING OUR PARTS: FINDING SOLUTIONS THROUGH EDUCATION WITH COLLABORATION
Many educational tools are available to help convey a consistent message aimed at improving our children’s health (Fig. 1). These resources provide reliable, easy-to-understand and teach nutrition and oral health information. Many of the resources are available at little or no cost: Canada’s Food Guide, the 2015 Dietary Guidelines for Americans, Choose My Plate, the Dairy Council of California, Nutrition Facts Label Interactive Guide, Healthier Fast Food Choices, and resources for Early Childhood Oral Health. All of these tools can be incorporated into patient education within a pediatric dental practice. Nappo-Dattoma provides a succinct overview of nutrition education resources for the oral health professional as well.16 
While there are many resources available, all of the educational messages need to be clear, concise, easy to understand, and consistent. This consistency makes it easier to incorporate education into healthcare settings. Delivering important information in a caring, family-centered, coordinated environment can help to establish successful dental homes. According to the American Academy of Pediatric Dentistry (AAPD), “the dental home is inclusive of all aspects of oral health that result from the interaction of the patient, parents, dentists, dental professionals, and non-dental professionals”.17
ACT ONE: DELIVERY OF THE NUTRITION AND ORAL HYGIENE MESSAGE IN THE PEDIATRIC DENTAL OFFICE – “PLAQUE CONTROL”
Dentists, particularly pediatric dentists, are uniquely positioned to play an expanded role in the detection, early recognition, and management of a wide range of complex oral and general diseases and conditions.3 The pediatric dental office seems the logical place to provide more family centered oral health and nutrition education. As we move toward the collaborative model of delivering a consistent message regarding proper nutrition and oral hygiene, it is important to consider resource allocations and scope of practice for those within the pediatric dental office, and then ask: what, when, how and by whom will the services be provided.
One example of what, when, and how can be seen below, in a program known as Plaque Control, which has been integrated within a pediatric dental practice in Southern California since 1977. The script overview can be seen in Figure 2. Initially, a patient is scheduled to see the dentist for an exam. Then the patient and patient’s family are also to visit the “plaque control therapist” (PCT) for a 30-60 minute nutrition and oral hygiene education, toothbrush prophylaxis, and fluoride application, which also includes scheduling a follow up PCT visit in three months. At the three month follow up, the PCT schedules the patient for the six month visit with the dentist and follow up with the PCT.
The Plaque Control script presented above is meant to serve as an example of a way in which the information can be delivered. There are many effective ways to present the information, and it is important to find the way that works best for each individual practice.
THE PLAY BILL: RESOURCE ALLOCATION IN A PEDIATRIC DENTAL PRACTICE: SMART MESSAGING
Perhaps the most critical question to ask is by whom should the messages be delivered within a pediatric dental office? Factors to consider include who has the expertise (both dental and nutrition), as well as the time to deliver the education. Should
it be the dentist, dental hygienist, dental assistant, or a registered dietitian (the nutrition expert)? What is the scope of practice for each? What makes sense, in so far as what it costs to deliver the services?
ACT TWO: SUMMARIZING THE MESSAGE
Pediatricians, pediatric dentists, dietitians, and other health care advocates have a duty and an opportunity to be a part of our children’s healthcare and prevention strategy. Each brings a unique skill set to the equation, and a chance to teach and learn from one another. Through collaboration, this strong alliance can help deliver a consistent message to parents and children, integrating education regarding nutrition and oral hygiene.
The “integration of oral health and nutrition health promotion and disease management,” including education, “supports collaborative care”, helping to translate dietary recommendations and guidelines into achievable, [consistent], and healthful messages.1
ENCORE: SEPARATING NUTRITION FACTS FROM FICTION
It seems that everyday we are faced with the “latest news breaking” information on nutrition, most of which is contradictory and contrary to what we had been told in the past. It is challenging to evaluate what information is based on scientific evidence from what is fiction, or based on misinformation. Figure 3 provides some examples of websites that provide helpful resources for evaluating claims.
The integration of accurate oral health and nutrition health education is a crucial component of working together to improve the quality of care to all. OH
Terri Lisagor is an Associate Professor of Nutrition and Food Science and Chair of the Department of Family and Consumer Sciences at California State University, Northridge; she is also a Registered Dietitian. She helped establish nutrition and oral hygiene education programs in several pediatric dental practices in the U.S.
Oral Health welcomes this original article.
REFERENCES
1. Position of the Academy of Nutrition and Dietetics [AND]: Oral Health and Nutrition. J Acad Nutr Diet:2013:113(5):693-701. 693 p.
2. Carmona RH. National call to action to promote oral health. J Am Coll Dent. 2005: 72(4):8-10.
3. US Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General— Executive Summary. Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health. 2000.
4. Schlosser, E. Fast food nation. Boston: Hough Mifflin Company; 2001. 243 p.
5. Garriguet, D. Nutrition: Findings from the Canadian Community Health Survey 2004. Overview of Canadians’ Eating Habits. Statistics Canada. 2006: Catalogue no. 82-620-MIE–No. 2.
6. Roberts, KC, Shields, M, de Groh, M., Aziz, A, & Gilbert, J. Canadian Health Measures Survey. Overweight and obesity in children and adolescents: Results from the 2009 to 2011. Statistics Canada. 2012:Catalogue no. 82-003-XPE–No. 3.
7. Klimis-Zacas, D. J. (Ed.). Healthy People 2010: Overweight and Obesity. Guilford, CT: McGraw-Hill/Dushkin; 2001.
8. Lytle, LA. Nutritional issues for adolescents. Journal of the American Dietetic Association. 2002:102(Suppl 3):S8-S12.
9. Wardlaw, GM, Smith, A. Contemporary nutrition: issues and insights. 9th ed. Boston: McGraw-Hill; 2012
10. Hayden C, Bowler JO, Chambers S, Freeman R, Humphris G, Richards D, Cecil JE. Obesity and dental caries in children: a systematic review and meta-analysis. Community Dent Oral Epidemiol:2013:41(4):289-303.
11. Ludwig, DS, Peterson, KE, & Gortmaker, S. Relation between consumption of sugar-sweetened drinks and childhood obesity: a prospective, observational analysis. Lancet. 2001:357:505-508.
12. DeBate, RD, Tedesco, LA, & Kerschbaum, WE. Knowledge of Oral and Physical Manifestations of Anorexia and Bulimia Nervosa Among Dentists and Dental Hygienists. J Dent Educ:2004:69(3):346-354.
13. Fitzsimons, D., Dwyer, JT, Palmer, C, Boyd, LD. Nutrition and oral health guidelines for pregnant women, infants, and children. Journal of the American Dietetic Association:2002:98(2):182-186.
14. DeFonseca, MA.The effects of poverty on children’s development and oral health. Ped Dentistry:2012):14(1):32-38.
15. Committee on Oral Health Access to Services, Board on Health Care Services, Institute of Medicine, National Research Council. Improving Access to Oral Health Care for Vulnerable and Underserved Populations. Washington, DC: National Academies Press;2011.
16. Nappo-Dattoma, L. Updated Dietary Standards: The 2010 Dietary Guidelines for Americans, MyPlate and Other Nutrition Education Resources for the Oral Health Professional. Access:2011:25(8):16-19.
17. American Academy of Pediatric Dentistry: Oral Health Policies. Reference Manual. (2010). 35(6) 13/14. www.aapd.org/media/policies_guidelines/p_dentalhome.pdf.
