|
| A) | Staphylococcus aureus | ||
| B) | Streptococcus mutans | ||
| C) | Pseudomonas aeruginosa | ||
| D) | Streptococcus pneumoniae |
Untreated dental caries among deciduous ("baby/milk") teeth is the most prevalent childhood ailment, affecting 514 million children globally. Overall, dental caries affects 97% of the global population at some point in their lives [3,4]. The accepted theory of caries formation is related to the acids produced by oral bacteria removing tooth surface minerals, eventually causing a cavitation. Streptococcus mutans (S. mutans), S. sobrinus, Bifidobacterium species, and Lactobacillus micro-organisms have all been found to aid in caries progression [5,6]. These same bacteria are associated with root caries, as are the micro-organisms Actinomyces viscosus and A. naeslundii, which are notably present in active lesions [7].
| A) | 30% | ||
| B) | 50% | ||
| C) | 70% | ||
| D) | 90% |
Dental caries is a preventable disease that affects a majority of the population. According to the 2011–2016 National Health and Nutritional Examination Survey, approximately 90% of adults 20 to 64 years of age had at least one decayed tooth [1]. Data collected between 2017 and 2020 indicate that among children and adolescents 2 to 19 years of age, 46.0% had one or more carious lesions in their primary or permanent teeth [2]. These statistics show the increase in caries incidence over time, making it important for dental professionals to develop strategies for determining caries risk and counseling patients to reduce risk and a future of dental caries.
| A) | 2.0 | ||
| B) | 4.2 | ||
| C) | 5.5 | ||
| D) | 8.0 |
When fermentable carbohydrates are introduced into the mouth, the sugars begin to be broken down to acid by oral bacteria. This acid lowers the pH of the saliva and oral plaque biofilm and may increase the rate of demineralization of tooth surfaces. Tooth enamel begins to demineralize at a pH of 5.5, and root surface demineralization occurs at an even milder pH of 6.2 [11]. Once the pH dips into these ranges, the outer layer of the tooth loses minerals. This causes a loss in surface hardness and increases the possibility of caries lesion progression.
| A) | shiny. | ||
| B) | dull. | ||
| C) | brown. | ||
| D) | white. |
Caries lesions are detected a number of ways [3,12,13,14]:
Visual examination is employed for diagnosing large pit and fissure, root surface, and facial and lingual smooth surface caries lesions.
Inspection with a blunt explorer or probe over the surfaces of teeth is the tactile method of detecting caries lesions. This exploration is especially effective around margins of existing restorations.
Using the air/water syringe to visualize teeth wet and dry is helpful. Demineralized surfaces will look dull, chalky, and irregular when dry.
Radiographs can be used to identify interproximal caries before they can be detected visually or tactilely, allowing for diagnosis when they are small or incipient.
Transillumination is the technique of shining light through the teeth with a dental light and mirror or with fiber-optic equipment. Various lasers for caries detection are available from dental equipment manufacturers. These methods allow tooth examination without risking cavitation of decalcified tooth surfaces, as may occur with the use of dental instruments.
| A) | occlusal lesions. | ||
| B) | cervical demineralization. | ||
| C) | interproximal lesions. | ||
| D) | white spot lesions. |
Caries lesions are detected a number of ways [3,12,13,14]:
Visual examination is employed for diagnosing large pit and fissure, root surface, and facial and lingual smooth surface caries lesions.
Inspection with a blunt explorer or probe over the surfaces of teeth is the tactile method of detecting caries lesions. This exploration is especially effective around margins of existing restorations.
Using the air/water syringe to visualize teeth wet and dry is helpful. Demineralized surfaces will look dull, chalky, and irregular when dry.
Radiographs can be used to identify interproximal caries before they can be detected visually or tactilely, allowing for diagnosis when they are small or incipient.
Transillumination is the technique of shining light through the teeth with a dental light and mirror or with fiber-optic equipment. Various lasers for caries detection are available from dental equipment manufacturers. These methods allow tooth examination without risking cavitation of decalcified tooth surfaces, as may occur with the use of dental instruments.
| A) | using saltwater rinses to raise oral pH. | ||
| B) | eating a diet high in fermentable carbohydrates. | ||
| C) | limiting snacks and eating a balanced diet. | ||
| D) | replacing toothbrushes every 12 months. |
To prevent tooth decay, the American Dental Association recommends the following oral hygiene behaviors [16]:
Brush teeth twice a day.
Brush for two to three minutes.
Use a fluoride toothpaste that is ADA-accepted.
Replace the toothbrush every three to four months, or more frequently if bristles are fraying.
Floss or use an interdental cleaner daily to remove bacteria between teeth and under the gum line.
Limit snacking and eat a balanced diet.
Develop a customized at-home oral hygiene regimen that includes the use of prescription-strength fluoride gels or toothpastes.
Establish a dental recall schedule that reflects the patient's ability to maintain ideal oral hygiene.
| A) | Snacking, fast food meals, and soda consumption | ||
| B) | Alcohol consumption and chewing sugarless gum | ||
| C) | Drinking nonfluoridated water and milk | ||
| D) | Chewing sugarless gum and eating a raw-foods diet |
Snacking is a common habit in the United States, with 90% of U.S. adults reporting one or more snacks per day—which accounts for approximately 22% of their daily energy intake [18]. Snacking promotes caries for a number of reasons. First, patients do not often brush or floss after eating snacks, leaving food debris and dental plaque biofilm in the mouth for extended periods. Second, most snack foods either have elevated sugar content or—like potato chips and crackers—are high in fermentable carbohydrates, allowing for acid formation from oral bacteria. Third, snacks are usually eaten throughout the day, permitting oral bacteria to produce acid and lower the salivary and plaque biofilm pH multiple times in a relatively short period.
Snacking habits have changed over the years, making it important for dental professionals to stay abreast of healthy options and nutritional evaluation techniques. Over a span of 35 years—between 1977 and 2012—there was a significant increase in per capita energy intake from snacking. The snack foods and beverages consumed were typically sugar-sweetened beverages, desserts, sweets, and salty snacks, the consistent consumption of which is not ideal for oral or systemic health [18]. The consumption of such snacks between meals or at a time that is typically not conducive to tooth brushing leads to a cumulative effect of an increased potential for the development of carious lesions. It is estimated that in the United States, approximately 22% of the daily caloric intake is from snacks that are sweet, salty, or desserts despite dietary guidelines that these items should comprise a limited portion of the daily caloric intake [18]. Even patients trying to eat healthfully may fall prey to ingesting excessive sugar because many snack foods marketed as "low-fat" have increased sugar per serving to improve taste once the fat is removed.
The average American consumes approximately 20 teaspoons of sugar every day via ingredients in foods and beverages such as fructose, dextrose, and high-fructose corn syrup [19]. The amount of sugar in the typical American diet not only promotes caries but also underlies the increase in obesity, heart disease, and diabetes in the general population. The American Heart Association recommends that men consume no more than 9 teaspoons (36 grams or 150 calories) of added sugar per day and that women consume no more than 6 teaspoons (25 grams or 100 calories per day) of added sugar per day [20].
The Nutritional Questionnaire and Food Log shown in Table 1 is an example of a dietary questionnaire that clinicians can use to gather nutritional information that is pertinent to oral health. A food log can help the dental professional guide patients to modify snacking habits and include fewer fermentable carbohydrates and sugars. Some dental providers ask their patients each question, and the questions can be customized depending on previous knowledge. Other dental providers send questionnaires home with patients and assess them at a subsequent appointment.
The technique used would depend on the caries risk of the individual and the suspicion that diet plays a role. See the Resources section for websites that contain valuable information and interactive programs to help patients improve their diets.
To decrease caries risk, dental professionals should encourage patients to make changes in the composition and frequency of snacks—moving toward more healthy choices. Even minor changes, such as limiting snacks to a period of 10 to 15 minutes once a day and brushing teeth or chewing sugar-free gum after snacks, may decrease this common habit's negative effects on patients' teeth.
The American population's consumption of fast food has been growing steadily for many years. Data from the National Health and Nutrition Examination Survey of 2017–2018 indicated that on an average day, 36.5% of American adults consume fast food, which accounted for 13.8% of their daily calories [21]. Children and adolescents vary in their daily caloric intake from fast food consumption. Each day, approximately 36.3% of children and adolescents consume fast food, with 11.4% of children and adolescents obtaining more than 45% of their daily caloric intake from fast food; 13.8% obtaining 25% to 40% of their caloric intake from fast food; and 11.1% obtaining less than 25% of their caloric intake from fast food [22]. Clearly, millions of Americans consume fast food on a regular basis, and this is associated with a high caloric intake and poor diet quality. Patients who eat fast food meals or snacks laden with carbohydrates are at increased risk for caries due to the high amounts of sugar and fermentable carbohydrates present in fast food items [23]. Being armed with knowledge of the statistical relationships between fast food and caries may help the dental professional counsel patients on making healthier fast food choices.
In addition, there is a correlation between eating fast food on a regular basis and developing insulin resistance, which is a risk factor for type 2 diabetes [24]. To guide patients with diabetes and the general public toward healthier fast food options, the practitioner can refer patients to the American Diabetes Association website (http://www.diabetes.org), their physician, or a nutritionist for guidance specific to the patient's health condition, keeping in mind that as a dental professional, oral health should remain a focus.
Within the United States, the median annual per capita consumption of sugar-sweetened beverages (SSB) in 2021 was 37.1 gallons, with the annual per capita consumption of SSB the lowest in Hawaii (23.5 gallons) and the highest in Missouri (51.8 gallons) [25]. Most people are unaware of the sugar content of their favorite sugar-sweetened beverage or soda, and they are not aware of the daily recommended maximum amount of sugar. The World Health Organization has recommended that for children the maximum daily consumption of sugar is 3 teaspoons. A 20-ounce bottle of soda contains about 16 teaspoons of sugar, while a 12-ounce can contains about 10 teaspoons of sugar [26]. Many nutritional experts and health organizations believe that soda and SSB in general are a major contributing factor to the escalation of childhood and adult obesity [27]. The consumption of soda doubles the risk of the development of carious lesions in children and increases the potential for the development of carious lesions in adults [26].
The patient education pamphlet "Sip All Day, Get Decay!" produced by the Minnesota Dental Association (available at http://www.sipallday.org) states that the average 12-ounce can of soda has 10 teaspoons of sugar and a pH just over 3. The low pH of soft drinks results from the ingredient phosphoric acid. Sodas also contain carbonic acid, and many contain citric acid. Therefore, even diet sodas are detrimental to oral health due to their acidic pH levels.
Patients who sip soda throughout the day cause their oral pH to plunge due to the acidity of the soda and the acid formed from oral bacteria metabolizing the sugars with this extended exposure a source of an increased risk for the development of dental caries [28].
Sports drinks and fruit juices also tend to be acidic and contain high amounts of sugar [29,30]. The use of these products should be limited. Milk and water remain the best drink options for healthy teeth. The development of flavored, unsweetened water gives patients another drink option that is not detrimental to their teeth.
| A) | 10% | ||
| B) | 22% | ||
| C) | 30% | ||
| D) | 36% |
Snacking habits have changed over the years, making it important for dental professionals to stay abreast of healthy options and nutritional evaluation techniques. Over a span of 35 years—between 1977 and 2012—there was a significant increase in per capita energy intake from snacking. The snack foods and beverages consumed were typically sugar-sweetened beverages, desserts, sweets, and salty snacks, the consistent consumption of which is not ideal for oral or systemic health [18]. The consumption of such snacks between meals or at a time that is typically not conducive to tooth brushing leads to a cumulative effect of an increased potential for the development of carious lesions. It is estimated that in the United States, approximately 22% of the daily caloric intake is from snacks that are sweet, salty, or desserts despite dietary guidelines that these items should comprise a limited portion of the daily caloric intake [18]. Even patients trying to eat healthfully may fall prey to ingesting excessive sugar because many snack foods marketed as "low-fat" have increased sugar per serving to improve taste once the fat is removed.
| A) | carbonation. | ||
| B) | acidic pH level. | ||
| C) | alkalinity. | ||
| D) | food color chemicals. |
The patient education pamphlet "Sip All Day, Get Decay!" produced by the Minnesota Dental Association (available at http://www.sipallday.org) states that the average 12-ounce can of soda has 10 teaspoons of sugar and a pH just over 3. The low pH of soft drinks results from the ingredient phosphoric acid. Sodas also contain carbonic acid, and many contain citric acid. Therefore, even diet sodas are detrimental to oral health due to their acidic pH levels.
| A) | Fruit juices | ||
| B) | Milk and water | ||
| C) | Alcoholic drinks | ||
| D) | Coffee and tea |
Sports drinks and fruit juices also tend to be acidic and contain high amounts of sugar [29,30]. The use of these products should be limited. Milk and water remain the best drink options for healthy teeth. The development of flavored, unsweetened water gives patients another drink option that is not detrimental to their teeth.
| A) | Eating in front of the television | ||
| B) | Eating a healthy breakfast | ||
| C) | Drinking fruit juice with meals | ||
| D) | Eating fruits and vegetables |
Children tend to emulate their parents' food choices [39,40]. Parents' food choices and nutritional guidance can be driven by habits, myths, misinformation, weight control efforts or problems, availability, and their own nutritional knowledge [17,41]. Other factors that influence dietary choices include cultural preferences, parenting styles, and family dynamics [17]. Dental professionals should guide parents to not buy sodas and low-nutrient foods in an effort to discourage the formation of habits such as snacking and soda consumption that can contribute to caries. Parents may need to be guided to make healthy, affordable choices for themselves and their families. Also, parents can limit snacking by not allowing children to eat while watching television or playing video games. Educating parents about their influence and guiding them toward healthy food choices can benefit the entire family.
Eating habits start early and may be difficult to change, especially as time solidifies these behaviors [39,42]. Habits such as eating at the table, having a healthy breakfast, and eating fruits and vegetables can and should start in childhood; however, it is never too late to start these beneficial habits [40,43]. Through discussing habits with patients, dental professionals can encourage behaviors that will promote oral health and identify caries-promoting practices that need to be altered.
| A) | excessive caries in poor and near-poor populations. | ||
| B) | at least three carious teeth in a child younger than age 6 years. | ||
| C) | a genetic enamel disorder activated by poor oral hygiene. | ||
| D) | one or more decayed, missing, or filled tooth surfaces in the primary dentition of a preschool-age child. |
Because all teeth, once erupted, are susceptible to dental caries, even very young children are vulnerable. Early childhood caries (ECC) is defined as the presence of one or more decayed, missing (due to caries), or filled tooth surfaces in the primary dentition of a preschool-age child [49]. This condition is seen throughout the general population but is more common in the poor and near-poor preschool children. In the United States, it is estimated that between 3% and 6% of children have early childhood caries [50]. The National Institute of Dental and Craniofacial Research (NIDCR) has indicated that between the years of 2011–2016 that 23% of children between the ages of 2 and 5 years had carious lesions in their primary teeth and that children from lower-income families were twice as likely to have decay in their primary teeth compared to children from higher-income families [51]. Among children ages 6 to 11 years, 17% had decay in their permanent teeth [51].
| A) | before they are 3 months old. | ||
| B) | no later than their first birthday. | ||
| C) | between the ages of 1 and 2 years. | ||
| D) | between the ages of 3 and 4 years. |
To prevent ECC development, the American Academy of Pediatric Dentistry (AAPD) recommends that children have their first dental appointment soon after their first tooth erupts and no later than their first birthday [49]. Educating the child's primary caregiver about oral hygiene care for the child and proper use of bottles is one of the main objectives of this appointment. Sodas, juices, and other sugared drinks should not be given to children, or they should be given very sparingly, and they should never be dispensed through a bottle. Children using bottles should not be allowed to go to sleep with them unless the bottle contains water. The AAPD also advises eliminating the use of a baby bottle by age 12 months and avoiding foods and drinks that contain sugar for children under 2 years of age [49].
| A) | children. | ||
| B) | adolescents. | ||
| C) | adults. | ||
| D) | the elderly. |
Research shows that this age group responds to health behavior change requests through motivational interviewing (MI) techniques, rather than the traditional dissemination of information and dispensing of advice [53]. Motivational interviewing, a collaborative, goal-oriented form of communicating behavior change, has been shown to positively affect adolescents' change in diet, exercise, and compliance with medications. MI techniques that will help professionals better communicate oral healthcare principles with this age group and the mechanisms by which MI works to instill behavioral changes in adolescents is an area of continued research [54]. Among high school students between 2019–2021, approximately 16.5% of boys and 12.7% of girls had consumed one or more sugar-sweetened soda beverages each day [55,88]. Soda is included with other sugary products and those made with solid fats in the category of empty calories. Empty calories account for 30.2% to 34.4% of 9- to 13-year-olds' daily caloric intake and 30.5% to 35.5% of that of 14- to 18-year-olds [56]. Utilizing the principles of MI, the dental professional can work with each teenager to find easily accessible and tasty alternatives to sugar-laden foods. The Resources section contains links to websites that can be shared with young patients and their parents.
| A) | Not drinking enough water | ||
| B) | Side effects of medication | ||
| C) | Illicit drug use | ||
| D) | Rinsing with mouthwashes containing alcohol |
Saliva production can decrease with age [59,66]. Moreover, some medications are commonly associated with xerostomia. More than 500 medications have reduced saliva as a side effect [62,67]. The main medication classes associated with xerostomia include antidepressants, antihypertensives, antihistamines, antipsychotics, sedatives, anorexiants, antiparkinsonism agents, opioids, muscle relaxants, and diuretics [65]. Head and neck radiation therapy and the autoimmune disease Sjögren syndrome are other common causes of salivary gland dysfunction that results in dry mouth [62,68].
| A) | is metabolized by oral bacteria to produce acid that is detrimental to enamel. | ||
| B) | contributes to the remineralization of enamel. | ||
| C) | has 4 calories per gram. | ||
| D) | is not available in a toothpaste formulation. |
Xylitol, a sugar alcohol (polyol), is a sugar substitute that helps to prevent dental caries because oral bacteria are unable to break it down to an acid [49,75]. Xylitol also inhibits plaque formation, especially that of mutans streptococci, and has been shown to contribute to remineralization [76,77].
Nutritionally, xylitol has fewer calories than sugar—2.4 calories per gram versus approximately 4.0 calories per gram of sugar [76]. It is also safe for diabetic patients to consume, making it a wise choice for replacing sugar in patients' diets for reasons beyond caries control because xylitol lowers the insulin response compared to foods sweetened with sorbitol or ordinary sugar [78]. Replacing sugar with xylitol has been shown to cause a statistically significant reduction in S. mutans, which is the primary cariogenic bacterial species [79].
New studies are seeking to determine the efficacy and optimal dosage of erythritol, another polyol, for caries prevention. The efficacy of polyols to prevent caries when used to sweeten gum, candy, and food may be confounded by the presence of natural and added fluoride in the diets of the study participants. Some studies have revealed that the combination of xylitol and fluoride can reduce the biofilm in which the cariogenic bacteria reside [80].
Dosage recommendations for xylitol as an anticaries agent include several small exposures during the day, with a plateau effect for the reduction of the cariogenic bacterium S. mutans noted between 6.88 grams per day and 10.32 grams per day [76]. This can be accomplished by using toothpastes, gums, and mints that contain xylitol and using xylitol as a sugar replacement to sweeten foods and drinks. Xylitol can also be used in place of sugar in baking, but patients should be cautioned that consuming large quantities of xylitol may cause gastrointestinal upset.
| A) | severe halitosis. | ||
| B) | aphthous ulcers. | ||
| C) | gingival sensitivity. | ||
| D) | gastrointestinal upset. |
Dosage recommendations for xylitol as an anticaries agent include several small exposures during the day, with a plateau effect for the reduction of the cariogenic bacterium S. mutans noted between 6.88 grams per day and 10.32 grams per day [76]. This can be accomplished by using toothpastes, gums, and mints that contain xylitol and using xylitol as a sugar replacement to sweeten foods and drinks. Xylitol can also be used in place of sugar in baking, but patients should be cautioned that consuming large quantities of xylitol may cause gastrointestinal upset.
| A) | Poor oral hygiene | ||
| B) | Tooth alignment | ||
| C) | Mixed dentition | ||
| D) | Protein-rich diets |
Dental caries is a multifactorial disease. Counseling a patient who is at risk for caries requires the clinician to consider the various factors that can put patients at risk for, or protect them from, dental caries. In addition to caries-promoting diets and belonging to one or more of the high-risk populations discussed previously, the following are factors that can increase an individual's caries risk [15,28,83]:
Poor oral hygiene
Family history of poor dental health
Prolonged bottle- or breastfeeding
High bacterial titers of S. mutans
Intermittent dental care
Mental or physical disabilities that limit oral hygiene ability
Numerous multisurface restorations
Restorations with open or overhanging margins
Orthodontic appliances
Enamel defects and genetic tooth abnormalities
Radiation or chemotherapy treatments
Eating disorders
Alcohol and drug abuse
Smoking and vaping
| A) | Low caries risk | ||
| B) | Moderate caries risk | ||
| C) | High caries risk | ||
| D) | Unable to determine caries risk from the information provided |
There are several caries risk assessment tools available [4,84]. Practitioners need to find a tool that allows them to evaluate the variety of factors associated with caries risk as they begin to discuss how diet and nutrition affect the patient's risk for caries. Caries risk assessments categorize patients into one of three categories. A patient at low caries risk exhibits no caries risk factors and a dental history of no incipient or active caries lesions in the past three years. Patients at moderate risk for caries include those that had either one or two incipient or active caries lesions in the past three years or no caries history in the past three years but at least one caries risk factor. High caries risk is the determination given to patients who have developed three or more caries lesions (incipient or active) in the past three years, have low fluoride contact, present with multiple caries risk factors, or have severe xerostomia [85].
| A) | asthma. | ||
| B) | acid reflux. | ||
| C) | lyme disease. | ||
| D) | rheumatoid arthritis. |
Occasionally, a patient may benefit from a referral to a dietician, nutritionist, or primary care physician. This is especially true if a condition such as acid reflux, an eating disorder, or chemical dependency is suspected or confirmed.