Theory based interventions for caries related sugar intake in adults: systematic review

Finding the person behind caries disease: The dental caregivers' experiences of empowering patients to implement beneficial behavioral changes

OBJECTIVES

This study aimed to elucidate dental professionals' experiences of how to empower patients at risk of developing new or additional caries to promote caries-related preventive behavioral changes.

METHODS

Semi-structured in-depth interviews were conducted, audio-recorded, transcribed verbatim, and subjected to qualitative content analysis. To provide credibility and high-quality data, participant recruitment followed strategic sampling. The 10 participants included nine women and one man; six participants were dentists, and four were dental hygienists. In the data analysis, five descriptive and five strategic themes emerged that formed an overarching theme: Finding the person behind caries disease.

RESULTS

The results indicated that by initially getting to know the person behind the patient, trusting relationships and knowledge can be generated to successfully influence patients' behaviors related to caries. The five descriptive themes included: Building a treatment alliance, Understanding habitual patterns, Motivating for changes, Implementing new behaviors, and Preserving behavioral improvements. The descriptive themes each revealed a strategy theme containing several strategy proposals for initiating and supporting caries-preventing behavioral changes.

CONCLUSIONS

This study highlights the importance of establishing a treatment alliance to improve the patient's skills, knowledge, and motivation. It underscores the significance of recognizing the individual behind the patient, to facilitate optimal behavior change at the lowest possible level of treatment.

CLINICAL SIGNIFICANCE

Our findings could assist in strengthening caries-related health promotion, caries prevention, and understanding of oral health literacy techniques.

Components in downstream health promotions to reduce sugar intake among adults: a systematic review

Excessive sugar consumption is well documented as a common risk factor for many Non-Communicable Diseases (NCDs). Thus, an adequate intervention description is important to minimise research waste and improve research usability and reproducibility. A systematic review was conducted to identify components in published evidence interventions pertaining to the health promotions on reducing sugar intake among adults. The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and used the Mixed Methods Appraisal Tool (MMAT) for quality appraisal. The period for the selected study was from 2000 to 2022, and articles were retrieved from Web of Science (WOS), Medline, Scopus, and PubMed. The target population was adults aged 18 years old and above who underwent intervention to assess the changes in their sugar intake. Data sources and all human epidemiologic studies were included. Out of the 9,333 papers identified, 25 were included. The overall quality of evidence of the studies was considered moderate. Apart from the characteristics of the reviewed studies, components of interventions are including the basis of theoretical or model for the intervention, which majority use Social Cognitive Theory, followed by PRECEDE-PROCEED model, socio-ecological and process-improvement theories and Transtheoretical Model; providers, who are commercial provider, qualified nutritionist, professor of nutrigenomics and nutrigenetics, doctor, dietitian nutritionist, lifestyle coaches, and junior public health nurses; duration of the intervention and follow-up time, varies from as short as one month to as long as 24 months; material provided either softcopy or hardcopy; tailoring approach, based on the individual goals, the process of change, genotype analysis, beliefs, barriers, and sociocultural norms; delivery mechanism either face-to-face or technology-mediated; and tools to measure the sugar consumption outcome mostly used Food Frequency Questionnaire (FFQ), besides 24-h dietary recalls, and food diaries. There are various components in downstream health promotion to reduce sugar intake among adults that can be adapted according to the local health promotion and intervention context. More well-designed interventions using integration components are encouraged in further studies.

Comparing the effects of dietary sugars on cognitive performance and reaction time: A randomized, placebo- controlled and double-blind experimental trial

The aim of the study was to compare the effects of acute intake dietary sugars on cognitive performance and reaction time. This study was, randomized, placebo-controlled, double-blind experimental design, conducted with 75 healthy adults. At the beginning of the study, the participants (36 male, 39 female; 21.6 ± 1.3 years of age; body mass index: 21.59 ± 1.94 kg/m²) were randomly divided into equal five groups (n:15) (glucose (10 g), fructose (10 g), sucrose (10 g), saccharin (0.24 g), placebo), and received dietary sugars dissolved in 200 mL of water. Cognitive performance was determined with Cancelation Test, and the Simple Response Time and Ruler Drop Tests were used in order to response and reaction time of participants, respectively. General score of cognitive performance (0.93 ± 0.1), reaction (295 ± 20 ms), and response (204 ms) were highest in glucose and lowest in placebo (0.63 ± 0.1; 368 ± 22 ms; 251 ms, respectively) (p < .001). Saccharin groups had a higher reaction (312 ± 22 ms) and response (216 ms) time score compared to consumed fructose (316 ± 39; 227 ms), sucrose (354 ± 26; 246 ms), and placebo (368 ± 22; 251 ms) groups, respectively (p < .001). These findings show that differences in the absorption pattern and sweetness levels of sugar types may have different effects on cognitive performance and reaction time.

Infancy Dietary Patterns, Development, and Health: An Extensive Narrative Review

Correct dietary patterns are important for a child’s health from birth to adulthood. Understanding a child’s health as a state of entire physical, mental, and social well-being is essential. However, reaching adulthood in a complete health proper state is determined by feeding and dietary habits during preconception, pregnancy, or children infancy. Different factors, such as the mother’s lifestyle, culture, or socioeconomic status, are crucial during all these phases. In this review, we aimed to assess the long-term associations between infancy dietary patterns and health and their influence on development and growth. To reach this objective, a consensus critical review was carried out using primary sources such as scientific articles, and secondary bibliographic indexes, databases, and web pages. PubMed, SciELO, and Google Scholar were the tools used to complete this research. We found that high-income countries promote high-calorie foods and, consequently, obesity problems among children are rising. However, undernutrition is a global health issue concerning children in low- and middle-income countries; thus, parental socioeconomic status in early life is essential to children’s health and development, showing that biological, social, and environmental influences are increased risk factors for chronic diseases. This narrative review is aimed to collect evidence for early nutritional intervention and future disease prevention.

Children's and Parents' Marburg Sugar Index (MSI) Values: Are They Comparable?

Studies on children’s nutritional behaviour (CNB) rarely compare children’s answers regarding the frequency of their sugar intake with the respective statements of their parents. Therefore, data from a prevention study were used to analyse this aspect, as well as a potential correlation between Marburg Sugar Index (MSI) values and caries experience of children. The present study based its questionnaire data on CNB and caries data. Pairs of questionnaires filled in separately by children and parents of the participating families were dichotomised by either having completed the diet section entirely (Group A) or in part (Group B). The MSI scores were calculated separately for children and parents. The statistical confidence level was set at α = 0.05 (two-sided). Furthermore, the Pearson correlation coefficient was calculated and tested for “r = 0”. Additionally, a test for equality of the correlations was applied. The number of available questionnaire pairs was 429 in Group A and 400 in Group B. In both groups, significant correlations between children’s and parents’ MSI scores (A: r = 0.301, p < 0.001; B: r = 0.226, p < 0.001) were found. Using Spearman’s Rho, a significant correlation between MSI scores and children’s caries experiences was observed in Group A. MSI scores based on dietary questionnaires can be used to obtain consistent information on children’s CNB provided by the children themselves or their parents. This is true even when the MSI score has to be calculated on the basis of incomplete questionnaires. Questionnaire-based CNB information can improve the effectiveness of individual or group preventive measures supplemented by individually adapted nutritional counselling.

The Association between Nutritional Alterations and Oral Lesions in a Pediatric Population: An Epidemiological Study

The oral conditions of an individual are the result of different factors, including the subject's genotype, oral hygiene habits, the type of diet, and lifestyle, such as smoking. Nutrition in the first years of life can affect dental health for a long time. To prevent mouth diseases, it is also important to eliminate unfavorable eating behaviour and to amplify protective ones. Eating habits, especially in pediatric age, are an easily modifiable and controllable factor, and diet, in addition to influencing the health of the oral cavity, plays a fundamental role in systemic health. Indeed, a sugar-rich diet can lead to conditions, such as diabetes, being overweight, and obesity. The present research was an epidemiological study, with the aim of highlighting some of the associations between nutrition and oral health. In particular, we studied those lesions of hard and soft tissues that are diagnosed most frequently by dentists: caries, enamel hypoplasia, periodontal disease, and aphotoxic lesions and their associations with nutritional deficiencies and excesses including proteins, vitamin A, vitamin D, B vitamins, and iron and calcium minerals. To perform this study, we recruited 70 patients from the pediatric and orthodontic clinics, aged between 3 and 15 years (y), with mean age of 10.4 y.o. The study was conducted by providing a questionnaire to pediatric patients' (supported from their parents or guardians) on individual eating habits, followed by an accurate oral cavity specialistic examination. The nutritional data were processed by using Grana Padano Observatory (OGP) software, freely provided online by the OPG. The statistical tests performed were the chi-square (χ²) for independence, and Cramér's V test was used to evaluate the associations between eating habits and oral pathologies. The results showed that certain nutritional vitamin deficiencies and nutritional excesses were associated with definite oral pathologies.

A feasibility and acceptability study of an e-training intervention to facilitate health behaviour change conversations in dental care settings

Introduction Health behaviours result in oral health problems. Behaviour change techniques, informed by behaviour science, are rarely utilised by dental care professionals (DCPs) within routine care.Aim To develop a theory-informed intervention to support DCPs' behaviour change conversations and evaluate its feasibility and acceptability.Intervention A behaviour change toolkit (Toothpicks) comprising 33 behaviour change techniques relevant to dentistry, delivered within an interactive online course.Design Development and mixed-methods evaluation of the intervention.Materials and methods Participants' motivation to discuss behaviour change with patients was measured before and after training using a validated questionnaire. Acceptability was assessed through semi-structured interviews.Results DCPs' (N = 32) motivation increased significantly post-training. Participants found the training acceptable and reported subsequently implementing techniques into their practice. Potential barriers preventing implementation to clinical practice include perceived lack of opportunities to effect change within the constraints of the clinical context.Conclusions Acceptable theory-informed training that is acceptable and accessible can be developed that increases DCPs' motivation to discuss behaviour change with patients. Further research is necessary to establish the longer-term impact of brief behaviour change training on DCPs' clinical practice and patient health behaviours.

Mobile Apps for Dental Caries Prevention: Systematic Search and Quality Evaluation

Background

Dental caries is the most common multifactorial oral disease; it affects 60% to 90% of the global population. Dental caries is highly preventable through prevention behaviors aimed at improving oral hygiene, adequate fluoride usage, and dietary intake. Mobile apps have the potential to support patients with dental caries; however, little is known about the availability, target audience, quality, and features of these apps.

Objective

This review aims to systematically examine dental caries prevention apps; to describe their content, availability, target audience, and features; and to assess their quality.

Methods

We systematically identified and evaluated apps in a process paralleling a systematic review. This included a search strategy using search terms; an eligibility assessment using inclusion and exclusion criteria focused on accessibility and dental caries self-management behaviors, including oral hygiene, dietary intake, and fluoride usage; data extraction on app characteristics, including app store metrics; prevention behavior categorization; feature identification and description; a quality appraisal of all apps using the validated Mobile App Rating Scale (MARS) assessment tool; and data comparison and analysis.

Results

Using our search strategy, we retrieved 562 apps from the Google Play Store and iTunes available in Australia. Of these, 7.1% (40/562) of the apps fit our eligibility criteria, of which 55% (22/40) targeted adults, 93% (37/40) were free to download, and 65% (26/40) were recently updated. Oral hygiene was the most common dental caries prevention behavior domain, addressed in 93% (37/40) of the apps, while dietary intake was addressed in 45% (18/40) of the apps and fluoride usage was addressed in 42% (17/40) of the apps. Overall, 50% (20/40) of the apps addressed only 1 behavior, and 38% (15/40) of the apps addressed all 3 behaviors. The mean MARS score was 2.9 (SD 0.7; range 1.8-4.4), with 45% (18/40) of the apps categorized as high quality, with a rating above 3.0 out of 5.0. We identified 21 distinctive features across all dental caries prevention behaviors; however, the top 5 most common features focused on oral hygiene. The highest-ranking app was the Brush DJ app, with an overall MARS score of 4.4 and with the highest number of features (n=13). We did not find any apps that adequately addressed dental caries prevention behaviors in very young children.

Conclusions

Apps addressing dental caries prevention commonly focus on oral hygiene and target young adults; however, many are not of high quality. These apps use a range of features to support consumer engagement, and some of these features may be helpful for specific patient populations. However, it remains unclear how effective these apps are in improving dental caries outcomes, and further evaluation is required before they are widely recommended.

A behavioural intervention for young adults with dental caries, using acceptance and commitment therapy (ACT): treatment manual and case illustration

Background

There is a need for effective behavioural interventions in dentistry. This paper presents an innovative behavioural intervention for young adults with dental caries, in an interdisciplinary collaboration between dental personnel and licensed psychologist in general dental care. The intervention has been evaluated in an RCT, with positive effects on oral health behaviour.

Method

The intervention, Acceptance and Commitment Therapy (ACT), a recent form of cognitive behaviour therapy (CBT), was adapted to young adult patients (18–25 years of age) with high dental caries activity.

Results

The intervention included two individual sessions, provided by a clinical psychologist at general dental clinics. The rationale for selecting ACT as the theory base is presented, together with the treatment manual and a case illustration.

Conclusions

ACT may be a promising alternative for behavioural interventions in dentistry for patients with oral diseases, specifically dental caries. Interprofessional collaboration between psychologists and dental personnel opens up for new possibilities to help and treat patients with various health issues in public dental care.

Trial registration

TRN ISRCTN15009620www.isrctn.com, retrospectively registered 14/03/2018.

Behavioral Sciences in the Promotion of Oral Health

The importance and value of behavioral sciences in dentistry have long been recognized, and their contribution to dental education, research, clinical practice, and oral health policy has been significant over the past half century. Over time behavioral sciences have expanded our understanding of oral health beyond "disease" to a broader biopsychosocial concept of oral health. This in turn has led dentistry away from a focus of "treatment" to oral health "care," notably in the new millennium. Key oral health behaviors have been identified for more than half a century: the importance of diet, oral hygiene, dental services, and other factors. Various behavioral models and theories have been proposed, particularly since the 1970s, providing useful frameworks with sound psychological basis to help understand the paths of oral health behaviors. These models draw on theories of self-efficacy, motivation, counseling, and "behavior change." Since the 1980s, there has been a greater understanding that these behaviors often share a common pathway with the etiology of other diseases (common risk factors). Furthermore, the relationship between individual factors and the broader environmental factors has been increasingly emphasized since the 1990s, leading to a united call for action in addressing oral health inequalities. Within the past decade, there are useful examples of models, frameworks, and techniques of behavior change with respect to oral health, involving planning, prompting, encouraging, goal setting, and/or motivating. In particular, there is a growing interest and use of motivational interviewing. Likewise, behavioral therapies, such as cognitive behavioral therapy, are increasingly being employed in dental practice in the management of dental anxiety, pain, and psychosomatic dental and oral problems, with promising results. Recommendations are outlined for future directions for behavioral sciences in the promotion of oral health.

The Psychological Models of Health-related Behavior in Understanding Sugars Intake in Adults: A Review

Free sugars intake plays a major role in dental caries formation and other general health issues such as obesity. Therefore, interventions, which assist individuals or populations in the control of their free sugars intake, are of central importance in caries prevention strategies. There is good evidence that behavioral interventions benefit from a foundation in conceptual theories of behavior change founded on empirical data. In this review, we discuss the future application of seven theories, including six common psychological theories in predicting and developing interventions to reduce free sugars intake related to dental caries among adults. For each model, we summarize its key features and the data derived from its application in general and oral health settings and make recommendations for future research. We searched Medline, PsycINFO, Global Health, PubMed, and Embase databases to identify items dealing with dental caries, adults, sugars intake, and six psychological theories. These included the Transtheoretical Model of Change, Theory of Planned Behavior, Social Cognitive Theory, Information-Motivation-Behavioral Skills model, PRIME Theory, and Behavior Change Wheel theories. We searched literature published in the last 10 years, and priority was given to systematic reviews and randomized control trials. Although there is extensive literature on the application of the six psychological theories, there is a gap in knowledge about their effectiveness in reducing free sugars intake related to dental caries among adults. There is a need for better-designed trials of interventions based on the clear operationalization of psychological constructs to reduce sugars intake among the adult population.

Added Sugar and Dental Caries in Children: A Scientific Update and Future Steps

Excess added sugars, particularly in the form of sugar-sweetened beverages, is a leading cause of tooth decay in US children. Although added sugar intake is rooted in behavioral and social factors, few evidence-based, theory-driven socio-behavioral strategies are currently available to address added sugar intake. Dental health professionals are in a position to help identify and address problematic sugar-related behaviors in pediatric patients and advocate for broader upstream approaches, including taxes, warning labels, and policy changes, that can help reduce added sugar intake, prevent tooth decay, and improve health outcomes in vulnerable child populations.

Can a brief psychological intervention improve oral health behaviour? A randomised controlled trial

Background

Dental caries is a major public health issue affecting a large proportion of the general population. The disease is associated with behavioural factors and is thus preventable to a high degree. Individuals may need assistance to be able to change their oral health behaviour. There is a lack of such interventions for adults affected by severe caries. The aim of the study was to evaluate the effect of Acceptance and Commitment Therapy (ACT), a form of cognitive behavioural therapy, on oral health behaviour in young adults with poor oral health.

Methods

The study included a two group parallel randomised controlled trial at general dental clinics, with young adults, 18–25 years of age, ≥ two manifest proximal dental caries lesions (n = 135); 67 were treated with ACT and 68 with standard disease information only, respectively. Primary outcomes: oral health behaviours (tooth-brushing, flossing, use of toothpicks, and additional fluoride use). The CONSORT principles for RCTs were used, including intention-to-treat and per protocol analyses. The Chi-square, Mann-Whitney, and Wilcoxon Signed Rank tests were applied, including effect sizes.

Results

The study groups did not differ with regard to oral health behaviour variables at baseline. The intervention group improved all their oral health behaviours significantly over time (effect sizes, 0.26–0.32), while the control group showed improved behaviours on two measures (flossing and additional use of fluoride, effect sizes, 0.22–0.23).

Conclusions

By testing a psychological intervention on young adults (18–25 years of age) with a high prevalence of caries, we found an immediate positive effect with improved oral health behaviours.

Trial registration

TRN ISRCTN15009620, retrospectively registered 14/03/2018.

The Joint ORCA-EADPH Symposium on Sugar: The Oral Health Perspective - A Commentary

Caries is the most prevalent chronic condition worldwide and the association between high-level intake of sugars and dental decay is strong and well established. Interestingly, to combat caries, dental practitioners and public health dentists in many countries have focused mainly on the application of different kinds of fluorides and fissure sealants but not on the reduction of sugar intake. Furthermore, for many years, sugars have not been the focus of dental research activities presented at the annual conferences of the European Organisation for Caries Research (ORCA) and the European Association of Dental Public Health (EADPH). In 2015, following the publication of the new WHO guidelines on the intake of sugars, the boards of ORCA and EADPH agreed to organize a common symposium entitled "Joint ORCA-ADPH Symposium on Sugar: The Oral Health Perspective". This symposium was organized by a scientific committee and took place on July 6, 2016, in association with the 63rd ORCA Congress in Athens, Greece. It included 9 lectures highlighting different aspects of sugar consumption, contribution of sugar to dental caries, measuring sugar consumption, and fighting against sugar on a patient and public health basis. The purpose of this commentary is to give background information about the rationale of the above-mentioned symposium.