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Supporting Your practice

Helping Patients with Erosive Tooth Wear Change Dietary Habits

For patients with dental erosion and sensitive teeth, consumption of acidic drinks (like pop and juice) and fruits can be a contributing factor to these conditions. Dr. Saoirse O’Toole, clinical lecturer in prosthodontics at King’s College London, is the lead researcher on a series of studies 

1–3 that examined the impact of acidic food and drinks on tooth wear and hypersensitivity and tried to identify more effective ways to encourage patients to change their dietary habits. We asked her to tell us more about her findings.

Why were you interested in studying dental erosion?I think we’re all seeing an increase in the prevalence of tooth wear; several reviews have shown that the prevalence is increasing globally. Part of my research shows the impact of diet on tooth wear and identifies the underlying risk factors.

What does your research show?We found that the frequency of dietary acid intake—of fruits like apples, citrus and berries, and drinks like carbonated beverages, fruit drinks, fruit teas and wine, particularly between meals—is an important factor in erosive tooth wear, which wasn’t surprising. But it’s important for patients to know that it’s the daily intake of acidic drinks and foods that matters.

So only asking a patient what acidic drinks/foods they consume may not pick up on their risk factors. They need to be having acids multiple times a day and this may mean the same type of acid (e.g., three cans of cola a day) or different types of acid (e.g., orange juice in the morning, fruit as a snack and a glass of wine in the evening). This was fine if it was once or twice a week. But if they did it every day, we started to see an increased risk of tooth wear.

How many acidic intakes per day is acceptable?We found that every single additional intake of an acidic food or drink dramatically increased an individual’s risk of tooth erosion. One a day or less was not associated with increased risk. With two daily intakes, an individual was two times more likely to have erosive tooth wear, compared to an intake of one. With three or more daily intakes of an acidic food or drink, the risk jumps up considerably; an individual was 13–14 times more likely to have erosive tooth wear.

saoirse.otoole@ kcl.ac.uk

Dr. Saoirse O’Toole

The views expressed are those of the author and do not necessarily reflect the opinions or official policies of the Canadian Dental Association.

We think behaviour change intervention is more effective than advice alone in helping patients change their dietary habits.

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Visit CDA Oasis to hear Dr. O’Toole

discuss her research findings and behaviour

change intervention to help patients change

their dietary habits: wp.me/p2Lv6A-604

Does it matter if the acidic foods/drinks are consumed with meals? Yes, the risk was almost halved when these were had with meals. There were also different risks for drinks than for fruit. When fruit was consumed with meals there was no increased risk of tooth wear even when fruit was had with every meal. But when fruit was consumed outside of meals, the risk of tooth wear increased with the number and frequency of fruits eaten between meals.

In contrast, acidic drinks were significantly associated with tooth wear, whether a person drank them with meals or between meals.

What kind of advice can we give to patients who are concerned about tooth erosion?There is good evidence to suggest that only giving patients dietary advice like “Cut down on the amount of juices or carbonated drinks you have,” is ineffective in changing behaviours. So our research team developed a behaviour change technique called an “If-Then Plan,” which helps individuals plan how to make the change.

In a randomized controlled trial, we gave basic dietary advice to half the group, while we gave the other half an If-Then Plan. We found that both groups claimed they reduced their dietary acid intake but only those who had the If-Then Plan actually showed a reduced amount of tooth wear over the six-month period. So we think the behaviour change intervention is more effective than advice alone in helping patients change their dietary habits.

How does an If-Then Plan work?The If-Then Plan gets the patient to identify the behaviour they want to change, the dietary substitution they would make, and the steps they would take to make a change, which involves identifying any obstacles to making a substitution and how they might

overcome that obstacle. For instance, I tell my patients, “If you want to have an acidic fruit or drink, have it less than daily and then if you are going to have it, try to have it with a meal.” And then I also try and incorporate some type of planning. So I might say, “When you go for your juice in the morning, what could you have instead?” And then they will usually say something like, “Oh, I’ll just have water,” which I think the patient may find to be an unsatisfying substitution. So I’ll say, “Is that going to be a nice enough drink for you, or is there something else that you’d prefer?” Or if they usually have a cola drink, I ask if they are looking for the fizziness or the caffeine, and then ask what would help them make a change.

How does an If-Then Plan differ from Motivational Interviewing techniques?Motivational Interviewing (MI) has also been tried in dental practice to change behaviours and there is evidence showing that it can be effective. However, MI techniques require intensive training and are reliant upon a good rapport between the patient and the clinician. This may not be possible to build in a single dental examination. In contrast, this behaviour change intervention is directive and prescriptive while requiring little training. The clinician and the patient quickly identify which behaviour they are going to target, make specific plans to target the behaviour, discuss obstacles to the specific behaviour change and plan to overcome these obstacles. This can be done objectively without establishing a strong bond. Planning actions have been successful regardless of motivation levels of the patient, which again contrasts with motivational interviewing techniques.

What were your findings on dentin hypersensitivity?We know that dietary acids can cause dentine hypersensitivity. Our research showed that factors related to how the food or drink is consumed, in terms of the contact time with dietary acids, was a bigger predictor of dentine hypersensitivity than it was of tooth wear. People with dentine

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Supporting Your practice

hypersensitivity were more likely to report a drinking habit such as sipping, swishing or holding drinks in the mouth, compared to those without dentine hypersensitivity. So those with dentine hypersensitivity might not always have tooth wear, and people with tooth wear might not have dentine hypersensitivity. a

References1. O’Toole S, Bernabé E, Moazzez R, Bartlett D. Timing of dietary acid intake and erosive tooth wear: A case-control study. J Dent. 2017; 56:99-104. 2. O’Toole S, Bartlett D. The relationship between dentine hypersensitivity, dietary acid intake and erosive tooth wear. J Dent.2017;67:84-87.3. O’Toole S, Newton T, Moazzez R, Hasan A, Bartlett D. Randomised Controlled Clinical Trial Investigating The Impact of Implementation Planning on Behaviour Related to The Diet. Sci Rep. 2018;8(1):8024.

Carbonated flavoured drinks

Water, Sparkling Water,

Milk*, Tea,

Coffee

• If you do have carbonated drinks, have them as infrequently as possible and over a short time period.

• Try not to sip, swish or hold the drinks in your mouth.

Juices Water, Milk*,

Tea, Coffee

• If you are going to have juices try and drink them only with meals.

• Try and dilute them with water to gradually wean yourself off the taste.

Wine, Beer, Cider, Spirit with mix

It is always better to drink alcohol with meals.

• Remember to drink alcohol sensibly• Most mixers are acidic so try to

cut down on these outside of meals.• Try to avoid putting slices of lemons/limes

in your drink.

Fruits as snacks Vegetables – carrot sticks, celery sticks, cucumber, peppers; Nuts; Cheese*

• Try and eat fruits with meals, as a dessert.• If you can, snack on vegetables. • If you are going for a fruit as a snack avoid

citrus fruits and apples. Try a banana or a plum instead.

• Try to eat the fruit over a small time period, i.e. have 10 strawberries/grapes at once rather than nibbling on one every few minutes.

• Try to eat any acidic foods with something that contains calcium e.g. yogurt* or milk*

Vinegars, pickles, ketchups, lemon juice-based dressings

Mayonnaise* • Try to reduce the amount of these dressings that you put on foods

• If you can, avoid having them on foods in between meals

For thisSwap this Helpful tips

*Try to choose low-fat alternatives

Dietary Tips for Preventing Erosive Tooth WearProtecting your teeth against acid attack should be part of an overall balanced diet and these suggestions should help you keep to an eating pattern which is healthy – not too high in fat, salt, sugar and alcohol with plenty of vegetables and fruit at mealtimes.

pAtieNt resourCe: The following diet prompt sheets were used in Dr. O’Toole’s study on patient behaviour change3 and have been adapted and reprinted in CDA Essentials, with permission.

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Vegetables

Breadsticks, crackers (unsalted)

Tortilla chips (baked, not fried)

Cheeses*, milk-based products (e.g. natural yogurt)

Nuts, pumpkin seeds, sunflower seeds, hummus

Plain popcorn (not sweetened or buttered)

Between Meals: How to Avoid Acid AttackTo stop the damage that acidic foods are doing to your teeth you need to make small adjustments in the way you eat and drink some foods. You can do this in three ways.

Choose alternative snacks and drinks to reduce how often you have acidic drinks and foods. When you do have acidic foods, have them with other foods, at mealtimes rather than snacks. Make sure that acidic foods and drinks are in contact with your teeth for the shortest time possible (e.g., eat things at one

sitting, use a straw for drinks, not sipping or holding drinks in your mouth).

SAFE Snacks between meals

Drinks to AVOID between meals

Foods to AVOID between meals

Water

Milk*

Tea/coffee without sugar

Herbal teas without fruits/citrus flavour

Fruits, particularly citrus fruits

Tomatoes

Vinegars particularly apple cider vinegar, pickles, ketchups

Lemon juice-based salad dressing

Carbonated drinks except unflavoured sparkling water.

Carbonated diet drinks, sports and energy drinks

All juices, particularly citrus fruit juices

Smoothies

Vitamin C drinks

Beer and wine

Fruit teas, herbal teas with fruit/citrus

SAFE Drinks between meals

* Choose low-fat options when available