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• Published: 25 January 2019

Experts set top priorities for oral health research

British Dental Journal volume  226 ,  page 92 ( 2019 ) Cite this article

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Dental health professionals, members of the public, patients, and carers have for the first time worked together to identify the most pressing unanswered research questions on how to improve oral and dental health for individual patients, communities and the population.

In 2017, a partnership between the National Institute for Health Research (NIHR) Clinical Research Network Oral and Dental Health Specialty Group in collaboration with the Dental Schools Council and Public Health England (PHE) was launched to identify unanswered questions relating to oral and dental health research from a patient, public and clinical perspective.

The work has taken 18 months to complete and identified gaps in knowledge about oral and dental care using a method tested by the James Lind Alliance, the non-profit making initiative established to bring patients, carers and clinicians together in Priority Setting Partnerships (PSPs) to identify and prioritise unanswered questions or evidence uncertainties.

Despite improvements, dental health remains a major public health problem, according to the NIHR, pointing to the fact that a quarter of five-year-olds in England have had tooth decay and nearly three times as many children from the poorest families are affected than those from the richest.

The new priorities, 1 published on 19 December 2018, are:

What is the best way to prevent tooth decay, and reduce oral health inequalities at a community or population level?

How can access to dental services be improved for the general public?

What are the most effective ways of increasing early detection/diagnosis of oral cancer?

How can access to dental services be improved for people with additional needs?

How can dental health professionals work with other health professionals to help improve oral health?

How can basic oral hygiene be achieved for people with additional care needs?

How to improve communication between dental teams and patients/carers?

Is there a role for dental health professionals in treating oral health problems to improve general health?

What is the best way to prevent gum disease, and reduce oral health inequalities at a community or population level?

What role do digital technologies play in the provision of dental care?

Professor Peter Robinson of the University of Bristol and the NIHR who led the Priority Setting Partnership said: 'It is hugely important to have worked with our patients and the general public to have identified these Top 10 questions.

'With 60 million patients nationally and so many different diseases to consider, these priorities will help researchers concentrate on the most pressing problems. Agencies who fund research have already said they will focus their efforts on the topics we have identified today, that means the questions we have identified today will now be answered in the next few years.'

National Institute for Health Research. The Top 10 Priorities for Oral and Dental Health Research. 2018. Available at https://www.nihr.ac.uk/nihr-in-your-area/oral/documents/JLAOralandDentalPSPFinalTop10Priorities.pdf (accessed January 2019).

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Experts set top priorities for oral health research. Br Dent J 226 , 92 (2019). https://doi.org/10.1038/sj.bdj.2019.66

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Oral Epidemiology

A Textbook on Oral Health Conditions, Research Topics and Methods

• © 2021
• Marco A. Peres 0 ,
• Jose Leopoldo Ferreira Antunes 1 ,
• Richard G. Watt 2

National Dental Research Institute, National Dental Centre Singapore, Singapore

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School of Public Health, University of São Paulo Faculty of Public Health, São Paulo, Brazil

Dept. of epidemiology and public health, university college london, london, uk.

• Reviews the international literature regarding a wide range of oral health conditions
• Describes prevalence, disease-specific measures, and associated factors
• Discusses cutting-edge research topics
• Describes epidemiological methods and tools

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Table of contents (34 chapters)

Front matter, oral health diseases and disorders, the contribution of epidemiology to oral health research.

• Marco A. Peres, Jose Leopoldo Ferreira Antunes, Richard G. Watt

Global Burden of Oral Conditions

• Wagner Marcenes, Eduardo Bernabé

Dental Caries

• Karen Glazer Peres, Marco A. Peres, Jose Leopoldo Ferreira Antunes

Epidemiology of Periodontal Diseases

• Vibeke Baelum, Rodrigo López

Malocclusions

• Karen Glazer Peres, Paulo Frazão, Carlos Flores-Mir

Orofacial Pain

• Mario Vianna Vettore, Gabriela de Almeida Lamarca

Dental Fluorosis: Epidemiological Aspects

• Loc G. Do, Diep H. Ha

Traumatic Dental Injuries

• Carlos Alberto Feldens, Fernando Freitas Portella, Paulo Floriani Kramer

Epidemiology of Cleft Lip and Palate

• Kaye Roberts-Thomson

Enamel Defects

• David J. Manton, Felicity Crombie, Falk Schwendicke

Oral Cancer

• Jose Leopoldo Ferreira Antunes, Tatiana Natasha Toporcov, Maria Gabriela Haye Biazevic, David I. Conway

Dental Erosion

• Karen Glazer Peres, Fabiana Vargas-Ferreira
• Paulo Nadanovsky

Oral Lesions in Soft Tissues

• Sandra Beatriz Chaves Tarquinio, Marco A. Peres, Luísa Jardim Corrêa de Oliveira, Karine Duarte da Silva

Causal Inference in Oral Health Epidemiology

• Gustavo G. Nascimento, Benjamin W. Chaffee

Socio-Economic Inequalities in Oral Health

• Ankur Singh, Jose Leopoldo Ferreira Antunes, Marco A. Peres
• Public oral health
• Research methods in oral health
• Oral diseases
• Inequalities in oral health
• Dental public health
• Epigenetic in oral health

About this book

Editors and affiliations.

Marco A. Peres

Jose Leopoldo Ferreira Antunes

Richard G. Watt

About the editors

Marco A Peres is a dentist, graduated in the School of Dentistry, University of Sao Paulo Brazil, with a PhD in Epidemiology. Marco was an Associate Professor of Department of Public Health, Federal University of Santa Catarina, Brazil (1995-2012), Director of the Australian Research Centre for Population Oral Health (ARCPOH), University of Adelaide, Australia (2012-2018),  a Professor of Dental and Oral Health Research, School of Dentistry and Oral Health, Griffith University, Australia (2018-2020). Currently, Marco is a Professor at the National Dental Research Institute Singapore, National Dental Centre Singapore and Oral Health ACP, Health Services and Systems Research Programme, Duke-NUS Medical School, Singapore.

His research areas of interest include health services research, data linkage, oral health surveillance, use of fluorides, inequalities in oral health, life course epidemiology and the relationship between oral health and general health. Marco is afounder member of the International Centre for Oral Health Inequalities Research and Policy (ICOHIRP) based at University College London, United Kingdom, a member of the Brazilian Commission of Social Determinants of Health and a member of the Global Burden of Metabolic Risk Factors for Chronic Diseases Collaboration, the deputy chair of the Expert Working Group for Fluoride of the Australian and New Zealand Nutrient Reference Values for Fluoride, a member of the Oral Health Expert Group of the Australian Burden of Diseases 2011 Study, and a member of the Australian Dental Association Oral Health Tracker Expert Group.

Marco is an internationally recognised researcher in the field of Population Oral Health and Oral Epidemiology, he has been cited in a paper published in 2016 in Community Dentistry and Oral Epidemiology (doi: 10.1111/cdoe.12249) as the seventh most productive researcher in Public Health Dentistry in the world in the last half - century. Marco was the recipient of the 2017 International Association for Dental Research (IADR) Distinguished Scientist Award for Global Oral Health Research. Currently Marco is the Vice-president of the IADR Global Oral Health Inequalities Research Network (GOHIRN).

Marco was on the Editorial Board of the Community Dentistry and Oral Epidemiology (2010-2012) and is currently Associate Editor of Revista de Saude Publica/Journal of Public Health (2015-) and Brazilian Journal of Epidemiology (2012-) and member of the Advisory Board of the Australian Dental Journal (2016-).

In the past 10 years Marco has given oral presentations at 45 conferences in Australia, Brazil, USA, UK, Finland, Spain, Portugal, Italy, Poland, Canada, Uruguay, South Korea, Singapore, Japan, and Thailand.

Marco has supervised 38 Honours, Masters and PhD students in Public Health, Dentistry and Epidemiology, authored three books, fifteen book chapters and more than 250 peer reviewed papers. His work has received more than 13,000 citations, an H index of 65.

Jose Leopoldo Ferreira Antunes is Professor of Epidemiology and Head of the Department of Epidemiology at the School of Public Health, University of São Paulo (USP), Brazil. Dr. Antunes was awarded his Bachelor’s degree in Social Sciences from USP in 1984 and went on to gain an MSc and a PhD in Sociology at the university before completing a postdoctorate in Dentistry (2005). He has acted as a researcher of the National Council for Scientific and Technological Development since 2001 and became a Full Professor in 2010. In 2003 he was named an Eminent Scientist of the Year (Brazil, South America), a World Scientist Forum International Award of the International Research Promotion Council. Dr. Antunes is Editor in Chief of Revista de Saude Publica and an Associate Editor of Oral Diseases . He is the author of almost 200 publications, including many in leading journals in the field.

Richard G. Watt is Professor and Honorary Consultant in Dental Public Health, Department of Epidemiology and Public Health, University College London (UCL), UK. He is Director of Research, Development & Innovation and an Honorary Consultant in Dental Public Health for the Central North West London NHS Foundation Trust. His previous posts include Head of Department, Research Department of Epidemiology and Public Health, UCL. In 2014 he received a Distinguished Scientist Award for Behavioural, Epidemiologic and Health Services Research from the International Association for Dental Research, and in 2016 an NIHR Senior Investigator Award.  He has received numerous research grants and fulfiled a variety of leadership roles on research and advisory committees and groups. He is the author of 238 publications in total.

Bibliographic Information

Book Title : Oral Epidemiology

Book Subtitle : A Textbook on Oral Health Conditions, Research Topics and Methods

Editors : Marco A. Peres, Jose Leopoldo Ferreira Antunes, Richard G. Watt

Series Title : Textbooks in Contemporary Dentistry

DOI : https://doi.org/10.1007/978-3-030-50123-5

Publisher : Springer Cham

eBook Packages : Medicine , Medicine (R0)

Copyright Information : Springer Nature Switzerland AG 2021

Hardcover ISBN : 978-3-030-50122-8 Published: 20 October 2020

Softcover ISBN : 978-3-030-50125-9 Published: 20 October 2021

eBook ISBN : 978-3-030-50123-5 Published: 19 October 2020

Series ISSN : 2524-4612

Series E-ISSN : 2524-4620

Edition Number : 1

Number of Pages : XVIII, 536

Number of Illustrations : 50 b/w illustrations, 54 illustrations in colour

Additional Information : Originally published by Livraria Santos Editora Ltda., São Paulo, 2013

Topics : Dentistry , Public Health

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Innovate to Elevate: Exploring the Trends in Public Health & Community Oral Health Research and Practice

Dr. Carolina Borges has worked as a public health leader, professor, and consultant for over 15 years. She is an experienced social Epidemiologist, Doctor of Dental Surgery, and holds a PhD in public health dentistry (UFMG/Brazil) with a fellowship at Harvard C.H. Chan School of Public Health. She holds a MPH/Epidemiology (UFSC/Brazil). She co-led three humanitarian missions in Haiti for three years in a row. She has passionately taught public health to over 2,500 students. She served as a senior Epidemiologist at Princeton Health Department during Covid-19 pandemic (2020-22). 

Dr. Borges was appointed as a Visiting Scientist at Harvard University (2020-21) to investigate social capital and trust. She founded the Social Epidemiology Lab, research focused on social epidemiology, health (in)equity & social determinants of health. She has published several papers and abstracts in scientific journals. Currently, she is an Associate Professor at The College of New Jersey where she co-founded the department of Public Health.

Disclosure: Dr. Borges has no relevant financial relationships to disclose.

Course Description

This lecture will provide an overview of the latest trends driving advancements in Dental Public Health and Community Oral Health - research and practice - globally and in the U.S. To understand how innovations serve as a catalyst for enhancing Community Oral health practices, it is crucial to identify some of the major root causes of persistent disparities in oral health outcomes. Implications of innovation in decreasing these disparities will be discussed. Additionally, we are going to present groundbreaking innovations, including technological advances and new methodologies, that have been transforming the present and future of Dental Public Health initiatives. We will explore how innovation can positively impact oral health outcomes including, health equity, disease prevention, oral health promotion, and access to oral care of high quality among diverse populations.

Educational Objectives

• Identify the current trends and innovations in Dental Public Health and Community Oral Health research and practice.
• Explore best practices of interdisciplinary collaborations to enhance innovation in community oral health interventions and programs.
• Comprehend the positive impact of innovation on health equity, oral health promotion, disease prevention, and access to oral care globally and in the U.S.  

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May 22, 2024

12:00 PM - 01:00 PM ET

CE CREDITS - 1.0

LL19A/B, Penn Dental Medicine

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Oral Hygiene in Adolescence: A Questionnaire-Based Study

Associated data.

The data presented in this study are available on request from the corresponding author.

Oral health is fundamental to our well-being, especially in adolescence. The aim of this study is to investigate oral hygiene knowledge through a questionnaire in a sample of adolescents, paying particular attention to those wearing orthodontic braces. The study was designed as a descriptive report of a local survey. An anonymous questionnaire was distributed to individuals born between 2000 and 2005, both on paper and online. Among 213 adolescents answering the questionnaire, 206 went to the dentist at least once (most of them between 5 and 9 years old), and 144 experienced at least one session of professional oral hygiene. Approximately 83% of the sample brushed their teeth at least twice a day, while only 7% used dental floss daily. Only 54% of respondents wearing orthodontic braces were advised to undergo professional oral hygiene during their orthodontic treatment. Education on oral hygiene at home came only from their parents for 61% of the whole sample. Most respondents had their first visit to the dentist apparently too late. Flossing was rare, whether the adolescents wore orthodontic braces or not. In many cases, professional oral hygiene was not common during orthodontic treatment. Adolescents did not learn about oral hygiene from a dental specialist.

1. Introduction

During adolescence, we grow up both physically and psychologically [ 1 ]. From a biological standpoint, adolescence coincides with an increase in hormone levels that leads to complete sexual maturity, which becomes apparent with a physical remodeling of adipose tissue and muscle, growth of genitals and development of secondary sexual characteristics [ 2 ]. Along with physical development, adolescents experience personal growth deriving from social, cognitive and emotional experiences.

Like every other part of the body, the oral cavity is also affected by physical and psychological changes associated with this phase of development. Increasing sexual hormones during puberty have a marked effect on the composition of subgingival bacterial flora showing higher levels of Gram-negative bacteria compared to earlier or later stages of life [ 3 , 4 ]. One of the first bacteria to be identified as growing, particularly in this age group, is Prevotella intermedia , which relies on estrogen and progesterone as growth factors [ 5 ]. Another type of bacterium that uses these hormones as growth factors is called Porphyromonas intermedius . This chromogenic bacterium tends to leave a black stain on the surface of the teeth, causing considerable esthetic damage. This micro-organism has also been isolated in children, but to a much lesser degree [ 5 ].

Nutrition has an important role in an individual’s health at every stage of life, but even more so at developmental age. A diet with a high intake of simple sugars contributes to the onset and progression of tooth decay [ 6 ]: according to the World Health Organization’s guidelines, these sugars should make up less than 10% of the total energy intake [ 7 ]. Adolescents also often have an inadequate intake of vitamin C, which has an important role as a cofactor in the formation of hydroxyproline, which is essential to the production of collagen [ 8 ]. The oral cavity is directly influenced by an individual’s diet but also by any related health issues. Eating disorders, such as anorexia and bulimia, damage the oral cavity involving salivary glands, oral mucosa and teeth: the most typical sign is dental erosion due to frequent episodes of self-induced vomiting [ 8 ].

Bad habits, such as smoking, drinking alcohol and abuse of narcotics, are mostly tried for the first time during adolescence and damage the body with repercussions that also become evident in the oral cavity. Studies have shown that smoking represents one of the main risk factors for periodontal disease because tobacco smoke alters the oral mucosa’s inflammatory response. The use of narcotics can influence the oral cavity in various ways causing extrinsic staining of the teeth, a reduced flow of saliva and a lower pH, oral mucosa erosion and ulceration, loss of the sense of taste and a generalized inflammation of the tissues supporting the teeth (gingivitis and periodontitis) due to poor oral hygiene and a very poor diet [ 9 ]. Oral cancer is among the most severe consequences of smoking, use of alcohol and narcotics [ 9 , 10 ].

Oral health is strongly influenced by an individual’s daily oral hygiene routine at home. Unless dental plaque is removed daily, it facilitates the onset of diseases of the gums and teeth (gingivitis, periodontitis and caries) [ 11 ].

Malocclusions may require orthodontic treatment with braces, which can have a negative effect on oral health by facilitating the accumulation of bacterial biofilm and hindering oral hygiene procedures at home [ 12 ]. Therefore, it is fundamental to ensure that adolescents wearing braces are given adequate instructions about oral hygiene and kept motivated by dental specialists [ 13 ].

Previous studies were found to assess oral hygiene focusing on adolescents: knowledge about this topic and oral hygiene routines varied throughout the literature. Many factors were proposed to explain the observed differences, such as socioeconomic status, gender element and geographical area of origin [ 12 , 14 , 15 , 16 , 17 , 18 , 19 ].

In the North-East region of Italy, a lot of interest is focused on improving preventive measures of the public health system. To assess the oral hygiene knowledge of young adults in this region, a questionnaire study was planned and subjected to patients attending a public clinic. Since no studies were conducted on this topic in this specific geographical region, the results from the present work could help implement preventive measures.

The aim of this study is to investigate oral hygiene knowledge in a sample of adolescents through a questionnaire examining actions they take and tools they use in their daily oral hygiene routines. The main variable considered is the past or present use of orthodontic braces to see how this might influence adolescents’ oral hygiene practices.

2. Materials and Methods

All patients attending the Borgo Cavalli Clinic in Treviso and the Dental Clinic of Padova University were considered as potential participants for the study to select a convenience sample of adolescent patients representing the Veneto region located in North-East Italy. Participants who were born before January 2000 and after December 2005 were excluded.

The questionnaire was distributed in an anonymous format, and it was administered in two ways: a printed paper copy and online through Google Forms platform. The questionnaire began with a brief explanation of the study’s purposes and asked respondents to answer as sincerely as possible. Before the beginning of the study, each patient was asked to provide an informed online consent explaining the purpose of the research and given authorization to use the collected data. Complete confidentiality was guaranteed to all patients.

The questionnaire was divided into four parts: general information, oral hygiene at home, professional oral hygiene and education on oral hygiene ( Table 1 ). The questionnaire was made of one open question and 18 multiple-choice questions: 15 with only one possible answer and 2 with the opportunity to choose more than one. Some questions were linked to others, i.e., a positive or negative answer to one question enabled or denied the opportunity to answer the next one. The questionnaire was subjected to a pilot group of 40 patients for its validation; modifications were made where necessary to resolve ambiguities.

Complete questionnaire subjected to all patients.

Data are presented with descriptive statistics indicating the frequency distribution of the answers.

The questionnaire was completed by 213 adolescents; none of the questionnaires collected were rejected due to errors in their completion ( Figure 1 ). The study population included 69 males (32%) and 144 females (68%); the mean age was 17 years old (range 14–19 years old).

Flowchart of the study.

Of these 213 respondents, 206 (97%) reported having been to the dentist at least once in their life. When asked to specify at what age they first saw a dental specialist (choosing one of four age brackets), 61% (126 out of 206) declared that they were between 5 and 9 years old at the time ( Figure 2 ).

Age at first visit to dentist.

3.1. Oral Hygiene at Home

Table 2 contains the information collected on respondents’ oral hygiene at home, distinguishing between males (69) and females (144) and between those who were wearing orthodontic braces (46) and those who were not (167).

Oral hygiene at home: numbers are displayed as total and percentage of subjects.

The majority of respondents declared to use a manual toothbrush. A subset of adolescents used both manual and electric toothbrushes, while none of our respondents used a sonic toothbrush. More than 80% of the sample brushed their teeth at least twice a day, but only 7% used dental floss every day. Approximately half of the respondents reported routinely cleaning their tongues.

3.2. Professional Oral Hygiene

Differences regarding professional oral hygiene between adolescents with and without orthodontics are shown in Table 3 . Overall, 83% of respondents knew about this procedure, and 67% experienced a session of professional oral hygiene with a dental hygienist at least once in their life. The frequency of these sessions varied considerably from one respondent to another. The study sample included 46 adolescents undergoing orthodontic treatment at the time and another 67 who had had orthodontic treatment in the past. Out of these 113 respondents, only 61 (54%) claimed to have been advised about submitting a session of professional oral hygiene during their orthodontic treatment ( Figure 2 ).

Data obtained about professional oral hygiene.

3.3. Education on Oral Hygiene at Home

The last part of the questionnaire focused on education regarding appropriate oral hygiene practices. Respondents could choose among multiple answers. The collected data (see Table 4 ) show that most of the sample (128 adolescents) learned how to manage their oral hygiene exclusively from their parents and not from any other sources. There were 26 adolescents (12% of the sample) who reported having taken part in meetings on the topic of oral hygiene held outside the setting of the dentist’s surgery, and 175 (82%) indicated that they were interested in receiving more information on the topic.

Training on oral hygiene.

4. Discussion

The present study aimed to investigate oral hygiene habits among adolescents in a regional contest in Italy through a questionnaire.

Results showed that almost all adolescents went to a dentist at least once in their lives (206 out of 213; 97%), and 126 out of 206 (61%) were between 5 and 9 years old at the time of their first visit.

Literature indicates that age at first dental visit widely ranges between 1 and 6 years worldwide. A recent questionnaire-based study conducted by Qu et al. (2022) [ 14 ] reported a mean age of 4.8 and 5.4 years old for preventive and symptomatic first dental visits, respectively. Furthermore, the study indicated that early preventive dental visits were associated with a lower rate of dental caries. Another study conducted by Alshahrani et al. (2018) [ 20 ] recorded a range of 3–6 years old at the time of the first dental visit. Mika et al. (2018) [ 21 ] reported a mean age of 3.79 years old at the time of the first dental visit, with most of the patients seeking dental treatment and only 36.9% for preventive measures. This suggests that the first dental visit occurs in a very wide age range, often in need of dental treatment, and there is no accordance between clinicians about the ideal age, regardless of country or region. Nevertheless, American guidelines suggest that the first dental visit should happen at the time of the first tooth eruption or no later than the first year of age.

Only 23% of our respondents met a dentist before they were five years old. There are various reasons to recommend regular visits to the dentist also for toddlers: (i) educate children and their parents to adopt good habits regarding their oral hygiene in order to maintain a good state of oral health in years to come, (ii) identify any lesions or disorders early on, and take corrective action as soon as possible, (iii) educate parents on the topic of nutrition and a balanced diet and (iv) establish a trusting relationship between the child and the dentist that will facilitate their trouble-free cooperation in the future [ 22 ]. Seeing a dentist for a check-up at a younger age also has a positive influence on the costs associated with dental treatments for children [ 23 ].

The present study produced some significant findings regarding adolescents’ oral hygiene at home in terms of the actions taken as part of their daily routine to look after their teeth and gums. According to the Italian National Guidelines for the promotion of oral health and the prevention of oral disease at developmental age, adolescents should brush their teeth twice a day. An ample majority (83%) of the adolescents in our sample reportedly complied with this recommendation, while the remainder (17%) only brushed their teeth in the morning or evening or not at all (only two adolescents reported never cleaning their teeth).

Brushing teeth is very important to remove plaque, but not enough. Some areas, such as the space between two adjacent teeth, are impossible to reach with a toothbrush, so other methods are required [ 24 ]. Adolescents should use dental floss daily; however, this study showed otherwise: only 35% of the subjects flossed often (only one subject flossed every day), while others did not like it (35%) or never tried it at all (30%).

According to Mottos-Silveira et al. [ 25 ], the main reason why flossing is so rarely performed lies in a lack of cooperation of the individuals, and any manual difficulty encountered with the flossing procedure itself would apparently be a minor issue. It is up to dentists and dental hygienists to educate adolescents and motivate them to make flossing a habit, also reminding the parents of its importance if necessary.

While results about brushing teeth in the present study mostly agreed with previous research, the frequency of interdental flossing varied throughout the literature.

Ericsson et al. (2012) [ 15 ] stated that 76% of adolescents brushed their teeth at least two times a day, with only 4% of the sample flossing every day. In a study conducted by Inquimbert et al. [ 19 ], the majority (69%) of adolescents declared brushing their teeth twice a day, with a higher frequency found in the subjects undergoing orthodontic treatment. Interdental flossing was still performed more often in the latter group compared to others (35.1% vs. 4.4%). A survey conducted among 879 adolescents from Portugal, Romania and Sweden reported that 77.4% brushed their teeth two or more times a day, while only 14.4% flossed daily (54% never used dental floss) [ 16 ]. Nasir et al. (2022) [ 17 ] stated that 66.8% of the sample reported brushing their teeth at least twice a day, while 14.2% reported at least once a day. In a study conducted by Veiga et al. (2014) [ 18 ] among Portuguese adolescents, results showed that 90.6% of the sample brushed their teeth twice a day or more, and 6% performed daily flossing.

When gender differences were considered, girls showed better compliance than boys in terms of both brushing their teeth and flossing (although the percentages for flossing were always very low). Girls were more attentive regarding tongue cleaning (an important step to effectively reduce bacterial load in the oral cavity and help prevent halitosis [ 26 ]).

Epidemiological studies point to a greater prevalence of gingivitis among males rather than females: one of the possible explanations lies in the amount of time spent on oral hygiene at home [ 27 ]. Other studies have also shown how girls usually have more knowledge and therefore pay more attention to oral hygiene procedures [ 15 , 28 , 29 ]. Our findings are consistent with the scientific literature, showing that adolescent females complied more with oral health care recommendations than their male counterparts, especially regarding cleaning interdental spaces and tongue.

The present study also found differences between adolescents with and without orthodontic braces: a better oral hygiene routine at home in the former can probably be explained by more frequent visits to the dental surgery. That said, the proportion of adolescents routinely using dental floss was still very low: only 10% of girls wearing braces were flossing regularly. Greater attention to oral hygiene procedures was found among adolescents that undergo orthodontic treatments compared to their counterparts [ 19 ].

Another finding that emerged from the questionnaire concerns the knowledge of what professional oral hygiene involves and the frequency of its sessions: 79% of our respondents reported knowing what it is, and 67% experienced a session of professional oral hygiene at least once in their life. However, the relationship between professional oral hygiene and orthodontic treatments seems to be particularly interesting: this supportive treatment was not provided for 46% of the adolescents wearing braces. This is particularly important while orthodontic treatments are underway, given the greater difficulty of daily teeth cleaning [ 30 ].

Providing instructions on how to manage oral hygiene at home is one of the main responsibilities of dentists and dental hygienists and a fundamental part of primary prevention strategies. When our sample of adolescents was asked to indicate who had taught them how to clean their teeth, 60% (128 respondents) reported having received instructions only from their parents. This finding is significant, keeping in mind that 206 out of 213 respondents went to a dentist at least once, and 143 attended a session of professional oral hygiene. This points to a failure on the part of dental professionals to educate their patients about oral hygiene. Instructing and motivating patients to routinely take care of their teeth and gums is a fundamental part of the dentist’s job and even more for dental hygienists. It is a fundamental primary prevention measure. Proper instructions enable individuals to maintain a healthy oral cavity, especially if they have received them already in childhood or adolescence. Our study findings also suggest that adolescents attribute importance to their oral hygiene, as 75% of our respondents reported being interested in having more information on the topic.

In this study, some limitations must be considered. First, a wider sample is needed to allow for generalization of the results; furthermore, the questionnaire was administered at a public dental hospital, limiting the population. Another limit is intrinsic to a research questionnaire-method based: self-reported data examined about childhood events (e.g., first visit to the dentist), making obtained data not completely reliable. Furthermore, clinical assessment of oral hygiene (e.g., bleeding on probing, plaque index) could have been helpful in comparing the data obtained from the questionnaire.

Future studies should be performed to investigate wider samples through validated questionnaires, possibly involving multiple clinical centers to minimize the geographic factor. Oral health indexes should be collected from clinical practice to compare them with the ones obtained through questionnaires.

5. Conclusions

Despite the limited number of patients interviewed, the present study produced some significant findings on oral hygiene behavior both at home and at the dental office. Most respondents claimed that they had their first visit to the dentist when aged between 5 and 9 years, which, according to the literature, seems to be too late. The majority of teenagers state toothbrushing as their only oral hygiene habit and therefore do not use any other oral hygiene item at home. Only a small percentage floss daily. Even adolescents wearing braces resulted in having inadequate compliance despite the closer recalls they need to undergo due to the ongoing orthodontic treatment. Professional oral hygiene is claimed to be widely known by the respondents; nonetheless, a significant amount of them never experienced it. Although orthodontic patients need to undergo this session even with a higher frequency compared to other patients, many dentists still do not suggest it during orthodontic treatments. Poor oral hygiene knowledge could increase the risk of dental caries in adulthood, as suggested by previous reviews. These findings should encourage the public health system to improve the preventive measure through better communication. Especially patients wearing braces should undergo a careful professional hygiene maintenance program to prevent tooth decay along with the orthodontic treatment.

Funding Statement

This research received no external funding.

Author Contributions

Conceptualization, L.S. and L.B.; methodology, L.B.; data curation, L.B.; writing—original draft preparation, L.S. and L.B.; writing—review and editing, L.S., F.E., C.B. and A.D.F.; visualization, C.B. and A.D.F.; supervision, L.S.; project administration, L.S. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

The study was conducted according to the guidelines of the Declaration of Helsinki. Participants’ personal information was anonymized and collected using codes.

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement

Conflicts of interest.

The authors declare no conflict of interest.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Nutrition and Oral Health

• A bidirectional relationship exists between oral health and diet and nutrition. Diet and nutrition affect the health of the tissues in the mouth; and the health of the mouth affects nutrients consumed.
• The consumption of sugars has been associated with an increased risk of developing dental caries.
• The complex nature of periodontal disease makes it difficult to determine its relationship with diet and nutrition.
• Frequent consumption of acidic food and beverages is associated with an increased risk of erosive tooth wear.

Diet and nutrition are significant influencers of oral health, and can affect the development and progression of oral diseases and conditions such as caries, periodontal disease, erosion, and others. While nutrition can be defined as the micro- (vitamins and minerals) and macro- (carbohydrates, protein, and fat) nutrients as they relate to the body’s dietary needs, diet refers to the specific foods consumed. The relationship that diet and nutrition have with oral health is bidirectional, as compromised integrity of the oral cavity can also influence an individual’s ability to eat. 1

There are different types of nutrition studies such as epidemiological studies, case-control studies, and clinical trials. While all study types may be used to generate useful information, they differ in terms of reliability and how to interpret the data. For instance, epidemiological studies are primarily observational, meaning that the populations compared can differ from each other by any number of uncontrolled factors. They look for associations between nutritional factors and a given outcome in large populations. It is important to remember that finding an association is not the same as demonstrating causation. In case-control studies , two groups of closely matched subjects (by age, sex, race, etc.) that differ in the presence or absence of a particular condition of interest are compared to see what factors might differ between the groups, providing potential clues about cause and prevention of that condition. However, even though a number of variables are matched, the populations compared can differ in important ways. Clinical trials generally control for more factors, using a sample size calculated to be sufficient to detect a statistically significant change in the variable of interest. 2 With any study involving nutrient intake or dietary patterns, it can be challenging to follow participants for a meaningful length of time.

A variety of dietary factors are hypothesized to influence the oral cavity, including macro- and micronutrients, vitamins, pH properties, as well as the behaviors associated with their consumption. Additionally, factors such as stage of development, specific medical conditions, and socioeconomic status may indicate particular diet and nutritional considerations. Older patients, for example, may experience tooth loss, reduced masticatory ability, and decreased appetite, which may, in turn, influence their nutritional status. 3 A systematic review examined the association between food intake and oral health in the elderly found that tooth loss in the older population was associated with changes in food intake and nutritional deficiency. 4

Dental caries is the most common disease worldwide. The term dental caries can be used to describe both the disease process and the cavitated or noncavitated lesions that form as a result of the disease process. 5 The caries disease process is biofilm-mediated, sugar-driven, multifactorial, and dynamic in the phasic demineralization and remineralization of dental hard tissues. 6

The relationship between caries and carbohydrates is fairly well understood; dental hard tissues are demineralized by acidic by-products produced by bacteria in biofilm (dental plaque) via fermentation of dietary carbohydrates. 6 More specifically, there is a rapid fall in pH (to 5.5 or below) in tooth biofilm after carbohydrates are ingested. This lower pH can also affect the balance of microbes in the biofilm such that there is a higher proportion of acidic biofilm species, compounding tooth demineralization. 7 Carbohydrate consumption is therefore an important nutritional factor in the development of caries.

For more information on dental caries, visit the ADA Oral Health Topics page on caries risk assessment and management .

Types of Carbohydrates

The relationship between carbohydrates and dental caries depends on the type of carbohydrate (sugars or starches) consumed because the cariogenic potential (i.e., promoting the development of tooth decay) of a given carbohydrate is dependent on how efficiently it can be metabolized by the bacteria that ferment it. 8 Sugars, specifically, are considered to be the most important drivers of caries development. The term free sugar includes all sugars added to food/beverages, as well as the naturally occurring sugars found in fruit juices and concentrates, honey, and natural syrups. Collectively, natural and free sugars (e.g., sucrose, glucose, fructose) are considered the primary necessary factors in the development of caries. 8 Sucrose, a disaccharide of glucose and fructose, is the most cariogenic sugar. 8 Sucrose acts as a substrate for the synthesis of intra- and extracellular polysaccharides in dental plaque. 8-10 Additionally, dental plaque formed in the presence of sucrose has been shown to have lower concentrations of calcium, inorganic phosphate, and fluoride, which are the ions required to remineralize enamel and dentin. 10, 11 Sucrose and its constituent monosaccharides, glucose and fructose, are also more cariogenic than starches because they enter the glycolytic pathway more rapidly and result in a more pronounced drop in pH. 12 Although lactose is also a sugar, it is less cariogenic than sucrose, fructose, and glucose because its fermentation produces a smaller drop in pH. 9, 13

Amount/Frequency of Sugar Intake

In addition to the type of sugar consumed, the amount consumed may affect caries development. A 2014 systematic review examining the effect of free sugar consumption on dental caries observed a consistent association between free sugar intake and caries development; higher incidence of caries was found in populations where free sugar intake was greater than 10% of total energy intake compared to those with free sugar intake of less than 10%. 14 This systematic review informs the World Health Organization (WHO) guidelines for sugar intake, which recommends that free sugars be less than 10% of total energy intake, with a further reduction to less than 5% suggested. 15

Frequency, or how often free sugars are consumed, may also play a role in caries development. Increased frequency of sugar consumption and additional snacking between meals have been hypothesized to be more important in predicting caries risk than total sugar consumption. 16-18 A possible rationale for this concept is that it takes approximately 30 minutes for the pH to drop after an intake of sugar, so additional sugar intake within that 30-minute period is less harmful than additional intake after 30 minutes. 16 It is, however, difficult to determine the relative contribution of amount of sugar and frequency of sugar consumption to dental caries risk, given that the two are highly interrelated. 16, 19

The recent systematic reviews and guidelines mentioned above 14, 15, 20 present data that support the association between sugar consumption and/or snacking with caries development. Although not evidence for causality, these reviews are consistent in their findings that increased free sugar consumption is associated with an increased risk of caries.

There is ongoing research to determine strategies to decrease the consumption of sugar-sweetened beverages (SSBs), as they are a significant contributor to free sugar consumption. A tax on SSBs is one strategy that has been attempted; studies suggest that taxation of SSBs may decrease SSB consumption, caries incidence, and caries-related costs. Although public acceptance and efficacy of this strategy are still unclear, a 2019 systematic review and meta-analysis 21 found that the equivalent of a 10% tax on SSBs was associated with an average decline in SSB purchase and intake of 10.0%. 21-23 In addition to interventions effective at the population level, there is a need for high-quality evaluations with long-term study designs examining efficacy. 24

Early childhood caries (ECC) is the presence of one or more decayed, missing, or filled tooth surface in children under 6 years of age. 25 ECC was formerly referred to as “baby bottle tooth decay” and is primarily due to prolonged exposure of the enamel to sweetened liquids causing caries in small children. To address ECC, both the Academy of Nutrition and Dietetics and American Academy of Pediatrics promulgate guidance limiting fruit juice consumption by babies and toddlers. 25, 26

Limited income or access to food can have a negative impact on intake of fruits and vegetables, lean meat, whole grains, and dairy. This inadequate consumption of nutrient-dense foods combined with a lower health literacy and limited access to oral health care can put low-income populations at an increased risk for caries and other oral diseases. 25

Foods such as milk and dairy products, apples, cranberries, tea, and high-fiber foods have been suggested to have cariostatic properties (i.e., inhibiting the development of caries), although more careful examination is needed. 27 It has been postulated that the calcium in dairy products offsets some of the cariogenic properties of lactose by limiting enamel undersaturation during acidogenesis. As mentioned above, lactose fermentation also results in a smaller reduction in pH compared with other simple sugars. Data from studies examining the association between milk consumption and caries suggests milk consumption does not increase caries risk and may actually reduce it. 28

Some studies indicate that sugar alcohols such as xylitol and sorbitol used in chewing gums and as artificial sweeteners may have cariostatic effects, but overall findings are equivocal. Postulated mechanisms by which xylitol may reduce caries risk include simple substituting for fermentable carbohydrates, 29 reducing the acidogenic potential, 30 inhibiting the growth of Streptococcus mutans (plaque bacteria that contribute to tooth demineralization), 31 or just increasing salivary flow (especially in the case of sugar-free chewing gums). 32, 33 Although non-sugar sweetened gum is eligible for application to the ADA Seal of Acceptance, the ADA does not have a policy on the use of xylitol for caries prevention. The Council on Scientific Affairs expert panel report on Nonfluoride Caries-Preventive Agents concluded that evidence of xylitol’s benefit as an adjunctive therapy in children and adults who are at a high risk for developing caries is of low quality. 34 For more information on chewing gum , visit the ADA Oral Health Topics page.

Vitamin D influences the regulation of calcium and phosphate metabolism. 35 According to some observational studies, higher prenatal intakes of vitamin D and prenatal serum vitamin D levels may be associated with reduced caries risk in children and infants. 36, 37 Historical reports 38 as well as a 2016 cross-sectional study suggest an association between dental caries and lower serum levels of vitamin D in children. 39

The American Academy of Periodontology defines periodontitis as “the inflammation of the periodontal tissues resulting in clinical attachment loss, alveolar bone loss, and periodontal pocketing.” 40 It is caused by specific microorganisms in dental plaque and excessive host response to this bacterial challenge, resulting in progressive destruction of tooth-supporting apparatus (i.e., gingiva, periodontal ligament, and alveolar bone). 41 The effect of nutrition status on the body’s immune response may modify factors affecting management of periodontal disease; however, the multifactorial nature of periodontal disease and nutritional status makes it difficult to determine such effects. 25

Compared with caries, there are fewer studies exploring the relationship between nutrition and periodontal disease. Existing studies linking nutrition to periodontal disease have focused primarily on the intake of lipids and various micronutrients. However, the two systematic reviews examining the role of dietary minerals 42 and lipids 43 on the onset, severity/progression, and treatment of periodontal disease found insufficient evidence of any associations.

Dental erosion is clinically defined as “the progressive and irreversible loss of dental hard tissue caused by a chemical process of acid dissolution that does not involve bacteria,” 44 and while acid reflux and some medications can contribute to erosive tooth wear, the most significant source of acid for tooth erosion is the diet. 45 Specifically, frequency of consumption, patterns of consumption, and time in contact with acidic food or beverage influence erosive tooth wear. 46 However, pH alone is not the only factor affecting how erosive a food/beverage may be. The pH and buffering capacity collectively determine how erosive a food or beverage is. 47 Yogurt, for example, has a pH of about 4.0, but is not considered erosive due its high calcium content, which acts as a buffer. 48

A meta-analysis conducted in 2012 found that soft drinks and chewable vitamin C tablets were both associated with the development of erosive tooth wear while juice, sports drinks, milk, and yogurt were not. 49 This is somewhat at odds with a meta-analysis conducted in 2015 that found soft drinks and acidic snacks, as well as fruit juices, increased the odds for tooth erosion in children; and, in addition, found that intake of milk and yogurt was associated with a reduction in the occurrence of erosion. 50

Dental erosion may also be caused by intrinsic factors such as stomach acid in those with gastroesophageal reflux disease (GERD) or individuals with who vomit frequently. 51-53 Compared to erosion caused by extrinsic factors (i.e., dietary factors) which commonly affects the facial and occlusal surfaces of teeth, erosion caused by gastric acid primarily occurs on the palatal and occlusal surfaces of the anterior maxillary teeth and on the buccal and occlusal surfaces of the mandibular teeth. 54

For more information on dental erosion, visit the ADA Oral Health Topics page on dental erosion .

Calcium is a mineral found in many foods, and is essential for forming and maintaining healthy bones and teeth, 55 including hydroxyapatite, the primary calcium phosphate mineral in bone and enamel. Dietary calcium is absorbed from the intestine into the blood, from human or animal milk and dairy products (e.g., cheese, yogurt), or foods fortified with calcium (in accord with eCFR §104.20 ). The 2015-2020 Dietary Guidelines for Americans recommend 700 mg of calcium per day as the recommended dietary allowance (RDA) for children aged 1-3 years, and 1000 mg of calcium per day for children aged 4-8 years. 56

In the United States, an estimated 72 percent of calcium intake occurs from consumption of dairy and products to which dairy has been added. 55 Numerous varieties of plant-based milk alternatives, including products made with soy, almonds, oats, nuts, potato, flaxseed or hemp, are a growing segment of the consumer marketplace. 57 Many exist in forms fortified with one or more nutrients, often including calcium. 58-60 However, a technical report from national health and nutrition organizations concludes that plant milks/non-dairy beverages are not recommended from 0-12 months of age; and that unsweetened plant milks/non-dairy beverages other than soy milk are not recommended for exclusive consumption in place of dairy milk. 61

Oral and Oropharyngeal Cancer

With the exception of heavy alcohol consumption, which is associated with an increased risk of developing oral cancer, 62 other than generalized findings, no direct relation between diet and oral and oropharyngeal cancer risk has been identified. If consistent with what is observed with other cancers, the consumption of fruits and vegetables may be protective. 1 A meta-analysis showed a lower risk of oral cancer associated with increased fruit and vegetable consumption, 63 and a large prospective observational study 64 found total fruit and vegetable intake was associated with a reduced head and neck cancer risk.

For more information on oral and oropharyngeal cancer, visit the ADA Oral Health Topics page on cancer of the head and neck .

Aphthous Ulcers

There is a lack of rigorous studies examining the role of diet in the management of recurrent aphthous stomatitis (RAS), also known as canker sores. Reported dietary triggers include hard, acidic, and salty substances as well as alcoholic and carbonated beverages. 65 Preliminary data suggest that zinc deficiency is more common in those with RAS than healthy individuals without them 66 and that zinc-supplementation improved RAS resolution in zinc-deficient individuals. 67

Xerostomia (dry mouth) and its associated effects on oral health and overall quality of life may be exacerbated by dietary factors such as dry or acidic foods, caffeine, and alcohol. 68

For more information on dry mouth, visit the ADA Oral Health Topics page on xerostomia/dry mouth .

Policies and Recommendations on Diet and Nutrition

Read the ADA policy and recommendations on diet and nutrition. American Dental Association Adopted 2016 (2016:320)

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• Kazemi S, Savabi G, Khazaei S, et al. Association between food intake and oral health in elderly: SEPAHAN systematic review no. 8. Dent Res J (Isfahan) 2011;8(Suppl 1):S15-20.
• Selwitz RH, Ismail AI, Pitts NB. Dental caries. Lancet 2007;369(9555):51-9.
• Pitts NB, Zero DT, Marsh PD, et al. Dental caries. Nat Rev Dis Primers 2017;3:17030.
• Tinanoff N, Baez RJ, Diaz Guillory C, et al. Early childhood caries epidemiology, aetiology, risk assessment, societal burden, management, education, and policy: Global perspective. Int J Paediatr Dent 2019;29(3):238-48.
• Sheiham A, James WP. Diet and Dental Caries: The Pivotal Role of Free Sugars Reemphasized. J Dent Res 2015;94(10):1341-7.
• Palacios C, Rivas-Tumanyan S, Morou-Bermudez E, et al. Association between Type, Amount, and Pattern of Carbohydrate Consumption with Dental Caries in 12-Year-Olds in Puerto Rico. Caries Res 2016;50(6):560-70.
• Cury JA, Rebelo MA, Del Bel Cury AA, Derbyshire MT, Tabchoury CP. Biochemical composition and cariogenicity of dental plaque formed in the presence of sucrose or glucose and fructose. Caries Res 2000;34(6):491-7.
• Paes Leme AF, Koo H, Bellato CM, Bedi G, Cury JA. The role of sucrose in cariogenic dental biofilm formation--new insight. J Dent Res 2006;85(10):878-87.
• Bibby BG, Krobicka A. An in vitro method for making repeated pH measurements on human dental plaque. J Dent Res 1984;63(6):906-9.
• Johansson I, Lif Holgerson P. Milk and oral health. Nestle Nutr Workshop Ser Pediatr Program 2011;67:55-66.
• Moynihan PJ, Kelly SA. Effect on caries of restricting sugars intake: systematic review to inform WHO guidelines. J Dent Res 2014;93(1):8-18.
• Moynihan P. Sugars and dental caries: evidence for setting a recommended threshold for intake. Adv Nutr 2016;7(1):149-56.
• van Loveren C. Sugar Restriction for Caries Prevention: Amount and Frequency. Which Is More Important? Caries Res 2019;53(2):168-75.
• Rodrigues CS, Sheiham A. The relationships between dietary guidelines, sugar intake and caries in primary teeth in low income Brazilian 3-year-olds: a longitudinal study. Int J Paediatr Dent 2000;10(1):47-55.
• Feldens CA, Giugliani ER, Vigo A, Vitolo MR. Early feeding practices and severe early childhood caries in four-year-old children from southern Brazil: a birth cohort study. Caries Res 2010;44(5):445-52.
• Bernabe E, Vehkalahti MM, Sheiham A, Lundqvist A, Suominen AL. The Shape of the Dose-Response Relationship between Sugars and Caries in Adults. J Dent Res 2016;95(2):167-72.
• World Health Organization. Guideline: Sugars Intake for Adults and Children . Geneva: World Health Organization 2015. Accessed July 7, 2023.
• Teng AM, Jones AC, Mizdrak A, et al. Impact of sugar-sweetened beverage taxes on purchases and dietary intake: Systematic review and meta-analysis. Obes Rev 2019.
• Schwendicke F, Thomson WM, Broadbent JM, Stolpe M. Effects of Taxing Sugar-Sweetened Beverages on Caries and Treatment Costs. J Dent Res 2016;95(12):1327-32.
• Jevdjevic M, Trescher AL, Rovers M, Listl S. The caries-related cost and effects of a tax on sugar-sweetened beverages. Public Health 2019;169:125-32.
• von Philipsborn P, Stratil JM, Burns J, et al. Environmental interventions to reduce the consumption of sugar-sweetened beverages and their effects on health. Cochrane Database Syst Rev 2019;6:CD012292.
• Academy of Nutrition and Dietetics. Practice Paper of the Academy of Nutrition and Dietetics: Oral Health and Nutrition. June 2014. Accessed August 27, 2019.
• Heyman MB, Abrams SA. Fruit Juice in Infants, Children, and Adolescents: Current Recommendations. Pediatrics 2017;139(6).
• Moynihan P. Foods and dietary factors that prevent dental caries. Quintessence Int 2007;38(4):320-4.
• Bradshaw DJ, Lynch RJ. Diet and the microbial aetiology of dental caries: new paradigms. Int Dent J 2013;63 Suppl 2:64-72.
• Van Loveren C. Sugar alcohols: what is the evidence for caries-preventive and caries-therapeutic effects? Caries Res 2004;38(3):286-93.
• Bradshaw DJ, Marsh PD. Effect of sugar alcohols on the composition and metabolism of a mixed culture of oral bacteria grown in a chemostat. Caries Res 1994;28(4):251-6.
• Vadeboncoeur C, Bourgeau G, Mayrand D, Trahan L. Control of sugar utilization in the oral bacteria Streptococcus salivarius and Streptococcus sanguis by the phosphoenolpyruvate: glucose phosphotransferase system. Arch Oral Biol 1983;28(2):123-31.
• Dowd FJ. Saliva and dental caries. Dent Clin North Am 1999;43(4):579-97.
• Janket SJ, Benwait J, Isaac P, Ackerson LK, Meurman JH. Oral and Systemic Effects of Xylitol Consumption. Caries Res 2019:1-11.
• Rethman MP, Beltran-Aguilar ED, Billings RJ, et al. Nonfluoride caries-preventive agents: executive summary of evidence-based clinical recommendations. J Am Dent Assoc 2011;142(9):1065-71.
• Esposito S, Leonardi A, Lanciotti L, et al. Vitamin D and growth hormone in children: a review of the current scientific knowledge. Journal of Translational Medicine 2019;17(1):87.
• Tanaka K, Hitsumoto S, Miyake Y, et al. Higher vitamin D intake during pregnancy is associated with reduced risk of dental caries in young Japanese children. Ann Epidemiol 2015;25(8):620-25.
• Schroth RJ, Lavelle C, Tate R, et al. Prenatal vitamin D and dental caries in infants. Pediatrics 2014;133(5):e1277-e84.
• Mellanby M, Pattison CL. The Action of Vitamin D in Preventing the Spread and Promoting the Arrest of Caries in Children. Br Med J 1928;2(3545):1079-82.
• Schroth RJ, Rabbani R, Loewen G, Moffatt ME. Vitamin D and Dental Caries in Children. J Dent Res 2016;95(2):173-9.
• American Academy of Periodontology. AAP Connect: Periodontitis. Accessed July 7, 2023.
• Genco RJ, Williams RC. Periodontal disease and overall health: a clinician’s guide. Yardley, Pennsylvania, USA: Professional Audience Communications Inc 2010:254-63.
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• Varela-Lopez A, Giampieri F, Bullon P, Battino M, Quiles JL. Role of Lipids in the Onset, Progression and Treatment of Periodontal Disease. A Systematic Review of Studies in Humans. Int J Mol Sci 2016;17(8).
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• Carvalho TS, Colon P, Ganss C, et al. Consensus Report of the European Federation of Conservative Dentistry: Erosive tooth wear diagnosis and management. Swiss Dent J 2016;126(4):342-6.
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• Lazarchik DA, Filler SJ. Dental erosion: predominant oral lesion in gastroesophageal reflux disease. Am J Gastroenterol 2000;95(8 Suppl):S33-8.
• Institute of Medicine (US) Committee to Review Dietary Reference Intakes for Vitamin D and Calcium. Dietary Reference Intakes for Calcium and Vitamin D. 2, Overview of Calcium. Washington (DC): National Academies Press (US) 2011. https://www.ncbi.nlm.nih.gov/books/NBK56060/ . Accessed July 7, 2023.
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• Sethi S, Tyagi SK, Anurag RK. Plant-based milk alternatives an emerging segment of functional beverages: a review. J Food Sci Technol 2016;53(9):3408-23.
• Thorning TK, Raben A, Tholstrup T, et al. Milk and dairy products: good or bad for human health? An assessment of the totality of scientific evidence. Food Nutr Res 2016;60:32527.
• Verduci E, D'Elios S, Cerrato L, et al. Cow's Milk Substitutes for Children: Nutritional Aspects of Milk from Different Mammalian Species, Special Formula and Plant-Based Beverages. Nutrients 2019;11(8): 1739.
• Vanga SK, Raghavan V. How well do plant based alternatives fare nutritionally compared to cow's milk? J Food Sci Technol 2018;55(1):10-20.
• Lott M CE, Welker Duffy E, Story M, Daniels S.  Healthy beverage consumption in early childhood: recommendations from key national health and nutrition organizations. Technical scientific report. 2019.
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For Professionals

ADA Oral Health Topics

• Cancer (Head and Neck)
• Caries Risk Assessment and Management
• Chewing Gum
• Dental Erosion
• Xerostomia/Dry Mouth

For Patients

• ADA MouthHealthy.org page on Nutrition
• Saving Your Mouth From Sugar
• Feeding a Healthy Smile

Materials from the Academy of Nutrition and Dietetics on how to eat a healthy diet

U.S. Department of Agriculture’s MyPlate

Prepared by:

Research Services and Scientific Information, ADA Library & Archives.

Content on the Oral Health Topics section of ADA.org is for informational purposes only. Content is neither intended to nor does it establish a standard of care or the official policy or position of the ADA; and is not a substitute for professional judgment, advice, diagnosis, or treatment. ADA is not responsible for information on external websites linked to this website.

• Open access
• Published: 13 May 2024

Relationship between the number of lost teeth and the occurrence of depressive symptoms in middle-aged adults: a cross-sectional study

• Martyna Głuszek–Osuch 1 ,
• Elżbieta Cieśla 1 &
• Edyta Suliga 1  

BMC Oral Health volume  24 , Article number:  559 ( 2024 ) Cite this article

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Metrics details

Many recent studies suggest the existence of a relationship between oral health and the occurrence of depressive symptoms. The aim of this study was to assess the relationship between the number of lost teeth and the occurrence of depressive symptoms in middle-aged adults.

An analysis was performed on the data obtained from the PONS project (POlish-Norwegian Study), conducted in the Świętokrzyskie Province in Poland in 2010–2011. The research material included the cross-sectional data of 11,901 individuals aged 40–64 years (7967 women). Depressive symptoms, used as outcome variables, were assessed with a questionnaire. The participants provided the responses to questions concerning the occurrence of eight symptoms over the last 12 months. The answers were scored as 1 point or 0 points. The participants were divided into three tercile groups based on their total scores: no or mild (0–2 points), moderate (3–5 points), and severe depressive symptoms (6–8 points). The self-reported number of lost teeth was analysed according to the following categories: 0–4, 5–8, 9–27, and a complete lack of natural teeth. Multivariable logistic regression analysis for depressive symptoms was used in relation to the number of lost teeth. The following covariates were included in the adjusted model: age, sex, place of residence, education, marital status, BMI, diabetes status, stressful life events in the last year, use of antidepressants, smoking, and sugar and sweet consumption.

The likelihood of both moderate (OR = 1.189; 95%CI: 1.028–1.376; p  < .020) and severe (OR = 1.846; 95%CI: 1.488–2.290; p  < .001) depressive symptoms showed the strongest relationship with a total lack of natural teeth. A loss of more than 8 natural teeth was also significantly associated (OR = 1.315; 95%CI: 1.075–1.609; p  < .008) with the occurrence of severe depressive symptoms.

Conclusions

The loss of natural teeth was positively related to the occurrence of depressive symptoms in middle-aged adults. Thus, there is an urgent need to intensify stomatological prophylaxis, education and treatment for middle-aged individuals.

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Introduction

Depression is one of the most common mental health disorders worldwide and can originate from genetic, biological, and environmental factors [ 1 , 2 ]. Depressive symptoms, such as lowered mood (sadness, despondency, reliving of negative events, anhedonia, and indifference); decreased psychomotor drive (psychomotor retardation or inhibition, loss of energy, and persistent fatigue); abnormal circadian rhythm; and somatic symptoms (hyposomnia, hypersomnia, dry mucous membranes in the mouth, and weight changes), may also occur in people who do not meet the clinical diagnostic criteria for depression and who experience subthreshold depression. Many recent studies suggest the existence of a relationship between oral health and the occurrence of depressive symptoms [ 3 , 4 ]. One of the most severe oral conditions is tooth loss [ 5 , 6 ]. Its direct causes are usually untreated caries and periodontal diseases [ 7 , 8 , 9 ]. The prevalence of tooth loss and the factors that directly determine it depend largely on economic development, access to dental care, social factors, and lifestyle, which is why they may differ between countries and regions [ 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 ]. Loss of teeth not only reduces the effectiveness of mastication but also contributes to a limitation, or even complete elimination, of hard products from the diet (e.g., nuts and some raw fruits and vegetables), significantly reducing the nutritional value of food [ 16 ]. Consequently, such changes may impact the nutritional status and health of individuals. Loss of teeth results in a gradual decrease in bone tissue and may lead to malocclusion and disorders of the temporomandibular joints. It also causes speech impediments, especially lisping, since without proper support in the form of teeth, the tongue cannot be positioned to correctly articulate some sounds [ 17 ]. Furthermore, visibly missing teeth constitute an aesthetic blemish, while poorly fitted dentures and incorrect articulation reduce self-confidence, make it difficult for individuals to be active in the job market, and cause individuals to withdraw from social life, which in turn may reduce mental well-being [ 17 , 18 ]. These relationships have, to date, been analysed predominantly among elderly individuals, with very few publications addressing the topic among middle-aged adults. The aim of this study was to assess the relationship between the number of lost teeth and the occurrence of depressive symptoms among individuals aged 40–64 years. According to our hypothesis, the number of lost natural teeth shows a positive relationship with the occurrence of depressive symptoms among middle-aged adults.

Materials and methods

Study design.

An analysis was performed on the cross-sectional data obtained as part of the PONS project (POlish-Norwegian Study), which was conducted in the Świętokrzyskie Province in Poland in 2010–2011. The goal of the project was to observe the health and prevalence of chronic noncommunicable diseases among the residents of southeastern Poland [ 19 ]. This was a facility-based survey. All participants of the project were volunteers. The study in its entirety (both the measurements and the interviews) was conducted in the medical institutions that took part on the project. The Ethics Committee at the Cancer Center and Institute of Oncology in Warsaw (No. 69/2009/1/2011) approved the project and method of data collection. Further data analysis was also approved by the Committee on Bioethics at the Faculty of Health Sciences, Jan Kochanowski University in Kielce (No. 45/2016).

Participants

Participants were recruited by invitations to participate in the project to all men and women aged 45–64 years living in the Kielce District (Świętokrzyskie Province, Poland). The participants were invited to take part in the study through advertisements and promotional articles in local newspapers, radio and TV programmes, informative materials (leaflets, billboard advertising, information charts and a website), co-operation with family doctors and medical institutions participating in the project, which sent the invitations via mail. Therefore, all participants of the project were volunteers. The sole inclusion criterion for the whole project was age 45–64 years and being a resident of the city of Kielce and the surrounding rural area (the Kielce County). We did not directly calculate the sample size. We assumed a response rate of at least 10% among the target group and the actual response rate was 12%. Many more women than men from the target age group volunteered to participate. A small number of participants who were younger (37–44 years) and older (65–66 years) than the target age group also volunteered for the study. Consequently, the collected data encompassed the results of 13,172 individuals aged 37–66 years. For the purposes of the analyses conducted in this study, individuals aged ≥ 65 years and < 40 years, as well as participants whose data were incomplete, were excluded (1271 individuals). Ultimately, the research material for the study included the data of 11,901 individuals aged 40–64 years (3934 men).

Measurements

Sociodemographic data and data related to depressive symptoms, the declared number of lost teeth, and lifestyle factors were collected via face-to-face interviews with structured questionnaires. The sociodemographic variables included sex (male or female), age (years), place of residence (the city of Kielce (200 thousand inhabitants) and the rural county of Kielecki (village), education level (higher, secondary, primary, or vocational), and marital status (married or in a stable relationship, single, or widowed/widowered). Measurements of depressive symptoms, used as outcome variables, were adapted from the Prospective Urban and Rural Epidemiological (PURE) study [ 20 ]. The participants were assessed based on the responses provided to eight questions concerning the occurrence of the following symptoms in the last 12 months: fatigue (loss of energy), weight gain or loss, problems falling asleep, loss of concentration, loss of interest and pleasure, feeling of helplessness (low self-esteem), sadness (worry), and thoughts about death. The respondents answered “yes” or “no” to each question. The answers were scored as 1 point or 0 points. The participants were then divided into three tercile groups based on their total scores (from 0 to 8 points): no or mild depressive symptoms (0–2 points), moderate depressive symptoms (3–5 points), and severe depressive symptoms (6–8 points) [ 21 ]. The respondents were also asked about the use of antidepressants and whether they had experienced any stressful life events in the last year, such as a serious disease or injury or death or serious disease of a close family member. The categories of the variable “number of lost teeth” were distinguished based on the quartile distribution of this characteristic among the analysed population. Thus, the self-reported number of lost teeth was analysed according to the following categories: 0–4, 5–8, 9–27, and a complete lack of natural teeth. Body height and mass were measured and subsequently used to calculate BMI (kg/m 2 ). The assessment of diabetes status included a diagnosis of diabetes, diabetes treatment, or current abnormal fasting glucose in the blood serum (≥ 100 mg/dL/5.5 mmol/L) measured using the enzyme method with hexokinase. Participants who did not meet the above criteria were classified as nondiabetic. Total consumption of sugar, sweets, and sweetened beverages was assessed with a validated, semiquantitative food frequency questionnaire from the PURE study, which was used in the PONS project [ 22 ]. The questionnaire was administrated in Polish. The method of FFQ development and validation was carefully standardised for all PURE study participating countries [ 22 ]. One hundred and forty-six study participants in the Polish arm of the PURE study completed the 134-item FFQs as well as four 24-h dietary recalls during a 12-month period. The FFQ has good validity and reproducibility in relations to the reference method. The study participants were asked about how frequently they consumed certain portions of each product containing sugar over the last year. The frequencies of consumption were classified as follows: 6 times a day or more, 4–5 times a day, 2–3 times a day, once a day, 5–6 times a week, 2–4 times a week, once a week, 1–3 times a month, less frequently than once a month or not at all. The reported frequencies of consumption and sizes of portions of the analysed food products were converted into mean daily doses (min–max = 0.00–27.64 times/day). Smoking status was determined by dividing the respondents into current smokers (smoking every day), former smokers (those who had not smoked for more than six months at the time of the study), and never smokers (the remaining respondents).

Statistical analysis

The data were analysed using STATISTICA 13.3 software (STATSOFT, PL). The results were considered significant at p  ≤ 0.05. Counts and percentages were calculated for each categorical (qualitative) variable. The arithmetic mean ( X ) and standard deviation ( SD ) were calculated for the continuous variables, i.e., age, BMI, and sugar and sweets consumption. The internal consistency and reliability of the eight-question test used to assess depressive symptoms were calculated based on Cronbach’s alpha, which equaled 0.81 in this sample. Simple and multivariable logistic regression analyses were conducted to calculate odds ratios (ORs ) and 95% confidence intervals (CIs ). The number of lost teeth was an independent variable (ref. 0–4). Depressive symptoms were analysed according to three categories, with moderate (3–5 points) and severe (6–8 points) symptoms forming the model categories and no or mild (0–2 points) symptoms forming the reference group (ref.). Multivariable models were calculated adjusted for the following covariates: age and consumption of sugar and sweets (continuous variables) and categorical variables: sex (ref. women), place of residence (ref. city), education (ref. higher), marital status (ref. in a relationship), BMI (ref. 18.5–24.9 kg/m 2 ), diabetes status (ref. no), stressful life events in the last year (ref. no), use of antidepressants (ref. no), and smoking (ref. never smokers). The goodness-of-fit model was assessed using the Akaike Information Criterion (AIC). The covariates were selected based on a review of the subject literature [ 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 17 , 18 , 23 , 24 , 25 , 26 , 27 , 28 , 29 ] and a previous study [ 21 ] (Fig.  1 ).

Relationship between dependent and independent variables and confounders [ 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 17 , 18 , 21 , 23 , 24 , 25 , 26 , 27 , 28 , 29 ]

Table 1 presents the sociodemographic and clinical data of the participants. The majority of the participants were women (63.89%), lived in a city, had secondary education, and were in a stable relationship. The mean BMI was 28.14 ± 4.65 kg/m 2 , and diabetes or elevated glucose was observed in more than 1/3 of the participants. In terms of the number of lost teeth, the largest group included individuals who lost 9 or more teeth (28.56%). The mean intensity of depressive symptoms was 2.22 ± 2.29 points. Only 2.91% of the participants used antidepressants regularly. Over 22% declared experiencing stressful life events in the last year. The mean total consumption of sugar, sweets, and sweetened beverages was 4.32 ± 3.60 times/day. Almost 1/5 of the participants were current smokers.

According to the unadjusted model, a greater number of lost teeth was associated with a greater likelihood of both moderate and severe depressive symptoms (Table  2 ). After adjusting for the confounding variables, the relationships between the number of lost teeth and depressive symptoms were weaker, but a total lack of natural teeth was still the factor that was most strongly connected with the likelihood of both moderate ( p  < 0.020) and severe ( p  < 0.001) symptoms (Table  3 ). A loss of more than 8 natural teeth was also significantly associated ( p  < 0.008) with the occurrence of severe depressive symptoms.

The obtained results confirmed the hypothesis about the existence of a positive relationship between the number of lost teeth and the occurrence of depressive symptoms among middle-aged adults. Furthermore, the results indicated that individuals with severe edentulism in particular should be assessed for depressive symptoms.

Most long-term studies have demonstrated that oral health problems and a lack of natural teeth may play a role in the development or worsening of depressive symptoms [ 30 , 31 ]. In a study conducted in Brazil, individuals who experienced tooth loss over a six-year follow-up were at a greater risk of exhibiting depressive symptoms (adjusted prevalence ratio = 1.86; 95% CI: 1.01–3.53) [ 32 ]. In the Chilean population, individuals aged 38–74 years with fewer than 20 natural teeth were shown to have higher odds of incident depression at two- and four-year follow-ups [ 33 ]. The existence of positive relationships between tooth loss and the occurrence of depressive symptoms was also substantiated by the results of meta-analyses [ 34 ] and cross-sectional studies [ 35 , 36 ]. Matsuyama et al. [ 36 ] reported that the effect of tooth loss on depression seemed to be greater in young adults. This phenomenon can be explained by the fact that individuals usually associate the loss of teeth with old age, and consequently, if the problem occurs at a young age, it may exacerbate depressive symptoms. Elderly individuals may treat tooth loss as a natural consequence of old age and adapt their daily life to it more easily than young individuals. The oral health of Poles has remained unsatisfactory for many years compared to that of other European countries, despite a recent trend toward improvement [ 12 , 37 , 38 ]. A total lack of natural teeth, reported by 22.37% of the participants in this study aged 40–64 years, was similar in prevalence to the global prevalence among individuals aged ≥ 45 years, which amounts to 22% [ 39 ]. As a result, all negative health outcomes of tooth loss can be expected to appear much earlier in the Polish population.

The mechanism of the relationship between the loss of natural teeth and depressive symptoms has not been investigated or explained in depth thus far. In their long-term study, Yamamoto et al. [ 30 ] observed that problems with smiling, laughing, and exposing teeth without embarrassment may cause individuals to isolate themselves and eat alone, which in turn exacerbates their depressive symptoms. Kusama et al. [ 18 ] also reported that the deterioration of oral function and orofacial appearance are the main factors contributing to the development of depression due to the loss of natural teeth. Sun et al. [ 40 ], based on research conducted among the Chinese population, concluded that dietary dissatisfaction was a contributing factor to the development of depressive symptoms following the loss of teeth. This occurs because food plays an important role in meetings with family and friends and is a medium for maintaining social contact, expressing friendships, and caring for family members. In middle-aged individuals, embarrassment and dissatisfaction with one’s own appearance due to loss of teeth also led to frustration and problems with satisfying activity on the job market, even when dentures were used [ 17 ], because removable, unstable dentures did not eliminate certain problems related to aesthetics and oral health. Researchers suggest that depressive symptoms may also be further exacerbated by inflammation of the nervous system resulting from a history of periodontitis or autonomic nerve imbalance caused by oral pain and discomfort [ 34 ]. Moreover, Wingfield et al. [ 41 ] noted that depression may be related to the state of the oral cavity microbiome. The authors described explicit changes in the composition and amount of specific bacterial taxa in the salivary microbiome in young adults with depression compared to a reference group of individuals without depression.

Limitations

The limitations of this study include, first and foremost, its cross-sectional design. Moreover, the persons who agreed to participate were volunteers. Thus, they may not be representative of the entire target population. This may result in a sampling bias and limit the generalisability of the results. It should be noted that the relationship between tooth loss and the occurrence of depressive symptoms may be bidirectional [ 34 ]. Analysis of depressive symptoms suggested that self-neglect, lowered mood, and lack of energy may cause individuals to neglect oral hygiene and proper eating habits, leading to health problems in the form of oral diseases and tooth loss [ 35 ]. Aldosari et al. [ 31 ] demonstrated that oral cavity disorders, including tooth loss, were more prevalent among individuals with severe internalization problems. Another limitation that should be mentioned is the potential effect of other factors that have not been included in this study on loss of teeth and the occurrence of depressive symptoms, such as oral hygiene habits [ 10 , 12 ], number of visits to a dentist [ 10 , 12 ], well-being [ 42 ] or overuse of alcohol [ 43 ]. Furthermore, the research tool did not allow for a clinical diagnosis of depression. However, the questionnaire used in this paper has been successfully applied for the assessment of depressive symptoms in other international studies [ 20 ]. Conversely, the strengths of this study were the large sample size, uniformity in terms of age, and large number of confounders included in the analysis.

As has been mentioned in the introduction, the prevalence of missing teeth and factors that determine it depend on economic development, access to dental care, social factors and lifestyle, which is why they may differ between countries and regions [ 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 ]. The obtained results indicated a need for improvement in dental care for middle-aged patients. However, the results may also be used in other European countries with similar living conditions, in particular, in East-Central European countries.

The results indicated that loss of natural teeth was positively related to the occurrence of depressive symptoms in middle-aged adults. Edentulism showed the strongest relationship with the likelihood of both moderate and severe depressive symptoms. The results of this study have indicated an urgent need to intensify stomatological prophylaxis, education and treatment for middle-aged individuals. Preventing the loss of teeth may potentially reduce the risk of depressive symptoms in this group. This will require the involvement of not only psychologists but also the entire medical community, including dentists, as well as the introduction of appropriate changes in the health care system in Poland aimed at increasing the real availability of dental services.

Better integration of mental and oral health prevention and treatment are recommended. Further longitudinal studies are required to establish the causal and temporal relationship between depressive symptoms and oral health status.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author upon reasonable request.

Abbreviations

POlish-Norwegian Study

Prospective Urban and Rural Epidemiological Study

Arithmetic mean

Standard deviation

Body mass index

Confidence interval

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Acknowledgements

The data collection was supported by the Maria Sklodowska-Curie Institute of Oncology in Warsaw (Poland) and the Polish-Norwegian Foundation Research Fund.

This study was supported by Jan Kochanowski University in Kielce, Poland (No 2024). The founders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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Martyna Głuszek–Osuch, Elżbieta Cieśla & Edyta Suliga

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MG-O contributed to the study conception and interpretation of the data and wrote the manuscript. EC performed the statistical analysis and revised the paper. ES contributed to the study conception and interpretation of the data and revised it critically for important intellectual content. All authors approved the final version of the manuscript prior to submission.

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Correspondence to Edyta Suliga .

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The study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee at the Cancer Center and Institute of Oncology in Warsaw (No. 69/2009/1/2011). Written informed consent was obtained from participants before the survey. The material analyses were approved by the Committee on Bioethics at the Faculty of Health Sciences, Jan Kochanowski University in Kielce (No. 45/2016).

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Głuszek–Osuch, M., Cieśla, E. & Suliga, E. Relationship between the number of lost teeth and the occurrence of depressive symptoms in middle-aged adults: a cross-sectional study. BMC Oral Health 24 , 559 (2024). https://doi.org/10.1186/s12903-024-04337-z

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• National Institute of Dental and Craniofacial Research. Oral Health in America: Advances and Challenges. US Department of Health and Human Services, National Institutes of Health; 2021. Accessed October 27, 2023. https://www.nidcr.nih.gov/sites/default/files/2021-12/Oral-Health-in-America-Advances-and-Challenges.pdf
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• Centers for Disease Control and Prevention. Oral Health Surveillance Report: Trends in Dental Caries and Sealants, Tooth Retention, and Edentulism, United States, 1999–2004 to 2011–2016. US Dept of Health and Human Services; 2019.
• Community Preventive Services Task Force. Oral Health: Preventing Dental Caries, School-based Dental Sealant Delivery Programs. US Department of Health and Human Services; 2016. https://www.thecommunityguide.org/sites/default/files/assets/Oral-Health-Caries-School-based-Sealants_0.pdf [PDF-579KB]
• Community Preventive Services Task Force. Oral Health: Preventing Dental Caries, Community Water Fluoridation. US Department of Health and Human Services; 2017. https://www.thecommunityguide.org/sites/default/files/assets/Oral-Health-Caries-Community-Water-Fluoridation_2.pdf [PDF-590KB]
• Leite RFM, Nascimento GG, Scheutz F, Lopez R. Effects of smoking on periodontitis: a systematic review and meta-regression. Am J Prev Med. 2018; 54(6):831–841.
• Leite RS, Marlow NM, Fernandes JW, Hermayer K. Oral health and type 2 diabetes. Am J Med Sci. 2013;345(4):271–273.
• Naavaal S, Kelekar U. School hours lost due to acute/unplanned dental care. Health Behav Policy Rev. 2018;5(2);66–73.
• Righolt AJ, Jevdjevic M, Marcenes W, Listl S. Global-, regional-, and country-level economic impacts of dental diseases in 2015. J Dent Res. 2018;97(5):501–507.
• Atchison KA, Weintraub JA, Rozier RG. Bridging the dental-medical divide: case studies integrating oral health care and primary health care. J Am Dent Assoc. 2018;149(10):850-858.

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Simple 'swish-and-spit' oral rinse could provide early screening for gastric cancer

by Digestive Disease Week

A simple oral rinse could provide early detection of gastric cancer, the fourth-leading cause of cancer deaths worldwide, according to a study scheduled for presentation at Digestive Disease Week (DDW) 2024.

"In the cancer world, if you find patients after they've developed cancer, it's a little too late," said Shruthi Reddy Perati, MD, author and general surgery resident at Rutgers Robert Wood Johnson School of Medicine. "The ideal time to try to prevent cancer is when it's just about to turn into cancer. We were able to identify people who had pre-cancerous conditions. As a screening and prevention tool, this has enormous potential."

Researchers analyzed bacteria samples from the mouths of 98 patients scheduled for endoscopy, including 30 known to have gastric cancer , 30 with premalignant gastric conditions and 38 healthy controls. They found distinct differences between the oral microbiomes of the healthy group compared to the cancerous and pre-cancerous patients.

They also found very little difference between the samples from pre-malignant patients and those with cancer, suggesting that the changes in the microbiome may occur as soon as the stomach environment starts to undergo changes that can eventually turn into cancer.

"We see that the oral microbiome and the stomach microbiome are connected, and knowing what bugs are in your mouth tells us what the stomach environment is like," Perati said. "That has a huge implication that could lead to some practice-changing tests and guidelines."

The findings suggest that oral bacteria alone could be biomarkers for gastric cancer risk. Based on their findings, the authors developed a model of the 13 bacterial genera representing the most significant differences between controls and the cancer and pre-cancer patients.

"No formal screening guidelines for gastric cancer are available in the United States, and more than half of patients with gastric cancer receive a diagnosis when the cancer is already at an advanced stage ," Perati said.

Researchers plan to conduct larger studies in multiple institutions to ensure findings are generalizable to a wider population.

"Even with a small cohort, we were able to see some stark differences and believe the findings are very promising," Perati said.

Dr. Perati will present data from the study, "Oral microbiome signatures as potential biomarkers for gastric cancer risk assessment," abstract 949, on Monday, May 20, at 4:15 p.m. EDT.

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