Assessment of knowledge, attitude and practices of diet and nutrition on oral health among dental students

INTRODUCTION

Oral health is governed by a multitude of factors which influence its state in health and disease. Dental diseases impair quality of life and have a negative impact on self-esteem, eating ability and health, causing pain, anxiety, and impaired social functioning.^[1,2] Tooth loss reduces the ability to eat a nutritious diet, the enjoyment of food and confidence to socialize.^[3,4]

Dental caries was first described in Miller’s chemo-parasitic theory in 1890.^[5] Caries is caused by the dissolution of the teeth by acid produced by the metabolism of dietary carbohydrates by oral bacteria. Diet and nutrition may interfere with the balance of tooth demineralization and remineralization in several ways.^[6]

According to the American Dietetic Association, “nutrition is an integral component of oral health.”^[7] Oral health and nutrition have a synergistic relation.^[6] The assertion that diet plays a central role in the development of dental caries is unquestionable. Observations in humans, in animals, and in vitro have shown clearly that frequent and prolonged oral exposures to certain carbohydrates are fundamental to caries activity.^[8]

Sugars enter the diet in two forms: Those found naturally in foods and those that are added to foods during processing.^[9] Many factors, in addition to sugars, affect the caries process. Sucrose is generally considered the prime culprit in the causation of dental caries. Other disaccharides have a lower cariogenic risk than sucrose.^[6] Periods of demineralization result in a fall in dental plaque pH caused by organic acids increasing the solubility of calcium hydroxyapatite in the dental hard tissues.^[10] Duration may also be influenced by the frequency and amount of fermentable carbohydrate consumed.^[11,12] The frequency of consumption seems to be a significant contributor to the cariogenicity of the diet, although Bowen et al. concluded that it is not the frequency of ingestion per se that is related to the development of caries but the time that sugars are available to microorganisms in the mouth.^[13-17]

Patients need to be made aware of the effect diet and nutrition has on their oral health. Dietary advice to dental patients should be positive and personalized if possible. Patients should also be encouraged to reduce the frequency of intake of sugary foods.^[18] A diet lower in added sugars and fermentable carbohydrates and high in calcium-rich cheese may also favor remineralization of the tooth.^[6] Dentists need to have adequate knowledge regarding diet and nutrition and its effects on oral health. Dental students can be targeted at an early stage as they will be the beacons of dentistry and carry on the knowledge into private practice. Having asserted the influence of diet and nutrition on dental caries, the present study was conducted to assess the knowledge of the undergraduate students regarding the importance of diet and nutrition in oral health as well as their attitude toward diet counseling.

METHODOLOGY

RESULTS

Out of a total of 203 participants included in the study, 122 (60.1%) of the participants were from the 3^rd year BDS, followed by 59 (29.1%) residents and the least being the final year BDS students who were 22 (10.8%) [Table 1].

The frequency distribution of the responses that were recorded along with the Pearson Chi-square result is tabulated in Table 2. Most of the questions tested the knowledge of the students regarding diet and nutrition and its effect on oral health. Only two of the questions involved attitude and practice-based assessment.

A total majority of 167 (82.3%) students said that sucrose was the most cariogenic among lactose and maltose. Among the different years of study, 54.2% of the 3^rd year students, 22.7% of the residents, and 5.4% of the final year students agreed that sucrose was the most cariogenic. A highly significant statistical difference was observed with P = 0.001. When asked about the sugar substitute that reduces the chances of dental caries the most, 29.1% of the 3^rd years said the answer was saccharine, while 16.3% of the residents thought the answer was xylitol. The difference was statistically significant with P = 0.026 [Graph 1].

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Graph 1: Percentage of association between the year study and the responses.

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With regard to the most anticariogenic food, 122 (60.1%) of the participants felt nuts were the most anticariogenic. About 39.9% of these were 3^rd year undergraduates and 15.3% were residents. About 4.9% each answered milk and nuts among the final year participants (P = 0.011). A significant difference was seen when the students were quizzed with regard to the form of food which helps in preventing dental caries and strengthening the periodontium (P = 0.027). With a large number of participants (84.2%) suggesting firm and fibrous food be the best option, 49.8% of these were 3^rd year followed by 26.6% were residents [Graph 2].

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Graph 2: Percentage of association between the year study and responses.

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When asked which plays a greater role in caries formation, 130 (64%) said the frequency of sugar consumption was the main determinant while 155 (76.4%) of them said that both sugar content and sugar concentration in food was a major consideration in determining the cariogenic potential of sugar. Among all the participants, a significant number of participants; 152 (74.9%) thought that therapeutic and supportive were the two types of Vitamin C supplements.

About 143 (70.4%) of the total students were aware that both Vitamins C and B12 as well as Iron deficiency manifest as oral symptoms. Out of these, 44.3% were 3^rd year students, 18.2% were residents, and 7.9% were final year students. Participants were asked to choose the genetic disease in which carries was practically absent, to which, 46 (22.7%) of the 3^rd year and 11 (5.4%) of final years chose Hereditary lactose intolerance while 26 (12.8%) of the residents felt the answer was Hereditary glucose intolerance [Graph 3].

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Graph 3: Percentage of association between year of study and responses.

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From among rinse, chewing gum and tablets, participants were asked to pick the one which is not a fluoride supplement. About 92 (45.3%) felt the answer was chewing gums, while 78 (38.4%) and 33 (16.3%) felt the answer were tablets and rinse, respectively. When asked regarding the term “perimolysis,” 54.7% of the participants chose the correct option while a close percentage (41.9%) said they were not sure what the term meant.

About 111 (54.7%) of the participants suggested that bulimia and anorexia were the psychological disorders which affect the nutritional status and oral health of an individual. About 35.5% were from 3^rd year, 7.4% were from final year, and 11.8% were from among the residents. A close number of residents (9.9%) also felt the answer could be schizophrenia. Participants were questioned about the strongly cariostatic element present in trace amount in food, to which 150 (73.9%), thought the answer to be fluoride. Out of the total, 91 (44.8%), 16 (7.9%), and 43 (21.2%) were from 3^rd year, final year, and residentship, respectively [Graph 4].

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Graph 4: Percentage of association between year of study and responses.

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The participants were asked if they counsel patients with high caries risk to which, 67.5% said they always counsel the patients and a minority of 3% accepted they never counsel the patients. Finally, the students were questioned if they thought diet counseling could help in the prevention of dental caries. Most of the participants, 83.3% agreed that diet counseling can help in caries prevention. Yet, a meager 3.4% of the participants thought diet counseling could play no role in the prevention of caries (P = 0.277) [Graph 5].

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Graph 5: Percentage of association between year of study and responses.

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DISCUSSION

Professionals from various fields have stressed the importance of diet and nutrition on general health. Yet, not many studies were found to have been conducted among dental students and the assessment of their knowledge regarding diet and nutrition. Moreover, the comparison between the years of study has not been done. The present study was conducted to assess the knowledge of dental students toward the importance of diet and nutrition on oral health. The study concluded that 169 (83.3%) participants from 203 believed that diet counseling could help in the prevention of dental caries.

In the present study, the majority (82.3%) of the participants reported sucrose to be the arch-criminal of caries. This was similar to the results obtained by Sivakumar et al., in a study conducted among dental students in India, regarding their perception of diet counseling. Most of the students (64%) reported sucrose as the most cariogenic sugar in the study by Sivakumar et al.^[19]

There are some human studies which demonstrate that the frequency of sugar intake is an important etiological factor for caries development.^[20,21] There is also evidence to show that both the frequency and the amount of sugars consumed are associated with dental caries.^[22-24]

The primary evidence for the belief that the prevalence of dental caries is directly related to the frequency with which sugar is eaten comes from the Vipeholm study.^[14] These results were in synchrony with the results of our study, with 64% of the participants relating frequency of sugar consumption with dental caries occurrence.

Cheese stimulates the salivary secretion and increases plaque calcium concentration. The calcium concentration of dental plaque strongly influences the balance between demineralization and remineralization of enamel.^[10,25] In an epidemiological study, cheese intake was higher in children who remained caries-free over a 2-year period than in those who developed caries.^[23] Yet, in the present study, least number (19.2%) of students thought of cheese as the most anticariogenic and 60.1% believed nuts were the most anticariogenic food.

The total sugar content per serving of a food is not a major consideration in determining its cariogenic potential; rather, it is the concentration of sugar of food which is more important.^[26] Only 18.7% of the participants in the present study felt sugar concentration was considered in determining the cariogenic potential, with 76.4% considering both sugar content and concentration as a major consideration in determining cariogenic potential.

It can be inferred from the present study that a majority (83.3%) of the students did have a positive attitude toward diet counseling as a tool in the prevention of dental caries. Similar findings have been reported by Carole et al. in whose study dental students expressed a generally favorable attitude toward nutrition and nutritional counseling of their patients. Of the subjects, 42% reported that dietary advice was sometimes rendered to the patients, while a few rarely did the same.^[27] Two studies conducted with caries- active individuals also showed that dietary counseling and reinforcement reduced caries increment by 85% and 60%.^[28,29]

Overall, the present results suggest that the undergraduates have fairly sufficient knowledge and attitude toward diet and nutrition and its role on the maintenance of oral health.

CONCLUSION

The focus of diet counseling has mostly been on the management of diseases. However, the focus should be on health promotion, disease prevention, and comprehensive care. Dentists can be considered “gatekeepers” for recognizing dietary risk and referring patients to dieticians and physicians for further care when indicated. These visits can also provide an opportunity to improve lifestyle, as well as oral hygiene and can be a form of motivation to the patients to bring about positive changes in their general and dental health through diet modifications.