The Contribution of Dietary Factors to Dental Caries and Disparities in Caries

  • Connie Mobley
    Correspondence
    Address correspondence to Connie Mobley, PhD, RD, University of Nevada Las Vegas School of Dental Medicine, 1001 Shadow Lane, MS 7410, Las Vegas, Nevada 89106-4124.
    Affiliations
    Department of Professional Studies, School of Dental Medicine, University of Nevada, Las Vegas, Nev (Dr Mobley); Department of Preventive and Community Dentistry, College of Dentistry, University of Iowa, Iowa City, Iowa (Dr Marshall); Northwest/Alaska Center to Reduce Oral Health Disparities, Seattle, Wash (Dr Milgrom); and Department of Dental Public Health Sciences, University of Washington, Seattle, Wash (Dr Coldwell)
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  • Teresa A. Marshall
    Affiliations
    Department of Professional Studies, School of Dental Medicine, University of Nevada, Las Vegas, Nev (Dr Mobley); Department of Preventive and Community Dentistry, College of Dentistry, University of Iowa, Iowa City, Iowa (Dr Marshall); Northwest/Alaska Center to Reduce Oral Health Disparities, Seattle, Wash (Dr Milgrom); and Department of Dental Public Health Sciences, University of Washington, Seattle, Wash (Dr Coldwell)
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  • Peter Milgrom
    Affiliations
    Department of Professional Studies, School of Dental Medicine, University of Nevada, Las Vegas, Nev (Dr Mobley); Department of Preventive and Community Dentistry, College of Dentistry, University of Iowa, Iowa City, Iowa (Dr Marshall); Northwest/Alaska Center to Reduce Oral Health Disparities, Seattle, Wash (Dr Milgrom); and Department of Dental Public Health Sciences, University of Washington, Seattle, Wash (Dr Coldwell)
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  • Susan E. Coldwell
    Affiliations
    Department of Professional Studies, School of Dental Medicine, University of Nevada, Las Vegas, Nev (Dr Mobley); Department of Preventive and Community Dentistry, College of Dentistry, University of Iowa, Iowa City, Iowa (Dr Marshall); Northwest/Alaska Center to Reduce Oral Health Disparities, Seattle, Wash (Dr Milgrom); and Department of Dental Public Health Sciences, University of Washington, Seattle, Wash (Dr Coldwell)
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      Frequent consumption of simple carbohydrates, primarily in the form of dietary sugars, is significantly associated with increased dental caries risk. Malnutrition (undernutrition or overnutrition) in children is often a consequence of inappropriate infant and childhood feeding practices and dietary behaviors associated with limited access to fresh, nutrient dense foods, substituting instead high-energy, low-cost, nutrient-poor sugary and fatty foods. Lack of availability of quality food stores in rural and poor neighborhoods, food insecurity, and changing dietary beliefs resulting from acculturation, including changes in traditional ethnic eating behaviors, can further deter healthful eating and increase risk for early childhood caries and obesity.
      America is witnessing substantial increases in children and ethnic minorities living in poverty, widening the gap in oral health disparities noted in Oral Health in America: A Report of the Surgeon General. Dental and other care providers can educate and counsel pregnant women, parents, and families to promote healthy eating behaviors and should advocate for governmental policies and programs that decrease parental financial and educational barriers to achieving healthy diets. For families living in poverty, however, greater efforts are needed to facilitate access to affordable healthy foods, particularly in urban and rural neighborhoods, to effect positive changes in children's diets and advance the oral components of general health.

      Key Words

      The prevalence of dental caries in primary teeth, early childhood caries (ECC), increased from approximately 40% in children aged 2 to 11 years in the 1988–1994 National Health and Nutrition Examination Survey (NHANES)—reported in the 2000 Oral Health in America: A Report of the Surgeon General
      US Department of Health and Human Services
      Oral Health in America: A Report of the Surgeon General–Executive Summary. Rockville, Md: US Department of Health and Human Services, National Institute of Dental and Craniofacial Research.
      —to 42% in the 1999–2004 survey.
      • Dye B.A.
      • Tan S.
      • Smith V.
      • et al.
      Trends in oral health status: United States, 1988–1994 and 1999–2004.
      For children aged 2 to 5 years, the rate of increase was greater, rising from 24% to 28%. Increases were identified specifically among ethnic and racial minorities and children living in households with incomes at or below the federal poverty level.
      • Dye B.A.
      • Tan S.
      • Smith V.
      • et al.
      Trends in oral health status: United States, 1988–1994 and 1999–2004.
      As the number of children in these groups increases, the chasm of disparity widens.
      • Tomar S.
      • Reeves A.F.
      Changes in the state of oral health of US children and adolescents since the release of the Surgeon General's Report on Oral Health.
      Understanding the roles of diet, eating behaviors, demographics, and environmental factors in contributing to increased caries rates in children is essential to improving their oral health.
      • Roberts M.W.
      Dental health of children: where we are today and remaining challenges.
      In particular, an established relationship has been reported linking malnutrition in children, inappropriate infant feeding practices, and excessive intakes of simple sugars to ECC.
      • Roberts M.W.
      Dental health of children: where we are today and remaining challenges.

      Patrick DL, Lee RSY, Nuci M, et al. Reducing oral health disparities: a focus on social and cultural determinants. BMC Oral Health. 2006;6(suppl 1):1–17.

      The association of dental caries to excessive sugar intake has been affirmed by an expert panel of the World Health Organization, whose members reviewed the strength of evidence linking dietary factors to caries in 2003. The panel reported an increased risk of caries associated with frequent and total intake of simple sugars,
      The World Health Organization
      The World Oral Health Report 2003.
      although longitudinal studies to support the role of specific nutrient and food components in caries risk or progression are lacking.
      • Moynihan P.
      • Petersen P.E.
      Diet, nutrition and the prevention of dental diseases.
      Multiple environmental, social, and personal factors associated with eating behaviors can be represented in the ecological model shown in the Figure.
      • Beydoun M.A.
      • Wang Y.
      How do socio-economic status, perceived economic barriers, and nutritional benefits affect quality of dietary intake among US adults?.
      • Sheiham A.
      Oral health, general health and quality of life.
      This review examines dimensions of this social-ecological model relevant to ECC.
      Figure thumbnail gr1
      FigureAn ecological model identifying factors influencing eating behaviors. USDA indicates United States Department of Agriculture.

      Malnutrition

      Malnutrition results from adverse changes in dietary intake, digestive and metabolic malfunctions, or the excretion of essential metabolically required nutrients.
      Undernutrition—an insufficient intake of nutrients, overnutrition—an intake beyond required needs, and nutrient imbalances are all forms of malnutrition.
      Overnutrition is commonly associated with the substitution of low-cost, low-nutrient–dense foods such as snacks that contain excessive quantities of sugar, salt, and fat for lower energy, high-nutrient–dense foods such as fruits.
      • Ebbeling C.B.
      • Pawlak D.B.
      • Ludwig D.S.
      Childhood obesity: public health crisis, common sense cure.
      Analysis of data from NHANES III (1988–1994) indicates that 8- to 18-year-old Americans who reported consuming excessive numbers of low-nutrient–dense foods are more likely to report less than the estimated average daily requirements of nutrients essential for optimum health.
      • Kant A.K.
      Reported consumption of low-nutrient-density foods by American children and adolescents.
      Dietary quality data expressed in the Healthy Eating Index from the same source for 2- to 5-year-old children indicates those with the best dietary practices are 44% less likely to exhibit severe ECC compared with children with the worst practices.
      • Nunn M.E.
      • Braunstein N.S.
      • Krall K.E.A.
      • et al.
      Healthy eating index is a predictor of early childhood caries.
      Increased consumption of sugar-sweetened beverages, candy, chips, and cookies provides excessive calories to the child, increases the risk of caries, and when combined with inadequate intake of fruits and vegetables, deprives the child of nutrients essential to growth and development.
      • Ballew C.
      • Kuester S.
      • Gillespie C.
      Beverage choices affect adequacy of children's nutrient intakes.
      Low-nutrient–dense foods are ubiquitous and largely responsible for many chronic health problems in both developing nations and developed parts of the world.
      • Kant A.K.
      Reported consumption of low-nutrient-density foods by American children and adolescents.
      • Ballew C.
      • Kuester S.
      • Gillespie C.
      Beverage choices affect adequacy of children's nutrient intakes.

      Dietary Guidance and Food Assistance Programs

      Since 1977, the federal government has established and has periodically reviewed and updated US dietary guidelines supporting nutrition and health and physiological requirements for maintaining an adequate nutritional status. The current 2005 version, including toolkits and the Healthy Eating Index dietary assessment tool, are accessible on government Web sites to aid all health professionals with diet planning and counseling in clinical, community, and private practice settings.

      US Department of Health and Human Services, US Department of Agriculture. Dietary Guidelines for Americans, 2005. 6th ed. Washington, DC: US Government Printing Office; 2005. Available at: http://www.health.gov/DietaryGuidelines/resources.htm. Accessed June 15, 2009.

      Frequency of intake is not addressed in these resources, however, and should be included in interventions designed to address and improve oral health. Food assistance programs such as the Women, Infants, and Children Program, Head Start, and the United States Department of Agriculture Food and Nutrition Services that includes school meals programs, are designed to improve access to healthy food and beverage options for infants and children. Participation in these programs is available to children and families at no cost based on family income. The availability of fruits and vegetables in school lunch programs has been correlated with increased consumption of these foods by school children.
      • Glanz K.
      • Sallis J.F.
      • Saelens B.E.
      • Frank L.D.
      Healthy nutrition environments: concepts and measures.
      A 2008 study of the quality of diets of children participating in school lunch programs reported the diets to be nutritious, but cautioned policy makers about the increased prevalence of high sodium and high saturated fat intakes among some low-income participants.

      Cole N, Fox MK. Diet Quality of American School Age Children by School Lunch Participation: Data from the National Nutrition and Health Examination Survey, 1999-2004. Alexandria, Va: US Department of Agriculture, Food and Nutrition Services; 2008. Available at: http://www.fns.usda.gov/ora/MENU/Published/CNP/FILES/NHANES-NSLP.pdf. Accessed October 10, 2009.

      Many after-school programs receive food aid from the US government because they serve disadvantaged and minority youth.

      United States Department of Agriculture, Food and Nutrition Service. School meals. Available at: http://www.fns.usda.gov/cnd/. Accessed on June 22, 2009.

      Little is known about the quality of these programs and what impact they may have on oral health disparities related to diet.

      Global Influences on Dietary Choices

      What people eat is affected by many complex variables, including socioeconomic status (SES), the cost of food, the industrialization of agriculture, the location of food outlets, and the effects of advertising and marketing. The use of high fructose corn syrup and other starch by-products (eg, maltodextrin, modified starches) has resulted in an increased availability and consumption of sweetened beverages and a variety of dessert-type snacks.

      Wells HF, Buzby JC. High fructose corn syrup usage may be leveling off. Amber Waves. February 2008. Available at: http://www.ers.usda.gov/AmberWaves/February08/Findings/HighFructose.htm. Accessed August 28, 2008.

      Individual packaging and increased market outlets ensure that cariogenic foods and beverages are readily available at most children's venues—the ballpark, playgrounds, movies, and school. Although there have been suggestions of taxation for sweetened beverages, this is not likely to result in families choosing healthful, affordable, and appropriate foods.
      • Brownell K.D.
      • Frieden T.R.
      Ounces of prevention-the public policy case for taxes of sugared beverages.
      Food cost has a strong influence on food purchases. Energy-dense foods are generally more palatable and can be purchased at a lower marginal cost than healthier alternatives.
      • Drewnowski A.
      • Darmon N.
      Food choices and diet costs: an economic analysis.
      Education addressing strategies to improve nutrient quality while managing food cost is needed.
      In-school product marketing and sales promotion of high-fat snacks and carbonated, sweetened beverages has been a growing concern.
      • French S.A.
      • Story M.
      • Fulkerson J.A.
      • Geriach A.F.
      Food environment in secondary schools: a la carte, vending machines, and food policies and practices.
      There is aggressive marketing for candy, snacks, sugared cereals, and fast food that is targeted toward children and adolescents.
      Foods purchased and consumed anywhere outside of the home comprise at least one third of the caloric intake of children and adolescents. In these settings, the foods have higher fat content than foods consumed at home.
      Government policies in the form of sugar and corn subsidies may help to reduce costs of some of these foods, making such snacks more affordable. However, there is no documented evidence to suggest that inexpensive low-nutrient–dense food production is overtly supported by government-subsidized commodity foods.
      • Miller J.C.
      • Coble K.
      Cheap food policy: fact or rhetoric?.

      Parenting Practices

      The first years of life mark a time of rapid development and dietary change as children transition from an exclusive milk diet to a modified adult diet. Human milk has been identified as the ideal food for infants and is recommended throughout the first year of life. And although human milk contains sugar, an analysis from the NHANES III 1999–2004 survey of a subset of children aged between 2 and 5 years concluded that there was no evidence that breastfeeding or its duration per se were independently associated with an increased risk for ECC.
      • Hiroko I.
      • Auinger P.
      • Billings R.J.
      • Weitzman M.
      Association between infant breastfeeding and early childhood caries in the United States.
      However, children living in poverty, Mexican American children, and those exposed to maternal smoking behaviors were at increased risk for poor oral health in the early years.
      • Hiroko I.
      • Auinger P.
      • Billings R.J.
      • Weitzman M.
      Association between infant breastfeeding and early childhood caries in the United States.
      Other investigators have confirmed these findings and have identified milk bottle feeding at night (in which the sweetened liquid remains in contact with the developing dentition) as the most significant determinant of ECC.
      • Mohebbi S.Z.
      • Virtanen J.I.
      • Vahid-Golpayegani M.
      • Vehkalahti M.M.
      Feeding habits as determinants of early childhood caries in a population where prolonged breastfeeding is the norm.
      • Kramer M.S.
      • Vanilovich L.
      • Matush L.
      • et al.
      The effect of prolonged and exclusive breast-feeding on dental caries in early school-age children.
      During the transition to solid foods, parents are the major influence on what children eat and like, the quality of their diet, and their weight status.
      • Savage J.S.
      • Fisher J.O.
      • Birch L.L.
      Parental influence on eating behavior: conception to adolescence.
      The strongest factors associated with healthy eating behaviors at home are availability and accessibility of nutritious food.
      • Cullen K.W.
      • Baranowski T.
      • Owens E.
      • et al.
      Availability, accessibility, and preferences for fruit, 100% fruit juice, and vegetables influence children's dietary behavior.
      As role models, parents can encourage eating fruits and vegetables by regularly serving them at meals and eating them themselves. On the other hand, parents also may encourage the habitual consumption of cheap, highly palatable, energy-dense foods, such as sweetened beverages and snacks, which lead to increased risk for caries, overeating, and weight gain. To counter these patterns, parents need guidance regarding food choices and relative cost-to-nutrient ratio.
      • Savage J.S.
      • Fisher J.O.
      • Birch L.L.
      Parental influence on eating behavior: conception to adolescence.
      Structured meal and snacking patterns, allowing for 1 to 3 daily snacks, are desirable as opposed to free access to juice, other sugared beverages, and snacks over the course of the day. Such behaviors favor the intake of nutrient-poor foods and increase the risk of obesity and dental caries.
      • Marshall T.A.
      • Broffitt B.
      • Eichenberger-Gilmore J.M.
      • et al.
      The roles of meal, snack and daily total food and beverage exposures on caries experience in young children.
      • Dubois L.
      • Girard M.
      • Ptovin K.M.
      • et al.
      Breakfast skipping is associated with differences in meal patterns, macronutrient intakes and overweight among preschool children.
      The American Academy of Pediatric Dentistry's policy on dietary recommendations to decrease caries risk for infants, children, and adolescents supports the adoption of a diverse and balanced diet based on US dietary guidelines.
      Clinical Affairs Committee
      Policy on Dietary Recommendations for Infants, Children and Adolescents.

      Cultural and Socioeconomic Norms

      Within families, traditional cultural norms as well as SES help to shape attitudes toward eating behaviors associated with ECC. In terms of food selection, Barker and colleagues
      • Barker M.
      • Lawrence W.
      • Woadden J.
      • et al.
      Women of lower educational attainment have lower food involvement and eat less fruit and vegetables.
      found that lower educational attainment was associated with less fruit and vegetable consumption compared with high-fat, sugary foods that are often associated with caries risk. Other studies have shown that many low-income mothers viewed an infant who is large for his/her age as healthy, in contrast to health professionals who found that same infant to be overweight.
      • Baughcum A.E.
      • Burklow K.A.
      • Deeks C.M.
      • et al.
      Maternal feeding practices and childhood obesity: a focus group study of low-income mothers.
      • Bentley M.
      • Gavin L.
      • Black M.M.
      • et al.
      Infant feeding practices of low-income, African-American adolescent mothers: an ecological, multigenerational perspective.
      Food and beverages provided on a regular, frequent, and continuous basis increase risk of both ECC and obesity.
      The World Health Organization
      The World Oral Health Report 2003.
      • Barker M.
      • Lawrence W.
      • Woadden J.
      • et al.
      Women of lower educational attainment have lower food involvement and eat less fruit and vegetables.
      Marshall and colleagues
      • Marshall T.A.
      • Eichenberger-Gilmore J.M.
      • Broffitt B.
      • et al.
      Dental caries and childhood obesity: roles of diet and socio-economic status.
      reported that caries and obesity coexist in young children of low SES and that both mother's education and soda intake were closely associated with caries experience.
      High intake of unhealthy snack foods and low intake of fruits and vegetables have both been linked to high parental pressure to eat. This parenting style is commonly observed among nonwhite fathers and parents of younger children.
      • Brown K.A.
      • Ogden J.
      • Vogele C.
      • et al.
      The role of parental control practices in explaining children's diet and BMI.
      In contrast, covert control of children's diets (keeping unhealthy foods out of the home and avoiding fast food restaurants) is associated with healthy child nutrition practices and with appropriate growth, development, and decreased caries risk.
      Such covert control of a child's diet is positively associated with parental level of education.
      • Brown K.A.
      • Ogden J.
      • Vogele C.
      • et al.
      The role of parental control practices in explaining children's diet and BMI.
      Ethnicity is associated with differences in food-related beliefs, preferences, and behaviors. The interaction between ethnicity and environments with lower-than-average neighborhood availability of healthful foods and higher-than-average availability of fast food restaurants, along with exposure to ethnically targeted food marketing, may contribute to reliance on high calorie, low-nutrient–dense foods and beverages.
      • Kumanyika S.K.
      Environmental influences on childhood obesity: ethnic and cultural influences in context.
      Ethnic differences in food choices and inappropriate child-feeding practices may increase risks of malnutrition during gestation, infancy, childhood, and adolescence and manifest nutrient deficiencies in altered tooth morphology and eruption patterns.
      • Oliveira A.F.B.
      • Chaves A.M.B.
      • Rosenblatt A.
      The influence of enamel defects on the development of early childhood caries in a population with low socioeconomic status: a longitudinal study.
      Alternatively, ethnic food choices may include increased access to desirable diets rich in fruit and vegetables.

      The Neighborhood

      Where people live influences their ability to acquire adequate supplies of healthy foods and may present particular problems for low SES and ethnic populations. In both rural and urban communities, convenience stores offering high-energy, low-nutrient–dense foods are more common than full supermarkets offering a wide variety of fruits and vegetables and other healthy foods.
      • Liese A.D.
      • Weis K.E.
      • Pluto D.
      • et al.
      Food store types, availability, and cost of foods in a rural environment.
      • Galvez M.P.
      • Morland K.
      • Raines C.
      • et al.
      Race and food store availability in an inner city neighbourhood.
      • Sharkey J.R.
      • Horel S.
      Neighborhood socioeconomic deprivation and minority composition are associated with better potential spatial access to the grounded food environment in a large rural area.
      In one rural South Carolina county covering 1106 square miles, with 91 582 people, there were 1.1 supermarkets, 0.7 grocery stores, and 5.2 convenience stores per 100 square miles.
      • Liese A.D.
      • Weis K.E.
      • Pluto D.
      • et al.
      Food store types, availability, and cost of foods in a rural environment.
      Greater access to convenience stores would suggest inadequate access to a variety of foods. In the entire state, 52% of children in the third grade had experienced caries, and 33% went untreated, compared with national data of 50% and 26%, respectively.
      • Carlson V.
      • Veschucio C.
      The Burden of Oral Diseases in South Carolina.
      An association between access to markets, rural disparities, and poor oral health is supported by these data. Dependence on reliable cars and the price of gas may also limit access to supermarkets and larger grocery stores for individuals living in rural communities. Within inner cities, the type of food store available also differs by racial groups. In predominantly African American census blocks in East Harlem, there were no supermarkets or grocery stores, whereas Latino census blocks had more specialty food and convenience stores than racially mixed census blocks.
      • Galvez M.P.
      • Morland K.
      • Raines C.
      • et al.
      Race and food store availability in an inner city neighbourhood.
      Community-based organizations have attempted to provide access to healthy foods through advocacy campaigns and policy changes. For example, the Pennsylvania Fresh Food Financing Initiative, the nation's first statewide program to increase supermarket development in underserved areas, is a grass roots attempt to provide the underserved and those with limited incomes access to affordable fresh food from retailers who offer greater variety, which potentially contributes to a nutritionally balanced diet.
      • Giang T.
      • Karpyn A.
      • Laurison H.B.
      • et al.
      Closing the grocery gap in underserved communities: the creation of the Pennsylvania Fresh Food Financing Initiative.

      Countervailing Forces

      Two forces increasingly evident in American society are working to change America's dietary habits. One is the widespread recognition of the epidemic of obesity that is affecting children and adolescents as well as adults.
      • Ebbeling C.B.
      • Pawlak D.B.
      • Ludwig D.S.
      Childhood obesity: public health crisis, common sense cure.
      Americans have come to realize that fast food chains are major contributors to excessive calories, and in response the chains themselves are moderating selections to include more healthy choices. Also of significance is a growing emphasis on the role of nutrition and diet in health promotion and disease prevention. Availability of unprocessed fresh foods, fortified processed foods, and the management of the food supply system require health literacy messages that address the significance of food and dietary practices for general and oral health. How these trends play out and whether or not they have an effect in all neighborhoods is unknown, but they deserve attention in meeting the needs of children.

      Recommendations

      Addressing the role of dietary factors in decreasing caries disparity in children requires a comprehensive perspective and consideration of the multiple, constantly changing variables that affect eating behaviors and health status (Figure). Closing the gap among racial, ethnic, and demographic minorities who experience higher rates of diseases compared with those who have access to education and health care can begin with education but will require government and community action as well. The measures needed require the actions of multiple partners: health care providers (pediatricians, other physicians, dentists, dietitians, and allied health professionals), local community leaders, legislators, government agencies, educators, the media, industry, and other concerned individuals and organizations. Programs to improve children's oral and general health include the following necessary elements:
      • 1.
        Dietary counsel. Health professionals and others as appropriate need to counsel parents, other caretakers, and children to moderate sugar, salt, and fat intake to achieve adequate growth and development and adhere to high-quality diets, following dietary guidelines by using MyPyramid resources provided by the USDA.

        US Department of Health and Human Services, US Department of Agriculture. Dietary Guidelines for Americans, 2005. 6th ed. Washington, DC: US Government Printing Office; 2005. Available at: http://www.health.gov/DietaryGuidelines/resources.htm. Accessed June 15, 2009.

        • Marshall T.A.
        • Broffitt B.
        • Eichenberger-Gilmore J.M.
        • et al.
        The roles of meal, snack and daily total food and beverage exposures on caries experience in young children.
        Education should include the role of frequency of consumption of sugary foods and beverages and why frequency can increase caries risk. Support for inclusion of nutrition education and skill development in health literacy for future medical and dental professionals and continuing education for practitioners can enhance these efforts.
        • Touger-Decker R.
        • Mobley C.C.
        Position paper of the American Dietetic Association: oral health and nutrition.
        Registered dietitians can guide practices and provide consultation to health professionals and the public and develop skills in addressing the oral components of general health.
      • 2.
        Advocacy. Health professionals and allies should organize, lead, and work with local community, state, and national organizations to improve access necessary for a healthful diet, including, for example, the promotion of legislation to provide incentives for establishing well-stocked supermarkets and grocery stores in poor neighborhoods.
      • 3.
        Health professional training. Health professional training and continuing education should include skill development in diet promotion and counseling in support of oral and general health. Representation on local, regional, and state boards involved in improving environments that support healthy communities, schools, and families should be sought and leadership should be achieved.
      • 4.
        Advice to expectant mothers. Educational protocols need to be established to advise pregnant women about healthy diets and provide guidance on infant feeding, emphasizing the value of breast feeding and the necessity of restricting nighttime bottle feeding to decrease caries risk.
      • 5.
        Guidance on home eating patterns. Parents should be advised that they are role models able to set eating behaviors at home by providing high-quality meals and having fruits and vegetables and other healthy foods available as snacks. Advice should include discouraging frequent consumption of high-fat, high-sugar foods and the realization that acceptance of new foods may require repeated presentations of the food. Community resources to assist families in developing skills in purchasing and preparing healthy foods and meals should be included in patient education.
      • 6.
        Cultural/ethnic sensitivity. Family demographics, cultural/ethnic practices, and food related environmental issues should be routinely taken into consideration to tailor education and counseling to the unique needs of a family.
      • 7.
        Skilled health care providers. Multidisciplinary teams including dental professionals, pediatricians, nurses, registered dietitians, family practice physicians, and other allied health care professionals should be trained to screen, educate, and counsel children and families to access care and seek medical and dental homes with active health promotion programs that include diet, nutrition, and dental education resources. Awareness among primary care providers of the potential association between obesity and caries can lead to early interventions and improved health status for all children.

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        • Smith V.
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        Changes in the state of oral health of US children and adolescents since the release of the Surgeon General's Report on Oral Health.
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