Keywords
oral hygiene - oral health - diet - oral habits - nutrition - omnivorous - vegetarian
- vegan - women - Italy
Introduction
The relationships between oral health habits, dietary practices, and oral health status,
in the population of Italian women, are complex. Indeed, there are many mutual and
interrelating factors which play an important role. Just as inadequate nutrition can
affect oral health, poor oral health status affects food choices and, thus, nutritional
status.[1] It is clearly essential that the primary care practitioner and/or screening health
professionals always include an evaluation of oral status in the assessment of general
health of a patient. Moreover, dentists and dental hygienists are in the unique position
to provide both oral hygiene instruction and basic nutrition information related to
oral health. Unfortunately, many patients may not be aware of the effects of diet
and nutritional status on the development and maintenance of a healthy mouth and caries-free
teeth. Therefore, it is vitally important for these professional figures to perform
basic nutrition screening to assess clients' dietary habits for potential risk factors
for dental caries and periodontal disease. Collaboration between dietetics professionals
and oral health care professionals is essential in identifying, educating, and treating
oral health problems related to nutrition. Such partnerships will encourage improved
levels of oral health care.[2]
However, one health challenge is maintaining a natural and healthy dentition throughout
the life span[3]
[4]
[5]
[6]
[7] because this has a considerable impact on the chewing function. In addition, chewing
is also a critical first step in oral processing of food materials for nutrient procurement.[8]
In conclusion, an individual's oral health status has a profound impact on the intake
and utilization of nutrients. Moreover, interchangeable nutrients tend to determine
the state of oral health by preventing tooth loss and oral diseases. In view of this,
the purpose of this study is to highlight the link between nutrition and oral health
in a sample of women in Italy and discuss in which way oral health professionals can
integrate nutrition counseling.
Materials and Methods
In the period between February 2020 and July 2020, an anonymous questionnaire, made
up of 20 questions, was administered to a sample of Italian women, aged between 15
and 60 years. The questionnaire was prepared and administered through the “Google
Forms” platform and posted on social network groups (Facebook) in Italy.
The questionnaire was prepared together with a statistician that established the sample
size sufficient for study validity. Among the 400 surveys received, 44 were incomplete;
among the remaining 356, an established sample of 120 subjects was randomized through
an algorithm generated though the SAS Software (Analytics Software & Solutions) (SAS
Inc., United States, 2020).
The study protocol complied with the Guidelines for Good Clinical Practice, according
to the Declaration of Helsinki (1975). The study was approved by the Institutional
Review Board of territorial NHS facilities (no. 3003/19).
The 20 questions, in the questionnaire, were divided into two parts. In the first
part, there were questions that aimed at collecting information regarding their age,
their type of diet, and the period when they embraced their current dietary style.
In the second part, questions regarding their oral hygiene, dental and periodontal
health (presence of bleeding, mobility, sensibility), and frequency of dental checkups
were asked.
Statistical Analysis
The data gathered were recorded with a specially designed computer program and collected
in a Microsoft Excel database. Data were evaluated using standard statistical analysis
software (version 20.0, Statistical Package for the Social Sciences, IBM Corporation,
Armonk, New York, United States). Descriptive statistics including percentage and
frequency values were calculated for each variable. The relationship between the following
variables was explored:
-
Type of diet and bad breath
-
Type of diet and sensitivity
-
Type of diet and bleeding
-
Type of diet and dry mouth
-
Number of checkup visits and dental mobility
-
Number of checkup visits and gum bleeding
-
Number of checkup visits and bad breath
-
Use of dental floss and gum bleeding
-
Use of dental floss and bad breath
-
Use of interdental cleaning brush and dental mobility
-
Type of toothbrush and gum bleeding.
For all categorical variables, group comparisons were assessed by chi-square test
of homogeneity, if expected cell frequencies were lower than five, Fisher's exact
test was used. Phi (ϕ) measures were used to evaluate the effect size of a nominal-by-nominal
relationship. The effect size of each association was evaluated according to the following
conversion table:
Score from 0.1 to 0.20: weak association;
Score > 0.20 to 0.30: moderate;
Score > 0.30: strong.
A p-value of ≤0.05 was considered as statistically significant.
Results
In the period between February 2020 and July 2020, 120 questionnaires were collected.
All of them were properly filled and none was excluded.
Results are presented in accordance with a first descriptive evaluation of parameters
followed by a correlation analysis between some of them. Among the data collected
from the questionnaires and then submitted to statistical analysis, there are many
statistically significant associations. However, some results with a nonstatistical
p-value (p-value <0.05 as significant) were chosen to be reported, considered important for
the purpose of this study.
Descriptive analysis shows a female population, and the majority (73%) is 36 to 55
years old and follows an omnivorous diet ([Table 1]). Most of the women declare good manual skills in oral hygiene (50%) but just less
than half of them brushes their teeth more than three times a day ([Table 2]). Regarding oral hygiene habits, a great part uses a whitening toothpaste (18%).
The prevalence in use of dental floss, interdental cleaning brush, brush tongue cleaning,
and mouthwash is described in [Table 3].
Table 1
Different kind of diet followed
|
Frequency (N)
|
Percentage (%)
|
|
Omnivorous diet
|
85
|
70.8
|
|
Vegan diet
|
7
|
5.8
|
|
Vegetarian diet
|
28
|
23.3
|
|
Total
|
120
|
100.0
|
Table 2
Frequency of brushing
|
Frequency (N)
|
Percentage (%)
|
|
1
|
11
|
9.2
|
|
2
|
60
|
50.0
|
|
>3
|
49
|
40.8
|
|
Total
|
120
|
100.0
|
Table 3
The prevalence in the use of dental floss, interdental cleaning brush, brush tongue
cleaning, and mouthwash
|
Frequency (N)
|
Percentage (%)
|
Cumulative percentage (%)
|
Frequency (N)
|
Percentage (%)
|
Cumulative percentage (%)
|
Frequency (N)
|
Percentage (%)
|
Cumulative percentage (%)
|
Frequency (N)
|
Percentage (%)
|
Cumulative percentage (%)
|
|
Frequency in using dental floss
|
Frequency in using interdental cleaning brush
|
Frequency in using brush tongue cleaner
|
Frequency in using mouthwash
|
|
Everyday
|
17
|
14.2
|
14.2
|
4
|
3.3
|
3.3
|
6
|
5.0
|
5.0
|
6
|
5.0
|
5.0
|
|
Often
|
32
|
26.7
|
40.8
|
12
|
10.0
|
13.3
|
10
|
8.3
|
13.3
|
22
|
18.3
|
23.3
|
|
Sometimes
|
32
|
26.7
|
67.5
|
27
|
22.5
|
35.8
|
18
|
15.0
|
28.3
|
45
|
37.5
|
60.8
|
|
Almost never/never
|
39
|
32.5
|
100.0
|
77
|
64.2
|
100.0
|
86
|
71.7
|
100.0
|
47
|
39.2
|
100.0
|
|
Total
|
120
|
100.0
|
|
120
|
100.0
|
|
120
|
100.0
|
|
120
|
100.0
|
|
Among all the women who filled the questionnaire, only 4.2% declare a constant presence
of bleeding after brushing teeth, while 9.2% say they have dental sensitivity. On
the other hand, the same percentage of women (0.8%) declares to have bad breath and
dental mobility. All the results reflect a population of women who, for ∼55%, did
not use to undergo very often to dental checkups. Indeed only 29% of all women went
to the dentist every 6 months.
Regarding statistical correlation between different parameters, it is appropriate
to start mentioning data correlated with diet, in accordance with the focus of the
article. Data reveal that among all women who completed the questionnaire, even though
the correlation is not statistically significant (p-value <0.05 as significant), the relationship shown between the type of diet and
several oral symptoms is interesting. The only case in which results reveal the constant
presence of bad breath is when women follow a vegetarian diet; on the other hand,
the omnivorous diet shows the majority percentage of women with no halitosis problems
(75.4% omnivorous women reporting not to have it vs. 18 and 6.6% of vegetarian and
vegan, respectively). However, according to dental sensitivity, the major percentage
(54.5%) of women who always feel it is present in women who follow a vegetarian diet,
while omnivorous diet reveals the highest score of no sensitivity at all (74.3% of
omnivorous vs. 20 and 5.7% of vegetarian and vegan not having it).
Regarding gum bleeding, among the omnivorous women, low percentages were reported
to be suffering from it always or often (3.5% always and 20% often). Similar was for
vegetarian women (7.1% always and 17.9% often) and for vegan women (0.0% always and
14.3% often) ([Fig. 1]).
Fig. 1 Correlation between kind of diet and gum bleeding.
In addition, among the interviewed women, very few of them (12.5%) reported to be
often feeling dryness in the mouth (xerostomia), among these, 46.7% were omnivorous,
another 46.7% were vegetarian, and the remaining 6.6% were vegan ([Fig. 2]).
Fig. 2 Correlation between kind of diet and mouth dry.
The first moderate association (ϕ = 0.227) with significant p-value (p = 0.036) was obtained between dental mobility and gum bleeding with checkup visits.
In fact, 71% of women, who had undergone dental examination, did not reveal dental
mobility, while only 0.8% showed an evident mobility of teeth. On the other hand,
38% of women, who followed frequent checkup visit, did not show gum bleeding compared
with a small percentage (4%) with gingival inflammation.
Another moderate statistical association (ϕ = 0.278; p = 0.034) exists between the use of dental floss with gum bleeding and bad breath
after brushing the teeth. In fact, among women who use dental floss, 40% have just
sometimes showed gum bleeding, while 37% never suffered from this problem ([Fig. 3]). Otherwise, considering the correlation with bad breath, data show that 41% of
women felt bad breath despite the use of dental floss versus 51% who almost have never
had this discomfort ([Fig. 4]).
Fig. 3 Correlation between flossing and gum bleeding.
Fig. 4 Correlation between flossing and halitosis.
In addition to dental floss, there is a strong statistical correlation (ϕ = 0.441)
also between interdentally cleaning brush and dental mobility (p = 0.015). Indeed, 50%, among who often use interdentally cleaning brush, had no dental
mobility; the remaining 50% also had low teeth mobility. Otherwise, among the ones
who have never used this device, 42% had no dental mobility and only 0.8% reported
a considerable mobility of teeth.
Looking at the association between the kind of toothpaste and the presence or absence
of gum bleeding, data reveal different percentages. The toothpaste for sensitive teeth,
together with natural toothpaste, showed the highest percentage in association of
gum bleeding (20%) followed by toothpaste for periodontal disease (2.5%). Instead,
tartar control toothpaste obtained the highest score (39%) in no bleeding among all
toothpastes analyzed. [Fig. 5] shows, in more detail, the results obtained.
Fig. 5 Correlation between type of toothpaste and gum bleeding.
Looking at other statistically significant data, results reveal that among who follow
checkup visits every 6 months, 19 and 24% have almost never had bad breath (ϕ = 0.512;
p = 0.006) and dental mobility (ϕ = 0.318; p = 0.021), respectively. Among the ones undergoing dental checkups twice a year, 82.9%
declared not to be having dental mobility, as well as 77.8% who undergo dental checkups
once a year; the percentage dramatically drops in women who never go to the dentist,
rising on the other side the percentage of reported dental mobility (66.7%).
Age, different kinds of toothbrush, and mouthwash reveal no statistical correlation
but, at the same time, it is interesting analysis of some specific characteristics.
For example, the toothbrushes with medium bristle are associated with the highest
percentage (53%) of no dental mobility. In addition, despite the values are not statistically
significant, there is also increasing bleeding and bad breath in the ones who brush
their teeth only once, when compared with the ones who brush their teeth at least
three times a day.
Discussion
This study aimed to find a link between nutrition and oral health in a sample of women
in Italy and discuss in which way oral health professionals can integrate nutrition
counseling that affects food choices and, thus, nutritional status.
Unfortunately, this topic is poorly discussed in literature, so it was hard to make
a great comparison between results obtained and what literature explains.
However, starting from how aliments and diet influence oral health, different studies
face the association between the amount and frequency of free sugar intake and dental
caries.[9]
[10]
[11] Although other fermentable carbohydrates may not be totally blameless, epidemiological
studies show that the consumption of starchy staple foods and fresh fruit is associated
with low levels of dental caries. In addition, the frequency of consumption of foods
containing free sugar should be limited to a maximum of four times per day.[9]
Otherwise, regarding different types of diets, it seems that the number of people
embracing a vegetarian lifestyle is constantly growing. Indeed, studies involving
countries all over the world produced variable results of vegetarianism prevalence
among the general population: 0.77% in China, 0.79% in Italy, 1.5% in Spain, 3.3%
in Germany, 3.8% in Norway, 4.1% in Finland, from 3 to 5% in Latvia, 11.2% in Australia,
33% in Southern Asia, and from 4.8 to 5.6% in Sweden.[10] Vegetarianism implies a dietary regime, or conception, lacking meat, poultry, or
fish. There are many reasons, related to health, ethical, social, or environmental
motivations, that lead to take up a vegetarian diet.[11] Veganism, as well, is generally adopted to carry out ethical principles related
to animals' rights and well-being, but also to comply with spiritual, moral, and religious
values, for socioeconomic considerations and for environmental reasons, supporting
concepts such as energy saving and the use of natural resources in food production.[12]
[13]
[14]
[15]
[16]
[17]
Vegetarian diets are characterized by different nutritional models according to the
exclusion of one or more type of food. The most common ones are the lacto-ovo vegetarian
diet (it excludes meat and fish, but includes dairy, eggs, and honey, together with
a great variety of vegetal food), the lactovegetarian diet (– it excludes meat, fish,
and eggs, but includes dairy, honey, and great variety of vegetal food), the ovovegetarian
diet (it excludes meat, fish, and dairy, but includes eggs and honey, together with
great variety of vegetal food), and the vegan diet (it excludes meat, fish, dairy,
eggs, and honey, but includes a great variety of vegetal food).[14]
Particularly, scientific evidence suggests vegetarian diet carries out a positive
impact on body mass index, cholesterol levels, glucose levels, and risk of cardiovascular
diseases and cancer.[18] However, to this day, it is not clear if a vegetarian diet may have effect on oral
cavity health. Several associations have been made between diet and oral health, such
as the connection between the consumption of sugar and the onset of caries or periodontal
problems.[19]
[20]
[21] Nevertheless, studies that focus on the association between the type of diet and
diseases in the oral cavity are not many.[22] Since the 1970s, some studies have examined possible connections between vegetarianism
and dental health,[19] analyzing the correlation of acid food consumption and dental erosion. Scientific
evidence from the most recent studies shows variable results; while some found positive
associations, others found negative ones.[23]
[24] Our study showed how in this sample of women, the most common diet is the omnivorous
one (70.8%). Indeed, results showed that, when compared with women following vegetarian
diet, there was less incidence of bad breath (75.4% omnivorous women reporting not
to have it vs. 18 and 6.6% of vegetarian and vegan, respectively). Even though the
correlation is not statistically significant, this is probably due to the difference
in number of the groups: omnivorous, vegetarian, and vegan; further investigations
with more homogenous samples will be interesting to research to affirm a certain factor
in vegetarian and vegan diet that would support the higher presence of halitosis.
Moreover, for future research, differential diagnosis among physiological halitosis,
pathological halitosis, pseudo halitosis, and halitophobia could be performed through
different methods (organoleptic evaluation, gas chromatography, and salivary β-galactosidases
activity).[25]
[26] This can be diriment in understanding if a connection between halitosis and vegetarian
diet exists. The same kind of reasoning goes for the sensitivity aspect, for which
higher percentages in omnivorous women declared not to have it (74.3% of omnivorous
vs. 20 and 5.7% of vegetarian and vegan, respectively). For this reason, it could
be interesting for future research purposes to investigate the etiopathology of this
hypersensitivity.
Concerning gum bleeding, there are no studies in the literature which aim to examine
it. From our results, no significant difference was recorded for the different types
of diet, with relatively similar and low percentages reported in the three groups,
suggesting that there may not be a correlation between diet and gum bleeding.
The last aspect analyzed regarding xerostomia and diet showed equal percentages for
omnivorous and vegetarian women, and a lower one for vegan, but no significant correlation
between the two variables. This might suggest that the difference in the diets does
not influence the sensation of dryness in the mouth and that the lower percentage
of reported xerostomia might be related to the poorer numerosity of the women following
that type of diet.
For what that concerns the aspect of vegetarian subjects' oral health, some mechanisms
that might explain the potential associations between vegetarianism and dental health
have been proposed. Even if at this day, it is still controversial, some results in
scientific literature show potential evidence related to the risk of dental erosion
in people following a vegetarian diet versus the ones not following it. People exclusively
assuming vegetable food tend to eat more fruit and vegetables compared with people
following a nonvegetarian diet, therefore introducing more acid foods that cause a
reduction of the salivary pH.[19] To this day, there are still few scientific data available regarding the correlation
between vegetarian diet and oral health. Some epidemiological studies suggest a multifactorial
etiology for white lesions of dental enamel (demineralization), erosion, and abrasion,
for which food habits can play a significant etiological role.
Another interesting data emerging from literature is the absence of caries in individuals
following a vegetable-based diet, most likely connected to the consumption of fresh
fruit during lunch that demonstrated to be significant in self-cleansing. In fact,
among the individuals exclusively eating vegetable-based food, a lower incidence of
gingival tissues inflammation was observed.[23]
Time also resulted to be another important factor to be considered. In fact, potential
harmful factors for dental health may show up more probably in subjects who follows
this kind of diet since birth rather than in the ones following it for few months
or years.[19]
This study, as well as other present in literature,[19]
[27]
[28] confirms the good oral hygiene habits of vegetarian and vegan subjects.
Moving onto the topic of oral hygiene habits, it is widely known that good oral hygiene
practices are broadly considered important in maintaining good oral health, and flossing
has long been considered an indispensable part of an effective oral hygiene routine.[29]
Our study showed statistically significant results (p = 0.034) that strengthen the association between flossing and healthier gums, as
37% never suffered from this problem and 40% have just sometimes showed gum bleeding
using floss or interdentally brushes in addition to tooth brushing may reduce gingivitis
or plaque, or both, more than tooth brushing alone.[30]
[31]
[32] Therefore, as in some cases, these conditions may lead to dental mobility, the risk
of it might be as well reduced. Our study showed a significant result correlating
the use of interdentally cleaning brushes and mobility: 50% of the women who often
use interdentally cleaning brush had no dental mobility; the remaining 50% also had
low teeth mobility.
In the end, it is important to remark the importance of regular dental checkups, which
is highlighted by the high percentages of the women reporting teeth mobility and never
going to the dentist (66.7%), opposite to the higher percentages of the women not
reporting it and regularly undergoing dental checkups; this statistically significant
p-Value (p = 0.006) suggests how the correlation between the low presence of dental mobility
and regular checkups is not casual, but supports the fact that regular visits and
professional oral health care can positively affect and benefit oral health status.
Finally, although the values are not statistically significant, there is also increasing
bleeding and bad breath in the ones who brush their teeth only once, when compared
with the ones who brush their teeth at least three times a day, strengthening once
again how important are proper and regular oral hygiene habits.
Conclusion
In conclusion, this study highlights how more awareness needs to be raised concerning
oral hygiene habits and diet, and also regarding the often-underestimated importance
of regular dental checkups. Furthermore, not only brushing at least twice or three
times a day needs to be encouraged but also the valid support of dental aids has to
be in the everyday domestic oral hygiene protocol, as scientific evidence demonstrates.
A thorough anamnesis regarding the diet should be performed during dental visits,
followed by proper nutritional advice related to oral health influence. Future clinical
studies need to be performed on a more consistent number of vegetarian and vegan patients,
to obtain more statistically significant results and support future research that
will compare omnivorous, vegetarian, and vegan diets and their influence on oral health
status. Furthermore, more variables that could influence results should be included
in future studies, such as socioeconomic status, education, and other variables that
could have impacted access to dental care and have influenced dental habits.
