5 Reasons Why Sugar-Shaming is Not the Answer to Avoiding Cavities

Uh oh.

Dentists are not going to like this.

For that matter, hygienists probably won’t like it either.

But as one who grew up needing obligatory fillings practically every year (but hasn’t had a new cavity in over a decade despite a penchant for baked goods) I know more than a little about this.

So I’m throwing my towel into the sugar vs. tooth decay ring.

I’m talking about the persistent proclamations to cease and desist eating sugary foodstuffs as the way to reduce tooth decay.

Is sugar so vile that it warrants regulation? Maybe. Maybe not. Even if only 1% of what’s purported as ‘dangerous’ is true, surely that would appeal to someone…

I mean, we live in a world where even hints of regulation (however necessary or unnecessary they may be) make for an unhappy populace. Let’s see:

The British Tea Act and the resultant Boston Tea Party in 1773.

Prohibition in the 1920s until 1933.

The ponderous 100+ year, $1 trillion+ war on drugs that continues to cost $50 billion annually.

Marijuana debate in the 21st century, with ever-evolving information.

Of course, like the gun debate, the sugar blame-game still arises passions.

I’m sure you’ve been told your zeal for ‘sweets’ is the root cause to your tooth decay.

Well, as it happens, that’s not the full story and you don’t have all the information you should.

It’s no secret that casual relationships between sugar intake and tooth decay exist. But thus far, no mathematical equation has been devised that equates eating “X” amount of sugar produces “Y” amount tooth decay.

I mean, if such an equation exists, please let me know – I will be happy to modify my opinion and eat my words.

But there isn’t. If there was, our dental professionals would happily tell us about it, while food marketers would creatively answer in kind.

So why isn’t there an immutable sugar-tooth decay relationship?

Because it’s not only about sugar.

It’s about behavior. It’s about what we eat, how much and how frequently.

And it’s about our oral hygiene regimen and the nature of the products we use.

And it’s about our oral health knowledge as patients.

And, it’s about our personal genetic disposition to tooth decay.

And the list continues.

By the way, tooth decay isn’t just a disease borne from convenience and comfort foods: did you know tooth decay is at least a million years old?

Anyway, unless you’re held hostage by the sugar-plum fairy whose cake-decorating tip is sweetly directed at your teeth, let’s gather ourselves.

Railing against sugar isn’t new. And sugar-shaming might be a bit over the top.

Yes, I realize ‘Big Sugar’ and ‘Big Food’ certainly contribute to the problem. And, it doesn’t help when the desire to embrace progressive change is stonewalled by the very organizations these ‘big bad companies‘ look to for regulatory and public sentiment guidance.

But I’m not questioning data, business models, agendas, or moral imperatives.

Why?

Because constant pestering and demonizing of sugar isn’t working, may worsen the problem, and it masks underlying issues.

Wait. It worsens the problem? What do you mean by that?

Plenty.

Below are five reasons why popular calls for sugar restriction remain ineffective.

#1. Reactance theory explains why some consumers refuse to limit or avoid sugar intake.

Postulated by Brehm in 1966, reactance theory is based on an actual or perceived threat to an individual’s freedom. The consequence of such a threat is to stimulate the individual into acting opposite of the message, including those driven by health experts. In other words, no one likes to be told they can’t do something (e.g., Billy Joel would probably agree). This holds true whether the individual is 2 or 102 years old, and is an especially sensitive issue for teenagers and young adults who often do not want to be viewed as being conformists or traditionalists.

So a dentist’s health message to restrict or avoid sugar may be received by the patient as a threat to the patient’s freedom to choose foods or drinks. Thus, calls for suppression of sugar intake may stimulate a reactance response that results in sugary consumption indulgence (perhaps even over-indulgence), perhaps to the detriment of the patient’s health. And in a twist of irony, this would seem to risk violating the Hippocratic oath (or the ‘golden rule’) to ‘do no harm’.

So how to combat reactance theory?

This is a notoriously difficult problem, but recognizing reactance responses are quite common is a good place to start. In general, those with dominant, authoritarian directives are likely to stimulate such undesirable reactance responses. Probably, the best bet here is to tone down the tenor and focus on improved doctor-patient communication. Obviously, this is not an easy task given the relative infrequency of which the patient visits the clinic. In any event, knowing that ‘stay away from sugar’ likely pushes the patient in a corner, this should be considered when dental professionals insist on hardline stances against sugar.

Or, for those preferring the cliff-note version:

Be informative, but be nice about it. No one likes to be told what they can (or can’t) do.

#2. Sugar abstinence isn’t realistic.

OK, so we all know too much sugar does crazy things to us (e.g., SNL):

But I get frustrated when advice is given to simply reduce sugar intake in order to reduce tooth decay.

As consumers, we don’t fully read or understand food labels, or even understand how many calories we’re consuming.

Given that deciphering food labels is tricky – and nutrition in general is not well understood – what’s your response to the following from WebMD regarding tooth decay?

“Tooth decay occurs when foods containing carbohydrates (sugars and starches), such as breads, cereals, milk, soda, fruits, cakes, or candy are left on the teeth.”   

To me, it’s defeating, as this statement lumps most of the food groups into one class: the tooth decaying class. And here I thought milk was helpful against tooth decay. Silly me.

Oh, I forgot to mention: tooth decay can also develop from starches, which introduces yet a ton of other food types, including for instance, potatoes and pasta.

By the way, don’t you know that many dried-fruit snacks, yogurts and smoothies have as much or more sugars than cookies and sugary snacks?

And there’s more: did you know some dentists point out that crackers are way worse than sugars?

So although most foods we eat can lead to tooth decay, we’re supposed to formulate a failsafe plan to reduce sugars from our daily diet?

Easier said than done.

Perhaps that’s why some choose to eliminate sugar altogether.

Here are four reasons why abstaining from sugar isn’t realistic:

Reason #1: Requires responsible behavior – all the time.

Sugar can certainly be addictive. As anyone with an addiction knows, it’s hard to quit and even harder to manage once overcome. Same thing with sugar: it can be hard to quit. Especially during the holidays.

But is sugar so evil that even a little bit is deplorable? I don’t think so.

Of course, problems arise with excessive consumption of anything (including cell phone use). But, like cell phones, consumption of sugar requires stewardship, not an all-or-nothing approach.

Oh, and there’s that risk in rendering sugar taboo, which can elevate its appeal. Ergo, this circles back to reactance theory discussed above.

Reason #2: When can I expect the cavity to form? Oh, that’s right: it’s difficult to predict – you know, kinda like the weather.

When it comes to sugar consumption and tooth decay, the cause-and-effect relationship is fuzzy because tooth decay typically doesn’t develop immediately (note: it depends on saliva and other factors).

As consumers, we don’t immediately understand what reducing sugar intake looks like, how one misstep can affect the rest of our daily diet, or how this impacts the teeth.

Because tooth decay is a gradual process, even some dentists admit that a sugar-binging event (a la Halloween) won’t likely ‘do much damage’.

So indulge if you must, but know that without sufficient hygiene (which will vary from person-to-person), eventually decay will follow.

Reason #3: Don’t mess with my energy source.

Another reason resides in our human nature and activity needs, both of which fundamentally require carbohydrates.

Example: Kids and teenagers are high-performance machines: they require a ton of sleep and energy as part of the growing/maturing process. And, if the child, teenager, or even adult is regularly active or has elevated activity due to competitive sports, caloric needs are compounded.

So, messing with your energy source, messes with your metabolism.

The point is, don’t drive yourself nuts attempting to abstain from a natural energy need.

Besides: it’s dangerous.

Reason #4: Life simply gets in the way.

Time is a luxury, and unfortunately, many of us believe we’re time-poor, including those working, those that have children, and if you’re a woman under 50.

Yes, it’s hard to get organized and prioritize.

Yes, we could be doing better.

But that’s irrelevant, because we just don’t believe we have much time.

In fact, ‘busy schedules’ are often a reason why some kids skip toothbrushing: for example, a working mother confessed

“I don’t have time to brush their teeth in the morning. I mean… I leave at 7 am and I have to dress two children, make breakfast for them, and so on. Of course I have a partner, but he’s like ‘Ah, don’t worry…’”

So it’s completely understandable that translating nutritional labels is not top priority when pressed for time.

We get it: those foods and drinks that tend to be readily accessible, quick to eat, easy to transport and taste good tend to have sugar.

So is the harried consumer hell-bent on going sugar-free, when simply getting to work or school on time is often a remarkable accomplishment? Umm, no.

#3. An individual’s response to sugar is, well, individual-dependent.

Consider two 11-year-olds: Johnny and Janet.

Johnny is more prone to decay from eating sweets, but Janet isn’t. Their dentist, adamant about abstaining from sugar, explains that sugar leads to cavities. Despite the cautionary words, each child hears a different version of this advice: Johnny becomes concerned (maybe a little fearful) while Janet is bored.

But there’s more, as since Johnny and Janet are siblings and are persistently trying to one-up the other. Do you think Janet might gloat to Johnny about her ability to eat sugary treats without leading to decay, including eating a yummy-looking cookie in full view, or receiving special privilege treatment from the parent/guardian? And, in turn, might it be possible that Johnny, acting out of frustration but yearning for control, will ignore the dental advice, perhaps sneaking whenever possible, or quietly swearing an oath to be able to eat whatever the hell he wants when he grows up and damn the consequences? In any event, do you think this might weaken the children’s view of the dental professional and his advice?

Dental professionals could probably split their patients into two categories: those with tooth decay, and those without.

This was certainly the case for my brother and I: while I seemingly developed tooth decay at every dental visit, my brother never did, despite both of us having similar brushing and eating habits!

Of course, some have great oral hygiene, while others, not so much (e.g., when was the last time you flossed?).

But there’s more to the story than food selection and hygienic routine. It turns out that beyond structural differences in teeth between those susceptible to tooth decay and those who aren’t, there are also clear differences in the mouth’s microbial makeup of those with and without tooth decay.

Therefore, regardless of the absence or presence of sugar, bacterial composition plays a major role in determining whether the individual is prone to tooth decay or not.

And I’m not the only one who has experienced the frustrations of being particularly prone to tooth decay: despite adequate care of the teeth and a proper diet, dental decay can persist due to the nature of our oral bacterial. Thus, avoiding tooth decay is not as ‘simple’ as some believe.

This explains, in large part, why my brother didn’t experience tooth decay. This also explains why the ‘anti-sugar’ message from the dentist has not proven effective: for example, tooth decay is increasing among children!).

The point is, a boilerplate proclamation to avoid sugars resonates differently among people. While over-consumption of anything (including sugar!) is not recommended, the sensitivity to a given agent (i.e., sugar) is specific to an individual. Therefore, well-intended warnings that do not always ring true diminish over time, a la Aesop’s tale ‘The boy who cried wolf’. And because tooth decay is a gradual process, the clinician’s warning today may not reveal itself until months – or even years – later.

So what’s the answer?

For some, it seems tooth decay is similar to the legendary Yeti: some people (e.g., dentists, hygienists, some patients, such as Johnny and myself) enthusiastically have seen it, lived it, and believe in it, while others (e.g., Janet and my brother), not so much.

The clinician (perhaps it’s you) must recognize if the patient carries higher risks for tooth decay, not only tell them (which seems obvious but is not always discussed) but also inform him/her of options (aside from ‘avoiding sugar’)! In doing so, additional preventive strategies besides ‘avoid sugar’ can be proposed, including placing sealants, providing prescription-strength fluoride toothpaste, advocating more frequent drinking of fluoridated water, and so on.

In turn, the patient (perhaps it’s you) must be committed to understanding he/she/you have an inherent susceptibility that is not driven solely by the sugar. Here is where additional focus and effort is required to manage and thwart tooth decay.

Here’s a logical example: if you desire to reside in a region reputed for its acid rain, protective measures must be made to ensure your home remains uncompromised.

Knowing that the region (i.e., the ‘mouth’) will continually produce acid rain (i.e., the ‘acids’ produced from the bacteria of one who is inherently susceptible to tooth decay), it makes sense to protect the structure (i.e., the ‘tooth’) with appropriate precautionary actions (i.e., sealants, fluoride varnish, high-fluoride toothpaste, frequent fluoridated water intake, etc.).

Reason #4. Capitalism provides options.

So vile sugary products peddled via appealing packing and advertisements are bothering you?

Boo. Hoo.

Please tell me you don’t really think your options are limited here in the 21st century where Google and Amazon can find you practically anything you want?

Not only is ‘sugar-free’ a familiar term, several non-sugar options exist, such as sorbitol, xylitol, and erythritol, that can actually help fight against tooth decay!!

Oh there may be gastronomic challenges, but these are temporary issues (your gut bacteria are actually undergoing shifts to repopulate with non-sugar-eating bacteria) and likely worth the effort, especially if tooth decay is your Achilles heel.

So instead of blowing the bullhorn to get the blasé anti-sugar message out, why not turn up the volume on non-sugar alternatives? After all, there are a ton of options out there, from sugar-free chewing gums and mints to raw ingredients for cooking and baking.

Of course, if you can’t find what you’re looking for, perhaps you’re not the only one. And if you’re so inclined, maybe, just maybe, there’s a business waiting to burst forth with your savvy solution.

 

Reason #5. Sugar is just one of several tooth-risky food/drink characteristics.

As explained in my book, there are other food and drink ingredients that contribute to loss of tooth structure, including the degree of acidity (i.e., low pH) and type of acid (e.g., phosphoric, citric, etc.). In fact, these two characteristics are more damaging than sugar and starches since they etch microscopic homes into the tooth for the bacteria and the bacterial acids.

The acidity and acid content of the food or drink produce dental damage much more quickly than sugar and starches.

First, acidity. Let’s consider, for example, sports drinks (e.g., Gatorade®), which presents risks for dental damage even if it’s sugar-free. Why? Any drink exhibiting a pH level less than 5 means that it can erode enamel: enamel begins to dissolve around a pH of 5; the pH of sports drinks and most carbonated, flavored, and alcoholic drinks is less than 5.

Then, there’s the matter of acid type: while many colas contain phosphoric acid, other drinks such as carbonated beverages, sports drinks, and waters contain citric acid. Both acids are highly erosive to tooth structure.

Out of habit or perhaps for performance reasons, but flat-out damaging, many people (especially kids and athletes) hold or swish sports drinks in their mouths – this behavior escalates the erosive effect on the teeth, resulting in increased risks for loss of tooth minerals.

Did you know most things sour contain citric acid? A surefire way to limit erosive damage is to choose non-sour options (think mint or cinnamon). And if you wish to preserve your pearly whites, stop sucking on lemons, limes and oranges: after all, these are called ‘citrus’ fruits for a reason.

Perhaps you’re an oenophile? If so, you obviously don’t chug it. No, you sip it, especially because it’s a social drink. Well, it’s not only the color of your teeth you have worry about: wine pH is inherently low, which means it’s causing major mouth stress throughout your wine-infused social (or private) event.

But talking about acidity, here it’s important to point out a note of caution: do not immediately brush your teeth after drinking or eating something acidic, as this can worsen acidic effects. So what you can do? Wait about 20 minutes for your oral pH to recover to neutral conditions. And, if possible, drink water, or even have a sugar-free mint or gum to expedite your mouth’s return to a healthier pH.

And, while we might be pressed to believe sugar is our enemy, what about these artificial sweeteners – aren’t they safe for your teeth? Maybe they don’t degrade your enamel, but they surely work on other aspects of your health.

Besides the obvious tip of toothbrushing after enjoying a sugary snack (in fact, my 11-year-old son does this), just remember these pearls of wisdom: whatever you’re eating or drinking,

  • drink plenty of water;
  • maintain a rock-solid oral hygiene regimen;
  • consider food and drink options with calcium;
  • ensure your behavior with your drink or food isn’t compromising your tooth structure; and,
  • after your sugary treat, enjoy a sugar-free mint or gum to help your saliva counter the effects of sugar.

 

 

2018-03-09T22:14:55+00:002018|Blog|

Robert L. Karlinsey, PhD

Dr. Robert L. Karlinsey earned a BS in Physics and PhD in Chemical Physics, holds several patents, and has published in multiple fields including dentistry, chemistry, and materials science. His lifelong struggles with his own dental decay ultimately inspired him to investigate the remineralization of teeth.  
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