An evidence-based summary from the British Association for the Study of Community Dentistry

The British Association for the Study of Community Dentistry (BASCD) is the UK’s professional association for the science, philosophy and practice of promoting oral health in society. They work with – and support – partners to improve population oral health and reduce health inequalities. In this article, they address some of the questions arising during the COVID-19 pandemic and signpost readers to helpful evidence-based information sources, to assist in the return to work and the ‘new normal’.

Do you think eating habits have worsened or improved with the lockdown?

This is difficult to determine as we do not yet have any formal evidence available quantifying the effects of lockdown on eating habits, as the coronavirus pandemic and the response to it happened so quickly.

On the one hand, eating habits may have improved because, based at home, some families may be cooking from scratch more often.

Some may be trying to eat healthily to boost immunity and reduce vulnerability to illness. But for other families, it could have worsened due to restrictions on shopping habits, such as not being able to shop around for the best buys when on a limited budget with more reliance on convenience foods. Also being at home means there’s easier access to the fridge or snack cupboard.

There is some emerging evidence that people wanted to eat more healthily during lockdown. For most, this also requires dietary improvements on a restricted budget, because of the financial consequences of lockdown.

In a recent survey, almost half (45%) of consumers wanted to reduce their sugar intakes (Hughes, 2020). This opportunity can be easily addressed by communicating simple effective messages to our patients – whether by social media or on returning to work. It has never been more important to stay informed.

With the eradication of ‘eating out’ there is more reliance on home-cooked food and this brings with it some real positives. Cooking can be a good way to reduce stress, improve self esteem and bring the family closer together.

There is an increase in social media and TV content on meal planning, too, and, whilst some are focusing on nourishing meals and healthy snacks following healthy eating guidelines, we need to be careful when stuck at home that we plan our snacks and meals based on our current activity intakes (WHO, 2020).

Sugary 'comfort' foods, large portion sizes and boredom eating need to be controlled. Remember eating well is important for physical and emotional health as well as oral health.

Why is it important to keep track of eating habits?

The UK suffers from unacceptably high levels of both tooth decay and obesity. The consequences include health issues, such as diabetes that can then have an effect on periodontal health. Approximately one third of children aged 5 to 12 years (CDHS, 2013) and a third of dentate adults in the UK (ADHS, 2009) have experience of dental caries. In addition, obesity in the UK has increased by 92% since the 1990s. The UK is the most obese country in Western Europe with 26.9% of the UK population classified as obese in 2015 (OECD 2017).

Excess calorie consumption can occur from eating too much of any food. However, the availability and low cost of high sugar, high calorie foods and beverages is giving cause for concern (WHO, 2015; SACN, 2015).

Recent recommendations for carbohydrates and the 2016 updated Eatwell Guide both advised significant reductions in free sugar intakes for the UK population (SACN and DH).

The carbohydrate recommendations halved from no more than 10% to 5% of total energy intake; the maximum daily amount differs depending on age. In addition, the Eatwell Guide relocated high fat sugar salt (HFSS) foods outside of the plate confirming the need to eat these less often and in smaller portions (Figure 1).

Bearing in mind the maximum allowance for children aged 11+ and adults of all ages is 30g per day free sugars (or seven sugar cubes) eating more sugary snacks, desserts, and confectionery to help overcome the boredom of lockdown will exceed this limit – building up consequences for general and oral health.

So, there is a need to take care not to increase your sugar intake – avoid sugary snacks especially with easier access at home. It is important to reduce both the amount and frequency of sugar intakes (PHE and DH, DBOH, 2017).

When buying food, make a list and look at the labels to check the sugar content per portion when you can (Fairchild & Morgan 2019). Checking labels online and in advance of going shopping might be easier now with social distancing measures in shops. The NHS Sugar App can help you track how much sugar is in the food you are buying (Figure 1).

ν https://www.nhs.uk/change4life/food-facts/sugar

ν https://apps.apple.com/gb/app/change4life-be-food-...

ν https://play.google.com/store/apps/details?id=com....

Also, NHS Choices has some very practical tips for some 100kcal snack ideas, including popcorn, three-fruit salad and apple and peanut butter https://www.nhs.uk/live-well/eat-well/surprising-1...

See the WHO healthy eating tips at

https://www.who.int/news-room/campaigns/connecting...

– particularly their sugar tips

ν Reduce intake of sweets and sugary drinks such as fizzy drinks, fruit juices and juice drinks, liquid and powder concentrates, flavoured water, energy and sports drinks, ready-to-drink tea and coffee and flavoured milk drinks.

ν Choose fresh fruits instead of sweet snacks such as cookies, cakes and chocolate. When other dessert options are chosen, ensure that they are low in sugar and consume small portions.

ν Avoid giving sugary foods to children. Sugars (and salt) should not be added to complementary foods given to children under two years of age, and should be limited beyond that age.

The UK government’s daily lockdown graphics based on Google mobility data highlight the significant reduction in shopping trips to purchase food and groceries. In contrast, there has been a significant rise in online grocery shopping. Before the coronavirus pandemic online supermarkets had a market share of 7-8%; this has grown by 33% since the crisis began, according to Mintel (2020). The market research agency reported that 37% of over-65s have increased the amount of online shopping they do since the outbreak started.

Furthermore, if we are going out to shop, we are shopping local. In a Which? survey conducted between 24-28 April, 36% of respondents said they had shopped at independent and convenience stores more than usual since the start of the coronavirus outbreak, with 35% saying they’d shopped in supermarkets less than usual (Which, 2020).

It is a bit too early to tell whether these changes to our shopping habits have impacted on public health with regards to the types of ‘unhealthy’ high fat and sugary foods purchased. Mintel (2020), however, has reported that cakes and other sweet-baked goods sales are reduced by around 2.8%, as we congregate with friends and family less often and home baking has become the nation’s favourite hobby.

Although there has been an increase of 46% in retail sugar sales (Kantar 2020) likely to be linked to ‘lockdown home baking’, larger commercial sales to bakers, manufacturers and restaurants, have fallen, so we will have to hold our breath to see if as a nation, on balance we have managed to reduce our sugar consumption.

Why did the BASCD feel it was important to reach out to patients with a video?

We have prepared two main videos. The first entitled Looking after you, your family and all your smiles! provides some helpful pointers for the general public, emphasising how to look after their teeth and mouth during lockdown which is especially important when access to dentistry is limited at the moment.

The second video explained how to access dentistry during lockdown; there were four versions of these one each for the constituent countries of the UK (with contact numbers for all areas within England, Scotland, Northern Ireland and Wales).

We were aware of the gap in knowledge about accessing NHS dentistry during the crisis and that’s why we created them.

As restrictions are now being eased, the information will need to be revised to reflect the changes in the four countries as we move forward. As we write this (early June 2020) we are about to update the accessing dentistry video.

Both videos are co-badged with the Faculty of Public Health, who see that the head is part of the rest of the body and that a healthy mouth has implications for general as well as oral health.

Is this something practices can share with their patients?

Most definitely – we have been sharing the links to the videos on social media (Facebook, Twitter and Instagram). Since their release in early May, they have been really popular with general dental practices and those working in primary medical and dental services, with hundreds of retweets, shares and likes and tens of thousands of impressions!

How important a role does social media have in maintaining patient engagement at this time?

BASCD has an important role as a professional organisation sharing good quality and easy to understand information; social media has an important role in engaging with the general public in this regard.

When considering ‘nudge theory’ i.e. positive reinforcement and indirect suggestions as ways to influence the behaviour and decision making, social media provides alternative ways of communicating with people on a regular basis. It also has a wider reach when compared with our traditional ways of communicating with the public and patients, e.g. information leaflets, letters, websites etc.

This wider reach enables us to communicate with groups who are harder to reach in other ways. Given the current times we need to be agile and responsive to the coronavirus situation so we can communicate quickly. Furthermore, lockdown has given our audience time to go on social media to use it as a resource.

From a general practice perspective, social media when used appropriately can be very important. Any means by which patient communication can be improved is useful but dental practices still need to engage with their patients and be available for consultations over the phone, email and social media can be used to reinforce dental health messages.

Our first video – Looking after you, your family and all your smiles! – provides advice to all on keeping teeth healthy and try to avoid building up oral health problems when access to dentistry is limited. Social media has been very effective in getting the message out there!

Do you think there is a need to urge people to drink responsibly during pandemic, as figures suggest a surge in at-home drinking?

From a ‘making every contact count’ and a nudge theory perspective, dental teams are in a unique position to provide brief advice and support to their patients who drink above the lower risk levels. This remains important during these uncertain times. Delivering Better Oral Health – an evidenced based toolkit for prevention outlines the Chief Medical Officer’s guidelines for alcohol consumption and the role of the dental team in supporting drinkers. (PHE and DH, DBOH Section 8 Alcohol Misuse, 2017).

What do you think will be the legacy of lockdown once dentists can return to practising?

The major impact from lockdown is about managing what would have been done in that time. Dental practitioners are already experts in protecting their patients and themselves from passing on infection – for example, we are used to seeing dentists with face masks and eye protection. But we might see some adjustments to the practice environment to facilitate social distancing.

We will have to wait and see if individuals’ behaviours in lockdown have resulted in any detriment to their oral health. There will inevitably be a need to address the backlog of routine care and people may have to wait longer between visits if capacity is stretched.

Opportunities have arisen. Out of necessity, we have had to work a different way e.g. video consultations, increased partnership working with pharmacy colleagues – hopefully, these innovations will not be lost and will be built upon and developed as we move forward.

On a positive note although dentistry is in the top 10 of at risk professions with regards to COVID-19 infection, the death rate is very low amongst dental personnel, likely to be associated with the consistent and correct use of PPE (ONS, 2020, Dentistry.co.uk 2020).

Could the delays in treatment and gap in dental education lead to a worsening oral health crisis?

Whether there is a long-term effect on the worsening of oral health may be debatable. It has only been a few months.

Dental caries is a relatively chronic disease and early stages are entirely reversible, but it is still important for people to get back into routine dental care.

The patients most at risk by long delays are those with poor periodontal conditions (e.g. smokers, heavy drinkers and those living with diagnosed or undiagnosed diabetes) and poor oral hygiene. They require intensive reviews and regular reinforcing of the message.

People with diabetes have a higher risk to die from COVID-19 and develop more severe complications after infection. Therefore, they should take extra precautions to avoid becoming infected.

Are dentists and their teams well placed to discuss COVID-19 health risks with their diabetic patients?
A diet high in sugar is not good for any of us in terms of our general and oral health. Making every contact count with patients living with diabetes, is an important aspect of the dental team’s role.

National nutrition and healthy eating guidelines, such as the Eatwell Guide, apply to those living with diabetes, too.

For specific advice, Diabetes UK have some helpful information about coronavirus, diabetes and food, in particular how to handle the rise in home baking and comfort eating at: https://www.diabetes.org.uk/about_us/news/coronavi...

Do you think there will be a reluctance by patients to return to dental practices? If so, what can the dental profession do to reassure them of safety in the chair?

Some may be reluctant due to anxieties about the pandemic. However, the public and media have campaigned for NHS Dental Services to resume.

The most important thing for the public to know is that dental practices will look different as they will be operating in a way that observes COVID-19 social distancing and hygiene rules, as part of measures taken to ensure patient, staff and public safety. The dental team will also be wearing different protective equipment to what they are used to seeing. It will likely be some months before the services return to providing care in a similar manner to that which they previously experienced and will be dependent on the further easing of COVID-19 control measures.

As members of the public, we have all become trained to respect social distancing so getting up close and personal with anyone outside of your household may initially feel wrong.

However, dentists are used to being in very close contact with their patients and are trained to a high level to prevent cross infection, so people are in very good hands in dental practices.

The importance of communication and reassurance from the profession will be very important in allaying any persisting concerns.

References

Adult Dental Health Survey Summary Report (2009) http://digital.nhs.uk/catalogue/PUB01086 (accessed May 2020).

Child Dental Health Survey Summary Report (2013) http://digital.nhs.uk/catalogue/PUB17137 (accessed May 2020).

Department of Health (2016) The Eatwell Guide https://www.gov.uk/government/publications/the-eat... (accessed May 2020).

R Fairchild, M Morgan. Taking back control of what you eat. BDJ Team 6, 19016 (2019). https://doi.org/10.1038/bdjteam.2019.16

M Hughes. (2020) Evolving eating habits as a result of covid-19. New Food Magazine. May. https://www.newfoodmagazine.com/article/109890/evo... (accessed May 2020).

Kantar. (2020) https://www.kantarworldpanel.com/en/PR/Grocery-gro... (accessed May 2020).

Mintel. (2020) Cakes, Cake Bars and Sweet Baked Goods: Inc Impact of COVID-19 - UK - April 2020. (accessed May 2020).

Organisation for Economic Co-operation and Development (2017) obesity update. https://www.oecd.org/els/health-systems/Obesity-Up... (accessed May 2020).

Public Health England and the Department of Health, Delivering better oral health: an evidence-based toolkit for prevention. 3^rd Edition. 2017. https://assets.publishing.service.gov.uk/governmen... (accessed May 2020).

Scientific Advisory Committee on Nutrition (2015) Carbohydrates and Health. https://assets.publishing.service.gov.uk/governmen... (accessed May 2020).

World Health Organization (2015) Guideline: sugar intake for adults and children. http://www.who.int/mediacentre/news/releases/2015/... (accessed May 2020).

World Health Organization (2020) Healthy at home. https://www.who.int/news-room/campaigns/connecting... (accessed May 2020).

Which? (2020) Coronavirus supermarkets latest: Asda launches virtual queuing system. https://www.which.co.uk/news/2020/05/supermarkets-... (accessed May 2020).

Visit https://www.dentistry.co.uk/2020/05/12/dental-role...

Visit https://www.ons.gov.uk/peoplepopulationandcommunit...
elateddeathsbyoccupationeng
landandwales/deathsregistered
uptoandincluding20april2020

Author: Julie Bissett