&Jof

The Australian

New Zealand

ournal

DENTAL AND ORAL HEALTH THERAPY

ISSN: 2200-3584 ISSUE 2 DECEMBER 2016

Guest Editorial

Collaborative advocacy on oral health – the National Oral Health Alliance Tony McBride Tony McBride is a consultant in primary health care and the NGO sectors. He has worked in consumer advocacy and research, community health, local and Federal Governments, and academia. He was Chair of the Australian Health Care Reform Alliance for six years until recently. He has been a long time advocate for more equitable oral health care, co-initiating the Molar Energy Campaign in Victoria in the mid 1980s. He is currently the Spokesperson for the National Oral Health Alliance (NOHA) although the views in this article are not necessarily those of NOHA.

As this journal’s readers will be well aware, getting politicians or the media to take interest in improving the population’s oral health status is not an easy task. When opportunities or threats arise, such as the Government’s attempted closing of the Child Dental Benefits Schedule (CDBS), there needs to be a quick response and pressure from beyond the oral health professional bodies to that of the broader community. Such a capacity to respond has historically been mostly limited to the professional bodies. There are relatively few broad-based organisations active in advocating and researching around oral health. This contrasts with the number of organisations in the mental health or chronic disease or drugs and alcohol fields, for example, where government-funded commissions and councils, as well as sector-funded pressure groups abound. This gap was the trigger a few years ago for the establishment of the National Oral Health Alliance (NOHA), mostly stemming out of the concerns about inequity in access to oral health care. The initial members were a small grouping of non-professional bodies (including the Australian Health Care Reform Alliance, Public Health Association of Australia, Australian Council of Social Service, Australian Healthcare and Hospitals Association and the National Rural Health Alliance). However, the alliance was strengthened considerably when the professional bodies joined (including the Australian Dental & Oral Health Therapists Association, the Australian Dental Association and the Dental Hygienists’ Association of Australia). NOHA has continued to grow and now has 12 members including the Association Dental Prosthetists of Australia, Consumers Health Forum of Australia, Royal Flying Doctor Service and very recently the Council on the Ageing. NOHA members all strongly believe that oral health is an essential component of overall health and well-being and that all Australians should be able to access affordable and high quality oral health care.

Choice or access? The Productivity Commission is currently considering whether public dental services should be considered for reform to engender greater user choice, competition and contestability. While this discussion is welcome, seeking to provide greater user choice is a moot point – particularly when you look at oral health services outside the major metropolitan centres. While user choice is not unimportant, it is a secondary issue when a significant proportion of the population simply cannot access regular oral health care. There is an urgent need to address the deficiencies in dental health access (both public and private) in rural and remote Australia. It is not just rural and remote residents who are disadvantaged in the current oral health arrangements. Some of the population with access to public dental services have Health Care Cards (HCCs) and are eligible for public dental services. However, such services are severely under-funded relative to the need. In the current context, exercising choice for this group is simply choosing which unsatisfactorily long queue you should join. For those not eligible for HCCs but living on lower than average incomes, it is well documented that cost is the crucial barrier that prevents people accessing private dental services. Choice in this current context equates to choosing which service you cannot afford. The Child Dental Benefit Scheme (CDBS) has successfully utilised the private dental network as well as public services and made care more accessible. However, CDBS is not yet a mature system. Promotion of the scheme to families has been extremely limited, so it is not at all well known. As a result, take-up of the program, although growing, is only at 30% of potentially eligible users. Offers have been made to work with Government to support improved take-up of the program. ...continued on page 4

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The Australian and New Zealand Journal of Dental and Oral Health Therapy (Issue 2, 2016)

CONTENTS Management of Patients with Autism Spectrum Disorder in the Dental Environment; CM Purnat............................................................................................................5 Health beliefs and behaviours of individuals on a vegan diet in relation to oral health; Christopher Howlett, Dr Helen Tane..................................................... 11 Perceived barriers to dietary advice provision by medical, dental and nursing personnel: a review of the literature; Allana Coxon, Dr Melanie J. Hayes, Dr Janet Wallace...................................................................................................................................................................................................................18 Smoking cessation brief intervention at the chairside: implementingw oral health promotion and policy; Greer Dawson, Jennifer Noller, John Skinner and Joanne Travaglia..........................................................................................................................................................................................22 College of Oral Health Academics’ 15th Annual meeting...................................................................................................................................................................................................27 Child Oral Health Promotion Systematic Review ..................................................................................................................................................................................................................27 Congratulations on your PhD: Dr Susan Moffat........................................................................................................................................................................................................................28 Websites of Interest.....................................................................................................................................................................................................................................................................................28 Congratulations on your PhD: Dr Jenny Miller...........................................................................................................................................................................................................................29 Thank you to our Peer Reviewers......................................................................................................................................................................................................................................................30 NoticeBoard......................................................................................................................................................................................................................................................................................................31 Colgate Corner...............................................................................................................................................................................................................................................................................................32

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Inserts (2000 x A4 page supplied by advertiser) $2000 Advertising – per ad single issue Full page $1000 Half page $750 Quarter page $400 Notice Board entry (2-3 lines) $100 The ANZJDOHT is published twice per year Deadlines are 30 April and 30 September each year Subscription Information Institutional subscription per year $100 AUD Advertising & Subscription Enquiries to Kirsten McEvoy: [email protected]. au THE AUSTRALIAN AND NEW ZEALAND JOURNAL OF DENTAL AND ORAL HEALTH THERAPY © ANZJDOHT ISSN: 2200-3584 EDITOR Dr Julie Satur Assoc Professor Oral Health Melbourne Dental School The University of Melbourne 720 Swanston Street, Melbourne VIC 3000, Australia Email: [email protected] ANZJDOHT EDITORIAL COMMITTEE Julie Satur, Rebecca Ahmadi, Amanda Blyton-Patterson, Kimberly Coulton, Mark Gussy, Jennifer Miller, Carol Nevin, Agnes Smith, Erekle Siashavilli, Leonie Short, Helen Tane, Carol Tran, Janet Wallace ADMINISTRATIVE SUPPORT Kirstin McEvoy – email: [email protected] Guidelines for submitting authors can be found on the ADOHTA Website at: www.adohta.net.au/menu_page.php?page_id=journalpublicaccess and on the NZDOHTA website at: www.nzoral.org.nz/assets/oht_authorguidelines_anzjdoht.pdf

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C O N TA C T S NEW ZEALAND DOHTA [email protected] PO Box 9893, Marion Square, Wellington 6141 Ph +64 4 473 9547 www.nzoral.org.nz AUSTRALIAN DOHTA [email protected] PO Box 337, Modbury North SA 5092 Phone 0498 664 943 www.adohta.net.au AUSTRALIAN CAPITAL TERRITORY PO Box 1114, Woden ACT 2606 [email protected] WESTERN AUSTRALIA PO Box 111, Como WA 6952 [email protected] QUEENSLAND PO Box 405, Nundah QLD 4012 [email protected] NEW SOUTH WALES PO Box 343 Ourimbah NSW 2258 [email protected] SOUTH AUSTRALIA / NORTHERN TERRITORY PO Box 159, Mitchum Shopping Centre SA 5032 [email protected] VICTORIA PO Box 154, Parkville VIC 3052 [email protected] TASMANIA 1175 Elderslie Road, Broadmeadow TAS 7030 [email protected] FIND US ON FACEBOOK

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Presidents’ Message ADOHTA and the NZDOHTA would like to thank the many people involved in the production, editing and peer review of this journal and acknowledge the contribution of Colgate who generously support its printing and distribution. The objectives of the journal are to: 1. provide a vehicle for communication between dental and oral health therapists in Australia and New Zealand Hellene Platell President ADOHTA

2.  develop dental and oral health therapists’ access to self directed professional development 3. provide a vehicle for the reporting of new learning and research in the field of dental and oral health therapy 4. develop a capacity to contribute to the body of knowledge around the discipline of dental and oral therapy, for dental therapists, oral health therapists, dental hygienists and the wider health care field We are proud to present this edition of the ANZJDOHT and we hope you enjoy reading it. Hellene Platell, President ADOHTA & Arish Narish, Chair NZDOHTA

Arish Narish Chair NZDOHTA

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The Australian and New Zealand Journal of Dental and Oral Health Therapy (Issue 2, 2016)

...continued from page 1

The CDBS service model, however, provides a good example of how to make the best use of both public and private service delivery to reach those most in need. If we can work with government to improve uptake and look at how to also address adult needs, possibly using a similar model, we could have the best of both worlds.

Inequities in system overall As readers would be well aware, inequities in access to oral health care have always been a feature of the Australian system. The unfortunate current structure of the oral health ‘system’ is well known and comprises predominantly private practices, with a comparatively small set of public services in each state – recent data show that 85% of dentists are in private practice. For private dental care, consumers’ out-of-pocket costs remain at four times higher than the average for all other health care (at about 60% of total costs). This is a significant cost barrier to regular care for many families and individuals throughout Australia living on below average incomes. Overall, in recent years there has been a continuing decline in the oral health of Australians coupled with growing disparities in access to dental care within our community. Decay rates remain at 50% for young children and teenagers and are higher in more disadvantaged groups such as Aboriginal and Torres Strait Islanders. And since the Coalition Government’s decision to hold back funding to the States in 2014, the information NOHA is receiving seems to indicate that waiting lists are again growing. Public dental waiting lists range from many months to several years and are on the rise. In many cases public waiting lists are so long that people do not even seek preventive care but wait until their problems become so serious that they require emergency treatment. NOHA supports a joint Commonwealth and State/Territory approach to improving access to oral health care, with a focus on groups identified as having poorer oral health status and difficulties in accessing care. However, we believe that the Federal Government has a crucial funding, coordination and leadership role to play on this issue to both avoid stark differences in care between States and to enable closer integration with primary health care policy over time. Since early 2016, NOHA’s focus has been predominantly on the CDBS, along with some action on fluoridation in Queensland, described below.

Child Dental Benefits Schedule NOHA remains strongly supportive of CDBS and Commonwealth funding to the States and Territories for oral health programs for adults. NOHA believes that not only historically has Commonwealth funding for oral health made a significant difference to oral health care for lower income adults (and hence waiting lists), but that the current CDBS is making preventive care available for the majority (about 66%) of Australian children through private practices, therefore making care both more accessible geographically and financially. Before and after the election, NOHA has advocated for the

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continuation of the CDBS. Apart from media releases, actions involved writing to the Health Minister, Shadow Minister, Leader of the Greens, all other Federal politicians and the eight State and Territory Health Ministers. NOHA asked them all to advocate to ‘ensure that all your constituents can access quality oral health services in the same way they can for diseases of any other part of the body.’ In particular, NOHA called on the Federal Government to: • retain the Child Dental Benefits Schedule, where 60% of Australian children are eligible for bulkbilled dental care, and • work with State/Territory Governments to continue and expand the National Partnership Agreement on Dental Health. This crucial agreement had been successfully reducing waiting times for adults in public dental services before mid-2014. Subsequently NOHA delegations have met with several crossbenchers to discuss this face to face. Although the Government included the CDBS’s abolition in the Federal Budget, the election interrupted its passage through Parliament. It was re-introduced in the Omnibus Bill when the re-elected Government sought to pass all its delayed legislation in one bill, including the abolition of the CBDS. However, the ALP and Greens stood out against the CDBS being included, and after negotiations, it was removed. The ALP quoted NOHA’s views in its media release announcing its decision. Despite this brief victory, the reality is that the Government is planning to reintroduce a bill to abolish the CDBS and also make savings. NOHA will continue to argue that the infrastructure of such a national scheme using all the oral health services, public and private, to meet children’s’ needs, is worth preserving, even if constrained in scope in some way. This would retain the building blocks for future iterations of the scheme. NOHA is also urging retaining funding for public adult services at the same time. At the time of writing, it is unclear how the Government is planning to proceed.

Fluoridation in Queensland NOHA has also taken the opportunity occasionally to advocate (or support others’ advocacy) when it has been timely to do so. For example, NOHA has also recently written to five Queensland councils that are considering removing fluoride from their water supplies. The letters described the case for retention of fluoridation and the well-documented health benefits to the population, especially children.

NOHA as an alliance This informal alliance is not a funded entity with any staff, but relies on members contributing ideas and time as possible. It is therefore a useful vehicle for oral health advocacy, but not necessarily a robust one. The key organising principle behind the alliance has been that members can share information and perspectives, and then advocate together on those issues where they have common positions (whilst acknowledging and respecting that all members

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may not necessarily agree on other issues). The alliance is a somewhat fluid entity so that members have the ability to opt out of particular media releases or letters to politicians, where they may have sensitivities or conflicts of interest. NOHA has a website (http://www.oralhealth.asn.au) and has encouraged people to sign up as ‘Supporters of a Fairer Dental System’. This acts not only as a way of distributing information but also of increasing the level of support NOHA can claim in its advocacy.

It is worth noting that the Alliance has now been working together for one year: longer than in its earlier period of activity. However, there is an understanding that there is a need for a funded advocacy body that can work collaboratively to respond in an ongoing manner to raise consciousness about oral health and promote new policy ideas over the long-term. The Alliance values the membership of the ADOHTA in NOHA. Please visit the NOHA website and support their advocacy activities at the local, state/territory and national level.

Management of Patients with Autism Spectrum Disorder in the Dental Environment CM Purnat Curtin University, Department of Dental Hygiene and Therapy, Western Australia, BSc Oral Health Therapy

Abstract The Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition (DSM-5) classifies Autism Spectrum Disorder (ASD) as a neurodevelopmental disorder. The incidence of this disorder is on the rise, suggesting the likelihood that more dental professionals will encounter individuals with ASD in their surgery. There are a limited number of studies conducted that encompass a variety of behavioural management techniques to assist dental professionals in providing appropriate care for individuals with ASD. The aim of this literature is to provide relevant background knowledge and suggest behavioural management techniques for dental professionals to utilise in the dental setting. The literature was reviewed using Dentistry and Oral Sciences Sources database, PubMed, Cochrane Library and Wiley Online Library, from 1998 to April 2015. This literature review outlines the current suggested behavioural management techniques for dental treatment as well as at home prevention for individuals with ASD and reports on their specific benefits and flaws. No single behavioural management technique is successful for all individuals with ASD as each individual displays various symptoms and behaviours, therefore individualised behavioural management interventions should be considered by the clinician with careful consideration of parents and caregivers.

Background Autism Spectrum Disorder is classified as a life-long neurodevelopmental disorder under the Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition (DSM – 5) (APA, 2013). Prior to 2013, Autistic Disorder was classified as a separate disorder to Asperger’s syndrome, and any other pervasive disorder not otherwise specified under the DSM – IV. Under the newly revised DSM-5, all three of these disorders are encapsulated under one name; Autism Spectrum Disorder. This disorder may influence a number of behaviours including the individual’s social skills, social development, cognitive development, and communication (Frith, 2008). In addition, restricted and repetitive behaviour and specific fixations are prominent key areas of deficit in patients with ASD (Steyn & Le Couteur, 2003). According to the most current data from the Australian Bureau of Statistics (2012), there was approximately 115,400 (0.5%) Australian individuals affected (ABS, 2013). Due to this overall increase, scientific studies and research has accelerated in order to discover the unknown aetiology (Dawson, 2013). Autism is not directly linked with any specific dental issues, however poor oral hygiene, behaviour factors, food rewards, and medications that cause xerostomia indicate that individuals with

ASD are at higher risk of caries (Marshall, Sheller & Mancl, 2010). Self-injurious behaviour can also occur with damage presenting within the oral cavity, including gingival trauma with fingernails, cheek/lip biting, and self-extraction of teeth (Johnson, Matt, Dennison, Brown & Koh, 1996). It is common for individuals with ASD to have unusual responses to sensation, rendering a simple dental appointment particularly daunting (Lai, Milano, Roberts & Hooper, 2011). This may ultimately compromise dental treatment in a clinical setting and preventive treatment at home (Lai, Milano, Roberts & Hooper, 2011). It is likely that due to the increase in incidence of ASD, more dental professionals will encounter individuals with ASD in their clinics (Stein, Polido, Cermak, 2013). The aim of this research paper is to increase the knowledge of ASD for dental health professionals, suggest the most effective techniques for managing individuals with ASD in a clinical environment and discuss options for establishing a stable at-home oral hygiene routine.

Methodology This research is a review of articles published in relation to ASD and dental management. A search was conducted to

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source literature relating to current behavioral management techniques used within dental environments. All articles used were published in the English language from 1998 to 2015 and were electronically sourced from the Dentistry and Oral Sciences Source database, PubMed, The Cochrane Library and Wiley Online Library. Search terms that were used included ‘Autism and dentistry’, ‘DSM-5 Autism Spectrum Disorder’, ‘Preventive dentistry and Autism’, ‘Caries risk and Autism’, and ‘Behavior management techniques, Autism and dentistry’. Recent statistics from government websites such as the Australian Bureau of Statistics (ABS) were utilised.

Aetiology Autism is often considered a multi-factorial disorder, with combined genetic and environmental factors (Rutter, 2005). Suggestions of causes including vaccinations, toxins, deficiency in Vitamin D, and infection have been reported (Cannell, 2010), however it is difficult to find reliable evidence that support these claims. As it stands, genetics are considered a highly suspected factor in the cause of ASD (Lauritsen & Ewald, 2001). This has been displayed due to a number of studies undertaken involving twins and families (Steyn & Le Couteur, 2003). Although there are a large quantity of theories and suggestions, it is evident that researchers are still a long way from identifying a simple genetic cause for ASD (Judd, 2007). Studies such as Hallmayer et al. (2011) conclude that susceptibility to ASD relates to genetics with a combined environmental component. Reported in a study by Volk, Lurmann, Penfold, Hertz-Picciotto & McConnell (2013), children with ASD were more likely to live in residences with high exposure to traffic-related air pollution during gestation and the first year of life. This places emphasis on the environmental component of the cause.

Diagnosis The diagnosis of Autism Spectrum Disorder involves the consideration of variations in individual behaviours which have the potential to change with age (Yates & Le Couteur, 2012). According to a recent Australian study, the most common age for diagnosis of ASD ranges from four years old to five years and nine months of age (Bent, Dissanayake & Barbaro, 2015). Published international guidelines such as the Diagnostic and Statistical Manual of Mental Disorders (DSM) should be utilised to assist diagnosis of ASD and abnormal or impaired development (Yates & Le Couteur, 2012). In May 2013, after a fourteen year revision process, the American Psychiatry Association (APA) published DSM-5, which reflected significant changes from the previous edition DSM-IV. DSM-5 includes a single diagnosis that encapsulates Autistic Disorder, Asperger’s Disorder and Pervasive Developmental Disorders not otherwise specified under one name; Autism Spectrum Disorder (APA, 2013). There has also been an introduction to ranking severity from level 1 to level 3 that demonstrates how much support the individual requires reflecting on the severity of symptoms. Level 1 is classified as ‘requiring support’ whilst level three requires ‘very substantial support’ (APA, 2013). It is important to note that due to the growing incidence, increased and improved health care needs associated with ASD may be required (Lai, Milano, Roberts & Hooper, 2011).

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Potential Obstacles in the Dental Environment Due to each individual with ASD presenting with different clinical features and a number of severities within the spectrum, there are variations in obstacles and barriers whilst in the dental environment (Lai, Milano, Roberts & Hooper, 2011). Lia, Milano, Roberts & Hooper (2011) reported that out of 555 children with ASD, only 150 had poor cooperation in the dental environment, with the remainder of children having fair to excellent cooperation. Contradictorily, a study by Marshall, Sheller, Williams, Mancl & Cowan (2007) demonstrated that out of 108 children with ASD, 65 percent were uncooperative in the dental environment. This contradiction may be due to each of the studies containing individuals with various severities on the spectrum and significant difference in sample size. In patients with ASD that require more substantial support, anxiety, communication and language impairment, comprehension difficulties, sensorimotor deficits, and attention issues make oral hygiene routines and behaviour management for individuals with ASD a difficult task for families, caregivers and dental professionals (Rapin & Tuchman, 2008). The age of the patient can also influence the ability to cooperate with dental interventions, with an increase in age commonly leading to an increase in cooperation (Stein, Polido, Najera & Cermak, 2012). Physical and verbal aggression may also be encountered during an appointment when fear is experienced by the individual (Bossù, Corridore, D’errico, Ladniak, Ottolenghi & Polimeni, 2014). These behaviors may appear unpredictable due to the difficulty of interpreting fear or anxiety, especially when the individual uses only non-verbal or has extreme communication and comprehension difficulties (Bossù, Corridore, D’errico, Ladniak, Ottolenghi & Polimeni, 2014). Dental pain can be expressed through aggression towards others and self-injurious behavior such as head-banging, mouth-punching and biting (Rada, 2013). In Rada’s (2013) study, three individuals with ASD had a history of aggressive and self-injurious behaviors which resolved when their dental treatment was completed. In this case, inability to verbalise that pain or discomfort was occurring, led to behavioral issues and self-harm. Sensory over-responsivity, an intensified response to a stimuli, is a well-researched topic as between 69% and 95% of individuals with ASD are estimated to experience some form of sensory processing difficulties (Baker, Lane, Angley & Young, 2008). Sensory over-responsiveness can occur over all sensory domains including tactile, visual and auditory, leading to inappropriate reactions to sensory stimuli such as those experienced in the dental office (Harrison & Hare, 2004). Stein, Polido & Cermak (2013) reported that in a study of individuals with ASD that were hypersensitive to stimuli (144 individuals), 44 percent of children were afraid of or complained about the dental lights. 59 percent complained or were afraid of the sounds within the dental surgery and 73 percent disliked the feeling of dental instruments within the mouth. These reactions negatively impact on the ability of the individual to withstand dental treatment in the dental environment and in an at-home setting (Stein, Polido & Cermak, 2013).

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Behavioural Management Techniques in the Dental Environment There are a number of behavioural management techniques (BMTs) suggested for appropriate management of individuals with ASD in the dental environment. As previously mentioned, each individual exhibits different deficits within the spectrum, therefore it would be unrealistic to assume that a single intervention will be successful for all individuals with ASD (Limeres-Posse, Castaño-Novoa, Abeleira-Pazos, & Ramos-Barbosa, 2014). Due to these differences, variations in behaviours and reactions will be present, often making treating individuals with ASD highly unpredictable for dental professionals (Limeres-Posse, CastañoNovoa, Abeleira-Pazos, & Ramos-Barbosa, 2014).

Parental Involvement Marshall, Sheller, Mancl & Williams (2008) demonstrated that parents and caregivers are often able to predict whether an individual is likely to cooperate with simple dental procedures. This emphasises the importance of gathering appropriate information from the parents or caregivers prior to dental treatment to assist in devising a customised behaviour management strategy and dental treatment plan (Limeres-Posse, Castaño-Novoa, Abeleira-Pazos, & Ramos-Barbosa, 2014). Involving parents/caregivers in dental appointments to assist with the use of basic behavioural guidance such as positive re-enforcement and desensitisation may result in increased patient cooperation (Charlop, Kurtz & Casey, 1990). Ensuring that parental concerns and preferences are addressed prior to deciding on a suitable BMT will encourage trust and good rapport from caregiver to clinician, ultimately resulting in the best treatment decisions for the individual (Ghandi & Klein, 2014).

Basic Behavioural Guidance BMTs such as those applied with typically anxious patients may also be successfully utilised for individuals with ASD but may require modification (Hernandez & Ikkanda, 2011). Basic behavioural guidance techniques such as tell-show-do, involving a task to be explained to the patient, then demonstrated externally and finally carried out on the patient, are commonly considered as repetitive situations appear to be favourable in patients with ASD (American Academy of Pediatric Dentistry Reference Manual, 2009). Voice control is commonly considered an unsuccessful technique as individuals with ASD often have difficulty interpreting emotions due to cognitive and social impairment (Philip et. al, 2010). If positive reinforcement is a chosen technique, the reward utilised should be discussed with the caregivers to ensure a greater chance of success as some individuals with ASD do not respond to traditional rewards such as stickers or toys (Charlop, Kurtz & Casey, 1990). Desensitisation is designed to repeatedly expose the individual to the dental environment and involves repetitive appointments, the same operator and dental chair, however this is a time consuming approach and it is impossible to predict success (Limeres-Posse, Castaño-Novoa, Abeleira-Pazos & Ramos-Barbosa, 2014). Desensitisation can be practiced at home in a mock environment prior to dental appointments, with the use of positive reinforcement to reward good behaviour (Ghandi & Klein, 2014). This reduces the time spent in the dental surgery, saving time for the dental clinician and reducing cost for the patient (Ghandi & Klein, 2014).

A reduction in waiting time is commonly believed to promote a more desirable behavioural outcome at a dental appointment as there is decreased time to comprehend negative thoughts and ideas (Barry, O’Sullivan & Toumba, 2013). Barry, O’Sullivan & Toumba (2013) demonstrated that caregivers emphasised the importance of reduced waiting times as 64.3 percent out of 43 children with ASD found that waiting to be seen for their dental appointment was difficult.

Visual Pedagogy The use of visual pedagogy prior to dental appointments to desensitise and familiarise individuals has been explored in studies and deemed beneficial (Barry, O’Sullivan, Toumba, 2014). This approach targets individuals with ASD that respond more readily to images rather than words (Barry, O’Sullivan, Toumba, 2014). Visual pedagogy used for dentistry may involve coloured pictures, photographs, books, social stories or video modelling (Backman & Pilebro, 1999). Backman & Pilebro (1999) demonstrated improved cooperation in preschool children with ASD by introducing a book with a series of coloured photographs to demonstrate the steps involved in a dental visit. After a year and a half, the group of children exposed to the intervention were compared with other children with ASD who were not introduced to the intervention and reported that the use of the book was beneficial.

Sensory-Adapted Dental Environments Due to sensory over-responsiveness being present in a vast majority of individuals with ASD, adaptation of the dental environment for individuals with developmental disabilities have been investigated. Shapiro, Melmed, Sgan-Cohen & Parush (2009) demonstrated that the use of a sensory-adapted dental environment provided an increase in relaxation and cooperation in 16 participants compared to a regular dental environment. In this study, all direct fluorescent lighting was removed, the usual dental overhead lamp was exchanged for a head lamp with narrow spectrum light and slow moving visual colour effects were created by a solar projector shining in the child’s field of vision. Rhythmic music was played through speakers while a bass vibrator was connected to the dental chair which produced sensory stimulation. An immobilisation wrap in the shape of a butterfly was used as a form of stabilisation, providing deep pressure. The ultimate attempt was to address and stimulate all sensory domains including visual, auditory, somatosensory and tactile creating a multisensory environment. This encourages minimisation of sensory discomforts and increased relaxation. The results of the study reported that the duration in minutes of accumulative anxious behaviours were less with the sensory adapted environment compared with the regular dental environment. Additionally, Cermak, Stein Duker, Williams, Dawson, Lane & Polido (2015) aimed to confirm the effectiveness of sensory adapted dental environments. A similar sensory-adapted dental environment to the Shapiro et.al (2009) study was created in a randomised control pilot study and also found favourable results.

Protective Stabilisation Protective stabilisation involving the dental team/parent/

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caregiver, a restrictive device or a combination is a commonly used behaviour guidance technique (Loo, Graham, Hughes, 2009). Physical restraints such as body wraps and restraint boards are still utilised, however these methods are controversial if applied without patient compliance (Klein & Nowak, 1998). There are descriptions regarding the use of physical restraints creating relaxing effects of deep touch pressure for children with ASD and exerting overall positive results (Edelson, Edelson, Kerr & Grandin, 1999).

Sedation Prior to consideration of sedation for dental treatment, the individual’s medical history and medications should be thoroughly assessed (Ghandi & Klein, 2014). Sedation may be considered for patients where basic BMTs have been unsuccessful (Ghandi & Klein, 2014). The use of benzodiazepines used in conjunction with nitrous oxide demonstrates high success rates (Pisalchaiyong, Trairatvorakul, Jirakijja, & Yuktarnonda, 2005). If sedation is not an appropriate, safe option for the individual, the use of general anaesthesia may be considered (Ghandi & Klein, 2014).

General Anaesthetic When an individual with ASD has extensive dental treatment needs and is resistant to dental care, the use of a general anaesthetic (GA) is frequently utilised (Rada, 2013). Prior to consideration of the use of GA, the dental clinician should endeavour to attempt all avenues of behavioural interventions (Dougherty, 2009). If this is found unsuccessful, dental treatment under a GA may be considered (Dougherty, 2009). General anaesthesia is considered safe when conducted in the correct environment, however there are still associated risks (Messiesha, 2009). Post-operative complications, risks, and side effects should be discussed with the parent or caregiver prior to the general anaesthetic to allow informed consent (Rada, 2013). Dental treatment for individuals with ASD under general anaesthesia is a frequently used option and can improve their overall quality of life due to increased comfort whilst eating and absence of dental pain without the traumatic experience of the dental procedure itself (Gaynor & Thompson, 2012).

Preventive Dental Care It has been reported that the presence of plaque is consistently high in individuals with ASD (DeMattei, Cuvo & Maurizio, 2007), therefore it is essential that the importance of a good oral hygiene routine is emphasised to the individual’s parents or carer (Rada, 2013). A study by Stein, Polido, Najera & Cermak (2012) reported that in comparison with typically developing children (10%), individuals with ASD (60%) experienced difficulty with oral care at home, with more than half of parents/caregivers claiming that ‘some’ or ‘complete’ physical assistance was required when tooth brushing. It is vital that early intervention is in place in regards to at home oral hygiene and care of an individual with ASD (Rada, 2013). It may be beneficial to include this if sensory therapies are undertaken as a part of the individuals overall intervention and education program (Rada, 2013). Individuals hypersensitive to stimuli may face issues whilst carrying out oral hygiene practices such as tooth brushing due to disliking the taste or texture of

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toothpaste or gagging whilst brushing (Stien, Polido & Cermak, 2013). To overcome this issue, a trial and error process should be undertaken with the help of caregivers to find a fluoride containing toothpaste that is tolerable to the individual, such as a flavourless or low-foaming variety (Gandhi & Klein, 2014). Pilebro & Backman (2005) investigated the use of images that displayed a structured method of tooth brushing, which was placed in the individual’s bathroom. Prior to the study, all caregivers expressed difficulties in regards to maintenance of oral hygiene. Twelve months later, all individuals were reexamined and showed improvement with a significant reduction in plaque. After eighteen months most caregivers reported that maintenance of oral hygiene was easier. This may be considered a useful technique for individuals with ASD as it utilises visual pedagogy to encourage repetitive behaviour for a positive outcome, ultimately developing a structured routine for oral care. Dias, Prado, Vadasz, & Siqueira (2010) explored the effectiveness of a dental plaque control program for patients with ASD. In this study, 38 patients with ASD were examined in the presence of their caregivers and the Fonnes tooth-brushing technique was demonstrated to the individual’s caregivers. The caregivers were also educated regarding the cause of dental disease. Compared to baseline, improvements in oral hygiene were evident in all individuals within the study. The positive results of the plaque control program demonstrated the importance of the role of the caregiver, suggesting that oral hygiene in patients with ASD can be improved through caregiver motivation.

Limitations The recently released DSM-5 (APA, 2013) categorises severities within the Autism Spectrum on a scale of one to three which indicates the level of support the individual requires. To be diagnosed with ASD a number of specific symptoms must be present, however different severities of symptoms and areas of deficit vary with each individual (APA, 2013). Variations within the Autism Spectrum can make comparisons among individuals difficult, which impacts the quality of all studies involving individuals with ASD. Some studies such as Stien, Polido & Cermak (2013) were limited in regards to diagnosis of individuals in the sample used, as diagnosis were parent-reported. Due to cooperation and compliance within the dental setting usually increasing with age, variations in age of participants may also present as a limitation (Stein, Polido, Najera & Cermak, 2012). Sample sizes are often small, this may be due to a number of reasons including accessing a large amount of individuals with ASD (in Australia, 0.5% affected) (ABS, 2012) and the amount of individuals and/or parents that wish to participate in the studies. Many studies are based on clinical notes taken from individual’s treatment cards which may leave information open to interpretation. Events that may have occurred during the treatment may have been incorrectly documented or written with a lack of detail. Questionnaires filled out by parents or carers are also frequently used in this area of study. As responses are provided by parents or carers, it leaves question on the reliability, accuracy and amount of bias present in the reported information. Additionally, questionnaires are usually conducted in the English language which leaves a deficit in the area of individuals from

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non-English speaking backgrounds (Lai, Milano, Roberts & Hooper, 2012). There were limited studies available that solely focused on prevention and at home dental care for patients with ASD. This created a limitation to this paper as there was inadequate amount of evidence to report and compare.

Recommendations This research has outlined multiple behavioural management techniques for the dental team to consider prior to dental management of patients on the Autism Spectrum. It has been established that information gathering from parents and caregivers prior to an appointment is a crucial step in patient management as caregivers are often able to gauge what the patient is likely to tolerate (Marshall, Sheller, Mancl & Williams, 2008). Taking into account caregivers suggestions or concerns and providing them with reassurance if required is vital to form a good rapport and increase motivation for the caregiver. A list of information to be sought from caregivers may comprise of • Known stimuli including if the patient is hypersensitive to noise, lighting, vibrations, and tastes that may result in a trigger of undesirable behaviour. For example, a patient may only tolerate a specific flavour of toothpaste, the caregiver can bring this to the appointment to allow it to be utilised instead of standard prophylaxis paste during a scale and clean appointment. • Investigating any fixations or routines that may positively or negatively influence the outcome of the appointment, this may include inquiring which colour toothbrush is utilised at home to ensure the same colour is selected for use at the appointment. • Ascertaining which rewards may interest the patient, such as playing a game, allowing positive reinforcement to be utilised if required. Within the clinic, some considerations prior to or at a dental appointment may include • An introductory visit, allowing patient to explore and become familiar with staff and surroundings prior to attempting examination or treatment. • Clearing benches and moving dental equipment out of the patient’s line of sight. • If the patient is hypersensitive to light, an examination without use of the dental light may be considered initially. • Ensuring minimal staff in the room in order to prevent overstimulation or unnecessary distraction. • Using a relatively monotonous tone of voice with clear and simple communication. For establishing at home oral hygiene routines, pictures or photographs demonstrating tooth brushing, brushing charts or social stories may be considered. Parental supervision or assistance may be required if the patient requires substantial support.

Conclusion Treating individuals with ASD in the dental setting and establishing an at home oral hygiene routine does not come

without complications. Understanding the background of the disorder as well as the variations in symptoms, including triggers to negative behaviour is important for dental professionals if they have an intention of treating individuals with ASD. This literature has provided multiple management techniques for dental professionals to consider in a clinical setting as well as suggestions for at home dental care. It has explored the option of utilising general anaesthetic as a treatment option and highlighted its generalised success. It would be highly beneficial for dental health professionals and caregivers if further studies in this area were conducted due to the increasing incidence and likelihood of encountering patients with ASD in the general dental setting.

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effects of deep pressure on children with autism: A pilot study evaluating the efficacy of Grandin’s Hug Machine. American Journal of Occupational Therapy, 53(2), 145-152. doi: 10.5014/ajot.53.2.145 Frith, U. (2008). Autism: A Very Short Introduction. United Kingdom: Oxford University Press. Gandhi, R. P., & Klein, U. (2014). Autism Spectrum Disorders: An Update on Oral Health Management. Journal of Evidence Based Dental Practice, 14, 115-126. doi: 10.1016/j. jebdp.2014.03.002 Gaynor, W. N., & Thomson, W. M. (2012). Changes in young children’s OHRQoL after dental treatment under general anaesthesia. International Journal of Paediatric Dentistry, 22(4), 258-264. doi: 10.1111/j.1365-263X.2011.01190.x Hallmayer, J., Cleveland, S., Torres, A.,Phillips, J., Cohen, B.,Torigoe, T., … Risch, N. (2011). Genetic heritability and shared environmental factors among twin pairs with autism. Arch Gen Psychiatry, 68(11), 1095-1102. doi:10.1001/archgenpsychiatry.2011.76. Harrison, J., & Hare, D. J. (2004). Brief report: assessment of sensory abnormalities in people with autistic spectrum disorders. Journal of Autism and Developmental Disorders, 34(6), 727-730. doi: 10.1007/s10803-004-5293-z Hernandez, P., & Ikkanda, Z. (2011). Applied behavior analysis: behavior management of children with autism spectrum disorders in dental environments. The Journal of the American Dental Association, 142(3), 281-287. doi: 10.14219/jada.archive.2011.0167 Johnson, C. D., Matt, M. K., Dennison, D., Brown, R. S., & Koh, S. (1996). Preventing factitious gingival injury in an autistic patient. The Journal of the American Dental Association, 127(2), 244-247. doi: 10.14219/jada.archive.1996.0176 Judd, S.J. (2007). Autism and Pervasive Developmental Disorders Sourcebook. USA: Health Reference Series. Klein, U., & Nowak, A. J. (1998). Autistic disorder: a review for the paediatric dentist. Paediatric dentistry, 20, 312-317. Kulage, K. M., Smaldone, A. M., & Cohn, E. G. (2014). How will DSM-5 affect autism diagnosis? A systematic literature review and meta-analysis. Journal of Autism and Developmental Disorders, 44, 1918-1932. doi: 10.1007/s10803-014-2065-2 Lai, B., Milano, M., Roberts, M, W. & Hooper, S, R. (2011). Unmet dental needs and barriers to dental care among children with autism spectrum. Journal of Autism and Developmental Disorders, 42(3) 1294-1303. doi: 10.1007/s10803-011-1362-2. Lauritsen, M. & Ewald, H. (2001). The genetics of autism. Acta Psychiatrica Scandinavica, 103(6), 411-427. doi: 10.1034/j.1600-0447.2001.00086.x Limeres-Posse, J., Castaño-Novoa, P., Abeleira-Pazos, M., & Ramos-Barbosa, I. (2014). Behavioural aspects of patients with Autism Spectrum Disorders (ASD) that affect their dental management. Medicina oral, patologia oral y cirugia bucal, 19(5), e467. doi: 10.4317/medoral.19566 Loo, C.Y., Graham, R. M., & Hughes, C.V. (2009). Behaviour guidance in dental treatment of patients with autism spectrum disorder. International Journal of Paediatric Dentistry, 19(6), 390-398. doi: 10.1111/j.1365-263X.2009.01011.x Marshall, J., Sheller, B., & Mancl, L. (2010). Caries-risk assessment and caries status of children with autism. Paediatric dentistry, 32(1), 69-75. Retrieved from: http:// web.a.ebscohost.com Marshall, J., Sheller, B., Mancl, L., & Williams, B. J. (2008). Parental attitudes regarding behavior guidance of dental patients with autism. Paediatric Dentistry, 30(5), 400-407. Retrieved from: http://web.a.ebscohost.com

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Marshall, J., Sheller, B.,Williams, B. J., Mancl, L., & Cowan, C. (2007). Cooperation predictors for dental patients with autism. Paediatric dentistry, 29(5), 369-376. Retrieved from: http://web.a.ebscohost.com Messieha, Z. (2009). Risks of general anaesthesia for the special needs dental patient. Special Care in Dentistry, 29(1), 21-25.doi: 10.1111/j.1754-4505.2008.00058.x Paris, J. & Phillips, J. (2013). Making the DSM-5: Concepts and controversies. New York: Springer Science and Business Media Philip, R. C. M., Whalley, H. C., Stanfield, A. C., Sprengelmeyer, R., Santos, I. M., Young, A. W., ... & Hall, J. (2010). Deficits in facial, body movement and vocal emotional processing in autism spectrum disorders. Psychological medicine, 40(11), 1919-1929. doi: 10.1017/ S0033291709992364 Pilebro, C., & Bäckman, B. (2005).Teaching oral hygiene to children with autism. International Journal of Paediatric Dentistry, 15(1), 1-9. doi: 10.1111/j.1365-263X.2005.00589.x Pisalchaiyong, T., Trairatvorakul, C., Jirakijja, J., & Yuktarnonda, W. (2005). Comparison of the effectiveness of oral diazepam and midazolam for the sedation of autistic patients during dental treatment. Pediatric dentistry, 27(3), 198-206. Retrieved from: http:// web.a.ebscohost.com Rada, R. E. (2013). Treatment needs and adverse events related to dental treatment under general anaesthetic for individuals with autism. Intellectual and Developmental Disabilities, 51(4), 246-252. doi:10.1352/1934-9556-51.4.246 Rapin, I., & Tuchman, R. F. (2008). Autism: definition, neurobiology, screening, diagnosis. Pediatric Clinics of North America, 55(5), 1129-1146. doi: 10.1016/j.pcl.2008.07.005 Reber, M. E. (2012). The autism spectrum: Scientific foundations and treatment. New York: Cambridge University Press. Rutter, M. (2005). Aetiology of autism: Findings and questions. Journal of Intellectual Disability Research, 49(4), 231-238. doi: 10.1111/j.1365-2788.2005.00676.x Shapiro, M., Melmed, R. N., Sgan-Cohen, H. D., & Parush, S. (2009). Effect of sensory adaptation on anxiety of children with developmental disabilities: A new approach. Paediatric Dentistry, 31(3), 222-228. Retrieved from: ncbi.nlm.nih.gov Souders, M. C., DePaul, D., Freeman, K. G., & Levy, S. E. (2002). Caring for children and adolescents with autism who require challenging procedures. Paediatric nursing, 28(6), 555. Retrieved from: http://web.a.ebscohost.com Stein, L. I., Polido, J. C., & Cermak, S. A. (2013). Oral care and sensory over-responsivity in children with autism spectrum disorders. Paediatric Dentistry, 35(3), 230-235.Retrived from: http://web.a.ebscohost.com Stein, L. I., Polido, J. C., Najera, S. O. L., & Cermak, S. A. (2012). Oral care experiences and challenges in children with autism spectrum disorders. Pediatric Dentistry, 34(5), 387391. Retrieved from: http://web.a.ebscohost.com Steyn, B. & Le Couteur, A. (2003). Understanding autism spectrum disorders. Current Paediatrics, 13, 274-278. doi: 10.1016/S0957-5839(03)00049-6 Volk, H.E., Lurmann, F., Penfold, B., Hertz-Picciotto, I., & McConnell, R. (2013). Trafficrelated air pollution, particulate matter and autism. JAMA Psychiatry, 70(1), 71-77. doi: 10.1001/jamapsychiatry.2013.266 Yates, K. & Le Couteur, A. (2012). Diagnosing Autism. Paediatrics and Child Health, 23(1), 5-10. doi: 10.1016/j.paed.2012.09.008 Zwaigenbaum, L., & Stone, W. (2006). Early screening for autism spectrum disorders in clinical practice settings. Social and communication development in autism spectrum disorders: Early identification, diagnosis, and intervention, 88-113.

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Health beliefs and behaviours of individuals on a vegan diet in relation to oral health Christopher Howlett1, Dr Helen Tane2 1 2

Final year BOH Student, School of Dentistry & Health Science, Charles Sturt University BOH Head of Discipline, School of Dentistry & Health Science, Charles Sturt University

Abstract Background: The vegan abstains from eating all animal products; meat, dairy, eggs, and avoids other products of animal origin, both dietary and non-dietary. The numbers of individuals following a vegan diet are increasing, and due to the elimination of some foods, many vegans have an increased intake of fruits, sugars, and fermentable carbohydrates in their diet. Current literature suggests that an increased risk of tooth erosion, white spot lesions, and tooth decay exists for vegans. Objective: To investigate whether or not vegans living in Australia have beliefs or behaviours that impact on their oral health, and the prevalence of these beliefs and behaviours. Method: A cross sectional study was posted to vegans in Australia through vegan social media groups and invited participants to complete an online questionnaire. Information gathered participant’s individual demographics, oral health beliefs and behaviours, such as fluoride beliefs, toothpaste and other dental product usage. Results: 503 Australian vegans completed the questionnaire, and a common trend of fluoride avoidance was found. 49% of vegans did not use fluoridated toothpaste, 51% use specifically branded vegan toothpaste, 19% believe fluoride was bad for their teeth, and 28% said that their concerns about fluoride outweighed any perceived benefits. Additionally, a significant number reported that they did not supplement known vitamins lacking in their diet, 75% did not supplement Vitamin D, 34% did not supplement vitamin B12, and 88% of vegans said they would not use a product recommended by their dental professional (such as CPP-ACP) if it had a dairy protein in it. Conclusion: While Australian vegans are a diverse population, it was found that a significant percentage of vegans who participated in this study hold beliefs and oral health behaviours that would negatively impact on their oral health, a situation that may be exacerbated by the vegan diet itself. A recommendation from this study is that health professionals need to be aware of the risks facing vegan patients, their specific oral health needs and provide a level of patient-centred care that is tailored for the vegan patient.

Introduction Worldwide, the number of individuals eating a vegan diet is increasing (Key, Appleby, & Roswell, 2006), and while there seems to be little demographic data available for Australian vegans, the data that is available suggests that vegans currently comprise approximately 1% of the population, a number which is similar to that of other affluent Western countries (Radnitz, Beezhold, & DiMatteo, 2015). Unlike a vegetarian diet which only excludes the consumption of meat, a vegan diet avoids all animal derived foods entirely (Ruby, 2012), including dairy and eggs. In addition to diet, vegans typically avoid non-food related animal products as well, such as leather, personal care goods, and other non-dietary related products that may contain animal products, and products from companies that conduct research on animals. A search for the term, ‘vegan’ using the search engine ScienceDirect shows that published articles relating to vegans and vegan diets have increased every year over the last decade (ScienceDirect.com, 2015). While there is a significant amount of literature discussing the vegan diet and different aspects of overall health, there has been minimal research examining the relationship of a vegan diet and oral health. The aim of this study was to investigate the prevalence of health beliefs and health behaviours among vegans that has an impact on their oral health.

General Health Implications Both the American Academy of Nutrition and Dietetics (CullumDugan, & Pawlak, 2015) and the Australian Dietary Guidelines

(National Health and Medical Research Council, 2013) state that a vegan diet can be suitable for all stages of life. An American study found that while there is some controversy about a vegan diet for all ages, vegans are typically believed to experience lower incidence of chronic diseases (Dyett, Sabaté, Haddad, Rajaram, & Shavlik, 2013) and there is a growing body of evidence that suggests there are a range of potential health benefits for a person on a vegan diet. Initial findings from an Adventist Health Study 2 (Orlich & Fraser, 2014) indicate that vegans have lower prevalence of type 2 diabetes, metabolic syndrome, hypertension, cancer in some instances, and lower ‘all-cause’ mortality. Other studies have found other health benefits, such as beneficial effects on the symptoms of fibromyalgia (Kaartinen, Lammi, Hypen, Nenonen, Hänninen, & Rauma, 2000), lower cholesterol (Bradbury, Crowe, Appleby, Schmidt, Travis, & Key, 2014), and greater amounts of protective gut micro biota (Glick-Bauer & Ming-Chin, 2014). In a very recent brief lifestyle intervention study (Sutliffe, Wilson, de Heer, Foster, & Carnot, 2015) it was found that a vegan diet reduced systemic inflammation when measuring circulating C-reactive protein, with substantial improvements for male study participants, and less but still noticeable improvements, for female study participants. These findings were further duplicated in a later study (Zotti, et al, 2014) which evaluated 50 vegans, all of whom were found to have developed visible white spot lesions and had decreased salivary pH. Recent studies in India found vegetarians to have higher incidence of tooth decay and eroding tooth enamel (Chopra, Chand Rao,

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Gupta, Vashisth, & Lakhanpal, 2015; Singh, Khatter, & Bal, 2011). These findings show a strong correlation with the vegan diet to a decrease in saliva flow, an increase in the prevalence of demineralised white spot lesions and eventual tooth decay.

Nutrition and Oral Diseases A number of international studies have found vegan communities are at risk of dietary deficiencies. An American study found that nutritional deficiencies resulting from a large range of vitamins and minerals, such as Vitamin B12, vitamin D, iron, zinc, and calcium, can negatively affect many important soft tissues of the mouth (Thomas & Mirowski, 2010). A German vegan study (Waldmann, Koschizke, Leitzmann, & Hahn, 2003) found that while vegans tend to be ‘healthier overall’, those taking suboptimal levels of calcium, iodine, and Vitamin B12, will have altered oral tissues. Furthermore, a British study named the EPIC-Oxford study, showed that there is widespread deficiency of Vitamin D amongst vegans (Crowe, Steur, Allen, Appleby, Travis, & Key, 2011).

Oral Health Implications Vegan diets tend to be typically higher in fruits and carbohydrates and an increased carbohydrate diet has an impact on the health of hard dental tissue (Zotti, Laffranchi, Fontana, Dalessandri, & Bonetti, 2014). The health of saliva can also be compromised for vegans, with one study showing the pH for vegans was 5-6 compared to 7-8 in the omnivorous control group (Laffranchi, Zotti, Bonetti, Dalessandri, & Fontana, 2010). There was also an increase in the number of white spot lesions within the vegan study participants compared to the omnivorous control group and significantly all individuals in the vegan group had developed white spot lesions from demineralised enamel, whereas only 2 individuals in the control group had. However, the vegan and vegetarian diet has been shown to have some benefits in periodontal health. Another study (Staufenbiel, Weinspach, Förster, Geursten, & Günay 2013) comprising of 100 vegetarians (of which 11 were vegan) and 100 non-vegetarians in the control group found vegetarians had better periodontal health than nonvegetarians, including smaller periodontal pocket depths, less bleeding on probing, lower levels of tooth mobility, and lower levels of plaque accumulation. But the findings in relation to loss of tooth enamel were similar to previous studies, as vegetarians and specifically more so, the vegans had higher rates of eroding tooth enamel and tooth decay. A follow-on from the 2010 study of the same population group four years later, found a large number of vegans had continued to develop a higher prevalence of demineralised enamel lesions, visible white spot lesions as well as having a lower salivary pH (Zotti et al, 2014). However, it has also been found that while vegans have a higher incidence of tooth decay, both vegetarians and vegans have better periodontal health when compared to an omnivorous control group (Staufenbiel, et al 2013).

Methodology A cross sectional questionnaire was designed to facilitate collection of the data and the questionnaire design was based on a previous questionnaire (Dyett et al 2013). Ethics approval (protocol number 400/2015/11) for this study was granted by the Charles Sturt University Human Ethics Committee on the 30th of April, 2015.

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Study Sample To strengthen the findings of this study, it was calculated in the planning phase that a sample size of 384 or more across all Australian states would be required to provide statistical significance with a 95% confidence interval and 5% margin of error, and to be considered to be a sample of the Australian population. Collection for this number of responses within the scope of this study necessitated the use of a convenience sample, so participants were sourced via Australian-wide vegan social media groups. A variety of groups with geographic locations throughout Australia were contacted to encompass as many Australian vegans as possible. While some groups did not reply to the request, the following Facebook groups did: “Vegans in Australia”, “Vegans of Melbourne”, “Brisbane Vegans”, “Friendly & Pragmatic Vegetarians and Vegans”, “Sydney Vegan Club”, and “Vegans of Perth”. The combined total membership of these groups was, at the time of the study 27,544, although it is difficult to know the true count of membership as members of each group can be members of multiple groups. Administrators of these groups were contacted to gain permission for the principle author to post a link inviting members of the group to visit the SurveyMonkey page where the online questionnaire was posted, and to participate if interested.

Design of the Questionnaire The design of the questionnaire was modelled on literature exploring elements of questionnaire design in nursing (Battray & Jones, 2012), with additional considerations regarding demographic questions designed with reference to questions asked in published vegan literature (Radnitz, et al. 2015 & Dyett, et al. 2013).

Study Participants Vegans were invited to fill out an anonymous online questionnaire with a total of 18 individual questions relating to veganism and oral health. Questionnaires were completed using software provided by SurveyMonkey which allowed automatic collection, and graphs were automatically generated giving easy to understand visual representation of the data collected. The questionnaire was prefaced with an information sheet that briefly explained the purpose of the study, contact information of the author and ethics committee, and stated that the questionnaire was open only to vegans living in Australia over the age of 18. General demographic questions were asked (sex, age, Australian state of residence) as well as questions relating to specific vegan demographics (length of time being vegan, reasons for becoming a vegan), and questions about toothpaste use (use of fluoridated toothpaste and use of a specific vegan toothpaste). Question 10 had 15 sub-statements, each answerable on a five point Likertscale with options ranging from ‘Strongly Disagree’, ‘Disagree’, ‘Neither Agree nor Disagree’, ‘Agree’, to ‘Strongly Agree’. These statements sought to gather information on beliefs that vegans have with regards to general health, fluoride, and other items associated with oral health. Two questions on vitamin intake followed, asking whether the participant had ever had levels of specific vitamins and minerals tested, and whether they supplemented their diet with these. The selection of minerals and vitamins to seek information about were determined by those most frequently found in the literature as being deficient in vegan diets, such as the Vitamin B12 and Vitamin D (Herrmann,

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Figure 1. Gender and age of study participants

35% (n=174) of participants were from Victoria, 28% (n=139) from New South Wales, 18% (n=90) from Western Australia, 15% (n=75) from Queensland, 2% (n=12) from South Australia, 2% (n=9) from Australian Capital Territory, 0.8% (n=4) from Tasmania, and 0 from Northern Territory. Participants ranged from 18 to 75 years with the largest groups in the age range 18-24 years olds (33%) and 25-34 year olds (33%). Twenty two percent of participants were aged between 35-44 years and those aged over 45 years comprised 13% of the sample. Figure 1 presents the participant age ranges.

Figure 2. Place of study participants’ residence & reason for being vegan

Participants were asked about their primary reason for being vegan, with the options of ethics/animal rights (80%, or n=404), environmental (4%, or n=21), health (9%, n=44), or other (7%, n=34). Those who specified ‘other’ were asked to fill in a text box specifying the reason. Given that these responses all involved variations of ‘all of the above’; with differing terms such as, “a combination of all three”, “all of the above”, “health, ethics, environmental”, “all three” etc;, an adjusted percentage has been given excluding this percent from the result, so that an accurate representation of the percentages can be shown. This data is presented in Table 1.

Toothpaste Use Figure 3 Fluoride toothpaste exposures of study participants

Obeid, Schorr, Hübner, Geisel &Sand-Hill 2009; Ho-Pham, Vu, Lai, Nguyen, 2012). Questions about overall oral health (brushing frequency, self-rating of dental health, and recent experience of dental pain) completed the formulated question section, with question 18 inviting comment from the participants. The questions relating to self-rating dental health and experience of dental pain were designed based on previous literature (Dyett et al 2013). Where ‘health belief ’ was a major motive for diet and lifestyle behaviours was investigated, the questions and Likert scales used were also modelled from the 2013 Dyett study. Questions other than 10 – 15 in the survey were closed-ended multiple choice questions with the exception of question 6 which was multiple choice with an, “other” option.

When asked whether they used toothpaste with fluoride in it, 51% of participants (n=255) said ‘yes’, and 49% (n=248) said ‘no’ (see Figure 3) . Results were similar with regard to whether participants use a toothpaste that is specifically marketed or branded as being vegan with 51% (n=254) saying that they did, and 50% (n=249) saying that they don’t. Participants were then asked that if they used a vegan branded toothpaste, and if they’d purchased any other toothpaste if they ran out of their vegan toothpaste. 17% (n=83) said that they would use any kind of toothpaste, 37% (n=186) said that they would not, 18% (n=92) indicated they were unsure, and 28% (n=142) indicated that that they did not use a vegan toothpaste.

Likert Scale Question 10 asked participants to rate their level of agreement with a range of statements using a Likert scale. The statements and the aggregated results are displayed in Table. 1. In questions 11 and 12 participants were given a list of vitamins and minerals and asked which ones they take as a supplement and if they have ever had their levels of these tested. The results are shown in Table 2.

Vegan Demographics

For tooth brushing frequency, 2% (n=10) of participants answered that they brush less than a few times week, 25% (n=125) brush once a day, 68% (n=340) brush twice a day, and 6% (n=28) brush more than twice a day. 27% (n=137) indicated that they had concerns or problems with their teeth in the last 12 months, and 73% (n=366) stated they had not had any problems. Many of the participants who responded that they had problems also left comments in the final open ended question, stating they believed the dental problems were not related to their vegan diet, citing reasons such as problems with wisdom teeth or long term dental problems that they had developed before they became vegan.

Of the 503 responses, an overwhelming majority of 86% were female (n=433) compared to 14% of males (n=70).

For overall oral health (gums, teeth, tongue), 27% (n=138) of participants indicated very good, 48% (n=242) good, 20%

Results In total, 519 participants completed the survey at which point access to the questionnaire was disabled. Of the 519 participants, 16 indicated that they were not from Australia and the data from these responses were excluded from the final results presented and analysed.

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Table 1 – Knowledge related to oral health among Vegans

(n=103) average, 4% (n=20) poor, and 0% very poor. When asked if they had experienced dental pain in the last 12 months, 57% (n=287) said they had experienced no dental pain, 34% (n=169) said little, 7% (n=36) said moderate dental pain, and 2% (n=11) said they experienced significant dental pain. The same result was seen in the feedback section, with participants indicating that their overall oral health was not related to their vegan diet. The next question asked participants to rate the appearance of their teeth and gums with 0.4% (n=2) answering Very Poor, 5% (n=23) Poor, 34% (n=171) Normal, 38% (n=192) Good, and 23% (n=115) Very Good.

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Table 2 – Supplement behaviours

Figure 4. Oral hygiene and self-rating of participants

Figure 5: Self-rated oral health status

in Australia. The questionnaire was limited to people aged 18 years of age and above and participants were asked to enter their specific age, with the results showing a significant distribution toward younger age groups. Although the study attempted to gain a fair representation of locations across Australia, the location specific groups where the link to the questionnaire was posted may have skewed the distribution of participants. 35% (n=174) of participants were from Victoria, 28% (n=139) from New South Wales, 18% (n=90) from Western Australia, 15% (n=75) from Queensland, 2% (n=12) from South Australia, 2% (n=9) from Australian Capital Territory, 0.8% (n=4) from Tasmania, and 0 from Northern Territory. It can be noted, however, that originally the questionnaire was posted only to the group, ‘Vegans of Australia’ and 84% of participants from that group indicated they were from Victoria suggesting that Victoria may in fact have a greater population of vegans than other states.

Fluoride & Tooth Decay in Vegans While 23% (n=117) of participants in this study stated that they didn’t believe that juices can affect their teeth, 22% (109) said they did not know what causes dental erosion, and 25% (n=125) said that carbohydrates do not play a role in tooth decay.

The final question in the questionnaire prompted for any further comments, and was answered by 144 participants.

Discussion Of the 503 responses, an overwhelming majority of 86% were female (n=433) compared to 14% of males (n=70). Although the literature indicates that women are more likely to be vegetarian than men (Ruby, 2012) it is difficult to determine how this result compares to the actual spread of population of vegans in Australia due to lack of pre-existing data on vegan demographics

A finding in this study was that avoidance and concerns about fluoride use were common amongst Australian study participants. One-fifth of participants believe that fluoride is bad for their teeth, 28% indicated that their concerns about fluoride outweigh any potential benefits, 32% actively avoid fluoridated toothpaste, 49% stated that they do not use fluoridated toothpaste and 25% reported they actively avoid water if it was fluoridated. A significant issue is emerging from the findings in this study; that while vegans are at an increased risk of developing tooth decay, a large proportion of vegans also specifically avoid fluoride, eliminating the opportunity to remineralise enamel and reverse the early stages of tooth decay. The previous study (Zotti, et al.

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2014) that found a definite causative effect between the vegan diet and changes to the hard tissue of the oral cavity, also found that topical fluoride reversed white spot lesions caused by the vegan diet for the study participants.

Toothpastes & Fluoridated Toothpastes The efficacy of fluoridated toothpastes in arresting tooth decay has long since been established (Twetman, Axelsson, Dahlgren, Holm, Källestål, Lagerlöl, & Söder, 2003), and yet it would seem from the study results that fluoride is of significant concern to the vegan population. This is also reflected in the amount of vegan toothpaste products that make specific mention of not including fluoride. In Australia, toothpaste manufacturers ‘Grants of Australia’ and ‘Red Seal’ both have toothpaste products available on supermarket shelves that make specific mention on its packaging of being vegan, and of not being testing on animals. They both also make specific mention of not containing fluoride. For vegans who may be looking at avoiding companies who test on animals, some vegan organisations list both ‘Colgate’ & ‘Oral-B’ as being companies that do conduct animal testing (Animals Australia, 2015), thus even vegans who are not attempting to avoid fluoride may have difficulty in having access to a suitable product due to animal testing.

Dental Products The results show only 6% (n=32) of vegans surveyed agreed that if their dental professional recommended a product containing a dairy protein that they would use it, with 88% (n=441) declaring that they would not use it. Casein phosphopeptides and amorphous calcium phosphate (CPP-ACP) is a dairy derived dental product often prescribed to patients in Australia in the form of the GC product ‘tooth mousse’. The efficacy of tooth mousse has been shown to remineralise enamel subsurface lesions in vivo (Cochrane & Reynolds 2009). However, other studies have questioned the efficacy of tooth mousse on its own (Wiegand, & Attin, 2014) with findings showing high fluoride (5,000ppm) toothpaste is most effective in treating white spot lesions (Oliveira, Ritter, Heymann, Swift, Donovan, Brock, & Wright, 2014). Another recent in-depth literature review (Jialing, Xiagiu, Yu, Wei, Antoun, Farella, & Mei 2014) also found that while CPPACP can be successful in the remineralisation of enamel, it is not necessarily more effective than the use of fluoride products and that there is a lack of sufficient evidence to confirm a synergistic effect with fluoride. Given that the efficacy of CPP-ACP is still developing, and that vegans have indicated a preference against the use of dairy products, it is recommended that dental professionals provide patient-centred care for vegan patients and be knowledgeable about alternatives they can offer. The significance of sound dietary advice and fluoride applications become heightened for the vegan patient. A significant number 43% (n=214) of Australian vegans in this study stated their dental professional was unable to provide a level of patient-centred care and this was of concern to them. They further stated that their dental professional did not understand their specific oral health needs as a vegan, that their vegan dietary requirements would not be fully understood by their dental practitioner, so it was less likely that they expressed their concerns at their dental visits.

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Vitamin B12 It has been asserted that vegans should either take Vitamin B12 supplements or eat foods fortified with B12 as there are no naturally occurring sources of B12 in the vegan diet (Pawlak, Lester & Babatunde 2014). The authors found that in the review of the published literature, there was evidence of a high prevalence of Vitamin B12 deficiency amongst all types of vegetarians, and additionally vegans specifically had statistically significantly greater rates of deficiency than vegetarians. These findings have been further strengthened by a study which followed healthy omnivores and vegans for 5 years, finding that even vegans who ate foods fortified with Vitamin B12 had a gradual decline in serum B12 concentration, concluding that supplementation is necessary (Mądry, Lisowska, Grebowiec & Walkowiak, 2012). However, just 2% (n=8) of participants in this study strongly disagreed and only 8% (n=42) disagreed with the statement “vegans should take Vitamin B12 supplements”. While this is only 10% (n=50) in total, a further 29% (n=146) neither disagreed nor agreed with the statement, leaving only 61% (n=306) agreeing with the statement, although when questioned on supplementation, 66% (n=333) of participants indicated that they do supplement their own diet with Vitamin B12, leaving 34% (n=170) at potential risk of deficiency. Vitamin B12 deficiency in vegans has been independently linked to increased bone turnover (Herrmann et al 2009), and this has potential impact on the supporting alveolar bone of the periodontium in the oral cavity. There are other oral conditions directly associated with Vitamin B12 deficiency, such as: megalobastic anaemia, and recurrent apthous stomatitis (Thomas & Mirowski, 2010), although no relevant literature pertaining to vegans and these conditions could be found.

Vitamin D In this study, 28% (n=142) of the participants said that vegans shouldn’t take Vitamin D supplements, only 26% (n=129) said that they personally supplement with Vitamin D, and 59% (n=297) had had their levels of vitamin D tested. This result suggests there is a potential for deficiency within the vegan population of this important vitamin. Vitamin D plays a role in oral homeostasis, and a dysfunction of homeostasis would affect periodontal outcomes (Amano, Komiyama, Makishima, 2009). Another study investigating osteoporosis in vegans (Smith, A 2006), found that there are widespread Vitamin D deficiencies among vegans. However, a further study found the difference in the rate of bone loss between vegans and omnivores is insignificant, despite the higher prevalence of vitamin deficiency (Ho-Pham, et al 2012). But a deficiency of vitamin D has been shown to have associations with progression of periodontal disease (Dietrich, Joshipura, DawsonHughs, & Bischoff-Ferrari, 2004), such as tooth loss and clinical attachment loss (Zhan, Samietz, Holtfreter, Hannemann, Meisel, Nauck, & Kocher, 2014).

Limitations While the findings of this study reveal new information about Australian vegans in relation to their oral health and general health, the study limitations of time, financial constraints and lack of a statistical data analysis need to be acknowledged. In

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the planning phases of the study, consideration was given to the sample size in order to strengthen the statistical findings, but the strength of these findings are not clear due to the lack of the statistical analysis. Another limitation may lie in the sample, as they may not have been sourced from a wide enough area across Australian states. Added to this, the questionnaire design would have benefited from pilot testing prior to implementation. However, while the strength of this study has been limited due to these issues, the findings in this study provide an insight for health professionals providing health care to Australian vegan patients. Further studies need to be undertaken to provide additional evidence to these study findings.

Conclusion The findings in this study demonstrate that a majority of Australian vegans who participated in this study hold beliefs that may negatively impact on their oral health. Despite available information about dietary deficiencies in the vegan diet, many Australian vegans do not supplement with vitamins B12 and vitamin D and may be at risk of other deficiencies which are likely to have an impact on the oral cavity. The results in this study further show that there is a common trend of fluoride avoidance and dental products commonly prescribed by dental practitioners. This is quite problematic given the increasing number of vegans, their increased risk for tooth decay among vegans and the clear role fluoride has in reversing and arresting early decay, especially in remineralising the increased prevalence of enamel erosion. This study has highlighted many areas of interest and concern in the relationship between the vegan diet and oral health.

Conflict of Interest Statement The authors declare that the first author, Christopher J. Howlett, identifies as vegan.

References

Amano, Y., Komiyama, K., & Makishima, M. (2009). Vitamin D and periodontal disease. Journal of Oral Science, 51(1), 11-20. Bradbury, K. E., Crowe, F. L., Appleby, P. N., Schmidt, J. A., Travis, R. C., & Key, T. J. (2014). Serum concentrations of cholesterol, apolipoprotein A-I and apolipoprotein B in a total of 1694 meat-eaters, fish-eaters, vegetarians and vegans. European Journal of Clinical Nutrition, 68(2), 178-183. Chopra, A., Chand Rao, N., Gupta, N.,Vashisth, S., & Lakhanpal, M. (2015).The Predisposing Factors between Dental Caries and Deviations from Normal Weight. North American Journal of Medical Sciences, 7(4), 151-159. Cochrane, N.J.; Reynolds, E.C. (2012) HYPERLINK “http://web.a.ebscohost.com.ezproxy. csu.edu.au/ehost/viewarticle/render?data=dGJyMPPp44rp2%2fdV0%2bnjisfk5Ie46bFL tquvSbKk63nn5Kx95uXxjL6nrkeypbBIr6yeTriqrlKzqJ5oy5zyit%2fk8Xnh6ueH7N%2fi Vaunr061p7NKsKqwPurX7H%2b72%2bw%2b4ti7fOLepIzf3btZzJzfhrutt0i3rrFRs5zk h%2fDj34y73POE6urjkPIA&vid=2&sid=21d4e471-0e2a-4ef1-b7c1-890076d8c3fe@ sessionmgr4009&hid=4214” \o “Calcium Phosphopeptides — Mechanisms of Action and Evidence for Clinical Efficacy. “ Calcium Phosphopeptides — Mechanisms of Action and Evidence for Clinical Efficacy. Advances in Dental Research. Sep2012,Vol. 24 Issue 2, p41-47 Crowe, F., Steur, M., Allen, N., Appleby, P.,Travis, R., & Key,T. (2011). Plasma concentrations of 25-hydroxyvitamin D in meat eaters, fish eaters, vegetarians and vegans: results from the EPIC-Oxford study. Public Health Nutrition, 14(2), 340-346. Cullum-Dugan, D., & Pawlak, R. (2015). Position of the Academy of Nutrition and Dietetics: Vegetarian Diets. Journal of the Academy of Nutrition & Dietetics, 115(5), 801-810 Dietrich, T., Joshipura, K., Dawson-Hughes, B., & Bischoff-Ferrari, H. (2004). Association between serum concentrations of 25-hydroxyvitamin D3 and periodontal disease in the US population. American Journal of Clinical Nutrition, 80(1), 108-113. Dyett, P. A., Sabaté, J., Haddad, E., Rajaram, S., & Shavlik, D. (2013).Vegan lifestyle behaviors. An exploration of congruence with health-related beliefs and assessed health indices. Appetite, 67119-124.

Glick-Bauer, M., & Ming-Chin,Y. (2014). The Health Advantage of a Vegan Diet: Exploring the Gut Microbiota Connection. Nutrients, 6(11), 4822-4838. Herrmann, W., Obeid, R., Schorr, H., Hübner, U., Geisel, J., Sand-Hill, M., & ... Herrmann, M. (2009). Enhanced bone metabolism in vegetarians – the role of vitamin B12 deficiency. Clinical Chemistry & Laboratory Medicine, 47(11), 1381-1387. Ho-Pham, L. T., Vu, B. Q., Lai, T. Q., Nguyen, N. D., & Nguyen, T. V. (2012). Vegetarianism, bone loss, fracture and vitamin D: a longitudinal study in Asian vegans and non-vegans. European Journal of Clinical Nutrition, 66(1), 75-82 Jialing, L., Xiaoqiu, X., Yu, W., Wei, Y., Antoun, J. S., Farella, M., & Mei, L. (2014). Long-term remineralizing effect of casein phosphopeptide-amorphous calcium phosphate (CPPACP) on early caries lesions in vivo: A systematic review. Journal of Dentistry, 42(7), 769-777. Kaartinen, K., Lammi, K., Hypen, M., Nenonen, M., Hänninen, O., & Rauma, A. (2000).Vegan diet alleviates fibromyalgia symptoms. Scandinavian Journal of Rheumatology, 29(5), 308313. Key, T., Appleby, P., & Rosell, M. (2006). Health effects of vegetarian and vegan diets. Proceedings of the Nutrition Society, 65(1), 35-41. Laffranchi, L; Zotti,F; Bonetti, S; Dalessandri, D; & Fontana, P (2010). Oral implications of the vegan diet: observational study. Minerva Stomatol, 59(11-12), 583-91. Mądry, E., Lisowska, A., Grebowiec, P., & Walkowiak, J. (2012). The impact of vegan diet of B-12 status in healthy omnivores: Five year prospective study. Acta Scientiarum Polonorum.Technologia Alimentaria, 11(2), 209-213. National Health and Medical Research Council: Department of Health and Aging, (2013). Australian Dietary Guidelines. Canberra: Australian Government. Oliveira, G. M., Ritter, A. V., Heymann, H. O., Swift Jr, E., Donovan, T., Brock, G., & Wright, T. (2014). Remineralization effect of CPP-ACP and fluoride for white spot lesions in vitro. Journal of Dentistry, 42(12), 1592-1602. Orlich, M. J., & Fraser, G. E. (2014). Vegetarian diets in the Adventist Health Study 2: a review of initial published findings. American Journal of Clinical Nutrition, 100353S-358. Pawlak, R., Lester, S. E., & Babatunde, T. (2014). The prevalence of cobalamin deficiency among vegetarians assessed by serum vitamin B12: a review of literature. European Journal of Clinical Nutrition, 68(5), 541-548. Radnitz, C., Beezhold, B., & DiMatteo, J. (2015). Investigation of lifestyle choices of individuals following a vegan diet for health and ethical reasons. Appetite. Ruby, M. B. (2012).Vegetarianism. A blossoming field of study. Appetite, 58(1), 141-150. ScienceDirect.com | Science, health and medical journals, full text articles and books. (n.d.). Retrieved September 10, 2015, from http://sciencedirect.com Singh, R. D., Khatter, R., & Bal, C. S. (2011). Prevalence of Dental Caries among the school going children of Amritsar city in relation of different associated factors. Indian Journal Of Comprehensive Dental Care (IJCDC), 1(1), 25-29. Smith, A. M. (2006). Veganism and osteoporosis: A review of the current literature. International Journal Of Nursing Practice, 12(5), 302-306. Staufenbiel, I., Weinspach, K., Förster, G., Geurtsen, W., & Günay, H. (2013). Periodontal conditions in vegetarians: a clinical study. European Journal Of Clinical Nutrition, 67(8), 836-840. Sutliffe, J. T., Wilson, L. D., de Heer, H. D., Foster, R. L., & Carnot, M. J. (2015). C-reactive protein response to a vegan lifestyle intervention. Complementary Therapies In Medicine, 23(1), 32-37. Thomas, D. M., & Mirowski, G. W. (2010). Nutrition and oral mucosal diseases. Clinics In Dermatology, 28(4), 426-431. Twetman, S., Susanna Axelsson, S., Dahlgren, H., Holm, A., Källestål, C., Lagerlöl, F., & ... Söder, B. (2003). Caries-preventive effect of fluoride toothpaste: a systematic review. Acta Odontologica Scandinavica, 61(6), 347-355. Which companies and brands still allow testing on animals? | Animals Australia. (n.d.). Retrieved  September  12, 2015, from http://www.animalsaustralia.org/features/animaltesting-list.php Waldmann, A., Koschizke, J. W., Leitzmann, C., & Hahn, A. (2003). Dietary intakes and lifestyle factors of a vegan population in Germany: results from the German Vegan Study. European Journal Of Clinical Nutrition, 57(8), 947. Wiegand, A., & Attin,T. (2014). Randomised in situ trial on the effect of milk and CPP-ACP on dental erosion. Journal Of Dentistry, 42(9), 1210-1215. doi:10.1016/j.jdent.2014.07.009 Zhan, Y., Samietz, S., Holtfreter, B., Hannemann, A., Meisel, P., Nauck, M., & ... Kocher, T. (2014). Prospective Study of Serum 25-hydroxy Vitamin D and Tooth Loss. Journal Of Dental Research, 93(7), 639-644. Zotti,  F., Laffranchi,  L., Fontana, P., Dalessandri,  D., & Bonetti,  S. (2014). Effects of fluoro therapy on oral changes caused by a vegan diet. Minerva Stomatol, 63(5), 179-88.

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Perceived barriers to dietary advice provision by medical, dental and nursing personnel: a review of the literature Allana Coxon1, Dr Melanie J. Hayes2, Dr Janet Wallace1

1 School of Health Sciences, Faculty of Health and Medicine, University of Newcastle, PO Box 127 Ourimbah NSW 2258. Email: [email protected] 2 Melbourne Dental School,The University of Melbourne, Australia, 720 Swanston Street, Melbourne VIC 3010. Email: [email protected] 

Abbreviations: CINAHL; Cumulative Index to Nursing and Allied Health Literature MD; Doctor of Medicine P; P-value n; number

Abstract Chronic diseases related to diet and nutrition present as a significant public health burden, in terms of the direct cost to society as well as disability adjusted life years. Research suggests that dietary advice provided by health professionals has the potential to influence patient eating habits. However, a wide gap exists between the public’s need for accurate and sensible dietary information and the availability of such advice from health professionals, indicating the presence of barriers. To critically analyse the literature and report on the barriers experienced by medical, dental and nursing personnel that prevent the provision of dietary advice. An electronic search was performed in May, 2014 to identify studies in the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline and Cochrane databases. Seven articles were found that met the criteria and the reference lists from the articles were also reviewed where an additional two articles were identified. A total of nine articles were included in this literature review. Lack of time, training and education, resources, confidence and reimbursement and vague guides were identified as the main barriers to the provision of comprehensive dietary advice. Numerous barriers limit the provision of clear and comprehensive dietary advice by medical, dental and nursing personnel. Further investigations into the current attitudes and practice behaviours of dental and nursing personnel, and the barriers preventing the provision of dietary advice, are needed. Keywords: Diet, dietary education, dietary advice, dietary counselling, barriers, and nutritional counselling

Introduction Diet and nutrition play an important role in promoting and maintaining good health throughout the entire life course [1]. Chronic diseases related to diet and nutrition present the greatest public health burden, either in terms of direct cost to society, or in terms of disability adjusted life years [2]. Poor dietary habits affect nutrient intake, including energy, protein, carbohydrates, essential fatty acids, vitamins and minerals as well as fibre and fluid. Poor nutrition can impair overall health, reduce quality of life and contribute to a multitude of health concerns included dental caries and erosion, high blood pressure, high cholesterol, heart disease and stroke, type-2 diabetes, osteoporosis, some cancers and depression [3]. Research carried out by Thompson et al. [4] demonstrated that dietary advice provided by health professionals has the potential to influence patient eating habits. However, a wide gap exists between the public’s need for accurate and sensible dietary information and the availability of such advice from health professionals [5]. Overseas studies suggest that health professionals may not take advantage of the opportunities to initiate nutrition care presenting to them. According to a survey by Weshcler et al. [6], less than half of medical professionals routinely ask about diet and exercise. A similar study in Oregon that assessed the dietary

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counselling practices of dental hygienists found that only 53% of dental hygienists provided any dietary advice to patients [7]. Despite these findings, it has been suggested that health professionals hold positive beliefs regarding the importance of diet counselling, and that effective dietary screening and counselling plays a key role in the detection of potential risk factors for nutrition-related problems in patients with chronic disease or conditions [8]. These results suggest that there may be barriers present preventing the provision of dietary advice by health professionals. Current literature suggests that many health professionals are not providing dietary advice and that the advice often varies greatly between practitioners [8]. More research is required in this area, particularly into identifying the barriers preventing the provision of sensible and accurate dietary advice. The proposed literature review will investigate the perceived barriers experienced by medical, dental and nursing personnel.

Methods and materials: An electronic search was performed in May 2014, to identify studies in the CINAHL, Medline and Cochrane databases. Search terms used included ‘diet*’ to include ‘dietary education’, ‘dietary advice’ and ‘dietary counselling’, ‘advice’ and ‘barrier*’ to include ‘barrier’ and ‘barriers’. To widen the area of research

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the following terms were also included in the search: ‘nutrition*’ to include ‘nutritional education’, ‘nutritional advice’ and ‘nutritional counselling’ and ‘counselling’.

[13]. The last study to utilise a survey approach was a 25 item survey mailed to a random sample of 300 Oregon licensed dental hygienists [7].

The initial search provided a total of 165 results. The search was limited to research articles in English and the participants included doctors, nurses, dentists, dental hygienists and oral health therapists with no limits placed on the clinicians’ or patients’ age, gender or socioeconomic status. To be included in this integrative literature review, articles had to address the barriers experience by medical, dental and nursing personnel regarding dietary advice. The study designs included were randomized controlled trials, controlled clinical trials, retrospective and prospective observational studies and existing literature reviews published in peer-reviewed journals. No restrictions were placed on the publication year of papers. Studies were excluded if they were not written in English or did not meet the criteria for quality. After the titles, keywords and abstracts were screened, and relevant articles underwent further analysis by a data extraction tool, seven articles were found that met this criterion. The reference lists from the articles were also reviewed and an additional two articles were identified. A total of nine articles were used for this literature review.

Interviews were employed in two of the studies identified to explore the barriers to the provision of dietary advice. A study from Australia utilised individual semi-structured telephone interviews to investigate 20 general practitioners perceptions of their role in nutrition care [14]. The other study conducted faceto-face, semi structured interviews with eighteen practitioners (twelve GPs and six nurses) who worked in general practices [15].

Study Characteristics In the included studies, the majority of population’s studied were general practitioners or physicians (doctor of medicine, MD) with one study including both physicians and nurses. A study of general practitioners and nutritionists was also included due to the limited amount of research on this subject. Only two studies were found that examined the barriers experienced by dental practitioners.

Study methods The included studies methods varied and included interviews (both face to face and telephone) focus group discussions and surveys. Aside from these approaches, no other methods were used to assess the barriers to dietary counselling. The methods utilised are appropriate given that the subject involves qualitative research to gather rich and insightful data on the participant’s experiences, attitudes and beliefs regarding the barriers to the provision of dietary advice. Interviews, focus groups and surveys are able to effectively explore the views, experiences, beliefs and/or motivations of the participants and generate rich and insightful data. Seven studies used surveys to identify barriers. A study of primary care providers used the results of open-ended interviews and focus groups to develop a 46 item, mail-type survey [9]. Mailed surveys were sent to randomly select Canadian-trained family physicians in a study in British Columbia [10]. A study addressing dental hygienists in North Caroline used a questionnaire to survey 264 dental hygienists attending a continuing education course [11]. In Australia, a survey method was utilised to look at general practitioners using a division mailing list for one study [12]. Another survey conducted by the same researchers employed a convenience sample of general practitioners and dieticians to be surveyed using a qualitative questionnaire [12]. The largest included study used a random-sample-mailed questionnaire to examine 1,103 primary care physicians from the United States

Results The included studies revealed numerous barriers to the provision of dietary advice experienced by medical, dental and nursing personnel. The results support many of the general observations made regarding the delivery of dietary advice and provides information regarding the current attitudes of dietary counselling among health care professionals. The themes in the studies are outlined below in order of the number of studies that included each particular barrier. Insufficient time was identified as a barrier across a number of studies. Nicholas et al. reported that the general practitioner respondents identified time as the predominant barrier to providing nutrition counselling [12]. Kushner reported that 68% of surveyed providers spent 5 minutes or less on nutrition counselling, and 2% do not discuss diet at all [13]. The study also found that participants ranked lack of time as the most commonly encountered problem (75%) [13]. The average time a general practitioner spends with a patient in Australia is 14.6 minutes per consultation [16]. However, Kushner’s study (1995) of 1,030 primary care physicians found that when nutrition counselling was instigated, time spent on discussing dietary change was 5 or fewer minutes [13]. If an Australian general practitioner spent a similar amount of time as that spent in the United States (equivalent to one third of an Australian consultation), there would be less time to spend on other issues [17]. Australia also has a fee-forservice system which makes nutrition counselling unattractive, as it rewards many standard consultations more than an extended consultation, even if the time spent is equivalent [18]. Another common barrier to the provision of dietary advice was a lack of provider training or education. This barrier was identified in five of the nine articles. The studies reported that providers felt a lack of knowledge about nutrition, and that made discussing the issue with patients difficult. In addition, the studies identified a lack of training in counselling techniques to be a barrier. A study by Wynn et al. found that training 82.3% of family physicians reported their formal nutrition training in University to be inadequate and only 30% of family physicians reported currently using any nutrition-related resources when providing dietary advice [10]. The study by Kushner found a significant association between the percentage of patient’s counselled and previous nutrition training: ¾ of physicians who provided counselling to >40% of their patients received training compared with only approximately one half of physicians who counselled ≤ 40% of patients [13]. The study also found that over half (58%) of respondents state that they previously received nutrition training in medical school (80%), during residency

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(51%), while in practice (45%) or through a fellowship (10%). Yet, despite these figures, 67% of physicians felt they lacked training in counselling skills and 50% lack confidence in ability to counsel patients about diets. Moreover, only 10% of physicians felt that they were very knowledgeable about nutrition [13]. Although this particular survey did not asses the quality of nature of the nutrition training, the data suggests that physicians appreciate the importance of diet and nutrition in patient care, but do not know how to implement these concepts into practice. It also suggests that current training in nutrition is not meeting the needs of primary care practitioners. Lack of resources was also identified in three of the included studies as a barrier to the provision of dietary advice. The study by Kushner found that 69% of respondents felt that inadequate materials were a barrier to providing dietary advice [13]. The study by Walker et al. identified a lack of resources as a key barrier to providing dietary advice in treating childhood obesity [15]. However, the type of resources was not defined within the article. Kenner et al. identified that the inability to obtain materials due to the cost or being unsure of sources were the most identified barriers to using nutritional wellness materials [9]. The study also identified that 83% of respondents ranked 1-page, printed handouts as the most preferred delivery format for nutrition and wellbeing patient education materials. The preference for a 1-page, printed handout was significant higher (P