’Educating the educated’: a report of an undergraduate medical student with multiple carious lesions and poor dietary habits

Case report

A 22-year-old female attended the undergraduate restorative clinic for a general check-up at Barts and the London School of Medicine and Dentistry. Having last visited a dentist two years previously, the patient was an irregular dental attender. She admitted being anxious regarding the dental appointment.

Her medical history revealed well-controlled Irritable Bowel Syndrome with no medications. There were no known allergies reported. Careful questioning concluded that her lifestyle is stressful and hectic as a medical student and she had a highly cariogenic diet with frequent sugar consumption on weekends whilst studying (Figure 1). The patient reported brushing her teeth twice daily using a standard fluoridated dentifrice with an electric toothbrush but failed to use interdental cleaning aids regularly and was unaware of the significance of fluoride usage. Before bed, whilst studying, the patient would continue to snack after brushing her teeth (Figure 1).

Clinical examination revealed a minimally restored dentition. Generalized marginal and interproximal plaque deposits were visible with mildly inflamed gingivae with immediate bleeding on probing in all sextants. The Basic Periodontal Examination scores were all marked as ‘2’ except a score of ‘1’ in the maxillary anterior sextant.

Clinically, suspected carious lesions were visible at the LL6 (distal), LL7 (mesial), LL8 (occlusal) and LR6 (distal) (Figure 2). These teeth were symptom free and the patient was surprised at the findings. Additionally, bitewing radiographs (Figure 3) revealed further radiolucencies consistent with caries:

The following diagnoses were subsequently made:

The treatment plan for this patient was divided into three main stages to ensure that a holistic approach to treatment planning was adopted and to help to reduce the patient's high caries risk and dental anxiety.

Subsequent appointments demonstrated that this systematic and methodical approach to treatment planning equipped the patient with the necessary knowledge and motivation to help stabilize and improve her oral health. As the patient was considered to be high caries risk, a reduced recall interval of 3 months, following the initial phase of treatment, was most appropriate. The review appointment identified that no new carious lesions developed and the patient had retained information and education provided previously, adopted a more adequate oral hygiene regimen and was more positive about the power she has to maintain and improve heroral health. Her reduction in plaque and reduced frequency of sugar consumption and snacking after brushing in the evenings proved promising (Figures 4 and 5).

Discussion

With such a case, detailed history-taking to identify a cariogenic diet and stressful lifestyle is the centre of the consultation. This can be used to formulate a personalized treatment plan that places an emphasis on prevention and education. Interestingly, this patient was aware of the benefits of a healthy and balanced diet and the effect of dietary carbohydrates on the human body, however, her awareness of their impact on her oral health was poor. Many students go through a transition period when they are at university. During this period, their routine lifestyle with their parents may discontinue and they may acquire a different perspective in eating habits.

It is also crucial that the dental anxiety of the patient is considered when treating and managing her oral health. Al-Omari and Al-Omiri assessed the anxiety scores for dental treatment amongst university students. The results revealed the highest dental anxiety scores for medical students and female students in all subjects when compared to the engineering and dental students.³ Kumar et al also identified that female medical students exhibited greater dental anxiety than male medical students.¹ It has been suggested that, ultimately, dental anxiety may lead to irregular dental attendance within female medical students⁴ and that it is related to personality traits and psychological status.⁵ These could be the main factors for the presence of higher levels of dental anxiety amongst female medical students but may also encourage poor dietary habits.

During the university years, the harsh reality of a competitive environment, continuous assessments, and psychological challenges may lead to inadequacy and self-doubt. All these factors may then contribute to conscious or unconscious eating habits that can adversely affect oral health. Additional adverse factors could be related to working stressful hours, staying up late to study, and long days on placements.

To aid management, prior to commencing restorative treatment, oral health promotion could begin with an explanation of the well-established link between dietary sugars and dental caries. A diet diary, containing work days and leisure days, is a useful tool for doing this. It enables the identification of the frequency of sugar intake as well as quantity. Whilst evoking behaviour change is more complex than this, it is useful in building a strong therapeutic relationship with patients, as well as preventing the patient from having such frequent sugar consumption within a day. This may help to reduce dental anxiety slightly at the first visit and also the fear and anxiety related to subsequent dental treatments.

Additionally, with patients of high caries risk and active dental caries, the prescription of a high fluoride toothpaste could be considered. Current Public Health England guidelines suggest that toothpaste with a high fluoride concentration may be prescribed in patients with active disease.⁶ According to these guidelines, for patients aged 10 or over, toothpaste containing 2,800 ppm fluoride may be prescribed whilst, for patients aged 16 or over, either 2,800 ppm or 5,000 ppm fluoride toothpaste can be prescribed.⁶ Clinicians may prefer to prescribe the lower concentration of 2,800 ppm in young patients since there is currently insufficient evidence to support that toothpaste containing 5000 ppm fluoride has a superior effect to the 2,800 ppm dentifrice for the management of dental caries.⁷ In this respect, the adverse systemic effects of long-term exposure to a higher concentration of fluoride also remain uncertain.^8,9

The lack of oral health knowledge demonstrated by the medical student was concerning. Taking time to identify patient risk factors and provide the basic knowledge in oral health could raise patient awareness. It is important that medical students and practitioners have a reasonable knowledge regarding dental caries and assessing the risk factors to improve the general health of their patients.

By joining dental practitioners at the forefront of the healthcare profession, medical practitioners are also influential and suitable for helping to reduce the global burden of dental caries by educating their patients on the impact of habits such as poor diet, and fluoride use, on their oral health. Further literature suggests that there is an unacknowledged need to identify and assimilate information regarding medical students' perceptions and knowledge of oral health.^10,11 It has been suggested that one way of achieving this is through embedding oral health teaching into the undergraduate medical school curriculum.^11,12,13 However, there is currently insufficient available evidence identifying the effectiveness of this approach.

Conclusion

This is an interesting case suggesting a potential lack of dental awareness within the medical profession and undergraduate medical curriculum. This emphasizes that there is a greater need to investigate the teaching and oral health perceptions of medical professionals. This case also highlights the importance of adopting a holistic approach to the history-taking process by asking questions about anxiety, stress and daily routines. There is a need to ensure that patients of all educational backgrounds are provided with adequate preventive dietary and oral hygiene advice to alleviate the demand for multiple restorative treatments at a young age and to help ensure that solidarity remains amongst healthcare professionals to maximize the chances of reducing the global burden of oral diseases.