Soft drinks are ingrained in American culture, and even more so in regions like Appalachia, where water quality varies in certain areas and a habit of day-long soda sipping is popular among many people.

Dr. Bill Collins, DMD, has practiced in eastern Kentucky for over 20 years, and has seen how tooth decay from sugary drinks threatens people at all age levels. Most troubling is how it often impacts kids early, resulting in lifelong problems. In the worst cases, Collins has had to extract all of a child’s baby teeth due to excessive decay, which leaves no eruption pattern set for the permanent teeth.

“This child had carbonated beverages in a sippy cup for several years,” Collins said on an episode of KET’s Kentucky Health when describing a 6-year-old’s severe tooth decay. “When they came to the dentist, it was just so bad, we had to take them to the operating room, and take all of their teeth out.”

Soft drinks contain high amounts of fructose, which is fed upon by bacteria in the mouth to form acids that erode tooth enamel. This effect becomes worse when drinking is done regularly throughout the day, and even more so at night.

“What sipping does is, at night especially, your salivary protection decreases,” Dr. Collins said. “So the acidic levels in the citric acid drinks… have a tendency to stay on the teeth longer, and can do more damage.”

Sipping soft drinks is perhaps the worst of several lifestyle habits contributing to tooth decay and tooth loss in Kentucky, habits that Dr. Collins and other dentists are working to change. A couple of years ago, one enterprising dentist in the region – the University of Kentucky College of Dentistry’s Dr. Daria “Nikki” Stone – came up with a creative and fun educational graphic that targets drinking habits as they are being formed.

Dr. Stone’s Drink Pyramid modifies the iconic format of the USDA Food Pyramid to instruct children about recommended daily drinking habits, with the goal of strictly limiting sugary drinks. The Drink Pyramid has been adopted by Kentucky schools, dentist offices, and organizations far outside its original service area, and has even received international support.

An Easy-to-Remember Reminder and a Paradigm Shift

Dr. Stone resides in Hazard and treats underserved children in a four-county region (Leslie, Perry, Knott, and Letcher). She created the Drink Pyramid to teach kids habits that they could easily remember and take home with them after they leave their school or after-school environment.

“Through our dental outreach program in eastern Kentucky, we learned that children were drinking a significant amount of soda pop and other sugary beverages such as sports and energy drinks,” Stone said. “We felt that this was a significant contributor to the very high tooth decay rates in our area, so the Drink Pyramid came out of a sense of frustration and a need to teach children and families about healthy drink choices.”

The four choices, ranging from bottom to top of the Drink Pyramid, are Water Whenever, Milk with Meals, Juice Just Once, and Pop at Parties. Their order reflects the general consensus among dentists and other health professionals about recommended daily requirements for children’s healthy teeth and gums, and for nutrition as well.

Most significantly, the Drink Pyramid restricts options that contain added sugars. Fruit juice may be a traditional part of breakfast for many families, but the added sugar content in most juices overwhelms any nutritional value they may have, especially when compared to actual fruit. The American Academy of Pediatrics recommends that children ages one to six drink 4 to 6 ounces of juice per day, and those ages seven to 18 drink 8 to 12 ounces per day.

As noted, soft drinks are notorious for lacking any nutritional value, and are cited in study after study as primary factors in rising obesity, diabetes, and tooth decay rates.

Success Leads to Wider Exposure

“I remembered the Food Pyramid from my childhood, and thought something similar might be easy for kids to remember,” Stone said. “The mnemonics were an added bonus… We found that even after one time seeing or learning about the Drink Pyramid, most children could remember the entire thing. They would see me at the grocery store, and recite the entire Drink Pyramid for me.”

Dr. Laura Hancock Jones, a dentist working with the UK College of Dentistry’s Western Kentucky Dental Outreach Program, is a colleague of Stone and incorporated the Drink Pyramid into her own outreach efforts. In her practice, she has also experienced the devastating effect high sugar and acidic concentration can have on a child’s developing teeth.

“It’s really important that we frame the sugar conversation, and there’s also, with the soda, the acid factor,” Jones told KET’s Renee Shaw. “It really affects that oral environment, and with the shift of acid in the mouth, it can really cause a lot of tooth decay to advance very rapidly, and that’s what we see with early childhood caries, is the constant exposure in the sippy cup or the bottle, time after time, feeding those bacteria to produce an acid that burns the tooth.”

Using grant money, Drs. Stone and Jones completed a project measuring how well children remembered the Drink Pyramid and followed its recommendations. Their survey found that kids exposed to the Drink Pyramid drank less sugary beverages and more water. Following this project, Stone copyrighted the Drink Pyramid, affixed it to drink cups (in recommended sizes) and magnets for her patients, and continued to spread the word.

It gained further exposure after being presented at a National Oral Health Conference and the Drink Pyramid is now a part of many Kentucky dentists’ and public health departments’ outreach and prevention programs. In addition, Stone said that the Drink Pyramid has been used in nine other states to date as well as in New Zealand.

Positive Oral Health Trends Found in Recent Data

Tooth decay rates among children in the 54 Kentucky counties that are part of the Appalachian region are consistently higher than state and national rates, and when the UK College of Dentistry’s first regional dental program launched in 2004, the oral health data for its four-county service area was poor. Stone led the program’s efforts in the region, targeting both elementary schoolkids and also preschool children in the federal Head Start program.

In addition to promoting the Drink Pyramid, the regional dental program has an Eastern Kentucky Ronald McDonald Care Mobile vehicle that reaches at-risk populations in their communities, and also provides preventive services such as fluoride varnishes and sealants to children.

The program is a partnership between UK’s College of Dentistry, other UK medical and health departments, county school boards of education and Head Start offices, local civic and church groups, the Ronald McDonald House, and other stakeholders. Its efforts have led to substantial reductions in tooth decay rates over a ten-year period, according to Stone.

“Over the ten years that we’ve been doing preventive care, we’ve brought that tooth decay number down from 7 out of 10 kids to 5 out of 10 kids, which is significant – 20 percentage points,” Stone said recently on an episode of KET’s Health Three60. “But we’ve got a long way to go to get to the national average, which is about 20 percent tooth decay.”

Read a comprehensive report from the Center for Health Workforce Studies at the State University of New York-Albany about Kentucky’s oral health

This KET article is part of the Inside Oral Health Care initiative, funded in part by the Foundation for a Healthy Kentucky.