Patient Experiences of a Four-Week Sugar Avoidance During Periodontal Therapy: A Qualitative Analysis of a randomized controlled clinical trial

Patient Experiences of a Four-Week Sugar Avoidance During Periodontal Therapy: A Qualitative Analysis of a randomized controlled clinical trial | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Patient Experiences of a Four-Week Sugar Avoidance During Periodontal Therapy: A Qualitative Analysis of a randomized controlled clinical trial Christina Laetitia Pappe, Carla Stella Bickmann, Johan Peter Woelber, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7779168/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Background and Aim: Excessive sugar intake is a central cause for caries and is associated with gingival inflammation and periodontitis. Although dietary changes have demonstrated clinical benefits, little is known about the practicability and patient perspective on sugar avoidance. Aim of this qualitative study was to explore experiences of patients who undertook a four-week sugar avoidance as an adjunct to non-surgical periodontal therapy (Step 1–2). Methods: Patients of the experimental group from a randomized controlled trial were interviewed using semi-structured phone interviews. Interviews were analyzed software-based using structured qualitative content analysis per Kuckartz and Rädiker’s framework. Categories were generated inductively and deductively with an intercoder reliability of > 0.8. Results: From ten patients of the experimental group (sugar-avoidance group), eight patient interviews could be analyzed. The qualitative analysis showed that three patients experienced initial withdrawal (e.g., headaches, cravings). Seven patients reported improved well-being, increased dietary awareness, and sustained reduction in sugar consumption. Challenges of sugar avoidance included social pressure, emotional dependency on sweets, and lack of governmental support. Conclusions: A structured four-week sugar avoidance adjunctive to non-surgical periodontitis therapy was perceived by patients as challenging initially but ultimately beneficial for physical, psychological, and sensory well-being. Patient-centered nutritional counseling should consider possible withdrawal symptoms and social challenges when addressing sugar avoidance. Trial registration: DRKS00026699, Date of registration: 14.10.2021 periodontitis periodontal therapy sugar qualitative research nutritional intervention Background Periodontitis is a multifactorial inflammatory disease affecting the supporting tissues of the teeth [ 1 ]. Its pathogenesis is characterized by a dysbiotic oral biofilm interacting with the inflammatory host immune response [ 2 ] strongly influenced by risk factors such as smoking, genetics, stress, and notably diet [ 3 ]. Furthermore, periodontitis is associated with numerous non-communicable chronic diseases (NCCDs) such as diabetes, cardiovascular diseases, obesity, and hyperlipidemia [ 4 ], with diet being a primary risk factor for all [ 5 ]. In particular, the globally high sugar consumption is highlighted as a contributing factor, significantly exceeding the recommended amount set by the WHO [ 6 ]. Significant associations between dietary sugar intake and numerous health issues, including cancer, endocrine disorders, metabolic conditions, and cardiovascular diseases are documented [ 7 ]. Further, free sugars added to foods and beverages—are implicated not only in caries but also in gingival inflammation and periodontitis progression [ 3 , 8 ]. While nutritional modifications, including Mediterranean diets and reductions in processed foods including refined carbohydrates, have demonstrated benefits for gingival and periodontal health [ 9 – 12 ], S3-level clinical practice guidelines indicate limited direct evidence supporting dietary counseling as an adjunct to periodontal therapy [ 13 , 14 ]. This limitation is primarily due to the short duration of available studies and the challenge of demonstrating significant additional effects beyond those achieved by established, highly effective periodontal treatments [ 15 ]. A recent randomized clinical trial could demonstrate an additional anti-inflammatory effect in periodontal parameters such as BOP and PISA in patients undergoing step one and two of periodontal therapy after avoiding free sugars for 4 weeks [ 16 ]. Furthermore, significant metabolic changes and an improved nutritional status were observed, including weight and visceral fat reduction and an increase of fruit, fiber and vitamin intake [ 16 ]. This is underlining the importance of addressing the shared risk factor nutrition, resulting in periodontal and overall health improvements. Outside dentistry, intervention studies reducing sugar intake report altered taste perception and withdrawal symptoms following sugar reduction, including heightened sweetness sensitivity and cravings [ 17 , 18 ]. However, contextual factors inherent to dental care—such as chair-side reinforcement and concurrent oral debridement—may modify patients’ experiences. To the best of the authors knowledge, until now patients' subjective experiences regarding a sugar avoidance intervention during periodontal therapy remain unexplored. Qualitative insights into how patients perceive, cope with, and evaluate such interventions may inform the development of more acceptable and sustainable dietary counselling during periodontal therapy [ 19 ]. Thus, this study aimed to explore how patients perceive a four-week period of sugar avoidance adjunctive to step one and two non-surgical periodontal therapy via semi-structured interviews and qualitative content analysis. Materials and Methods Study Context and Participants This qualitative substudy drew on patients from a randomized controlled clinical trial at Charité – Universitätsmedizin Berlin, Germany, investigating the effect of a four-week sugar avoidance on periodontal inflammation [ 16 ]. Ethical approval was obtained (Charité Ethics Commission EA1/162/21) and the study was registered in the German Clinical Trials Register (DRKS00026699). Inclusion criteria were: adults aged 18–75 years, diagnosed with stage I–III, grade A–B periodontitis, general Bleeding on Probing (BOP) > 30%, with a Western-style habitual diet, and requirement for non-surgical periodontal therapy. Exclusion criteria included stage IV periodontitis, medically managed diabetes, recent antibiotic or anticoagulant use, eating or severe psychiatric disorders, pregnancy/lactation, an impaired dental status (orthodontic treatment, xerostomia, etc.) and smoking > 5 cigarettes/day (see in more detail the original publication [ 16 ]). All participants underwent standardized non-surgical periodontal therapy (supragingival and subgingival instrumentation) and oral hygiene instruction according EFP guidelines [ 14 ]. Periodontal parameter such as BOP, plaque control record as well as metabolic parameters like body weight, visceral fat and HbA1c were documented at baseline, 4 weeks, and 8 weeks after subgingival instrumentation (see in more detail the original publication [ 16 ]). Dietary Counselling and sugar avoidance Patients in the test group received a single 45-minute telephone dietary counselling session by a nutritionist and dentist and were instructed to avoid all added/free sugars (no sugar, honey, syrups, sugar-sweetened beverages, desserts, sweets) and refined carbohydrates (white flour, white rice, etc.) for four weeks, while maintaining overall caloric intake via substitute foods (e.g., fruits, whole grains). Techniques such as motivational interviewing [ 20 ] and personalized action planning (theory of planned behavior) were applied [ 21 ] To assess and monitor dietary intake over the study period repeated dietary questionnaires by Robert Koch Institute’s DEGS and continuous glucose monitoring (CGM) sensors were applied (see in more detail the original publication [ 16 , 22 ]). Data Collection Semi-structured telephone interviews were conducted post-intervention. The interview guide included 17 questions across four domains (Supplementary file S1): Physical and psychological changes during and after abstinence (e.g., “Which side effects did you notice?”). Coping with sugar cravings (e.g., “How did you manage your desire for sugar?”; 0–10 difficulty rating). Dietary and social influences during and post-intervention (e.g., “How did your social environment react?”). Implementation challenges and improvement suggestions (e.g., “What would have made the intervention easier?”). Interviews were audio-recorded with participant consent. Transcription was performed twice (4 weeks after first transcription) with the MAXQDA-System (VERBI, Germany) in accordance with the Conversation Analytic Transcription System 2 (GAT2) protocol [ 23 ]. Qualitative Content Analysis After transcription of the interviews, the analysis employed the content-structuring qualitative approach of Kuckartz & Rädiker [ 24 ]. Analysis proceeded in seven iterative phases: Initiating Text Work : Immersion in transcripts; memoing and color-coding of key passages; writing case summaries to capture each participant’s core experiences. Main Category Development : Deductive–inductive creation of five principal categories aligned with research questions. First Coding Cycle : Two coders (CB, JPW) independently applied main categories; coding disagreements were resolved via consensual discussion[ 25 ]. Subcategory Formation : Inductive identification of subcategories emerging from coded data. Second Coding Cycle : Application of the refined codebook across all transcripts by CB. Intercoder Reliability : A third coder (CLP), trained in the codebook, independently coded two transcripts. Results Synthesis : Aggregation of coded excerpts into thematic narratives under each main category. This analysis focused on patients’ expectations, coping strategies, perceived effects (physical, psychological, sensory), social challenges, and motivations for maintaining reduced sugar intake. Main hypothesis comprised that a four-week sugar abstinence would improve physical and mental well-being. The secondary hypothesis assumed a decrease in sugar cravings and an increase in motivation to quit sugar long-term. Additionally, the study aimed to generate practical insights and hypotheses for future research. Results Between August 2022 and January 2023, semi-structured telephone interviews averaged 45 minutes (range 30–60) were conducted 3–8 months post-intervention to allow reflection yet minimize recall bias. Cohen’s κ coefficients ranged from 0.68–0.82 across subcategories, indicating good reliability between the two coders (CB, CLP) [ 24 ]. Of 11 patients randomized to the sugar avoidance group, eight completed both the intervention and subsequent interview. Two were unreachable for interview scheduling, and one was excluded after reporting negligible pre-intervention sugar intake. The final sample comprised five women and three men. Overview of the Category System Based on the interview transcripts, five main categories with 26 subcategories were evaluated and are illustrative presented in Table 1 . All subcategories are presented in Supplementary file S2. Table 1 Main categories and example subcategories Main Category Example Subcategories 1. Pre-intervention sugar consumption patterns Habitual sources; quantity estimates; emotional triggers 2. Expectations toward sugar avoidance Anticipated benefits; fear of withdrawal 3. Intervention adherence & coping strategies Planning/substitution; social negotiation 4. Evaluation of sugar avoidance Positive and negative physical and psychological effects 5. Post-intervention states Motivation to maintain; changed dietary habits Pre-Intervention Sugar Consumption Asking regarding the sugar consumption before the intervention, all patients reported daily consumption of free sugars. Most common sources included sweetened hot drinks, desserts, confectionery, and sugar-sweetened beverages. Emotional contexts (e.g., “stress snacking”, as a „treatment“) and social settings (“afternoon cake with colleagues”) were the most prominent triggers: Patient #22: “ In the evening after dinner that (sugar consumption) was pure reward for me. Super! Well done! Great day! It was in the afternoon from 3PM and then in the evening after dinner” (Interview 22, page 4). Expectations Toward Sugar Avoidance Most expected health improvements were reduced gingival inflammation, blood sugar reduction, weight loss and enhanced energy. Three participants hoped that the intervention could improve the results of periodontal therapy. Negative expectations encompassed anxiety regarding potential withdrawal symptoms or cravings. Patient #10: “I naturally hoped that it would improve my gums. I also hoped that it would somehow be noticeable physically—maybe a little weight loss, although I didn’t really expect to lose much weight through it. It wasn’t really necessary, that wasn’t why I did it. But I hoped it would also show in the values that were taken.” (Interview 10.2, page 3) Intervention Adherence & Coping Strategies Regarding the experiences during the intervention, all participants reported detailed meal planning (e.g., batch-cooking sugar-free recipes) and substitution of sugar with fruit, artificial sweeteners and a higher consumption of whole grain products. Strategies to cope with cravings included talking with other participants of the study, using sugar-free or sugar-reduced alternatives and explaining the intervention to family and friends helped garner support. Some brought their own sugar-free alternatives to social events. Others experienced peer pressure and exclusion especially in not at home settings: Patient 22 “Then comes the problem that you are a little socially incompetent because you cannot eat everything that the others eat” (Interview 22, page 1). There were differences in how patients evaluated sugary foods, the maximum acceptable total sugar content during the intervention, and the inclusion or exclusion of wheat products: Patient #02: “To find something without sugar and without wheat was very difficult. I will never forget: I was once in a restaurant and then they made me something and well I left hungry again.” (Interview 02, page 1) Patient #06: “I actually exclusively paid attention to this sugar information in the nutrition table” (Interview 06, page 3). Patient #06: “I had I think set myself a limit: less than uh I don’t know exactly anymore, I think less than 0.5 grams of sugar” (Interview 06.2, page 5). Patient #15: “I don’t have sugar at home that I mix into things but you naturally have some fructose like dried fruit, where you do look at how much sugar it contains. Or other products like whole grain products, where you look at how high the sugar content is, yes. And if it was too high, I left it there. That’s what I did during that time.” (Interview 15.2, page 5) Evaluation of Sugar Avoidance Overall, positive evaluations were made more frequently than negative ones (134 text segments vs. 75 segments). Participants rated the difficulty of the dietary change between 0 and 8 (0 = very easy, 10 = very difficult), with an average score of 3 (range 0–8), especially regarding the sugar avoidance in the home settings. Patients with previously high sugar consumption were more likely to use substitutes like dates - especially when daily routines or traditions were present. Physical and Psychological Effects Seven of eight participants reported positive physical and psychological effects during the intervention. Most reported transient energy dips and mood fluctuations (irritability, low mood, cravings) in the first week, followed by stable or improved energy levels. Three participants positively noted modest weight loss (1–2 kg). Successful adherence boosted confidence and self-efficacy. Most participants described pride in overcoming challenges. The heightened awareness of food choices extended beyond sugar, leading to more balanced meals („to try out new things“). Patient #10: “I felt really good. I had the feeling that the dietary change was good for me.” (Interview 10, page 1). Patient #15: “I really have to say I was clearly fitter, more awake. My joints - so I’m actually a healthy person - but somehow I really had the feeling with my hands. They felt so much clearer not that they are stiff but still I somehow noticed that I physically simply felt more oily” (Interview 15, page 1). Post-Intervention States All patients reported lasting reductions in sugar consumption, incorporation of sugar-free recipes, sustained label reading and a greater awareness of healthier products: Patient #22: “What I found even harder is that I discovered how extreme it is. How much sugar there is in every food that they give us. Which I had not noticed before and how hard it is to give up sugar.” (Interview 22, page 2). Other positive behavioral changes included increased consumption of whole grains, fruits, and vegetables. Four patients described sugar as addictive or dependency-forming as a result of the intervention and reported from remained sensitivity to sweetness. Challenges primarily included social events, holidays, and an unprepared work environment. The food industry, product labeling, and lack of public education were viewed critically, and sugar taxes were proposed. On a 0–10 scale, mean motivation to continue reduced sugar intake was 6,4 (range 3–10). Patient #22: “You are somehow displayed alone right? And if I do not want sugar then I must avoid 80 percent of the things that are in the supermarket.” (Interview 22, page 06). Patient #06: “Well difficult for me were all the things you normally eat like ready-made salads or sausage or so where there are hidden sugars. Where you don’t expect that sugar is in them. And that was difficult for me because it was just unusual. You don’t expect that sugar is in there and you first have to become aware of that.” (Interview 06, page 1). Evaluation of the Counselling Five patients evaluated the dietary counseling prior to the intervention positively. Two participants criticized it or noted insufficient information. Patients most commonly suggested providing an additional written list of permitted and prohibited foods to improve the intervention. Group-based implementation was also proposed as a potential enhancement. Additionally, two participants expressed a general wish for dietary counseling in dental practices, with one emphasizing its importance for children and adolescents. Patient #10: “And do you see a need for action among doctors and dentists? Yes, I think so. I think many already do that, but more would be good, especially for children and young people.” (Interview 10.2, page 6). Patient #02: “So I think it would really help me, and I believe it would motivate other people too, if there was concise information available that was easy to read and came from the dental clinic or somewhere like that.” (Interview 02.2, page 8). Discussion This post intervention evaluation could demonstrate that a single personalized dietary counselling prior to step 1 and 2 periodontal therapy could lead to behavioral dietary and psychological changes which persisted 3–8 months until the interview. Four of eight participants described sugar as addictive following the intervention. This perception aligns with existing research, including multiple animal studies, which suggest that sugar can trigger addiction-like responses [ 26 – 29 ]. Further research is needed to be able to classify sugar correctly also in humans. Within the framework of health/addiction psychology, the Transtheoretical Model of Behavior Change [ 30 ] describes six stages of change. All participants reached at least the “contemplation” phase, in which people start to recognize their problematic behavior and develop the intention to change it at some point. Even if some participants relapsed into sugar consumption, they became more aware of its disadvantages and developed a long-term motivation to change. The results show both internal and external conflicts: participants struggled not only with changing their own sugar habits but also with the food environment—specifically poor labeling and limited sugar-free options. They criticized the lack of clear information on added sugars and called for transparent front-of-pack labeling that differentiates between naturally occurring and industrial sugars. Currently, sugar content is hidden behind various terms (e.g., sucrose, fructose, syrup), making it difficult for consumers to recognize. A study by Zühlsdorf et al. [ 31 ] showed that although many consumers are critical of sugar, they misunderstand ingredient lists and overestimate the health value of products with claims like “no added sugar”. This implicates the need for better counselling, potentially in dental settings. Participants also suggested introducing a sugar tax and restricting food marketing aimed at children and adolescents. Over 50 countries worldwide have implemented sugar taxes, with studies showing reduced sugar consumption and product reformulation [ 32 , 33 ]. Patients reported from enhanced sweetness perception after sugar reduction which may have served as an intrinsic reinforcement for reduced sugar intake. This sensory shift, reported by participants and documented experimentally [ 17 ], could be harnessed in dietary counselling to motivate sustained abstinence. Based on the patients´ feedback, addressing the habitual nature of sugar consumption is essential for successfully implementing an anti-inflammatory, low-sugar diet in periodontal therapy. Motivational Interviewing (MI) —a communication method aimed at enhancing intrinsic motivation—can support behavioral change and encourage patients to reflect on their eating habits [ 34 , 35 ]. Rubak et al. [ 36 ] found it more effective than traditional counseling in treating various behavioral issues. Participants employed evidence-based coping strategies like meal planning, substitution, self-monitoring—that align with behavior change techniques [ 37 ]. The findings suggest that individualized action plans (e.g., "if I crave something sweet after dinner, I will eat dates") can help bridge the gap between intention and behavior, making health-promoting habits more sustainable, as it was also seen in other dental settings[ 38 ]. Self-efficacy emerged as a central facilitator: successful management of cravings increased confidence to sustain change. Social support, both in private and professional contexts, mitigated environmental challenges. Based on this, MI might be a helpful tool in supporting patient´s health behavior changes in periodontal therapy [ 39 , 40 ]. The EFP S3 guideline for periodontitis therapy recommends risk factor management in the beginning of periodontal therapy addressing lifestyle factors such as smoking and blood sugar control, but direct evidence is scarce for dietary interventions [ 14 ]. Especially in Germany, the initial step of therapy has gained more attention through preventive counselling or “speaking dentistry” focused on discussing risk factors during periodontal treatment, as it is now covered by public health insurance [ 41 ]. However, most dental clinicians lack training in nutritional counselling. From the present cohort, just one of eight participants received nutritional counselling prior the intervention from a dentist. The presented findings underscore the acceptability and feasibility of a single, focused counselling session prior step two of periodontal therapy. Similar findings regarding sustained improvements in general health following dietary coaching have been demonstrated elsewhere [ 42 ]. Periodontal outcomes were improved in the initial trial [ 16 ], with a greater reduction in bleeding on probing in the sugar avoidance group compared to the control group with continued sugar consumption. Qualitative experiences elucidated here suggest that dietary modifications were well tolerated and conferred psychosocial benefits, potentially reinforcing periodontal maintenance behaviors. Extracted from this investigation, exchanging ideas in group sessions, conducting follow-up during the intervention, and providing additional information would strengthen motivation and could help enhance long-term adherence. Dental professionals should be equipped to deliver brief nutritional interventions or refer to dietetic services, integrating oral and systemic health promotion. Strengths and Limitations Methodological strengths of this investigation include application of a rigorous, theory-guided qualitative analysis [ 24 ], triangulation of coders with good intercoder reliability, and rich contextual descriptions enhancing transferability. Additionally, the intervention was accompanied by CGM sensors, though CGM data were withheld, the sensing device itself may have served as a behavioral cue, enhancing adherence [ 22 ]. Limitations encompass a small, motivated sample, potential recall bias due to retrospective interviews, and lack of a comparison group without sugar abstinence. The 3–8 month interval between intervention and interview may have attenuated recall of early withdrawal experiences. Follow-up counseling during the intervention could have addressed these unresolved questions regarding sugar consumption. Future interventions could leverage peer support groups or digital platforms to bolster motivation and adherence. Further mixed-methods designs, combining longitudinal qualitative follow-up with quantitative measures of periodontal parameters, inflammatory biomarkers, and glycemic control should be employed. Larger, more diverse cohorts would assess transferability. Economic evaluations could determine cost-effectiveness of integrating dietary counselling into periodontal care pathways based on the immense costs of a sugary diet [ 43 ]. Based on the qualitative character of this study, only impulses for further quantitative research can be derived. Conclusion A structured four-week sugar avoidance adjunctive to non-surgical periodontitis therapy was perceived by patients as challenging initially but ultimately beneficial for physical, psychological, and sensory well-being. Embedding dietary counselling within periodontal practice can enhance patient engagement and may synergistically improve clinical outcomes. Future studies should refine intervention delivery, explore long-term adherence, and quantify periodontal and systemic health benefits. Abbreviations BOP Bleeding On Probing CB Carla Bickmann CGM Continuous Glucose Monitoring CLP Christina Laetitia Pappe GAT2 Conversation Analytic Transcription System 2 DEGS German Health Interview and Examination Survey for Adults EFP European Federation Of Periodontology Hba1c Glycated hemoglobin JPW Johan Peter Woelber NCCD Non-Communicable Chronic Disease PISA Periodontal Inflamed Surface Area in mm2 WHO World Health Organization Declarations Ethics approval and consent to participate The study was approved by the ethics committee of the Charité – Universitätsmedizin Berlin (Charitéplatz 1, 10117 Berlin, Deutschland). Committee’s reference number: EA1/162/21. The study adhered to the CONSORT reporting guidelines and followed the Declaration of Helsinki (1975, 2013). Detailed information on the study methods is provided in the original publication. The participants received written and verbal information about the study: the rationale and aim, as well as the design and procedure. Participants were also informed that they were free to withdraw without having to specify the reason and that confidentiality and anonymity in presentation were guaranteed. All participants signed the informed consent form. Consent for publication Not applicable Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests Funding Not applicable Authors' contributions CLP drafted the initial manuscript. CLP and JPW conceptualized the study and design, as well as analyzed and interpreted the data. CB collected and analyzed the data. AA and HD critically revised the manuscript. All authors read and approved the final manuscript. Authors' information (optional) Not applicable Acknowledgements The authors thank all study participants and acknowledge funding support from the Charité, Department of Periodontology, Oral Medicine and Oral Surgery. References Papapanou PN, Sanz M, Buduneli N, Dietrich T, Feres M, Fine DH, et al. Periodontitis: Consensus report of workgroup 2 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions. J Periodontol. 2018;89(Suppl 1):173–82. https://doi.org/10.1002/JPER.17-0721 . Hajishengallis G, Chavakis T, Lambris JD. Current understanding of periodontal disease pathogenesis and targets for host-modulation therapy. Periodontol 2000. 2020;84:14–34. https://doi.org/10.1111/prd.12331 . Chapple ILC, Bouchard P, Cagetti MG, Campus G, Carra M-C, Cocco F, et al. 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PLoS ONE. 2007;2:e698. https://doi.org/10.1371/journal.pone.0000698 . Prochaska JO, DiClemente CC. Stages and processes of self-change of smoking: toward an integrative model of change. J Consult Clin Psychol. 1983;51:390–5. https://doi.org/10.1037//0022-006x.51.3.390 . Zühlsdorf A, Jürkenbeck K, Mehlhose C, Spiller A. „Süße Marketingclaims: Wie verstehen Verbraucher Werbehinweise zu Zuckerreduktion, Süßungsmitteln und anderen süßenden Zutaten auf Lebensmitteln? Georg-August-Univ Gött. 2021;:186. Coyle N, Little E, Williamson S, Dodhia S. Sugar reduction: report on progress between 2015 and 2019. 2021;:194. Pedraza LS, Popkin BM, Batis C, Adair L, Robinson WR, Guilkey DK, et al. The caloric and sugar content of beverages purchased at different store-types changed after the sugary drinks taxation in Mexico. Int J Behav Nutr Phys Act. 2019;16:103. https://doi.org/10.1186/s12966-019-0872-8 . Miller WR. Motivational interviewing: research, practice, and puzzles. Addict Behav. 1996;21:835–42. https://doi.org/10.1016/0306-4603(96)00044-5 . Miller WR, Rollnick S. Motivational Interviewing. Guilford; 2023. Rubak S, Sandbaek A, Lauritzen T, Christensen B. Motivational interviewing: a systematic review and meta-analysis. Br J Gen Pract J R Coll Gen Pract. 2005;55:305–12. Michie S, Richardson M, Johnston M, Abraham C, Francis J, Hardeman W, et al. The behavior change technique taxonomy (v1) of 93 hierarchically clustered techniques: building an international consensus for the reporting of behavior change interventions. Ann Behav Med Publ Soc Behav Med. 2013;46:81–95. https://doi.org/10.1007/s12160-013-9486-6 . Sniehotta FF, Araújo Soares V, Dombrowski SU. Randomized Controlled Trial of a One-minute Intervention Changing Oral Self-care Behavior. J Dent Res. 2007;86:641–5. https://doi.org/10.1177/154405910708600711 . Kitzmann J, Ratka-Krueger P, Vach K, Woelber JP. The impact of motivational interviewing on communication of patients undergoing periodontal therapy. J Clin Periodontol. 2019;46:740–50. https://doi.org/10.1111/jcpe.13132 . Kopp SL, Ramseier CA, Ratka-Krüger P, Woelber JP. Motivational Interviewing As an Adjunct to Periodontal Therapy-A Systematic Review. Front Psychol. 2017;8:279. https://doi.org/10.3389/fpsyg.2017.00279 . Woelber JP, Lessing C, Oesterreich D. Mundgesundheitskompetenz und deren Vermittlung in der „sprechenden Zahnmedizin. Bundesgesundheitsblatt - Gesundheitsforschung - Gesundheitsschutz. 2021;64:986–92. https://doi.org/10.1007/s00103-021-03370-5 . Brittain M, Consedine N, Bagot KL, Booth N, Rodda SN. Sugar Habit Hacker: Initial evidence that a planning intervention reduces sugar intake. J Behav Addict. 2021;10:471. https://doi.org/10.1556/2006.2021.00054 . Meier T, Senftleben K, Deumelandt P, Christen O, Riedel K, Langer M. Healthcare Costs Associated with an Adequate Intake of Sugars, Salt and Saturated Fat in Germany: A Health Econometrical Analysis. PLoS ONE. 2015;10:e0135990. https://doi.org/10.1371/journal.pone.0135990 . Additional Declarations No competing interests reported. Supplementary Files Supplementaryfile1.docx Supplementaryfile2.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 24 Nov, 2025 Reviewers agreed at journal 13 Nov, 2025 Reviewers agreed at journal 13 Nov, 2025 Reviewers invited by journal 30 Oct, 2025 Editor invited by journal 16 Oct, 2025 Editor assigned by journal 15 Oct, 2025 Submission checks completed at journal 15 Oct, 2025 First submitted to journal 15 Oct, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Its pathogenesis is characterized by a dysbiotic oral biofilm interacting with the inflammatory host immune response [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] strongly influenced by risk factors such as smoking, genetics, stress, and notably diet [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Furthermore, periodontitis is associated with numerous non-communicable chronic diseases (NCCDs) such as diabetes, cardiovascular diseases, obesity, and hyperlipidemia [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], with diet being a primary risk factor for all [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In particular, the globally high sugar consumption is highlighted as a contributing factor, significantly exceeding the recommended amount set by the WHO [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Significant associations between dietary sugar intake and numerous health issues, including cancer, endocrine disorders, metabolic conditions, and cardiovascular diseases are documented [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Further, free sugars added to foods and beverages\u0026mdash;are implicated not only in caries but also in gingival inflammation and periodontitis progression [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. While nutritional modifications, including Mediterranean diets and reductions in processed foods including refined carbohydrates, have demonstrated benefits for gingival and periodontal health [\u003cspan additionalcitationids=\"CR10 CR11\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], S3-level clinical practice guidelines indicate limited direct evidence supporting dietary counseling as an adjunct to periodontal therapy [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. This limitation is primarily due to the short duration of available studies and the challenge of demonstrating significant additional effects beyond those achieved by established, highly effective periodontal treatments [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. A recent randomized clinical trial could demonstrate an additional anti-inflammatory effect in periodontal parameters such as BOP and PISA in patients undergoing step one and two of periodontal therapy after avoiding free sugars for 4 weeks [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Furthermore, significant metabolic changes and an improved nutritional status were observed, including weight and visceral fat reduction and an increase of fruit, fiber and vitamin intake [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. This is underlining the importance of addressing the shared risk factor nutrition, resulting in periodontal and overall health improvements. Outside dentistry, intervention studies reducing sugar intake report altered taste perception and withdrawal symptoms following sugar reduction, including heightened sweetness sensitivity and cravings [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. However, contextual factors inherent to dental care\u0026mdash;such as chair-side reinforcement and concurrent oral debridement\u0026mdash;may modify patients\u0026rsquo; experiences. To the best of the authors knowledge, until now patients' subjective experiences regarding a sugar avoidance intervention during periodontal therapy remain unexplored. Qualitative insights into how patients perceive, cope with, and evaluate such interventions may inform the development of more acceptable and sustainable dietary counselling during periodontal therapy [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Thus, this study aimed to explore how patients perceive a four-week period of sugar avoidance adjunctive to step one and two non-surgical periodontal therapy via semi-structured interviews and qualitative content analysis.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy Context and Participants\u003c/h2\u003e\u003cp\u003eThis qualitative substudy drew on patients from a randomized controlled clinical trial at Charit\u0026eacute; \u0026ndash; Universit\u0026auml;tsmedizin Berlin, Germany, investigating the effect of a four-week sugar avoidance on periodontal inflammation [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Ethical approval was obtained (Charit\u0026eacute; Ethics Commission EA1/162/21) and the study was registered in the German Clinical Trials Register (DRKS00026699). Inclusion criteria were: adults aged 18\u0026ndash;75 years, diagnosed with stage I\u0026ndash;III, grade A\u0026ndash;B periodontitis, general Bleeding on Probing (BOP)\u0026thinsp;\u0026gt;\u0026thinsp;30%, with a Western-style habitual diet, and requirement for non-surgical periodontal therapy. Exclusion criteria included stage IV periodontitis, medically managed diabetes, recent antibiotic or anticoagulant use, eating or severe psychiatric disorders, pregnancy/lactation, an impaired dental status (orthodontic treatment, xerostomia, etc.) and smoking\u0026thinsp;\u0026gt;\u0026thinsp;5 cigarettes/day (see in more detail the original publication [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]).\u003c/p\u003e\u003cp\u003eAll participants underwent standardized non-surgical periodontal therapy (supragingival and subgingival instrumentation) and oral hygiene instruction according EFP guidelines [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Periodontal parameter such as BOP, plaque control record as well as metabolic parameters like body weight, visceral fat and HbA1c were documented at baseline, 4 weeks, and 8 weeks after subgingival instrumentation (see in more detail the original publication [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eDietary Counselling and sugar avoidance\u003c/h3\u003e\n\u003cp\u003ePatients in the test group received a single 45-minute telephone dietary counselling session by a nutritionist and dentist and were instructed to avoid all added/free sugars (no sugar, honey, syrups, sugar-sweetened beverages, desserts, sweets) and refined carbohydrates (white flour, white rice, etc.) for four weeks, while maintaining overall caloric intake via substitute foods (e.g., fruits, whole grains). Techniques such as motivational interviewing [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] and personalized action planning (theory of planned behavior) were applied [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] To assess and monitor dietary intake over the study period repeated dietary questionnaires by Robert Koch Institute\u0026rsquo;s DEGS and continuous glucose monitoring (CGM) sensors were applied (see in more detail the original publication [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]).\u003c/p\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003eSemi-structured telephone interviews were conducted post-intervention. The interview guide included 17 questions across four domains (Supplementary file S1):\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003ePhysical and psychological changes\u003c/b\u003e during and after abstinence (e.g., \u0026ldquo;Which side effects did you notice?\u0026rdquo;).\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eCoping with sugar cravings\u003c/b\u003e (e.g., \u0026ldquo;How did you manage your desire for sugar?\u0026rdquo;; 0\u0026ndash;10 difficulty rating).\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eDietary and social influences\u003c/b\u003e during and post-intervention (e.g., \u0026ldquo;How did your social environment react?\u0026rdquo;).\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eImplementation challenges and improvement suggestions\u003c/b\u003e (e.g., \u0026ldquo;What would have made the intervention easier?\u0026rdquo;).\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003e Interviews were audio-recorded with participant consent. Transcription was performed twice (4 weeks after first transcription) with the MAXQDA-System (VERBI, Germany) in accordance with the Conversation Analytic Transcription System 2 (GAT2) protocol [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eQualitative Content Analysis\u003c/h3\u003e\n\u003cp\u003eAfter transcription of the interviews, the analysis employed the content-structuring qualitative approach of Kuckartz \u0026amp; R\u0026auml;diker [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Analysis proceeded in seven iterative phases:\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eInitiating Text Work\u003c/b\u003e: Immersion in transcripts; memoing and color-coding of key passages; writing case summaries to capture each participant\u0026rsquo;s core experiences.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eMain Category Development\u003c/b\u003e: Deductive\u0026ndash;inductive creation of five principal categories aligned with research questions.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eFirst Coding Cycle\u003c/b\u003e: Two coders (CB, JPW) independently applied main categories; coding disagreements were resolved via consensual discussion[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eSubcategory Formation\u003c/b\u003e: Inductive identification of subcategories emerging from coded data.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eSecond Coding Cycle\u003c/b\u003e: Application of the refined codebook across all transcripts by CB.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eIntercoder Reliability\u003c/b\u003e: A third coder (CLP), trained in the codebook, independently coded two transcripts.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eResults Synthesis\u003c/b\u003e: Aggregation of coded excerpts into thematic narratives under each main category.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003eThis analysis focused on patients\u0026rsquo; expectations, coping strategies, perceived effects (physical, psychological, sensory), social challenges, and motivations for maintaining reduced sugar intake. Main hypothesis comprised that a four-week sugar abstinence would improve physical and mental well-being. The secondary hypothesis assumed a decrease in sugar cravings and an increase in motivation to quit sugar long-term. Additionally, the study aimed to generate practical insights and hypotheses for future research.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eBetween August 2022 and January 2023, semi-structured telephone interviews averaged 45 minutes (range 30\u0026ndash;60) were conducted 3\u0026ndash;8 months post-intervention to allow reflection yet minimize recall bias. Cohen\u0026rsquo;s κ coefficients ranged from 0.68\u0026ndash;0.82 across subcategories, indicating good reliability between the two coders (CB, CLP) [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Of 11 patients randomized to the sugar avoidance group, eight completed both the intervention and subsequent interview. Two were unreachable for interview scheduling, and one was excluded after reporting negligible pre-intervention sugar intake. The final sample comprised five women and three men.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eOverview of the Category System\u003c/h2\u003e\u003cp\u003eBased on the interview transcripts, five main categories with 26 subcategories were evaluated and are illustrative presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. All subcategories are presented in Supplementary file S2.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eMain categories and example subcategories\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMain Category\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eExample Subcategories\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1. Pre-intervention sugar consumption patterns\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHabitual sources; quantity estimates; emotional triggers\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2. Expectations toward sugar avoidance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAnticipated benefits; fear of withdrawal\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3. Intervention adherence \u0026amp; coping strategies\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePlanning/substitution; social negotiation\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4. Evaluation of sugar avoidance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePositive and negative physical and psychological effects\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5. Post-intervention states\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMotivation to maintain; changed dietary habits\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003ePre-Intervention Sugar Consumption\u003c/h3\u003e\n\u003cp\u003eAsking regarding the sugar consumption before the intervention, all patients reported daily consumption of free sugars. Most common sources included sweetened hot drinks, desserts, confectionery, and sugar-sweetened beverages. Emotional contexts (e.g., \u0026ldquo;stress snacking\u0026rdquo;, as a \u0026bdquo;treatment\u0026ldquo;) and social settings (\u0026ldquo;afternoon cake with colleagues\u0026rdquo;) were the most prominent triggers:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003ePatient #22: \u0026ldquo;\u003cem\u003eIn the evening after dinner that (sugar consumption) was pure reward for me. Super! Well done! Great day! It was in the afternoon from 3PM and then in the evening after dinner\u0026rdquo; (Interview 22, page 4).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003eExpectations Toward Sugar Avoidance\u003c/h3\u003e\n\u003cp\u003eMost expected health improvements were reduced gingival inflammation, blood sugar reduction, weight loss and enhanced energy. Three participants hoped that the intervention could improve the results of periodontal therapy. Negative expectations encompassed anxiety regarding potential withdrawal symptoms or cravings.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003ePatient #10: \u0026ldquo;I naturally hoped that it would improve my gums. I also hoped that it would somehow be noticeable physically\u0026mdash;maybe a little weight loss, although I didn\u0026rsquo;t really expect to lose much weight through it. It wasn\u0026rsquo;t really necessary, that wasn\u0026rsquo;t why I did it. But I hoped it would also show in the values that were taken.\u0026rdquo; (Interview 10.2, page 3)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eIntervention Adherence \u0026amp; Coping Strategies\u003c/h2\u003e\u003cp\u003eRegarding the experiences during the intervention, all participants reported detailed meal planning (e.g., batch-cooking sugar-free recipes) and substitution of sugar with fruit, artificial sweeteners and a higher consumption of whole grain products. Strategies to cope with cravings included talking with other participants of the study, using sugar-free or sugar-reduced alternatives and explaining the intervention to family and friends helped garner support. Some brought their own sugar-free alternatives to social events. Others experienced peer pressure and exclusion especially in not at home settings:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003ePatient 22 \u0026ldquo;Then comes the problem that you are a little socially incompetent because you cannot eat everything that the others eat\u0026rdquo; (Interview 22, page 1).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThere were differences in how patients evaluated sugary foods, the maximum acceptable total sugar content during the intervention, and the inclusion or exclusion of wheat products:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003ePatient #02: \u0026ldquo;To find something without sugar and without wheat was very difficult. I will never forget: I was once in a restaurant and then they made me something and well I left hungry again.\u0026rdquo; (Interview 02, page 1)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003ePatient #06: \u0026ldquo;I actually exclusively paid attention to this sugar information in the nutrition table\u0026rdquo; (Interview 06, page 3).\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003ePatient #06: \u0026ldquo;I had I think set myself a limit: less than uh I don\u0026rsquo;t know exactly anymore, I think less than 0.5 grams of sugar\u0026rdquo; (Interview 06.2, page 5).\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003ePatient #15: \u0026ldquo;I don\u0026rsquo;t have sugar at home that I mix into things but you naturally have some fructose like dried fruit, where you do look at how much sugar it contains. Or other products like whole grain products, where you look at how high the sugar content is, yes. And if it was too high, I left it there. That\u0026rsquo;s what I did during that time.\u0026rdquo; (Interview 15.2, page 5)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eEvaluation of Sugar Avoidance\u003c/h2\u003e\u003cp\u003eOverall, positive evaluations were made more frequently than negative ones (134 text segments vs. 75 segments). Participants rated the difficulty of the dietary change between 0 and 8 (0\u0026thinsp;=\u0026thinsp;very easy, 10\u0026thinsp;=\u0026thinsp;very difficult), with an average score of 3 (range 0\u0026ndash;8), especially regarding the sugar avoidance in the home settings. Patients with previously high sugar consumption were more likely to use substitutes like dates - especially when daily routines or traditions were present.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003ePhysical and Psychological Effects\u003c/h2\u003e\u003cp\u003eSeven of eight participants reported positive physical and psychological effects during the intervention. Most reported transient energy dips and mood fluctuations (irritability, low mood, cravings) in the first week, followed by stable or improved energy levels. Three participants positively noted modest weight loss (1\u0026ndash;2 kg). Successful adherence boosted confidence and self-efficacy. Most participants described pride in overcoming challenges. The heightened awareness of food choices extended beyond sugar, leading to more balanced meals (\u0026bdquo;to try out new things\u0026ldquo;).\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003ePatient #10: \u0026ldquo;I felt really good. I had the feeling that the dietary change was good for me.\u0026rdquo; (Interview 10, page 1).\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003ePatient #15: \u0026ldquo;I really have to say I was clearly fitter, more awake. My joints - so I\u0026rsquo;m actually a healthy person - but somehow I really had the feeling with my hands. They felt so much clearer not that they are stiff but still I somehow noticed that I physically simply felt more oily\u0026rdquo; (Interview 15, page 1).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003ePost-Intervention States\u003c/h2\u003e\u003cp\u003eAll patients reported lasting reductions in sugar consumption, incorporation of sugar-free recipes, sustained label reading and a greater awareness of healthier products:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003ePatient #22: \u0026ldquo;What I found even harder is that I discovered how extreme it is. How much sugar there is in every food that they give us. Which I had not noticed before and how hard it is to give up sugar.\u0026rdquo; (Interview 22, page 2).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eOther positive behavioral changes included increased consumption of whole grains, fruits, and vegetables. Four patients described sugar as addictive or dependency-forming as a result of the intervention and reported from remained sensitivity to sweetness. Challenges primarily included social events, holidays, and an unprepared work environment. The food industry, product labeling, and lack of public education were viewed critically, and sugar taxes were proposed. On a 0\u0026ndash;10 scale, mean motivation to continue reduced sugar intake was 6,4 (range 3\u0026ndash;10).\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003ePatient #22: \u0026ldquo;You are somehow displayed alone right? And if I do not want sugar then I must avoid 80 percent of the things that are in the supermarket.\u0026rdquo; (Interview 22, page 06).\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003ePatient #06: \u0026ldquo;Well difficult for me were all the things you normally eat like ready-made salads or sausage or so where there are hidden sugars. Where you don\u0026rsquo;t expect that sugar is in them. And that was difficult for me because it was just unusual. You don\u0026rsquo;t expect that sugar is in there and you first have to become aware of that.\u0026rdquo; (Interview 06, page 1).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eEvaluation of the Counselling\u003c/h2\u003e\u003cp\u003eFive patients evaluated the dietary counseling prior to the intervention positively. Two participants criticized it or noted insufficient information. Patients most commonly suggested providing an additional written list of permitted and prohibited foods to improve the intervention. Group-based implementation was also proposed as a potential enhancement. Additionally, two participants expressed a general wish for dietary counseling in dental practices, with one emphasizing its importance for children and adolescents.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003ePatient #10: \u0026ldquo;And do you see a need for action among doctors and dentists?\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eYes, I think so. I think many already do that, but more would be good, especially for children and young people.\u0026rdquo; (Interview 10.2, page 6).\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003ePatient #02: \u0026ldquo;So I think it would really help me, and I believe it would motivate other people too, if there was concise information available that was easy to read and came from the dental clinic or somewhere like that.\u0026rdquo; (Interview 02.2, page 8).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis post intervention evaluation could demonstrate that a single personalized dietary counselling prior to step 1 and 2 periodontal therapy could lead to behavioral dietary and psychological changes which persisted 3\u0026ndash;8 months until the interview.\u003c/p\u003e\u003cp\u003eFour of eight participants described sugar as addictive following the intervention. This perception aligns with existing research, including multiple animal studies, which suggest that sugar can trigger addiction-like responses [\u003cspan additionalcitationids=\"CR27 CR28\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Further research is needed to be able to classify sugar correctly also in humans. Within the framework of health/addiction psychology, the Transtheoretical Model of Behavior Change [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] describes six stages of change. All participants reached at least the \u0026ldquo;contemplation\u0026rdquo; phase, in which people start to recognize their problematic behavior and develop the intention to change it at some point. Even if some participants relapsed into sugar consumption, they became more aware of its disadvantages and developed a long-term motivation to change. The results show both internal and external conflicts: participants struggled not only with changing their own sugar habits but also with the food environment\u0026mdash;specifically poor labeling and limited sugar-free options. They criticized the lack of clear information on added sugars and called for transparent front-of-pack labeling that differentiates between naturally occurring and industrial sugars. Currently, sugar content is hidden behind various terms (e.g., sucrose, fructose, syrup), making it difficult for consumers to recognize. A study by Z\u0026uuml;hlsdorf et al. [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] showed that although many consumers are critical of sugar, they misunderstand ingredient lists and overestimate the health value of products with claims like \u0026ldquo;no added sugar\u0026rdquo;. This implicates the need for better counselling, potentially in dental settings. Participants also suggested introducing a sugar tax and restricting food marketing aimed at children and adolescents. Over 50 countries worldwide have implemented sugar taxes, with studies showing reduced sugar consumption and product reformulation [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Patients reported from enhanced sweetness perception after sugar reduction which may have served as an intrinsic reinforcement for reduced sugar intake. This sensory shift, reported by participants and documented experimentally [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], could be harnessed in dietary counselling to motivate sustained abstinence.\u003c/p\u003e\u003cp\u003eBased on the patients\u0026acute; feedback, addressing the habitual nature of sugar consumption is essential for successfully implementing an anti-inflammatory, low-sugar diet in periodontal therapy. Motivational Interviewing (MI) \u0026mdash;a communication method aimed at enhancing intrinsic motivation\u0026mdash;can support behavioral change and encourage patients to reflect on their eating habits [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Rubak et al. [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e] found it more effective than traditional counseling in treating various behavioral issues. Participants employed evidence-based coping strategies like meal planning, substitution, self-monitoring\u0026mdash;that align with behavior change techniques [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. The findings suggest that individualized action plans (e.g., \"if I crave something sweet after dinner, I will eat dates\") can help bridge the gap between intention and behavior, making health-promoting habits more sustainable, as it was also seen in other dental settings[\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Self-efficacy emerged as a central facilitator: successful management of cravings increased confidence to sustain change. Social support, both in private and professional contexts, mitigated environmental challenges. Based on this, MI might be a helpful tool in supporting patient\u0026acute;s health behavior changes in periodontal therapy [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe EFP S3 guideline for periodontitis therapy recommends risk factor management in the beginning of periodontal therapy addressing lifestyle factors such as smoking and blood sugar control, but direct evidence is scarce for dietary interventions [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Especially in Germany, the initial step of therapy has gained more attention through preventive counselling or \u0026ldquo;speaking dentistry\u0026rdquo; focused on discussing risk factors during periodontal treatment, as it is now covered by public health insurance [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. However, most dental clinicians lack training in nutritional counselling. From the present cohort, just one of eight participants received nutritional counselling prior the intervention from a dentist. The presented findings underscore the acceptability and feasibility of a single, focused counselling session prior step two of periodontal therapy. Similar findings regarding sustained improvements in general health following dietary coaching have been demonstrated elsewhere [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e].\u003c/p\u003e\u003cp\u003ePeriodontal outcomes were improved in the initial trial [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], with a greater reduction in bleeding on probing in the sugar avoidance group compared to the control group with continued sugar consumption. Qualitative experiences elucidated here suggest that dietary modifications were well tolerated and conferred psychosocial benefits, potentially reinforcing periodontal maintenance behaviors. Extracted from this investigation, exchanging ideas in group sessions, conducting follow-up during the intervention, and providing additional information would strengthen motivation and could help enhance long-term adherence. Dental professionals should be equipped to deliver brief nutritional interventions or refer to dietetic services, integrating oral and systemic health promotion.\u003c/p\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eStrengths and Limitations\u003c/h2\u003e\u003cp\u003eMethodological strengths of this investigation include application of a rigorous, theory-guided qualitative analysis [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], triangulation of coders with good intercoder reliability, and rich contextual descriptions enhancing transferability. Additionally, the intervention was accompanied by CGM sensors, though CGM data were withheld, the sensing device itself may have served as a behavioral cue, enhancing adherence [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Limitations encompass a small, motivated sample, potential recall bias due to retrospective interviews, and lack of a comparison group without sugar abstinence. The 3\u0026ndash;8 month interval between intervention and interview may have attenuated recall of early withdrawal experiences. Follow-up counseling during the intervention could have addressed these unresolved questions regarding sugar consumption. Future interventions could leverage peer support groups or digital platforms to bolster motivation and adherence. Further mixed-methods designs, combining longitudinal qualitative follow-up with quantitative measures of periodontal parameters, inflammatory biomarkers, and glycemic control should be employed. Larger, more diverse cohorts would assess transferability. Economic evaluations could determine cost-effectiveness of integrating dietary counselling into periodontal care pathways based on the immense costs of a sugary diet [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Based on the qualitative character of this study, only impulses for further quantitative research can be derived.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eA structured four-week sugar avoidance adjunctive to non-surgical periodontitis therapy was perceived by patients as challenging initially but ultimately beneficial for physical, psychological, and sensory well-being. Embedding dietary counselling within periodontal practice can enhance patient engagement and may synergistically improve clinical outcomes. Future studies should refine intervention delivery, explore long-term adherence, and quantify periodontal and systemic health benefits.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eBOP\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Bleeding On Probing\u003c/p\u003e\n\u003cp\u003eCB\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Carla Bickmann\u003c/p\u003e\n\u003cp\u003eCGM\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Continuous Glucose Monitoring\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCLP\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Christina Laetitia Pappe\u003c/p\u003e\n\u003cp\u003eGAT2\u0026nbsp; \u0026nbsp; \u0026nbsp;Conversation Analytic Transcription System 2\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDEGS\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;German Health Interview and Examination Survey for Adults\u003c/p\u003e\n\u003cp\u003eEFP\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;European Federation Of Periodontology\u003c/p\u003e\n\u003cp\u003eHba1c\u0026nbsp; \u0026nbsp;\u0026nbsp;Glycated hemoglobin\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eJPW\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Johan Peter Woelber\u003c/p\u003e\n\u003cp\u003eNCCD\u0026nbsp; \u0026nbsp; \u0026nbsp;Non-Communicable Chronic Disease\u003c/p\u003e\n\u003cp\u003ePISA\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Periodontal Inflamed Surface Area in mm2\u003c/p\u003e\n\u003cp\u003eWHO \u0026nbsp; \u0026nbsp; \u0026nbsp;World Health Organization\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the ethics committee of the Charité \u0026nbsp;– Universitätsmedizin Berlin (Charitéplatz 1, 10117 Berlin, Deutschland). Committee’s reference number: EA1/162/21. The study adhered to the CONSORT reporting guidelines and followed the Declaration of Helsinki (1975, 2013). Detailed information on the study methods is provided in the original publication. The participants received written and verbal information about the study: the rationale and aim, as well as the design and procedure. Participants were also informed that they were free to withdraw without having to specify the reason and that confidentiality and anonymity in presentation were guaranteed. All participants signed the informed consent form.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCLP drafted the initial manuscript. CLP and JPW conceptualized the study and design, as well as analyzed and interpreted the data. CB collected and analyzed the data. AA and HD critically revised the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' information (optional)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank all study participants and acknowledge funding support from the Charité, Department of Periodontology, Oral Medicine and Oral Surgery.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003ePapapanou PN, Sanz M, Buduneli N, Dietrich T, Feres M, Fine DH, et al. Periodontitis: Consensus report of workgroup 2 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions. 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PLoS ONE. 2015;10:e0135990. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1371/journal.pone.0135990\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0135990\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"periodontitis, periodontal therapy, sugar, qualitative research, nutritional intervention","lastPublishedDoi":"10.21203/rs.3.rs-7779168/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7779168/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground and Aim:\u003c/h2\u003e\u003cp\u003eExcessive sugar intake is a central cause for caries and is associated with gingival inflammation and periodontitis. Although dietary changes have demonstrated clinical benefits, little is known about the practicability and patient perspective on sugar avoidance. Aim of this qualitative study was to explore experiences of patients who undertook a four-week sugar avoidance as an adjunct to non-surgical periodontal therapy (Step 1\u0026ndash;2).\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e\u003cp\u003ePatients of the experimental group from a randomized controlled trial were interviewed using semi-structured phone interviews. Interviews were analyzed software-based using structured qualitative content analysis per Kuckartz and R\u0026auml;diker\u0026rsquo;s framework. Categories were generated inductively and deductively with an intercoder reliability of \u0026gt;\u0026thinsp;0.8.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e\u003cp\u003eFrom ten patients of the experimental group (sugar-avoidance group), eight patient interviews could be analyzed. The qualitative analysis showed that three patients experienced initial withdrawal (e.g., headaches, cravings). Seven patients reported improved well-being, increased dietary awareness, and sustained reduction in sugar consumption. Challenges of sugar avoidance included social pressure, emotional dependency on sweets, and lack of governmental support.\u003c/p\u003e\u003ch2\u003eConclusions:\u003c/h2\u003e\u003cp\u003eA structured four-week sugar avoidance adjunctive to non-surgical periodontitis therapy was perceived by patients as challenging initially but ultimately beneficial for physical, psychological, and sensory well-being. Patient-centered nutritional counseling should consider possible withdrawal symptoms and social challenges when addressing sugar avoidance.\u003c/p\u003e\u003ch2\u003eTrial registration:\u003c/h2\u003e\u003cp\u003eDRKS00026699, Date of registration: 14.10.2021\u003c/p\u003e","manuscriptTitle":"Patient Experiences of a Four-Week Sugar Avoidance During Periodontal Therapy: A Qualitative Analysis of a randomized controlled clinical trial","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-10 16:36:26","doi":"10.21203/rs.3.rs-7779168/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-11-24T07:16:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"192696686262180277947129240621715076624","date":"2025-11-13T21:15:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"334921380458310247156740917572392592465","date":"2025-11-13T10:28:28+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-30T12:47:20+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-10-16T07:50:22+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-15T13:03:31+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-15T12:01:29+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Oral Health","date":"2025-10-15T11:57:56+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ed844527-b406-4f41-a948-f56994a8767d","owner":[],"postedDate":"November 10th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-11-10T16:36:26+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-10 16:36:26","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7779168","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7779168","identity":"rs-7779168","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}