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  • Saliva provides protection against caries in several ways. First, it acts as a buffer by neutralizing much of the acids produced by plaque biofilm as a result of carbohydrate metabolism. Second, normal saliva contains bicarbonate, phosphate, and protein that dilute and neutralize acids to maintain oral pH. A neutral pH is around 7. Therefore, after an acidic drink is consumed, the pH of the oral cavity is rapidly normalized by the components of saliva. However, if the frequency or duration of the acidic drink is extended, it becomes more difficult for saliva to buffer the continuous supply of acid and no longer offers caries protection. Because saliva is saturated with calcium, phosphate, and fluoride ions, the potential for remineralization (restoration of damaged enamel) and resistance to enamel dissolution exists. Finally, antimicrobial elements in saliva, such as immunoglobulin IgA, either interfere with adherence of bacteria or compete with bacteria to attach to the tooth surface. An alkaline saliva offers protection, whereas an acidic saliva increases susceptibility to caries.
  • The pH of diet and regular soft drinks, bottled iced teas, and sports drinks ranges from 2.5 to 3.5.

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  • 1. NUTRITIONAL ASPECTS OFNUTRITIONAL ASPECTS OF DENTAL CARIES: CAUSES,DENTAL CARIES: CAUSES, PREVENTION, AND TREATMENTPREVENTION, AND TREATMENT CHAPTER 17CHAPTER 17 Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
  • 2. 2Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. PrevalencePrevalence Nutrients have topical and systemic effects thatNutrients have topical and systemic effects that can be primary or secondary factors in thecan be primary or secondary factors in the development of dental cariesdevelopment of dental caries National Call to Action to Promote Oral HealthNational Call to Action to Promote Oral Health stresses preventionstresses prevention Dental caries remain the most common chronicDental caries remain the most common chronic childhood diseasechildhood disease Certain racial, ethnic, and lower-income populationsCertain racial, ethnic, and lower-income populations suffer disproportionately higher rates of cariessuffer disproportionately higher rates of caries
  • 3. 3Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. PrevalencePrevalence Caries rates rise with ageCaries rates rise with age 28% of children ages 2–5 years28% of children ages 2–5 years 49% of children ages 6–11 years49% of children ages 6–11 years 68% of adolescents 12–19 years68% of adolescents 12–19 years 75% of adults75% of adults Prevalence of root caries also rises with agePrevalence of root caries also rises with age 9.4% among persons ages 20–39 years9.4% among persons ages 20–39 years 17.8% among those ages 40–59 years17.8% among those ages 40–59 years 31.6% among those ages31.6% among those ages >>60 years60 years From Bird DL, Robinson DS: Torres and EhlrlichFrom Bird DL, Robinson DS: Torres and Ehlrlich Modern Dental Assisting, ed 9. St. Louis: Saunders,Modern Dental Assisting, ed 9. St. Louis: Saunders, 2009.2009.
  • 4. 4Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. Major Factors in the Dental CariesMajor Factors in the Dental Caries ProcessProcess Caries results from a combinationCaries results from a combination of factorsof factors Susceptible host or tooth surfaceSusceptible host or tooth surface Sufficient quantity of cariogenicSufficient quantity of cariogenic microorganisms in the mouthmicroorganisms in the mouth Presence of fermentablePresence of fermentable carbohydratescarbohydrates Particular composition or flow ofParticular composition or flow of salivasaliva From Darby ML, Walsh MM: Dental Hygiene:From Darby ML, Walsh MM: Dental Hygiene: Theory and Practice, ed 2. St. Louis: Saunders,Theory and Practice, ed 2. St. Louis: Saunders, 2003.2003.
  • 5. 5Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. Major Factors in the Dental CariesMajor Factors in the Dental Caries ProcessProcess Tooth structureTooth structure Resistance againstResistance against demineralization beginsdemineralization begins in pre-eruptive phasein pre-eruptive phase with adequate intakeswith adequate intakes of calcium;of calcium; phosphorus; vitaminsphosphorus; vitamins A, C, and D; fluoride;A, C, and D; fluoride; and proteinand protein Deep pits and fissuresDeep pits and fissures increase susceptibilityincrease susceptibility Host factorsHost factors Food selection andFood selection and dietary patternsdietary patterns Oral hygiene habitsOral hygiene habits GeneticsGenetics Race or ethnic groupRace or ethnic group AgeAge SES (socioeconomicSES (socioeconomic status)status)
  • 6. 6Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. Major Factors in the Dental CariesMajor Factors in the Dental Caries ProcessProcessSalivaSaliva Availability of essentialAvailability of essential nutrients duringnutrients during development of salivarydevelopment of salivary glandsglands Protection provided byProtection provided by adequate salivary flowadequate salivary flow and saliva’s bufferingand saliva’s buffering capacitycapacity Plaque biofilmPlaque biofilm Composition of plaque isComposition of plaque is altered and stronglyaltered and strongly influenced by dietinfluenced by diet By-products of sucroseBy-products of sucrose and glucose metabolismand glucose metabolism produce acids; lowers pHproduce acids; lowers pH to create environment forto create environment for growth of bacteria, suchgrowth of bacteria, such asas S. mutansS. mutans From Fehrenbach MJ, Herring SW: Illustrated AnatomyFrom Fehrenbach MJ, Herring SW: Illustrated Anatomy of the Head and Neck, ed 3. St. Louis: Saunders, 2007.of the Head and Neck, ed 3. St. Louis: Saunders, 2007.
  • 7. 7Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. Major Factors in the Dental CariesMajor Factors in the Dental Caries ProcessProcess Cariogenic foodsCariogenic foods Salivary amylase breaks down oral mono- andSalivary amylase breaks down oral mono- and disaccharidesdisaccharides Sucrose is used to produce glucans that facilitateSucrose is used to produce glucans that facilitate adherence of bacteria (adherence of bacteria (S. mutans)S. mutans) to the dentalto the dental pelliclepellicle Processed starches (instant oatmeal) are often moreProcessed starches (instant oatmeal) are often more fermentable than their nonprocessed counterparts duefermentable than their nonprocessed counterparts due to partial hydrolysis or diminution of particle sizeto partial hydrolysis or diminution of particle size High concentration of fructose found in juices isHigh concentration of fructose found in juices is potential source of substratepotential source of substrate
  • 8. 8Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. Major Factors in the Dental CariesMajor Factors in the Dental Caries ProcessProcess Anticariogenic properties of foodAnticariogenic properties of food Sugar alcoholsSugar alcohols  Fermented more slowly than mono- and disaccharides;Fermented more slowly than mono- and disaccharides; therefore, buffering effects of saliva neutralize destructive acidstherefore, buffering effects of saliva neutralize destructive acids produced by plaque biofilmproduced by plaque biofilm  Oral flora do not contain enzymes to ferment xylitolOral flora do not contain enzymes to ferment xylitol  Microorganisms, such as S. mutans, are inhibited Nonnutritive sweetenersNonnutritive sweeteners  Not metabolized by microorganisms; do not promote cariesNot metabolized by microorganisms; do not promote caries
  • 9. 9Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. Major Factors in the Dental CariesMajor Factors in the Dental Caries ProcessProcess Protein and fatProtein and fat  Considered cariostatic because do not lowerConsidered cariostatic because do not lower plaque pHplaque pH Phosphorus and calciumPhosphorus and calcium  Provide a buffering effect in the salivaProvide a buffering effect in the saliva Dairy productsDairy products  Protein,Protein, caseincasein (principal protein in milk), phosphorus,(principal protein in milk), phosphorus, calcium are ingredients of anticariogenic or evencalcium are ingredients of anticariogenic or even cariostatic foods, such as cheese and milkcariostatic foods, such as cheese and milk  Although lactose is cariogenic (but the least cariogenic ofAlthough lactose is cariogenic (but the least cariogenic of all saccharides), these other elements in milk and milkall saccharides), these other elements in milk and milk products decrease risk of dental cariesproducts decrease risk of dental caries
  • 10. 10Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. Major Factors in the Dental CariesMajor Factors in the Dental Caries ProcessProcess Other foods with protective factorsOther foods with protective factors Constituent in chocolate, known as theConstituent in chocolate, known as the cocoa factor, has shown anticariogeniccocoa factor, has shown anticariogenic properties in Vipeholm studyproperties in Vipeholm study Glycyrrhiza, the active ingredient inGlycyrrhiza, the active ingredient in licorice, also anticariogeniclicorice, also anticariogenic
  • 11. 11Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. Major Factors in the Dental CariesMajor Factors in the Dental Caries ProcessProcess Dental hygiene considerationsDental hygiene considerations Encourage meticulous oral self-care, regularEncourage meticulous oral self-care, regular preventive dental visitspreventive dental visits Promote sealants for deep pits and fissuresPromote sealants for deep pits and fissures In high-risk patients encourage use of aIn high-risk patients encourage use of a chlorhexidine, fluoride, xylitol protocolchlorhexidine, fluoride, xylitol protocol Encourage healthy eating habits with minimalEncourage healthy eating habits with minimal fermentable CHO intake between mealsfermentable CHO intake between meals Eating low-fat cheese as snack or at end of a mealEating low-fat cheese as snack or at end of a meal could provide anticariogenic effectscould provide anticariogenic effects From Bird DL, Robinson DS:From Bird DL, Robinson DS: Torres and Ehlrlich ModernTorres and Ehlrlich Modern Dental Assisting, ed 9. St. Louis:Dental Assisting, ed 9. St. Louis: Saunders, 2009.Saunders, 2009.
  • 12. 12Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. Major Factors in the Dental CariesMajor Factors in the Dental Caries ProcessProcess Dietary factorsDietary factors mustmust be modified to reduce thebe modified to reduce the risk of caries. Dietary recommendations needrisk of caries. Dietary recommendations need to address the following dietary factors:to address the following dietary factors: Frequency of eating meals and snacksFrequency of eating meals and snacks Oral retentiveness of foodsOral retentiveness of foods Sequence of food consumptionSequence of food consumption Amount of fermentable carbohydrate consumedAmount of fermentable carbohydrate consumed Sugar concentration of the food or drink itemSugar concentration of the food or drink item Physical form of the carbohydratePhysical form of the carbohydrate Proximity of eating to bedtimeProximity of eating to bedtime
  • 13. 13Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. Major Factors in the Dental CariesMajor Factors in the Dental Caries ProcessProcess Physical formPhysical form Liquids include fruit juice, soda, sportsLiquids include fruit juice, soda, sports drinks, energy drinks, liquid medicationsdrinks, energy drinks, liquid medications  An acidic medium that further demineralizesAn acidic medium that further demineralizes the tooththe tooth  Diet soft drinks contain added citric and phosphoric acidsDiet soft drinks contain added citric and phosphoric acids Retentive CHOs include bakery items, crackers,Retentive CHOs include bakery items, crackers, potato chips, pretzelspotato chips, pretzels Slowly dissolving CHOs include antacids, coughSlowly dissolving CHOs include antacids, cough drops, breath mintsdrops, breath mints
  • 14. 14Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. Major Factors in the Dental CariesMajor Factors in the Dental Caries ProcessProcess Frequency of intakeFrequency of intake Linear relationship between caries rate and numberLinear relationship between caries rate and number of meals and/or snacks consumedof meals and/or snacks consumed  Each time a food containing carbohydrates is eaten, theEach time a food containing carbohydrates is eaten, the salivary pH drops below the critical level for approximatelysalivary pH drops below the critical level for approximately 40 minutes40 minutes  Enamel demineralization occursEnamel demineralization occurs  Acid exposure is additive throughout the dayAcid exposure is additive throughout the day  Eventually demineralization progresses to the point at whichEventually demineralization progresses to the point at which decay may be detected clinicallydecay may be detected clinically  The calcium and phosphorus in saliva need time toThe calcium and phosphorus in saliva need time to remineralize the tooth between meals/snacksremineralize the tooth between meals/snacks
  • 15. 15Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. Major Factors in the Dental CariesMajor Factors in the Dental Caries ProcessProcess Timing and sequence in a mealTiming and sequence in a meal Amount of acid is reduced if a fermentableAmount of acid is reduced if a fermentable carbohydrate food is eaten before or between othercarbohydrate food is eaten before or between other noncariogenic foodsnoncariogenic foods  Dairy products, such as cheese, reduce demineralization ofDairy products, such as cheese, reduce demineralization of the tooth and help buffer acids produced by the bacteriathe tooth and help buffer acids produced by the bacteria  Sialagogues, like sugar-free chewingSialagogues, like sugar-free chewing gum, stimulate the saliva andgum, stimulate the saliva and promote buffering of acidspromote buffering of acids produced by bacteria and aidproduced by bacteria and aid in oral clearance of the foodin oral clearance of the food
  • 16. 16Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. Major Factors in the Dental CariesMajor Factors in the Dental Caries ProcessProcess Dental hygiene considerationsDental hygiene considerations Review diet history for patterns of fermentableReview diet history for patterns of fermentable carbohydrate consumption, frequency, and formcarbohydrate consumption, frequency, and form Consume fermentable carbohydrates within a meal orConsume fermentable carbohydrates within a meal or eat a noncariogenic food at the endeat a noncariogenic food at the end Noncariogenic snacks include raw fruits andNoncariogenic snacks include raw fruits and vegetables; low-fat cheese, milk, and yogurt; nuts;vegetables; low-fat cheese, milk, and yogurt; nuts; popcorn; seeds; pizza and tacospopcorn; seeds; pizza and tacos Encourage limiting of soft drinks and sports/energyEncourage limiting of soft drinks and sports/energy drinksdrinks
  • 17. 17Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. Dental Hygiene PlanDental Hygiene Plan AssessmentAssessment Gather information about the quality of the patient’s mealGather information about the quality of the patient’s meal pattern and eating habits with a 24-hour diet recall or 3-pattern and eating habits with a 24-hour diet recall or 3- to 7-day food recordto 7-day food record Use MyPyramid as a guide to assess adequacy of foodUse MyPyramid as a guide to assess adequacy of food intake with cooperation of the patientintake with cooperation of the patient Have the patient highlight all the fermentableHave the patient highlight all the fermentable carbohydrates and note form, frequency, and when eatencarbohydrates and note form, frequency, and when eaten  Estimate amount of time teeth are exposed to cariogenic foodsEstimate amount of time teeth are exposed to cariogenic foods  More than 2 hours of acid exposure generally considered highMore than 2 hours of acid exposure generally considered high
  • 18. 18Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. Dental Hygiene PlanDental Hygiene Plan GoalsGoals Help patient develop realistic goalsHelp patient develop realistic goals Goals need to be flexible to meet the patient’s needs,Goals need to be flexible to meet the patient’s needs, preferences, and lifestylepreferences, and lifestyle EducationEducation Education alone does not guarantee behavioralEducation alone does not guarantee behavioral changechange Assessment and goals are the basis for anyAssessment and goals are the basis for any recommendationsrecommendations Dispel myths, redirect inappropriate habits, andDispel myths, redirect inappropriate habits, and provide new ideasprovide new ideas