A dynamic relation exists between sugars and oral health.
Diet affects the integrity of the teeth; quantity, pH, and
composition of the saliva; and plaque pH. Sugars and other
fermentable carbohydrates, after being hydrolyzed by
salivary amylase, provide substrate for the actions of oral
bacteria, which in turn lower plaque and salivary pH. The
resultant action is the beginning of tooth demineralization.
The deciduous teeth erupt from 6 months and are lost by the
early teens. The permanent dentition replaces the deciduous
dentition from the age of 6 years and is complete by age 21.
Teeth are most susceptible to dental caries soon after they erupt;
therefore, the peak ages for dental caries are 2–5 years for the
deciduous dentition and early adolescence for the permanent
dentition. In developed countries, there is a trend for older adults
now to retain their teeth for longer, however, if the gums recede
with age the roots of the teeth become exposed, and, being
relatively less mineralized than the tooth crowns, are susceptible
to decay known as ‘root caries’
The patient's diet and dental caries activity are related. From the
dietic viewpoint, dental caries is widely accepted as being
caused by the injestion of fermentable carbohydrates,
particularly Sucrose, fermentable carbohydrates and more
specifically sucrose are rarely eaten as such. They are eaten as
components of foods that contain other ingredients and have
different textures. the cariogenic potential of foods containing
sucrose depends on many variables such as the ability to
1. Be Retained by teeth
2. Form acids
3. Dissolve enamel
4. Neutralize or buffer acids.
Certain characteristics of sucrose-containing foods or conditions
surroundings their consumption are more important in terms of cariogenicity
than the amount of sugar they contain. Thus, Solid and retentive sucrose-
containing foods are more cariogenic than sugar-containing foods that are
liquid and non-retentive the frequency and the time of ingestion of foods are
also important. the sucrose-containing food becomes more dangerous if it is
eaten more frequently. food eaten at meals produces less caries than the same
eaten in between meals.
In decreasing order of cariogenicity, the food are grouped as:
-- Adherent, Sucrose-containing foods eaten frequently between meals.
-- Adherent, Sucrose-containing foods eaten during meals.
-- Non-retentive (liquid) Sucrose-containing beverages consumed frequently
-- Non-retentive (liquid) Sucrose-containing foods consumed during meals.
1. the form of food or fluid
2. the duration of exposure
3. nutrient composition
4. sequence of eating
5. salivary flow
6. presence of buffers
7. and oral hygiene.
Dental caries was first described in Miller’s chemo parasitic
theory in 1890. Caries is caused by the dissolution of the
teeth by acid produced by the metabolism of dietary
carbohydrates by oral bacteria. The 2 primary bacteria
involved in caries formation are mutans streptococci and
lactobacilli. In the 1960s the caries theory was depicted as 3
circles representing the3 prerequisites for dental caries: the
tooth, the diet, and dental plaque
Mechanisms proposed to explain the anticariogenic effects of
cheeses are as follows:
1-increased salivary flow and the
Subsequent buffering effect,
which can neutralize plaque acids
2-inhibition of plaque bacteria and the effect of that
inhibition on reducing the amount of bacteria, thereby
reducing acid production; and
3-intake of increased alkaline substances, calcium, inorganic
phosphate, and casein, which decrease demineralization and
When we say “sugar”, we usually mean granulated Table sugar.
However there are so many kinds of sugars these days, we need to be
very clear the word “sugar” includes these things ending in “ose”:
1. Sucrose (Table sugar) a simple sugar made from cane sugar or
2. Fructose, a simple sugar in fruits, plants and honey.
3. Maltose, a complex sugar in barley and malt syrups.
4. Lactose, a complex sugar in milk.
5. Dextrose, a refined simple sugar from corn, sugar cane or beets.
6. Glucose, a simple sugar in fruits, vegetables and grains.
The recommended intake of non-milk extrinsic sugars is a
maximum of 60g/day, which is about 10% of daily energy
1. reduces and inhibits demineralization.
2. Re-mineralization of enamel .
3. affects plaque :by inhibiting bacterial metabolism
of sugar thus reducing acid production.
1. types of carbohydrate
2. physical form of food retention and oral clearance time
3. factor in the diet that protect against dental caries
4. intake frequency
5. nature of diet
CLASSIFICATION OF SUGARS FOR DENTAL HEALTH
Forms of sugars and starch in the diet
1. Sugars are a form of fermentable carbohydrate.
Fermentable carbohydrates are carbohydrates (sugar
sand starch) that begin digestion in the oral cavity via
salivary amylase. Sugars enter the
2. diet in 2 forms: those found naturally in foods (e.g.,fruit,
honey, and dairy products) and those that are added to
foods during processing to alter the flavour, taste, or
texture of the food
Prolonged oral retention of cariogenic components of food
may lead to extended periods of acid production and
demineralization and to shortened periods of re-
mineralization. Retentiveness of foods is not the same as
stickiness. A caramel or jellybean may be sticky, but its
retentive properties are fairly low and they are cleared from
the oral cavity faster than are retentive foods such as cookies
or chips .
1. metabolism by microorganisms
2. adsorption onto oral surfaces
3. degradation by plaque and salivary enzymes
4. saliva flow, and
5. swallowing. Most carbohydrates will be cleared by these
The frequency of consumption seems to be a significant
contributor to the cariogenicity of the diet, although Bowen
et al (10) concluded that it is not the frequency of ingestion
per sec that is related to the development of caries but the
time that sugars are available to microorganisms in the
mouth caries is regarded as the outcome of the alternation of
demineralization and re-mineralization. Higher frequency
means more demineralization and less re-mineralization.
The duration of the decrease in pH after intake of a
cariogenic food is an importan tconfounder in this relation
Polyphenols such as tannins in cocoa, coffee, tea, and many fruit juices
may reduce the cariogenic potential of foods. In vitro experiments have
shown that these polyphenolic compounds may interfere with
glucosyltransferase activity of mutans streptococci, which may reduce
plaq.ue formation. In rat experiments, tea polyphenols .
Sugar alcohol–based products Sugar-free gums can stimulate
saliva, increasing the clearance of sugars and other
fermentable carbohydrates from the teeth and the oral cavity
and increasing buffer capacity. Tooth-friendly polyols include
sorbitol, xylitol, mannitol, erythritol, and isomalt. However,
xylitol carbon sugar that oral microflora cannot metabolize—
has additional anti cariogenic effect sattributable to
antimicrobial action, stimulation of saliva resulting in
increased buffer activity and an increase in pH, and enhanced
re-mineralization .Sorbitol-sweetened gums simulate saliva
without causing a drop to the critical pH and have been shown
to be equal to xylitol gum in terms of caries control
Tooth erosion is the progressive loss of dental hard tissue by
acids in a process that does not involve bacteria or sugars. The
intrinsic acids are from vomiting, gastroesophageal reflux, and
regurgitation. Thee xtrinsic acids are from the diet [e.g. sports
beverages and citrus products, including citrus fruit, juices, soft
drinks, and citrus-flavored candies and lozenges]or from the
occupational environment (e.g.,battery and galvanizing
factories). Tooth erosion as a result of eating disorders (bulimia
nervosa) and dietary practices involving frequent intake of acidic
foods and beverages can weaken tooth integrity.
1. Infants and toddlers with prolonged breast-feeding on demand Infants and
toddlers provided with a feeding bottle at bed time, or bottle suspended in
the cot for use during the night, with sugar containing liquid
2. People with increased frequency of eating because of a medical problem,
e.g., gastrointestinal disease, eating disorders, uncontrolled diabetes.
3. Those with an increased carbohydrate intake due to a medical problem e.g.,
Crohn’s disease, chronic renal failure, or other chronic illness, malnutrition
or failure to thrive.
4. Those with reduced salivary secretion. Sjogren’s syndrome, irradiation in the
region of the salivary glands.
5. Athletes taking sugar-containing sport supplement
6. Workers subject to occupational hazards such as
food sampling and those on a monotonous job such
as a nightshift.
7. Drug abusers who have a craving for sugar and a
prolonged clearance rate as a result of reduced
8. People of any age, on long term and/or multiple
medications. Are these sugar-based and/or do they
cause a dry mouth?
9. Any sugary bedtime snacks or drinks.
1. eat a balanced diet rich in whole grains, fruit, and
vegetables and practice good oral hygiene—particularly
the use of fluoridated toothpastes—to maximize oral and
systemic health and reduce caries risk.
2. eat a combination of foods to reduce the risk of caries and
erosion; include dairy products with fermentable
carbohydrates and other sugars and consume these food
swith, instead of, between meals; add raw fruit or
vegetables to meals to increase salivary flow; drink
sweetened and acidic beverages with meals, including
foods that can buffer the acid ogenic effects
4. chew sugarless gum between meals and snacks to
increase salivary flow.
5. rinse mouth with water, chew sugarless gum (particularly
those containing sugar alcohols, which stimulates re-
mineralization), and eat dairy product such as cheese
after the consumption of fermentable carbohydrates.
6. drink, rather than sip, sweetened and acidic beverages.
7. moderate eating frequency to reduce repeated exposure
to sugars, other fermentable carbohydrates, and acids.
8. avoid putting an infant or child to bed with a bottle of
milk, juice, or other sugar-containing beverage.
1. Bread (sandwiches, toast, crumpets, pitta bread).
2. Pasta, rice, starchy staple foods
4. Fibrous foods (e.g. raw vegetables)
5. Low sugar breakfast cereals (e.g. shredded wheat)
6. Fresh fruit (whole and not juices)
7. Peanuts (not for children under 5 years)
8. Sugar-free chewing gum
9. Sugar-free confectionery
10. Water, Milk, Sugar-free drinks, Tea and coffee (unsweetened)