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Diet and dental caries / endodontics courses

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The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.

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Diet and dental caries / endodontics courses

  1. 1. www.indiandentalacademy.com
  2. 2. Introduction Definitions Current concepts of caries etiology Pathogenesis of caries Physical properties of foods and cariogenicity Individual components effects on DC Carbohydrates. Proteins. Fats. Vitamins. Calcium and Phosphorus. Trace elements
  3. 3. Studies providing evidence for relationship between diet in dental caries. Interventional studies Non interventional studies Special group population Assessment of cariogenic potential of food stuff Sugar substitute and alternative sweeteners Dietary screening and education in the dental practice Dietary recommendations Conclusion References
  4. 4.  Aristotle- “ why do figs, when they are soft and sweet , produce damage to the teeth?”  Miller’s – Contribution of micro flora in fermentation process and linked - diet  In 1930 : Voluminous literature .
  5. 5. Dental caries: Is a progressive irreversible microbial disease affecting the hard parts of the tooth exposed to the oral environment, characterized by demineralization of inorganic substance followed by dissolution of organic constituents leading to the formation of a cavity Is a microbial disease of the calcified tissues of the teeth characterized by demineralization of the inorganic portion & destruction of organic substance of the tooth.
  6. 6. Food: That which is taken in and absorbed for the growth and repair of organisms. Diet: Encompasses every thing that is eaten, regardless of its nutritional value and regardless of its fate in the digestive tract. Nutrition: Deals with those elements of the diet that are absorbed from the intestinal tract and enter into the metabolic processes of the body.
  7. 7. Multifactorial disease External (environmental factors) Internal (endogenous factors) Four factors HOST MICROFLORA SUBSTRATE OR DIET TIME Microorganisms Substrate Time Host & teeth
  8. 8. ENAMEL PELLICLE + BACTERIA PLAQUE FORMATION PLAQUE BACTERIA + FERMENTABLE CARBOHYDRATE ( FOOD) ACID PRODUCTION DEMINERALISATION AND DISSOLUTION OF INORGANIC AND ORGANIC STRUCTURES OF TOOTH DENTAL CARIES
  9. 9. Mechanical properties Geometric properties Others
  10. 10. Mechanical properties Cohesion: tendency of food to stick itself Adhesion: pressure applied to food – interproximal and occlusal sites : masticatory stress Adhesiveness: firm attachment between the food and the tooth surface Tackiness : ability of food to stick to the tooth when minimal force is involved
  11. 11. Effects of Carbohydrates. Effects of Proteins. Effects of fats. Effects of Vitamins. Effects of Calcium and Phosphorus. Effects of Trace elements
  12. 12. TYPES OF SUGARS AND USES CLASSIFICATION OF SUGARS SUCROSE A UNIQUE SUBSTRATE FOR CARIOGENIC FLORA FACTORS AFFECTING CARIOGENECITY OF SUCROSE IN DIET STARCHES AND DENTAL CARIES
  13. 13. Types of sugar Raw sugar , Turbinado sugar ,White granulated refined sugar, Corn syrup , Honey Sugar manufacture’s : Blended sugar. Pure invert sugar. Common invert sugar Uses of sugars : Sweetening agent Flavor blender and modifier Texture and bodying agent Dispersing/ lubricating agent.
  14. 14. Smooth surface caries- biochemical grounds depends on growth of dental plaque
  15. 15. St. Mutans - Synthesize dextrans /glucans and levans. Glucans: insoluble ,serve as structural Components of the plaque matrix- gluing certain bacteria to the tooth Levans – soluble, serve as transient reserves of fermentable carbohydrates- prolonging duration of acid production
  16. 16. Polysaccharide built: glucose units are transferred from sucrose to the active sites of enzyme- to growing chain Enzymes : Sugar 1- phosphate, nucleosidediphosphate- sugar: transfer glucose/ fructose units directly to growing polymer. Enzymes conserves: high energy( dihemiacetals) btn two C1 of glucose and C2 of fructose ( 6600Cal/ Mol)
  17. 17. Streptococcus sanguis and S.mutans: Glucosyl 1- transferases- Paque matrix material Fructosyl transferses- Organic acids. Clinical relevance Highly specific for sucrose Broad pH optimum 5.2 to 7 coinciding with pH range of dental plaque Sucrose is not required : formation of above enzymes
  18. 18. Frequency of eating Oral clearance Effective concentration of Sucrose
  19. 19. Cannot directly serve as substrate . Two varieties of Starch – Cooked Starches and Uncooked Starches. Cooked Starches Ex : Rice , Potatoes and Bread -cariogenic. Uncooked Starches – Virtually non cariogenic. Untreated Starchy foods – Lower caries promoting potential. Addition of sugars – Increases cariogenicity. Less refined Starchy foods – Protect teeth.
  20. 20. Gross protein deficiencies are rare Adding of Casein to diet – Significantly less caries susceptibility Amount and quality of protein – Important factors. Ayad et al 2000 – There is no direct evidence.
  21. 21.  Williams et al 1982 – Certain fatty acids , antimicrobial action.  Deficiency of essential fatty acids in man – rare.  Oleic and lenolic fatty acids – bactericidal activity.  Oleic acid – protection against decalcification.  Cheese – Remineralization and Neutralizes acids.
  22. 22. The mechanisms whereby fats act to reduce dental caries.  Coating of tooth surface with a oily substance.  Prevent fermentable sugar from being reduced to acids.  May interfere with the growth of cariogenic bacteria.  Increased dietary fat – Decrease the amount of dietary fermentable carbohydrate.
  23. 23. Vitamin D : Many authors have suggested the synergistic action of malnutrition and infection as the most probable causative factor (Sweeney et al 1971). Hypocalcemia a Specific Cause of Enamel Hypoplasia Recently evidence has suggested that the etiology of enamel hypoplasia is highly specific and linked with disorder of calcium homeostasis (Nikiforuk et al 1979).
  24. 24. Mellanby (1936) reported that there was a strong correlation between hypoplasia in the teeth of British School children and caries susceptibility Several other surveys have supported this conclusion (Allen, 1941, Bibby 1943, Care 1953). The prevalence of enamel hypoplasia and dental caries is higher in prematurely born children than in controls (Rosenweig et al 1962). Other Vitamins and Dental Caries Vitamin A Vitamin K (2-methyl-1,4-naphthoquinone) Burrill and associates (1945) Vitamin B complex
  25. 25.  Gustafson et al 1963 – Level of calcium in the diet is a determining factor.  Phosphate – Locally Cariostatic.  Local effect P+ is due to : Reduce the rate of dissolution Redeposit CaPo4 Buffer organic acids Desorb proteins
  26. 26. Minerals that may inhibit or promote caries : Strongly cariostatic : Fluorine , Phosphorous. Mildly cariostatic : Molybdenum, Strontium, Calcium, Boron, Lithium , Gold , Copper. Promoting elements : Selenium, Magnesium, Cadmium, Platinum, Lead, Silicon. Caries inert : Barium, Aluminium, Nickel, Iron ,Titanium. Doubtful : Beryllium, Cobalt , Manganese , Tin, Zinc, Bromine, Iodine.
  27. 27. INTERVENTIONAL STUDIES VIPEHOLM STUDY HOPEHOOD HOUSE STUDY TURKU SUGAR STUDY NON INTERVENTIONAL STUDIES EPIDEMIOLOGICAL STUDIES CROSS- SECTIONAL STUDIES OBSERVATIONAL STUDIES
  28. 28. Vipeholm study Sweden (1945- 1954): Mental institution at the Vipeholm hospital near Lund, Sweden Purpose- to determine the effects of frequency and quantity of sugar intake on the formation of caries. Conclusion : physical form of carbohydrate ( stickiness, oral clearance time, frequency of intake) much more important in carcinogenicity than the total amount .
  29. 29. Increase in caries activity due to.. Increased carbohydrate intake sugars retained on the surfaces of teeth Consumed between the meals Varies between the individual Withdrawal of sugar – caries activity rapidly disappears Prolonged retention of high concentration sugar in solution Clearance time of the sugar
  30. 30. 1942, 80 children, 7-14 yrs (10yr period) Vegetarian diet- largely raw Absence of meat and rigid restriction of refined carbohydrate Caries reduced to a minimal level by dietary means alone in spite of unfavorable hygiene and fluoride levels Dental caries prevalence in young children almost negligible in primary dentition and approx. 1/10 that seen in the permanent teeth of Australian child
  31. 31. Seventh Day Adventist dietary counsels advise limitation of use of sugar, sticky desserts, highly refined starches, and between- meal snacking Adventist children tends to be lower than that in non- Adventist children in same geographic location and socioeconomic stratum.
  32. 32. In Turku, Finland, by Scheinin, Makinen, etal Aim: To test the effects of chronic consumption of sucrose, fructose, and xylitol on dental and general health. (1972- 1974) Basis : Xylitol is a sweet substance not metabolized by plaque organisms. Investigated by comprehensive program including clinical radio graphical biochemical and micro biochemical, determinants of health
  33. 33. Caries reduction -after 2 years of xylitiol consumption: acceptable metabolite Fructose was as cariogenic as sucrose for first 12 months but became less at the end of 24 months Chewing of a xylitol gum produced an anticariogenic effect- in between meals.
  34. 34. Subjects are free to choose whatever diet they please, correlation bet caries increment and dietary factor is low. Based on dietary recall No control over amount/ frequency of sugar intake
  35. 35. Before world war II estimated sugar consumption rate 15 kg/person/ year-reduced to less than 0.2 kg/person/year Dental caries rate dropped during war time and rose when sugar restriction were lifted -England, Norway and Japan
  36. 36. Nursing bottle caries Cereal studies Hereditary fructose intolerance Industrial risk
  37. 37. Jacobi – relation between practice of feeding infants sucrose- containing beverages and milk at bedtime Lactose –responsible Added sugar or sugar dipped pacifier at bed time – (Fass) At will breast feeding – primary dentition in infants 7.2 % lactose by weight in human milk: 4.5 % in bovine milk
  38. 38. Sugar coated – highly cariogenic Eating sucrose during meal time as part of a diet does not increase dental caries -swallowed before the sweetness is extracted -increased salivation during meal time removes dissolved sugar Buffering capacity of milk proteins or high phosphate content According to Shaw…..1 ounce /day total consumption- 2 pounds/week
  39. 39. Nature provided subjects – strict dietary pattern First noticed at weaning---- (1956) AR disorder of fructose metabolism Reduced levels of fructose-1- phosphate Avoid any food that contains fructose or sucrose If ingested – nausea, vomiting, malaise, tremor, excessive, sweating, and even coma ( fuctosemia)
  40. 40. Most of the symptoms due to secondary hypoglycemia Comfortable with other foods containing glucose, galactose, and lactose Dental caries prevalence of these subjects – extremely low Highly significant differences in the proportion of Streptococcus mutans and Lactobacillus Low prevalence of caries indicates- starchy food per se do not produce decay , where as sugary foods do Observation also emphasize that plaque micro flora is directly influenced by the type of dietary sugar ingested
  41. 41. Bakeries – air polluted with sugar dust exceed 200 mg/m3 : workers consume relative large amounts of sugar----- textile industry Chocolate factory ----- employees at a shipyard Sugar cane cutters (macheteros) habitually chew raw sugar and consume large quantities of raw sugar cane juice (guarapo)---- textile workers These Habits illustrate the fact the raw sugar can be as deleterious to dental health as refined sugar
  42. 42. METHODS TO MEASURE THE CARIOGENIC POTENTIAL In vitro caries models In vivo/ In vitro caries models Adhesiveness of foods Plaque PH measurements
  43. 43. Food consumption and dietary habits – favorable and unfavorable Influence the type and proportions of specific cariogenic microorganisms found in the dental plaque Sequence of eating pattern Ideal test: should include host and micro flora as well as substrate- combination of tests
  44. 44. Currently accepting methods: pH measurements and animal testing ( control –sucrose) No cariogenic potential: do not lower plaque pH significantly Low cariogenic potential: causes less than 40% of the caries High cariogenic potential: similar to positive control group Large group fall into an intermediate category between low and high – becos of overlap of standard deviation
  45. 45. Food is mixed with an inoculum of salivary flora- amount of acid formed Adhesiveness of food Enamel demineralization Production of titratable acid an artificial mouth Limitation – Remote from the real life. Salivary flow Salivary flora is not representative of the plaque microbes
  46. 46. Two tests, ICT and IPT Intraoral Caries Test – Enamel hardness. Iodine Permeability Test – Permeability. Bovine enamel block mounted on the prosthesis – worn intraorally Limitation – Food only in solution and Patient compliance.
  47. 47. Methods – Sampling Touch electrode Built-in electrodes Sampling : plaque is removed from the teeth at intervals after ingestion of the test food limitations: plaque is disturbed pooling of different sites measurements is intermittent
  48. 48. Microelectrodes placed with in plaque on the tooth surface at intervals after food ingestion Direct reading of pH Antimony and glass electrode- Limitations: Disrupts the plaque structure Outer surface of plaque pH
  49. 49. Miniature electrode built in to prosthesis pH readings taken continuously by either wire or radio telemetry Previously glass electrode- slow response(30 sec) Hydrogen ion sensitive field transistor Extremely small : 1mm2 -si3N4 Low electric resistance Rapid response time (10sec) Indwelling bimetallic ( palladium/ palladium oxide)- versatile
  50. 50. Criticism: Pattern and sequence of food intake – influence plaque pH used in small no. of persons Permutations of sequence and frequency intake - impossible
  51. 51. Swiss Office of Health Plaque pH below 5.7 during and up to 30 min “Safe for teeth” or Zahnschonend Labeling the product: non cariogenic (nicht kariogen)
  52. 52.  Most important role :Sugar free confectionery, chewing gums soft drinks, table top sweeteners and in liquid oral medicines.  Non sugar sweeteners : 1. Bulk sweeteners or Caloric sweeteners. Ex: Polyalcohol (Sorbitol , Xylitol), Starch hydrylsates 2. Intense sweeteners or Non caloric sweeteners. Ex: Aspartams, Saccharine, Cyclamate, Some Plant sources
  53. 53. Bulk sweeteners : Chemically similar to sugars. Add volume and sweetness to a product. 0.5 to 1.0 times as sweet as sucrose. Have an energy value ( Kilocalories ). Naturally found in foods.
  54. 54. Sorbitol Prepared from glucose by hydrogenation. One half as sweet as sucrose . Slowly and incompletely absorbed from the intestine : result in osmotic diarrhoea. Microbial Metabolism of Sorbitol. Most oral microorganisms lack the enzymatic makeup to utilize Sorbitol.
  55. 55. Xylitol  Absorption slow and incomplete .  Used in Diabetics.  Metabolism by Oral Microorganisms :Human oral microorganisms do not have enzymes to utilize xylitol. Starch hydrylsates  Lycasin :Hydrogenated glucose syrup produced from starches  Caloric value – Similar to other carbohydrates.
  56. 56. Not chemically related to sugars. Added in very small quantities and not volume. 100 to 1000 times sweeter than sucrose. Negligible energy value ( Kilocalories ) Low caloric sweeteners are used in: Gelatin desserts puddings Desert toppings Soft drinks Chewing gums Medicinal preparations Dentifrices and mouth washes
  57. 57. Aspartame  180-200 times as sweet as sucrose.  Composed 2 amino acids : L-aspartic acid and Methyl ester of L-phenylalanine.  Reduces caries – Limiting the amount or frequency of fermentable sugar in the diet. Saccharine  Pharmacologically inert and is stable.  Widely used in – diets , soft drinks , dietic food , mouth washes , medicinal preparations , sweeteners for table use. Cyclamate  Organic sweetener .  Economical.
  58. 58. Other sweeteners derived from plant sources  500-3000 times as sweet as sucrose. Ex: Monelin, Licorice, Dihydrochalcone, Miraculin Sugar Substitutes in Pharmaceutical Preparations  Xylitol, Mannitol , Sorbitol , Lycasin. Food Additives  May decrease the local caries challenge or conversely enhance the local natural defense mechanisms . Ex : Presence of Ca and P in Saliva.
  59. 59.  Routinely screen patients.  Screening activity: Assessment of determinants of dietary intake Behaviors that associate with dental health and caries risk  Screening - Two parts Part – A Part – B
  60. 60.  Restrict the number of eating times to three main meals.  Avoid carbohydrate ( sugars ) snacks in between meals.  Take low carbohydrate and high protein snacks and fibrous fruits in between meals, if required.  Eliminate eating sticky sweets like chocolates, toffees, candles, cake, and pastries, if not completely then as much as possible.
  61. 61. Increase eating of high protein food like meat, fish, milk, egg, pulses and beans. Restrict carbohydrate eating so that they only provide between 30 to 50 percent of total calories requirement of the body. Eat firm detersive food like raw vegetables and fruits which will reduce dental plaque formation and increase salivary flow. Fluoride If present ,Free sugars – 15 to 20 Kg/person/year ( 40-55 g/day ). If Absent, Free sugars – below 15Kg/person/year ( 40g/day).
  62. 62. Dentistry for Child & Adolescent – Mc Donald 8th Edition Newbrun, Cariology 1stEdition. Shoba Tandon Rugg- gun ,Diet Nutrition and Dental Caries. 1st Edition. Per Axelsson- diagnosis and risk prediction of dental caries Essentials of preventive and community dentistry, 2nd edition, Soben peter. DCNA:1999:43:4:615-633. DCNA:2003:47:319-336

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