DIET AND DENTAL CARIES.pptx

DIET AND DENTAL
CARIES
DR. RITU RANDAD
1

CONTENT LIST
• Introduction
• Concept of dental caries
• Stephan’s curve
• Food, diet and nutrition
• Classification of Carbohydrates and sugars
2

• Evidences/studies linked with Diet and Dental Caries
• Preventive dietary programs
• Dietary counselling
• Patient selection
• Food diary/Diet diary
• Communication technique
3

• Communication techniques
• Tooth friendly snack or ideal mid meal snack
• Sugar substitutes/classifications
• Dental Dietary Guidelines for various age groups (children)
• Summary
4

INTRODUCTION
Dental caries is a derived from a Latin word called “carius” meaning rottenness
or decay and is commonly called as tooth decay.
Dental caries (Shafers) is defined as “ an infectious microbial disease that
begins as demineralization of inorganic portion of tooth, followed by
destruction of organic portions, leading to caries formation.”
5
R. Rajendra, B Sivapathasundharam, Shafers Textbook of Oral Pathology, 7th edition, Elsevier, 2016.

Definitions
• Dental caries is an irreversible microbial disease of the calcified
tissues of the teeth, characterized by demineralization of the
inorganic portion and destruction of the organic substance of
the tooth, which often leads to cavitations.
According to
Shafers
• Dental caries is an infectious microbiologic disease of the
teeth that results in localized dissolution and destruction of
calcified tissues.
Sturdevant (2002)
•
Dental caries is a complex disease caused by an imbalance in
the physiologic equilibrium between
tooth mineral and biofilm fluid.
Fejerskov (2004)
11/30/2023 6

• Dental caries the disease of civilization has been affecting man since the
dawn of time. Caries have been noted in the fossil remains early ancestors of
man. Caries seems to have increased considerably in Homo sapiens during
Neolithic period when it was perhaps as high as seen in any primitive people.
• It has been found that, in prehistoric skulls about 5% of the teeth exhibits
caries.
7

• Dental caries has multifactorial aetiology.
• The disease is not only treatable but also most of the aspects have a
preventable factor.
8

• Tooth decay is an infectious disease generally affected by diet and the pattern
of consumption by the host.
• Sound enamel demineralizes, if plaque bacteria are mixed with carbohydrate
substrate and they produce acids, but the presence of saliva in mouth acts as
a buffering agent, which in turn to an extend can inhibit the demineralization
process.
9
E. Nizel and S. Papas . Nutrition in Clinical Dentistry. 3rd edition, Saunders company, London., 1989

• The progression of carious lesions is not only inevitable but also the disease
occurrence can be controlled.
10

Theories of dental caries
• The legend of worms
o Ancient Sumerian text known as the ‘Legend of Worms’ from about 5,000 BC
o From the writings of Homer who made a reference to worms as the cause of toothache.
• Endogenous theories
o Dental caries was thought to be produced by internal action of acids and corroding
humors
o Early Greek physicians such as Hippocrates, Celsus, and Galen, proposed the vital theory
of tooth decay, which postulated that tooth decay originated, like a bone gangrene, from
within the tooth itself.
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• Chemical theory
o Proposed that an unidentified ‘chymal agent’ was responsible for caries.
o Further supported by Robertson in 1835 who proposed that dental decay was caused by
acid formed by fermentation of food particles around the teeth.
• Parasitic theory
o Erdl in 1843 described filamentous organisms in the membrane removed from teeth.
o Similarly many observations by Clark(1871,1879), Tomes (1873), Magitot (1878),
Underwood and Miller (1880) concurred that bacteria was essential for caries.
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The proteolytic theory (Gottlieb and Applebaum in 1944)
• Organic or protein elements of a tooth are the initial pathway of invasion by
microorganisms
• Enamel lamellae are pathways for organisms in the progress of dental caries
Theory
• “Caries is essentially a proteolytic process: the microorganisms invade the organic
pathways and destroy them in their advance. Acid formation accompanied
proteolysis”
Gottlieb and Gottlieb,
Diamond and
Applebaum
• No satisfactory evidence to support the claim that the initial attack on enamel is
proteolytic
• Gnotobiotic studies: Caries can occur in the absence of proteolytic organisms
Drawbacks
• Proteolysis in the initiation of dental caries is likely to be of no significance, but its
role in the progression of the more advanced carious lesions cannot be ruled out
Conclusion
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Proteolysis chelation theory (Schatz et al in 1955)
• Simultaneous microbial degradation of the organic components and the dissolution of the
minerals of the tooth by the process known as chelation
Theory
• A process involving the complexing of a metallic ion to a substance through a covalent bond
which results in a highly stable, poorly dissociated or weakly ionized compound (chelas: claw)
Chelation
• Independent of pH of the medium
• Removal of metallic ions such as calcium from a biologic calcium-phosphorus system may
occur at a neutral or even alkaline pH
Effects of
chelation
• The proteolysis-chelation theory resolves the argument as to whether the initial attack of
dental caries is on the organic or inorganic portion of enamel by stating that both may be
attacked simultaneously
And thus
11/30/2023 14
R. Rajendra, B Sivapathasundharam, Shafers Textbook of Oral Pathology, 7th edition,
Elsevier, 2016.

Miller’s chemicoparasitic theory (1882)
• Caries is caused by acids produced by microorganisms of the mouth
Theory
• Dental decay is a chemico-parasitic process consisting of two stages: O Decalcification of
enamel and dentin (preliminary stage)
• Dissolution of the softened residue (subsequent stage) Acids resulting in primary
decalcification are produced by the fermentation of starches and sugar from the retaining
centers of teeth.
States that
• Oral microorganisms
• Carbohydrate substrate
• Acid
Essential role of three
factors
• Predilection of specific sites on a tooth
• Initiation of smooth surface caries
• Why some populations are caries free?
• Phenomenon of arrested caries
Unanswered questions
by the theory
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Pathogenesis of dental caries
• Dental caries is a multifactorial disease with interplay of three primary factors:
the host, the microbial flora, and the substrate with time, as an inevitable fourth
factor.
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Primary factors responsible for dental caries
Tooth
Dental
plaque
Diet Time
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Pathogenesis of dental caries
ENAMEL PELLICLE + BACTERIA
PLAQUE FORMATION
PLAQUE BACTERIA + FERMENTABLE CARBOHYDRATE ( FOOD)
ACID PRODUCTION (lowering of the plaque pH)
DEMINERALISATION OF INORGANIC AND DISSOLUTION OF ORGANIC STRUCTURES OF TOOTH
DENTAL CARIES
18

Stephan Curve
• A typical pH response to plaque following exposure to a glucose rinse was
obtained creating decrease in the curve.
• These curves are often referred to as STEPHAN CURVES and have 3
main characteristics. (dental plaque, fermentable carbohydrate and cariogenic
bacteria)
• Under resting conditions, the pH of plaque is reasonably constant, 6.9 to
7.2. following exposure to sugars, the pH drops very rapidly (few minutes) to
the low level (5.5 to 5.2 pH), at this pH, tooth surface is at risk.
19

• Later, slowly it turns to it original value over the period of 10-40 minutes,
approximately this is called as, CRITIAL PERIOD.
• During this time, the tooth mineral dissolves to buffer further acid at lower
pH in the plaque-enamel interface and also results in tooth loss.
• Repeated fall of pH over a period of time leads to more and more mineral
loss from the tooth surface and ultimately leading to unfavourable way
resulting in initiation of the dental caries.
20

During the time when the
tooth mineral dissolves to
buffer acid at lower pH, the
plaque pH drops to 3-4.
If pH drops to 3-4, the
surface layer is irreversibly
lost.
Frequent ingestion of
sucrose has a lot of
influence in initiation and
development of caries
process in newly erupted
teeth.
21

Food, Diet, Nutrition and Balanced Diet
• Food- anything that is eaten, drunk or absorbed for maintenance of life, growth and repair of the tissues
(Nizel, 1989).
• Diet- habitual choice of food and drink. Those food which are eaten regularly over a period of time
which determines exposure.(C. Pine)
• Nutrition- the intake and absorption of nutrients from the food and drink (C.Pine)
22
• E. Nizel and S. Papas . Nutrition in Clinical Dentistry. 3rd edition, Saunders company, London., 1989
• C Pine, R. Harris, Community oral health, 3rd edition, Quiescence books.

• Balanced diet- Is a diet which contains varieties of food in such
quantities & proportions that the need for energy, amino acids, vitamins,
fats, carbohydrates & other nutrients is adequately met for maintaining
health, vitality, and general well being & also makes provision for short
duration of leanness (Chauliac 1984)
23

Role of Diet in dental caries
• The effect of diet on caries is considered under two headings:
a) Systemic effect
b) local effect
• Nutritional effects are mediated systemically, and dietary effects are mediated locally in oral
cavity. The systemic effects result from the absorption and circulation of nutrients to all
cells and tissues and may be mediated through influences, on development of teeth,
the quality and quantity of salivary secretion, improved host resistance and
improved function.
24

• Dietary constituents exert their local effects by influencing the metabolism
of the oral flora and by modifying salivary flow rates and indirectly the
qualitative aspect of salivary secretion.
25

Dietary factors
• Increased Susceptibility
• Fermentable Carbohydrates
– Sugars
– Sugar/Starch Combination
Decreased Susceptibility
• Proteins
• Fats: Cheese, Nuts
• Foods with Sugar Alcohols
• “Healthy” Snacks
26
Fermentable carbohydrates (sugar and
starch) are the ones that begin their digestion
in the oral cavity via salivary amylase.

CLASSIFICATION OF
SUGAR/CARBOHYDRATE
• Monosaccharides- are simplest of the carbohydrates and are classified
according to the number of carbon atoms in the chain
Eg: glucose, fructose and galactose
• Disaccharides- have linkage of two monosaccharide units. They have a
sweet taste, water soluble and crystalline solids.
Eg: sucrose, lactose and maltose.
27

• Polysaccharides- are complex carbohydrates made up of many monosaccharides
linked together. They are tasteless, used for storing energy and other perform
structural functions.
Eg: starch, glycogen and cellulose.
Sucrose is having highest cariogenicity followed by glucose, fructose, lactose
and galactose. Glucose syrups and hydrogenated glucose syrups have less
cariogenicity than sugars, whereas sugar substitutes like xylitol, sorbitol,
mannitol are not cariogenic.
28

• Sugar - combination of monosaccharide & disaccharide, -
highest % of carbohydrate on a dry weight basis.
• Sugars classified as entered in the diet : those found naturally in
foods (eg, fruit, honey, and dairy products) and those that are added
to foods during processing to alter the flavor, taste, or texture of the
food.
29

• According to the sugar molecules :
I. Intrinsic sugars are formed inside the cell structure of certain
unprocessed food stuffs, mostly in fruits and vegetables.
II. Extrinsic sugars are located outside the molecules of food and drinks.
There are two types: milk and non milk extrinsic sugars(more cariogenic
and plays a vital role in caries process).
30

• According to the sugar mixes:
1. Blended sugar(50% sucrose and 50% glucose)
2. Pure invert sugar (50% glucose and 50% fructose)
3. Common invert sugar (50% sucrose 25%glucose and 25% fructose).
31

• Sucrose is regarded as the arch criminal in dental caries:
• The dietary sugars all diffuse rapidly into the plaque and are fermented to lactic and
other acids or can be stored as intracellular polysaccharides by the bacteria, prolonging
the fall in pH and promoting a suitable environment for other aciduric and acidogenic
bacteria.
• Sucrose is unique because it is the substrate for production of extracellular
polysaccharides (fructan and glucan) and insoluble matrix polysaccharides (mutans).
32

• Thus, sucrose favors colonization by oral microorganisms and increases the
stickiness of the plaque allowing it to adhere in larger quantities to the teeth.
• A combination of soluble starch and sucrose would be expected to
be a more powerful caries risk factor than sucrose alone, because
the increased retention of the food on the tooth surfaces would
prolong sugar clearance time.
33

Evidences/studies linked with Diet and Dental
Caries
• The evidences linking diet and dental caries can be summarized under the
following headings:
34
Historical
evidence
Epidemiological
evidence
Experimental
evidence
Murray J.J. Prevention of dental diseases , 4th edition, Oxford publication, 2003

Evidence for a relationship between diet and
dental caries comes from different types of
studies
• Human intervention studies (clinical trials)
• Human observational studies
• Animal experiments
• Plaque pH studies
• Enamel slab experiments
• Incubation studies
35

World wide epidemiological observational
studies
• Sugar intake and levels of dental caries can be compared between countries.
• Sreebny (1982) correlated dental caries experience of primary dentition of 5
and 6 years old with sugar supplies data of 23 countries and dental
cares experience of 12 years old to supplies data of 45 countries.
• Observed: 52% variation in caries levels could be explained by per
capita availability of sugar. For every 25g of sugar per day, one tooth
per child would become decayed, missing or filled.
36

• The countries with an intake of sugar below 18kg/person per year had
caries below DMFT 3 whereas in excess of sugar 44kg/person per
year had higher levels of caries.
37

38
Study conducted in 1982 with the association of per capita sugar availability and dental caries
experience among 12 year olds

• Further analysis in 1994, had no such strong association between per capita
sugar availability and mean DMFT of 12 year old in developed (29) and
developing (61) countries.
• Reason: very high availability of sugar in these countries, changing the
level of sugar intake by few kilograms per year does not influence the
caries challenge.
• In 23 out of 26 countries 28% variations of levels of dental caries with
50g/day had mean DMFT for 12 years below 3.
39

• Stecksen- Blicks and Gustafsson (1996)- measured caries increment over
one year of time among 8 and 13 year old children and related it to diet at
one point of time .
• despite the short duration of observation, a significant relationship was
found both for primary and permanent dentition dental caries and the
intake of sugar.
40

• Grindefjord et al. 1996, found a close association between the
consumption of confectionery and sugar containing beverages and
caries increment in longitudinal study. the age group of the children was
between 1 to 3.5 years.
• Rugg-Gunn et al. in 1984 performed a comprehensive study with 400
English children and found that a small but significant association
between intake of total sugars and caries increment over 2 years.
41

Michigan
study
42
Brut (1988)- study in USA between 1982 to
1985 studied relationship between sugar
intake and dental caries increment. Over 3
years in children 10-15 years with total 499
children
More the dietary sugar intake, higher
caries increment for approximal caries
along with amount to sugar eaten during
the meals.
No significant association between the
sugar intakes and pit and fissure caries.

• When the high caries increment were compared with low caries increment,
higher tendency was seen towards more frequent snacking.
• Sugar intake was high overall in the group except 20 out of 499 children
consuming less than 75g/day, whereas the lowest intake of the lowest
quartile consumption being 109g/day of the energy intake.
43

HUMAN INTERVENTION STUDIES
Vipeholm study, 1954 (Gustaffsone at al , Sweden)
The study was conducted in Sweden over 5-year period in a mental institute during
1945-1953.
• Purpose- to determine the effects of frequency and stickiness of sugar on the
formation of caries at different times throughout the day.
• Institutionalized patients 436 were divided into 6 experimental and 1 control group.
44

Groups divisions
1. Control group - low sugar diet only at meals
2. Sucrose group - high- sugar diet (300g) mostly in drinks
with meals
3. Bread group - sweetened bread at meals (sugar- ½ or
equal to normal)
4. Caramel group- 22 sticky candies 2 portions at meals (carbohydrate study I) 4
portions between meals (carbohydrate study II)
5. 8- toffee group
6. 24-toffee group- throughout day, twice normal total
intake of sugar
7. Chocolate group- milk chocolate- 4 portions bet meals(CSII) 45

• Study was conducted in 3 phases:
1. 1945-1947: preparatory and vitamin period, all subjects received diet low in
sugar
2. 1947-1949: Carbohydrate study 1- 2years, twice the normal amount of sugar
but only at meals
3. 1949-1951: carbohydrate study 2- next 2years, normal amounts of sugar
some at meals and others both at and between meals
46

• Findings:
1. Positive association in caries increment with increase sucrose-containing
snacks intake between meals- time factor.
2. Positive association with consumption of sucrose with dental caries
experience- frequency.
3. Positive association with sugar increasing activity and form of sugar
consumed with stronger tendency to retain-retention
4. Cariogenicity of solid food more than liquid containing sucrose - form. 47

5. Caries lesions disappear on withdrawal from sucrose rich food consumed in
manner of favouring caries- reduction in total sugar intake.
6. Restrictions of natural sugars and total dietary carbohydrates, for the decreased
caries incidence.
7. Positive association with increase in caries activity with increase duration of sugar
clearance from saliva-clearance of saliva.
8. Increment in dental caries depends on individuals-variation in individuals.
9. Positive association with increase in carbohydrates leads and increase dental caries.
48

49
SUMMARY OF THE VIPEHOLM STUDY (1954)

• Turku sugar study, Finland (Scheinin and Makinin) 1972-1975
AIM - To compare the cariogenicity of sucrose, fructose and xylitol. (1972-1974)
Control group- Xylitol is a sweet substance not metabolized by plaque organisms.
• 125 subjects with 3 groups, 12-53 years for 25 months (monitored at 6 months by
one person)
• foods were manufactured for fructose and xylitol but subjects were asked to
avoid sweet fruits such as dried fruits.
50

• Sucrose was replaced with xylitol
• One group given chewing gums containing sucrose
• Another group was given chewing gums containing
fructose.
• The third group was given chewing gums having
xylitol.
• 85% reduction in dental caries was observed in
xylitol group
51

• Findings:
1. Dramatic reduction was seen in dental caries after 2 years among the
subjects of xylitol group.
2. Fructose group developed more caries than xylitol group.
Between meals chewing of xylitol was anticariogenic.
52

• Granath ((1978) studied 500 4 year-old Swedish children to sugar
consumption, fluoride supplementation and oral hygiene practices.
• Most important factor- intake of sugar in between meals.
• Findings- effects of oral hygiene and fluoride showed 86% less buccal
and lingual caries and 68% proximal caries in low sugar intake than
the high sugar intakes between meals.
53

Hopewood house study- Harris (1942-1967)
Conducted in New South Wales, Australia. Being an orphan house containing children
from birth to 12 years of age. These subjects were on lactovegetarian diet- rich in
milk products and vegetables, low in sugars and refined flour.
oral hygiene practices and fluoride exposure were poor.
Their diet mainly consisted of whole meat, soyabeans and nuts. Cheese, sugar and
refined carbohydrates were totally excluded. Follow up study till 13 years.
54
HUMAN OBSERVATION STUDY

55

• 46% of the 12-year-old in Hopewood house were caries free compared to
the 1% of the children from state schools.
• After 12 years, the association with home ended, lead to increase in
caries level due to intake of more food rich in cariogenicity (sugar
and refined flour) than low vegetarian sugar diet.
• Significant caries reduction on diet restriction inspite of poor oral
hygiene and low fluoride consumption.
56

Epidemiological Evidence
• During World War II, due to the sugar restrictions in 1939-1944, dental
caries reduced among the civilians. At the same time, dental caries experience
among army personnel was increased due to increase in sugar consumption
as more ready to eat food items were supplied during that time period.
• During the World War II, a reduction in intake of sugar was not only
the dietary change but also intake of other carbohydrates.
57

Tristan da
Cunha study.
• Tristan da Cunha is a remote rocky
island in South Atlantic region.
Before 1930 and 1940 onwards
study showed no evidence of dental
caries in this region because of
consumption of raw meat.
• In 1940, after opening of the
trading store selling imported sugar
and sugar-containing foods showed
high caries prevalence and
severity of dental caries in all the
age group between 1937 and 1966.
58

• Hereditary fructose intolerance (HFI), by Marthaler (1967) is an
autosomal recessive disorder of fructose-1-phosphate. Patients having
intolerance of fructose avoid, because its consumption causes malaise,
nausea, vomiting, sweating, coma and finally death.
Hence, dental caries experience in this patients is very less.
Significant association with lesser caries increment in individuals
avoiding sucrose and fructose but not for consumption of other sugars
and complex carbohydrates.
59

Experimental studies- animal based
• Kite et al in 1950, one group of rats was fed a caries-producing diet by
means of a stomach tube, with no food coming in contact with the teeth.
No caries resulted.
• When the same diet was fed orally and allowed to come in contact with
the teeth, caries did occur
These two studies conclusively demonstrate that:
(1)the role of saliva in protecting against dental caries , and
(2) the action of the sugar in carious development is local, not
systemic.
60

• Brut (1968) conducted a study on animals at defined times and under feeding
ensured that the animals ate all the feed provided. In such studies a clear positive
relationship between frequency of feeding and caries severity. Animals fed ad
libitum consumed 11.7 g food per day which was nearly twice the 6g fed to other
groups in whom frequency was controlled.
• The results show that frequency of eating a cariogenic diet is more important
than the overall amount consumed.
61

• In an experiment where animals received 18 portions of feed per day, one group
received 3*6 portions, with no time between consumption of the 6 portions. The
other group had a 30-minute interval between each of the 18 portions. Caries
development was greater in the later group with 18 portions.
• The amount of time between food intake and the caries experience.
62

• Hefti and Schmid (1979)- conducted a study to examine effect of
concentration of sugar in the diet.
• diet containing sugar (~10%)causes more caries than sugar- free diet, but no
increase in caries was seen when sugar concentration increased above 10%.
• The non sugar diet is important for caries formation but presence of
starch or diet rich in fat will reduce the initiation of caries formation.
63

• Caries severity has shown increase with increasing sugars concentration up
to 40% in experimental rats super infected with S. mutans and Actinomyces
viscosus.
64

Animal studies showing caries and sugar
relationship
• Relationship between frequency of consumption of cariogenic diet and
severity of dental caries.
• Increase in caries with increase sugar concentration.
• Little difference in the cariogenicity of glucose, fructose and maltose
and increased cariogenicity of sucrose only when animals are super
infected with S. mutans.
65

Enamel slab
experiment
• Uses- oral appliances that hold slabs of
bovine or human enamel retained in mouth
for 1 to 6 weeks.
• procedure- slabs exposed to dietary factor in
situ or by removal of the appliances to dip in
dietary test substances.
• Objective- measure the demineralization
of the enamel and also the role of saliva
as protective agent.
66

• Von der Fehr (1970)
and Geddes et al (1980).
67

Plaque pH
studies
• Stephan curve showed curves to rank the
acidogenicity of snack foods showed that
boiled sweets have lowest pH (~5.2), sweeten
tea and coffee gives low pH values. And food
sweetened with non sugar sweeteners(diabetic
and normal chocolate) and salivary stimulants
such as peanuts gives highest pH values.
(Hayes and Robert, 1976)
68

69

Incubation experiments
• Simple in vitro tests that measure if plaque bacteria can metabolize
carbohydrate in test food to produce acid.
• Pure cultures of micro-organisms are also replaced with the whole plaque.
Rapid acid production and low final pH is interpreted to mean that a food is
potentially acidogenic, while high pH has lesser clinical significance.
• All monosaccharides and disaccharides produce a final pH of below 4.5
when incubated with plaque.
70

71
van Loveren C. Sugar Restriction for Caries Prevention: Amount and Frequency. Which Is More Important? Caries Res. 2019;53(2):168-175.
doi: 10.1159/000489571. Epub 2018 Aug 8. PMID: 30089285; PMCID: PMC6425816.

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73

Author (year of
study)
Population group objectives Conclusions
Q. Yank (2021) Primary school
children in Riyadh,
Saudi Arabia,
578 male children of 6-
8 years
To estimate the prevalence of dental
caries and identify key associated factors
in four major risk domains, including
socioeconomic factors, child oral health
behavior and practices, child feeding
practices, and dietary habits among
primary school children in Saudi Arabia
Individual factors were
associated with increased
free sugars intake and
increase caries increment.
X. Wang (2021) 12-15 year olds in
England, Wales and
Northern Ireland.
To examine the distribution of dental
caries in 12- and 15-year-olds in England,
Wales and Northern Ireland, by severity
threshold, at surface, tooth and child
level and explored its association with
socioeconomic, psychological and
behavioural factors.
high frequency sugar
consumption was
associated with greater
caries experience
74

75
Author (year of
study)
N. Jahid (2020) 273 Nepali children,
age group of less than 6
months to 12 years.
aims to assess relationship of intake of
sugar and dental caries among a
convenience sample of 273 children age six
months to less than 12 years in three
communities in Nepal.
Positive associations
between daily consumption
of sweets and processed
snacks with severe caries
and association between
severe caries and poorer
nutritional status.
A. Sanders (2018) 14,517 dentate men and
women of the Hispanic
Community
To assess the broader relationship between
diet quality and dental caries in a diverse
Latinx adult population.
intake of sugar-sweetened
beverage and fruit juice
was positively associated
with dental caries, whereas
vegetables (excluding
potatoes); whole grains; and
omega-3 fats were inversely
associated with dental caries

76
Author (year of
study)
C. Palacious (2017) 1,587 12 years-olds in
Puerto Rican children
To identify the types, food sources, and
pattern of carbohydrates that significantly
contribute to dental caries in Puerto Rican
children.
Significant associations of
high intake for the sugars
and dental caries and
increased significantly in
caries increment in
children whose 10% of
total energy intake was
from total sugars.

Epidemiological studies of the sugar and caries
relationship.
1. A marked increase in prevalence and severity of dental caries has been
observed in populations who changed their traditional way of eating
and adopted modern diet, high in sugars.
2. Sub groups consuming high sugar diet had shown higher levels of
dental caries compared to general population.
3. Studies with longitudinal design, measuring diet and change in level of
dental caries over time provides with stronger evidence.
77

Preventive dietary program
• Exclude fermentable sugars from diet.
• If child is found of sweets, give them all at the meal time, not between meals.
• Include vegetables and fruits, nuts and cheese as basic diet (increase salivation)
• Avoid solid and sticky sugary foods
• Reduce the number of sugar exposures during the day, consumption during
the meals only.
78

79
Shaw states that “the frequency of eating, the amount of food
retained in the mouth particularly on tooth surfaces, and the length
of time that food residues are retained in critical areas are more
important than the total amount of sugars consumed”
The diet counsellor should incorporated when possible:
1. A nutritional balanced varied diet from the high-density nutritious basic four
groups.
2. Eliminate high-sugar snacks, whenever possible
3. If sugar-containing foods must be included for providing the energy needs
restrict them to mealtime
4. Recommend hard cheeses and nuts as between meal snacks.

Dietary counselling
• It deals with providing guidance in the art of food planning and food
preparation and food services. It assists a person to adjust food
consumption to his or her health needs. (Nizel)
• OBJECTIVES OF COUNSELING
1. Correction of diet imbalance, that could affect the patients’
general health and sometimes reflect on his oral health.
2. Modification of dietary habits, particularly the ingestion of
sucrose containing foods in forms, amounts, and circumstances
that cause caries formation.
80

• The basic pre-requisites for dietary changes are:
1. That the patient not the counsellor bears the responsibility for making the
change.
2. The counsellor should explain candidly the need for full cooperation and
sincere effort by patient to modify the diet, and the patient should agree to.
81

• Minimal requirements for successful counselling includes:
1. Enrolling active patient involvement in planning, implementation and
evaluation of diet before and after dietary counselling.
2. Insisting on series of follow-ups visits to tailor the diet according to
patients needs and likes, and avoid if possible dislikes without jeopardizing
the dental-oral health status.
82
A simple screening of typical 24 hour food intake will disclose
possible dietary inadequacies, excesses or both having negative
influence on an individual’s dental health-a potential cariogenic
diet.

• GUIDELINES FOR COUNSELING
• Gather information
• Evaluation and interpretation
• Develop and implement plan of action
• Seek active participation of family
• Follow-up the progress and assessment made
Patient Selection
– Children under the age of 6 years
– Elementary school child.
– To the Adolescent group.
83

Patient selection
• The patient selected should :
1. Be willing to improve current undesirable food selections and eating habits.
2. Give high priority to preventive dentistry and should be willing to expend long-
term efforts to maintain their natural dentition in good health for a lifetime.
The Dental Health Diet Score is a screening device to achieve the
objective of dietary improvement based on current food intake regimen.
It is a simple scoring device that can disclose a potential dietary problem
likely to effect the dental health.
84

• Who does the Dental Health Diet Score works?
By giving points earned as a result of an adequate intake of food from
each of the food groups plus the points for ingestion of food
recommended as they are the best source of 10 essential nutrients for
achieving and maintaining dental health.
From this sum, points are subtracted for frequent ingestion of foods that
are overtly sweet. The difference is Dental Health Diet Score .
85

FOOD DIARY or DIET DIARY
• It is the records of all the foods and beverages consumed
during
5 or 7 day period .
• It can be 24 hours recall or 3,5,7 days record of food intake.
• It helps to determine-
• Type, frequency, consistency of food intake.
• Proper diet planning for oral health.
The choice depends on the amount of details required.
86

• Diet survey is the practical method of assessing the quality of person’s
nutrient intake. It is done by comparing the foods in the food groups with
the sources of nutrients obtained from each and then compensating for the
nutrients that are high or low.
• Disadvantage
Time consuming
Nutrient content of the food varies with the preparation method,
type of plant and even the location of the plant.
89

90

91

92

• All the food group scores, and sweet scores summed to the totaling score.
• If the food scores is barely adequate or inadequate or sweet score is
“watch out” zone (needs counselling)
• NUTRITION-COUNSELING is required.
4 food group scores combined should range within:
72-96 -----Excellent
64-72 -----Adequate
56-64 -----Barely adequate
56 or less -----Not adequate.
Score 60-100 is acceptable, and diet counseling is given only at patient’s request.
if 56 or less ,then dietary counseling is both recommended and indicated as a part of
preventive program. 93

Communication techniques
• Creates motivation for change. Communication is giving and sharing of
information, involves knowledge, thoughts and opinions of the counsellor and the
patient.
1. During face to face interview, keep eye contact with patient is a
powerful device for motivating behaviour change
2. Can be both verbal or non-verbal. Words transmit information. The
interviewer’s tone, expressions and gestures convey sincerity,
empathy and enthusiasm.
3. Personalization of message is more likely to result in a sustained
change in behaviour.
94
Combination of
interviewing,
teaching,
counselling and
motivation.

Interviewing and physical setting
Purpose: to understand
95
The problem
The factor
contributing
to it
The
personality of
the patient
Privacy, comfortable
and relaxed
atmosphere
Separate counselling
room with table,
chairs, boards and
visual aids
The private place
will create free and
easy conversation

• Counseling should be done in a step by step procedure
starting with:
• Interviewing, where the diet diary is introduced with a brief discussion of
the purpose of diet
• 24-hour diet record prepared to get an idea of food, the child is consuming
• Six-day diet diary advised to be prepared by patient.
• Complete record of 6-day diet diary is analyzed regarding the balanced
and unbalanced diet.
96

• • Isolate the sugar factor.
• Educating the patients in the role of sugars in the process.
• Consumption of acceptable substitutes of more cariogenic
food.
• Recognition of practical limitation to immediate success.
97

• 6 questions are to be made before making decision about which patients will benefit
from diet counseling
• 1. WHO may be benefited?
2. WHAT are the objectives of diet and nutrition counseling?
3. WHY is counseling beneficial?
4. WHEN is counseling conducted?
5. WHERE should the counseling occur?
6. HOW to counsel?
98

Guidelines for counselling
1. Gather information
2. Evaluate and interpret information
3. Develop and implement a plan of
action
4. Seek active participation of patient’s
family
5. Follow up to assess the progress made.
99
MOTIVATION
AWARENES
INTEREST
INVOLVEMENT
ACTION
HABIT

Tooth friendly snack or ideal snack
1. It should stimulate salivary flow.
2. It should have minimal retention on the tooth
3. It should have faster oral clearance rate (fibrous diet)
4. Snacks should be rich in proteins, minimal in carbohydrates and moderate
in the quality of fats.
100

Sugar substitute/ classification
• Two groups:
• Intense sweeteners (non-caloric)
• Bulk sweeteners (caloric)
101

• Intense Sweeteners
• Are not chemically related to sugars
• Added in small quantities for sweetness and not
bulk
• They are 100- 1000 times more sweeter than sugars
• Have negligible or no energy value
• Eg: acesulfame(130), aspartame(200),
saccharin(500), thaumatin(3000)
102

• Bulk Sweeteners
• Are chemically similar to sugars
• Add sweetness
• 0.5-1.0 times as sweet as sucrose
• • Have an energy value
• Many are naturally found
• Eg : isomalt(0.5), cycasin, maltitol, mannitol(0.7),
sorbitol(0.5),and xylitol(1.0)
103

• Sorbitol and mannitol:
They occur naturally in plants, sorbitol is used in foods for diabetics as the metabolism
of sorbitol is insulin independent. Sorbitol is commonly used as sweetener in sugarless
syrup medicines. Mannitol is used in chewing gums.
• Hayes and Roberts 1978: sorbitol and mannitol are fermented slowly by plaque
organisms and depress plaque pH only slightly( Rugg gunn 1988).
• In enamel slab experiments: sorbitol and mannitol gave rise to 45% of the
demineralization of enamel attributable to sucrose.
Conclusion: sorbitol is noncariogenic and does not promote tooth decay
104

• Xylitol:
It occurs naturally in foods and is used at present in confectionery
and tooth pastes.
Hayes and Roberts 1978: xylitol is fermented to acid slowly in
comparison with glucose and sorbitol
Imfeld 1977: plaque pH study – xylitol is non acidogenic
Turku sugar study: dietary sugar by xylitol resulted in low caries
incidence
105

• Saccharin was discovered in 1879 , bitter taste it is used as a
table top sweetener and in soft drinks marketed as calorie low.
• Aspartame is dipeptide, consisting of aspartic acid and
phenyalanine.
• Thaumatin is a sweet tasting protein extracted from plant, it is
used as flavor enhancer in pharmaceutical products
106

Dental dietary Guidelines for children at
various age groups
I. Prenatal Growth.
• Poor Prenatal nutrition
• Children with hypoplastic enamel
• Mothers guided with active caries and its effects.
II.
Birth to 1 year.
• importance of Breast milk and infant formula.
• ≤ 6 months of age.
• At age of 6 months.
107

Guidelines for promoting good nutrition and
decrease caries risk in infants
• Discourage the behavior of placing a child to bed with bottle.
• Prohibit dipping pacifiers in sugar, honey or syrup.
• Discourage a child from carrying and continuously drinking from
bottle or sippy cup.
• Introduce cup from bottle.
• Reduce use of beverages, other than breast milk, infant formula or
water.
108

Guidelines for promoting good nutrition and
decrease caries risk in toddlers
• Discourage the behavior of placing a child to bed with a bottle.
• Discourage a child from carrying and continuously drinking from a
bottle or sippy-cup.
• Limit juices or sugar-containing drink in take to 4oz/day and only in
cup.
• Restrict cariogenic foods to meal times.
• Establish routine meal with family members eating together.
• Stimulate a child’s appetite at meal time by reducing between meal
snacking. 109

Conclusion
• Dental caries is a diet-related disease that continues to be a problem for
certain dental patients. Frequent consumption of fermentable
carbohydrates that have low oral clearance rates the increase in the risk of
enamel caries. Highly acidogenic snack foods should be consumed at meal
times to reduce the risk and also between the meals snacks should be non-
acidogenic.
110

Name of the article Level of evidence Results Conclusion
Kim JA, Choi HM, Seo Y,
Kang DR. Relations among
obesity, family socioeconomic
status, oral health behaviors,
and dental caries in
adolescents: the 2010-2012
Korea National Health and
nutrition examination survey.
3a In males, associations between
family income and dental
caries on permanent teeth
were noted after adjusting for
confounding variables; the
odds ratios and 95%
confidence intervals thereof
were for low-middle, middle-
high, and high family income,
respectively. Smoking
experience showed a
significant association with
dental caries on permanent
teeth in females.. There was
no association between obesity
and dental caries on
permanent teeth in either male
or female adolescents.
factors associated with dental
caries in adolescents differ
according to gender.
Therefore, gender-specific
interventions may be
warranted to improve dental
health among adolescents.
111

References
• E. Nizel and S. Papas . Nutrition in Clinical Dentistry. 3rd edition,
Saunders company, London., 1989
• Murray J.J. Prevention of dental diseases , 4th edition, Oxford publication,
2003
• Thylstrup A, Fejerskov O. text book of clinical cariology. 2nd edition:
Munsksgaard, Denmark., 1999
• Axelsson p. diagnosis of risk prediction of dental caries. Volume 2:
Quintessence publishing, Chicago., 2000
112

• van Loveren C. Sugar Restriction for Caries Prevention: Amount and Frequency. Which Is More
Important? Caries Res. 2019;53(2):168-175. doi: 10.1159/000489571. Epub 2018 Aug 8. PMID:
30089285; PMCID: PMC6425816.
• R. Rajendra, B Sivapathasundharam, Shafers Textbook of Oral Pathology, 7th edition, Elsevier, 2016
• C Pine, R. Harris, Community oral health, 3rd edition, Quiescence books.
• Alhabdan YA, Albeshr AG, Yenugadhati N, Jradi H. Prevalence of dental caries and associated factors
among primary school children: a population-based cross-sectional study in Riyadh, Saudi Arabia.
Environ Health Prev Med. 2018 Nov 30;23(1):60. doi: 10.1186/s12199-018-0750-z. PMID: 30497366;
PMCID: PMC6267843.
• Yang Q, Xi Y, Liu H, Luo J, Ouyang Y, Sun M, Yong C, Xiang C, Lin Q. Free Sugars Intake among
Chinese Adolescents and Its Association with Dental Caries: A Cross-Sectional Study. Nutrients. 2021
Feb 26;13(3):765. doi: 10.3390/nu13030765. PMID: 33652968; PMCID: PMC7996778.
113

• Wang X, Bernabe E, Pitts N, Zheng S, Gallagher JE. Dental caries thresholds among
adolescents in England, Wales, and Northern Ireland, 2013 at 12, and 15 years: implications
for epidemiology and clinical care. BMC Oral Health. 2021 Mar 19;21(1):137. doi:
10.1186/s12903-021-01507-1. PMID: 33740952; PMCID: PMC7980596.
• Palacios C, Rivas-Tumanyan S, Morou-Bermúdez E, Colon AM, Torres RY, Elías-Boneta AR.
Association between Type, Amount, and Pattern of Carbohydrate Consumption with Dental
Caries in 12-Year-Olds in Puerto Rico. Caries Res. 2016;50(6):560-570. doi:
10.1159/000450655. Epub 2016 Oct 28. PMID: 27788518; PMCID: PMC5311111.
• Palacios C, Rivas-Tumanyan S, Morou-Bermúdez E, Colon AM, Torres RY, Elías-Boneta AR.
Association between Type, Amount, and Pattern of Carbohydrate Consumption with Dental
Caries in 12-Year-Olds in Puerto Rico. Caries Res. 2016;50(6):560-570. doi:
10.1159/000450655. Epub 2016 Oct 28. PMID: 27788518; PMCID: PMC5311111.
114

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