Diet and dental caries/prosthodontic courses

Diet and dental caries
INDIAN DENTAL ACADEMY
Leader in continuing Dental Education
www.indiandentalacademy.com

Introduction

Definitions
Diet -Refers to the customary allowance of
food and drink taken by any person from day to
day.
Dental caries-is a microbial disease of the
calcified tissue of teeth characterized by
demineralization of inorganic portion and
destruction of organic substance of tooth
Food -That which is taken in and absorbed for
the growth and repair of organisms.

Caries
Multi factorial disease
External (environmental factors)
Internal (endogenous factors)
Four factors
– HOST
– MICROFLORA
» SUBSTRATE OR DIET
» TIME

ENAMEL PELLICLE + BACTERIA
PLAQUE FORMATION
PLAQUE BACTERIA + FERMENTABLE CARBOHYDRATE
( FOOD)
ACID PRODUCTION
DEMINERALISATION AND DISSOLUTION OF INORGANIC
AND ORGANIC STRUCTURES OF TOOTH
DENTAL CARIES
Pathogenesis

Fermentable carbohydrate

Why sucrose

Smooth surface caries- depends on growth of dental
plaque
St. Mutans - Synthesize 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

Polysaccharide is built by extrusion from enzyme
Glucose units are transferred from sucrose to the active sites of
enzyme- to growing chain
Extra cellular synthesis transfer glucose/ fructose units directly to
growing polymer.
Enzymes conserves high energy( dihemiacetals) btn two C1 of glucose
and C2 of fructose ( 6600Cal/ Mol) found in sucrose

Streptococcus sanguis and S.mutans:
Glucosyl 1- transferases- Paque matrix material
Fructosyl transferses- Organic acids.
Properties of these enzyme of 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

Factors affecting for cariogenicity of
sucrose
Frequency of eating
Oral clearance
Effective concentration of Sucrose

Sugar clocks
(Johansson and Birkhed 1994)
Frequent eating-acid production
No acid production

Types of study providing evidence
for the relationship b/w diet and dental
caries

Epidemiological observation
Modern diet Vs primitive diet
Caries prevalence of ancient Hawaiians was extremely low in contrast
to today's
Dental caries incidence in native population -Australian Aboriginees,
Bantu tribes of South Africa, the New Zealand Maoris, the Eskimos
were low before introduction of modern diet

War time diet
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

Institutional studies
Vipeholm study(1946-51)
Conducted in viphelom hospital near lund in
Sweden
Study conducted on adult inmates in mental hospital
Experimental design
• Contained 436 adults divided in to seven groups
Purpose-To determine the effect of frequency
and quantity of sugar intake on dental caries

Control group
Sucrose group(300g)
Bread group (50g)
Chocolate group(65g)
Caramel group(22car-70g)
8 toffee group(60g)
24 toffee group(120g)

Main conclusion of the study
Increase in carbohydrate increases the caries activity
Risk of caries if sugar is consumed which retains
Risk increase if sugar is consumed b/w meals and form
of sugar
Upon withdrawal of sugars-caries activity disappears
Caries continues to appear despite restriction of sugar
A high con of sugar in sol and its retention on tooth
surface leads to increased caries activity
Clearance time of sugar co-relates closely with caries
activity

Hope wood house children
Longitudinal study conducted on 3-14 yr
children residing in hope wood house in
Bowral, New south wales-10 yr
Absence of meat and rigid restriction of refined
carbohydrate were the principle
25 out of 82 remained caries free over 5 yr
As children left the institution sharp raise in
caries(13-18)

Seventh day Adventist study
Seventh Day Adventist dietary counsels advise limitation of
use of sugar, sticky desserts, highly refined starches, and
between- meal snacking depend upon religious motivation
Adventist children tends to be lower caries than that in non-
Adventist children in same geographic location and
socioeconomic stratum.

Turku sugar studies
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

Study conducted includes
125 young adult(27.6yr)
Divided into 3 groups
• Sucrose group
• Fructose group
• Xylitol group

Caries reduction -after 2 years of xylitol consumption
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.

Animal studies

General conclusion
Fed by stomach tube did not develop caries
Sugar sol produced less caries than solid sugar
Coarse particles are less cariogenic than fine
Post eruptive maturation of teeth was reduced
Raw starch has less ability to cause caries
Streptococci do not induce caries in absence of
carbohydrate
Frequent in take of sucrose has –rampant caries
P,Fl addition has reduced the dental caries
Sugar alcohol has no ability to initiate caries

Survey of dietary habits of children
Zita et al –no relation ship b/w the 2
Total amount of sugar consumed and caries
Relation bw no of sugar in take and dmfs
Weiss and Trihart-
Relation bw sugar and caries

Availability of sweet and candy
Fanning at al
Examined 1226-found fewer DMFS where sweets are not
available
Study on south Australian children
• Frequent users of canteen sweets had high caries
• Infrequent users had less
Dentist children have better oral health than others
Educational level of parent positive core dental health

Special population group
Nursing bottle caries
Cereal studies
Hereditary fructose intolerance
Industrial risk

Nursing bottle caries
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)
Breast feeding – primary dentition in infants
7.2 % lactose by weight in human milk: 4.5 % in bovine
milk

Cereal
studies

Cereal studies
Sugar coated cereal – 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
Shaw…..amount of pre sweetened cereal is less than total
amount ingested daily
Still controversy exists regarding cariogenicity of cereal

Hereditary fructose intolerance
Caused by reduced level of fructose 1aldose
Person learn to avoid food contain fructose or
sucrose
Dental caries in these –extremely low
Siblings of these showed similar incidence of
caries

Industrial risk
Persons in bakery and candy factories showed
higher incidence of caries than workers in textile
factories
Employees in chocolate factory showed more
caries than person in ship yard
Sugar cane workers had more caries incidence
than workers in textile industry

Assessment of cariogenic potential
of food stuff
METHODS TO MEASURE THE CARIOGENIC
POTENTIAL
In vitro caries models
In vivo/ In vitro caries models
Adhesiveness of foods
Plaque PH measurements

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

In vitro caries model
Food is mixed with an inoculums of salivary flora-
amount of acid formation
Short comings
Salivary flora in not representing plaque micro biota
There in no continues salivary flow
Results obtained by such result does not match findings in
animal studies

In vivo caries model
Two tests, ICT and IPT
Use blocks of bovine enamel mounted on prosthesis worn intra
orally
Plaque is grown on enamel surface
Extent of demineralization is compared with enamel hardness,
permeability of iodine
limitation– Food only in solution and Patient compliance.

Adhesiveness food
Cohesion: tendency of food to stick itself
Adhesion: firm attachment bw food and tooth surface
pressure applied to food – interproximal and occlusal sites :
masticatory stress
Tackiness : ability of food to stick to the tooth when minimal force
is involved
The adhesion test involved measurement of tensile force required
to break a bond bw food and saliva and tooth surfacewww.indiandentalacademy.com

Plaque ph measurement
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 each time
pooling of plaque from different sites
measurements is intermittent than continues

Touch electrode
Microelectrodes placed with in plaque on the tooth surface
at intervals after food ingestion
Direct reading of ph
plaque surface
Investigation on antimony and glass electrode-
Limitations:
Disrupts the plaque structure
Outer surface of plaque pH

Built in electrode
Miniature electrode built in to prosthesis
pH
readings taken continuously by either wire or radio telemetry
Previously glass electrode- slow response(30 sec) to ph
Recently hydrogen ion sensitive field transistor
ph sensitive tip- extremely small : 1mm2
-Si3N4
– Low electric resistance
– Rapid response time (10sec)
Indwelling bimetallic ( palladium/ palladium oxide)- versatile
rapidly responds to ph changes

Ph telemetry
Method used by Swiss health authority to classify
food for labeling
If food or beverages does not cause ph below 5.7
for 30 min then food is safe
Foods which had ph below range
Sugar containing foods and beverages
Non nutritive sweetener showed to be non
acidogenic by ph telemetry

Cariogenicity of other food

Protein and dental caries
Protein in carbohydrate containing food may influence
caries incidence
Physical properties of wheat are imp for decay
Addition of lysine has reduced cariogenicity
Lysine probably reduce the rate of decalcification

Fats dental caries
Institutional study has reported high fat diets arrest
tooth decay
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.

Starch and dental caries
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.

Milk and dental caries
Substantial source of sugars in the diet of young children.
Lactose – Less acidogenic.
Phosphorus, Calcium and Casein – demineralization .
Animal studies – Anti cariogenic.
Human breast milk – Higher lactose but Lower P and Ca

Caries inhibiting food and food components

Phosphates
Phosphate in animal diet has shown caries
reduction
Sodium metaphosphate appears to be effective
Local factors thought to reduce dental caries
• Reduction of enamel solubility
• Buffering effect in neutralizing salivary, bacterial
plaque, food ph
• Interference with membrane condition, enzymatic
process on enamel surface
• Decrease in bacterial adhesion
• Interference with extra cellular polysaccharide
formation
• Increase of plaque calcium and phosphorus

Sugar substitute
 Most important role :Sugar free confectionery, chewing gums
soft drinks, table top sweeteners and in liquid oral medicines
.
 Non sugar sweeteners :
Bulk sweeteners or Caloric sweeteners.
Ex: Polyalcohol (Sorbitol , Xylitol), Starch hydroylsates
Intense sweeteners or Non caloric sweeteners.
Ex: Aspartams, Saccharine, Cyclamate, Some plant sources

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.
Naturally found in foods.

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.

Xylitol
Absorption slow and incomplete .
Used in Diabetics.
Metabolism by Oral Microorganisms :Human oral
microorganisms do not have enzymes to utilize xylitol.
Starch hydrolysates
Lycasin :Hydrogenated glucose syrup produced from starches
Caloric value – Similar to other carbohydrates.

Intense sweetener
Not chemically related to sugars.
Added in very small quantities and not volume.
100 to 1000 times sweeter than sucrose.
Negligible energy value
Low caloric sweeteners are used in:
Gelatin desserts puddings
Desert toppings
Soft drinks
Chewing gums
Medicinal preparations
Dentifrices and mouth washes

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 , dieted food , mouth washes ,
medicinal preparations , sweeteners for table use.
Cyclamate
Organic sweetener .
Economical.

Dietary consideration
Evaluation of dietary factor
Data obtained provides caries risk assessment and also
aid in counseling in related to caries control and in
promoting general health
Aimed at estimating the cariogenic challenges caused by
carbohydrate and assessing general nutritive value

Dietary history
BY INTEVIEW
24 hour recall-
pt is asked about 24 hr diet
Dietary records/food dairies
To make the evaluation as accurate as possible
Record should be kept precisely
• How many slice and what kind of bread is used
• What is drunk with b/w meals
• Is jam or sugar is used
• How many lumps of sugar
• Vegetables raw or boiled
Include all snack-soft drinks sweet roll, fruit puree

Food frequency questionnaire
Contains list of food items-selected to whole
diet or specific diet
Used to estimate nutrient in take
Method is un complicated and inexpensive and
useful as screening instrument or for obtaining
dietary data at a group level

Analysis of dietary data
Done once completion of data collection and
check on plausibility of reported consumption
Evaluation of the cariogenic potential
• Estimation factors as no of intake
• Consumption of snacks and sugar containing
fermentable carbohydrate
• Retentiveness of cariogenic products

Dietary recommendation
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,
candies, cake, and pastries, if not completely then as
much as possible.

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).www.indiandentalacademy.com

References
• Pediatric dentistry-Ray e Stewart
• Clinical pedodontics-Sidney B.Finn
• Cariology –Ernest Newbrun

Diet and dental caries/prosthodontic courses

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