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Definations Introduction Diet and Dental Caries Major factors in dental caries process Stephens curve Factors affecting caries process Dietry constituents and cariogenicity Food guide pyramid Sugar clocks Epidemiological human studies 1.Interventional human studies 2.Non interventional human studies Starch and Dental caries Cariogenicity of Food Can food be ranked acc to cariogenic potential
contents
Role of fats ,proteins &vitamins in dental caries
Definations
Diet :
Total oral intake of a substance that provides nourishment and energy (Nizel,1989)
Balanced Diet
It is one which contains varities of foods in such quantities & proportion that the need for amino acids,vitamins,fats,carbohydrates &other nutrients is adequetly met for maintaining health ,vitality & general well-being and also makes provision for a short duration of leaness(Chauliac,1984)
Child diet
Combination of food consumed and the nutrients contained there in, which have a profound ability to influence cognition, behavior and emotional development in addition to ultimate physical growth & development (DCNA 2003)
Dental caries:
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 cavitation
Introduction
Diet :plays imp role in which contribute to development
of caries
Dietry sugar : Most imp etiology of Dental Caries
Multifaced
a) Fermentable carbohydrate b) High pronounced starch containing food c) Novel synthetic carbohydrate(oligofruct ose,sucrose,glucose d) Non cariogenic sweetners
b) Use of flouride
c) Diet control
To determine the effect of diet :assessment of form & frequency of carbohydrate should be made earlier than clinical examination of caries 2nd problem :evaluating diet & caries in large intra individually and inter individually
Diet
Extracelllular Storage polysaccharides
Dental caries
Periodontal disease
Lingstrom et al 2000:
When evaluating starch in animal human plaque ph response in situ caries model studies Results: Processed food starches in mordern diet posses a significant cariogenic potential
Lingstrom et al 2000 studies on human provide unequivocal data on actual cariogenicity historical data->starch has low caries effect Moredern sources->starch contribute to caries development
Dental caries is caused by interaction between oral bacteria, their access to fermentable carbohydrates and vulnerable parts of the tooth. Classic graph which bears Stephan's name, shows the rapid drop in plaque pH after a glucose rinse The drop in pH is the result of fermentation of carbohydrates by some plaque bacteria. The gradual return of the pH is the result of buffers present in plaque and saliva. Provided the pH does not drop below 5.3 the enamel remains intact, but below this critical level, crystals of apatite dissolve (demineralise).
Stephens curve
Fortunately both plaque and saliva are saturated with calcium and phosphate ions, so that if the pH returns fairly rapidly above the 5.3 level, ions will go back into the enamel and recrystallise (remineralise). Acid environments favour demineralisation and occur when there is a plaque biofilm, a supply of sugar for them and little saliva. Neutral or alkali environments favour emineralisation and occur when there is good oral hygiene, no sugar and plenty of saliva. The presence of fluoride ions in the tooth or in the plaque also help remineralisation to take place.
4 sugars
sucrose
Fructose
Main polysaccharidestarch (not highly cariogenic)(cariogenic in some circumstances Japan & italy known to consume high amount of starch caries rate relatively low Studiesexcessive & frequent use of highly fermentable mono & disaccharides correalted with high caries rates
Glucose,fructose,lactose and mannose-cariogenic bt minor constituents in human food Sucrose commenest dietary sugar
Texture of food
Caldwell,1970 Texture of food & subjective descriptions of
food items by the use of terms as soft-hard,crumbly-brittle,tendertough,sticky-gooey,gritty-coarse,dry-moist arise from physical properties
Slack and martin,1958-study on effect of apples & dental health gave indications of caries reduction other fibrous vegetables a celery also exerts mechanical cleansing effects & not strongly acidic as apples.
Jenkins ,1966
Protective substance in cereals-PHYTATE a polyphosphate PHYTATE=when applied to tooth enamel reduces solubility & has caries inhibiting effect
Acidity of Foods
Acidic diet usually affect in transient manner ,ph in plaque and saliva. Natural foods such as lemons,apples,fruit juices and carbonated beverages sufficiently acidic demineraliztion of enamel Above items in normal dietary usage no influence on dental caries process Excessive usage of foods and beverages causes etching of enamel and cavitation Reports of excessive frequency of consumption of carbonated beverages,having a low ph ,continuous chewing & habitual sucking of lemons causes dental erosion
Important factor in the prevention of dental caries is limiting the number of times in a day that sugar enters the mouth.
simply illustrated by using the sugar clock.
The effectiveness of this as a technique for teaching 9-11year-old children the importance of limiting frequency of sugar intakes was tested in a controlled study.
Four weeks and 4 months after sugar clocks were used with a study group of children, they showed a significant increase over baseline in the number of correct answers given to a questionnaire. A control group showed no significant increase.
No acid formation
It was concluded that the sugar clock is an effective method of teaching the importance of limiting frequency of sugar intake to this age group
Starch consumed during earlier periods differ from highly gelatinized processed starch today constitute majority of mordern diet.
Rugg-gunn,1986 studies point out low caries prevalence during starch Schamschula ,1978
ed caries has been observed in relation to certain starches such as diet consisting frequent consumption of sago starch in grps of people in new guinea
Caries prevalence fall
toverud,1951
marked changes in intake of refined carbohydrate in europe and japan
Reduction in caries
Newbrun et al,1980
a. 17 human subjects ,the sugar intake was 2.5g for H & 48.2g for control grp. Corresponding DMFT index 2.1 & 14.3 Both grps ate high levels of starch(160g/day in H grp & 140g/day in cntrl grp)
b. c.
INTERVENTIONAL STUDIES VIPEHOLM STUDY HOPEHOOD HOUSE STUDY TURKU SUGAR STUDY EXPERIMENTAL CARIES STUDY NON INTERVENTIONAL STUDIES EPIDEMIOLOGICAL STUDIES CROSS- SECTIONAL STUDIES OBSERVATIONAL STUDIES
Interventional studies
1) Vipeholm study, Lund (Sweden) 1945- 1954 1930,Hojer and Maunsbach, Gustafson 1954 Purpose- to determine the effects of frequency and quantity of sugar intake on the formation of caries. Institutionalized patients (436- 32yrs) were divided into 6 experimental and 1control group Poor oral hygiene, twice normal sugar
Seven groups
Control group - low sugar diet only at meals Sucrose group - high- sugar diet (300g) mostly in drinks with meals Bread group - sweetened bread at meals (sugar- or equal to normal) Caramel group- 22 sticky candies 2 portions at meals (carbohydrate study I) 4 portions between meals (carbohydrate study II) 8- toffee group 24-toffee group- throughout day, twice normal total intake of sugar Chocolate group- milk chocolate- 4 portions bet meals( CSII)
Studies were divided into 3 phases 1. clinical experimental studies of the relation bet diet and caries 2. Supplementary studies 3. Special studies (Hojer and Maunsbach 1954) Preparatory period (1945- 1946)
2) Carbohydrate study
To examine how caries activity was influenced by the ingestion of carbohydrates under controlled conditions
Preparatory and vitamin period- low sugar= 0.34 carious lesions/pt/yr Carbohydrate I- twice the normal amt of sugar, only at meals Carbohydrate II- normal amt of sugar only at meals/ at and bet meals
Results
Little effect- sweet drinks with meals bread sugar in non sticky
Moderate increase in carieschocolate (4times) bet meals Dramatic increase- 22 caramels 8 / 24 toffees bet or after meals
0 A B C D E
CONTROL GROUP The effect of frequency and form of carbohydrate intake on dental caries activity
Coronal caries
Cementum caries
to ffe e8
ch oc ol at e ca ra m el 22
to ffe e2 4 po st st ud y
pr es tu dy
co nt ro l
br ea d
br ea d
su ga r
2) Microbiological studies
(Grubb and Krasse 1953, 1954) Differences in lactobacilli and carbohydrate caries promoting diet=>caries, high LB count
Other studies
a) Consumption of sweets and caries activity in school children an Hungarian farm workers-showed increase in caries with increase in high sucrose diet b) Studies on the inhibition of acid production by substance produced by chocolate bean showed significant decrease in caries and streptococcous mutans
IMPLICATIONS All the sweets you like but only once a week sugar substitutes Malmo study 1976- consumption of sugar (sticky) form bet meals= >caries incidence + high LB count Vipeholm study - Citation classic
Conclusion
Increase avg sugar consumption(30-330g/day) showed very little increase in caries(0.27-0.43 cs/yr) provided additional sugar was consumed at meals in solution In patients with poor oral hygiene - caries Varies from person to person Subsides- withdrawal of sugar containing foods Great risk Sugar (retained on tooth surf) Greatest risk- bet meals, form Increase in duration of Sugar clearance from the saliva
Limitations
No possibility of matching the age Initial caries Mentally handicapped- instructions Dietary regimes of various groups
Caries if present limited to pits & fissures & usually not in smooth surfaces Indicative of starchy foods do not produce decay sugary foods do
Results 1) Early white spot lesions Sucrose group- DMFS- 3.6 After 1 yr- sucrose and fructose= equal xylitol= no caries 2nd year- sucrose- increase fructose- unchanged Xylitol- zero Xylitol- non cariogenic / anticariogenic
S- 7.2
F- 3.8 X- 0.0
10.5
6.1 0.9
Conclusion
Substitution of xylitol for sucrose in normal Finnish diet resulted in low caries incidence. Reduced the number of most microorganism
to test the effects of xylitol gum 102 subjects- 22.2yrs 2 groups (chewing gum) 1) sucrose (4.2 sticks/day) 2) xylitol (4.9 sticks/day) Saliva- remineralistion Xylitol- anticariogenic effect
Conclusion
Sugar is modifying risk factor Dental plaque is a etiological factor Clean teeth- no caries
I. Epidemiological studies
Sugar consumption in selected countries in1977
Australia Finland Iceland Japan Canada China Cuba USSR Sweden Switzerland USA England
10
20
30
40
50
During world war II in Europe and Japan wartime food restrictions 15kg- 0.2kg nutrition Marthaler 1967 (1941-1946)- less decay Sreenby 1982 international data 6yr (23 nations), 12yr (43 nations) <50gms- <3 DMFT
Granath et al 1976,1978- level of sugar-controoled, Fl was given Oral hygiene (6yr, 4yr)-result low caries prevalence
Hausen et al 1981 2000 finish school children, least caries prevalence- sugar exposure Marthaler 1990- sugar main threat Wendt et al 1995,1996- 700 infants,1-3yr Bottle fed/breast fed>12mon Less fl toothpaste Oral hygiene and diet-result :high caries prevalence
a) Intraoral bioavailability of starch Polymers of glucose Starch molecules- starch granules (grains and vegetables) Gelatinization (8-100 c)
Salivary
Starch
Bacterial amylase
Maltose + maltriose
dextrin and glucose (mormann and muhleman1981) Modifiers starch protein, starch lipid interactions
b) Applications to cariology
1)Starch consumption, frequency and retention
Stickiness of starches in human mouth
(Bibby etal 1957,Gustafson 1953,Caldwell 1975)
Kashket et al 1991 increased starch food particles related to increased caries Lingstorm et al 1997 high cariogenic potential
Turku sugar study 3 groups- sucrose, fructose, xylitol Xylitol- little / no caries
Newbrun et al 1980
HFI (hereditary fructose tolerance)= little caries Little sucrose(2.5g/d), total carbohydrate (160g/d)
Cariogenecity of foods
(ADA 1985)
Edgar 1985-
ch ee s e
m ilk be ve ra ge
su cr os e
ca ra m el
cr ac ke r
ch ip s
S LA S m ilk ch oc
co co
ok i rn f la w he a
ke tfl a
ke
Milk sugar Cooked potatoes, rice, legumes, grains, cornstarch and bananas Cellulose, pectin, gums Sorbitol, mannitol, xylitol Lactitol,maltitol, HSH aspartame Saccharin Acesulfame sucralose
low yes
Non fermentable 1) fiber 2) Sugar alcohols High intensity sweetners 1)nuritive 2) Non nutritive
no
no no
2) Chocolate
milk
apple
Bread , butter
3) Carbonated beverages
banana
4) Apple/orange juice
Dates Bread jam Raisins Sweet biscuits Sweetened cereal Apple pie Clear mints Fruit gums Fruit lollipops
5) 6)
Cariogenecity of foods
Based on acidogenic potential
Raw vegetables<nuts<milk<corn chips<fresh fruit<ice cream<French fries<dried fruit.
Retention
High sugar foods- caramel, chocolate bars Sucrose+ cooked starch
Cariogenecity- food composition, texture, solubility, retentiveness, and rate of salivary clearance than sucrose alone
xylitol
Metabolism by microorganisms- lacks enzyme to utilize xylitol Frequency 3 times a day Timing- long term
Caries prevention
Turku 1975- 90% reduced Gallium 1981- 70%- candies Isokangas 1987- gum Makinen et al 1995 (Belize study) pellet and sticky gums
sorbitol
Fermented by microorganisms (Slow- SM) Substrate for microorganisms Diffuses out acid Slack et al 1964- 48% reduction Birkhed and bar 1991- acidogenecity reduced Glass et al 1983,szoke et al 2001- gum Von loveran 2004- between /after meal
sweeteners
Non caloric Not fermented by oral microorganisms
SOFT DRINKS AND CARIES Potentially cariogenic 10% sucrose Carbonic and phosphoric acids- pH 2.4-2.5 (transitory) Oral sugar clearance is rapid Apple and orange juice- heavily buffered
Trace elements
Trace elements in diet can be cariostatic or caries promoting Grpd in to a. Cariostatic Fl,P b. Midly cariostatic Mo,V,Cu,Sr,B,Li,Au,Fe c. Doubtful cariostatic-Be,Co,Mn,Sn,Zn,Br,I,Y d. Caries inert Ba,Al,Ni,Pd,Ti e. Caries promoting Se,Mg,Cd,Pt,Pb,Si
Trace elements divided in to 2 categories 1.Those that have well defined human requirements,namely iron,zinc,iodine,copper,flourine 2.Those that are integral constituents or activators of enzymes namely manganese ,molybdenum,selenium,chromium ,cobalt
Acts like flouride ,other elements can modify the physical and chemical composition of the teeth thus affecting the soluability of the enamel to acid attacks
References
Understanding dental caries-Niki foruk Dental caries-The disease and its clinical management-Ole Fejerskov & Edwina Kidd Nutrition in clinical dentistry 3rd edition-Athena Papas(nizel) Textbook of Pedodontics 2nd edition Shobha Tandon Laura M.Romito.Nutrition and oral health .The Dental clinics of North America2003 vol 47(2) S S Fuller & M Harding The use of the sugar clock in dental health education British Dental Journal 170, 414 - 416 (1991)