Lactobacilli and Streptococcus mutans in saliva, diet and caries increment in 8- and 13-year-old children

CHRISTINA STECKSEN-BLICKS
Departments of Pedodanties and Oral Microbiology, University of Umm, Umed, Sweden

Stecksen-Blicks G: Lactobacilli and Streptococcus mutans in saliva, diet and caries increment in 8- and 13-year-old children. Scand J Dent Res 1987; 95: 18-26. Abstract The aim of this paper was to evaluate the correlation between some dietary factors and prevalence of lactobacilli and S. mutans in saliva in randomly selected groups of 8- and 13-yr-old children. The relation between these parameters and caries increment over a 1-yr period was also sttidied. In general there was a weak correlation hetween the number of these bacteria in saliva and total intake of sugar, sucrose intake and meal frequency. However, the probability of finding low total sugar intake, low sucrose intake and a low meal frequency was highest when there was a low prevalence of both bacteria and finding high total sugar, high sucrose and high meal frequency when there was a high prevalence of both bacteria. It was also shown that knowledge of sugar intake and meal frequency provided some supplement to bacterial tests in the selection of caries-risk patients. Key words: dental caries; diet; lactobacilli; S. mutans. Christina Stecksen-Blicks, Department of Pedodontics, University of Utnea, S-901 87 Umea, Sweden. Accepted for publication 25 January 1986.

Denta! caries is induced by acid produced by microorganisms frotn dietary sugars. There is broad evidence for a correlation between sugars in the diet and caries (1, 2) and some experimental evidence that it is the frequency, rather than the size, of sugar intake, that is important (3). Furthermore a positive correlation between the prevalence of lactobacilli and S. mutans in plaque or saliva, and caries increment is well documented (48). Experimental studies have shown that the number of lactobacilli in saliva can be al-

tered by changes in intake of dietary sugars (914) and also that there is a correlation between the sucrose content of the diet and S. mutans levels in plaque (1416). In the Vipeholm caries study it could not, however, be demonstrated that the lactobacillus count correlated to the intake of sugars (17), but the differences in sugar consumption between the trial groups was large enough to cause differences in caries activity (3). It has also been shown that S. mutans can remain in the mouth after a reduction of sucrose in the diet {14, 18, 19).

LACTOBACILLI, S. MUTANS, DIET AND CARIES All previous studies concerning diet and the prevalence of lactobacilli and S. mutans in plaque or saliva have been experimental. Whether there is a correlation between the presence of these bacteria in saliva and the intake of dietary sugars in a child population is not known, but a correlation has often been taken for granted in the individual case as well. If this could be confirmed, it would be of clinical importance since the problems involved in questioning patients about their sugar intake are well known and probably more pronounced in a professional dental environment (20). In 1980/81 a thorough study of the dietary habits and nutrient intake of children in different parts of Sweden was carried out by the Swedish Board of Nutrition. The study was performed by well-trained dieticians with no association with dentistry, which is probably important for the validity of the answers concerning sugar intake. A deotal health examination including saliva sampling was performed in a subsample, which made it possible to study the correlation between some dietary factors and lactobacilli and S. mutans in the saliva. The relation between these parameters and caries increment over a period of 1 yr was also studied.

19

The caries examination at baseline included two posterior bitewing radiograiphs when approxima! surfaces could not be inspected. Decayed, missing and filled surfaces were recorded (dmfs/DMFS). In the 8~yr-olds the dmfs-values included only primary molars and canines. Ali initial caries lesions (caries that had only penetrated 2/3 of the enamel) were included in the dmfs/DMFS-vaiues. Mean dmfs/DMFS score at baseline was 7.1 6.6/3.3 + 3.2 in the 8-yr-olds and corresponding mean DMFS score was 9.3 6.6 in the 13-yr-olds. From those children who had neither cavitation nor defective fillings, saliva was collected after stimulation by chewing paraffin wax, and a Dentocult dip-slide was inoculated (22, 23). The samples were incubated at 37C in an aerobic environment and read after 4 days. Saliva stimulated by chewing paraffin wax was also collected with a spatula for cultivation of S. mutans using
a method described by KOHLER & BRATTHALL

(24). These samples were incubated in an atmosphere of 5% CO2 and 10% H2 in Nj at 37C and read after 2 days. A total of > 20 CFU on the predetermined area of the agar-plate was counted as equivalent to > 10^ S. mutans/ml saliva (24). Those children who had cavitadon and/or defective fillings first receii'ed restorative treatment as recommended by CROSSNER (4). Saliva samples were then taken within 1 week after finishing this treatment for cultivation of lactobacilli and S. mutans as described above. The children were re-examined for caries 1 yr 1 tnonth after the bacteriologic sampling. During the course of the study five 8-yr-olds and nine 13-yr-olds dropped out, which meant that Material and methods caries increment was assessed in 83 8-yr-olds and The children included in this study were part of 88 13-yr-olds. All new caries lesions were recorded a larger material randomly selected in order to whether manifest or inidal. The net caries instudy the dietary habits, nutrient intake and den- crement was calculated in each child. In the 8-yrtal health of 4-, 8- and 13-yr-old children in differ- olds the sum of increment in pritnary and permaent parts of Sweden (21). In the town of Umea, nent teeth was calculated. The dietary information was collected using a which constituted one of the areas in the above mentioned study, 113 8-yr-old and 120 B-yr-old 7-day record for the 8-yr-olds and a dietary history healthy children were selected. Of these 18 8-yr- for the 13-yr-olds, both preceded by careful inolds and 19 13-yr-olds refused to participate in the struction. To help estimate quantities in the 8-yrdental health examination and saliva sampling for olds photographs of food in portions of various cultivation of lactobacilii and S. mutans. Another sizes were used. In the 8-yr-group all the foods seven 8-yr-olds and four 13-yr-olds dropped out eaten during 1 week were recorded hy the parents in the dietary study. The retnaining groups of 88 on a special form. When recording school lunches 8-yr-olds and 97 13-yr-olds constituted the ma- the children had to cooperate with their parents. For nine 8-yr-olds the dietar>' record was kept for terial on which this paper is based.

20

STECKSEN-BLICKS

only 5' or 6 days. In the 13-yr-group the interview Analysis of variance was used to test difTerences started with a mapping of the general meal pat- between mean values (26). tern, followed by a careful interview of the average intake of common foods and dishes during the last 2 months. The dietary history was taken in the Results absence of the parents and lasted about 1 h for In the 8-yr-olds, total sugar and sucrose coneach child. sumption and number of meals per day were The use of two different methods was the result of experience gained in a pilot study, where it was statistically significantly correlated to salifound difficult to get the necessary cooperation for vary S. mutans count (P<0.05, /'<0.01) a 7-day recording in the 13-yr-group (25). The (Table 1). No statistically significant corredietary information obtained was coded and lation was found between the dietary parahousehold measures were transformed into weights meters and the lactobacillus count in this by use of a standardized system. The data were age group. carefully controlled before data processing to In the 13-yr-olds a statistically significant avoid punching errors and finally processed with correlation was found between salivary the aid of a computerized food data bank delactobacillus count and total sugar and sucveloped by the Nadonal Swedish Food Administradon. This data bank contains information on rose consumption (g/day) and also number the energy and nutritional content of B O foods of meals per day (P<0.01) (Table 1), but O and 500 dishes. The mean daily intake in grams there was no such correlation between these of total sugar and of sucrose, and mean daily meal parameters and salivary S. mutans count. frequency were calculated for each child. Scoring a total of > 10^ lactobacilli/ml saThe children taking part in this study were all liva and > 10* S. mutans/ml saliva as a posigiven free annual dental care, which if needed tive test (high), we were able to divide the included professional toothcleaning and topical children into four different groups A, B, G fluoride treatment. 94% of the children in both and D (Table 2). With the children divided age groups took part in the weekly niouthrinsing into these groups it was shown in an earlier program with 0.2% NaF solution in school, and 84% and 91% respecdvely used fluoride tooth- paper (6) that these bacteria provided a paste. The amount of fluoride in the drinking valuable aid in. the identification of groups of caries-risk patients. In neither age group, water was 0.3 ppm. Statistical method Pearson's coefficient of corre-however, in this study cotild statistically siglation was used to test correlation between factors. nificant differences in mean scores for exatn-

Tahle i
Correlation of totai sugar and sucrose intakes fglday) and meal frequencies with salivary laetobacilli and S. mutans counts and caries increment in 8- and 13-y^-old children

8-yr-olds Total sugar g/day Sucrose g/day No. of meals/day 13-yr-olds Total sugar g/day Sucrose g/day No. of meals/day

Lactobacilli Corr coeff (R) K=88 0.144 NS 0.155 NS 0.117 NS

K = 97

S. mutans Corr coeff (R) n = 88 0.184 P<0.05 0.192 /'<0.05 0.285 P<0.01 n = 97 0.125 NS 0.134 NS 0.114NS

Caries increment
K = 83

0.100 NS 0.190 NS 0.044 NS .. n = B8 0.100 NS 0.214 P<0.05 0.214 F< 0.05

0.272 P<0.01 0.259 /'<0.01 0.264/><0.01

LACTOBACILLI, 8. MUTANS, DIET AND CARIES Table 2

21

A^ean total sugar and sucrose intakes and number of meals in S- and 13-yr-old children witk different salivary levels of lactobacilli and S. mutans. High number of Uictobaeilli: >.10^lml saliva. High number of S. mutans: >20 CFU transferred from spatula 8-yr-olds Lbc A B C D Total 13-yr-olds Lbc A B C D Total Low High Low High Low High Low High S.m. Low Low High High n 49 6 19 14 88 Total sugar g/day X SD 103.2 92.0 108.2 113.4 105.1 26.8 33.2 20.7 29.6 26.2 Sucrose g/dag
X

SD 17.1 18.5 12.6 21.8 17.6

No. of meals/day X SD 5.0 4.6 5.2 5.4 5.1 l.O 1.7 l.l 1.0 l.l

45.1 36.5 47.4 55.1 46.6

S.m. Low Low High High

n 44 11 24 18 97

Total sugar g/day X SD 156.4 194.9 160.6 192.5 168.5 64.1 83.2 118.2 111.5 91.5

Sucrose g/day
X

SD 35.2 44.8 89.4 54.0 57.2

No. of meals/day X SD 5.2 5.9 5.5 5.8 5.5 1.0 Li 0.8 Ll 1.0

59.0 84.6 71.0 82.0 . 69.4

Table 3 Met mean caries increment (mean and SD) in 8-yr-old childrai in different bacteriahgic strata witk different total sugar and sucrose intakes and meal frequencies. Average intake for tke age group is used as cut-off point. Ko.. of mealsjday 0-5=0, >6= 1, sucrose intake gfday: 0-^7g = 0, >48 = !, total sugar intake gjday 0-105g = 0, >106 g = 1. High number of lactobacilli: >10^lml saliva. High number ofS. mutans: > 20' CFU transferred from spatula Caries Total sugar increment n Mean SD g/day 0 1 0 1 0 1 0 ! 0 1 Total 29 19 48 4 2 6 5 12 17 4 8 12 42 41 83 1.2 1.3 1.2 0.8 1.5 1.0 1.0 1.2 1.1 2.8 3.8 3.4 l.,3 1.7 1.5 2.0 2.1 2.0 1.5 0.7 1.3 1.7 1.9 l.,8 2.5 4.1 3.6 2.0 2.6 2.3 Sucrose g/day 0 1 0 1 0 1 0 1 0 1 Caries increment Mean .3D 0.9 .9 2 LO .0 .0 .0 .2 .1 2.8 3.8 3.4 1.1 2.1 1.5 1.2 2.9 i.O 1.7 1.0 .3 1.7 1.9 .8 >.5' 1.1 i.6 .5 i.O :2.3 Meals/day 0 1 0 1 0 i 0 ! 0 1 25 23 48 2 4 6 7 10 17 3 9 12 37 46 83 Caries increment tnean SD 1.2 1.2 1.2 1.5 0.8 1.0 1.9 0.6 i.l 2.0 3.9 3.4 1.4 1.6 1.5 2.1 1.9 2.0 2.1 1.0 1.3 2.3 1.3 1.8 .1.7 4.0 3.6 2.0 2.5 2.3

Lbc A Low Total B High Total C Low Total

S.m. Low

n 32 16 48 3 3 6 5 12 17 4 8 12 47 36 83

Low

High

D High High Total

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STECKSEN-BLICKS and a meal frequency above the average for the age group generally had a higher caries increnient than those who were below the cut-off point. When salivary levels of lactobacilli and S. mutans were also taken into account,, the Tables show that information on both dietary factors and salivary lactobacillus and S. mutans counts innproved the chance of predicting groups of individuals with a high caries increment. Tables 3 and 4 also show that the probability of finding a low daily total sugar and sucrose consumption and a meal frequency of 5 meals/day or less was higher when both salivary lactobacillus and S. mutans were low (Group A). Discussion The results show generally weak correlations between the dietary parameters studied and lactobacillus and S. mutans levels in the sali-

ined dietary parameters be shown between the groups A, B, G and D. 43% of the 8-yr-olds .and 38% of the 13yr-olds had no caries increment at all during the course of the study. The net mean increment in the 8-yr-oIds (primary and permanent dentition) was 1.5 2.3 (124 surfaces) and in the 13-yr-oMs 3.6 + 6.3 (315 surfaces). The correlations between the dietary parameters studied and caries increment were generally low (Table 1). Only in the 13-yrold group were daily sucrose consumption and number of meals/day significantly correlated with caries increment {P<0.05). In Tables 3 and 4 material is divided according to intake of different sugars and meal frequency, with the mean intake of the original group at baseline (Table 2) used as a cut-off point. In both age groups, children with a total sugar and sucrose consumption

Table 4
Net mean caries increment (mean and SD) in 13-yr-old children in different hacteriologic strata with different total sugar and sucrose intakes and meal frequencies. Average intake fm tke age group is used as eut-off point. Mo. of mealsjday: 0-5=0, > 6= I, sucrose intake gjday: 0-69 = 0, >70 = l, total sugar intakegjday: 0-169 = 0, >170 = 1. High number of lactobaeilli: >10^ mljsaliva. High number of S. mutans: >20 CFU transferred from spatula

Lbc A Low

S.m.
Low

Caries Total sugar increment n g/day Mean SD

0
1

Sucrose g/day
0 1 0 1 0 I 0 1 0 1

Caries increment Mean SD

1.4 3.4 2.0 1.7 3.3 2.2 5.2 1.4 4.3 6.1 8.6 7.5 3.1 4.6 3.6 2.3 5.1 3.5 1.2 2.1 1.6 9.4 1.7 8.4 4.7

Meals/day
n 0 1 0 1 0 1 0 1 0 I 27 15 42 3 6 9 12

Caries increment tnean SD

1.3 3.3 2.0 2.3 2.2 2.2 1.9 7.4 4.3 8.8 6.9 7.5 1.9 5.2 3.5 2.3 1.5 1.6 3.3

Total
B High Low 0 1 0 1 0 1

30 12 42 6 3 9 17 4 21 10 6 16 63 25 88

1.4 3.5 2.0 1.5 3.7 2.2 4.9 1.8 3.3 5.1

2.4 5.4 3.5 1.2 1.5 1.6 9.2 1.7 8.4 4.7

28
14 42 6 3 9 16 5

Total
C Low

High

Total D High High Total 0

1

21 7 9 16 57 31 88

9 21 5 11 16 47 41 88

11.8
8.4 4.1

11.5
7.5 3.0 5.2 3.6

12.5
8.7 5.6 7.7 6.3

11.1
8.7 5.7 7.2 6.3

10.3
8.7 3.4 8.3 6.3

2.3 5.0 3.6

Total

LACTOBACILLI, S. MUTANS, DIET AND CARIES va, and they differ between the two age groups. In the 8-yr-old grotip only the S. mutans count turned out to be significantly correlated to the dietary parameters (P<0.01,, P<0.05). The sqtiared coefficient of correlation R* expresses the percentage of the variation explained. Thus the total sugar consumption explains 3.4%, the sucrose consumption 3.7% and the frequency of meals 8.1% of the variation in S. mutans level in the saliva of the 8-yr-olds. In the 13-yr-olds all the dietary parameters were significantly correlated with the lactobacillus count, but not with the S. mutans count. Total sugar consumption accounted for 7.4%, sucrose consumption for 6.7% and frequency of meals for 6.9% of the variation in lactobacillus level. The children in this study were taking part in a larger study of children's diet and dental health (21). The dental health and the socioeconomic group of the dropouts have been checked from the Public Dental Service records and do not differ from those of the group examined. It can therefore be assumed that the dropouts would not have influenced the results in any definite direction, if they had been included. Different nmethods of collecting dietary data were used in the two age groups, and this may have infiuenced the results. The reliability of the dietary history used with the 13-yr-olds has been shown to be good (25) but it gives higher values than a 7-day recall used with the 8-yr-olds (27). However, it is not possible to determine which of the methods gives the most correct estimation of the true intakes (28). The dietary information was obtained by a trained dietician in the children's homes, which probably has produced truer answers about the intake of sugar containing products than if the interview had been performed in a dental environment by dental personnel. It has been suggested that the quality of 7-day records may decline during the recording period (25). It is therefore assumed that

23

the absence of information for 1 or 2 days with regard to nine 8-yr-old children can have had only an insignificant effect on the estimated daily mean intake of sugars and the number of meals. The present data suggest that in these children the lactobacilltis and S. mutans levels in saliva are not particularly reliable in reflecting total sugar intake, sucrose intake and meal frequency. In the case of S. mutans they rather support the conclusions drawn by ScHEiE et al. (18), namely that salivary levels of S. mutans are not systematically affected by a reduction of sucrose in the diet. Earlier studies have shown that under experimental conditions the sucrose content of the diet is positively correlated to the prevalence of S. mutans (1416), but also that an established level of S. mutans is only slightly affected by a reduction of sucrose in the diet (14, 18, 19). In the 13-yr-olds, a higher percentage of the children with a high S. mutans level reported a low total sugar and/or low sucrose intake than in the 8-yr-olds (Tables 3 and 4). It may be that the older children have cut down the amount of sugar in their diet to a larger degree than the younger ones after colonization by S. mutans. This may explain the difference in results between the two age groups. Factors other than sugars may also determine the level of S. mutans in the saliva, e.g. more retention sites in the 13yr-olds. As far as the correlation between diet and lactobacillus count is concerned, it has earlier been shown that the lactobacillus count in plaque or saliva may be brought down by a reduction of dietary sugars (9^14). In the present study, the percentage of children with a high lactobacillus count who reported a low sucrose and/or low total sugar consumption was almost the same in both age groups. However, the lack of a significant correlation between the intake of dietary sugars and the prevalence of lactobacilli in the saliva in the 8-yr-old group may be partly caused by a lower prevalence of lactobacilli

24

STECKSEN-BLICKS In spite of general weak correlations between the intake of dietary sugars and prevalence of lactobacilli and S. mutans in the saliva demonstrated in this paper, it has also been shown that the knowledge of sugar consumption supplemented the bacterial tests in the selection of caries risk patients. This indicates the importance of including dietary information with special emphasis on sugar consumption in the preventive work.

in this age group, probably due to a lower number of teeth and thus fewer retention sites for these bacteria in this age group (29, 30). The effect of dietary sugars on the prevalence of lactobacilli and S. mutans in the saliva may be influenced by factors in the saliva which promote or prevent colonization of bacteria and/or by oral cleansing forces. The topical fluoride applications received by the children included in this study, i.e. fluoride rinsings, fluoride toothpaste and fluoride varnish, may not have had any effect on the prevalence of S. mutans (31-33) but may still have prevented bacteria from producing acid by affecting the carbohydrate metabolism (34) and thus have restricted the development of caries in some children. The effect offluorideon the metabolistn of lactobacilli seems to be less than the effect on streptococci (35). However, the caries inhibiting efFect of fluoride by its action on the enamel surface should not be disregarded. Two 8-yr-olds and three 13-yr-olds were given repeated professional toothcleaning during the year of the study, which may have reduced their caries activity without reducing the lactobacillus and S. mutans population (36, 37). It has been shown in an earlier paper (6) that a combination of counts of salivary lactobacilli and S. mutans is more useful in caries prediction than either count used alone. But it was also shown that children with high numbers of lactobaciili aod S. mutans cotild have very little or no caries increment, while children with low numbers of lactobacilli and S. mutans could develop several new carious lesions in 1 yr. Results in Tables 3 and 4 show a tendency for caries increment to be higher when dietary factors included are unfavourable in all bacteriologic strata. Pattern of intake and consistency of sugary products have not been taken into account, btit are presumed to have influenced the results.

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