Understanding the Relationship Between Diet and Dental Caries

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Diet and dental Caries
 
DENTAL CARIES SEVERITY
CLASSIFICATION SCALE
 
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Local dietary effects
 
Dietary carbohydrate are caries conductive by the following points:
All dietary sugars (sucrose, glucose, fructose, lactose) are used in
the energy metabolism of plaque bacteria
Carbohydrates can be used directly by bacteria or stored as intra or
extracellular polysaccharides
 Fermentation of carbohydrate's by bacteria causes increase in the
organic acid concentration mainly lactic acids, under-saturation of
calcium and phosphate and tooth demineralization
.
 
Carbohydrate nomenclature
 
Monosaccharaides
Glucose (dextrose)
Fructose (fruit sugar)
Galactose
Invert sugar (50% fructose + 50% glucose)
Disaccharides
Sucrose (table sugar)
Maltose
Lactose (milk sugar)
Trehalose (mushroom sugar)
Natural and manufactured oligosaccharides (3–10 units)
Polysaccharides (˃10 units)
Starch
 
 
Evidence for a relationship between diet and
dental caries comes from different types of
studies
• Human intervention studies
• Human observational studies
• Animal experiments
• Plaque pH studies
• Enamel slab experiments
• Incubation studies
 
Epidemiological(observational)
studies
 
Population that had reduced sugar availability during the 
Second
World War 
showed a reduction in dental caries which subsequently
increased again when the restriction of sugar was lifted
Isolated communities with primitive way of life and low sugar
intake have low dental caries level. As such societies shift towards
habits and diets of modern living(nutrition transition), marked
increase in dental caries was  observed
 
People with high sugar consumption also have high level of caries
like confectionary industry workers and children with chronic
disease requiring long-term sugar-containing medicine
 
Human intervention studies
 
Rare studies due to problems in trying to describe
diet for long period of time
Old studies conducted  in pre-fluoride era on
highly selected group of people
Not possible to repeat due to ethical constraints
Hopewood House study, Vipeholm study, Turku
sugar studies
 
Hopewood House study
 
Children living in the Hopewood House children’s home in New
South Wales received annual dental surveys between 1947 and 1962.
A lacto-vegetarian one with an almost negligible amount of refined
carbohydrates and the presence of minimal animal protein. Whole
meal bread, soya beans, wheat germ, oats, rice and potatoes were the
main sources of carbohydrates. The majority of the food were eaten
uncooked - this was highly unusual, coupled with the fact that sugar,
white flour and products made from these items were rarely included
in meals.
Fluoride content in the water and food consumed was also
insignificant and meals and snacks were taken with great regularity.
 
Hopewood House study
 
Dental caries levels were much lower than in children of the same
age and socioeconomic background attending state schools in New
South Wales
46% of 12-year-olds in Hopewood house were caries-free compared
with 1% of the children from state schools.
The Hopewood House study goes to show that in institutionalized
children at least, dental caries can be reduced significantly, even
without the beneficial influence of fluoride and in the presence of
unfavorable oral hygiene.
However, after 12 years of age, when the children’s association with
the home ended, the rate of caries increased to levels observed in
children from the state schools.
 
The Vipeholm study
 
The Vipeholm study was conducted shortly after the Second World
War in an adult mental institution in Sweden between 1945 and
1953
The aim of the Vipeholm Study was to determine the relationship
between diet, frequency of sugar intake and dental caries. The
variables included the type of sugar ingested (sticky or non-sticky
form) and the frequency of sugar intake (at meals or in between
meals). The subjects (436 patients) were split into one control
group and six main test groups, where the 'bread' and '24-toffee'
groups were further divided into two separate groups according to
gender.
 
 
The Vipeholm study
 
The dietary regimes were given in two periods. The first
carbohydrate period was between 1947 and 1949 and the second
carbohydrate period in which the regimens were changed
slightly between 1949 and 1951.
A period of vitamin supplementation occurred for 1.5 years
prior to the carbohydrate periods
 
The Turku sugar studies
 
A second important intervention study was the Turku study. This
was a controlled longitudinal study carried out in Finland in the
1970s
The study investigated the effect of almost total substitution of
sucrose in a normal diet with either fructose or xylitol on caries
development
Three groups of subjects (n = 125 in total) aged 12–53 years, with
65% being in their twenties, consumed a diet sweetened with
either sucrose, fructose, or xylitol for a period of 25 months and
dental caries increment was monitored blindly at six-month
intervals
 
The Turku sugar studies
 
Foods were specially manufactured for the fructose and xylitol
groups and intake of starch was not restricted but subjects were
asked to avoid sweet fruits such as dried fruits since sugars in
these foods could not be substituted.
The xylitol group consumed xylitol-containing foods
significantly less frequently than the sucrose or fructose groups
consumed their sweetened foods and the overall intake of xylitol
in the xylitol group was lower than that of sucrose or fructose in
the other groups
 
The Turku sugar studies
 
An 85% reduction in dental caries was observed in
the xylitol group who had removed sugar from their
diet.
Conclusions of the Turku study are that substitution
of sucrose with xylitol resulted in a markedly lower
dental caries increment in both cavities and at the
pre-cavitation stage.
 
Animal experiments
 
Animal experiments have enabled study of different types,
concentrations, and frequencies of carbohydrates and sugars
under specified conditions. It would not be possible to test such
dietary regimens in humans due to problems of palatability and
compliance.
Animal experiments most commonly use the rat model; however,
mice, hamsters, and monkeys are also used
 
Enamel slab experiments
 
Enamel slab experiments use oral appliances that hold slabs of
bovine or human enamel. Plaque forms on the enamel slabs that
remain in the mouth for 1 to 6 weeks. The slabs are exposed to the
dietary factor being tested, by either consumption with the slabs in
situ or by removal of the appliances several times a day to dip into
vessels containing the dietary test substances
 
Incubation studies
 
Incubation studies are simple in vitro tests that measure if plaque
bacteria can metabolize carbohydrate in a test food to produce acid.
 Pure cultures of micro-organisms may also be used in place of
whole plaque. Rapid acid production and/or a low final pH is
interpreted to mean that a food is potentially cariogenic, while a
slow rate of acid production or higher final pH is likely to be of
little clinical significance. All mono and disaccharides (10%
solutions) produce a final pH of below 4.5 when incubated with
plaque.
 
Plaque pH studies
 
Plaque pH studies measure changes in the pH of plaque following
consumption of a carbohydrate or carbohydrate-containing food.
They measure acidogenic potential, which is taken as an indirect
measure of cariogenic potential, although acidogenicity does not
take into account protective factors in foods consumed and,
salivary factors that may modify the carcinogenicity of a food.
 
Many factors can determine the shape of Stephan
curve
 
Site of dental plaque (less pH responses in lower jaw than upper
jaw and anterior sites than posterior)
The role of saliva in countering the pH drop
Food acidogenicity
Its easy to rank the relative cariogenic potential of foods by
evaluation and comparing Stephan curves derived when such food are
eaten under controlled condition.
pH values differ in the plaque of sound tooth comparing with
active and inactive lesions
Buffering capacity of plaque
 
Types of sugar and dental caries
 
Sucrose (the arch criminal of dental caries) is more cariogenic
according to the animals experiments
 
(the amount of plaque formed is not necessarily related to
cariogenicity)
Turku study showed no significant difference in caries
development among subjects on diets sweetened with sucrose
compared with fructose
 
 
Frequency of sugar intake and
caries development
 
The More occasions of sugar is taken, the greater the number of
times plaque pH will bellow a level where demineralization can
occur
The primary evidence for the belief that the prevalence of dental
caries is directly related to the frequency and to the form, in which
sugar is eaten, comes from the Vipeholm study
 
Starches and dental caries
conclusions:
 
Cooked staple starchy foods such as rice, potatoes, and
bread are of low cariogenicity in humans
The cariogenicity of uncooked starch is very low
Finely ground and heat-treated starch may cause dental
caries but the amount of caries is less than that caused
by sugars
 The addition of sugars increases the cariogenicity of
cooked starchy foods. Foods containing cooked starch
and substantial amounts of sucrose appear to be as
cariogenic as similar quantities of sucrose
 
Fruit, vegetables and dental
caries
 
The preference towards whole fruits and vegetables is because
these contain more non-starch polysaccharides and plant cell wall
materials that benefit health.
 From a dental point of view, it is also preferable to consume whole
fresh fruit as opposed to juices, because their mastication provides
a good stimulus to salivary flow. In addition, fresh fruit juices
contain non-milk extrinsic sugars, since liquidation releases the
fruit sugars from the cellular structure of the fruit
Dried fruit, potentially, may be more cariogenic; since the drying
process breaks down the cellular structure of the fruit releasing
extrinsic sugars
 
Protective food components
 
Foods and food components that have anti-cariogenic
properties are sometimes referred to as ‘cariostatic
factors
Fluoride is undoubtedly the most effective of these
factors.
Dairy products, plant foods, tea, and even chocolate
contain factors that protect against decay.
 
Milk and dental caries
 
Normal milk consumption does not cause dental caries; and an
inverse relationship between the consumption of milk and caries
increment has been reported
Cow’s milk contains lactose, which is less acidogenic than other
mono and disaccharides, and it also contains calcium, phosphorus,
and casein, all of which are cariostatic.
Human milk is more cariogenic than cow milk probably because
of its lower mineral content and higher level of lactose. however,
normal breast feeding does not cause dental caries.
Prolonged and nocturnal suckling have been associated with
increased caries risk
 
Cheese and dental caries
 
Numerous animal studies and experimental studies have indicated
that cheese is anticariogenic. Plaque pH studies have shown that
consuming cheese following a sugary snack virtually abolishes the
usual fall in pH that is associated with sugars consumption.
Cheese stimulates salivary secretion, increased rate of sugar
clearance due to the diluting action of cheese stimulated saliva
increases plaque calcium and phosphorus concentration
Both casein and cheese protein seem to be involved in the
reduction of enamel demineralization and responsible for some
anti-cariogenicity
 
 
Tea and apples
 
There is increased interest in foods that contain polyphenols, as
animal and experimental studies have shown that these compounds
have antibacterial properties. Apples contain polyphenols and are a
good stimulus to salivary flow. Tea also contains polyphenols in
addition to fluoride
Black tea extracts have been shown to inhibit salivary amylase
activity and reduce dental caries in animal studies
Polyphenols such as tannins found in cocoa, coffee, tea may reduce
the cariogenic potential of foods by interfering with
glucosyltransfersase activity of MS which may reduce plaque
formation.
 
Fats
 
Fats seem to reduce the cariogenicity of food
Replacing carbohydrate in diet
Form a protective barrier on enamel or surround carbohydrates,
making these less available and speeding up their removal from the
mouth
Bacterial surface properties involved in plaque formation could
also be altered by fats
Certain fatty acid have anti microbial effects and have been shown
to inhibit glycolysis in human dental plaque
 
Oral carbohydrate clearance
 
The practical ways to  speed up the carbohydrate
clearance
Tooth brushing immediately after meals
Eating tough or highly flavored foods at the end of meal
like fresh fruits and raw vegetables (detergent food)
Eating peanuts or cheese immediately after sweet dessert
to reduce the drop in plaque pH
 
(apples generally didn’t have this effect)
Chewing paraffin or sugar free chewing gums
Rinsing with water have a very limited effects
 
 
Oral carbohydrate clearance
 
It is also advised to consume sugar-rich foods at
mealtimes rather than alone, in between meals. This is
because, when consumed with other foods the effect on
pH is minimized probably due to
 (1)  dilution effect
(2) the increased salivary flow rate due to mastication of
other foods.
 
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Dental caries is a common chronic disease affecting all age groups, characterized by demineralization of tooth tissues due to microbial activity. Carbohydrates in the diet play a crucial role in caries development. Evidence shows a clear link between diet and caries incidence through various studies, highlighting the impact of sugar availability on dental health.


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  1. Diet and dental Caries

  2. DENTAL CARIES SEVERITY CLASSIFICATION SCALE

  3. Dental caries is an infectious microbiologic disease of the calcified tissues of the teeth, characterized by demineralization of the inorganic portion and destruction of the organic substance of the tooth. It is a common chronic disease that leads to pain and disability across all age groups. The Dental Caries Process

  4. Local dietary effects Dietary carbohydrate are caries conductive by the following points: All dietary sugars (sucrose, glucose, fructose, lactose) are used in the energy metabolism of plaque bacteria Carbohydrates can be used directly by bacteria or stored as intra or extracellular polysaccharides Fermentation of carbohydrate's by bacteria causes increase in the organic acid concentration mainly lactic acids, under-saturation of calcium and phosphate and tooth demineralization.

  5. Carbohydrate nomenclature Monosaccharaides Glucose (dextrose) Fructose (fruit sugar) Galactose Invert sugar (50% fructose + 50% glucose) Disaccharides Sucrose (table sugar) Maltose Lactose (milk sugar) Trehalose (mushroom sugar) Natural and manufactured oligosaccharides (3 10 units) Polysaccharides ( 10 units) Starch

  6. Evidence for a relationship between diet and dental caries comes from different types of studies Human intervention studies Human observational studies Animal experiments Plaque pH studies Enamel slab experiments Incubation studies

  7. Epidemiological(observational) studies Population that had reduced sugar availability during the Second World War showed a reduction in dental caries which subsequently increased again when the restriction of sugar was lifted Isolated communities with primitive way of life and low sugar intake have low dental caries level. As such societies shift towards habits and diets of modern living(nutrition transition), marked increase in dental caries was observed People with high sugar consumption also have high level of caries like confectionary industry workers and children with chronic disease requiring long-term sugar-containing medicine

  8. Human intervention studies Rare studies due to problems in trying to describe diet for long period of time Old studies conducted in pre-fluoride era on highly selected group of people Not possible to repeat due to ethical constraints Hopewood House study, Vipeholm study, Turku sugar studies

  9. Hopewood House study Children living in the Hopewood House children s home in New South Wales received annual dental surveys between 1947 and 1962. A lacto-vegetarian one with an almost negligible amount of refined carbohydrates and the presence of minimal animal protein. Whole meal bread, soya beans, wheat germ, oats, rice and potatoes were the main sources of carbohydrates. The majority of the food were eaten uncooked - this was highly unusual, coupled with the fact that sugar, white flour and products made from these items were rarely included in meals. Fluoride content in the water and food consumed was also insignificant and meals and snacks were taken with great regularity.

  10. Hopewood House study Dental caries levels were much lower than in children of the same age and socioeconomic background attending state schools in New South Wales 46% of 12-year-olds in Hopewood house were caries-free compared with 1% of the children from state schools. The Hopewood House study goes to show that in institutionalized children at least, dental caries can be reduced significantly, even without the beneficial influence of fluoride and in the presence of unfavorable oral hygiene. However, after 12 years of age, when the children s association with the home ended, the rate of caries increased to levels observed in children from the state schools.

  11. The Vipeholm study The Vipeholm study was conducted shortly after the Second World War in an adult mental institution in Sweden between 1945 and 1953 The aim of the Vipeholm Study was to determine the relationship between diet, frequency of sugar intake and dental caries. The variables included the type of sugar ingested (sticky or non-sticky form) and the frequency of sugar intake (at meals or in between meals). The subjects (436 patients) were split into one control group and six main test groups, where the 'bread' and '24-toffee' groups were further divided into two separate groups according to gender.

  12. The Vipeholm study The dietary regimes were given in two periods. The first carbohydrate period was between 1947 and 1949 and the second carbohydrate period in which the regimens were changed slightly between 1949 and 1951. A period of vitamin supplementation occurred for 1.5 years prior to the carbohydrate periods

  13. The Turku sugar studies A second important intervention study was the Turku study. This was a controlled longitudinal study carried out in Finland in the 1970s The study investigated the effect of almost total substitution of sucrose in a normal diet with either fructose or xylitol on caries development Three groups of subjects (n = 125 in total) aged 12 53 years, with 65% being in their twenties, consumed a diet sweetened with either sucrose, fructose, or xylitol for a period of 25 months and dental caries increment was monitored blindly at six-month intervals

  14. The Turku sugar studies Foods were specially manufactured for the fructose and xylitol groups and intake of starch was not restricted but subjects were asked to avoid sweet fruits such as dried fruits since sugars in these foods could not be substituted. xylitol group consumed significantly less frequently than the sucrose or fructose groups consumed their sweetened foods and the overall intake of xylitol in the xylitol group was lower than that of sucrose or fructose in the other groups The xylitol-containing foods

  15. The Turku sugar studies An 85% reduction in dental caries was observed in the xylitol group who had removed sugar from their diet. Conclusions of the Turku study are that substitution of sucrose with xylitol resulted in a markedly lower dental caries increment in both cavities and at the pre-cavitation stage.

  16. Animal experiments Animal experiments have enabled study of different types, concentrations, and frequencies of carbohydrates and sugars under specified conditions. It would not be possible to test such dietary regimens in humans due to problems of palatability and compliance. Animal experiments most commonly use the rat model; however, mice, hamsters, and monkeys are also used

  17. Enamel slab experiments Enamel slab experiments use oral appliances that hold slabs of bovine or human enamel. Plaque forms on the enamel slabs that remain in the mouth for 1 to 6 weeks. The slabs are exposed to the dietary factor being tested, by either consumption with the slabs in situ or by removal of the appliances several times a day to dip into vessels containing the dietary test substances

  18. Incubation studies Incubation studies are simple in vitro tests that measure if plaque bacteria can metabolize carbohydrate in a test food to produce acid. Pure cultures of micro-organisms may also be used in place of whole plaque. Rapid acid production and/or a low final pH is interpreted to mean that a food is potentially cariogenic, while a slow rate of acid production or higher final pH is likely to be of little clinical significance. All mono and disaccharides (10% solutions) produce a final pH of below 4.5 when incubated with plaque.

  19. Plaque pH studies Plaque pH studies measure changes in the pH of plaque following consumption of a carbohydrate or carbohydrate-containing food. They measure acidogenic potential, which is taken as an indirect measure of cariogenic potential, although acidogenicity does not take into account protective factors in foods consumed and, salivary factors that may modify the carcinogenicity of a food.

  20. Many factors can determine the shape of Stephan curve Site of dental plaque (less pH responses in lower jaw than upper jaw and anterior sites than posterior) The role of saliva in countering the pH drop Food acidogenicity Its easy to rank the relative cariogenic potential of foods by evaluation and comparing Stephan curves derived when such food are eaten under controlled condition. pH values differ in the plaque of sound tooth comparing with active and inactive lesions Buffering capacity of plaque

  21. Types of sugar and dental caries Sucrose (the arch criminal of dental caries) is more cariogenic according to the animals experiments (the amount of plaque formed is not necessarily related to cariogenicity) Turku study showed no significant difference in caries development among subjects on diets sweetened with sucrose compared with fructose

  22. Frequency of sugar intake and caries development The More occasions of sugar is taken, the greater the number of times plaque pH will bellow a level where demineralization can occur The primary evidence for the belief that the prevalence of dental caries is directly related to the frequency and to the form, in which sugar is eaten, comes from the Vipeholm study

  23. Starches and dental caries conclusions: Cooked staple starchy foods such as rice, potatoes, and bread are of low cariogenicity in humans The cariogenicity of uncooked starch is very low Finely ground and heat-treated starch may cause dental caries but the amount of caries is less than that caused by sugars The addition of sugars increases the cariogenicity of cooked starchy foods. Foods containing cooked starch and substantial amounts of sucrose appear to be as cariogenic as similar quantities of sucrose

  24. Fruit, vegetables and dental caries The preference towards whole fruits and vegetables is because these contain more non-starch polysaccharides and plant cell wall materials that benefit health. From a dental point of view, it is also preferable to consume whole fresh fruit as opposed to juices, because their mastication provides a good stimulus to salivary flow. In addition, fresh fruit juices contain non-milk extrinsic sugars, since liquidation releases the fruit sugars from the cellular structure of the fruit Dried fruit, potentially, may be more cariogenic; since the drying process breaks down the cellular structure of the fruit releasing extrinsic sugars

  25. Protective food components Foods and food components that have anti-cariogenic properties are sometimes referred to as cariostatic factors Fluoride is undoubtedly the most effective of these factors. Dairy products, plant foods, tea, and even chocolate contain factors that protect against decay.

  26. Milk and dental caries Normal milk consumption does not cause dental caries; and an inverse relationship between the consumption of milk and caries increment has been reported Cow s milk contains lactose, which is less acidogenic than other mono and disaccharides, and it also contains calcium, phosphorus, and casein, all of which are cariostatic. Human milk is more cariogenic than cow milk probably because of its lower mineral content and higher level of lactose. however, normal breast feeding does not cause dental caries. Prolonged and nocturnal suckling have been associated with increased caries risk

  27. Cheese and dental caries Numerous animal studies and experimental studies have indicated that cheese is anticariogenic. Plaque pH studies have shown that consuming cheese following a sugary snack virtually abolishes the usual fall in pH that is associated with sugars consumption. Cheese stimulates salivary secretion, increased rate of sugar clearance due to the diluting action of cheese stimulated saliva increases plaque calcium and phosphorus concentration Both casein and cheese protein seem to be involved in the reduction of enamel demineralization and responsible for some anti-cariogenicity

  28. Tea and apples There is increased interest in foods that contain polyphenols, as animal and experimental studies have shown that these compounds have antibacterial properties. Apples contain polyphenols and are a good stimulus to salivary flow. Tea also contains polyphenols in addition to fluoride Black tea extracts have been shown to inhibit salivary amylase activity and reduce dental caries in animal studies Polyphenols such as tannins found in cocoa, coffee, tea may reduce the cariogenic potential of glucosyltransfersase activity of MS which may reduce plaque formation. foods by interfering with

  29. Fats Fats seem to reduce the cariogenicity of food Replacing carbohydrate in diet Form a protective barrier on enamel or surround carbohydrates, making these less available and speeding up their removal from the mouth Bacterial surface properties involved in plaque formation could also be altered by fats Certain fatty acid have anti microbial effects and have been shown to inhibit glycolysis in human dental plaque

  30. Oral carbohydrate clearance The practical ways to speed up the carbohydrate clearance Tooth brushing immediately after meals Eating tough or highly flavored foods at the end of meal like fresh fruits and raw vegetables (detergent food) Eating peanuts or cheese immediately after sweet dessert to reduce the drop in plaque pH (apples generally didn t have this effect) Chewing paraffin or sugar free chewing gums Rinsing with water have a very limited effects

  31. Oral carbohydrate clearance It is also advised to consume sugar-rich foods at mealtimes rather than alone, in between meals. This is because, when consumed with other foods the effect on pH is minimized probably due to (1) dilution effect (2) the increased salivary flow rate due to mastication of other foods.

  32. Thank you

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