Diet and dental caries

Diet n Dental caries diet counseling

1. DIET AND DENTAL CARIES Dr. HARSHMIR NAGRA

2. CONTENTS INTRODUCTION TERMINOLOGY CLASSIFICATION OF FOODS FOOD GUIDE PYRAMID ETIOLOGY OF DENTAL CARIES EFFECTS OF NUTRTION ON DENTAL CARIES STUDIES PROVIDING EVIDENCE FOR THE RELATIONSHIP BETWEEN DIET AND DENTAL CARIES DIET COUNSELLING FORNPREVENTION OF DENTAL CARIES CONCLUSION REFERENCES

3. INTRODUCTION Through centuries, diet has been recognized important for human beings in health and disease. Every part of the body is derived from nutrients contained in the diet. The nutrients form an essential and continuing component in the complex process of maintaining optimal health throughout life. Diet plays a major in development of dental caries. It has firmly been established that dietary Carbohydrates are caries conductive, and that they exert cariogenic effect locally on the tooth surface.

4. TERMINOLOGY DIET: Def: Diet is defined as the types and the amount of food eaten daily by an individual. (FDI, 1994) Diet refers to the local action of the foods in oral tissues and encompasses the composition of the food, its consistency pattern and frequency of eating. It encompasses the food that is eaten regardless of its fate and exerts local/direct effect upon the dentition. NUTRTION: Def: Nutrition is defined as the sum of processes by which an individual takes and utilizes food. (FDI, 1994) Nutrition differs from diet. In that it deals with those elements of food that are absorbed through the intestinal tract and enter into metabolic processes in the body in the formation and replacement of the tissue. It exerts systemic effects upon the dentition via the pulpal blood supply and the saliva.

5. I BALANCED DIET: Def: A balanced diet is one in which each nutrient from each food group is recommended servings is present for the optimal functioning of the human. It contains variety of foods in such quantities and proportions that the need for energy, amino acids, vitamins, minerals, fats, carbohydrates, and other nutrients is adequately met for maintaining health, vitality and general well-being and also makes a small provision for extra nutrients to withstand short duration of leanness. DENTAL CARIES: Def: 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 portion substance of the tooth, which often leads to cavitations. (Shafer’s)  

6. CLASSIFICATION OF FOODS By origin: Foods of animal origin Foods of vegetable origin By chemical origin: Proteins, fats, carbohydrates, vitamins, minerals By predominant function: Body building foods – milk, meat, poultry Energy-giving foods – cereals, sugars, roots Protective foods – vegetables, fruits, milk By nutritive value: Cereals and millets, pulses, vegetables, nuts and oilseeds, fruits, animal foods, fats and oils, sugars and jiggery.

7. The food guide pyramid can help to choose a variety of foods to help achieve a balanced diet. Selecting foods from each group will provide the many nutrients needed by the body. The dietary goals (prudent diet) recommended by the expert committees of WHO are: Dietary fat should be limited to 15-20% of total daily diet. Saturated fats – not more than 10% of total energy intake Excessive consumption of refined carbohydrate to be avoided Salt intake reduced to not more than 5gm/day Protein – 10-15% of daily intake Reduced consumption of colas, ketchups and other foods that supply empty calories. FOOD GUIDE PYRAMID

8. ETIOLOGY OF DENTAL CARIES Dental caries is a multifactorial disease. According to the current concepts, mainly four factors are responsible for the causation of the dental caries.i.e . Diet Bacteria Susceptible tooth surface Time  

9. EFFECTS OF NUTRTION ON DENTAL CARIES

10. PRE-ERUPTIVE EFFECTS: Mineral malnutrition may be due to inadequate quantities of calcium, phosphorus and iron. In deciduous teeth the dental dysplasias caused are Odontoclasia Yellow teeth Infantile melanodontia Lesion cauque: it occurs due to deficiency of vitamin A or neonatal infection Pulpal stone formation: due to L- ascorbic acid 2.) POST-ERUPTIVE EFFECTS:

11. ROLE OF VITAMIN D IN MAINTAINING DENTAL HEALTH  

12. STUDIES PROVIDING EVIDENCE FOR THE RELATIONSHIP BETWEEN DIET AND DENTAL CARIES : CONCEPT OF NOBLE SAVAGE: Developed during later part of the 18 th century An understandable development from this ideal was the belief that the apparent freedom from caries enjoyed by so called primitive races should be attributed to the natural diet on which they existed Eating hard, fibrous, unprocessed food to better development of the jaws and teeth helped to clear the food debris from the teeth Humans started eating soft processed food, highly fermentable carbohydrate which did not properly exercise the masticatory apparatus and lead to dental decay  

13.   WALLACE-1902, was a firm proponent of cleansing foods, stated that the accumulation of fermentable carbohydrate were the cause of caries and that such deposits could be removed by eating hard and fibrous foods(cleansing/detersive foods) PICKERILL – 1923, stated that if a meal was finished with a salivary stimulant like apple, the mouth would be kept free of fermentation both by physical cleansing effect of fibrous food and also because of induced salivary flow.  

14. OBSERVATIONAL STUDIES 1.) EPIDEMOLOGICAL OBSERVATION: Modern diet v/s primitive diet Caries prevelance of ancient Hawaiians was extremely low in contrast to the present scenario 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 2). WORLD WAR II STUDIES: Toverud 1957 Scandinavian countries: Decrease in dental caries among 7 and 8 years old children about 1-3 years after reduction in sugar intake. Caries rates increased 12 years after rise of sucrose in postwar diets in children.

15. 3.) HOPEWOOD HOUSE STUDIES: Sullivan and Harris – 1958 80 children – entered soon after birth Duration – 12 years (1947-1962) Diet – lacto vegetarian Whole meat flour - brad, biscuits Strictly vegetarian, restriction of refined carbohydrate Vitamin supplements and fluoride concentration of water is very less Oral hygiene was virtually absent At the end of 12 years, 13 year children represented: Mean DMFT – 1.6, while of general population – 10.7 53% of hopewood house population is caries free while only 0.4% of state school children were caries free.  

16. 4.) VIPHOLM STUDIES: Gustaffson et al 1954 Duration: 5 year study Vipeholm Hospital, Lund(Sweden) - an institution for mentally defective individuals. The 436 patients involved in this study were divided into 6 control groups. They were as follows: Sucrose group (300gm) Bread group (345gm) Chocolate group (65gm) Caramel group (22 – 70gm) 8 toffee group (60gm) 24 toffee group (120gm)

17. 5.) TURKU SUGAR STUDIES: Schenin and Makenin – 1975 Location – Turku, Finland Aim: to compare the cariogenicity of sucrose, fructose and xylitol as xylitol is a sweet substance not metabolized by plaque microorganisms. Duration: 2 years Mean age of subjects: 27.6 years Total subjects : 125 Sucrose – 35 Fructose – 38 Xylitol – 52 Findings: After one year: sucrose and fructose are equal cariogenic whereas xylitol produced almost no caries After 2 years: caries had continued to increase in sucrose group but remained unchanged in the fructose group whereas xylitol produced almost no caries.  

18. 6.) PLAQUE PH STUDIES: Measures acidogenic potential Four methods: Metal probes (which can be inserted in situ into plaque) Glass probes Miniature glass electrodes (built into partial dentures that stays in the mouth for several days to enable plaque to grow on surface) Harvesting method: most accepted (removing small samples of plaque from selected tooth and measuring pH outside the mouth) Stephen (1940, 1944) – demonstrated the relationship between sugar exposure resulting in the acidification of dental plaque and caries experience. These studies have been used to rank the acidogenecity of snack foods Boiled sweets: lowest plaque pH Sweetened tea and coffee: low pH Foods sweetened with nonsugar sweeteners (e.g. sugar free chewing gum {pH-6.8}, diabetic chocolate sweetened with sorbitol ) and salivary stimulants {peanuts}:high pH

19. SURVEY OF DIEATARY HABITS IN CHILDREN 1.) AVAILABILITY OF SWEET AND CANDY: Fanning et 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 had better oral health than others Educational level of parent positive core dental health 2.) SPECIAL POPULATION GROUP: NURSING BOTTLE CARIES Jacobi found the relation between the practice of feeding infants with sucrose containing beverages and milk at bedtime Lactose is responsible Added sugar or sugar dipped pacifier at bedtime – Breast feeding – primary dentition 8in infants 7.2% lactose by wt in human milk: 4.5% in bovine

20. CEREAL STUDIES Sugar coated cereal – highly cariogenic Eating sucrose during mealtime as a part of 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 suggested that amount of presweetened cereal is less than total amount ingested daily Still controversy exists regarding cariogenicity of cereal HEREDITARY FRUCTOSE INTOLERANCE Caused by reduced level of fructose Person learns to avoid food containing fructose or sucrose Dental caries in theses is extremely low Siblings of theses showed similar incidence of caries INDIVIDUAL RISK Persons in bakery and candy factories showed higher incidence of caries than the workers in textile industries Employees in chocolate factory showed more caries than person in shipyard Sugarcane workers had more caries incidence than workers in textile industry  

21. DIET COUNSELLING FOR THE PREVENTION OF DENTAL CARIES PRINCIPLES OF DIET MANAGEMENT Maintain overall nutritional adequacy by confirming to the USDA daily food guide for at least the recommended number of servings from each of the food groups. The prescribed diet should vary from the normal diert pattern as little as possible The diets should meet the body’s requirements for the essential nutrients The prescribed diet should take into consideration and accommodate the patient’s likes and dislikes, food habits, and other environmental factors as long as they do not interfere with the objectives

22. DIET COUNSELLING 1.) PATIENT SELECTION: Diet counseling will not succeed with every patient Potential candidates for counseling should give high priority to preventive dentistry and should be willing to expend long term efforts to maintain their natural dentition good health for a long time. In addition to a positive attitude, they should have a demonstrable need for dietary improvement based on their current food intake regimen 2.) FOOD DIARY: A food diary is a record of all foods and beverages consumed during a specific period If the child is young the mother usually completes the food diary at home, writing in foods after they are eaten. The patient is instructed to be as accurate as possible in determining quantities and to record in detail everything eaten or drunk during or between meals, the size serving in household measures, the addition of suagar, milk, syrups, to anything consumed. A food or diet diary can be either of 24 hours or one week. The 24 – hour recall is valuable tool for obtaining a sketchy picture of patient’s food intake

23. 3.) CALCULATION OF DENTAL HEALTH DIET SCORE: It is a simple scoring procedure that can disclose a potential dietary problem that is likely to adversely affect a patient’s dental health. Dental health diet score = Food score + Nutrient score – Sweet score Food score – adequate intake of foods from each of the food groups Sweet score - ingestion of foods that are overly sweet sugars Food RDA Number of servings Points Milk 3 *8   Meat 2 *12   Fruits and vegetables 1 *6   Vitamin c 1 *6   Others 2 *6   Breads and cereals 4 *6  

24. NUTRIENT SCORE TABLE Mark one score for each nutrient consumed Protein and Vitamin A Iron Folic acid Riboflavin Vitamin c Cheese, dried beans, dried peas, meat, milk, apricot,butter, carrot Beef, eggs, liver, green leafy vegetables Cereals, spinach, yeasts, Broccoli, chicken breasts, eggs, milk, mushrooms Grapefruit, green peppers, oranges, strawberries, tomatoes, calcium and phosphorus – cheese, eggs, green leafy vegetables, milk

25. SWEET SCORE TABLE   Classify the sweet by its nature and multiply according to severity Liquid: (*5) Solid and sticky: (*10) Slowly dissolving: (*15) Soft drinks, fruit drinks, cocoa, sugar and honey in beverages, ice cream, flavored yogurt, pudding, custard Cake, doughnuts, sweet rolls, pastry, canned fruit in syrup, bananas, cookies, chocolate candies, caramel, chewing gum, dried fruit, marshmallows, jelly, jam Hard candies, breath mints, antacid tablets, cough drops,

26. ASSESSMENT OF DENTAL HEALTH SCORE Score Result Interpretation 72-96 Excellent Counseling not required 64-72 Adequate Educate the patient 56-64 Barely adequate Counseling required 56 or less Not adequate Counseling with diet modifications

27. 4.) COMMUNICATION TECHNIQUES: It is the basic tool in practice of preventive dentistry. Communication is the giving and receiving of information; it involves the knowledge of patients, thoughts, and opinions of the counselor and the patient. During a face – to – face interview, keeping eye contact with the patient is a persuasive and powerful device for motivating behavioral change. Communication can be: Verbal – words transmit information Non verbal – tone of voice, gestures, and facial expressions convey sincerity, enthusiasm, and empathy. These actions can influence eth patient to change his behavior. Personalization of the message is more likely to result in a sustained change in behavior. To communicate with the patient, a combination of interviewing, teaching, counseling, and motivation is used.

28. INTERVIEWING: Purpose: the basic goal is to understand thr problem, the factors that contribute to it and the personality of the patient. Advantages: it serves as a valuable diagnostic aid to provide knowledge of a person’s daily routine for adapting a caries preventive diet. Physical setting: Privacy, comfortable, and relaxed interview are important requisites for an interview. The interview should not take place on the chair side in the dental operatory, as it can be a threatening atmosphere that may lead to fear and withdrawal. It should take place in a separating counseling room that contains a small conference table, a few chairs, a blackboard and visual aids. Diet interviewer: good interviewing requires skill, time and some background knowledge of the science and practice of nutrition, including familiarity with ways in which food habits are formed. Procedure: Start with a brief introductory statement about the purpose of the interview Encourage the patient’s expression of feelings by asking questions.. Listen before speaking Allow patient to make choices based on what he has learnt Recapitulating the learned knowledge TEACHING AND LEARNING: Present the information with sufficient impact to stimulate the action by the learner Booklets can be used as teaching aids.

29. 5.) COUNSELLING: Approaches to the counseling can be divided as follows: Directive approach: Patient is passive Decisions are made by the counselor Non directive approach: the counselors role is to Aid the patient in clarifying and understanding his or her own situation Provides guidance to the patient to make his/her own final decision as to type of action to be taken. Non directive approach is recommended for counseling. Guidelines for counseling : Gather information: Personal identifying data. Likes and dislikes, and the patient’s perception. Evaluate and interpret information: relative adequacy of the diet and eating habits Develop and implement a plan of action: qualitative modifications of the diet Seek active participation of the patients family in all aspects of dieatary changes Follow up to assess the progress made Pre-requirements of counseling Elicit a true response Phase the question correctly Listen and wait for the answer

30. 6.) COUNSELLING VISIT: Persue diary for completion Explain cause for decay Isolate sugar factor Analyze the sweet intake Determine adequacy of diet Diet, prescription and suggested menu Reinforcement by follow up reevaluation 7.) MOTIVATION: It is an incentive for action The counselors positive attitude and conviction as to necessity and effectiveness of nutrition counseling can stimulate the patient to initiate an improved dietary pattern A person passes through five preliminary decision changes in changing a dietary pattern i.e. Awareness- it is recognition that a problem exists, but without an inclination to solve it, Interest – it is greater degree of awareness but still with no inclination to act. Involvement – it is a definite intention to act . Action – it is a trial performance Habit – it is a commitment to perform this action regularly over a sustained period of time

31. CONCLUSION OF DIET COUNSELLING Improve general and dental health Significantly reduce caries reoccurrence To realize maximum patient acceptance and cooperation with the diet prescription The objectivity, personalization of the diet, and the time spent in counseling are rewarded both financially and by the satisfaction performing a useful health care and preventive dentistry

32. CONCLUSION Dental caries is a multifactorial, infectious disease affecting a significant percentage of the population. It is more accurate to consider caries as caused, not by an infectious agent, but by a shift in oral micro flora to caries-causing types in response to acidity resulting from metabolism of sugars. The development of caries is dependent on the interaction of four primary factors. These are a host (tooth surface), a substrate (food), the presence of oral bacteria, and time. Caries will not develop if any of these four primary factors are not present. Understanding the etiology and pathways of progression of dental caries will enable the profession to strive toward early intervention and, hopefully, prevention.  Inadequacy of the host's immune-defenses may play a role in the acquisition of carious lesions. However, feeding habits are more important, especially in early childhood, and the role of feeding habits and behaviors in producing   dental decay  in childhood has been established by numerous studies. There are epidemiological or intervention studies concerning the association between the oral health and the role of diet and nutrition in this association. Primary health care providers and dentists should thoroughly understand the relationship of diet to caries and conscientiously apply that knowledge to educate the patients in general as well as counsel special high risk individuals.              

33. REFERENCES Textbook of pediatric dentistry , Third edition, By Nikhil Marwah Essentials of Public Health Dentistry, (Community Dentistry) , 6 th Edition, By Soben Peter