Diet And Dental Caries 22.ppt diet and caries

diet and caries

1. Diet And Dental Caries
Dr G. Kayalvizhi
PG in Dept of Pedodontia

2. •Introduction
•Definitions
•Unique forms of food
•Sugars and dental caries
•Interventional and non-interventional studies
•Longitudinal and cross sectional studies
•Starch and dental caries
•Cariogenecity of foods
•Role of fats, proteins, vitamins
•conclusion

3. •Diet - the customary allowance of food and
drink taken by any person from day to day.
Unique forms of food
•Monosaccharide
•Disaccharides
•polysaccharides

4. Diet
Sucrose +
other carbohydrates
Adhesive
Extracelluar
polymers
Intracellular
storage
polysaccharides
Glycolytic
metabolism
Extracelllular
Storage
polysaccharides
Dental caries Periodontal disease
Plaque
accumulation
Lactic
acid
production
Co2
fixation
ATP
production
Biosynthesis of
toxic
macromolecules
growth

5. Physical properties of foods and cariogenecity
•Mechanical- Hardness, cohesiveness,
viscosity, adhesiveness
•Geometric- particle size and shape
•Others- moisture and fat content
•Affect- food retention, food clearance,
solubility and oral hygiene
Recommended-
•improves cleansing action
•Increase salivary flow
•Reduce the retention of food

6. Sugars and dental caries
•Metabolic fate of carbohydrates in plaque
•Oral sugar clearance
•Frequency of eating
•Effective concentration of sugar
•Relationship bet sugar and dental caries

7. saliva
Plaque micro organisms
starches
Maltose
Glucose
Lactose
fructose
sucrose
sucrose
Energy +
Organic
acids
glycogen
Sucrose
phosphate
Glucose
fructose
Sucrose
phosphate
Soluble
polysaccharides
Glucose/fructose
Insoluble
polysaccharides
extracellular
intracellular
polysaccharides
Bacterial
capsule

8. Dietary sugars and caries
SUCROSE-ARCH CRIMINAL (Newbrun 1969 )
•Effect on plaque
•substrate for cariogenic microflora
Sucrose polymers bulk of plaque
attachment of bacteria
High free energy, high specificity of
enzymes
SUGARS – THE ARCH CRIMINAL (zero 2004)

9. Frequency of eating
•Weiss and trithart 1960- 1000 children
(candies, cookies)- DMFT rates
•Konig et al 1968- caging system in animals
•Fanning et al 1969- school canteen
•Effective concentration of sucrose

10. CAGE SYSTEM – KONIG ET AL

11. Sugar clocks
(Johansson and Birkhed 1994)
Frequent eating - Acid
No acid formation

12. Oral sugar clearance
•Salivary rinsing, masticatory muscle activity
•Lagerlof et al – 20% sucrose, solid foods
•Retentive, sticky, sweet foods with less self cleansing
property.
Effective concentration of sucrose
•Natural sugar in fruits (50-60%) – occlusal surfaces
•Processed cane sugar (5-50%)- maximum acid
production- plaque flora gets saturated
•King et al 1955 – addition of sucrose – no drop in pH

13. Relationship bet sugar intake and caries
a) b) Newbrun 1982-
S- shaped curve
c) Woodward and
walker 1994- linear
d) Zero 2004-
individuals with
good oral hygiene
and regular fl
exposure, higher
level of sugar can
be tolerated

14. Relationship bet sugar and dental caries
Marthaler 1967 Simple sugars than starch
Newbrun 1969 Elimination of sucrose
Bibby 1975 snacks
Sreenby 1982 Total consumption and
frequency of intake?
Newbrun 1982/sheiham
1983
Proportion of sucrose
Rugg- Gunn 1986 Cooked starch+sucrose
Bowen and birkhed 1986/
Konig and navia 1995/
Ruxton 1999
frequency
Marthaler 1990 Fl, sugar- caries
Van loveran 2000 Oral hygiene, fl
Sheiham 2001 Sucrose- >60g/d, >4times

15. STEPHEN’S CURVE
10% sucrose solution- 40min
4
4.5
5
5.5
6
6.5
7
0 10 20 30 40 50 60
pH
PLAQUE
pH
TIME IN MINS

16. INTERVENTIONAL STUDIES
•VIPEHOLM STUDY
•HOPEHOOD HOUSE STUDY
•TURKU SUGAR STUDY
EXPERIMENTAL CARIES STUDY
NON INTERVENTIONAL STUDIES
•EPIDEMIOLOGICAL STUDIES
•CROSS- SECTIONAL STUDIES
•OBSERVATIONAL STUDIES

17. 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

18. 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-
½ 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)

19. Studies were divided into 3 phases
I.clinical experimental studies of the
relation bet diet and caries
II.Supplementary studies
III.Special studies (Hojer and Maunsbach
1954)
Preparatory period (1945- 1946)
pts were selected, recording methods

20. I Clinical experimental studies
1) Vitamin study (1945-1946)
Vit A,C,D, 1mg Fl tab
Basic diet- sugar (1/2) + starch = low caries
2) Carbohydrate study
To examine how caries activity was influenced by
the ingestion of carbohydrates under controlled
conditions
•Study 1 (1947- 49)
SUGAR - solution/ sticky form at (new bread) /bet
meals( toffees)
•Study 2 (1949- 51)
Types of sweets were similar

21. 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

22. Results
•Little effect- sweet drinks with meals
bread
sugar in non sticky
•Moderate increase in caries- chocolate
(4times) bet meals
•Dramatic increase- 22 caramels
8 / 24 toffees bet or after meals

23. Effect of frequency and CHO intake
(Davies 1955)
0
1
2
3
A B C D E
CONTROL GROUP
NEW CARIOUS
SURFACES
/PERSON/YEAR

24. Influence of carbohydrate type and frequency
on dental caries
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
p
r e
s t u
d
y
c
o
n
t r o
l
s
u
g
a
r 4
b
r e
a
d
1
b
r e
a
d
4
c
h
o
c
o
l a
t e
c
a
r a
m
e
l 2
2
t o
f f e
e
8
t o
f f e
e
2
4
p
o
s t s t u
d
y
Sugar with meals sugar with and bet meals
Coronal
caries
Cementum
caries

25. II Supplementary and special studies
Supplementary study
Quensal et al 1954 – reliability of the method in
determination of caries, caries activity was
statistically significant in all groups (sticky)
Special studies
1) Biochemical studies
(Lundquist 1952, Swenander lanke 1957)
sugar content of blood and urine, pH viscosity, buffer
capacity, ca p conc in saliva and oral sugar
clearance.

26. 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.
b) studies on the inhibition of acid production by
substance produced by chocolate bean.

27. 3) Genetic study (Book and Grahnen 1953)
Parents and siblings of caries free recruits - low caries
prevalence, no diff bet oral hygiene and dietary
habits.
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

28. 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

29. Limitations
•No possibility of matching the age
•Initial caries
•Mentally handicapped- instructions
•Dietary regimes of various groups

30. Hopewood study in Bowral, N.S.W,
Australia
•1942, 80 children, 7-14 yrs (10yr period)
•Vegetarian diet- carbohydrates (whole meal bread,
whole meal porridge, biscuits, wheat germ,
fruits ,vegetables, dairy products)
•1948- 49 – meat
•Vitamin concentrates, nuts and honey
•Unfavorable oral hygiene, insignificant fl, meals
controlled = Toothsome diet
•Results- 13yr old (DMF) -1.6(53%) HH
-10.7(0.4%) general

31. Turku sugar study, Finland
(Scheinen and Makinen 1975)
•AIM - To compare the cariogenecity of sucrose,
fructose and xylitol. (1972-1974)
•BASIS- Xylitol is a sweet substance not metabolised
by plaque organisms.
•125 subjects (115), 27.6yrs (15-45yr)
3 groups – sucrose (S), fructose (F) and xylitol (X)
•Examination- clinically, radiographically
•Precavitational and cavitational lesions
•primary and secondary caries

32. 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
2) cavitation- low DMFS –xylitol than sucrose and fructose.

33. Development of primary and secondary caries
(24 mon)
Primary secondary
S- 7.2 10.5
F- 3.8 6.1
X- 0.0 0.9

34. conclusion
•Substitution of xylitol for sucrose in normal
Finnish diet resulted in low caries incidence.
•Reduced the number of most microorganism

35.  second 1yr trial –
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

36. IV. Experimental Caries Study
Von der fehr 1970-buccogingival enamel caries
•23 days,50% sucrose solution (9 timesdaily)
•After 30 days- oral hygiene and fl rinses.
•Critical factor- duration and frequency
Loe et al 1972- 3 weeks, chemical plaque control twice
daily (CHX) but no Fl, no caries
conclusion
Sugar is modifying risk factor
Dental plaque is a etiological factor
Clean teeth- no caries

37. Non interventional human studies
•Subjects are free to choose whatever diet
they please, correlation bet caries increment
and dietary factor is low.
•Based on dietary recall
•No control over amount/ frequency of sugar
intake

38. I. Epidemiological studies
Sugar consumption in selected countries in1977
0 10 20 30 40 50
Consumption (kg/y) / person
Australia
Finland
Iceland
Japan
Canada
China
Cuba
USSR
Sweden
Switzerland
USA
England

39. Sugar consumption in Sweden 1960-1990
0
20
40
60
80
100
120
1960 1970 1980 1990

40. •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
•Confectionary workers and bakers

41. II. Cross sectional studies
•Goose1967, Goose and Gittus 1968, James et al
1957, Winter et al 1966, 1971
labial incisor caries and sugared pacifiers
•Granath et al 1976,1978- level of sugar, Fl
Oral hygiene (6yr, 4yr)
•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

42. III. Observational studies
•Axelsson and El Tabakk 2000- 685, 12yr old (period
of 2yrs) with poor oral hygiene, sugar diet.
•Rugg- Gunn et al (1984) North thumberland,
England and Burt et al 1988 in Michigan
Assessed frequency and grouping of foods

North
thumberland
Michigan
Duration 2yr 3yr
age 11.5 11-15
subjects 456 499
Frequency of
eating
Diet diary
6.8 t/d
15 day diary
4.3t/d
3-10 day
Total sugars 118g/d 142g/d
Caries incidence 1.21 DMFS/Y 0.97 DMFS/Y

43. Starch and dental caries
•Swenander lanke 1957
•Dietary starch - mixture of starch products with
apparently widely varying potentials to serve
as substrates for bacterial acidogenesis in
plaque and hence induce cariogenesis.

44. a) Intraoral bioavailability of starch
•Polymers of glucose
•Starch molecules- starch granules
(grains and vegetables)
•Gelatinization (8-10
0
c)
•Starch

dextrin and glucose (mormann and muhleman1981)
•Modifiers – starch protein, starch lipid
interactions
Salivary
Bacterial amylase
Maltose + maltriose

45. 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
•Lingstorm et al 1997 – high cariogenic potential

46. 2) Studies of starch caries issues with humans
•Classic vipeholm study
•Hopewood house experiments
•Turku sugar studies
•HFI individual study
Draw backs
1) Frequency of consumption
2) plaque pH lowering potential
3) bioavailability

47. Hopewood house study
•Lacto vegetarian diet
•3 meals with milk upon rising and milk/fruit
after dinner
•Low caries
Vs and HHS – not caries inducive
Turku sugar study
•3 groups- sucrose, fructose, xylitol
•Xylitol- little / no caries

48. Newbrun et al 1980
•HFI (hereditary fructose tolerance)= little caries
•Little sucrose(2.5g/d), total carbohydrate (160g/d)
Rugg gun et al 1987 – (2yr)
•High starch/ low sugar diet- no reduction caries
Sreenby 1983, 1996- 12yr children
•Various starches + little sucrose=low
Schamschula et al 1978-
•Starch diet+ sugar + frequency= caries

49. Studies of starch caries issue with animals
•classic animal model (van Houte 1980,1994)
MS free rats fed with high sucrose diet
sucrose replaced by starch – fissure caries
•Bowen et al 1980- starch sucrose diet
•Processed starches
•Amylopectin and amylose
•Firestone et al 1984- cooked wheat starches
pH remained low for longer periods
•Co-carcinogen

50. Starch and dental caries???
Non cariogenic or cariogenic???
•Non cariogenic
•Starch products can be , but frequently are not,
as effective as sucrose in inducing enamel caries
1) lower bioavailability of starches
2) diminished delivery of glucose and maltose to
plaque bacteria.
•Co- carcinogen
• Enhanced retentiveness of starchy foods

“It is premature to consider starches in modern diet
as safe for teeth”

51. Cariogenecity of foods (ADA 1985)
•Cariogenic potential- a foods ability to foster
caries in humans under conditions conducive
to caries formation. (Stamm et al 1986)
•Diet counselling
•methods to assess
Animal models, plaque acidity models,
demineralization and in vitro models.
•Influenced by- sugar content, protective
factors, consumption pattern and frequency
(Bowen et al 1980)= CPI

52. Edgar 1985-
•food factors- Amt and type of CHO, food pH,
buffer, consistency , retention in mouth,
eating pattern, factors modifying enamel
solubility.
•Cultural and economic factors- availability
and distribution

53. Can foods be ranked according to
their cariogenic potential??
•Foods – 2 categories ( Switzerland )
acidogenic / non- acidogenic
1.Cheddar cheese
2.non fat dry milk solution
3.10% sucrose solution, fruit beverage
4.caramel. cracker, potato chip. SLS
5.Milk chocolate, sugar cookie, corn and
wheat flake.

54. Minimum pH obtained with reference foods
(schachtele and Jensen)
3
4
5
6
7
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b
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c o
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w
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a
t f l a
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55. Caries promoting potential
categories examples CPP details
1) Simple sugars
Disaccharides
Sucrose
maltose
Dextrin, corn syrup,
fruit sugar, powdered
sugar, honey
yes Carbonated and bottle
drinks, vegetables and
processed foods with
added sugars
2) lactose Milk sugar low Galactose?
Fermentable CHO-
polysaccharides-
starch
Cooked potatoes,
rice, legumes, grains,
cornstarch and
bananas
yes Gelatinized
Non fermentable –
1) fiber
Cellulose, pectin,
gums
no Grains, fruits,
vegetables
2) Sugar alcohols Sorbitol, mannitol,
xylitol
Lactitol,maltitol, HSH
30-90% sweet
High intensity
sweetners
1)nuritive
aspartame no Food additives in
desserts
>200-700 times
2) Non nutritive Saccharin
Acesulfame
sucralose
no

56. Snack foods – acidogenic potential Edgar 1981
Group1
Beverages Fruit etcBaked goodssweets
Least
Acidogenic
1) Milk peanuts Sugarless
gum
2) Chocolate
milk
apple Bread ,
butter
Caramels
Sugared
gum
chocolate
3) Carbonated
beverages
banana Cream filled
cakes ,sand
wich cookies
Orange
jellies
4)
Apple/orange
juice
Dates
Raisins
Sweetened
cereal
Bread jam
Sweet
biscuits
5) Apple pie Clear mints
6) Fruit gums
Fruit
lollipops

57. 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

58. Role of vitamins in dental caries
Vitamin B1- thiamine
Caries promoting effect
Vitamin B6 (pyridoxine)
•Cole et al 1980 – reduce caries in rats
•High doses - drug (pregnant women and
children)
•Local effect?
•Affect growth rates, metabolism and
microbial composition of dental plaque (by
stimulating/ inhibiting microbial species)

59. Role of fats in dental caries
Post eruptive consumption- reduce caries
Mechanism ??
•Protects the enamel surface by fatty film
•Reduces the contact bet CHO and bacteria
•Antimicrobial action? (Williams et al 1982)
•Replace carbohydrates (Michigan 1994)
•Rapid clearance of carbohydrates from oral
cavity.

60. Role of proteins in dental caries
•Shaw 1970 and Navia 1979-
protein deficiency during dental development
in rats - caries susceptibility
•Experimental and control rat pups on
cariogenic diet
Mechanism?
Posteruptively – direct action on plaque met
Short exposure time in mouth
Replace CHO
weak proteolytic activity in mouth

61. 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

62. 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

63. sweeteners
•Non caloric
•Not fermented by oral microorganisms
Saccharin- (Grenby et al 1991)
•active cariostatic property
•Inhibit bacterial growth
Aspartame (NutraSweet)- reduce caries

64. 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

65. Protective food components
•Fluoride
•Phosphates- capo4 toothpaste, ACP-CPP
•Fatty acids- replace carbohydrates (Michigan
1994)
•Arginine rich peptides and pyridoxine (basic)
•Calcium lactate
•Dietary acids and flavors (foods and
beverages)
•Tea and starch
•Aged cheddar cheese- antiacidogenic effect
•Chocolate ad extracts, glycyrrhizin/ liquorice
•Sugar substitutes

66. REFERENCES
•DIAGNOSIS OF CARIES- AXELSSON
•CARIOLOGY – NEWBRUN
•CARIOLOGY TODAY- GUGGENHEIM
•UNDERSTANDING DENTAL CARIES-
NIKIFORUKH
•CARIES RESEARCH 2004
•J DENT RES 2001
•ACTA ODONT SCAND 1975
•DCNA 1999
•DCNA 2003