DIET AND DENTAL CARIES.pptx

Dental caries occur when the demineralization of the enamel exceeds its demineralization capacity. Dental caries is a dynamic process that involves susceptible tooth surfaces, cariogenic bacteria, mainly Streptococcus mutans, and a fermentable carbohydrate source. Sucrose is the most common dietary sugar and is considered the most cariogenic carbohydrate. Frequent consumption of carbohydrates in the form of simple sugars increases the risk of dental caries. This article discusses the role of sugar in developing dental caries, provides concise dietary guidelines for expecting mothers, children, and adults, and highlights the role of the interprofessional team in preventing dental caries through dietary education.

1. DIET AND DENTAL CARIES DR. RITU RANDAD 1

2. CONTENT LIST Introduction Concept of dental caries Stephan’s curve Food, diet and nutrition Classification of Carbohydrates and sugars 2

3. Evidences/studies linked with Diet and Dental Caries Preventive dietary programs Dietary counselling Patient selection Food diary/Diet diary Communication technique 3

4. Communication techniques Tooth friendly snack or ideal mid meal snack Sugar substitutes/classifications Dental Dietary Guidelines for various age groups (children) Summary 4

5. INTRODUCTION Dental caries is a derived from a Latin word called “ carius ” meaning rottenness or decay and is commonly called as tooth decay. Dental caries ( Shafers ) is defined as “ an infectious microbial disease that begins as demineralization of inorganic portion of tooth, followed by destruction of organic portions, leading to caries formation .” 5 R. Rajendra, B Sivapathasundharam , Shafers Textbook of Oral Pathology, 7 th edition, Elsevier, 2016.

6. Definitions 11/30/2023 6

7. Dental caries the disease of civilization has been affecting man since the dawn of time. Caries have been noted in the fossil remains early ancestors of man. Caries seems to have increased considerably in Homo sapiens during Neolithic period when it was perhaps as high as seen in any primitive people. It has been found that, in prehistoric skulls about 5% of the teeth exhibits caries. 7 R. Rajendra, B Sivapathasundharam , Shafers Textbook of Oral Pathology, 7 th edition, Elsevier, 2016.

8. Dental caries has multifactorial aetiology. The disease is not only treatable but also most of the aspects have a preventable factor. 8 R. Rajendra, B Sivapathasundharam , Shafers Textbook of Oral Pathology, 7 th edition, Elsevier, 2016.

9. Tooth decay is an infectious disease generally affected by diet and the pattern of consumption by the host. Sound enamel demineralizes, if plaque bacteria are mixed with carbohydrate substrate and they produce acids, but the presence of saliva in mouth acts as a buffering agent, which in turn to an extend can inhibit the demineralization process. 9 E. Nizel and S. Papas . Nutrition in Clinical D entistry. 3 rd edition, Saunders company, London., 1989

10. The progression of carious lesions is not only inevitable but also the disease occurrence can be controlled. 10 E. Nizel and S. Papas . Nutrition in Clinical D entistry. 3 rd edition, Saunders company, London., 1989

11. Theories of dental caries The legend of worms Ancient Sumerian text known as the ‘Legend of Worms’ from about 5,000 BC From the writings of Homer who made a reference to worms as the cause of toothache. Endogenous theories Dental caries was thought to be produced by internal action of acids and corroding humors Early Greek physicians such as Hippocrates, Celsus , and Galen, proposed the vital theory of tooth decay, which postulated that tooth decay originated, like a bone gangrene, from within the tooth itself. 11/30/2023 11 R. Rajendra, B Sivapathasundharam , Shafers Textbook of Oral Pathology, 7 th edition, Elsevier, 2016.

12. Chemical theory Proposed that an unidentified ‘ chymal agent’ was responsible for caries. Further supported by Robertson in 1835 who proposed that dental decay was caused by acid formed by fermentation of food particles around the teeth. Parasitic theory Erdl in 1843 described filamentous organisms in the membrane removed from teeth. Similarly many observations by Clark(1871,1879), Tomes (1873), Magitot (1878), Underwood and Miller (1880) concurred that bacteria was essential for caries. 11/30/2023 12 R. Rajendra, B Sivapathasundharam , Shafers Textbook of Oral Pathology, 7 th edition, Elsevier, 2016.

13. The proteolytic theory (Gottlieb and Applebaum in 1944) 11/30/2023 13 R. Rajendra, B Sivapathasundharam , Shafers Textbook of Oral Pathology, 7 th edition, Elsevier, 2016.

14. Proteolysis chelation theory (Schatz et al in 1955) 11/30/2023 14 R. Rajendra, B Sivapathasundharam , Shafers Textbook of Oral Pathology, 7 th edition, Elsevier, 2016.

15. Miller’s chemicoparasitic theory (1882) 11/30/2023 15 R. Rajendra, B Sivapathasundharam , Shafers Textbook of Oral Pathology, 7 th edition, Elsevier, 2016.

16. Pathogenesis of dental caries Dental caries is a multifactorial disease with interplay of three primary factors: the host, the microbial flora, and the substrate with time, as an inevitable fourth factor. 11/30/2023 16 R. Rajendra, B Sivapathasundharam , Shafers Textbook of Oral Pathology, 7 th edition, Elsevier, 2016.

17. Primary factors responsible for dental caries 11/30/2023 17 R. Rajendra, B Sivapathasundharam , Shafers Textbook of Oral Pathology, 7 th edition, Elsevier, 2016.

18. Pathogenesis of dental caries ENAMEL PELLICLE + BACTERIA PLAQUE FORMATION PLAQUE BACTERIA + FERMENTABLE CARBOHYDRATE ( FOOD) ACID PRODUCTION (lowering of the plaque pH) DEMINERALISATION OF INORGANIC AND DISSOLUTION OF ORGANIC STRUCTURES OF TOOTH DENTAL CARIES 18

19. Stephan Curve A typical pH response to plaque following exposure to a glucose rinse was obtained creating decrease in the curve. These curves are often referred to as STEPHAN CURVES and have 3 main characteristics. (dental plaque, fermentable carbohydrate and cariogenic bacteria) Under resting conditions, the pH of plaque is reasonably constant, 6.9 to 7.2. following exposure to sugars, the pH drops very rapidly (few minutes) to the low level (5.5 to 5.2 pH), at this pH, tooth surface is at risk. 19 R. Rajendra, B Sivapathasundharam , Shafers Textbook of Oral Pathology, 7 th edition, Elsevier, 2016.

20. Later, slowly it turns to it original value over the period of 10-40 minutes, approximately this is called as, CRITIAL PERIOD. During this time, the tooth mineral dissolves to buffer further acid at lower pH in the plaque-enamel interface and also results in tooth loss. Repeated fall of pH over a period of time leads to more and more mineral loss from the tooth surface and ultimately leading to unfavourable way resulting in initiation of the dental caries. 20 R. Rajendra, B Sivapathasundharam , Shafers Textbook of Oral Pathology, 7 th edition, Elsevier, 2016.

21. 21 R. Rajendra, B Sivapathasundharam , Shafers Textbook of Oral Pathology, 7 th edition, Elsevier, 2016.

22. Food, Diet, Nutrition and Balanced Diet Food- anything that is eaten, drunk or absorbed for maintenance of life, growth and repair of the tissues ( Nizel , 1989). Diet- habitual choice of food and drink. Those food which are eaten regularly over a period of time which determines exposure.(C. Pine) Nutrition- the intake and absorption of nutrients from the food and drink ( C.Pine ) 22 E. Nizel and S. Papas . Nutrition in Clinical D entistry. 3 rd edition, Saunders company, London., 1989 C Pine, R. Harris, Community oral health, 3 rd edition, Quiescence books.

23. Balanced diet- Is a diet which contains varieties of food in such quantities & proportions that the need for energy, amino acids, vitamins, fats, carbohydrates & other nutrients is adequately met for maintaining health, vitality, and general well being & also makes provision for short duration of leanness ( Chauliac 1984) 23 E. Nizel and S. Papas . Nutrition in Clinical D entistry. 3 rd edition, Saunders company, London., 1989

24. Role of Diet in dental caries The effect of diet on caries is considered under two headings: a) Systemic effect b) local effect Nutritional effects are mediated systemically , and dietary effects are mediated locally in oral cavity. The systemic effects result from the absorption and circulation of nutrients to all cells and tissues and may be mediated through influences, on development of teeth, the quality and quantity of salivary secretion, improved host resistance and improved function . 24 E. Nizel and S. Papas . Nutrition in Clinical D entistry. 3 rd edition, Saunders company, London., 1989

25. Dietary constituents exert their local effects by influencing the metabolism of the oral flora and by modifying salivary flow rates and indirectly the qualitative aspect of salivary secretion. 25 E. Nizel and S. Papas . Nutrition in Clinical D entistry. 3 rd edition, Saunders company, London., 1989

26. Dietary factors Increased Susceptibility • Fermentable Carbohydrates – Sugars – Sugar/Starch Combination Decreased Susceptibility • Proteins • Fats: Cheese, Nuts • Foods with Sugar Alcohols • “Healthy” Snacks 26 Fermentable carbohydrates (sugar and starch) are the ones that begin their digestion in the oral cavity via salivary amylase. E. Nizel and S. Papas . Nutrition in Clinical D entistry. 3 rd edition, Saunders company, London., 1989

27. CLASSIFICATION OF SUGAR/CARBOHYDRATE Monosaccharides- are simplest of the carbohydrates and are classified according to the number of carbon atoms in the chain Eg : glucose, fructose and galactose Disaccharides- have linkage of two monosaccharide units. They have a sweet taste, water soluble and crystalline solids. Eg : sucrose, lactose and maltose. 27 E. Nizel and S. Papas . Nutrition in Clinical D entistry. 3 rd edition, Saunders company, London., 1989

28. Polysaccharides- are complex carbohydrates made up of many monosaccharides linked together. They are tasteless, used for storing energy and other perform structural functions. Eg : starch, glycogen and cellulose. Sucrose is having highest cariogenicity followed by glucose, fructose, lactose and galactose. Glucose syrups and hydrogenated glucose syrups have less cariogenicity than sugars, whereas sugar substitutes like xylitol, sorbitol, mannitol are not cariogenic. 28 E. Nizel and S. Papas . Nutrition in Clinical D entistry. 3 rd edition, Saunders company, London., 1989

29. • Sugar - combination of monosaccharide & disaccharide , - highest % of carbohydrate on a dry weight basis. • Sugars classified as entered in the diet : those found naturally in foods ( eg , fruit, honey, and dairy products) and those that are added to foods during processing to alter the flavor, taste, or texture of the food . 29 E. Nizel and S. Papas . Nutrition in Clinical D entistry. 3 rd edition, Saunders company, London., 1989

30. According to the sugar molecules : Intrinsic sugars are formed inside the cell structure of certain unprocessed food stuffs, mostly in fruits and vegetables. Extrinsic sugars are located outside the molecules of food and drinks. There are two types: milk and non milk extrinsic sugars(more cariogenic and plays a vital role in caries process). 30 E. Nizel and S. Papas . Nutrition in Clinical D entistry. 3 rd edition, Saunders company, London., 1989

31. According to the sugar mixes: Blended sugar(50% sucrose and 50% glucose) Pure invert sugar (50% glucose and 50% fructose) Common invert sugar (50% sucrose 25%glucose and 25% fructose). 31 E. Nizel and S. Papas . Nutrition in Clinical D entistry. 3 rd edition, Saunders company, London., 1989

32. Sucrose is regarded as the arch criminal in dental caries: • The dietary sugars all diffuse rapidly into the plaque and are fermented to lactic and other acids or can be stored as intracellular polysaccharides by the bacteria, prolonging the fall in pH and promoting a suitable environment for other aciduric and acidogenic bacteria. • Sucrose is unique because it is the substrate for production of extracellular polysaccharides ( fructan and glucan) and insoluble matrix polysaccharides ( mutans ). 32

33. Thus, sucrose favors colonization by oral microorganisms and increases the stickiness of the plaque allowing it to adhere in larger quantities to the teeth. A combination of soluble starch and sucrose would be expected to be a more powerful caries risk factor than sucrose alone, because the increased retention of the food on the tooth surfaces would prolong sugar clearance time. 33

34. Evidences/studies linked with Diet and Dental Caries The evidences linking diet and dental caries can be summarized under the following headings: 34 Murray J.J. Prevention of dental diseases , 4 th edition, Oxford publication, 2003

35. Evidence for a relationship between diet and dental caries comes from different types of studies Human intervention studies (clinical trials) Human observational studies Animal experiments Plaque pH studies Enamel slab experiments Incubation studies 35 Murray J.J. Prevention of dental diseases , 4 th edition, Oxford publication, 2003

36. World wide epidemiological observational studies Sugar intake and levels of dental caries can be compared between countries. Sreebny (1982) correlated dental caries experience of primary dentition of 5 and 6 years old with sugar supplies data of 23 countries and dental cares experience of 12 years old to supplies data of 45 countries. Observed: 52% variation in caries levels could be explained by per capita availability of sugar. For every 25g of sugar per day, one tooth per child would become decayed, missing or filled. 36 Murray J.J. Prevention of dental diseases , 4 th edition, Oxford publication, 2003

37. The countries with an intake of sugar below 18kg/person per year had caries below DMFT 3 whereas in excess of sugar 44kg/person per year had higher levels of caries. 37 Murray J.J. Prevention of dental diseases , 4 th edition, Oxford publication, 2003

38. 38 Study conducted in 1982 with the association of per capita sugar availability and dental caries experience among 12 year olds

39. Further analysis in 1994, had no such strong association between per capita sugar availability and mean DMFT of 12 year old in developed (29) and developing (61) countries. Reason: very high availability of sugar in these countries, changing the level of sugar intake by few kilograms per year does not influence the caries challenge. In 23 out of 26 countries 28% variations of levels of dental caries with 50g/day had mean DMFT for 12 years below 3. 39 Murray J.J. Prevention of dental diseases , 4 th edition, Oxford publication, 2003

40. Stecksen - Blicks and Gustafsson (1996)- measured caries increment over one year of time among 8 and 13 year old children and related it to diet at one point of time . despite the short duration of observation, a significant relationship was found both for primary and permanent dentition dental caries and the intake of sugar. 40 Murray J.J. Prevention of dental diseases , 4 th edition, Oxford publication, 2003

41. Grindefjord et al. 1996, found a close association between the consumption of confectionery and sugar containing beverages and caries increment in longitudinal study . the age group of the children was between 1 to 3.5 years. Rugg-Gunn et al. in 1984 performed a comprehensive study with 400 English children and found that a small but significant association between intake of total sugars and caries increment over 2 years . 41 Murray J.J. Prevention of dental diseases , 4 th edition, Oxford publication, 2003

42. Michigan study 42 Murray J.J. Prevention of dental diseases , 4 th edition, Oxford publication, 2003

43. When the high caries increment were compared with low caries increment, higher tendency was seen towards more frequent snacking . Sugar intake was high overall in the group except 20 out of 499 children consuming less than 75g/day, whereas the lowest intake of the lowest quartile consumption being 109g/day of the energy intake. 43 Murray J.J. Prevention of dental diseases , 4 th edition, Oxford publication, 2003

44. HUMAN INTERVENTION STUDIES Vipeholm study, 1954 ( Gustaffsone at al , Sweden) The study was conducted in S weden over 5-year period in a mental institute during 1945-1953. • Purpose- to determine the effects of frequency and stickiness of sugar on the formation of caries at different times throughout the day. • Institutionalized patients 436 were divided into 6 experimental and 1 control group. 44 Murray J.J. Prevention of dental diseases , 4 th edition, Oxford publication, 2003

45. Groups divisions 1. Control group - low sugar diet only at meals 2. Sucrose group - high- sugar diet (300g) mostly in drinks with meals 3. Bread group - sweetened bread at meals (sugar- ½ or equal to normal) 4. Caramel group- 22 sticky candies 2 portions at meals (carbohydrate study I) 4 portions between meals (carbohydrate study II) 5. 8- toffee group 6. 24-toffee group- throughout day, twice normal total intake of sugar 7. Chocolate group- milk chocolate- 4 portions bet meals(CSII) 45 Murray J.J. Prevention of dental diseases , 4 th edition, Oxford publication, 2003

46. Study was conducted in 3 phases: 1945-1947 : preparatory and vitamin period, all subjects received diet low in sugar 1947-1949 : Carbohydrate study 1- 2years, twice the normal amount of sugar but only at meals 1949-1951 : carbohydrate study 2- next 2years, normal amounts of sugar some at meals and others both at and between meals 46 Murray J.J. Prevention of dental diseases , 4 th edition, Oxford publication, 2003

47. Findings: Positive association in caries increment with increase sucrose-containing snacks intake between meals- time factor. Positive association with consumption of sucrose with dental caries experience- frequency. Positive association with sugar increasing activity and form of sugar consumed with stronger tendency to retain- retention Cariogenicity of solid food more than liquid containing sucrose - form. 47 Murray J.J. Prevention of dental diseases , 4 th edition, Oxford publication, 2003

48. Caries lesions disappear on withdrawal from sucrose rich food consumed in manner of favouring caries- reduction in total sugar intake. Restrictions of natural sugars and total dietary carbohydrates, for the decreased caries incidence. Positive association with increase in caries activity with increase duration of sugar clearance from saliva- clearance of saliva. Increment in dental caries depends on individuals- variation in individuals. Positive association with increase in carbohydrates leads and increase dental caries. 48 Murray J.J. Prevention of dental diseases , 4 th edition, Oxford publication, 2003

49. 49 SUMMARY OF THE VIPEHOLM STUDY (1954) Murray J.J. Prevention of dental diseases , 4 th edition, Oxford publication, 2003

50. Turku sugar study, Finland ( Scheinin and Makinin ) 1972-1975 AIM - To compare the cariogenicity of sucrose, fructose and xylitol . (1972-1974) Control group- Xylitol is a sweet substance not metabolized by plaque organisms. • 125 subjects with 3 groups , 12 -53 years for 25 months (monitored at 6 months by one person) • foods were manufactured for fructose and xylitol but subjects were asked to avoid sweet fruits such as dried fruits. 50 Murray J.J. Prevention of dental diseases , 4 th edition, Oxford publication, 2003

51. Sucrose was replaced with xylitol One group given chewing gums containing sucrose Another group was given chewing gums containing fructose. The third group was given chewing gums having xylitol. 85% reduction in dental caries was observed in xylitol group 51 Murray J.J. Prevention of dental diseases , 4 th edition, Oxford publication, 2003

52. Findings: Dramatic reduction was seen in dental caries after 2 years among the subjects of xylitol group. Fructose group developed more caries than xylitol group. Between meals chewing of xylitol was anticariogenic. 52 Murray J.J. Prevention of dental diseases , 4 th edition, Oxford publication, 2003

53. Granath ((1978) studied 500 4 year-old Swedish children to sugar consumption, fluoride supplementation and oral hygiene practices. Most important factor- intake of sugar in between meals. Findings- effects of oral hygiene and fluoride showed 86% less buccal and lingual caries and 68% proximal caries in low sugar intake than the high sugar intakes between meals. 53 Murray J.J. Prevention of dental diseases , 4 th edition, Oxford publication, 2003

54. Hopewood house study- Harris (1942-1967) Conducted in New South Wales, Australia. Being an orphan house containing children from birth to 12 years of age. These subjects were on lactovegetarian diet- rich in milk products and vegetables, low in sugars and refined flour. oral hygiene practices and fluoride exposure were poor. Their diet mainly consisted of whole meat, soyabeans and nuts . Cheese, sugar and refined carbohydrates were totally excluded. Follow up study till 13 years. 54 E. Nizel and S. Papas . Nutrition in Clinical D entistry. 3 rd edition, Saunders company, London., 1989 HUMAN OBSERVATION STUDY

55. 55 E. Nizel and S. Papas . Nutrition in Clinical D entistry. 3 rd edition, Saunders company, London., 1989

56. 46% of the 12-year-old in Hopewood house were caries free compared to the 1% of the children from state schools. After 12 years, the association with home ended, lead to increase in caries level due to intak e of more food rich in cariogenicity (sugar and refined flour) than low vegetarian sugar diet. Significant caries reduction on diet restriction inspite of poor oral hygiene and low fluoride consumption. 56 E. Nizel and S. Papas . Nutrition in Clinical D entistry. 3 rd edition, Saunders company, London., 1989

57. Epidemiological Evidence During World War II, due to the sugar restrictions in 1939-1944, dental caries reduced among the civilians. At the same time, dental caries experience among army personnel was increased due to increase in sugar consumption as more ready to eat food items were supplied during that time period. During the World War II, a reduction in intake of sugar was not only the dietary change but also intake of other carbohydrates. 57 Murray J.J. Prevention of dental diseases , 4 th edition, Oxford publication, 2003

58. Tristan da Cunha study. Tristan da Cunha is a remote rocky island in South Atlantic region. Before 1930 and 1940 onwards study showed no evidence of dental caries in this region because of consumption of raw meat. In 1940, after opening of the trading store selling imported sugar and sugar-containing foods showed high caries prevalence and severity of dental caries in all the age group between 1937 and 1966. 58 Murray J.J. Prevention of dental diseases , 4 th edition, Oxford publication, 2003

59. Hereditary fructose intolerance (HFI), by Marthaler (1967) is an autosomal recessive disorder of fructose-1-phosphate . Patients having intolerance of fructose avoid, because its consumption causes malaise, nausea, vomiting, sweating, coma and finally death. Hence, dental caries experience in this patients is very less. Significant association with lesser caries increment in individuals avoiding sucrose and fructose but not for consumption of other sugars and complex carbohydrates. 59 Murray J.J. Prevention of dental diseases , 4 th edition, Oxford publication, 2003

60. Experimental studies- animal based Kite et al in 1950 , one group of rats was fed a caries-producing diet by means of a stomach tube, with no food coming in contact with the teeth. No caries resulted. When the same diet was fed orally and allowed to come in contact with the teeth, caries did occur These two studies conclusively demonstrate that: (1) the role of saliva in protecting against dental caries , and (2) the action of the sugar in carious development is local, not systemic . 60 Murray J.J. Prevention of dental diseases , 4 th edition, Oxford publication, 2003

61. Brut (1968) conducted a study on animals at defined times and under feeding ensured that the animals ate all the feed provided. In such studies a clear positive relationship between frequency of feeding and caries severity . Animals fed ad libitum consumed 11.7 g food per day which was nearly twice the 6g fed to other groups in whom frequency was controlled. The results show that frequency of eating a cariogenic diet is more important than the overall amount consumed. 61 Murray J.J. Prevention of dental diseases , 4 th edition, Oxford publication, 2003

62. In an experiment where animals received 18 portions of feed per day, one group received 3*6 portions, with no time between consumption of the 6 portions. The other group had a 30-minute interval between each of the 18 portions. Caries development was greater in the later group with 18 portions. The amount of time between food intake and the caries experience . 62 Murray J.J. Prevention of dental diseases , 4 th edition, Oxford publication, 2003

63. Hefti and Schmid (1979)- conducted a study to examine effect of concentration of sugar in the diet. diet containing sugar (~10%)causes more caries than sugar- free diet, but no increase in caries was seen when sugar concentration increased above 10%. The non sugar diet is important for caries formation but presence of starch or diet rich in fat will reduce the initiation of caries formation. 63 Murray J.J. Prevention of dental diseases , 4 th edition, Oxford publication, 2003

64. Caries severity has shown increase with increasing sugars concentration up to 40% in experimental rats super infected with S. mutans and Actinomyces viscosus . 64 Murray J.J. Prevention of dental diseases , 4 th edition, Oxford publication, 2003

65. Animal studies showing caries and sugar relationship Relationship between frequency of consumption of cariogenic diet and severity of dental caries. Increase in caries with increase sugar concentration. Little difference in the cariogenicity of glucose, fructose and maltose and increased cariogenicity of sucrose only when animals are super infected with S. mutans . 65 Murray J.J. Prevention of dental diseases , 4 th edition, Oxford publication, 2003

66. Enamel slab experiment Uses- oral appliances that hold slabs of bovine or human enamel retained in mouth for 1 to 6 weeks. procedure- slabs exposed to dietary factor in situ or by removal of the appliances to dip in dietary test substances. Objective- measure the demineralization of the enamel and also the role of saliva as protective agent. 66 Murray J.J. Prevention of dental diseases , 4 th edition, Oxford publication, 2003

67. Von der Fehr (1970) and Geddes et al (1980). 67

68. Plaque pH studies Stephan curve showed curves to rank the acidogenicity of snack foods showed that boiled sweets have lowest pH (~5.2), sweeten tea and coffee gives low pH values. And food sweetened with non sugar sweeteners(diabetic and normal chocolate) and salivary stimulants such as peanuts gives highest pH values. (Hayes and Robert, 1976) 68 Murray J.J. Prevention of dental diseases , 4 th edition, Oxford publication, 2003

69. 69 Murray J.J. Prevention of dental diseases , 4 th edition, Oxford publication, 2003

70. Incubation experiments Simple in vitro tests that measure if plaque bacteria can metabolize carbohydrate in test food to produce acid. Pure cultures of micro-organisms are also replaced with the whole plaque. Rapid acid production and low final pH is interpreted to mean that a food is potentially acidogenic, while high pH has lesser clinical significance. All monosaccharides and disaccharides produce a final pH of below 4.5 when incubated with plaque. 70 Murray J.J. Prevention of dental diseases , 4 th edition, Oxford publication, 2003

71. 71 van Loveren C. Sugar Restriction for Caries Prevention: Amount and Frequency. Which Is More Important? Caries Res. 2019;53(2):168-175. doi : 10.1159/000489571. Epub 2018 Aug 8. PMID: 30089285; PMCID: PMC6425816.

72. 72 van Loveren C. Sugar Restriction for Caries Prevention: Amount and Frequency. Which Is More Important? Caries Res. 2019;53(2):168-175. doi : 10.1159/000489571. Epub 2018 Aug 8. PMID: 30089285; PMCID: PMC6425816.

73. 73 van Loveren C. Sugar Restriction for Caries Prevention: Amount and Frequency. Which Is More Important? Caries Res. 2019;53(2):168-175. doi : 10.1159/000489571. Epub 2018 Aug 8. PMID: 30089285; PMCID: PMC6425816.

74. Author (year of study) Population group objectives Conclusions Q. Yank (2021) Primary school children in Riyadh, Saudi Arabia, 578 male children of 6-8 years To estimate the prevalence of dental caries and identify key associated factors in four major risk domains, including socioeconomic factors, child oral health behavior and practices, child feeding practices, and dietary habits among primary school children in Saudi Arabia Individual factors were associated with increased free sugars intake and increase caries increment. X. Wang (2021) 12-15 year olds in England, Wales and Northern Ireland. To examine the distribution of dental caries in 12- and 15-year-olds in England, Wales and Northern Ireland, by severity threshold, at surface, tooth and child level and explored its association with socioeconomic, psychological and behavioural factors. high frequency sugar consumption was associated with greater caries experience 74

75. 75 Author (year of study) Population group objectives Conclusions N. Jahid (2020) 273 Nepali children, age group of less than 6 months to 12 years. aims to assess relationship of intake of sugar and dental caries among a convenience sample of 273 children age six months to less than 12 years in three communities in Nepal. Positive associations between daily consumption of sweets and processed snacks with severe caries and association between severe caries and poorer nutritional status. A. Sanders (2018) 14,517 dentate men and women of the Hispanic Community To assess the broader relationship between diet quality and dental caries in a diverse Latinx adult population. intake of sugar-sweetened beverage and fruit juice was positively associated with dental caries, whereas vegetables (excluding potatoes); whole grains; and omega-3 fats were inversely associated with dental caries

76. 76 Author (year of study) Population group objectives Conclusions C. Palacious (2017) 1,587 12 years-olds in Puerto Rican children To identify the types, food sources, and pattern of carbohydrates that significantly contribute to dental caries in Puerto Rican children. Significant associations of high intake for the sugars and dental caries and increased significantly in caries increment in children whose 10% of total energy intake was from total sugars.

77. Epidemiological studies of the sugar and caries relationship. A marked increase in prevalence and severity of dental caries has been observed in populations who changed their traditional way of eating and adopted modern diet , high in sugars. Sub groups consuming high sugar diet had shown higher levels of dental caries compared to general population. Studies with longitudinal design, measuring diet and change in level of dental caries over time provides with stronger evidence. 77 Murray J.J. Prevention of dental diseases , 4 th edition, Oxford publication, 2003

78. Preventive dietary program Exclude fermentable sugars from diet. If child is found of sweets, give them all at the meal time, not between meals. Include vegetables and fruits, nuts and cheese as basic diet ( increase salivation) Avoid solid and sticky sugary foods Reduce the number of sugar exposures during the day, consumption during the meals only. 78 E. Nizel and S. Papas . Nutrition in Clinical D entistry. 3 rd edition, Saunders company, London., 1989

79. 79 Shaw states that “the frequency of eating, the amount of food retained in the mouth particularly on tooth surfaces, and the length of time that food residues are retained in critical areas are more important than the total amount of sugars consumed” The diet counsellor should incorporated when possible: A nutritional balanced varied diet from the high-density nutritious basic four groups. Eliminate high-sugar snacks, whenever possible If sugar-containing foods must be included for providing the energy needs restrict them to mealtime Recommend hard cheeses and nuts as between meal snacks. E. Nizel and S. Papas . Nutrition in Clinical D entistry. 3 rd edition, Saunders company, London., 1989

80. Dietary counselling It deals with providing guidance in the art of food planning and food preparation and food services. It assists a person to adjust food consumption to his or her health needs. ( Nizel ) OBJECTIVES OF COUNSELING 1. Correction of diet imbalance, that could affect the patients’ general health and sometimes reflect on his oral health. 2. Modification of dietary habits, particularly the ingestion of sucrose containing foods in forms, amounts, and circumstances that cause caries formation. 80 E. Nizel and S. Papas . Nutrition in Clinical D entistry. 3 rd edition, Saunders company, London., 1989

81. The basic pre-requisites for dietary changes are: That the patient not the counsellor bears the responsibility for making the change. The counsellor should explain candidly the need for full cooperation and sincere effort by patient to modify the diet, and the patient should agree to. 81 E. Nizel and S. Papas . Nutrition in Clinical D entistry. 3 rd edition, Saunders company, London., 1989

82. Minimal requirements for successful counselling includes: Enrolling active patient involvement in planning, implementation and evaluation of diet before and after dietary counselling. Insisting on series of follow-ups visits to tailor the diet according to patients needs and likes, and avoid if possible dislikes without jeopardizing the dental-oral health status. 82 A simple screening of typical 24 hour food intake will disclose possible dietary inadequacies, excesses or both having negative influence on an individual’s dental health-a potential cariogenic diet. E. Nizel and S. Papas . Nutrition in Clinical D entistry. 3 rd edition, Saunders company, London., 1989

83. GUIDELINES FOR COUNSELING • Gather information • Evaluation and interpretation • Develop and implement plan of action • Seek active participation of family • Follow-up the progress and assessment made Patient Selection – Children under the age of 6 years – Elementary school child. – To the Adolescent group. 83 E. Nizel and S. Papas . Nutrition in Clinical D entistry. 3 rd edition, Saunders company, London., 1989

84. Patient selection The patient selected should : Be willing to improve current undesirable food selections and eating habits. Give high priority to preventive dentistry and should be willing to expend long-term efforts to maintain their natural dentition in good health for a lifetime. The Dental Health Diet Score is a screening device to achieve the objective of dietary improvement based on current food intake regimen. It is a simple scoring device that can disclose a potential dietary problem likely to effect the dental health. 84 E. Nizel and S. Papas . Nutrition in Clinical D entistry. 3 rd edition, Saunders company, London., 1989

85. Who does the Dental Health Diet Score works ? By giving points earned as a result of an adequate intake of food from each of the food groups plus the points for ingestion of food recommended as they are the best source of 10 essential nutrients for achieving and maintaining dental health. From this sum, points are subtracted for frequent ingestion of foods that are overtly sweet. The difference is Dental Health Diet Score . 85 E. Nizel and S. Papas . Nutrition in Clinical D entistry. 3 rd edition, Saunders company, London., 1989

86. FOOD DIARY or DIET DIARY It is the records of all the foods and beverages consumed during 5 or 7 day period . It can be 24 hours recall or 3,5,7 days record of food intake. It helps to determine- • Type, frequency, consistency of food intake. • Proper diet planning for oral health. The choice depends on the amount of details required. 86 E. Nizel and S. Papas . Nutrition in Clinical D entistry. 3 rd edition, Saunders company, London., 1989

87. 87

88. 88

89. Diet survey is the practical method of assessing the quality of person’s nutrient intake. It is done by comparing the foods in the food groups with the sources of nutrients obtained from each and then compensating for the nutrients that are high or low. Disadvantage  Time consuming  Nutrient content of the food varies with the preparation method, type of plant and even the location of the plant. 89 E. Nizel and S. Papas . Nutrition in Clinical D entistry. 3 rd edition, Saunders company, London., 1989

90. 90 E. Nizel and S. Papas . Nutrition in Clinical D entistry. 3 rd edition, Saunders company, London., 1989

91. 91 E. Nizel and S. Papas . Nutrition in Clinical D entistry. 3 rd edition, Saunders company, London., 1989

92. 92 E. Nizel and S. Papas . Nutrition in Clinical D entistry. 3 rd edition, Saunders company, London., 1989

93. All the food group scores, and sweet scores summed to the totaling score. If the food scores is barely adequate or inadequate or sweet score is “watch out” zone (needs counselling) NUTRITION-COUNSELING is required. 4 food group scores combined should range within: 72-96 -----Excellent 64-72 -----Adequate 56-64 -----Barely adequate 56 or less -----Not adequate. Score 60-100 is acceptable , and diet counseling is given only at patient’s request. if 56 or less ,then dietary counseling is both recommended and indicated as a part of preventive program. 93 E. Nizel and S. Papas . Nutrition in Clinical D entistry. 3 rd edition, Saunders company, London., 1989

94. Communication techniques Creates motivation for change. Communication is giving and sharing of information, involves knowledge, thoughts and opinions of the counsellor and the patient. During face to face interview, keep eye contact with patient is a powerful device for motivating behaviour change Can be both verbal or non-verbal. Words transmit information. The interviewer’s tone, expressions and gestures convey sincerity, empathy and enthusiasm. Personalization of message is more likely to result in a sustained change in behaviour. 94 Combination of interviewing, teaching, counselling and motivation. E. Nizel and S. Papas . Nutrition in Clinical D entistry. 3 rd edition, Saunders company, London., 1989

95. Interviewing and physical setting Purpose: to understand 95 E. Nizel and S. Papas . Nutrition in Clinical D entistry. 3 rd edition, Saunders company, London., 1989

96. Counseling should be done in a step by step procedure starting with: • Interviewing, where the diet diary is introduced with a brief discussion of the purpose of diet • 24-hour diet record prepared to get an idea of food, the child is consuming • Six-day diet diary advised to be prepared by patient. • Complete record of 6-day diet diary is analyzed regarding the balanced and unbalanced diet. 96 E. Nizel and S. Papas . Nutrition in Clinical D entistry. 3 rd edition, Saunders company, London., 1989

97. • Isolate the sugar factor. • Educating the patients in the role of sugars in the process. • Consumption of acceptable substitutes of more cariogenic food. • Recognition of practical limitation to immediate success. 97 E. Nizel and S. Papas . Nutrition in Clinical D entistry. 3 rd edition, Saunders company, London., 1989

98. 6 questions are to be made before making decision about which patients will benefit from diet counseling 1. WHO may be benefited? 2. WHAT are the objectives of diet and nutrition counseling? 3. WHY is counseling beneficial? 4. WHEN is counseling conducted? 5. WHERE should the counseling occur? 6. HOW to counsel? 98 E. Nizel and S. Papas . Nutrition in Clinical D entistry. 3 rd edition, Saunders company, London., 1989

99. Guidelines for counselling Gather information Evaluate and interpret information Develop and implement a plan of action Seek active participation of patient’s family Follow up to assess the progress made . 99 E. Nizel and S. Papas . Nutrition in Clinical D entistry. 3 rd edition, Saunders company, London., 1989

100. Tooth friendly snack or ideal snack It should stimulate salivary flow. It should have minimal retention on the tooth It should have faster oral clearance rate ( fibrous diet) Snacks should be rich in proteins, minimal in carbohydrates and moderate in the quality of fats. 100 E. Nizel and S. Papas . Nutrition in Clinical D entistry. 3 rd edition, Saunders company, London., 1989

101. Sugar substitute/ classification Two groups: • Intense sweeteners (non-caloric) • Bulk sweeteners (caloric) 101 Murray J.J. Prevention of dental diseases , 4 th edition, Oxford publication, 2003

102. Intense Sweeteners • Are not chemically related to sugars • Added in small quantities for sweetness and not bulk • They are 100- 1000 times more sweeter than sugars • Have negligible or no energy value • Eg : acesulfame(130), aspartame(200), saccharin(500), thaumatin(3000) 102 Murray J.J. Prevention of dental diseases , 4 th edition, Oxford publication, 2003

103. Bulk Sweeteners • Are chemically similar to sugars • Add sweetness • 0.5-1.0 times as sweet as sucrose • Have an energy value • Many are naturally found • Eg : isomalt (0.5), cycasin, maltitol, mannitol(0.7), sorbitol(0.5),and xylitol(1.0) 103 Murray J.J. Prevention of dental diseases , 4 th edition, Oxford publication, 2003

104. Sorbitol and mannitol: They occur naturally in plants, sorbitol is used in foods for diabetics as the metabolism of sorbitol is insulin independent. Sorbitol is commonly used as sweetener in sugarless syrup medicines. Mannitol is used in chewing gums. Hayes and Roberts 1978: sorbitol and mannitol are fermented slowly by plaque organisms and depress plaque pH only slightly( Rugg gunn 1988). In enamel slab experiments: sorbitol and mannitol gave rise to 45% of the demineralization of enamel attributable to sucrose. Conclusion: sorbitol is noncariogenic and does not promote tooth decay 104 Murray J.J. Prevention of dental diseases , 4 th edition, Oxford publication, 2003

105. Xylitol: It occurs naturally in foods and is used at present in confectionery and tooth pastes. Hayes and Roberts 1978: xylitol is fermented to acid slowly in comparison with glucose and sorbitol Imfeld 1977: plaque pH study – xylitol is non acidogenic Turku sugar study: dietary sugar by xylitol resulted in low caries incidence 105 Murray J.J. Prevention of dental diseases , 4 th edition, Oxford publication, 2003

106. Saccharin was discovered in 1879 , bitter taste it is used as a table top sweetener and in soft drinks marketed as calorie low. Aspartame is dipeptide, consisting of aspartic acid and phenyalanine . Thaumatin is a sweet tasting protein extracted from plant, it is used as flavor enhancer in pharmaceutical products 106 Murray J.J. Prevention of dental diseases , 4 th edition, Oxford publication, 2003

107. Dental dietary Guidelines for children at various age groups Prenatal Growth. • Poor Prenatal nutrition • Children with hypoplastic enamel • Mothers guided with active caries and its effects. Birth to 1 year. • importance of Breast milk and infant formula. • ≤ 6 months of age. • At age of 6 months. 107 E. Nizel and S. Papas . Nutrition in Clinical D entistry. 3 rd edition, Saunders company, London., 1989

108. Guidelines for promoting good nutrition and decrease caries risk in infants Discourage the behavior of placing a child to bed with bottle. Prohibit dipping pacifiers in sugar, honey or syrup. Discourage a child from carrying and continuously drinking from bottle or sippy cup. Introduce cup from bottle. Reduce use of beverages, other than breast milk, infant formula or water. 108 E. Nizel and S. Papas . Nutrition in Clinical D entistry. 3 rd edition, Saunders company, London., 1989

109. Guidelines for promoting good nutrition and decrease caries risk in toddlers Discourage the behavior of placing a child to bed with a bottle. Discourage a child from carrying and continuously drinking from a bottle or sippy-cup. Limit juices or sugar-containing drink in take to 4oz/day and only in cup. Restrict cariogenic foods to meal times. Establish routine meal with family members eating together. Stimulate a child’s appetite at meal time by reducing between meal snacking. 109 E. Nizel and S. Papas . Nutrition in Clinical D entistry. 3 rd edition, Saunders company, London., 1989

110. Conclusion Dental caries is a diet-related disease that continues to be a problem for certain dental patients. Frequent consumption of fermentable carbohydrates that have low oral clearance rates the increase in the risk of enamel caries. Highly acidogenic snack foods should be consumed at meal times to reduce the risk and also between the meals snacks should be non-acidogenic. 110

111. Name of the article Level of evidence Results Conclusion Kim JA, Choi HM, Seo Y, Kang DR. Relations among obesity, family socioeconomic status, oral health behaviors , and dental caries in adolescents: the 2010-2012 Korea National Health and nutrition examination survey. 3a In males, associations between family income and dental caries on permanent teeth were noted after adjusting for confounding variables; the odds ratios and 95% confidence intervals thereof were for low-middle, middle-high, and high family income, respectively. Smoking experience showed a significant association with dental caries on permanent teeth in females.. There was no association between obesity and dental caries on permanent teeth in either male or female adolescents. factors associated with dental caries in adolescents differ according to gender. Therefore, gender-specific interventions may be warranted to improve dental health among adolescents. 111

112. References E. Nizel and S. Papas . Nutrition in Clinical D entistry. 3 rd edition, Saunders company, London., 1989 Murray J.J. Prevention of dental diseases , 4 th edition, Oxford publication, 2003 Thylstrup A, Fejerskov O. text book of clinical cariology. 2nd edition: Munsksgaard , Denmark., 1999 Axelsson p. diagnosis of risk prediction of dental caries. Volume 2: Quintessence publishing, Chicago., 2000 112

113. van Loveren C. Sugar Restriction for Caries Prevention: Amount and Frequency. Which Is More Important? Caries Res. 2019;53(2):168-175. doi : 10.1159/000489571. Epub 2018 Aug 8. PMID: 30089285; PMCID: PMC6425816. R. Rajendra, B Sivapathasundharam , Shafers Textbook of Oral Pathology, 7 th edition, Elsevier, 2016 C Pine, R. Harris, Community oral health, 3 rd edition, Quiescence books. Alhabdan YA, Albeshr AG, Yenugadhati N, Jradi H. Prevalence of dental caries and associated factors among primary school children: a population-based cross-sectional study in Riyadh, Saudi Arabia. Environ Health Prev Med. 2018 Nov 30;23(1):60. doi : 10.1186/s12199-018-0750-z. PMID: 30497366; PMCID: PMC6267843. Yang Q, Xi Y, Liu H, Luo J, Ouyang Y, Sun M, Yong C, Xiang C, Lin Q. Free Sugars Intake among Chinese Adolescents and Its Association with Dental Caries: A Cross-Sectional Study. Nutrients. 2021 Feb 26;13(3):765. doi : 10.3390/nu13030765. PMID: 33652968; PMCID: PMC7996778. 113

114. Wang X, Bernabe E, Pitts N, Zheng S, Gallagher JE. Dental caries thresholds among adolescents in England, Wales, and Northern Ireland, 2013 at 12, and 15 years: implications for epidemiology and clinical care. BMC Oral Health. 2021 Mar 19;21(1):137. doi : 10.1186/s12903-021-01507-1. PMID: 33740952; PMCID: PMC7980596. Palacios C, Rivas-Tumanyan S, Morou-Bermúdez E, Colon AM, Torres RY, Elías- Boneta AR. Association between Type, Amount, and Pattern of Carbohydrate Consumption with Dental Caries in 12-Year-Olds in Puerto Rico. Caries Res. 2016;50(6):560-570. doi : 10.1159/000450655. Epub 2016 Oct 28. PMID: 27788518; PMCID: PMC5311111. Palacios C, Rivas-Tumanyan S, Morou-Bermúdez E, Colon AM, Torres RY, Elías- Boneta AR. Association between Type, Amount, and Pattern of Carbohydrate Consumption with Dental Caries in 12-Year-Olds in Puerto Rico. Caries Res. 2016;50(6):560-570. doi : 10.1159/000450655. Epub 2016 Oct 28. PMID: 27788518; PMCID: PMC5311111. 114