diet and dental caries seminar

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Diet and Dental caries Dr Deepthi Athuluru , III-Post graduate, public health dentistry


Contents Definitions Introduction Diet and dental caries Major factors in dental caries process Dietary Factors affecting caries process Dietary constituents and cariogenicity


STUDIES: 1. Animal studies 2. Studies on Preeruptive effect 3. Interventional Studies Vipeholm Study Hopehood House Study Turku Sugar Study Experimental Caries Study


4. Non Interventional Studies Epidemiological Studies Cross- Sectional Studies Observational Studies 5. Frequency of feeding studies 6. Studies on concentration of sugars 7. Plaque pH studies 8. Incubation experiments 9. Enamel slab experiments 10. Fruits and dental caries Summary


Anti caries diet Phosphates and other dietary items protective against caries: inorganic phosphates, trimetaphosphates , phytates , honey, fats and proteins Alternative sweeteners Adverse effects of sweet tasting compounds Conclusion


Diet counselling Introduction Definition Objectives Of Counseling Aims Of Counseling Diet Analysis Dental Health Diet Score Diet Diary Food Pyramid Dietary Counseling In Children Conclusion References

Definitions :

Definitions If we eat wrongly, no doctor can cure us & if we eat rightly, no doctor is needed” - Victor.G.Rocine 1930 Food Nutrition Diet Balanced diet


FOOD: - Anything that is eaten, drunk or absorbed for maintenance of life, growth & repair of the tissues ( Nizel 1989)


NUTRITION: - The science of food and its relationship to health . It is concerned primarily with the part played by the nutrient in body growth, development and maintenance. (W.H.O 1971)


DIET: - It is the total intake of substance that furnish nourishment & or calories to the body (P.M Randelph 1981)


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)


Dental caries equation: Sugar + Bacteria from plaque = Caries Diet and dental caries



Role of Diet in Dental Caries: :

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, 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. 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.1

Major factors in dental caries process :

Major factors in dental caries process Factors that proved in cross-sectional studies, to be significantly associated with increased prevalence of specific disease – Risk indicators (RI ) Factors that have proved, in well- controlled prospective studies, to increase significantly the risk of onset or progression of a specific disease- Risk factors (RF) and Prognostic risk factors (PRF)


Among external modifying RI, RF, and PRF, for dental caries are… Fermentable carbohydrates Poor socioeconomic statue Systemic disease Medication that impairs salivary function Irregular dental care habits

Dietary Factors :

Dietary Factors Increased Susceptibility Fermentable Carbohydrates – Sugars – Sugar/Starch Combination Decreased Susceptibility Proteins Fats: Cheese, Nuts Foods with Sugar Alcohols “Healthy” Snacks Fermentable carbohydrates are carbohydrates (sugars and starch) that begin digestion in the oral cavity via salivary amylase.


General classifications of Fermentable Carbohydrates

what are sugars?:

what are sugars? Sugars are a form of fermentable carbohydrate. Sugar - combination of mono &disaccharide, - highest % of carbohydrate on a dry weight basis. Sugars enter the diet in 2 forms: 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


Classifications of Sugars – Total Sugars Intrinsic Sugars Extrinsic Sugars Milk Sugars Non Milk Extrinsic Sugars ( NMES) No Harm to Teeth Harm to Teeth Classifications of Sugars


Sugars and dental caries. Touger-Decker R, van Loveren C. American J Clin Nutr 2003;78(suppl):881S-92S.


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 ). Thus, sucrose favors colonization by oral microorganisms and increases the stickiness of the plaque allowing it to adhere in larger quantities to the teeth


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


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.



Interventional studies 1) Vipeholm study, Lund (Sweden) 1946- 1951:

Interventional studies 1) Vipeholm study, Lund (Sweden) 1946- 1951 The study was conducted in sweden over 5 year period 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

Study was divided into 3 phases:

Study was divided into 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

Seven groups:

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)

Results :

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


conclusion Consumption of sugar, even in large quantities, is associated with only a small increase in caries incidence when ingestion is limited to meal times In subjects with poor oral hygiene, consumption of sugar both between meals and at meals is associated with a marked increase in caries incidence. Under unifrom experimental conditions, the increase in caries incidence varies widely from person to person


Caries activity subsides once sugar rich foods are withdrawn from the diet In subjects with poor oral hygiene, carious lesions occur despite the avoidance of sugar


Because of their poor oral hygiene, they had abundant amounts of plaque, the subjects were therefore not representative of the general population


1942, 80 children, 7-14 yrs (10yr period) Vegetarian diet- largely raw Absence of meat and rigid restriction of refined carbohydrate Caries reduced to a minimal level by dietary means alone in spite of unfavorable hygiene and fluoride levels Dental caries prevalence in young children almost negligible in primary dentition and approx. 1/10 that seen in the permanent teeth of Australian child Hopewood study in Bowral, N.S.W, Australia


When the children became old enough to earn wages in the outside economy, they deviated from the original diet. A steep increase of decayed, missing, and filled teeth (DMFT) after the age of 11 years indicates that the teeth did not acquire any permanent resistance to caries

Turku sugar study, Finland (Scheinen and Makinen 1975):

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 ) for 24 months 3 groups – sucrose (S), fructose (F) and xylitol (X ) Examination- cavitated and precavitated lesion Primary and secondary caries

Development of primary and secondary caries (24 mon):

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


C onclusion Substitution of xylitol for sucrose in normal Finnish diet resulted in low caries incidence. Reduced the number of most microorganism

Experimental caries study:

Experimental caries study Vonder fehr et al 1970, over a period of 23 days, dental students rinsing nine times daily with 10ml of a 50% sucrose solution developed a higher caries index and more early lesion than did the control group. Both groups abstained from oral hygiene. After 30 days of oral hygiene and daily fluoride rinses, the caries index returned to preexperimental levels


Subsequently, the sucrose rinsing experiment was repeated for 3 weeks. This time the subjects employed chemical plaque control by rinsing twice a day with 0.2% chlorhexidine solution but used no fluoride, no caries developed


These two short term studies showed that: Sugar is not etiologic factor for caries development, but it is a modifying risk factor Dental plaque is an etiologic factor for caries development Despite frequent sugar intake, clean teeth do not develop caries, even in the absence of fluoride

Non interventional human studies:

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

I. Epidemiological studies Sugar consumption in selected countries in1977 :

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

Sugar consumption in Sweden 1960-1990:

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


- 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

II. Cross sectional studies:

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

III. Observational studies:

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


Before world war II estimated sugar consumption rate 15 kg/person/ year-reduced to less than 0.2 kg/person/year Dental caries rate dropped during war time and rose when sugar restriction were lifted -England, Norway and Japan War time diets




Increase in the total caloric intake of western Greenlanders from 17% (1901) to an avg. of 63% (1930) Diet – Imported foods, Especially Sugar and Cereals In East Greenland Natives of isolated settlements received relatively no imported food Those nearing trading posts less when compared to their contemporaries of the western side WHY SO HIGH INCIDENCE OF CARIES IN WEST GREENLAND …………???


Nature provided subjects – strict dietary pattern Reduced levels of fructose-1- phosphate Avoid any food that contains fructose or sucrose If ingested – nausea, vomiting, malaise, tremor, excessive, sweating, and even coma ( fuctosemia ) Hereditary fructose intolerance


Most of the symptoms due to secondary hypoglycemia Comfortable with other foods containing glucose, galactose , and lactose Dental caries prevalence of these subjects – extremely low Highly significant differences in the proportion of Streptococcus mutans and Lactobacillus Low prevalence of caries indicates- starchy food do not produce decay , where as sugary foods do Observation also emphasize that plaque micro flora is directly influenced by the type of dietary sugar ingested Hereditary fructose intolerance


Those HFI individuals who have survived this disorder by successfully avoiding fructose or sucrose from any source are either caries-free or have very few caries. The low prevalence of caries in HFI patients indicates that starchy foods alone do not produce decay, whereas sugary foods do.


Seventh Day Adventist dietary counsels advise limitation of use of sugar, sticky desserts, highly refined starches, and between- meal snacking Adventist children tends to be lower than that in non- Adventist children in same geographic location and socioeconomic stratum. Seventh Day Adventist Children

Animal studies :

Animal studies Orland et al in 1954 , One group of rats was fed a caries-producing diet under germfree conditions, caries did not develop. In contrast to similar rats fed on the same diet but not reared under germfree conditions. Those rats receiving the cariogenic diet alone did not develop caries; those with the cariogenic diet plus the bacteria did develop lesions


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) bacteria are essential for caries development, regardless of diet, and (2) the action of the sugar in carious development is local, not systemic.

Studies on Pre eruptive effect:

Studies on Pre eruptive effect Sognnaes and white (1940): american children aged 4-13 years and their parents. 14 children caries free (CF) 18 children caries susceptible (CS) The mothers condition during pregnancy was poorer in the CS group, breast feeding was less prevalent, children psychological and medical condition was poorer, dental hypoplasia was more prevalent and severe in the CS group, the diet was lower in protective factors and higher in adhesive foods. Vit D intake was lower and in between meal carbohydrate intake is higher in the CS group.


Mellanby (1923,1937) observed that vit D deficiency in many children had hypoplastic teeth and that these tended to be more carious than teeth with sound enamel. A three year experiment was undetaken ( Mellanby , Young 1937) on Birmingham children initially aged 9 ½ years were given dietary supplements of either codliver oil (rich in Vit D) , olive oil (low in Vit D) or treacle. The children receiving cod liver oil had significantly less caries in their newly erupted teeth than those in the olive oil . In support of her theories Mellany pointed out that africans (whose skin exposed to plenty of sun) and eskimos (who ate an animal fat diet rich in Vit D) had very low caries prevalence.


An epidemiological investigation into the caries preventive effect of Vit D was reported in Hungary ( Bruszt et al 1977). The dental health of 1017 3-6 year old children, who had received regular vit D prophylaxis, was measured in 1975 and compared with the dental health of 620 children of the same age examined in 1955 who had not received vit D prophylaxis. Caries experience rose from 3.8dmft in 1955 to 5.3 dmft in 1975. however, sugar consumption in Hungary increased from 24kg/person /year in 1955 to 38 in 1975, leading the authors to conclude that vit D either does not possess a protective effect against caries.

Frequency of feeding studies:

A partial explanation for this related to the finding first clearly shown by the Vipeholm experience that the frequency of consumption of sugars and the oral clearance time for sugars (i.e. retentivity ) are important factors affecting cariogenicity .. Frequency of feeding studies


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




In addition, the salivary stimulation brought about by food and its mastication, the role of saliva in demineralization and remineralization of enamel all affect the rate of caries production The mechanism by which frequency of eating translates into increased caries activity is best explained by terms of intra plaque events. When sucrose is ingested frequently (over 5 times per day), even a relatively l ow concentration of 1.25%, will cause a drop in pH to between 4 and 5 depending on the site and method of measurement..

Studies on concentration of sugars:

The concept that a prolonged clearance of a local substrate potentiates caries has long been suspected and was clearly shown in the Vipeholm study . A significant correlation was found between a high sugar concentration in saliva with a prolonged clearance time and caries activity This finding implies that retentive, sticky, sweet foods with little detergency or self-cleaning properties may be potentially more cariogenic than foods that are detergent and rapidly clear the oral cavity, Studies on concentration of sugars


Huxley 1977, Hefti and schmid 1979 showed that caries severity increased with increasing sugar concentration although the increase in severity fell with sugar concentrartions above 40 percent. Hutchinson 1969 observed, in three out of four experiments, that in rats sucrose was more cariogenic than glucose or fructose but the differences were small. There was no difference in the cariogenicity of glucose and fructose. Grenby and leer 1974 found that 20 percent glucose syrup was less cariogenic than 20 percent sucrose syrup when taken by rats in drinking water, the difference being particularly marked in smooth surface caries.


Birkhed et al 1981 found that glucose + fructose (invert sugar) was less cariogenic than sucrose, rats who received the sucrose diet were superinfected with strep mutans but the rats who received the invert sugar are not.


Effective Concentration of Sucrose The reasons depend on availability of sucrose for support bacterial metabolism in plaque which is influenced by the texture, consistency of the food, the stimulation of saliva stimulated by chewing and the rapidity of clearance of the substrate.


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 Caries promoting potential of certain foods

Plaque pH studies:

Plaque pH studies If the acidogenic theory of caries aetiology is accepted, measurement of plaque pH before, during and after a food is eaten should be a guide to the cariogenic potential of that food. If measurements of plaque pH are made, the acidogenicity of various foods, drinks and meal pattern can be compared and the results used as a basis for advising on their potential cariogenicity .


78 STEPHEN’S CURVE 10% sucrose solution- 40min PLAQUE pH TIME IN MINS


Stephan Curve pH changes in plaque following application of different carbohydrate solutions

Methods of measuring plaque pH:

Methods of measuring plaque pH There are four main methods of measuring plaque pH. Firstly, metal probes inserted insitu into plaque. The antimony probe micro-electrode was used by stephan (1940,43,44) in his original stephan curve experiments. Yankell eta l 1983 used iridium oxide probes fitted into upper removable intra oral appliances; harper et al 1985) used a palladium oxide miniature probe. Secondly, glass probes have been used by charlton 1956.


Thirdly, a system employing a miniature glass electrode built into a partial denture that stays in the mouth for several days while plaque forms over the teeth and electrode. Recording of pH are made either via wires coming from the mouth or by radio telemetry. The fourth method involves the removal of small samples of plaque from representative teeth and the measurement of the ph of this plaque on a small saucer shaped glass electrode outside the mouth. This method was developed by Fosdick et al 1941


Sampling method used by Frostell 1972 and Rugg Gunn eta al 1978 has indicated that cooked starch are less acidogenic than sugar or high sugar foods. Frostell 1972 showed that uncooked starch was virtually non acidogenic .


Jensen and schachetele 1983 showed that starch is capable of depressing plaque pH below critical pH 5.5, hence starch cannot be lablled ‘safe for teeth’. These findings led Bibby et al 1986 to conclude that the starch in foods, a more contributor to the acidogenicity of sugar containing foods than is believed.


Rugg Gunn et al 1975 showed that eating cheese after a sugary food prevented the depression of plaque pH. The favorable action of cheese is likely to be due to High salivary flow rate induced by the strongly flavoured food Peanuts and sugarless chewing gum also have similar actions in raising the pH of plaque after it has been depressed by a sugary food. On the other hand, eating an apple was found to have little beneficial effect compared with peanuts Geddes et al 1977


85 Snack foods – acidogenic potential Edgar 1981 Group1 Beverages Fruit etc Baked goods sweets Least Acidogenic 1) Milk peanuts Sugarless gum 2) Chocolate milk apple Bread , butter Caramels Sugared gum chocolate 3) Carbonated beverages banana Cream filled cakes ,sandwich 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

Enamel slab experiments:

Enamel slab experiments Brudevold et al (1985) compared the effect of rinsing with solution of either raw starch or cooked starch, with no rinsing at all. The degree of demineralization was assessed by measuring the change in the iodine permeability of the enamel slab. These results showed that rinsing with a 10 percent sucrose rinse solution increased enamel permeability by 15.6 units, indication that sucrose had a considerably greater demineralization effect than either starch.

Incubation experiments:

Incubation experiments These are done outside the mouth and can be classed as ‘test tube experiments’. Saliva, which contains oral micro organisms or pure cultures of oral microrganisms have substituted for plaque ( Bibby et al 1951), rapid acid production indicates that the food under test is potentially cariogenic . Miller 1980 established, that when carbohydrate foods were incubated with oral organisms, acid was produced and this acidic incubate was capable of demineralizing tooth enamel


In some of these experiments, teeth or parts of teeth have been incubated with bacteria and the degree of dissolution of the enamel quantified, this has led to the construction of ‘artificial mouths’ (Huang et al). However the conditions in the mouths of living people are constantly changing and it is impossible to reproduce all of these. Bibby and Mundorff 1975 reported that sorbitol sweets produced eight times as much enamel dissolution as 2 percent sucrose, while lemon flavoured sugar candies produced only one fifth as much enamel dissolution as sucrose.

Does Fruit Cause Dental Caries?:

Does Fruit Cause Dental Caries? Studies in US, UK and Scandinavia- - ve correlation South African studies of workers in apple and grape orchards- + ve correlation Human interventional studies: Liverpool children's home(3 age groups 6, 6-10,11-15yrs) for 2 years and found no increase in caries Animal studies: Higher caries in rats feed with figs, apples, bananas grapes and resins in comparison to citrus foods, peanuts or dried apricots. Bananas and raisins more cariogenic than sucrose Ph studies: Apple, bananas & dried raisins more acidogenic for longer duration

Conclusions :

Conclusions Cooked staple starchy foods, such a rice, potatoes and bread would appear to be of very low cariogenicity in man If finely ground, heat treated and eaten frequently, starch can cause caries but the amount is much less than that caused by sucrose The addition of sugar increases the cariogenicity of cooked starchy foods. Foods containing baked starch and substantial amounts of sucrose appear to be as cariogenic as similar amount of sucrose.

Anti caries diet:

Anti caries diet

Milk and Dental Caries:

Milk and Dental Caries Milk has lactose which is less acidogenic Ca ,P & casein protect against demineralization Animal studies – anticariogenic Human breast milk – high lactose, less P & Ca Normal breast feeding no dental caries Prolonged nocturnal suckling –increased caries risk


CHEESE & DENTAL CARIES Animal & experimental studies: anticariogenic Due to : abolishes fall in ph increase salivary flow increase plaque Ca concentration Enamel slab studies: remineralization


PLANT FOOD & DENTAL CARIES Plant food pocess protective agents: Organic & inorganic phosphates Ca sucrose phosphate- cariostatic food additive Phytate - anti cariogenic Sodium tri meta phosphate most effective Stimulate saliva Detergent

Phosphates and other dietary items protective against caries:

Phosphates and other dietary items protective against caries Osborn et al 1937 observed that less enamel dissolved from teeth incubated with unrefined than with refined foods, they suspected that these protective factors act locally in the mouth rather than systematically via the developing tooth.


Inorganic phosphates Nizel and Harris in 1964 concluded that addition of inorganic phosphates to cariogenic diets reduced caries experience in rodents Averill et al 1966 studied the effect of 2 percent decalcium phosphate on the teeth of 6-13 year old children in brazil, they observed reduced caries experience over 20 mos and increase serum and saliva calcium levels Ashley et al 1974, 3 year clinical trial on 11-15 year old reported no reduction in caries in children consuming sweets supplemented with 3 percent dicalcium phosphate compared with control children consuming unfortified sweets


Trimetaphosphates Harris et al 1967 concluded that trimetaphosphates (TMP) were likely to be the most effective polyphosphate in preventing dental caries The addition of sodium trimetaphosphate to chewing gum was tested by Finn et al 1978 with positive results Phytates Jenkins et al 1959 reported that phytates in unrefined carbohydrate foods act as protective factors Cole et al 1980 observed a marked reduction in caries in monkeys fed on cariogenic diets in which sugar was supplemented with 1% sodium phytate


Honey and partially refined crystallized sugar Findings of rat experiments by Nizel 1973, konig 1967 observed that the cariogenicity of sucrose, jam or honey when spread on bread was apporx equal, while Shannon et al 1979 reported that honey was as cariogenic , in rats, as sucrose and a mixture of fructose, glucose and sucrose in the same proportion as occurred in the honey.


Fats and protein Frostell 1969 – Fat in diet reduce the cariogenicity of dietary sugar by the physical action of accelerating its clearance from the mouth Bibby 1966 – proteins adsorb onto enamel surfaces but the degree to which they protect against caries is unknown. Milk contains both fat and protein. The fall in pH after drinking milk is minimal and the high protein, ca, P content act as enamel protective effect (Jenkins, Fergusen , Frostell 1970) The caries preventive effect of cheese is well established from plaque pH studies ( Rugg Gunn et al 1975)


The mechanisms whereby fats act to reduce dental caries. Coating of tooth surface with a oily substance. Prevent fermentable sugar from being reduced to acids. May interfere with the growth of cariogenic bacteria. Increased dietary fat – Decrease the amount of dietary fermentable carbohydrate.


NON SUGAR SWEETENERS Two groups: Intense sweeteners (non-caloric) Bulk sweeteners (caloric)

Intense Sweeteners:

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)

Bulk Sweeteners:

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 (.5), lycasin , maltilol,mannitol (.7), sorbitol (.5),and xylitol (1.0)


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 sweetner 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 Conlusion : sorbitol is noncariogenic and does not promote tooth decay


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


Isomalt Imfeld 1983: Isomalt caused little acid production when incubated with oral strptococci and plaque pH is virtually unaffected after exposure to 10% percent solution

Intense sweeteners:

Intense sweeteners Saccharin was discovered in 1879 , bitter taste in conc. Over 0.1%, it is used as a table top sweetener and in softdrinks 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 flavour enhancer in pharmaceutical products


Cariogenicity of the intense sweeteners Linke 1977: Saccharin inhibit bacterial growth and metabolism Greenby 1984: inhibitory effect, rat caries development was small Leach et al 1983: thaumatin shown remineralization of early caries in rats

Adverse effects of sweet tasting compounds:

Adverse effects of sweet tasting compounds Osmotic diarrhoea in adults Drucker 1979 : sorbose associated with haemolytic anaemia , xylitol and sorbitol with diarrhoea , glycyrrhizin with hypertension, cyclamate and saccharin metabolites with bladder tumours and sucrose with caries, obesity, diabetes and coronary heart disease

Conclusion :

Conclusion Sucrose, glucose, maltose and fructose are most cariogenic sugars, while lactose less cariogenic . The bulk sweetners sorbitol , mannitol , and isomalt are noncariogenic . Xylitol , saccharin, aspartame and thaumatine are non cariogenic . Effective caries prevention by sugar control includes:


Deciding which types of food or eating habits are the most harmful: substitution of sugar in these foods by less cariogenic sweeteners might then be cost effective Development of new technology to reduce the cost difference between sucrose, glucose and fructose and other less cariogenic sweetners Development of sweeteners free from adverse effects

Diet counseling :

Diet counseling


DEFINITION It deals with providing guidance in the art of food planning and food preparation and food services. It assist a person to adjust food consumption to his or her health needs. ( Nizel )


OBJECTIVES OF COUNSELING Correction of diet imbalance, that could affect the pts general health and sometimes reflect on his oral health. Modification of dietary habits, particularly the ingestion of sucrose containing foods in forms, amt, and circumstances that cause caries formation.


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 yrs Elementary school child. To the Adolescent group.


ART OF COUNSELING Counseling is ONE-ONE basis. To be effective it should be in form of dialogues. e.g.:- Communication technique: Face-face interview. Communication can be both verbal and non-verbal. Messages must be adopted to pts needs and level of understanding.


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 hr diet record prepared to get an idea of food, the child is consuming Six-day diet diary advised to be prepared by pt. Complete record of 6 day diet diary is analyzed regarding the balanced and unbalanced diet. Isolate the sugar factor. Educating the pts in the role of sugars in the process. Consumption of acceptable substitutes of more cariogenic food. Recognition of practical limitation to immediate success.

Five ‘W’ and one ‘H’ of diet consultation.:

Five ‘W’ and one ‘H’ of diet consultation . 6 questions are to be made before making decision about which pts will benefit from diet counseling WHO, WHAT, WHY,WHEN, WHERE AND HOW. WHO may be benefited? WHAT are the objectives of diet and nutrition counseling? WHY is counseling beneficial? WHEN is counseling conducted? WHERE should the counseling occur? HOW to counsel?


FOOD DIARY or DIET DIARY MY DIET DIARY It is the records of all the foods and beverages consumed during 5 or 7 day period . It can be 24 hrs 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.


24 hr Recall It’s a valuable tool for obtaining a skeletal picture of patients food intake. It is done to determine whether the 5 day or the 7 day food diary is necessary for the diet modification (diet counseling). No comments or opinion should be given at this time, allow the patient to talk freely. This is the most rapid method (15-20min)for recording current food intake. Disadv :- it can be over or under estimation of food taken in a single day and may not represent the usual diet.

5-7 Day Diet Diary:

5-7 Day Diet Diary The pt or mother completes the food diary at home, by writing it immediately after each food consumption. Pt is instructed to be accurate as possible in determining quantities and to include a weekend day as a one of the recorded day. Instruction for recording the dairy : Record about everything you eat and drink and the time of eating. eg : between meals or during meals. Also the activity involved in. Record about the candies, chewing gums, cough syrups or other medication taken.


3. The following should be included- Kind of food Amt: in household measures. Order in which they are eaten. No. of teaspoons of sugar and sugar products used. Indicate the mood in which you are in, reason why you are eating. The diet is analyzed and cariogenic factors are isolated, average nutrition intake in checked.




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.

Dental health diet score:

Dental health diet score It is a screening device which is a simple scoring procedure that can disclose a potential problem that is likely to adversely affect the pts oral health. Dental Health Score- Total Food Score+ Nutrition Score- Sweet Score. Step I ( Food Score) To find out the average daily intake First, list everything you eat and drink on an ordinary weekday including snacks. Record time, amount, preparation method and no: of teaspoons of sugar was added.


Step II Circle the foods in diary that have been sweetened with added sugar or natural sweets (honey..) Classify uncircled foods or mixed food dishes For each serving of food listed in food diary place a check mark in appropriate food group block. Add the no: of checks and multiply by number shown. The max: number of points credits for each group ( 24x4=96 ). Add the points.


Step III ( Nutrition Score) This is to find out how much of the nutrients are present in the food taken. check the food in each column then, circle the number 7 besides the nutrients that head the column. Only 7 points are given per nutrient. Add the circled numbers. ( Perfect score-56 )


Step IV (Sweet Score) List the sweet, sugared foods, and the frequency with which they are consumed . Classify each sweet into liquid, solid and sticky or slowly dissolving. Place check mark in the frequency column of each item as long as they are eaten 20min apart. Add the checks- if sweets are liquid-x5, solid-x10,slowly dissolving-x15. (Highest Score-35).


StepV 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.- NUTRITION-COUNSELING is required. 4 food group scores 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 pt request. if 56 or less ,then dietary counseling is both recommended and indicated as a part of preventive program.



Normal Diets :

Normal Diets A Normal Diet consists of any and all foods eaten in health. It is planned keeping the basic food groups in mind so that optimum amounts of all nutrients are provided.  Foods Allowed: All foods that you eat in normal health. Foods partially restricted: · Fatty foods like rich cakes, pastries, halwa's etc. · Fried foods like puris , parathas and pakora's etc. · Strongly flavored vegetables like turnip, capscicum , radish etc. · Too many spices, relishes or pickles


DENTAL DIETARY GUIDANCE OF CHILDREN OF VARIOUS AGE GROUPS Prenatal Growth. Poor Prenatal nutrition Children with hypoplastic enamel Mothers with active caries. Birth to 1 year. Breast milk and infant formula. ≤ 6 months of age. At age of 6 months .


Guidance for promoting good nutrition and decreasing 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.


1-2 Years. Guidance for promoting good nutrition and decreasing caries 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.


2-5 Years. Good dietary habits with regular meal pattern. Non- cariogenic snacks should be provided at home and lunch boxes. Discourage Sugar containing snacks. Promoting nutrition ,non- cariogenic food for meals. Strongly discourage the consumption of slowly eaten, sugar-containing foods.


Family conflicts and emotional problems may arise due to a feeling of social inadequacy or pressure of school and college work. Though appetite is great, meal times are irregular due to pre-occupation with books, comics, friends and dating. Snacking in between meals is therefore common. The choice of foods is important. Snacks should be wholesome and not only a source of energy but also of proteins and other essential nutrients. Dental consideration II permanent molar, premolars and canine begin to erupt. Pre-pubertal growth spurts.


CONCLUSION Counseling involves willingness of 2 participants who meet to consider a problem, question or situation posed by one individual. Counseling is a face-face situation. Counseling takes place in privacy. Counseling demands a friendly, free atmosphere. Counseling is not controlling. Counseling is not a advice giving. Counseling is not census taking. Counseling is not an aimless exchange of pleasantries.


References Thylstrup A, Fejerskov O. text book of clinical cariology . 2 nd edition: Munsksgaard , Denmark., 1999 Axelsson p. diagnosis of risk prediction of dental caries. Volume 2: quintessence publishing, Chicago., 2000 Nizel , Papas T. Nutrition in clinical dentistry. 3 rd edition, Saunders company, London., 1989 Murray J.J. Prevention of dental diseases

Other relevant publications:

Other relevant publications Lingstrom P et al in his review on dietary factors in prevention of dental caries concluded that No study could be found that had evaluated the effect of information designed to reduce sugar intake/frequency as a single preventive measure. It is suggested that the evidence for the use of sorbitol or xylitol in chewing gum, or for the use of invert sugar, is inconclusive. No caries-preventive effect was found from adding calcium phosphate or dicalcium phosphate dihydrate to chewing gums. He suggested the the need for welldesigned randomised clinical studies, with adequate control groups and high compliance, looking at the effect of dietary measures on dental caries. Dietary factors in the prevention of dental caries: a systematic review. Acta Odontol Scand 2005; 61:331–340


Celia Monteagudo et al conducted a survey to assess the school dietary habits and incidence of dental caries. His results showed that Breakfast intake of bakery products/ cereals and of dairy products showed a significant inverse association with caries frequency. No significant relationship was observed between caries and Breakfast quality index score or oral hygiene factors. He concluded that further research is required to elucidate the role of diet in caries Nutr Hosp. 2015;32(1):383-388


Liliya Doichinova et al conducted a study to assess the food habits in healthy children aged 612 years and the effect on their oral risk profile. The results revealed unbalanced nutrition of the children and increased intake of simple sugar, which will increase the risk of development of dental caries. He concluded that It is necessary for dentists to administer control over the carbohydrate intake and the food habits of children, as well as to encourage non- cariogenic diet in order to keep their good oral health. Biotechnology & Biotechnological Equipment, 2015 Vol. 29, No. 1, 200204


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