DIET AND DENTAL CARIES

Submitted by:
Dr. Ankita Sundan
M.D.S IIIrd Year
Department of Pedodontics and
Preventive Dentistry
Contents
 Definitions
 Keyes Triad
 Caries tetrad
 The Caries Balance
 Diet & Nutrition
 Epidemiological & Experimental Studies
 World wide Epidemiological and Observational studies

 Hopewood House Study

 Human Experimental Studies

 Vipeholm Study
 Turku Study
 Factors Affecting the food Cariogenicity
 Sugar and Cariogenicity
 Starch and Dental Caries
 Fruit and dental caries
 Nutritional deficiencies and Dental caries
 Role of Protein in caries

 Vitamin content of Diet

 Role of minerals in dental careis

 Phosphate in dental caries

  Trace elements and dental caries
 Experimental animal studies
 Groups at increased risk of dental caries in relation to diet
 Infant and toddler

 Children and adolescent

 Individual with low socioeconomic status

 Elderly and medically compromised people

 Athletes
  Work environment
 Unhealthy lifestyle

 Conclusion
Definition:

 The word caries derived from the Latin word means

“decay” or “rotten”.
 It is an irreversible microbial disease of the
calcified tissues of the teeth, characterized by
demineralization of inorganic portion & destruction
of organic substance of teeth.
(Shafer’s
Textbook of Oral Pathology 7th Ed)
 Ostrom (1980) has defined it as a process of enamel
or dentin dissolution that is caused by microbial
action at- the tooth surface and is mediated by
physiochemical flow of water dissolved ions.
 WHO 1981- Dental caries is defined as a localized
post eruptive, pathological process of external
origin, involving softening of hard tooth tissues, and
proceeding into the formation of cavity.
 Caries is not simply a continuous and unidirectional
process of the demineralization of the mineral phase,
but appears to be cyclic, with periods of
demineralization immediately following metabolism
of a fermentable substrate by the plaque flora,
interspersed with periods of remineralization.”

Ernest Newbrun
 Dental caries is an infectious microbial disease of the
teeth that results in localized dissolution and
destruction of the calcified tissues.
(Sturdevant’s Art & Science of Operative Dentistry 5th Edition)
 Dental caries is the localized destruction of susceptible dental
hard tissue by acidic by-products from bacterial fermentation
of dietary carbohydrates. Thus ,it is bacterial driven, generally
chronic, site-specific, multifactorial, dynamic disease process
that results from the imbalance in the physiologic equilibrium
between the tooth mineral and the plaque fluid ; that is, when
the pH drop results in net mineral loss over time. The infection
disease process can be arrested at any point in time.
 (DCNA 2010,CARIOLOGY)
Keye's Caries Triad:

Keyes and Jordan (1960)

Keyes and Jordan: 1962
Caries Tetrad
 Newbrun (1982)
Diet:

 Diet - allowance of food and drink

taken by any person from day to day.
Thus, the diet exerts an effect on caries
locally in the mouth by reacting with
the enamel surface and by serving as
a substrate for cariogenic
microorganisms

(According to E. Newbrun, 1972)-

 Nutrition (According to E. Newbrun, 1972)-

 It concerns the assimilation of foods and their effect on

metabolic processes of the body. Nutrition can act only
through a systemic route and, therefore, influences the host
during tooth development.
Epidemiological (observational)
Experimental (interventional)
studies
 Worldwide epidemiological
observational studies:
Hopewood House Study of Australia:

 longitudinal study by (Sullivan and Harris, 1958;

Harris, 1963)
 Motherhouse for young children in Bowral, New South
Wales, Australia
 A population of 80 children

 Age from 3-14yr at end of 10 yr period

 no white or brown sugar and sugar- flour
confectionaries.

 fluoride content of the water & food was

insignificant

 No tea was consumed.

Result:

At the end of 10 year period,

 13 year old children of
Hopewood House had a
mean DMF per child of 1.6;

 the corresponding figure for

the general population of
state N.S.W. was 10.7
Result:

 Only 0.4% of the 13 year

old state children were free
from dental caries

 whereas 53% of Hopewood

House children had no
caries.
However, caries levels rose to those found in the
general population when the children left the home

(Harris, 1963)
Carbohydrate intolerance and
dental caries
PATIENTS WITH HEREDITARY FRUCTOSE INTOLERANCE:

 Congenital deficiency of fructose-1 phosphate

aldolase
 Consumption of fructose results in
 nausea
 hypoglycaemia;

 hence, all foods containing fructose and sucrose are

excluded from the diet.
Marthaler, 1967; Newbrun et al., 1980

 In a study of 17 HFI subjects,

 The sugar intake was 2.5 g for the HFI
 The sugar intake was 48.2 g for the control group.
 DMFT levels were :
 HFI- 2.1
 Control- 14.3

 These patients cannot tolerate fructose or sucrose and it has

been seen that the dental caries experience of such patients
was very low.
 Human experimental studies:
Vipeholm study :
 Sugar consumption was increased and the relationship
between a variety of sugar intakes and caries increment was
noted (Gustafsson et al., 1954).
 conducted over a 5-year period (1946–1951)
 Sweden
 population of adult mentally handicapped patients
 It investigated relationship between dental caries activity and
consumption of
 refined sugar in non sticky form at meals,

 a sticky form between meals and

 a sticky form at meals.

 436 subjects participated in the study, and

 in the beginning of the study, the DMFT was found to be very

low.
FIVE GROUPS

Control Sucrose Bread

group group group

Chocolate Caramel 8 toffee

group group group

24 toffee
group
 They were given a carbohydrate diets as follow:

1. Control group

2. Sucrose group: sucrose in solution at meals-300 gms which

was reduced to 75gm during last 2 years
3. Bread group: Sweetened bread-345 g of sweet bread
containing 50 g of sugar during 1 to 2 years and then

 during 2nd year, 4 portions of sweet bread were given daily

with all meals.
4. Chocolate group: sugar in solution (300g)during first 2
years then it was reduced to (110g) during last 2 years
supplemented with Milk chocolate 65 gms during meals.
5. Caramel group:
 2 years –control,
 3rd year 22 caramel in 2 portions between meals, 22 Caramel of
70 gms sugar 4 times a day, between meals in 4th year then again
control.
6. 8 toffee group: Toffee 8 in number at meals first and then
between meals
7. 24 toffee group: 24 toffees throughout day between meals,
last 2 year withdrawn.
Conclusion of the study:
A low caries incidence was found when a diet that was almost
free of sugars was consumed.

 Caries activity increased with the addition of sugars to the

diet, but to a varying degree depending on the manner of
consumption.

 Sugars consumed with meals, as sweet drinks or in bread,

resulted in a minor increase in caries rate.
 A moderate caries increase was observed for the groups
receiving chocolate four times daily, and

 dramatic increase for the groups receiving 22 caramels,

eight toffees or 24 toffees at and between meals.

 Sugars consumed between meals in a highly retentive

(sticky) form resulted in the highest caries activity.
 even when consumed in large amounts,
 had little effect on caries increment if ingested up to a
maximum of four times a day at meal times only.

 increased frequency of consumption of sugar in-between

meals
 was associated with a marked increase in dental caries.

 the increase in dental caries activity

 disappears on withdrawal of sugars.
Turku study :

 Scheinin & Mäkinen, 1975

 involved three groups of adult subjects

 2 year study:
 125 subjects

 Divided into 3 groups

 Sucrose group: 35
 Fructose group: 38
 Xylitol group: 52
An 85% reduction in caries was found
for the individuals in the xylitol group
and a 32% reduction for the fructose
group, compared with the sucrose group.
Conclusions:

 substitution of sucrose in the Finnish diet (a high sugar diet)

with xylitol resulted in a markedly lower dental caries
increment for both carious cavities and pre-cavitation lesions.
Experimantal production of caries in
man

 A method for inducing 'white spots' , presumed to be incipient

dental caries, on a short-term basis, in volunteer dental
students, has been tried in Denmark
 [von der Fehr et aI., 1970 and Britain [Edgar et al..l978]

 The procedures followed in these studies were

 9 daily rinses with 10 ml of 50% sucrose and

 discontinuance of active oral hygiene procedures.

 The original experiments lasted for 3 weeks

 white-spot lesions on smooth surfaces were produced in the

experimental group.
Results
 The rapidity with which initial carious lesions were observed
in' contrast to the slow rate of caries progression under
normal clinical conditions, is related to the high cariogenic
challenge.

 The dense bacterial plaque accumulation when oral hygiene

procedures are suspended and the protracted high
concentration of substrate produce a highly cariogenic
environment
 At the end of the experiment

 meticulous oral hygiene measures were reinstituted along with a

daily mouthrinse of 0.2% NaF.

 resulted in remineralization of the white spots and

 a reversal of the caries index scores to the same values as in the

control group.
 The method employed in this clinical study on humans may
have merit in short-term investigations of cariogenic
properties of food or the potential of caries-inhibiting agents.

 A difficulty is that different subjects in the same group do not

always respond in the same way and it is difficult to recruit
and organize sufficiently large groups to provide statistically
significant results.
Classic evidence from human studies supporting the
role of sugar in dental caries
DIETARY FACTORS CONTRIBUTING TO DENTAL CARIES-
FACTORS AFFECTING THE FOOD
CARIOGENICITY

 Types of carbohydrate
 Intake frequency
 Physical consistency
 Oral clearance
 Protective factors
 1-types of carbohydrate

sugars

Monosaccharide: Disaccharide:
naturally found in fruit Polysaccharide
,vegetable and honey

Glucose Fructose starch

Sucrose Maltose
Potatoes dextrin glycogen
peas and
found in Lactose delivered rice
sugar cane found in from
and sugar milk hydrolysis
beets of starch
Dietary constituents and cariogenicity

 The 4 carbohydrates comprise the greatest proportion of food-

 starch ,
 sucrose ,
 fructose
 glucose.
Sugars and cariogenecity
 Excessive and frequent use of highly fermentable
mono and disaccharide is correlated with high
caries rate.
 Rugg-Gunn et al., 1987

 The relative cariogenicity of starch and sugars was evaluated in

a 2 year longitudinal dietary study of English school children in
both dietary intake and dental caries increment were monitored.

 When divided according to carbohydrate intake,

 a lower mean caries increment was found for the high
starch/low-sugars group compared with the
 low-starch/high-sugars group.
 Less caries if it is consumed in conjunction with a low-
sugar diet and limited eating frequency.

 In contrast, the cariogenic effect may be amplified when

starch is consumed in combination with increased
consumption of sugars and high intake frequency.
Starches and dental caries
 Starches
 Products with increased gelatinization are more susceptible
to enzymic breakdown, resulting in a higher acidogenic
potential
 (Lingström et al., 2000).
 Epidemiological studies have shown that starch is of
low risk to dental caries.

 People who consume high-starch/low-sugars diets

generally have low levels of caries, whereas people
who consume low-starch/ high sugars diets have high
levels of caries .

 In Norway and Japan the intake of starch increased

during the Second World War, yet the occurrence of
caries was reduced.
 The heterogeneous nature of starch is of particular relevance
when assessing its potential cariogenicity.

 Several types of experiment have shown that raw starch is of

low cariogenicity.

 Cooked starch is about one-third to one-half as cariogenic as

sucrose

 Mixtures of starch and sucrose are, however, potentially more

cariogenic than starch alone.
Cooked and uncooked starch

 Results from an intra-oral demineralization test using enamel

slabs
 (Brudevold, Goulet, Tehrani, Attarzadeh, & van Houte,
1985).
 reported that the cooked starch was completely hydrolyzed in
2 minutes,

 while raw starch required 30 minutes. Hence, the difference

in demineralizing capacity is due to its rapid hydrolysis.
 Starch Change in enamel
permeability

Cooked starch Increase by 3.6 units

Raw starch Decrease by 6.7 units

No rinsing Decrease by 9.5 units

Sucrose solution Increase by 15.6 units

 This experiment shows that uncooked starch is insignificantly

cariogenic, whereas cooked starch significantly causes dental caries.
However, the cariogenicity is still much lower than that of sucrose.
Refinement of starch

 Refined starches, finely-ground starches and heat-treated

starches are more cariogenic than unrefined starches as they
are more rapidly hydrolyzed into sugars that are used by
dental plaque.

 Also ,Less refined starchy foods contain ‘protective

properties’, which enhances the teeth’s resistance against
demineralization.
 The fibrous content of these starches increases the salivary
flow rate and thus, raises the plaque pH.

 In addition, as phosphate is one of the main components of the

enamel,

 organic phosphates present in less refined starches slow down

dissolution of the enamel.
Milk and dental caries
 In 1989, United Kingdom's Committee on Medical Aspects of
Food Policy's (COMA) on dietary sugars and human disease
concluded that:
‘Although lactose alone is moderately
cariogenic, milk also contains factors which protect against
dental caries, so that milk without added sugars may be
considered to be virtually non-cariogenic.’
 (Department of Health,1989)
 Compared the cariogenicity of human milk and
cow’s milk
 (Rugg-Gunn & Hackett, 1993)
Type of milk Lactose Calcium Phosphorus
(g/100ml) (g/100ml) (g/100ml)

Human 7 33 15

Bovine 4.8 125 96

• Human and cow milk may contain lactose, but it is the least cariogenic of the
common dietary sugars. High concentrations of calcium and phosphorus also
boost the teeth’s resistance against dissolution, as the enamel composes largely
of calcium and phosphate. (Rugg-Gunn & Hackett, 1993)
 Cow’s milk does not promote caries, even in the highly caries-
conducive environment engendered,’ and ‘that milk or lactose-
reduced milk can be used safely by hyposalivary patients as a
salivary substitute.’
 Stephan (1966), Reynolds &Johnson (1981), as well as

Bowen, Pearson, VanWuyckhuyse, & Tabak (1991)

 Mature human milk contains
 3%--5% fat,
 0.8%--0.9% protein,
 6.9%--7.2% carbohydrate calculated as lactose, and
 0.2% mineral constituents expressed as ash.
 Its energy content is 60--75 kcal/100 ml.

( Jenness R.Semin 1979)

 Protein content is markedly higher and carbohydrate content
lower in colostrum than in mature milk.

 Fat content does not vary consistently during lactation but

exhibits large diurnal variations and increases during the
course of each nursing.
( Jenness R.Semin 1979)
 The principal proteins of human milk are a casein homologous
to bovine beta-casein, alpha-lactalbumin, lactoferrin,
immunoglobulin IgA, lysozyme, and serum albumin.

( Jenness R.Semin 1979)

 Fruit and dental caries

1. In experimental conditions in which fruit is a major

dietary constituent, fruits may participate in the caries
process

2. however, as consumed as part of the mixed human diet

there is little evidence to show fruit to be an important
factor in the development of dental caries.
 A number of studies have found fruit to be acidogenic (Ludgwig, Bibly,
1957; Hussain, Pollard, Gurzon 1996; Imfeld, 1983) though less than
sucrose although the extent of this varies according to texture and
sugars content (Imfeld, 1983).

 Animal studies have shown that, when fruit is consumed in high

frequencies (e.g. 17 times a day) it may induce caries
(Imfeld, 1991; Stephen, 1966).
Savara and Suher, 1955
 in a study of children in the US, found no association between
dental caries and the frequency of fruit consumption.
 found a negative association between caries increment over 1

year and the consumption of apples and fruit juice. Clancy et

al.,1977

 Similar findings were reported by Rugg Gunn et al.1984.

Grobler and Blignaut(1989)
 compared the dental caries experience of workers on apple and grape
farms with workers on grain farms.

 The frequency of intake of fruit by the workers were very high; the
workers on the apple farms consumed on average eight apples per day
whereas the workers on the grape farms consumed on average three
bunches of grapes per day.

 In both groups of fruit pickers, the mean DMFT was significantly

higher than that of workers on the grain farm.
Dried fruit

may potentially be more cariogenic since the drying

process breaks down the cellular structure of the fruit,
releasing free sugars and dried fruits tend to have a
longer oral clearance.(Moynihan, Petersen, 2004)
 Rugg-Gunn(1993)
 concludes ‘as eaten by humans
 fresh fruit appears to be of low cariogenicity and
citrus fruits have not been associated with dental
caries’.

 increasing consumption of fresh fruit in order to

replace ‘non-milk extrinsic sugars’ (free sugars) in
the diet is likely to decrease the level of dental
caries in a population.
Frequency:
 Frequency of consumption seems to be a significant
contributor to the cariogenicity of the diet.

 More frequent the intake – more the caries risk

 Frequent decrease in pH after intake

 Extended periods of acid production and
demineralization
 Shortened periods of remineralization
 Amit Arora & Robin Wendell Evans in 2012
 Concluded that Exposure to a high level of fruit consumption
was suggestive of increased caries risk.
 Longitudinal studies are required to investigate the
relationship between fruit consumption and dental caries.

 (Journal of Investigative and Clinical Dentistry (2012), 3, 17–

22)
 Petersen(1992)
 6-year-old children observed that high frequency of consumption of
sweets and sugary drinks implied significantly higher amount and risk of
dental caries.
 Stecksen-Blinks and Holm(1995)
 showed that snacking frequency was positively associated with dental
caries in the deciduous dentition of 4-year-old children in Sweden
 Hankin et al., 1973
 A positive correlation between the frequency of
consumption of confectionery and sugar-containing gum
and the DMF rate was also found in a study conducted on
14-year-old Caucasian, Hawaiian and Japanese
schoolchildren in Hawaii.

 A range in intake from zero to five or more sweets per day

was followed by a corresponding increase in DMF scores.
Physical Consistency:
 Form of food directly influences the duration of exposure and
retention of the food on the teeth.

 Sticky food like:

 Candies
 Breath mints
 Lollipops
 Biscuits

Extends the exposure time in oral cavity

 High fibrous, cellulose contents of plants, eating of raw fruits
and vegetables

 Improves cleansing action, reduce retention ,and increase

saliva flow.
 Particularlyhigh retention rates have been found for
products such as sweet biscuits and potato chips (crisps)

(Kashket et al., 1991)

Oral clearance:
 How fast and early the food is cleared from the oral cavity

 Depends on
 Metabolism by microorganisms,

 Adsorption onto oral surfaces,

 Degradation by plaque and salivary enzymes,

 Saliva flow,

 Swallowing
 Sugar clearance
 Saliva is responsible for sugar clearance from the mouth,
which is increased by an increased flow rate.

 The rate of clearance varies markedly at different oral sites

and is fastest lingual to the mandibular incisors and slowest on
the buccal surfaces of the teeth
 Acid clearance
 Saliva is responsible for acid clearance from dental plaque,
which depends primarily on the velocity of the salivary film
flowing over the plaque.

 Again, there is marked site specificity, and the velocity is

highest in the same locations where sugar clearance is fastest.

 These two factors seem to explain why smooth-surface caries

is more prevalent on buccal surfaces than on lingual surfaces.
 The most important time for people to brush their teeth is just before
bedtime, because salivary flow is negligible during sleep and the protective
effects of saliva are lost.

 Chewing sugar-free gum or consuming sugar-free candies stimulates

salivary flow, which benefits hard and soft oral tissues in many ways.
 Starch containing food

 more time to breakdown in mouth

 lesser the oral clearance

 more the cariogenicity of food

 A test of the salivary clearance of 3 different fermentable
carbohydrates (white bread, bananas, and chocolate)
Showed

clearance of carbohydrates from bananas and chocolate was

marginally faster than that from white bread (time needed
for starch breakdown by amylase.)

Luke GA, Hough H, Beeley JA, Geddes DAM. Human salivary sugar clearance after sugar rinses and intake of
foodstuffs. Caries Res 1999
Protective factors in foods:
 Diet high in calcium, phosphate, and protein – anticariogenic
 Like- cheese, butter, bovine milk

 Cheese consumption resulted in a pH of 6.5 compared with a

pH of 4.3 for sucrose alone.

Jensen and Wefel: Effects of processed cheese on human plaque

pH and demineralization and remineralization: 1990: Am J
Dent
 Intake of increased alkaline substances like calcium, inorganic
phosphate, and casein, etc
decrease

 demineralization and enhance remineralization.

Kashket S, DePaola D. Cheese consumption and the development and progression of dental
caries. Nutr Rev 2002
 Cow’s milk is non cariogenic.

 indicate a positive or neutral effect of cow’s milk consumption

on caries

(Levy et al., 2003; Marshall et al., 2003)

Phytate:
 anticariogenic

 acts by adsorbing to the enamel surface to form a physical

barrier that protects against plaque acids.

 Phytate rich food:

 Grains , Nuts, legumes,
 It can raise the risk of iron and zinc deficiency

 People who eat meat regularly, deficiencies caused by phytic

acid are not a concern.
 Phytate when applied to tooth enamel Reduces lts solubility
and has caries inhibiting effects when added to animal diets
 (jenkins 1966)
Tea :
 Tea extracts have also been shown to inhibit salivary
amylase activity (Kashket & Paolino, 1998).
 Tea also contains polyphenols, in addition to fluoride
and flavanoids.
 inhibition of the glucosyltransferase activity
 Animal studies have found that infusions of black tea
reduce dental caries (Rosen et al., 1984).
Polyphenols:
 Apples contain polyphenols and are a good stimulus to salivary
flow.
Cranberries:
 may act cariostatically through reducing bacterial
adherence and glucosyltransferase activity of S.
Mutans (Koo et al., 2006).
SUGAR
SUBSTITUTE
 DEFINITION Sugar substitute is based on the
concept of replacing sucrose in food stuff which are
proved to be highly cariogenic
TYPES

 These are of two types:

 Non nutritive sweeteners

 Nutritive sweeteners
NON NUTRITIVE SWEETNERS
 These are intense sweeteners,
 non caloric sweeteners
 Much sweeter than sugar
 Yield little or no energy, provide no bulk
 Used in small quantities in drinks orblended with
sugar substitutes infood & snacks
 Approved products in market are
 ASPARTATE

 SACCHARINE

 CYCLANATE

 SUCRALASE

 ACESULFAME-K

 From dental point of view caloric sweeteners are very useful

as they are not fermented to acid by oral bacteria
ASPARTATE
 White, crystalline, odourless, slightlywater soluble
non carbohydratepowder

 About 150 to 200 times sweeter thansucrose

 Used as low calorie sugar substitutein soft

drinks,table sweeteners &other food products.
SACCHARINE
 White, crystalline, odourless , slightly water soluble
powder produced synthetically
 500 times sweeter than sugar in dilute solution
 its soluble sodium salt is used as a noncaloric sugar
substitute
 Also called as benzosulfimide or gluside
 Widely used in “diet” soft drinks, dietic foods,
mouth washes, medicines & as a sweetener for
table use since 1940
 DISADVANTAGE
 May cause bladder cancer
 banned in USA & Canada
CYCLAMATE
 An organic sweetener
 30 times sweeter than sucrose
 When ingested, absorbed into blood streams &
excreted almost unchanged in urine
 However part of it is converted toCyclohexylamine
by microorganism inlower intestinal tract

 Banned in USA & Canada as it can cause cancer

 Cyclohexylamine can produce vasoconstriction &

hypertensive effect by affecting sympathetic
nervous system
NUTRITIVE SWEETENERS
 Sugar Caloric sweetener,
 Carbohydrate substitute
 Includes a large number of monosaccharide &
disaccharides , various polyols & starch
hydrolysates & hydrogenates
 Relative sweetness of these compounds is only
occasionally more than equal to sucrose, in most
instances it is lower
NUTRITIVE SWEETENERS

SUGAR SUGAR ALCOHOL

 Glucose  Sorbitolo
 Fructose  Mannitolo
 Lactose  Xylitol
 Maltose
SUGARS
 Sugars other than sucrose used now a days in a
large scale in various food items , reason for this is
not dental but rather technological or economical

 Lactose used in most of baby foods

 Has lower cariogenicity than sucrose, glucose &

fructose
 Since people can not tolerate its large amount so it
has a little practical importance as a sugar
substitute
 Now palatinose is used as a sugar substitute
 It is a disaccharides & “couplingsugar” & a mixture
of variousfructose –glucose polymers
SUGAR ALCOHOLS
 Not good substrate for plaque bacteria & therefore
produces only a minimal drop in plaque pH

 On metabolism it get oxidized to either to ketose or

aldose
SORBITOL
 White, crystalline, water soluble powder
 Used as sugar substitute in diabetes
 Prepared from glucose byhydrogenation
 About half as sweet as sucrose & used alone or with
other polyalcohols to provide a sweetener in dairy
foods , especially in chewing gums
 Following absorption , dietary sorbitolis oxidised to
fructose by “sorbitol dehydrogenase” & further
metabolismis like fructose
 WHO recommended intake rate ofsorbitol is up to
150mg/kg/day
MANNITOL
 White ,crystalline,watersoluble carbohydrate
alcohol
XYLITOL
 Well established that it is non cariogenic & is used
in chewing gums
 It is one of a sugar sweetner approved for use in
food & other items in many countries
 It has specific as well as non specific effects on oral
flora & especially on certain strains of mutans
streptococci add to its caries preventive profile
Nutritional influences and dental
caries
Role of proteins in caries

 Arginine rich peptides may have protective effect

against caries. The contributing factors for high caries
incidence with protein deprivation are:

1. Reduced salivary flow and, therefore, reduced

buffering capacity.
2. Reduced remineralization and antibacterial capacity
3. Decrease in immune response as the salivary Ig A
level falls.
VITAMIN CONTENT OF DIET
Role of vitamins in dental caries

 Vit. K – It might have anti caries property since it

can reduce the rate of acid production in mouth
(Fosdick et al 1949)
 Vit. D- Enamel Hypoplasia produced by its deficiency
predispose the tooth to caries.

 Vit. B6 - Studies suggest that pyridoxine may alter

oral flora and reduce caries incidence by promoting the
growth of non cariogenic organisms.

 Niacin - Low incidence of caries have been reported

due to niacin deficiency as it acts as an essential
nutrient for oral acidogenic flora and part of the
enzyme system concerned with the degradation of
fermentable carbohydrates .
Role of Minerals in Dental caries

 Calcium : Reduced levels of calcium in diet can result in

increase in caries.

 Magnesium :It was reported that cariostatic effect of F was

enhanced when Mg is added to drinking water. (Mc Clure
1948)
Phosphates and Dental Caries
 Phosphates as agents have been tested experimental
in human clinical trials. The cariostatic action has
demonstrated by inorganic phosphates added to
diets of rats or hamsters
 local effect can be attributed to a number of factors:
1. Reduce the rate of dissolution of hydroxyapatite of

the enamel;
2. Deposit calcium phosphate, particularly in areas
which have been partially demineralized;
3. buffer organic acids formed from fermentation of
plaque microflora
Lipids and dental caries

 reduces caries in animals

 Due to formation of fatty acid films which protects
enamel from demineralization
 Also due to substitution of the fat or oil for
carbohydrate.
 Another factor may be the contact between
carbohydrate food and bacteria may be reduced in
presence of fat.
 Medium chain fatty acids in diet have antimicrobial
action.
 (williams et al,1982)
 Potassium nonanoate has been studied when added to a
cariogenic diet to rats, it produced a significant
reduction .

 Human studies with a daily mouthwash containing

nonanoate demonstrated a change in including a
reduction in acidogenic microorganisms

(Shafer’s textbook of Oral Pathology 7th Edition)

 Trace Elements and Dental Caries

 Cariostatic –Fl,P
 Midly cariostatic –Mo,Cu,Sr,B,Li,Au,Fe
 Doubtful cariostatic-Be,Co,Mn,Sn,Zn,Br,I,Y
 Caries inert –Ba,Al,Ni,Pd,Ti
 Caries promoting –Se,Mg,Cd,Pt,Pb,Si
Trace elements divided in to 2 categories
1.Those that have well defined human requirements
, namely iron, zinc, iodine, copper, flourine

2.Those that are integral constituents or activators

of enzymes namely manganese, molybdenum,
selenium, chromium , cobalt.
Possible mechanism of trace elements

 Altering the resistance of the tooth itself or modifying the

local environment at plaque-tooth enamel interface

 Acts like flouride ,trace elements can modify the physical and
chemical composition of the teeth thus affecting the solubility
of the enamel to acid attacks
Experimental animal studies
Protein and calorie Deficiency and
dental caries

 Studies regarding protein and calorie deficiency

during dental development and there effect on teeth
in rats
(By Shaw(1970) & Navia(1979)
 Protein deficiency during dental development induced by
underfeeding the mothers during pregnancy and lactation

 Smaller teeth, delayed eruption and greater susceptibility to

caries
 Restriction of calorie intake to mother during pregancy

 Lower body weight of offspring but no dental effects

Results
 Dental defects could be reversed by administration of protein
supplement to malnourished pups.

 However ,calorie supplementation did not correct the dental

abnormalities.
Probable mechanism of dental caries due to
protein deficiency

 Reduced salivary flow and therefore reduced total buffering

capacity
 Reduced remineralizing and antibacterial capacity
 altered morphology of dentition
 Decrease in immune response
Groups at increased risk of dental
caries in relation to diet
 Infants and toddlers

 early childhood caries (ECC) or nursing-bottle

caries

 Frequency and duration of exposure are critical in

this respect, but the caries experience also often
correlates with social and other behavioural factors
within the family (Wendt et al., 1995).
 prolonged breastfeeding increase the risk of early
childhood caries (ECC), especially in the maxillary
incisors.

 constant, prolonged and nocturnal breastfeeding

after the age of 12 months raises the prevalence of
ECC.
{ van Palenstein Helderman, Soe, & van't Hof (2006)}
 Constant and prolonged contact between the
enamel and milk

 acidogenic environment in the teeth,

 provides less time for the teeth remineralise.

 Furthermore, reduced salivary flow at night
increases the level of lactose in the saliva and
dental plaque during nocturnal breastfeeding.

 It is also believed that mutan streptococci, a group

of caries-inducing bacteria may have passed from
the mother to the child; and thus, further increasing
the risks of ECC.
 Children and adolescents

 Based on fluid intake data from the Third National Health and
Nutrition Examination Survey (NHANES III, 1988–1994),
children in the USA aged 2–10 years with high carbonated
soft drink consumption were found to have a significantly
higher caries experience in their primary dentition,

 while consumption of mainly milk, water or juice was less

likely to be associated with caries (Sohn et al., 2006).
 Higher caries prevalence can also be found among older
children and adolescents, often associated with lifestyle
factors, including an increased intake frequency of candy and
soft drinks and snacking at school breaks (Flinck et al., 1999).
Individuals with low socioeconomic status

 Poor quality diets have been associated with increased

cariogenecity in the US population, particularly in certain
minority groups(Flegalet al., 2002).

 Reisine and Psoter (2001), based on the findings from a

systematic review, found fairly strong evidence for an inverse
relationship between SES and the prevalence of caries among
young children.
 The frequency of soft drink consumption has also been shown
to be a major determinant of caries experience in low-income
African–American adults (Burt et al., 2006)
 Elderly and medically compromised
people
 medical issues.

 chronic renal failure

1. a low-protein diet
2. high in refined carbohydrate, which will increase
the cariogenic load.
 dietary energy supplements (e.g. children with failure to
thrive, malnourished hospital patients, patients with Crohn’s
disease) are high in sucrose, other sugars and glucose
polymers.

 A significantly greater number of decayed, missing and filled

teeth have been found in patients with Crohn’s disease when
compared with matched controls (Rooney, 1984).
 slower clearance rates resulting in increased risk for
caries in the elderly (Hase et al., 1987), during an
artificially induced low secretion rate (Lingström &
Birkhed, 1993), and for individuals with normally
low secretion rates (Crossner et al., 1991).
 The clearance rate is believed to be of great
importance for today’s elderly population, where
medically induced low secretion rates are often
found in combination with a high number of teeth
remaining well into old age. This is of particular
importance for the relationship of diet to root caries
(Papas et al., 1995).
 Athletes

 The specific dietary patterns and increased

frequency of sport supplement drinks, often
consumed during periods when lower salivary
secretion rates may occur, are to be considered as
risk factors for dental caries and also dental erosion
owing to their acid content (Lussi & Jaeggi, 2006).
 Work environment
 of two kinds, increase access to fermentable carbohydrates:
 catering business or industrial food laboratories

 the confectionery industry or bakeries, where easy access to

sugary foods promotes frequent intake.

 For people working night shifts or those with monotonous

jobs, frequent intake of sugary products and snacks is
common to ‘keep them going’.
 Anaise(1978)
 confectionery industry workers had 71% higher dental
caries experience than factory workers from other
industries

 Katayama et al(1979)
 also found higher caries in confectionery workers (DMFT
17.2) compared with workers in other industries (DMFT
11.4).
 Danish chocolate factory workers had significantly
higher dental caries experience and higher tooth
loss than yard workers.
Petersen(1983)
 This was then confirmed in another study of biscuit
factory workers in Finland
(Masalin,1990)
 Unhealthy lifestyle

 diet in relation to drug abuse are also well known

(Rees, 1992).

 A craving for sugars is felt soon after the intake of drugs such as
cannabis and amphetamines.

 Certain drugs with a sticky consistency may increase the retention

time of sugars and many of them also cause dry mouth symptoms.

 These effects are often enhanced by general bad oral hygiene and an
increased intake of pastilles to cover a bad taste.
 Multifaceted disease process

 The multifaceted nature of the caries process is relevant to

any consideration of diet and caries. It may be an
oversimplification to attempt to relate the two without also
considering the other factors.

 This has been demonstrated by Sundin et al. (1992), who

found a low correlation when only caries incidence and
consumption of sweets were compared in 69 people aged
15–18 years. The correlation increased when various other
factors were combined and the subjects also had poor oral
hygiene, a high intake of other sugary products or a low
salivary flow rate.
 one cannot, in a complex disease such as the
development of caries, look exclusively at one
single factor – the diet –without relating it to other
factors.
Conclusion

 Dental caries is a multi-factorial disease requiring

the presence of a susceptible host, cariogenic
microflora and a diet conducive to tooth
demineralization.

 One cannot, in a complex disease such as the

development of caries, look exclusively at one
single factor , without relating it to other factors.
 Certain additives as well as sugar substitutes show
great promise for the provision of between-meal snack
foods that reduce the risk of dental caries.

 The dental team should thoroughly understand the

relationship of diet to caries and conscientiously apply
that knowledge to educate the patients in general as
well as counsel specific high-risk individuals.

 Further emphasis should be placed on the acquisition

of sound scientific data for counseling caries patients
concerning diet and dental caries.
Thank you…