There is considerable evidence for an association between dental caries and food starches. However, the intraoral utilization of starch may be quite complex, giving rise to conflicting results.
Demineralization induced by unsweetened cookies was examined in an intraoral model system that utilized palatal appliances containing blocks of bovine enamel. The enamel surfaces were covered with either a filter paper disc to trap sugars or a layer of Streptococcus mutans to metabolize the sugars and bring about enamel demineralization. Demineralization was determined as an increase in porosity with respect to iodide ions (delta Ip).
Measurements revealed a rapid elevation and maintenance of high levels of maltose in the plaque space after ingestion of the unsweetened or sweet cookies. Entrapped food particles appeared to serve as a reservoir of maltose.
Unsweetened cookies brought about enamel demineralization, but the pH of the streptococcal plaque fell slowly, and the initiation of demineralization was delayed.
Sweet cookies released sucrose and maltose and brought about a rapid onset of demineralization.
Kashket S et al., Delayed effect of wheat starch in foods on the intraoral demineralization of enamel. Caries Res, 1994, 28:4, 291-6.
Dental nutrition knowledge
Root caries (2)
Dental nutrition knowledge
Assessed the knowledge of the role of diet in the etiology of dental caries among nutritionists and public health dental hygienists.
One half of the nutritionists and three fourths of the hygienists recognized that dental caries was caused by a bacterial infection. Most dental researchers consider fluoride exposure and dental sealants to be highly effective caries-preventive measures; in contrast, WIC nutritionists and dental hygienists identified oral hygiene as being most important in preventing caries.
Frequency of snacking and retentiveness of food in the mouth were accurately rated important dietary factors in the development of dental caries by both groups. However, limiting intake of fermentable carbohydrates between meals was not considered the most important dietary advice for clients.
Results suggest that current research about the role of diet in the prevention of dental caries should be included in both nutrition and dental hygiene curriculums and continuing education courses for these professionals.
Faine MP & Oberg D: Survey of dental nutrition knowledge of WIC nutritionists and public health dental hygienists. J Am Diet Assoc, 1995 Feb, 95:2, 190-4.
Most childhood tooth decay is preventable with a combination of fluoride--which protects the smooth surfaces of a tooth--and dental sealants--which protect tooth surfaces with irregularities called pits and fissures. Sealants are plastic coatings that protect these vulnerable areas, often narrower than a single toothbrush bristle, from decay-causing bacteria and food in the mouth.
Yet, 1988-1991 data from the National Health and Nutrition Examination Survey showed that while many children still had cavities, over 80% of which were related to pits and fissures, relatively few children had sealants applied to permanent teeth.
As caries has gone from a ubiquitous disease to one affecting only half of children in early elementary school and two-thirds of those who are 15 years of age, dentists must consider how to best target sealants to individual children who are at greatest risk for new disease.
Most sealants are placed in private dental offices, but children at greatest risk for problems resulting from tooth decay are least likely to get private care. This article focuses on public health strategies for community-based prevention.
Siegal MD et al., Dental sealants. Who needs them? Public Health Rep, 1997 Mar-Apr, 112:2, 98-106; discussion 107.
International Association of Dental Research (IADR)
In 1993 the International Association of Dental Research (IADR) initiated a Nutrition Research Group within the Association and prompted a nutrition symposium related to diet and nutrition in health and disease. The IADR Nutrition Research Group is encouraged to collaborate with other nutritional research groups in important areas of medicine, food science technology, and agriculture to target health issues influenced by dietary choices, nutritional adequacy and dental health status.
Hargreaves JA: Discussion: diet and nutrition in dental health and disease. Am J Clin Nutr, 1995 Feb, 61:2, 447S-448S.
Root caries (1)
This study reports on the relationship between root caries and diet. Nutritional composition was derived from two 3-d food diaries.
When the individuals were segregated by their root DFS (decayed and filled surfaces) status into highest (> or = 7) and lowest (< or = 1) quartiles, the sucrose consumption was significantly higher in the higher DFS group. Mean energy consumption and mean number of teeth were the same in both groups.
When the individuals were segregated by sucrose consumption into highest (> or = 89 g) and lowest (< or = 31 g) quartiles, DFS root status was significantly higher (P < 0.01) in the highest quartile group (7 g) versus the lowest group (4 g). By using data from subjects with two food diaries, a stepwise-linear-regression model for root caries showed that 4.2% of the variance for root caries was explained by sucrose, 2.8% by plaque, 3.8% by total number of teeth, and 5.6% by gingival recession.
Data suggest that root caries has a similar dietary etiology to coronal caries.
Papas AS et al., Relationship of diet to root caries. Am J Clin Nutr, 1995 Feb, 61:2, 423S-429S.
Root caries (2)
In this pilot study, dietary habits, microbial factors, and salivary factors in 20 older adults who had active decay on root surfaces were compared with those of 20 adults who had inactive or no root caries.
Subjects completed a nutrition interview and a four-day food diary.
The root caries group had a greater mean number of eating occasions per day (6.1 vs. 4.6), more frequent exposures to fermentable carbohydrates (5.8 vs. 4.2), and higher average daily sugars intake (133 g/day vs. 105 g/day) than the control group.
Root caries subjects had significantly higher lactobacilli counts and less salivary buffering capacity.
Results show that frequent intake of simple sugars, high lactobacilli counts, and low saliva buffering capacity may be risk factors associated with root caries in older adults.
Faine MP et al., Dietary and salivary factors associated with root caries. Spec Care Dentist, 1992 Jul-Aug, 12:4, 177-82.
Good oral health is essential for both good nutrition and systemic health, in addition to the ability to taste, chew, swallow and speak. Oral diseases include dental caries, periodontal disease, oral mucosal alterations, precancerous lesions and cancer, and oral trauma.
Dental caries can be prevented through good oral hygiene and regular professional cleaning, a healthy, low-sugar diet and the use of fluoride and dental sealants.
Periodontal disease can be delayed by brushing with fluoride and obtaining professional scaling. Antibacterial mouthwashes may also be helpful. Careful denture cleaning and regular observation for medication side effects can decrease periodontal disease.
Tobacco is the most common cause of cancerous oral lesions. Trauma can be avoided by wearing proper protective gear during contact sports and while riding bicycles and motorcycles. Persons in lower income and educational groups have a higher risk of poor oral health.
Regular attention to this area by family physicians will decrease the chance of oral disease in patients.
Lokshin MF: Preventive oral health care: a review for family physicians [see comments]. Am Fam Physician, 1994 Dec, 50:8, 1677-84, 1687.
Dental schools tend to teach only the rudiments of this subject and this does not provide a good basis for dentists to advise patients and combat the misinformation surrounding the topic. The first article in the two-part series examines nutrition as it applies to dental caries, while part two will discuss some of the general principles of nutrition in relation to oral health, periodontal disease and the oral mucosa.
Speirs RL & Beeley JA: Food and oral health: 1. Dental caries. Dent Update, 1992 Apr, 19:3, 100-4, 106.
Food and oral health
Dental schools tend to teach only the rudiments of this subject and this does not provide a good basis for dentists to advise patients and combat the misinformation surrounding the topic. The first article in the two-part series examined nutrition as it applies to dental caries, while part two discusses some of the general principles of nutrition in relation to oral health, periodontal disease and the oral mucosa.
Speirs RL & Beeley JA: Food and oral health: 2. Periodontium and oral mucosa. Dent Update, 1992 May, 19:4, 161-2, 164-7.
Healthy People 2000
This communication presents the status of oral health objectives in Healthy People 2000, and summarizes major issues related to the outlook for the nation's oral health from the perspectives of participants in a July 1995 briefing session with the US Assistant Secretary for Health.
Data [obtained from sources such as the third National Health and Nutrition Examination Survey-Phase 1, the 1991 Indian Health Service Survey, and 1989-92 National Health Interview Surveys] were examined in relation to specific indicators and populations defined at baseline using mid-1980s data.
· Examination of baseline measures and progress data shows that the indicators for objectives are, for the most part, stable or improving slightly.
· Deaths due to oral cancer have decreased.
· Edentulousness is declining.
· Placement of dental sealants on children’s teeth is increasing.
· Adult dental visits are on the expected course. Little change has been observed in water fluoridation.
· Apparent declines in dental visits and increases in untreated dental decay for young children are potential concerns.
Concentrated and collaborative efforts are needed to achieve Healthy People 2000 targets.
Gift HC et al., The state of the nation's oral health: mid-decade assessment of Healthy People 2000. J Public Health Dent, 1996 Spring, 56:2, 84-91.
A prospective, 4-year longitudinal study of 209 Peruvian children was conducted to evaluate the effect of a single malnutrition episode occurring at infancy (i.e., < 1 year of age) on dental caries in the primary teeth.
Children were recruited into the study at age 6-11 months after they had suffered from a malnutrition episode and were thus classified by anthropometry as either: (1) Normal; (2) Wasted (low weight for height); (3) Stunted (low height for age); or (4) Stunted and Wasted (S and W).
Eruption of the primary teeth was significantly delayed in all malnourished children; however, the effect of stunting--that is, retarded linear growth--was more pronounced and lasted longer than that of wasting or acute malnutrition (i.e., 2.5 vs. 1.5 years, respectively). By age 4 years, children from group 4 (S and W) showed a significantly higher caries experience in the primary teeth than did those in any of the other 3 groups.
This longitudinal study has confirmed a cause-effect relationship between early malnutrition and increased dental caries.
Alvarez JO et al., A longitudinal study of dental caries in the primary teeth of children who suffered from infant malnutrition. J Dent Res, 1993 Dec, 72:12, 1573-6.
Xerostomia, a clinical manifestation of salivary gland dysfunction, affects many people. These individuals frequently sip liquids to alleviate the discomforts associated with hyposalivation.
Milk appears to have many of the chemical and physical properties of a good saliva substitute. Besides the obvious benefit of providing moisture and lubrication for the dehydrated mucosa, milk buffers oral acids, reduces enamel solubility, and contributes to enamel remineralization. These anticariogenic factors are generally attributed to the high calcium and phosphate content along with the milk phosphoproteins that strongly adsorb to enamel. Patients with xerostomia frequently have difficulty in obtaining proper nutrition due to problems associated with lubricating, masticating, tasting, and swallowing food. Milk is a food with high nutritional quality that would certainly benefit most patients with xerostomia.
Because of the nutritional, anticariogenic, and moisturizing properties of milk, patients with xerostomia may find milk of value as a saliva substitute to help reduce the oral health problems associated with hyposalivation.
Herod EL The use of milk as a saliva substitute. J Public Health Dent, 1994 Summer, 54:3, 184-9.
Nutrition and diet
Nutrition and health
Nutrition and diet
Nutrition and diet can affect teeth in three ways:
· by affecting the structure of teeth (and thus appearance),
· by causing dental caries and
· by eroding teeth.
The importance of dietary sugars in causing dental caries is clearly established and a reduction in consumption of non-milk extrinsic sugars recommended by government. The Health Education Authority has played a major role in promoting this aspect of dietary advice.
The structure of teeth is influenced by nutrition; much of the evidence for this being published by Mellanby and colleagues in Britain. Interest in this topic has increased recently and it seems probable that malnutrition enhances susceptibility to dental caries, and possible that it increases susceptibility to enamel defects especially in areas with moderate to high levels of fluoride ingestion. The prevalence and severity of dental erosion is likely to be increasing in Britain.
Rugg-Gunn AJ: Nutrition, diet and dental public health. Community Dent Health, 1993 Sep, 10 Suppl 2:, 47-56.
Nutrition and health
Recent findings of biochemical, immunological, and molecular biology investigations related to oral tissues have also added a new health dimension to this understanding. The major challenge ahead is not only to continue to expand the available scientific information, but to recognize the role that nutrition has for oral tissues, which is no different than the one it has for other tissues and organ systems.
Investigators in other fields have been incorporating these new concepts about nutrition in the planning of their research during the past decade, but this emphasis has been lacking in dental research and this needs to be corrected. Still, we have one more challenge ahead, and that is to transfer to the general public the information generated by research in our laboratories and clinics in a prudent and effective way. This will ensure that consumers will take advantage of nutrition information alongside oral health concepts to maintain good general health while preventing and controlling oral diseases.
Navia JM: A new perspective for nutrition: the health connection. Am J Clin Nutr, 1995 Feb, 61:2, 407S-409S.
The relationship between nutrition and dentistry has been longstanding. Today, dental healthcare providers need to broaden the definition of "dental nutrition" from a narrow focus on the relationship of foods to caries, periodontal disease and oral lesions, to concerns about the overall nutritional adequacy of a patient's diet. This article discusses some of the latest nutrition recommendations put forth by major United States' health organizations and comments on their applicability to dental patients.
Karp WB Nutrition update for the dental health professional. J Calif Dent Assoc, 1994 Aug, 22:8, 26-9.
Because of the critical role of nutrition in developmental events, effects of nutritional excesses and deficiencies may be more significant than would be predicted by a steady-state model. Dietary choice is as important in oral health as it is to the health of the entire body, thus it may ultimately serve not only to prevent, but also to treat certain oral diseases.
Lessard GM: Discussion: nutritional aspects of oral health--new perspectives. Am J Clin Nutr, 1995 Feb, 61:2, 446S.
School health programs
Healthy eating patterns in childhood and adolescence promote optimal childhood health, growth, and intellectual development; prevent immediate health problems, such as iron deficiency anemia, obesity, eating disorders, and dental caries; and may prevent long-term health problems, such as coronary heart disease, cancer, and stroke.
School health programs can help children and adolescents attain full educational potential and good health by providing them with the skills, social support, and environmental reinforcement they need to adopt long-term, healthy eating behaviors.
This report summarizes strategies most likely to be effective in promoting healthy eating among school-age youths and provides nutrition education guidelines for a comprehensive school health program. These guidelines are based on a review of research, theory, and current practice, and they were developed by CDC in collaboration with experts from universities and from national, federal, and voluntary agencies. The guidelines include recommendations on seven aspects of a school-based program to promote healthy eating:
· school policy on nutrition,
· a sequential, coordinated curriculum,
· appropriate instruction for students,
· integration of school food service
· nutrition education, staff training;
· family and community involvement, and
· program evaluation.
Anonymous: Guidelines for school health programs to promote lifelong healthy eating. Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep, 1996 Jun 14, 45:RR-9, 1-41.
Sugars (and fluoride)
Earlier studies (Kashket et al., 1991) showed that particles of high-starch snack foods remained longer on the teeth than those of high-sucrose, low-starch foods. The question arose whether the prolonged presence of food particles enhances cariogenicity. A study was undertaken to measure sugars, starches, and metabolic acids in retained food particles.
Subjects consumed portions of different foods, and particles were removed from all bicuspids and first molars at defined times after swallowing. Dry weights, sugars, and short-chain carboxylic acids were determined. High-sucrose foods were cleared rapidly from the teeth, while high-starch foods were retained for up to 20 min. Sucrose, glucose, and fructose persisted in the retained particles. Particles of high-starch foods accumulated maltose and maltotriose, presumably from the breakdown of starch by salivary amylase.
At maximum, maltose plus maltotriose constituted 94% of total sugars in particles of potato chips; corresponding values in doughnuts, peanut butter cookies, and salted crackers were 43, 51, and 61%, respectively.
Total fermentable sugars in the particles of high-starch foods were similar to those for the high-sucrose confectionery products. Carboxylic acids accumulated within the particles, presumably due to the fermentation of the sugars by entrapped salivary micro-organisms. At maximum (5 to 7 min), acetic, formic, lactic, and propionic acids rose 17-, 30-, 15-, and 1.3-fold, respectively, in doughnuts, and to smaller degrees in potato chips, salted crackers, and chocolate-caramel-peanut bars.
In summary, the study demonstrated the persistence of sugars, the progressive accumulation of starch breakdown products, and the fermentation of the accumulated sugars in retained food particles. The findings support the view that high-starch foods contribute to the development of caries lesions.
Kashket S et al: Accumulation of fermentable sugars and metabolic acids in food particles that become entrapped on the dentition. J Dent Res, 1996 Nov, 75:11, 1885-91.
Currently, in nutrition there are major anxieties over the bearing of high intakes of energy and certain nutrients (e.g. fat, sugar) on health/ill-health. Two questions concern a high intake of sugar:
Does it cause a deleterious imbalance or dilution of macro- and micro-nutrients? and (2) Does it promote degenerative diseases, in particular dental caries?
As to the first question, evidence from a variety of contexts indicates that nutrient intakes are not reduced; rather they are increased. Additionally, one accompaniment of a high sugar intake is a reduced intake of fat, one of the primary aims of nutritional guidelines. However, these do not license excessive sugar consumption.
As to sugar and degenerative diseases, evidence is lacking that sugar intake is significantly influential other than for dental caries. An examination of evidence indicates sugar consumption to be a weak factor in caries development; its intake explains little of the variance in caries occurrence. Clearly, additional factors are influential-genetic, exposure to fluoride, and dietary components other than sugar. Early detection of the relatively small proportion of caries-prone individuals by appropriate markers, must be sought.
Walker AR: Nutritional and dental implications of high and low intakes of sugar. Int J Food Sci Nutr, 1995 May, 46:2, 161-9.
Sugars (and fluoride)
The dental risk of dietary sugars is dependent mainly on the frequency of intake, but the prevalence of caries in a population is strongly modified by other dietary, social, and behavioral factors independent from intake of sugars.
Regarding dietary factors, it must be remembered that hidden sugars in fruit as well as polysaccharides are cariogenic. The most important of the other factors is regular tooth brushing, which results in the removal of the bacterial plaque that causes caries and periodontal diseases and makes fluoride (which is contained in every advanced toothpaste) available for maintenance of the hard dental tissues and for remineralization wherever demineralization has occurred.
This explains why in most highly developed countries caries prevalence has decreased markedly during the past 20 y although consumption of sugars remained high.
Knig KG & Navia JM: Nutritional role of sugars in oral health. Am J Clin Nutr, 1995 Jul, 62:1 Suppl, 275S-282S; discussion 282S-283S.
US adult data
These data are available from the caries examination from Phase 1 of the Third National Health and Nutrition Examination Survey, which found that 94% of adults in the United States show evidence of past or present coronal caries.
Among the dentate, the mean number of decayed and filled coronal surfaces per person was 21.5.
Estimates for race-ethnicity groups were standarized by age and gender to control for population differences among them. Dentate non-Hispanic blacks (11.9) and Mexican-Americans (14.1) had half the number of decayed and filled coronal surfaces as non-Hispanic whites (24.3), but more untreated surfaces (non-Hispanic whites, 1.5; non-Hispanic blacks, 3.4; Mexican-Americans, 2.8).
Root caries affected 22.5% of the dentate population.
Blacks had the most treated and untreated root surfaces with caries (1.6), close to the value for Mexican-Americans (1.4). The score for non-Hispanic whites was 1.1. Untreated root caries is most common in dentate non-Hispanic blacks (1.5), followed by Mexican-Americans (1.2), with non-Hispanic whites (0.6) having the fewest untreated carious root surfaces. Race-ethnicity groups were disparate with respect to dental caries; effort is needed to treat active caries common in some population subgroups.
Winn DM et al., Coronal and root caries in the dentition of adults in the United States, 1988-1991. J Dent Res, 1996 Feb, 75 Spec No:, 642-51.
This article provides estimates of dental caries experience and selected restorative and tooth conditions among U.S. adults, obtained from Phase 1 (1988-1991) of the Third National Health and Nutrition Examination Survey.
Between 1988 and 1991, 94 percent of adults in the United States showed evidence of past or present coronal caries. Based on the data collected, the authors estimate that about 40.5 percent, or 61.6 million, dentate adults had at least one tooth or tooth space that could potentially benefit from professional treatment. Minimally, it is estimated that 135.6 million tooth or tooth spaces among U.S. adults may benefit from professional treatment. These estimates supplement information available from the DMF index to provide a broader profile of the impact of dental caries on permanent tooth of U.S. adults.
Brown LJ et al., Dental caries, restoration and tooth conditions in U.S. adults, 1988-1991. Selected findings from the Third National Health and Nutrition Examination Survey. J Am Dent Assoc, 1996 Sep, 127:9, 1315-25.
To determine the influence of oral hygiene practices and additional fluoride on erosive tooth wear in eating disorders. The proportional dietary intake of carbohydrates, fats, and proteins was also investigated.
Tooth wear was measured with the use of the tooth wear index (TWI).
Oral hygiene practices between subjects with and without severe erosion were not significantly different. Only 8 bulimics spent more time brushing after vomiting than at other times.
The pH of vomitus from 6 subjects ranged between 2.9 and 5.0, with a mean of 3.8, well below the critical pH for enamel demineralization to occur.
Of the 20 follow-up subjects, 12 (60%) exhibited worsening tooth wear.
The contribution by toothbrush abrasion to the overall wear in the eroded dentition of bulimics is not significant. Therefore, immediate post-vomiting oral hygiene practices can be recommended.
Milosevic A et al., Dental erosion, oral hygiene, and nutrition in eating disorders. Int J Eat Disord, 1997 Mar, 21:2, 195-9.
Components of green and black tea may protect against dental cavities, according to this review article. The authors note that catechins present in tea have several anti-cavity characteristics: a bactericidal effect on cavity-causing bacteria, prevention of bacterial attachment to teeth, limitation of sticky glucan synthesis, and inhibition of human and bacterial enzymes. The authors also cite several human studies that link regular tea-drinking to decreased cavity incidence.
Hamilton-Miller JM: Anti-cariogenic properties of tea (Camellia sinensis), J Med Microbiol 2001 Apr;50(4):299-302
Green and roasted coffees of Coffea arabica and Coffea robusta may prevent cavities by interfering with the ability of bacteria to adhere to the tooth surface, according to this study. The coffee solutions prevented the attachment of Streptococcus mutans to saliva-coated hydroxyapatite (HA) beads when they were added with the bacterial mixture and when they were used to pretreat the HA beads. This suggests that the coffee molecules absorb to the surface of the tooth and prevent bacteria from binding to it. The active components of the coffee that may contribute to this action include: trigonelline, nicotinic and chlorogenic acids, and melanoidins. The antiadhesive properties found in all coffee solutions are made up of both naturally occurring and roasting-induced molecules.
Daglia M, Tarsi R, Papetti A, Grisoli P, Dacarro C, Pruzzo C, Gazzani G: Antiadhesive effect of green and roasted coffee on Streptococcus mutans' adhesive properties on saliva-coated hydroxyapatite beads, J Agric Food Chem 2002 Feb 27;50(5):1225-9
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