DIET AND NUTRITION RELATED TO

DENTAL CARIES

INTRODUCTION
The relation between diet and nutrition and oral health and disease
can best be described as a synergistic 2-way street. Diet has a local
effect on oral health, primarily on the integrity of the teeth, pH, and
composition of the saliva and plaque. Nutrition, however,has a
systemic effect on the integrity of the oral cavity, including teeth,
periodontium (supporting structure of the teeth), oral mucosa, and
alveolar bone. Alterations in nutrient intake secondary to changes in
diet intake, absorption, metabolism, or excretion can affect the
integrity of the teeth, surrounding tissues, and bone as well as the
response to wound healing.
The interaction between diet and tooth is of great importance in
relation to caries. Although, it is true that microorganisms are chiefly
responsible for caries but the importance of substrate cannot be
undermined because microorganisms cannot cause caries without a
suitable substrate. The occurrence of caries is dependent on two
factors – pre-eruptive (blood, saliva) and post-eruptive factors
(maturation, mineralization, chelation, plaque, bacteria).

RATIONALE
Oral health has often been viewed in isolation from the rest of the
body and from general health. In the past dental health professionals
have focused largely on local reparative treatment of oral disease.
However, modern-day dentistry places increased emphasis on
disease prevention and recognises the importance of the
interrelationship between health of the teeth and oral tissues and
the general health of the body. It is well established that a good diet
is essential for the development and maintenance of healthy teeth,
but healthy teeth are important in enabling the consumption of
a varied and healthy diet throughout the life cycle.
 In modern society, the most important role of teeth is to enhance
appearance; facial appearance is very important in determining an
individual’s integration into society. Teeth also play an important
role in speech and communication. In addition to being costly to
treat, dental diseases cause considerable pain and anxiety, and
eventually may lead to loss of teeth. Tooth loss, in turn, impairs
chewing function and may result in the consumption of a limited diet
of poor nutritional quality and may impact on diet-related quality of
life. It is, therefore, clear that dental diseases have a detrimental
effect on quality of life both in childhood and older age.
Nutrition and diet impact on oral health in many ways. Diet is a
major aetiological factor for dental caries and enamel erosion, and
nutritional status impacts on the development of the teeth and the
host’s resistance to many oral conditions, including periodontal
diseases and oral cancer.

THE BURDEN OF DENTAL DISEASES

Dental diseases are a costly burden to health care services.The
treatment of dental caries is expensive for governments of both
developed and developing countries and costs between 5 and 10% of
total health care expenditures in industrialised countries exceeding
the cost of treating cardiovascular disease, cancer and osteoporosis.
The level of caries is higher for the primary dentition than the
permanent dentition for children of several developing countries.
Available data show that the mean DMFT at age 12 years of low-
income countries is 1.9 compared with 3.3 DMFT for middleincome
countries and 2.1 DMFT for high-income countries.

FOOD
Food is a complex chemical mixture of organic and inorganic
materials containing both diet and nutrients.
DIET
Diet is the total intake of substances that provide nutrition and
energy. It may be dairy or milk group, meat or poultry group,
vegetable or fruit group and bread or cereal group.
Balanced diet: is defined as one which contains different types of
food in such quantities and proportion that need for energy, amino
acids, vitamins, minerals, fats, carbohydrates, and other nutrients is
adequately met for maintaining health, vitality and general well
being and also makes small provisions for extra nutrients to
withstand short duration of illness.

NUTRITION
Nutrition is defined as the science of how the body utilizes food to
meet requirements for development, growth, repair, and
maintenance.
COMPONENTS OF FOODS
There are six classes of nutrients found in foods: carbohydrates,
fats, proteins, vitamins, minerals, and water. The first three are
energy-producing nutrients; that is, they provide calories and enable
the body to generate energy for carrying on its many functions.
Although the latter three do not provide energy, they facilitate a
variety of activities in the body.

THE NUTRIENTS
Carbohydrates
Carbohydrates are most commonly classified as simple (sugars) or
complex (starches, fibers). Simple sugars (monosaccharides)
represent single carbohydrate units such as glucose, fructose, and
galactose. Disaccharides are formed by the bonding of two
monosaccharides. For example, sucrose, the sugar most commonly
associated with dental caries, is composed of glucose and fructose.
Polysaccharides such as starch and fiber are composed of many
monosaccharide units. Starches are derived from plant foods—
mainly grains, legumes, and some vegetables and fruits. Ultimately,
the digestive process breaks down the long chains of starch to
glucose. Fiber is similar to starch in that it is composed of long
strands of simple sugars; however, unlike starch, fiber cannot be
degraded by human digestive enzymes.
Sugar, legally defined as sucrose, has been accused of causing
hyperactivity, criminal behavior, obesity, and a host of other
maladies. Although research has not proven such accusations, an
abundance of refined sugars in the diet can contribute to dental
caries and nutrient displacement. This can deplete the body’s
reserves of nutrients and result in nutrient imbalances that may
affect proper development, wound healing, and immune response.
Processed, cooked starchy foods, especially when combined with
refined sugars (eg, donut, pastry, snack/potato chips, crackers) also
can contribute to dental caries and plaque formation, thereby
contributing to the development of periodontal disease. It is
recommended that when highly processed simple sugars and starchy
foods are consumed, they should be consumed sparingly and with
meals to decrease caries and periodontal disease risk.
Today, many processed foods utilize various forms of sugar such
as sucrose, fructose, high-fructose corn syrup, honey, molasses,
maltose, and others. Interestingly, honey is currently being
investigated for use in dentistry as an antibacterial agent. Although
considered as cariogenic as sucrose, the beneficial properties of
certain honeys (antioxidant, antiinflammatory, antimicrobial) may
outweigh the risks. Alternative sweeteners such as sugar alcohols
(eg, sorbitol, xylitol), aspartame, saccharin, sucralose, and
acesulfame K are also available in food products; they do not
contribute to dental caries and may be useful as sugar substitutes in
various food items. Xylitol in chewing-gum form was shown to inhibit
Streptotcoccus mutans activity and has been applied as part of a
caries control regimen. In addition, xylitol stimulates saliva
production and the bicarbonate ions generated help neutralize
plaque acids. Aspartame should not be consumed by persons with
phenylketonuria because their bodies cannot metabolize excess
phenylalanine, a component of the sweetener.
Lipids
Dietary lipids are divided into fats and oils; fats are generally solids at
room temperature, whereas oils are liquids. Dietary lipids are often
classified by their chemical structures as triglycerides, phospholipids,
and sterols. Saturation refers to the number of hydrogen atoms
attached to the carbon skeleton of the fatty acid. If a fatty acid can
acquire bonds with more hydrogen atoms, then it is termed
unsaturated. Double bonds connect the unsaturated carbons.
Saturated fats have no double bonds, monounsaturated fats have
one double bond, and polyunsaturated fats have two or more double
bonds.
In recent years, fat substitutes have come on the market. For
example, Simplesse (CP Kelco US Inc., Wilmington, DE) is a fat
substitute made from milk protein and egg whites. Olestra (Proctor
and Gamble), a sucrose-based synthetic fat, is frequently used in fat-
free foods. Because it is not digested or absorbed, it does not
contribute calories.
Fats are important to oral health from the standpoint that
phospholipids are a structural component of cell membranes, tooth
enamel, and dentin. Fats are involved in the initiation of calcification
and mineralization of teeth and bones. In addition, research indicates
that high-fat foods tend to be inhibitory towards dental caries. Small
quantities of nuts and cheeses, for example, can be good between-
meal snack foods or even as ‘‘dessert’’ substitutes for patients
concerned with dental caries.
The oral health care provider should be aware that some patients
concerned about fat content of their diet may drastically reduce fat
intake, with potential consequences. These patients may present
with sensitivity to cold, dry skin, dull hair, and gaunt appearance. The
dentist should inquire about the diet of such patients and suggest
referral to a physician if severe fat restriction is suspected. Infants
and children in the first 2 years of life should not have dietary fat
restrictions because this may contribute to failure to thrive.
Proteins
Dietary proteins are composed of amino acids, all of which have the
same basic structure that includes a central carbon atom with
hydrogen, an amino group, an acid group, and a side group. The
uniqueness of the side group gives each amino acid different
characteristics. The body can synthesize most amino acids, but there
are some that the body cannot manufacture and these are termed
essential amino acids. The essential aminio acids are histidine,
leucine, isoleucine, lysine, methionine, phenylalanine, threonine,
tryptophan, and valine. These essential amino acids must be
obtained through dietary means.
One of the main functions of proteins is in the building, repair,
and replacement of body tissues. Proteins also function as enzymes,
hormones, regulators of fluid and acid-base balance, transport
molecules (eg, hemoglobin), and antibodies. Like carbohydrates,
proteins provide 4 kcal/g; however, this is not their primary function.
Protein foods generally are not cariogenic, although they may be
high in fat. Excessive consumption should be avoided; however,
small amounts of nuts, seeds, dried beans and peas, boiled eggs, or
hard cheeses, for example, make for nutritious snacks with low
cariogenicity. Patients, especially older adults, may be unable to
consume enough protein in their diet if they have ill-fitting dentures,
are edentulous, experience gustatory changes associated with aging
and/or medications, or have limited funds or inaccessibility to a
grocery. Inadequate dietary protein may predispose such persons to
decreased immune function, impaired wound healing, and oral
infections.

Water
Water is an essential nutrient for life through which all body
processes occur. Nutrients and waste products are transported
throughout the body by water. Water serves the body as a solvent,
lubricant, shock absorber, temperature regulator, blood volume
regulator, and structural component of numerous molecules, and
participates in a variety of chemical reactions within the body. About
60% of an adult human body and an even greater percentage of a
child’s is composed of water. Water within the body is basically
intracellular or extracellular. Intracellular fluid accounts for two
thirds of body water and is high in phosphate and potassium. The
remainder is extracellular fluid that includes interstitial fluid (high in
sodium and chloride), plasma, and structural water such as in bones
and skin. The average adult requires 2000 ml to 3000 ml of water
daily (7–12 cups).
The oral mucosa is very sensitive to fluid volume. Xerostomia, dry,
shrunken, fissured tongue or mucous membranes, and dry skin may
be noted in patients presenting with fluid volume deficit. In addition,
a patient who has experienced rapid weight loss or whose denture
suddenly feels loose be experiencing a fluid volume deficit. The
dentist should inquire about medications being taken and dietary
and fluid intake in such patients. Patients experiencing edema may
note their denture fits tightly and may present with mucosal
irritations related to changes in fit of the prosthesis. Patients should
be encouraged to consume adequate daily water. Water should be
recommended over other beverages like coffee or tea because
caffeine is a diuretic. Sodas, juices, and concentrated sports drinks
that contain salt, sugars, and other chemicals must be diluted as they
enter the bloodstream, which causes fluid to be removed from the
cells (furthering dehydration) and also triggers the thirst mechanism.
Patients on high-protein diets require a much higher daily water
intake to eliminate the waste products associated with protein
metabolism.

Vitamins
Vitamins are generally classified as water soluble or fat soluble.
Watersoluble vitamins include vitamin C and the B vitamins (thiamin,
riboflavin, niacin, folate, vitamin B6, vitamin B12, biotin, and
pantothenic acid). The fat-soluble vitamins include vitamins A, D, E,
and K. In general, watersoluble vitamins are easily absorbed into the
bloodstream at the intestinal level and freely move about the cells.
They are not stored to any large degree and need to be obtained
from the diet on a regular basis. Fat-soluble vitamins first enter the
lymph and then the blood where their transport is often dependent
on protein carriers. They are stored in the liver and fatty tissues of
the body, so depletion takes much longer than with the watersoluble
vitamins. Toxicity, however, is more likely with fat-soluble vitamins,
especially if the source is vitamin supplements rather than
foodstuffs.

VITAMINS
Vitamins Actions Sources Deficiency
Fat soluble Responsible for Retinol in milk, Reduced night
A vision and growth; fortified vision; blindness
maintenance of margarine, butter, through corneal
mucous cheese, egg yolk, damage;
membranes, liver, fatty fish. reduced
epithelium Beta-carotenes in resistance to
milk, carrots, infection
tomatoes, dark
green vegetables
D Promotes calcium Sunlight, fortified Failure of bone
and phosphate margarine, egg calcification;
absorption yolk, fortified rickets in
cereals children,
osteomalacia in
adults
E Antioxidant Vegetables and May occur in
their oils; seeds, premature
nuts, whole grains infants or in
malabsorption
syndromes
K Essential to the Synthesized by gut Increased
formation of blood- microorganisms; clotting time
clotting proteins dark green leafy
vegetables
Water soluble Essential to collagen Fresh fruit/citrus Scurvy; poor
C (ascorbic acid) production—used in fruits, red and wound healing
the structure of green peppers, and bleeding
bone and broccoli, snow gums
 connective tissues; peas, Brussels
aids wound healing sprouts
and iron absorption
B1 (thiamin). Coenzyme in Lean pork, Beri-beri;
carbohydrate enriched Wernicke
metabolism breads/cereals, Korsakoff
legumes, seeds, syndrome in
nuts alcoholism
B2 (riboflavin) Coenzyme in fat and Enriched and Ariboflavinosis
protein, metabolism whole grains; with glossitis,
meats, liver, eggs, cheilitis, and
dairy products, seborrheic
fish, poultry, dark dermatitis
leafy vegetables
B3 (niacin) Cofactor to enzymes Meats, poultry, Pellagra; toxicity
involved in energy fish, whole and leads to
metabolism; enriched breads vasodilation,
glycolysis and TCA and cereals, milk liver damage,
cycle gout and
arthritic
symptoms
B6 (pyridoxine)Coenzyme in energy Meat, poultry, Altered nerve
metabolism; fish, whole grains, function
antibody and fortified cereals,
haemoglobin eggs
formation
B12 (cobalamin) Transport/storage Animal foods; Pernicious
of folate; energy fortified cereals anemia
metabolism; blood
cell and nerve
formation
Folic acid Coenzyme Green leafy Megaloblastic
(folate) metabolism; fetal vegetables, anemia
neural tube legumes, citrus
formation fruits

Minerals
Minerals provide structural components for the body (eg, in the form
of bones and teeth). They allow for nerve and muscle function, blood
clotting, tissue growth and repair, and acid-base balance of body
fluids, and act as cofactors for enzymes in chemical reactions within
the body. Minerals are classified as major or trace minerals. Major
minerals are needed from dietary sources in amounts greater than
100 mg/day. These include calcium, magnesium, phosphorus,
potassium, sodium, chloride, and sulfur. Trace minerals (elements)
are needed in lesser amounts and include fluoride, iron, zinc,
selenium, chromium, copper, iodine, molybdenum, and manganese.
Main dietary mineral sources include both plant-based and
animal-based foods. Some plant foods contain binders such as
oxalates, tannins, or phytates that bind the minerals within them,
rendering these minerals unavailable for digestion and absorption.
This is not a problem with minerals from animal-based foods. For
example, beans are a good source of calcium, but calcium in milk is
better absorbed.

MINERALS
Mineral Actions Sources Deficiency
Calcium Bone/tooth Milk-based Reduced bone
formation; blood foods, sardines density
clotting; with bones,
nerve/muscle green leafy
function; CNS; vegetables,
blood pressure legumes
Phosphorus Bone/tooth Dairy foods, Rare
formation; eggs, meat, fish,
metabolism; acid- poultry, legumes,
base balance whole grains
Magnesium Bone/tooth Whole grains, Associated with
formation; nerve green leafy FVD: weakness,
and muscle vegetables, hard muscle twitching,
function; blood water, meats, convulsions
clotting; cofactor dairy products,
in metabolism fish
Potassium Fluid/electrolyte Whole grains, Associated with
balance; muscle vegetables, FVD: weakness,
and nerve meats, legumes, confusion,
function; hormone dairy foods, arrhythmias
 release fruits,
unprocessed
foods
Chloride Fluid/electrolyte Table salt, Associated with
balance; gastric processed foods FVD
digestive acid
Sulfur Component of Protein foods: Associated with
body proteins (eg, eggs, meats, fish, protein deficiency
hair, cartilage, poultry, legumes
nails)
Sodium Electrolyte/fluid Table salt, Associated with
balance; nerve processed foods FVD: headache,
function; blood cramps, weakness,
pressure; confusion,
acid/base balance decreased appetite
Fluoride Bone/tooth Fluoridated Increased dental
formation; water, tea, caries
increases seafood,
resistance to seaweed
caries
Zinc Required for Protein foods; Retarded growth;
digestion, meats, fish, taste/smell
metabolism, poultry, eggs, alterations;
wound healing, legumes decreased immune
tissue growth and function and
repair, wound healing;
reproduction slow physical/
sexual maturity
Iron Growth; immune Liver and other Microcytic anemia
system health; meats, fish, eggs, (women and
haemoglobin and poultry, green children at risk)
myoglobin vegetables,
formation energy legumes,
production enriched breads
and cereals
Copper Coenzyme in Organ meats, Bone
antioxidant seafood, green demineralization
reactions and leafy vegetables, and anemia
energy nuts, seeds,
metabolism; iron water from
 use; wound copper pipes
healing; blood and
nerve fiber
production
Iodine Thyroxin Iodized salt, Goiter, tiredness,
synthesis; seafood weight gain
regulates
metabolism,
growth, and
development
Selenium Antioxidant; may Meats, fish, eggs, Predisposition to
be helpful in whole grains heart disease
periodontal
disease
Chromium Carbohydrate Whole grains, Possible
metabolism cheese, meats, cardiovascular
brewer’s yeast disorders and
insulin dysfunction
Molybdenum Coenzyme Whole grains, Unknown
legumes, milk
Manganese Metabolic reaction Whole grains, Unknown
participant green leafy
vegetables,
legumes

Nutrition-related pediatric disorders:

Malnutrition
The World Health Organization defines malnutrition as the cellular
imbalance between supply of nutrients and energy and the body's
demand for them to ensure growth, maintenance, and specific
functions. Malnutrition can either be over-nutrition or
undernutrition. Nutrients generally refer to both micronutrients and
macronutrients. Nutrition is an integral component of oral health.
There is a continuous synergy between nutrition and the integrity of
the oral cavity in health and disease. Malnutrition may affect the
development of the oral cavity and the progression of oral diseases
through altered tissue homeostasis, reduced resistance to microbial
biofilms and reduced tissue repair capacity.
 Malnutrition is also defined as a bad diet or nutritional state due
to excessive (eg, toxicity), inadequate (eg, deficiency), or an
unbalanced intake.

Early childhood caries (ECC) has been defined as ‘‘the presence of

one or more decayed (noncavitated or cavitated lesions), missing
(due to caries), or filled tooth surfaces in any primary tooth’’ in
children from birth through 71 months of age. Age-specific
definitions have been proposed to distinguish severe ECC from ECC.
Severe ECC is characterized by the presence of (1) one or more
decayed, missing, or filled smooth surfaces in children less than 36
months; (2) cavitated, filled, or missing (due to caries) smooth
surfaces in the primary maxillary anterior teeth; or (3) multiple
decayed, missing, or filled surfaces in children aged 36 to 71 months.
The etiology of ECC is multifactorial; the presence of oral bacteria
and fermentable carbohydrates are necessary, yet proper oral
hygiene and regular fluoride exposure reduce the risk of caries.
Several species of bacteria found in the oral cavity have been
associated with the caries process; however, the presence of
Streptococcus mutans is most commonly associated with ECC.
Colonization typically occurs after tooth eruption when S mutans can
attach to the hard surface.

Protein energy malnutrition: Protein deficiency in the form of protein

energy malnutrition (PEM) is more commonly seen in developing
countries but can be found in lower socioeconomic groups in
industrialized countries, in substance/alcohol abusers, and in those
with eating disorders or chronic illness. Poor bone calcification,
retarded centers of ossification, small teeth, delayed tooth eruption,
retarded jaw growth, and crowded dentition have been related to
protein deficiency during the critical growth periods. Postnatal
weight gain has been found to correlate positively with the age of
first tooth eruption. In addition, a study of premature infants who
required prolonged care involving oral intubation and nutrition
experienced delayed tooth eruption compared with healthy
premature infants.

Calcium, vitamin D, and phosphorus: are essential for the

formation of bones and teeth. Deficiencies of these nutrients during
critical periods of growth have been shown to have dental
implications such as retarded jaw, tooth, and condyle development,
and reduced quality of tooth enamel and dentin. Vitamin D and
calcium deficiencies have also been found to result in generalized
jaw bone resorption and loss of the periodontal ligament.

Vitamin C deficiency: has been related to loss of connective

tissue, gingival hemorrhage, and tooth mobility. These effects,
however, are resultant to the infectious process and highly variable
depending on the bacterial plaque present. Nonetheless, vitamin C
deficiency has been found to increase the risk of periodontal disease
among certain populations, including smokers and persons with
diabetes. Vitamin C is vital to collagen production for the formation
of teeth and bone and also has antioxidant properties. As such,
vitamin C is important in the healing of oral soft-tissue and hard-
tissue wounds.

Vitamin A deficiency: Animal studies have shown vitamin A and

beta-carotene to be indispensable to the proper growth and
development of periodontium, teeth, salivary glands, and oral
epithelium. Retinol deficiency can reduce mucin (Secretory protein
found within saliva, provide an effective barrier against desiccation,
penetration, physical and chemical irritants, and bacteria)
production, leading to compromised salivary flow, weakened tooth
integrity, and a marked increase in risk for caries. Vitamin A is also
vital to the wound-healing process, for example, as it contributes to
epithelialization, collagen formation, and immune response during
the inflammatory stage of healing.
 Nutrients such as vitamins A, C, and E and selenium have
antioxidant properties, that is, the ability to scavenge free radicals
and reactive oxygen molecules. These reactive species can cause cell
damage by reacting with their membrane lipids, denaturing proteins,
and altering nucleic acids. The antioxidant roles of these nutrients
could provide health benefits to oral tissues; for example, recent
studies suggest beta-carotene may have a role as a
chemotherapeutic agent in oral cancer.

B-complex vitamin deficiency may manifest as a magenta, raw,

fissured, smooth, or swollen tongue. Angular cheilitis, itchy eyes, and
scaly dermatitis may also be evident.

Patients with iron deficiency may present with tissue pallor,

spoon shape nails, pale, atrophic tongue, pale conjunctivae, and
sensitivity to cold.

The nutritional state of a person is often manifested in oral

tissues due to the rapid turnover of cells in this area and the
bacterial onslaught the area receives. Healthy oral epithelium, for
example, experiences a 3-day to 7-day cell turnover and acts as an
effective barrier to toxins. Inadequate nutrition may cause the
tissues to breakdown, become infected, and/or develop lesions.

Table I: ORAL MANIFESTATION OF NUTRITIONAL DEFICIENCIES

NUTRIENT DEFICIENCY CLINICAL MANIFESTATIONS

Vitamin A Gingivitis, Periodontitis, Hyperplasia of
the gingiva.
Thiamine/ Vitamin B1 Cracked lips, A satin looking gingiva and
tongue, Angular cheilosis.
Vitamin B2/Riboflavin Inflammation of the tongue.
Niacin Fiery red inflammation of the tongue,
Angular cheilosis, Ulcerative gingivitis.
Vitamin B6 Teeth or bone decay, Periodontal
disease, Anemia, Sore tongue, Burning
sensation in the oral cavity.
Vitamin B12 Angular cheilosis, Halitosis, Bone loss,
Hemorrhagic gingivitis, Detachment of
 periodontal fibers, Painful ulcers in the
mouth.
Vitamin C Bleeding gums, Mobile teeth, Delayed
wound healing.
Vitamin D Enamel hypoplasia, Absence of lamina
dura, Abnormal alveolar bone patterns.
Iron Very red, painful tongue with a burning
sensation, Dysphagia, Angular cheilosis.

EVIDENCE LINKING DIET AND DENTAL CARIES – LANDMARK

STUDIES

Historical Evidence
It was found that caries was present since 5 million years in South
Africa in hominids in Neolithics. Interestingly dietary pattern was not
known. Eskimos’ skulls were free from caries.

Epidemiological Evidence
Tristan da Cunha study. Tristan da Cunha is a remote rocky island in
south Atlantic region. Before 1930 and 1940 onwards study showed
no evidence of dental caries in this region because of consumption of
raw diet. But after volcanic eruption in 1964, people living in this
area moved to other areas where they developed dental caries
because of change in dietary habits.

During World War II. Due to sugar restriction (rationing) in World

War II (1939 – 1944), dental caries reduced among civilians. At the
same time, dental caries experience among army personnel was
increased due to increase in sugar consumption as more quantity of
ready-made food items were supplied during war time.

DIETARY STUDIES ON CONTROLLED HUMAN POPULATIONS:

1. VIPEHOLM STUDY (GUSTAFSSON et al-1954):

It was a five year investigation of 436 adult inmates in a mental
institution at the Vipeholm hospital near Lund, Sweden.
The institutional diet was nutritious, but contained little sugar,
with no provisions for between meal snacks. The dental caries
 rate in the inmates was relatively low. The experimental design
divided the inmates into 7 groups;
1. A control group.
2. A sucrose group (300gms of sucrose given in solution, but reduced to
75gms during the last 2 years).
3. A bread group (345gms of sweet bread containing 50gms of sugar
daily).
4. A chocolate group (65gms of milk chocolate daily between meals
during last 2 years).
5. A caramel group (22 caramels = 70gms of sugar in 4 portions between
meals).
6. An 8 toffee group (8 sticky toffees = 60gms of sugar daily for 3 years).
7. A 24 toffee group (24 sticky toffees = 120gms o sugar for 18 months).
The main conclusions of the Vipeholm study were;
1. An increase in carbohydrate (mainly sugar) definitely increases the caries
activity.
2. The risk of caries is greater if the sugar is consumed in a form that will be
retained on the surface of the teeth.
3. The risk of sugar increasing caries activity, is greatest, if the sugar is
consumed between meals.
4. The increase in caries activity varies widely between individuals.
5. Upon withdrawal of the sugar rich foods, the increased caries activity
rapidly disappears.
6. Caries lesions may continue to appear despite the avoidance of refined
sugars and maximum restrictions of natural sugars dietary
carbohydrates.
7. A high concentration of sugar in solution and its prolonged retention on
tooth surfaces leads to increased caries activity.
8. The clearance time of the sugar correlates closely with caries activity.
This study showed that the physical form of carbohydrates is
much more important in cariogenicity than the total amount of
sugar ingested.

2. HOPEWOOD HOUSE STUDY (SULLIVAN-1958, HARRIS-1963):

The dental status of children between 3 & 14 years of age
residing at Hopewood House, Bowral, New South Wales, was
studied longitudinally for 10 years. Almost all these children
had lived from infancy at Hopewood House. All lived on a
 strictly institutional diet, that, with the exception of an
occasional serving of egg yolk, was entirely vegetable in nature
and largely raw. The absence of meat and a rigid restriction of
refined carbohydrate were the two principal features of the
Hopewood House diet.
The meals were supplemented by vitamin concentrates and an
occasional serving of nuts and a sweetening agent such as
honey. The Fluoride content of water and food was
insignificant and no tea was consumed.
At the end of a ten year period, the 13 year old children had a
mean DMFT per child of 1.6. (The corresponding figure for the
general child population was 10.7%).
53% of the children at the Hopewood House were caries free
whereas only 0.4% of the 13 years old, state school children
were free from caries.
The children’s oral hygiene was poor, calculus uncommon, but
gingivitis was prevalent in 75% of children. This work shows
that, in institutionalized children, at least, dental caries can be
reduced by a Spartan diet, without the beneficial effects of
fluoride and in the presence of unfavourable oral hygiene.

3. TURKU SUGAR STUDIES (SCHEINN, MAKINEN et al 1975):

These studies were a series of collaborative studies carried out
in Turku, Finland, to test the effects of the chronic consumption
of Sucrose, Fructose, and Xylitol on dental caries. In a 2 year
feeding study, 125 young adults, divided into 3 groups,
consumed the entire dietary intake using these sugars
exclusively; Sucrose group-35 people, Fructose group-38
people, and Xylitol group-52 people. A dramatic reduction in
the incidence of dental caries was found after 2 years of Xylitol
consumption. Fructose was as cariogenic as Sucrose for the first
12 months but became less so at the end of 24 months. It was
also found that frequent between meal chewing of a Xylitol
gum produced an anticariogenic effect.
 4. HEREDITARY FRUCTOSE INTOLERANCE (HFI):
It is caused by the remarkably reduced levels of hepatic,
fructose-1-phosphate aldolase into 2, 3 carbon fragments to be
further metabolized.
Persons affected with this rare metabolic disorder have learned
to avoid any food that contains fructose or sucrose, because
the ingestion of these foods causes symptoms of nausea,
vomiting, malaise, tremor, excessive sweating, and even coma
due to fructosemia.
NEWBURN in 1969 tabulated the caries prevalence of 31
persons with HFI and found that the dental caries prevalence
was extremely low.

ANIMAL STUDIES
Orland et al (1954) did a study on rats. He showed that germ-free
rats fed on carbohydrates produced no caries. And also when rats
were fed through stomach tube in the presence of cariogenic
bacteria in the oral cavity, no dental caries found.

CARIOGENICITY OF SUCROSE
Sucrose induces the smooth surface lesion more than any other
carbohydrates, especially when treated with Streptococcus mutans.
Sucrose is the only carbohydrate diet degraded to glucans.
Cariogenicity of sucrose does not relate to the ability to increase
plaque, but ability of Streptococcus mutans to colonise smooth
surface in the presence of sucrose. Glucans limit the diffusion of
acids away from tooth surface.

STEPHEN CURVE (1940)

Stephan, by using antimony microelectrodes, recorded the pH values
of dental plaques in situ before, during, and after a glucose rinse. A
typical pH response to plaque following exposure to a glucose rinse is
obtained. These curves are often referred to as Stephan curves, and
they have 3 main characteristics. Under resting conditions, pH of
plaque is reasonably constant, 6.9-7.2. Following exposure to sugars
the pH drops very rapidly (in few minutes) to its lowest level (5.5 to
5.2 – critical pH) and at this pH, the tooth surface is at risk. During
this critical period, the tooth mineral dissolves to buffer further acid
at lower pH in the plaque-enamel interface and also results in
mineral loss. Repeated fall of pH over a period of time leads to more
and more mineral loss from the tooth surface and ultimately it
presents in unfavorable way resulting in initiation of dental caries.
Later slowly it returns to its original value over a period of 30-
60minutes, approximately.
The Stephan Curve

DIETARY SUGARS AND DENTAL CARIES

The evidence shows that sugars are undoubtedly the most important
dietary factor—and the factor studied most often—in the
development of dental caries.

Frequency of sugars consumption and the amount consumed

The importance of frequency versus the total amount of sugars is
difficult to evaluate as the two variables are hard to distinguish from
each other. An increase of either parameter often automatically
gives an increase in the other and likewise a reduction in frequency
in intake of sugars in the diet should result in a reduction in the total
sugars consumed.
Worldwide studies on human populations show an association
between sugar consumption and level of dental caries. Isolated
communities that consume a small amount of sugar have a very low
level of this disease. Groups of people with a high exposure to sugars
have a higher level. A strong correlation exists between both the
amount and frequency of sugar consumption and the development
of caries, even in countries that use preventative measures such as
water fluoridation. In addition to solid foods, consumption of sugary
drinks also increases the risk of developing dental cavities.
The link between dietary sugars and dental caries is supported by
a large body of evidence. However, the limitations of the different
types of studies should be considered when interpreting results :
 Caries develop over time and therefore the dietary factors, several
years previous to the appearance of caries, should be considered.
• Animals have different teeth than humans and therefore the
results of animal studies are not always transferable to human
cases.
• Studies sometimes measure the amount of acid produced from a
food when bacteria in the mouth ferment it, in order to estimate
the risk of caries, but such studies do not consider protective
properties, such as effects on the flow of saliva.

In summary, there is evidence to show that both the frequency of

intake of sugars and sugars-rich foods and drinks and the total
amount of sugars consumed are both related to dental caries. There
is also evidence to show that these two variables are strongly
associated. In addition, oral hygiene standard, socio-economic status
and fluoride exposure all influence the sugars-caries relationship.
Different types of sugars
Many of the earlier animal studies investigating the relationship
between sugars and dental caries focused on sucrose, which was at
that time the main dietary sugar that was added to the diet.
However, modern diets of industrialised countries contain a mix of
sugars and other carbohydrates including sucrose, glucose, lactose,
fructose, glucose syrups, high fructose corn syrups and other
synthetic oligosaccharides and highly processed starches that are
fermentable in the mouth. Oral bacteria metabolise all mono and di-
saccharides to produce acid and animal studies have shown no clear
evidence that, with the exception of lactose, the cariogenicity of
mono and disaccharide differs. However, early plaque pH studies
have shown plaque bacteria produce less acid from lactose
compared with other sugars. Some animal studies have reported an
increased cariogenicity of sucrose but in these studies the rats were
super infected with S. mutans which utilises sucrose in preference to
other sugars.
Studies in humans have also investigated the difference in the
cariogenicity of some sugars for example the aforementioned Turku
study showed no difference between the caries development
between subjects on diets sweetened with sucrose compared with
fructose. The Malmo study which investigated the effect of
substitution of sucrose with invert sugar (50% fructose + 50%
glucose) on caries development in preschool children in Sweden
showed the cariogenicity of invert sugar to be 20–25% less that that
of sucrose.

The form of sugar

It is sometimes stated that the cariogenicity of sugary food is related
to its stickiness. The longer it takes a food to clear the mouth the
longer the drop in pH will remain. The adhesiveness or ‘stickiness’ of
a food is not necessarily related to either oral retention time or
cariogenic potential. There is evidence to show that the amount and
frequency of consumption of high sugar drinks (with low
stickiness/oral retention) are associated with increased risk of dental
caries.

The influence of fluoride on the sugars–caries relationship

Fluoride undoubtedly protects against dental caries. The inverse
relationship between fluoride in drinking-water and dental caries is
well established. Fluoride reduces caries in children by between 20
and 40%, but does not eliminate dental caries.
Over 800 controlled trials of the effect of fluoride on dental caries
have been conducted and show that fluoride is the most effective
preventive agent against caries. Widespread use of fluoride largely
accounts for the decline in dental caries that has been observed in
developed countries over the past three decades.
Marthaler reviewed the changes in the prevalence of dental
caries and concluded that, even when preventive measures such as
use of fluoride are employed, a relationship between sugars intake
and caries still exits.
A recent systematic review that investigated the importance of
sugars intake in caries etiology in populations exposed to fluoride
concluded (1) where there is good exposure to fluoride, sugars
consumption is a moderate risk factor for caries in most people; (2)
sugars consumption is likely to be a more powerful indicator for risk
of caries in persons who do not have regular exposure to fluoride; (3)
with widespread use of fluoride, sugars consumption still has a role
to play in the prevention of caries but this role is not as strong as it is
without exposure to fluoride.

Fluoride intake and fluorosis

Ingested fluoride affects the teeth preeruptively. An excess fluoride
ingestion during enamel formation can lead to dental fluorosis and
this condition is observed particularly in countries that have high
levels of fluoride in water supplies. Reports indicate that the
prevalence of dental fluorosis ranges from 3 to 42% in low fluoride
areas and between 45 and 81% in areas with around 1mg fluoride/L
water. Enamel fluorosis as well as skeletal fluorosis are found in large
areas of India, Thailand, in the Rift Valley of East Africa and many
Arab States.

Starches and dental caries

Studies have shown that starches are generally a much lower risk
factor in developing dental caries than sugars. However, when
starches are cooked or combined with sugars, the risk is greater.
Rugg-Gunn extensively reviewed the evidence on the relationship
between starches and dental caries and concluded that:
 Cooked staple starchy foods such as rice, potatoes and bread
are of low cariogenicity in humans.
 The cariogenicity of uncooked starch is very low.
 Finely ground and heat-treated starch can induce dental caries
but the amount of caries is less than that caused by sugars.
 The addition of sugar increases the cariogenicity of cooked
starchy foods. Foods containing cooked starch and substantial
amounts of sucrose appear to be as cariogenic as similar
quantities of sucrose.
Starches have become more processed and frequencies of eating
may have increased in some countries. Many highly processed
starchy foods are also relatively high in fats and or free sugars and
salt (e.g. corn snacks, sweetened breakfast cereals, cakes and
biscuits). It is not the intake of these but the increased intake of
starchy staple foods (e.g. bread, potatoes and wholegrain foods) that
is being encouraged.

Fruit and dental caries

As part of a normal mixed diet there is little evidence that fruit
causes caries . Animal studies have shown that when fruit is
consumed in very high frequencies (e.g. 17 times a day) it may
induce caries.
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. Having
extensively reviewed the evidence linking fruit consumption to
dental caries, Rugg-Gunn concludes ‘as eaten by humans, fresh fruit
appears to be of low cariogenicity and citrus fruits have not been
associated with dental caries’. He also concluded that, on present
evidence, 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.

Novel carbohydrates and dental caries risk

Glucose polymers (glucose syrups and maltodextrins) comprise a
mixture of short chain saccharides and alphalimit dextrins and are
increasingly being added to foods in industrialised countries.
Evidence on the cariogenicity of these carbohydrates is sparse and
comes from animal studies, plaque pH studies and studies in vitro
which suggest that maltodextrins and glucose syrups are cariogenic.
The use of synthetic non-digestible oligosaccharides (prebiotics) is
also increasing. Plaque pH studies and experiments in vitro suggest
that isomaltooligosaccharides and glucooligosaccharides may be less
acidogenic compared with sucrose. However, there is evidence that
fructooligosaccharides, which are more widely available in foods, are
as acidogenic as sucrose.

Summary of the strengths and weaknesses for the evidence linking

diet to dental caries
Increased caries No relationship Decreased caries
Convincing Frequency of Starch intake Fluoride exposure
intake of free (cooked and raw
sugars starch foods, such
as rice, potatoes
and bread.
Excludes cakes,
biscuits and
snacks with
added mono
and/or
disaccharides)
 Amount of free –
sugars
Probable – Whole fresh fruit Hard cheese,
Sugar-free
chewing gum
Possible Undernutrition – Xylitol, Milk,
Dietary fibre
Insufficient Dried fruits – Whole fresh fruit

SAFE LEVELS OF CONSUMPTION OF FREE SUGARS

When consumption of sugars is less than 10 kg/person/year the level
of dental caries is low. Research has consistently shown that when
consumption of sugars exceeds 15 kg/person/year dental caries
increases and intensifies (i.e. occurs earlier post-eruptively and
progresses more rapidly), although exposure to fluoride may
increase the safe level of consumption of sugars to approximately 20
kg/year. WHO has recommended that countries with a low intake of
free sugars do not increase intake and those with higher intakes
(>15–20 kg/year) aim to reduce intake of free sugars to less than 10%
of energy intake (which equates to < 15–20 kg/year). It is also
recommended that the frequency of intake of free sugars is limited
to four times or less per day, because above this frequency the
amounts of sugars consumed tends to exceed 15 kg/year and higher
levels of caries occur.

DIETARY FACTORS IN CARIES PREVENTION

The caries-preventive action of cheese has been reported in
experimental, human observational, and intervention studies. Cow’s
milk contains calcium, phosphorus and casein, all of which inhibit
caries, and plaque pH and animal studies have indicated its caries-
preventive nature. Recent epidemiological studies have indicated a
positive or neutral effect of consumption of cow’s milk on caries.
Breastfeeding is associated with low levels of dental caries: only a
few specific case-studies have linked prolonged ad libitum and
nocturnal breastfeeding to dental caries. Foods that stimulate
salivary flow, including wholegrain foods, peanuts, hard cheese and
chewing gum protect against decay. Black tea contains fluoride,
polyphenols and flavanoids. Both animal studies and experimental
investigations in humans show that black tea extract increases
plaque fluoride concentration and reduces the cariogenicity of a
sugars-rich diet.

Diet recommendations for oral health are as follows:

1) Eat a balanced diet rich in whole grains, fruit, and vegetables and
practice good oral hygiene—particularly the use of fluoridated
toothpastes—to maximize oral and systemic health and reduce
caries risk.
2) Eat a combination of foods to reduce the risk of caries and
erosion; include dairy products with fermentable carbohydrates
and other sugars and consume these foods with, instead of,
between meals; add raw fruit or vegetables to meals to increase
salivary flow; drink sweetened and acidic beverages with meals,
including foods that can buffer the acidogenic effects.
3) Rinse mouth with water, chew sugarless gum (particularly those
containing sugar alcohols, which stimulates remineralization), and
eat dairy product such as cheese after the consumption of
fermentable carbohydrates.
4) Chew sugarless gum between meals and snacks to increase
salivary flow.
5) Drink, rather than sip, sweetened and acidic beverages.
6) Moderate eating frequency to reduce repeated exposure to
sugars, other fermentable carbohydrates, and acids.
7) Avoid putting an infant or child to bed with a bottle of milk, juice,
or other sugar-containing beverage.

CONCLUSIONS
It is important that there is a recommended maximum level for
consumption of free sugars because when consumption of free
sugars by a population is less than 15–20 kg/person/year levels of
dental caries are low. Population goals enable the health risks of
populations to be assessed and progress in achieving health-
promotion goals to be monitored.
Many countries that are currently undergoing nutrition transition
do not have adequate exposure to fluoride and increasing intake of
free sugars by these populations could have a severe impact upon
the burden of disease. Promotion of adequate exposure to fluoride is
important. To minimize dental erosion, the intake of acidic soft
drinks should be limited.
The elimination of malnutrition will help to prevent and control
developmental defects of the enamel, oral infectious diseases and
periodontal disease and may delay the manifestation of the oral
symptoms of HIV.
In line with the dietary goals for the prevention of all major diet-
related chronic diseases, a diet that is high in fruits, vegetables and
wholegrain starchy foods and low in free sugars and fat is likely to
benefit many aspects of oral health including prevention of caries,
periodontal conditions, oral infectious diseases and oral cancer.

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Peter.
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