NUTRITIONAL ASPECTS OF NUTRITIONAL ASPECTS OF DENTAL CARIES: CAUSES, DENTAL CARIES: CAUSES,

PREVENTION, AND TREATMENTPREVENTION, AND TREATMENT

CHAPTER 17CHAPTER 17

Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.

2Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.

PrevalencePrevalenceNutrients have topical and systemic effects that Nutrients have topical and systemic effects that

can be primary or secondary factors in the can be primary or secondary factors in the development of dental cariesdevelopment of dental caries

National Call to Action to Promote Oral Health National Call to Action to Promote Oral Health stresses preventionstresses preventionDental caries remain the most common chronic Dental caries remain the most common chronic

childhood diseasechildhood diseaseCertain racial, ethnic, and lower-income populations Certain racial, ethnic, and lower-income populations

suffer disproportionately higher rates of cariessuffer disproportionately higher rates of caries

3Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.

PrevalencePrevalence

Caries rates rise with ageCaries rates rise with age28% of children ages 2–5 years28% of children ages 2–5 years49% of children ages 6–11 years49% of children ages 6–11 years68% of adolescents 12–19 years68% of adolescents 12–19 years75% of adults75% of adults

Prevalence of root caries also rises with agePrevalence of root caries also rises with age9.4% among persons ages 20–39 years9.4% among persons ages 20–39 years17.8% among those ages 40–59 years17.8% among those ages 40–59 years31.6% among those ages 31.6% among those ages >>60 years60 years

From Bird DL, Robinson DS: Torres and Ehlrlich From Bird DL, Robinson DS: Torres and Ehlrlich Modern Dental Assisting, ed 9. St. Louis: Saunders, Modern Dental Assisting, ed 9. St. Louis: Saunders,

2009.2009.

4Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.

Major Factors in the Dental Caries Major Factors in the Dental Caries ProcessProcess

Caries results from a combination Caries results from a combination of factors of factors Susceptible host or tooth surfaceSusceptible host or tooth surfaceSufficient quantity of cariogenic Sufficient quantity of cariogenic

microorganisms in the mouthmicroorganisms in the mouthPresence of fermentable Presence of fermentable

carbohydratescarbohydratesParticular composition or flow of Particular composition or flow of

salivasalivaFrom Darby ML, Walsh MM: Dental Hygiene: From Darby ML, Walsh MM: Dental Hygiene:

Theory and Practice, ed 2. St. Louis: Saunders, Theory and Practice, ed 2. St. Louis: Saunders, 2003.2003.

5Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.

Major Factors in the Dental Caries Major Factors in the Dental Caries ProcessProcess

Tooth structureTooth structureResistance against Resistance against

demineralization begins demineralization begins in pre-eruptive phase in pre-eruptive phase with adequate intakes with adequate intakes of calcium; of calcium; phosphorus; vitamins phosphorus; vitamins A, C, and D; fluoride; A, C, and D; fluoride; and proteinand protein

Deep pits and fissures Deep pits and fissures increase susceptibilityincrease susceptibility

Host factorsHost factorsFood selection and Food selection and

dietary patternsdietary patternsOral hygiene habitsOral hygiene habitsGeneticsGeneticsRace or ethnic groupRace or ethnic groupAgeAgeSES (socioeconomic SES (socioeconomic

status)status)

6Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.

Major Factors in the Dental Caries Major Factors in the Dental Caries ProcessProcess

SalivaSalivaAvailability of essential Availability of essential

nutrients during nutrients during development of salivary development of salivary glandsglands

Protection provided by Protection provided by adequate salivary flow adequate salivary flow and saliva’s buffering and saliva’s buffering capacity capacity

Plaque biofilmPlaque biofilmComposition of plaque is Composition of plaque is

altered and strongly altered and strongly influenced by dietinfluenced by diet

By-products of sucrose By-products of sucrose and glucose metabolism and glucose metabolism produce acids; lowers pH produce acids; lowers pH to create environment for to create environment for growth of bacteria, such growth of bacteria, such as as S. mutansS. mutansFrom Fehrenbach MJ, Herring SW: Illustrated Anatomy From Fehrenbach MJ, Herring SW: Illustrated Anatomy of the Head and Neck, ed 3. St. Louis: Saunders, 2007.of the Head and Neck, ed 3. St. Louis: Saunders, 2007.

7Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.

Major Factors in the Dental Caries Major Factors in the Dental Caries ProcessProcess

Cariogenic foodsCariogenic foodsSalivary amylase breaks down oral mono- and Salivary amylase breaks down oral mono- and

disaccharidesdisaccharidesSucrose is used to produce glucans that facilitate Sucrose is used to produce glucans that facilitate

adherence of bacteria (adherence of bacteria (S. mutans)S. mutans) to the dental to the dental pelliclepellicle

Processed starches (instant oatmeal) are often more Processed starches (instant oatmeal) are often more fermentable than their nonprocessed counterparts due fermentable than their nonprocessed counterparts due to partial hydrolysis or diminution of particle sizeto partial hydrolysis or diminution of particle size

High concentration of fructose found in juices is High concentration of fructose found in juices is potential source of substrate potential source of substrate

8Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.

Major Factors in the Dental Caries Major Factors in the Dental Caries ProcessProcess

Anticariogenic properties of foodAnticariogenic properties of foodSugar alcoholsSugar alcohols

Fermented more slowly than mono- and disaccharides; Fermented more slowly than mono- and disaccharides; therefore, buffering effects of saliva neutralize destructive acids therefore, buffering effects of saliva neutralize destructive acids produced by plaque biofilmproduced by plaque biofilm

Oral flora do not contain enzymes to ferment xylitolOral flora do not contain enzymes to ferment xylitol Microorganisms, such as S. mutans, are inhibited

Nonnutritive sweetenersNonnutritive sweeteners Not metabolized by microorganisms; do not promote cariesNot metabolized by microorganisms; do not promote caries

9Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.

Major Factors in the Dental Caries Major Factors in the Dental Caries ProcessProcess

Protein and fatProtein and fat Considered cariostatic because do not lowerConsidered cariostatic because do not lower

plaque pHplaque pH

Phosphorus and calciumPhosphorus and calcium Provide a buffering effect in the salivaProvide a buffering effect in the saliva

Dairy products Dairy products Protein, Protein, caseincasein (principal protein in milk), phosphorus, (principal protein in milk), phosphorus,

calcium are ingredients of anticariogenic or even calcium are ingredients of anticariogenic or even cariostatic foods, such as cheese and milkcariostatic foods, such as cheese and milk

Although lactose is cariogenic (but the least cariogenic of Although lactose is cariogenic (but the least cariogenic of all saccharides), these other elements in milk and milk all saccharides), these other elements in milk and milk products decrease risk of dental caries products decrease risk of dental caries

10Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.

Major Factors in the Dental Caries Major Factors in the Dental Caries ProcessProcess

Other foods with protective factorsOther foods with protective factorsConstituent in chocolate, known as the Constituent in chocolate, known as the

cocoa factor, has shown anticariogenic cocoa factor, has shown anticariogenic properties in Vipeholm studyproperties in Vipeholm study

Glycyrrhiza, the active ingredient in Glycyrrhiza, the active ingredient in licorice, also anticariogeniclicorice, also anticariogenic

11Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.

Major Factors in the Dental Caries Major Factors in the Dental Caries ProcessProcess

Dental hygiene considerationsDental hygiene considerationsEncourage meticulous oral self-care, regular Encourage meticulous oral self-care, regular

preventive dental visitspreventive dental visitsPromote sealants for deep pits and fissuresPromote sealants for deep pits and fissuresIn high-risk patients encourage use of aIn high-risk patients encourage use of a

chlorhexidine, fluoride, xylitol protocolchlorhexidine, fluoride, xylitol protocolEncourage healthy eating habits with minimal Encourage healthy eating habits with minimal

fermentable CHO intake between mealsfermentable CHO intake between mealsEating low-fat cheese as snack or at end of a meal Eating low-fat cheese as snack or at end of a meal

could provide anticariogenic effectscould provide anticariogenic effects

From Bird DL, Robinson DS: From Bird DL, Robinson DS: Torres and Ehlrlich Modern Torres and Ehlrlich Modern

Dental Assisting, ed 9. St. Louis: Dental Assisting, ed 9. St. Louis: Saunders, 2009.Saunders, 2009.

12Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.

Major Factors in the Dental Caries Major Factors in the Dental Caries ProcessProcess

Dietary factors Dietary factors mustmust be modified to reduce the be modified to reduce the risk of caries. Dietary recommendations need risk of caries. Dietary recommendations need to address the following dietary factors:to address the following dietary factors:Frequency of eating meals and snacksFrequency of eating meals and snacksOral retentiveness of foodsOral retentiveness of foodsSequence of food consumptionSequence of food consumptionAmount of fermentable carbohydrate consumedAmount of fermentable carbohydrate consumedSugar concentration of the food or drink itemSugar concentration of the food or drink itemPhysical form of the carbohydratePhysical form of the carbohydrateProximity of eating to bedtimeProximity of eating to bedtime

13Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.

Major Factors in the Dental Caries Major Factors in the Dental Caries ProcessProcess

Physical formPhysical formLiquids include fruit juice, soda, sportsLiquids include fruit juice, soda, sports

drinks, energy drinks, liquid medicationsdrinks, energy drinks, liquid medications An acidic medium that further demineralizes An acidic medium that further demineralizes

the tooththe tooth Diet soft drinks contain added citric and phosphoric acidsDiet soft drinks contain added citric and phosphoric acids

Retentive CHOs include bakery items, crackers, Retentive CHOs include bakery items, crackers, potato chips, pretzelspotato chips, pretzels

Slowly dissolving CHOs include antacids, cough Slowly dissolving CHOs include antacids, cough drops, breath mintsdrops, breath mints

14Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.

Major Factors in the Dental Caries Major Factors in the Dental Caries ProcessProcess

Frequency of intakeFrequency of intakeLinear relationship between caries rate and number Linear relationship between caries rate and number

of meals and/or snacks consumedof meals and/or snacks consumed Each time a food containing carbohydrates is eaten, the Each time a food containing carbohydrates is eaten, the

salivary pH drops below the critical level for approximately salivary pH drops below the critical level for approximately 40 minutes 40 minutes

Enamel demineralization occursEnamel demineralization occurs Acid exposure is additive throughout the day Acid exposure is additive throughout the day Eventually demineralization progresses to the point at which Eventually demineralization progresses to the point at which

decay may be detected clinicallydecay may be detected clinically The calcium and phosphorus in saliva need time to The calcium and phosphorus in saliva need time to

remineralize the tooth between meals/snacksremineralize the tooth between meals/snacks

15Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.

Major Factors in the Dental Caries Major Factors in the Dental Caries ProcessProcess

Timing and sequence in a mealTiming and sequence in a mealAmount of acid is reduced if a fermentable Amount of acid is reduced if a fermentable

carbohydrate food is eaten before or between other carbohydrate food is eaten before or between other noncariogenic foods noncariogenic foods Dairy products, such as cheese, reduce demineralization of Dairy products, such as cheese, reduce demineralization of

the tooth and help buffer acids produced by the bacteriathe tooth and help buffer acids produced by the bacteria Sialagogues, like sugar-free chewing Sialagogues, like sugar-free chewing

gum, stimulate the saliva and gum, stimulate the saliva and promote buffering of acids promote buffering of acids produced by bacteria and aidproduced by bacteria and aidin oral clearance of the foodin oral clearance of the food

16Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.

Major Factors in the Dental Caries Major Factors in the Dental Caries ProcessProcess

Dental hygiene considerationsDental hygiene considerationsReview diet history for patterns of fermentable Review diet history for patterns of fermentable

carbohydrate consumption, frequency, and formcarbohydrate consumption, frequency, and formConsume fermentable carbohydrates within a meal or Consume fermentable carbohydrates within a meal or

eat a noncariogenic food at the endeat a noncariogenic food at the endNoncariogenic snacks include raw fruits and Noncariogenic snacks include raw fruits and

vegetables; low-fat cheese, milk, and yogurt; nuts; vegetables; low-fat cheese, milk, and yogurt; nuts; popcorn; seeds; pizza and tacospopcorn; seeds; pizza and tacos

Encourage limiting of soft drinks and sports/energy Encourage limiting of soft drinks and sports/energy drinksdrinks

17Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.

Dental Hygiene PlanDental Hygiene PlanAssessmentAssessment

Gather information about the quality of the patient’s meal Gather information about the quality of the patient’s meal pattern and eating habits with a 24-hour diet recall or 3- pattern and eating habits with a 24-hour diet recall or 3- to 7-day food record to 7-day food record

Use MyPyramid as a guide to assess adequacy of food Use MyPyramid as a guide to assess adequacy of food intake with cooperation of the patientintake with cooperation of the patient

Have the patient highlight all the fermentable Have the patient highlight all the fermentable carbohydrates and note form, frequency, and when eaten carbohydrates and note form, frequency, and when eaten Estimate amount of time teeth are exposed to cariogenic foodsEstimate amount of time teeth are exposed to cariogenic foods More than 2 hours of acid exposure generally considered highMore than 2 hours of acid exposure generally considered high

18Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.

Dental Hygiene PlanDental Hygiene PlanGoalsGoals

Help patient develop realistic goalsHelp patient develop realistic goalsGoals need to be flexible to meet the patient’s needs, Goals need to be flexible to meet the patient’s needs,

preferences, and lifestylepreferences, and lifestyle

EducationEducationEducation alone does not guarantee behavioral Education alone does not guarantee behavioral

changechangeAssessment and goals are the basis for any Assessment and goals are the basis for any

recommendationsrecommendationsDispel myths, redirect inappropriate habits, and Dispel myths, redirect inappropriate habits, and

provide new ideasprovide new ideas