Presented by, Dr.Shivashankar.K2nd year P.G.Dept. of Public Health Dentistry

Nutrition in Dental caries and

Periodontal diseases

Introduct ion Carbohydrate and dental car ies Prote in and dental car ies Fat and dental car ies Calc ium phosphate and dental car ies Vitamins and dental car ies Trace e lements and denta l car ies Diet in the et io logy of denta l car ies Diet and per iodontal d isease Prote in and per iodontal d isease Fat and per iodontal d isease Vitamins and per iodonta l disease Diet in the et io logy of per iodontal d isease Diet counse l l ing for per iodontal d iseases Recent s tudies Conc lus ion References

CONTENTS

INTRODUCTION

The science which deals with the study of nutrient and foods

and their effects on the nature & function or organism under

different condition of age, health & disease.

-NIZEL 1989

Nutrients are defined as the constituents of food, which

perform important functions in our body

Macro and Mirco nutrients

NUTRITION

Nizel (1989): Total oral intake of a substance that

provides nourishment & supply.

BALANCED DIET :

One providing each nutrient in the (neither deficient nor

excess) needed to maintain optimum health.

- Stewart

DIET

EFFECT OF DIET ON ORAL HEALTH

Systemic mechanism

Absorption and circulation of

nutritents to cells and tissues

These effects are mediated locally

Local mechanism

Development of teeth, quality and

quantity of salivary secretion

Influence the metabolism of oral

flora

DIET AND DENTAL CARIES

DENTAL CARIES

INFLUENCE OF NUTRIENT ON TOOTH DEVELOPMENT AND SUBSEQUENT CARIES

FORMATION

CLASSES OF NUTRIENTS

Carbohydrates – Body fuel

Lipids – body cushion

Proteins – body builder

Vitamins – director of cell processes

Minerals – regulators of body fluids

Water – vital for life

CARBOHYDRATES AND DENTAL CARIES

PROCESS OF CARIES FORMATION

1. Frequency of eating:

Vipeholm study showed that frequency of consumption of sugars and the oral clearance time for sugars are important factors affecting cariogenicity.

In a study of more than 1000 chi ldren in USA, indicated that the frequency or between meal snacks of candies, cookies, chewing gum or carbonated beverages correlated with the DMF rates (Weiss et al 1960)

When sucrose is ingested frequently even a relatively low concentration of 1.25% wil l cause a pH drop between 4 and 5.

FACTORS INFLUENCING CARIOGENICITY OF SUCROSE IN

DIETS

•A significant correlation was found between a high sugar concentration in saliva with a prolonged clearance time and caries activity (Lundquist, 1952).

• This finding implies that retentive, sticky, sweet foods with little detergency or self cleaning properties may be potentially more cariogenic than foods that detergent and rapidly clear the oral cavity.

ORAL CLEARANCE RATE

The availabil ity of sucrose for support of bacterial metabolism in plaque which is influenced by the texture, consistency of food, the stimulation of saliva by chewing and the rapidity of clearance of the substrate.

With the advent of highly concentrated processed canned sugar the level of sucrose consumption as well as concentration of sucrose in food item increased dramatically.

EFFECTIVE CONCENTRATION OF SUCROSE

• Many oral bacteria uti l ize sucrose, glucose, fructose and other simple sugars to produce organic acids (Lactic, acetic, propionic)

• It is only from sucrose that most bacteria are able to synthesize both soluble and insoluble extracellular polymers (dextrans and mutans) which increase the bulk of plaque and facilitate the attachment of bacteria, especially streptococcus mutans.

Sucrose a Unique Substrate for Cariogenic Flora

The concentrated and complex mixture of bacteria and plaque give rise to a wide variety of glycolytic products which cause pH to drop. STEPHAN (1940) using many microelectrodes, recorded the pH values of dental plaque in situ before, during, after a glucose rinse.

pH CHANGES IN PLAQUE FROM FOODS

DIETARY STUDIES IN HUMAN POPULATION

Artificial sugar substitutesSorbitalXylitolAspartameSaccharineCyclamate

Food aditives

REDUCING THE CARIOGENICITY OF THE DIET

A protein deficient diet fed to experimental animals during the preeruptive tooth development period increases their caries susceptibility (Navia J. et al 1970). The caries may be caused either by a quality defect in the matrix of the tooth enamel or equally important by alteration in the salivary gland.

PROTEIN AND DENTAL CARIES

Caries in rodents have been reduced significantly by adding casein to an otherwise cariogenic diet. Since casein is a phospho-protein, it is possible that phosphate in this protein compound may have exerted some anti cariogenic effect.

Several animal studies show that the aminoacids such as lysine and glycine help prevent caries (Nizel et al 1970 ; McClure et al 1955; Harris et al 1967).

PROTEIN AND DENTAL CARIES

There is indirect evidence that dietary fats may help prevent caries in humans. For example those Eskimos whose diets are almost solely of animal origin and furnish about 70-80% of their total calories as fat experience less decay. It is only when the fat content of the diet is reduced to 25% or less that decay starts to appear.

FATS AND DENTAL CARIES

Coating

fatty protective layer

interfere with the growth

decrease the amount

MECHANISM OF ACTION OF FAT

It has been observed that cheese and butter reduce the cariogenicity in rats. Ingestion of cheddar cheese caused the pH raise of buccal plaque (Rugg-Gunn et al 1975).

The mechanism of the effect of cheese in raising the plaque pH is still uncertain but one possibility is that the bicarbonates in the alkaline saliva secreted in response to cheese ingestion diffuses into plaque and neutralizes the acids.

An additional anticaries action of cheese is that calcium and phosphate ions are extracted from it during mastication and enter plaque thus reducing demineralization and favoring remineralization

CHEESE AND DENTAL CARIES

In Vitamin A deficient animals, atrophic changes in the ameloblasts, subsequent abnormalit ies in tooth morphology has been observed.

In man severe Vitamin A deficiency during tooth formation does not necessarily lead to defective enamel.

The only member of the Vitamin B complex which has been associated with caries is pyridoxine (Vitamin B 6 ) very high doses (10 times > than normal) have been reported in two small scale experiments in human subjects (pregnant and school children) to reduce caries. (Cole et al 1980).

VITAMINS AND DENTAL CARIES

TRACE ELEMENTS AND DENTAL CARIES

Caries promoting elements : Selenium, magnesium, Cadmium,

Platinum, Lead, Silicon.

Elements that are mildly cariostatic : Molybdenum, Vanadium,

Strontium, Calcium, Boron, Lithium, Gold.

Elements with doubtful effect on caries : Beryllium, Cobalt,

Manganese, Tin, Zinc, Bromine, Iodine.

Caries inert elements : Barium, aluminium, nickel, iron,

palladium, titanium.

Elements that are strongly cariostatic : Fluorine, phosphorous.

Fluoride : Water borne fluorides which originally were observed

to cause an unattractive discolouration and deformity to tooth enamel, when ingested at level above 2 ppm, later were proved to be essential of dental health because they reduced the incidence of dental decay when ingested daily at optimum levels of 1 ppm.

Fluoride acts to reduce dental decay

TRACE ELEMENTS AND DENTAL CARIES

Diet chartA diet history concerning food intake patterns, diet

adequacy, consumption of fermentable carbohydrates (including naturally occurring and added sugars), and the use of fluoridated toothpaste is a strategy for health professionals to use to determine the diet related caries risk habits of persons.

DIETARY MANAGEMENT

What food was eaten?

How much was eaten?

How was it prepared?

How was it served?

DIET RECALL

SUGAR-SWEETENED BEVERAGES AND DENTAL CARIES IN ADULTS: A 4-YEAR PROSPECTIVE STUDY

EDUARDO BERNABÉ ET AL. JOURNAL OF DENTISTRY 2014

Data from 939 dentate adults who participated in the Health 2000

Survey and the Follow-Up Study of Finnish Adults’ Oral Health

showed a positive association was found between frequency of

Sweetened Beverages consumption and 4-year net DMFT

increment. Adults drinking 1–2 and 3+ sweetened beverages

daily had, respectively, 31% and 33% greater net DMFT

increments than those not drinking any sugar sweetened

beverages.

Clinical significance: Drinking sugar-sweetened beverages on a

daily basis is related to greater caries risk in adults.

Exploring the relation between body mass index, diet, and dental caries among 6-12‑year‑old children Elangovan A, Mungara J, Joseph E Department of Pedodontics and Preventive Dentistry, RagasDental College and Hospital, Chennai, Tamilnadu, IndiaBackground and Aim: Childhood overweight and obesity are becoming a major public health concern all over the world. Change in lifestyles and economic growth have led to sedentary lifestyle and altered dietary patterns. There are conflicting reports in the literature regarding the association between body mass index (BMI) and dental caries from various parts of the world. The aim of the present study was to determine if there is an association between BMI‑for‑age and dental caries in children and to find out the role of diet with respect to BMI‑for‑age and dental caries. Materials and Methods: Demographics and anthropometric measurements were obtained for 600 children and BMI‑for‑age was calculated. Clinical examination for dental caries was carried out following WHO criteria. A diet recording sheet was prepared and children/parents were asked to record the dietary intake for 3 days. Data obtained were statistically analyzed using Chi‑square, analysis of variance (ANOVA), and multiple linear regression. Results: After excluding improperly filled diet recording sheets, 510 children were included in the study. Caries prevalence was more in obese children than in other BMI groups. Caries scores increased as BMI‑for‑age increased, though this was not statistically significant. Consumption of fatty foods and snacks was more with obese children compared to other groups. A correlation was found between caries and snacks. Conclusion: Dental caries scores showed no relationship between BMI‑for‑age in children. Both snacks and fatty food items were consumed more by obese children, which seeks attention.

DIET AND PERIODONTAL DISEASE

Glucose and other carbohydrates are also used to produce extracellular polysaccharides and, therefore, diets containing sucrose, glucose and other disaccharides can increase the plaque mass and facilitate the retention and colonization of the plaque biofilm which forms a substrate for bacteria to grow leading to periodontal diseases.

-Boyd (2003)

EFFECT OF DIET ON PERIODONTAL HEALTH

By interfering with the

A) integrity of gingival epithelial barrier.

B) tissue repair processes.

C) resistance mechanisms of the body.

NUTRITIONAL DEFICIENCIES CONTRIBUTES TO PERIODONTAL

DISEASE

The rapid rate of turnover of epithelium cells of the gingival sulcus indicates need for continuous synthesis of DNA and RNA and tissue protein.

This means that the sulcular epithelium has a high requirement for nutrient such as folic acid, and protein, which are involved in cell form. To maintain the integrity of the epithelium vitamin A is also needed.

At the base of the sulcular epithelium is a narrow basement membrane made up of collagen….acts as a barrier against the entrance of toxic meterials into the underlying connective tissue.

NUTRITION AND EPITHELIUM BARRIER

Protein and ascorbic acid are intimately involved in connective

tissue formation . Zinc seems to have the property of accelerating wound healing,

of which may be due to anti infective action. Since epithelium tissue contains 20% of the body's zinc and since zinc is involved in the healing process, it follows an adequate intake of foods that are good zinc sources can be helpful.

Calcium : Phosphorus are important nutrients for promoting density of alveolar bone.

NUTRITION AND THE REPAIR PROCESS

Protein deficiency impair the body's immune mechanism, they interfere with antibody formation, activity of the cell that ingest bacteria, and nonspecific resist factors.

  Protein deficiency diets interfere with body's formation of

immunoglobulin that act as antibodies to toxins. Consequently, infections will not be readily controllable.

NUTRITION AND IMMUNE MECHANISM

EFFECTS OF FOOD TEXTURES ON PERIODONTAL HEALTH

Glucose and other carbohydrates are also used to produce extracellular polysaccharides and, therefore, diets containing sucrose, glucose and other disaccharides can increase the plaque mass and facil itate the retention and colonization of the plaque biofilm which forms a substrate for bacteria to grow leading to periodontal diseases . -Boyd

(2003)

Research studies using an experimental gingivitis model have shown increased levels of bleeding on probing when participants were fed with a diet high in carbohydrates when compared to those on a low sugar diet

Carbohydrates and periodontal health

The epithelium of the gingival crevice or pocket

adheres to the tooth surface by physiochemical

forces mediated by the proteins and

glycoproteins in the gingival fluid.

When a foreign body is introduced into the

periodontal pocket in a protein – deficient

animal, the resorption of alveolar crest, the

down growth of the epithelial attachment, and

the inflammatory exudate are increased.

Role of protein on periodontal tissue

Periodontal tissues of the gingival crevice or pocket adheres to the tooth surface mucoproteins are essential for the maintenance of a regular distribution of water and electrolytes in the tissues.

Collagen deficiencies in connective tissue may be due to any of three factors: 1) An inabil ity of fibroblasts to synthesize collagen (owing to a deficiency in amino acids, such as in proline and lysine)

2)Failure of soluble collagen to form insoluble fibers

3)Degeneration of collagen by collagen-liquifying enzyme derived from Bacteroides melaninogenicus , an anaerobic organism associated with periodontal disease

Protein in the biochemistry periodontal tissues

Vitamin A deficiency produces hyperkeratosis and hyperplasia of gingival tissue. There is a tendency to periodontal pocket formation.

A suitable antimetabolite of vitamin K might interfere with the growth of Bacteroides Melaninogenicus and consequently, prevent the occurrence of periodontal disease.

The characteristic oral sign of Vitamin C deficiency is scurvy which results in enlargement of the marginal gingivae that envelopes and almost completely conceals the teeth.

EFFECTS OF VITAMIN DEFICIENCY ON PERIODONTIUM

Animal studies show that ascorbic acid may be involved in both the pathogenesis and severity of NUG through its act on collagen synthesis and its effect on neu trophils of the immune system

Thus, nutrit ional factors do not cause periodontal disease directly, but can play an important role in healing. In turn, periodontal conditions and their treatment may impair the desire and ability to eat and contribute to poor nutrit ion.

Necrotizing Ulcerative Gingivitis /Periodontitis

1)History - includes general and oral hygiene habits, socioeconomic status, and food l ikes and dislikes is necessary to understand the reasons for tood choices and dietary practices.

2)Dietary screening – screening the adequacy of the diet is to use the dental health diet score.

3)Dietary prescription - a)Daily food pattern

Dietary management of ANUG/NUP

Dietary management of ANUG/NUP

b)Frequency of meals:

c) Menu plan:

Vegetable-fruit group

Bread-cereal group

Milk-cheese group

Meat-poultry,fish and bean group

4)Vitamin supplementation- multivitamin combination (vitamin c

and B-complex)

Step 1 :Ascertain the dental health diet score and if necessary, demonstrate the method for keeping a food intake diary

Step 2 :explain the nutrition-periodontal relationship Step 3 : Assess nutritional status Step 4 : Prescribe a diet –improve adequacy of diet Emphasize foods that are particularly beneficial to periodontal

tissue-proteins,vit C,A,folic acid,calcium,iron and zinc Encourage the elimination of plaque forming sweets and

substitution of fibrous foods Allow the patient to prescribe meal. Step 5 :Follow up

NUTRITION COUNSELLING FOR A PATIENT WITH CHRONIC PERIODONTITIS

The National Health and Nutrition Examination Survey (NHANES) is a program of studies designed to assess the health and nutritional status of adults and children in the United States.

NCHS (national centre for health statistics) is part of the Centers for Disease Control and Prevention (CDC) and has the responsibility for producing vital and health statistics for the Nation.

The NHANES interview includes demographic, socioeconomic, dietary, and health-related questions.

The examination component consists of medical, dental, and physiological measurements, as well as laboratory tests.

EPIDEMIOLOGICAL SURVEYS

CONCLUSION

REFERENCES

Park K. Park’s Textbook of Preventive and Social Medicine, 21st Edition, Banarsidas Bhanot, 2007, Pg: 438 – 487. Abraham E. Nizel. The science of nutrition and its application in clinical dentistry 2nd edition, W, B Saunders Company, Philadelphia 1966.Paula J. Moynihan. The role of diet and nutrition in the etiology and prevention of oral diseases .Bulletin of the World Health Organization (BLT). Volume 83, Number 9, September 2005, 641-720Moynihan P, Petersen PE. Diet, nutrition and the prevention of dental diseases. Public Health Nutrition. 7(1A): 201–26Elangovan A, Mungara J, Joseph . Exploring the relation between body mass index, diet, and dental caries among 6-12‑year‑old children .J Indian Soc Pedod Prev Dent. 2012 Oct-Dec;30(4):293-300

Eduardo Bernabé et al. Sugar-sweetened beverages and dental caries in adults: A 4-year prospective study . Journal of dentistry 2014.

Kum Sun Lee, Nam-Joong Kim, Eun-Hee Lee, Ja-Won Cho . Cariogenic Potential Index of Fruits according to Their Viscosity and Sugar Content. Int J Clin Prev Dent 2014;10(4):255-258

Paula J. Moynihan . The role of diet and nutrition in the etiology and prevention of oral diseases . Bulletin of the World Health

Organization (BLT). Volume 83, Number 9, September 2005, 641-720

REFERENCES