1. Diet, Fluoride, and Dental Caries
Wendell Evans BDS MDS DDSc FICD
Population Oral Health
The University of Sydney

2. Dental caries was ranked as the highest diet-related disease in Australia in terms of both total costs and health care costs (Crowley et al 1992).
Crowley S, Antioch K, Carter R, Waters AM, Conway L, Mathers C (1992). The cost of diet related disease in Australia. Canberra: AIHW and NHMRC.

3. *Decayed, Missing, Filled
Annual sugar use (kg)
Age years
DMF* Teeth
*Decayed, Missing, Filled
FAO (Food and Agriculture Organsiation - United Nations 1960

4. 10% glucose rinse Dental plaque pH Minutes
Critical pH for tooth enamel dissolution
Minutes
Jenkins GN. The physiology and biochemistry of the mouth, 4th Edition. Oxford: Blackwell Scientific Publications, Page 388.

5. Jenkins GN. The physiology and biochemistry of the mouth, 4th Edition
Jenkins GN. The physiology and biochemistry of the mouth, 4th Edition. Oxford: Blackwell Scientific Publications, Page 389.

6. The Vipeholm Study of Diet and Dental Caries
Gustafsson et al. (1954). The Vipeholm dental caries study. Acta Odontlogica Scandinavica 11:

7. Gustafsson et al. (1954). The Vipeholm dental caries study
Gustafsson et al. (1954). The Vipeholm dental caries study. Acta Odontlogica Scandinavica 11:

8. New DMFT Sugar per consumed year gm per day 4 300 3 200 100 1 Liquid
Liquid 24
toffees
Gustafsson et al. (1954). The Vipeholm dental caries study. Acta Odontlogica Scandinavica 11:

9. The Dental Caries Experience of the Children of Hopewood House
Bowral, NSW
Lilienthal et al Med J Aust, June 1953

10. Hopewood House 82 Children aged 4-9 years Investigators Findings
Paediatricians
Dental scientists
Findings
well nourished
healthy
very poor oral hygiene
no dental caries
Lilienthal et al Med J Aust, June 1953

11. DMFT of children aged 6 – 9 years12 10
HOPEWOOD HOUSE
BOWRAL, NSW
DMFT of children aged 6 – 9 years 8 6 4 2
New Zealand
Sydney
Bowral
Lilienthal et al Med J Aust, June 1953

12. Lilienthal et al Med J Aust, June 1953

13. The Tennessee Study
Weiss RL, Trithart. Between meal eating habits and dental caries experience in preschool children. American Journal of Public Health 50: , 1960.

14. Weiss RL, Trithart. Between meal eating habits and dental caries experience in preschool children. American Journal of Public Health 50: , 1960.

15. Weiss RL, Trithart. Between meal eating habits and dental caries experience in preschool children. American Journal of Public Health 50: , 1960.

16. The cariogenicity of
refined carbohydrates

17. Beck DJ, Bibby BG. Acid production during the fermentation of starches by saliva. Journal of Dental Research 40: , 1961.

18. Calcium sucrose phosphate
Harris et al. Observations on the cariostatic effect on a group of children aged 5-17 years. Australian Dental Journal 12: , 1967.

19. Harris et al. Observations on the cariostatic effect on a group of children aged 5-17 years. Australian Dental Journal 12: , 1967.

20. Relationship between dietary habits and caries increment assessed over two years in 405 adolescent school children in Northeast England.
Rugg-Gunn et al (1984). Archives of Oral Biology 29: .

21. children initially aged 11.5 years 3 day diet diary on 5 occasions
2 year study
children initially aged 11.5 years
3 day diet diary on 5 occasions
annual bitewings
non-fluoridated environment
Rugg-Gunn et al. Archives of Oral Biology 29: , 1884.

22. Rugg-Gunn et al. Archives of Oral Biology 29:983-992, 1884.

23. Rugg-Gunn et al. Archives of Oral Biology 29:983-992, 1884.

24. Rugg-Gunn et al. Archives of Oral Biology 29:983-992, 1884.

25. The effects of sugars intake and frequency of ingestion of dental caries increment in a three-year longitudinal study – Michigan, USA
Burt et al. Journal of Dental Research 67: , 1988.

26. Michigan, USA 3 year study of 499 children initially aged 11-15 years
24 hour diet interviews on 3-4
occasions
non-fluoridated environment
annual bitewings
Burt et al. Journal of Dental Research 67: , 1988.

27. (3 years)
Burt et al. Journal of Dental Research 67: , 1988.

28. (3 years)
Burt et al. Journal of Dental Research 67: , 1988.

29. Summary of findings
Caries incidence was not related to total sugar intake nor to frequency of eating occasions.
Rugg-Gunn et al. Archives of Oral Biology 29: , 1884.

30. The Melbourne Study

32. Pit and fissure surface caries risk estimates

34. Effect of cheese
Eating cheese following consumption of a sugary snack (pears in sugary syrup) prevented the depression of plaque pH whereas drinking sugared coffee following pears consumption further depressed pH.

35. Rugg-Gunn et al. The effect of different meal patterns upon plaque pH n human subjects. British Dental Journal 139: , 1975.

36. Effect of war time diet
During WW2, severe rationing of sugar occurred. Caries incidence in both Scandinavia and Japan was correlated with sugar consumption.
Most recently, United Nations imposed sanctions against Iraq was associated with a dramatic decline in caries incidence.
These data show the potential for health promotion (at the population level) to target dietary sugar restriction. The common risk factor approach.

37. Toverud G (1957). The influence of war and post-war conditions on the teeth of Norwegian children. In: Rugg-Gunn AJ. Nutrition and Dental Health. Oxford: Oxford University Press, 1993, 129.

39. DMFT in Iraq before and after United Nations Sanctions (UNS)
Jamel H, Plasschaert A, Sheiham A. Dental caries experience and availabilit of sugars in Iraqi children before and after the United Nations sanction. International Dental Journal 54: 21-25, 2004

40. Fluorine 13th most abundant element in the earths crust (WHO,1984)
most electronegative of the elements
emitted from volcanoes as gaseous fluorine which
reacts immediately with water to form HF
mainly found in rock and soil in various forms of
barely soluble calcium fluorides
concentration in seawater about 1.2 mg/L (ppm)
concentration in fresh water ranges from near
zero to 25 ppm (in the Rift Valley, Tanzania)
world-wide fresh water fluoride concentrations
are generally less than 0.1 ppm but commonly up
to 2 ppm in some areas

42. 0.0 ppm
0.0 ppm
1.2 ppm
Source: McClure FJ. Water fluoridation: The search and the victory. Bethesda: National Institute of Dental Research, 1970.

43. Permanent teeth DMF reductions at Grand Rapids
0.1 ppm
1.0 ppm
1.2 ppm
Permanent teeth DMF reductions at Grand Rapids
after 10 and 15 years of fluoridation.
Source: McClure FJ. Water fluoridation: The search and the victory. Bethesda: National Institute of Dental Research, 1970.

44. Percent caries reduction in 113 studies into the effectiveness of water fluoridation in 23 countries.
Source: Murray JJ, Naylor MN. Fluorides and dental caries. In: Murray JJ (Editor). Prevention of oral disease 3rd edition. Oxford: Oxford University Press, 38, 1996.

45. Australian
12-year-olds

46. Victorian 12-year-olds The effect of water fluoridation
The combined effect of water fluoridation and fluoridated toothpaste
Victorian 12-year-olds

47. Source: Spencer AJ, Slade GD, Davies M. Water fluoridation in Australia. Community Dental Health 46: ,1986

48. Water fluoridation in the Blue Mountains reduces risk of tooth decay
RW Evans1, A Hsiau1, PJ Dennison1, A Paterson2,
and B.Jalaludin2
Australian Dental Journal 54: , 2009

49. Caries experience of lifelong
Primary teeth
Caries experience of lifelong
residents aged 6 – 8 years
Blue Mountains
2.58a
Hawkesbury
Mean
dmft
1.10
0.71
0.69b
1993
2003
a = 135% more than Hawkesbury at baseline
b = 73% less than Hawkesbury at baseline
A =
RW Evans1, A Hsiau1, PJ Dennison1, A Paterson2, and B.Jalaludin2
1Community Oral Health and Epidemiology, 2Formerly NSW Health

50. Percent of lifelong residents aged 6 – 8 years with no decay
Primary teeth
Percent of lifelong residents
aged 6 – 8 years with no decay
72%
71%
62%
38%
1993
2003
Blue Mountains
Hawkesbury
RW Evans1, A Hsiau1, PJ Dennison1, A Paterson2, and B.Jalaludin2
1Community Oral Health and Epidemiology, 2Formerly NSW Health

51. Caries experience of lifelong
PERMANENT TEETH
Caries experience of lifelong
residents aged 9 – 11 years
Blue Mountains
0.87a
Hawkesbury
Mean
DMFT
0.58
0.36
0.22b
1993
2003
a = 50% more than Hawkesbury at baseline
b = 75% less than Hawkesbury at baseline
RW Evans1, A Hsiau1, PJ Dennison1, A Paterson2, and B.Jalaludin2
1Community Oral Health and Epidemiology, 2Formerly NSW Health

52. Percent of lifelong residents aged 9 – 11 years with no decay
PERMANENT TEETH
Percent of lifelong residents
aged 9 – 11 years with no decay
87%
81%
71%
61%
1993
2003
Blue Mountains
Hawkesbury
RW Evans1, A Hsiau1, PJ Dennison1, A Paterson2, and B.Jalaludin2
1Community Oral Health and Epidemiology, 2Formerly NSW Health

53. Fluoride toothpaste

54. The Cochrane Database of Systematic Reviews
Fluoride toothpastes for preventing dental caries in children and adolescents
Marinho VCC, Higgins JPT, Sheiham A, Logan S
Date of Most Recent Substantive Update:
3 September 2002

55. The overall caries-inhibiting effect (that is preventive fraction, %PF) derived from the pooled results of 70 trials was 24% (95% CI, 21 to 28%).
This effect was independent of background domestic drinking water fluoride status.
The caries increments ranged from 1.14 to 7.66 D(M)FS per year.

56. In addition there was:
a 14% increase in the PF moving from once to twice
daily tooth brushing
an 8% increase in the PF per 1000 ppm increase in the
fluoride concentration

57. Fluoride varnish

58. The Cochrane Database of Systematic Reviews
Fluoride varnishes for preventing dental caries in children and adolescents
Marinho VCC, Higgins JPT, Logan S, Sheiham A.
29 May 2002

59. Nine studies were included in this meta-analysis, involving 2709 children.
For the seven studies that contributed data for the main meta-analysis, the D(M)FS pooled prevented fraction estimate was 46% (95% CI, 30% to 63%; p<0.0001).
The pooled d(e/m)fs prevented fraction estimate was 33% (95% CI, 19% to 48%; p<0.0001).

60. The role of diet in caries prevention – an ecological model

61. Caries risk Dietary challenge
For a given dietary challenge, risk of caries at any tooth site will depend on (1) fluoride exposure, (2) plaque bulk, and (3) access to saliva.
Loveren C van, Duggal MS. The role of diet in caries
prevention. International Dental Journal 51: ,2001.

62. Better use of fluorides
Better oral hygiene
Caries risk
Dietary challenge
Better access to saliva
For a given dietary challenge, risk of caries at any tooth site will depend on (1) fluoride exposure, (2) plaque bulk, and (3) access to saliva.
Loveren C van, Duggal MS. The role of diet in caries
prevention. International Dental Journal 51: ,2001.

63. Better use of fluorides
Better oral hygiene
Better
For reduced dietary challenge
Better access to saliva
Better access to saliva
For a given dietary challenge, risk of caries at any tooth site will depend on (1) fluoride exposure, (2) plaque bulk, and (3) access to saliva.
Loveren C van, Duggal MS. The role of diet in caries
prevention. International Dental Journal 51: ,2001.

64. Better use of fluorides
Better oral hygiene
Better
For reduced dietary challenge
Scope to reduce caries risk is limited
Better access to saliva
Better access to saliva
For a given dietary challenge, risk of caries at any tooth site will depend on (1) fluoride exposure, (2) plaque bulk, and (3) access to saliva.
Loveren C van, Duggal MS. The role of diet in caries
prevention. International Dental Journal 51: ,2001.