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

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.

*Decayed, Missing, Filled Annual sugar use (kg) Age 11-12 years DMF* Teeth *Decayed, Missing, Filled FAO (Food and Agriculture Organsiation - United Nations 1960

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, 1978. Page 388.

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, 1978. Page 389.

The Vipeholm Study of Diet and Dental Caries Gustafsson et al. (1954). The Vipeholm dental caries study. Acta Odontlogica Scandinavica 11:232-364.

Gustafsson et al. (1954). The Vipeholm dental caries study Gustafsson et al. (1954). The Vipeholm dental caries study. Acta Odontlogica Scandinavica 11:232-364.

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 11:232-364.

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

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

DMFT of children aged 6 – 9 years 12   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

Lilienthal et al Med J Aust, June 1953

The Tennessee Study Weiss RL, Trithart. Between meal eating habits and dental caries experience in preschool children. American Journal of Public Health 50:1097-1104, 1960.

Weiss RL, Trithart. Between meal eating habits and dental caries experience in preschool children. American Journal of Public Health 50:1097-1104, 1960.

Weiss RL, Trithart. Between meal eating habits and dental caries experience in preschool children. American Journal of Public Health 50:1097-1104, 1960.

The cariogenicity of refined carbohydrates

Beck DJ, Bibby BG. Acid production during the fermentation of starches by saliva. Journal of Dental Research 40:486-491, 1961.

Calcium sucrose phosphate Harris et al. Observations on the cariostatic effect on a group of children aged 5-17 years. Australian Dental Journal 12:105-113, 1967.

Harris et al. Observations on the cariostatic effect on a group of children aged 5-17 years. Australian Dental Journal 12:105-113, 1967.

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 29:983-992. .

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 29:983-992, 1884.

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

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

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

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 67:1422-1429, 1988.

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 67:1422-1429, 1988.

(3 years) Burt et al. Journal of Dental Research 67:1422-1429, 1988.

(3 years) Burt et al. Journal of Dental Research 67:1422-1429, 1988.

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 29:983-992, 1884.

The Melbourne Study

Pit and fissure surface caries risk estimates

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.

Rugg-Gunn et al. The effect of different meal patterns upon plaque pH n human subjects. British Dental Journal 139:151-156, 1975.

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.

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.

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

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

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.

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.

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.

Australian 12-year-olds

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

Source: Spencer AJ, Slade GD, Davies M. Water fluoridation in Australia. Community Dental Health 46:188-198,1986

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: 368-373, 2009

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

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

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

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

Fluoride toothpaste

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

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.

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

Fluoride varnish

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

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).

The role of diet in caries prevention – an ecological model

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 51:399-406,2001.

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 51:399-406,2001.

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 51:399-406,2001.

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 51:399-406,2001.