1. NUTRITIONAL ASPECTS OF DENTAL CARIES: CAUSES, PREVENTION, AND TREATMENT CHAPTER 17 Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.

2. 2 Prevalence Nutrients have topical and systemic effects that can be primary or secondary factors in the development of dental caries Nutrients have topical and systemic effects that can be primary or secondary factors in the development of dental caries National Call to Action to Promote Oral Health stresses prevention National Call to Action to Promote Oral Health stresses prevention Dental caries remain the most common chronic childhood disease Dental caries remain the most common chronic childhood disease Certain racial, ethnic, and lower-income populations suffer disproportionately higher rates of caries Certain racial, ethnic, and lower-income populations suffer disproportionately higher rates of caries

3. 3Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. Prevalence Caries rates rise with age Caries rates rise with age 28% of children ages 2–5 years 28% of children ages 2–5 years 49% of children ages 6–11 years 49% of children ages 6–11 years 68% of adolescents 12–19 years 68% of adolescents 12–19 years 75% of adults 75% of adults Prevalence of root caries also rises with age Prevalence of root caries also rises with age 9.4% among persons ages 20–39 years 9.4% among persons ages 20–39 years 17.8% among those ages 40–59 years 17.8% among those ages 40–59 years 31.6% among those ages >60 years 31.6% among those ages >60 years From Bird DL, Robinson DS: Torres and Ehlrlich Modern Dental Assisting, ed 9. St. Louis: Saunders, 2009.

4. 4Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. Major Factors in the Dental Caries Process Caries results from a combination of factors occurring simultaneously Caries results from a combination of factors occurring simultaneously Susceptible host or tooth surface Susceptible host or tooth surface Sufficient quantity of cariogenic microorganisms in the mouth Sufficient quantity of cariogenic microorganisms in the mouth Presence of fermentable carbohydrates Presence of fermentable carbohydrates Particular composition or flow of saliva Particular composition or flow of saliva From Darby ML, Walsh MM: Dental Hygiene: Theory and Practice, ed 2. St. Louis: Saunders, 2003.

5. 5Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. Major Factors in the Dental Caries Process Tooth structure Tooth structure Resistance against demineralization begins in pre-eruptive phase with adequate intakes of calcium; phosphorus; vitamins A, C, and D; fluoride; and protein Resistance against demineralization begins in pre-eruptive phase with adequate intakes of calcium; phosphorus; vitamins A, C, and D; fluoride; and protein Deep pits and fissures increase susceptibility Deep pits and fissures increase susceptibility Overlapping/crowding Overlapping/crowding Host factors Host factors Food selection and dietary patterns Oral hygiene habits Genetics Race or ethnic group Age SES (socioeconomic status)

6. 6 Major Factors in the Dental Caries Process Saliva Saliva Availability of essential nutrients (vit A, iron,protein) during development of salivary glands (begins in 4 th prenatal week) Availability of essential nutrients (vit A, iron,protein) during development of salivary glands (begins in 4 th prenatal week) Protection provided by adequate salivary flow to wash away food, buffer and neutralize acids, remineralize teeth (calcium, phosphate, fluoride ions) and kill bacteria (IgA) Protection provided by adequate salivary flow to wash away food, buffer and neutralize acids, remineralize teeth (calcium, phosphate, fluoride ions) and kill bacteria (IgA) Plaque biofilm Plaque biofilm Composition of plaque is altered and strongly influenced by diet By-products of sucrose and glucose metabolism produce acids; lowers pH to 6.7-5.5 to create environment for growth of bacteria, such as S. mutans and Lactobacillus pH may reach as low as 4 in some areas for 1 hour

7. 7Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. Major Factors in the Dental Caries Process Cariogenic foods Cariogenic foods Salivary amylase breaks down oral monosaccharides (glucose) and disaccharides (fructose, sucrose, maltose) Salivary amylase breaks down oral monosaccharides (glucose) and disaccharides (fructose, sucrose, maltose) Sucrose is used to produce glucans (polysaccharides) that facilitate adherence of bacteria (S.mutans) to the pellicle Sucrose is used to produce glucans (polysaccharides) that facilitate adherence of bacteria (S.mutans) to the pellicle Processed starches (instant oatmeal) are often more fermentable than their nonprocessed counterparts due to partial hydrolysis or diminution of particle size Processed starches (instant oatmeal) are often more fermentable than their nonprocessed counterparts due to partial hydrolysis or diminution of particle size High concentration of fructose found in juices is potential source of substrate High concentration of fructose found in juices is potential source of substrate

8. 8Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. Major Factors in the Dental Caries Process Anticariogenic properties of food Anticariogenic properties of food Sugar alcohols Sugar alcohols Fermented more slowly than mono- and disaccharides; therefore, buffering effects of saliva neutralize destructive acids produced by plaque biofilm Fermented more slowly than mono- and disaccharides; therefore, buffering effects of saliva neutralize destructive acids produced by plaque biofilm Oral flora do not contain enzymes to ferment xylitol Oral flora do not contain enzymes to ferment xylitol Microorganisms, such as S. mutans, are inhibited Teeth are able to experience benefits of saliva without acidic insult, resulting in remineralization of incipient decay Nonnutritive sweeteners Nonnutritive sweeteners Not metabolized by microorganisms; do not promote caries Not metabolized by microorganisms; do not promote caries

9. 9Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. Major Factors in the Dental Caries Process Protein and fat Protein and fat Considered cariostatic because do not lower Considered cariostatic because do not lower plaque pH, may offer buffering effects Phosphorus and calcium Phosphorus and calcium Provide a buffering effect in the saliva Provide a buffering effect in the saliva Dairy products Dairy products Protein, casein (principal protein in milk), phosphorus, calcium are ingredients of anticariogenic or even cariostatic foods, such as cheese and milk Protein, casein (principal protein in milk), phosphorus, calcium are ingredients of anticariogenic or even cariostatic foods, such as cheese and milk Although lactose is cariogenic (but the least cariogenic of all saccharides), these other elements in milk and milk products decrease risk of dental caries Although lactose is cariogenic (but the least cariogenic of all saccharides), these other elements in milk and milk products decrease risk of dental caries

10. 10Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. Major Factors in the Dental Caries Process Other foods with protective factors Other foods with protective factors Constituent in chocolate, known as the cocoa factor, has shown anticariogenic properties in Vipeholm study Constituent in chocolate, known as the cocoa factor, has shown anticariogenic properties in Vipeholm study Glycyrrhiza, the active ingredient in licorice, also anticariogenic Glycyrrhiza, the active ingredient in licorice, also anticariogenic

11. 11Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. Major Factors in the Dental Caries Process Dental hygiene considerations Dental hygiene considerations Encourage meticulous oral self-care, regular preventive dental visits Encourage meticulous oral self-care, regular preventive dental visits Promote sealants for deep pits and fissures Promote sealants for deep pits and fissures In high-risk patients encourage use of a In high-risk patients encourage use of a chlorhexidine, fluoride, xylitol protocol Encourage healthy eating habits with minimal fermentable CHO intake between meals Encourage healthy eating habits with minimal fermentable CHO intake between meals Eating low-fat cheese as snack or at end of a meal could provide anticariogenic effects Eating low-fat cheese as snack or at end of a meal could provide anticariogenic effects From Bird DL, Robinson DS: Torres and Ehlrlich Modern Dental Assisting, ed 9. St. Louis: Saunders, 2009.

12. 12Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. Major Factors in the Dental Caries Process Dietary factors must be modified to reduce the risk of caries. Dietary recommendations need to address the following dietary factors: Dietary factors must be modified to reduce the risk of caries. Dietary recommendations need to address the following dietary factors: Frequency of eating meals and snacks Frequency of eating meals and snacks Oral retentiveness of foods (sticky, chewy, starchy) Oral retentiveness of foods (sticky, chewy, starchy) Sequence of food consumption Sequence of food consumption Amount of fermentable carbohydrate consumed Amount of fermentable carbohydrate consumed Sugar or acid concentration of the food or drink item Sugar or acid concentration of the food or drink item Physical form of the carbohydrate Physical form of the carbohydrate Proximity of eating to bedtime Proximity of eating to bedtime

13. 13Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. Major Factors in the Dental Caries Process Physical form Physical form Liquids include fruit juice, soda, sports Liquids include fruit juice, soda, sports drinks, energy drinks, liquid medications An acidic medium that further demineralizes An acidic medium that further demineralizes the tooth Diet soft drinks contain added citric and phosphoric acids Diet soft drinks contain added citric and phosphoric acids Retentive CHOs include bakery items, crackers, potato chips, pretzels Retentive CHOs include bakery items, crackers, potato chips, pretzels Slowly dissolving CHOs include antacids, cough drops, breath mints Slowly dissolving CHOs include antacids, cough drops, breath mints

14. 14Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. Major Factors in the Dental Caries Process Frequency of intake Frequency of intake Linear relationship between caries rate and number of meals and/or snacks consumed Linear relationship between caries rate and number of meals and/or snacks consumed Each time a food containing carbohydrates is eaten, the salivary pH drops below the critical level for approximately 40 minutes Each time a food containing carbohydrates is eaten, the salivary pH drops below the critical level for approximately 40 minutes Enamel demineralization occurs Enamel demineralization occurs Acid exposure is additive throughout the day Acid exposure is additive throughout the day Eventually demineralization progresses to the point at which decay may be detected clinically Eventually demineralization progresses to the point at which decay may be detected clinically The calcium and phosphorus in saliva need time to remineralize the tooth between meals/snacks The calcium and phosphorus in saliva need time to remineralize the tooth between meals/snacks

15. 15Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. Major Factors in the Dental Caries Process Timing and sequence in a meal Timing and sequence in a meal Amount of acid is reduced if a fermentable carbohydrate food is eaten before or between other noncariogenic foods Amount of acid is reduced if a fermentable carbohydrate food is eaten before or between other noncariogenic foods Dairy products, such as cheese, reduce demineralization of the tooth and help buffer acids produced by the bacteria Dairy products, such as cheese, reduce demineralization of the tooth and help buffer acids produced by the bacteria Sialagogues, like sugar-free chewing Sialagogues, like sugar-free chewing gum, stimulate the saliva and promote buffering of acids produced by bacteria and aid in oral clearance of the food Coffee with sugar after a meal decreases pH which increases cariogenicity Coffee with sugar after a meal decreases pH which increases cariogenicity

16. 16Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. Major Factors in the Dental Caries Process Dental hygiene considerations Dental hygiene considerations Review diet history for patterns of fermentable carbohydrate consumption, frequency, and form Review diet history for patterns of fermentable carbohydrate consumption, frequency, and form Consume fermentable carbohydrates within a meal or eat a noncariogenic food at the end Consume fermentable carbohydrates within a meal or eat a noncariogenic food at the end Noncariogenic snacks include raw fruits and vegetables; low-fat cheese, milk, and yogurt; nuts; popcorn; seeds; pizza and tacos Noncariogenic snacks include raw fruits and vegetables; low-fat cheese, milk, and yogurt; nuts; popcorn; seeds; pizza and tacos Encourage limiting of soft drinks and sports/energy drinks Encourage limiting of soft drinks and sports/energy drinks

17. 17Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. Dental Hygiene Plan Assessment Assessment Gather information about the quality of the patient’s meal pattern and eating habits with a 24-hour diet recall or 3- to 7-day food record Gather information about the quality of the patient’s meal pattern and eating habits with a 24-hour diet recall or 3- to 7-day food record Use MyPyramid as a guide to assess adequacy of food intake with cooperation of the patient Use MyPyramid as a guide to assess adequacy of food intake with cooperation of the patient Have the patient highlight all the fermentable carbohydrates and note form, frequency, and when eaten Have the patient highlight all the fermentable carbohydrates and note form, frequency, and when eaten Estimate amount of time teeth are exposed to cariogenic foods Estimate amount of time teeth are exposed to cariogenic foods More than 2 hours of acid exposure generally considered high More than 2 hours of acid exposure generally considered high

18. 18Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc. Dental Hygiene Plan Goals Goals Help patient develop realistic goals Help patient develop realistic goals Goals need to be flexible to meet the patient’s needs, preferences, and lifestyle Goals need to be flexible to meet the patient’s needs, preferences, and lifestyle Education Education Education alone does not guarantee behavioral change Education alone does not guarantee behavioral change Assessment and goals are the basis for any recommendations Assessment and goals are the basis for any recommendations Dispel myths, redirect inappropriate habits, and provide new ideas Dispel myths, redirect inappropriate habits, and provide new ideas