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Diet, Fluoride, and Dental Caries
The University of Sydney
Wendell Evans BDS MDS DDSc FICD
Population Oral Health
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.
FAO (Food and Agriculture Organsiation - United Nations 1960
DMF* Teeth *Decayed, Missing, Filled
Annual sugar use (kg)
Age 11-12 years
Jenkins GN. The physiology and biochemistry of the mouth, 4th Edition. Oxford: Blackwell Scientific Publications, 1978. Page 388.
Dentalplaque pH
Minutes
10% glucose rinse
Critical pH for tooth enamel dissolution
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. Acta Odontlogica Scandinavica 11:232-364.
Gustafsson et al. (1954). The Vipeholm dental caries study. Acta Odontlogica Scandinavica 11:232-364.
Sugarconsumed
gm per day
300
200
100
0 Liquid
24 toffees
NewDMFTperyear
4
3
1
0
The Dental Caries Experience of the Children ofHopewood House
Bowral, NSW
Lilienthal et al Med J Aust, June 1953
Hopewood House
82 Children aged 4-9 years
Investigators
Paediatricians
Dental scientists
Findings
• well nourished• healthy
• very poor oral hygiene• no dental caries
Lilienthal et al Med J Aust, June 1953
12
10
0
4
2
6
8
New Zealand
Sydney Bowral
HOPEWOOD HOUSE
BOWRAL, NSW
DMFT of children aged 6 – 9 years
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 ofrefined 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.
.
• 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.
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)
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
1.2 ppm
0.0 ppm
Source: McClure FJ. Water fluoridation: The search and the victory. Bethesda: National Institute of Dental Research, 1970.
0.1 ppm1.0 ppm
1.2 ppm
Permanent teeth DMF reductions at Grand Rapidsafter 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.
Australian12-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 theBlue Mountains reduces riskof tooth decay
RW Evans1, A Hsiau1, PJ Dennison1, A Paterson2, and B.Jalaludin2
Australian Dental Journal 54: 368-373, 2009
0
0.5
1
1.5
2
2.5
3
Blue Mountains
Hawkesbury
1993 2003
Meandmft
2.58a
0.69b
1.100.71
A = a = 135% more than Hawkesbury at baselineb = 73% less than Hawkesbury at baseline
Primary teeth Caries experience of lifelong
residents aged 6 – 8 years
RW Evans1, A Hsiau1, PJ Dennison1, A Paterson2, and B.Jalaludin2
1Community Oral Health and Epidemiology, 2Formerly NSW Health
0
10
20
30
40
50
60
70
80
90
100
1993 2003
Primary teeth Percent of lifelong residents
aged 6 – 8 years with no decay
62%71%
38%
72%
Blue MountainsHawkesbury
RW Evans1, A Hsiau1, PJ Dennison1, A Paterson2, and B.Jalaludin2
1Community Oral Health and Epidemiology, 2Formerly NSW Health
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
Blue Mountains
Hawkesbury0.87a
0.22b
0.58
0.36
PERMANENT TEETH Caries experience of lifelong residents aged 9 – 11 years
a = 50% more than Hawkesbury at baselineb = 75% less than Hawkesbury at baseline
MeanDMFT
1993 2003
RW Evans1, A Hsiau1, PJ Dennison1, A Paterson2, and B.Jalaludin2
1Community Oral Health and Epidemiology, 2Formerly NSW Health
Blue MountainsHawkesbury
PERMANENT TEETH Percent of lifelong residents
aged 9 – 11 years with no decay
0
10
20
30
40
50
60
70
80
90
100
1993 2003
61%
87%
71%
81%
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
Dietary challenge
Caries risk
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 access to saliva
Better oral hygiene
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.
Caries risk
Dietary challenge
Better use of fluorides
Better access to saliva
Better
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 access to saliva
Better use of fluorides
Better oral hygiene
For reduced dietary challenge
For reduced dietary challenge
Better access to saliva
Better use
Better
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.
Scope to reduce caries risk is limited
Better use of fluorides
Better access to saliva
Better oral hygiene