NUTRITIONAL ASPECTS OF NUTRITIONAL ASPECTS OF DENTAL CARIES: CAUSES, DENTAL CARIES: CAUSES,
PREVENTION, AND TREATMENTPREVENTION, AND TREATMENT
CHAPTER 17CHAPTER 17
Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
22Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
PrevalencePrevalenceNutrients have topical and systemic effects that Nutrients have topical and systemic effects that
can be primary or secondary factors in the can be primary or secondary factors in the development of dental cariesdevelopment of dental caries
National Call to Action to Promote Oral Health National Call to Action to Promote Oral Health stresses preventionstresses preventionDental caries remain the most common chronic Dental caries remain the most common chronic
childhood diseasechildhood diseaseCertain racial, ethnic, and lower-income populations Certain racial, ethnic, and lower-income populations
suffer disproportionately higher rates of cariessuffer disproportionately higher rates of caries
33Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
PrevalencePrevalence
Caries rates rise with ageCaries rates rise with age28% of children ages 2–5 years28% of children ages 2–5 years49% of children ages 6–11 years49% of children ages 6–11 years68% of adolescents 12–19 years68% of adolescents 12–19 years75% of adults75% of adults
Prevalence of root caries also rises with agePrevalence of root caries also rises with age9.4% among persons ages 20–39 years9.4% among persons ages 20–39 years17.8% among those ages 40–59 years17.8% among those ages 40–59 years31.6% among those ages 31.6% among those ages >>60 years60 years
From Bird DL, Robinson DS: Torres and Ehlrlich From Bird DL, Robinson DS: Torres and Ehlrlich Modern Dental Assisting, ed 9. St. Louis: Saunders, Modern Dental Assisting, ed 9. St. Louis: Saunders,
2009.2009.
44Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
Major Factors in the Dental Caries Major Factors in the Dental Caries ProcessProcess
Caries results from a combination of Caries results from a combination of factors occurring simultaneouslyfactors occurring simultaneouslySusceptible host or tooth surfaceSusceptible host or tooth surfaceSufficient quantity of cariogenic Sufficient quantity of cariogenic
microorganisms in the mouthmicroorganisms in the mouthPresence of fermentable carbohydratesPresence of fermentable carbohydratesParticular composition or flow of salivaParticular composition or flow of saliva
From Darby ML, Walsh MM: Dental Hygiene: From Darby ML, Walsh MM: Dental Hygiene: Theory and Practice, ed 2. St. Louis: Saunders, Theory and Practice, ed 2. St. Louis: Saunders,
2003.2003.
55Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
Major Factors in the Dental Caries ProcessMajor Factors in the Dental Caries ProcessTooth structureTooth structure
Resistance against Resistance against demineralization begins demineralization begins in pre-eruptive phase in pre-eruptive phase with adequate intakes with adequate intakes of calcium; of calcium; phosphorus; vitamins phosphorus; vitamins A, C, and D; fluoride; A, C, and D; fluoride; and proteinand protein
Deep pits and fissures Deep pits and fissures increase susceptibilityincrease susceptibility
Overlapping/crowdingOverlapping/crowding
Host factorsHost factorsFood selection and Food selection and
dietary patternsdietary patternsOral hygiene habitsOral hygiene habitsGeneticsGeneticsRace or ethnic groupRace or ethnic groupAgeAgeSES (socioeconomic SES (socioeconomic
status)status)
66
Major Factors in the Dental Caries ProcessMajor Factors in the Dental Caries Process
SalivaSalivaAvailability of essential Availability of essential
nutrients nutrients (vit A, iron,protein) (vit A, iron,protein)
during development of during development of salivary glands salivary glands (begins in 4(begins in 4thth prenatal week)prenatal week)
Protection provided by Protection provided by adequate salivary flow toadequate salivary flow to
wash away food, buffer wash away food, buffer and neutralize acids, and neutralize acids, remineralize teeth remineralize teeth (calcium, (calcium,
phosphate, fluoride ions) phosphate, fluoride ions) and and kill bacteria kill bacteria (IgA) (IgA)
Plaque biofilmPlaque biofilmComposition of plaque is Composition of plaque is
altered and strongly altered and strongly influenced by dietinfluenced by diet
By-products of sucrose By-products of sucrose and glucose metabolism and glucose metabolism produce acids; lowers pH produce acids; lowers pH to 6.7-5.5to 6.7-5.5 to create to create environment for growth of environment for growth of bacteria, such as bacteria, such as S. S. mutans and Lactobacillusmutans and Lactobacillus
pH may reach as low as 4 pH may reach as low as 4 in some areas for 1 hourin some areas for 1 hour
77Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
Major Factors in the Dental Caries Major Factors in the Dental Caries ProcessProcess
Cariogenic foodsCariogenic foodsSalivary amylase breaks down oral monosaccharides Salivary amylase breaks down oral monosaccharides
(glucose) (glucose) and disaccharides and disaccharides (fructose, sucrose, maltose)(fructose, sucrose, maltose)
Sucrose is used to produce glucans Sucrose is used to produce glucans (polysaccharides) (polysaccharides) that that facilitate adherence of bacteria facilitate adherence of bacteria ((S.mutans)S.mutans) to the pellicleto the pellicle
Processed starches Processed starches (instant oatmeal) (instant oatmeal) are often more are often more fermentable than their nonprocessed counterparts due to fermentable than their nonprocessed counterparts due to partial hydrolysis or diminution of particle sizepartial hydrolysis or diminution of particle size
High concentration of fructose found in juices is potential High concentration of fructose found in juices is potential source of substrate source of substrate
88Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
Major Factors in the Dental Caries Major Factors in the Dental Caries ProcessProcess
Anticariogenic properties of foodAnticariogenic properties of foodSugar alcoholsSugar alcohols
Fermented more slowly than mono- and disaccharides; Fermented more slowly than mono- and disaccharides; therefore, buffering effects of saliva neutralize destructive acids therefore, buffering effects of saliva neutralize destructive acids produced by plaque biofilmproduced by plaque biofilm
Oral flora do not contain enzymes to ferment xylitolOral 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 sweetenersNonnutritive sweeteners Not metabolized by microorganisms; do not promote cariesNot metabolized by microorganisms; do not promote caries
99Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
Major Factors in the Dental Caries Major Factors in the Dental Caries ProcessProcess
Protein and fatProtein and fat Considered cariostatic because do not lowerConsidered cariostatic because do not lower
plaque pH, may offer buffering effectsplaque pH, may offer buffering effects
Phosphorus and calciumPhosphorus and calcium Provide a buffering effect in the salivaProvide a buffering effect in the saliva
Dairy products Dairy products Protein, Protein, caseincasein (principal protein in milk), phosphorus, (principal protein in milk), phosphorus,
calcium are ingredients of anticariogenic or even calcium are ingredients of anticariogenic or even cariostatic foods, such as cheese and milkcariostatic foods, such as cheese and milk
Although lactose is cariogenic (but the least cariogenic of Although lactose is cariogenic (but the least cariogenic of all saccharides), these other elements in milk and milk all saccharides), these other elements in milk and milk products decrease risk of dental caries products decrease risk of dental caries
1010Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
Major Factors in the Dental Caries Major Factors in the Dental Caries ProcessProcess
Other foods with protective factorsOther foods with protective factorsConstituent in chocolate, known as the Constituent in chocolate, known as the
cocoa factor, has shown anticariogenic cocoa factor, has shown anticariogenic properties in Vipeholm studyproperties in Vipeholm study
Glycyrrhiza, the active ingredient in Glycyrrhiza, the active ingredient in licorice, also anticariogeniclicorice, also anticariogenic
1111Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
Major Factors in the Dental Caries Major Factors in the Dental Caries ProcessProcess
Dental hygiene considerationsDental hygiene considerationsEncourage meticulous oral self-care, regular preventive Encourage meticulous oral self-care, regular preventive
dental visitsdental visitsPromote sealants for deep pits and fissuresPromote sealants for deep pits and fissuresIn high-risk patients encourage use of aIn high-risk patients encourage use of a
chlorhexidine, fluoride, xylitol protocolchlorhexidine, fluoride, xylitol protocolEncourage healthy eating habits with minimal Encourage healthy eating habits with minimal
fermentable CHO intake between mealsfermentable CHO intake between mealsEating low-fat cheese as snack or at end of a meal Eating low-fat cheese as snack or at end of a meal
could provide anticariogenic effectscould provide anticariogenic effects
From Bird DL, Robinson DS: From Bird DL, Robinson DS: Torres and Ehlrlich Modern Torres and Ehlrlich Modern
Dental Assisting, ed 9. St. Louis: Dental Assisting, ed 9. St. Louis: Saunders, 2009.Saunders, 2009.
1212Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
Major Factors in the Dental Caries Major Factors in the Dental Caries ProcessProcess
Dietary factors Dietary factors mustmust be modified to reduce the be modified to reduce the risk of caries. Dietary recommendations need risk of caries. Dietary recommendations need to address the following dietary factors:to address the following dietary factors:Frequency of eating meals and snacksFrequency of eating meals and snacksOral retentiveness of foods Oral retentiveness of foods (sticky, chewy, starchy)(sticky, chewy, starchy)Sequence of food consumptionSequence of food consumptionAmount of fermentable carbohydrate consumedAmount of fermentable carbohydrate consumedSugar or acid concentration of the food or drink itemSugar or acid concentration of the food or drink itemPhysical form of the carbohydratePhysical form of the carbohydrateProximity of eating to bedtimeProximity of eating to bedtime
1313Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
Major Factors in the Dental Caries Major Factors in the Dental Caries ProcessProcess
Physical formPhysical formLiquids include fruit juice, soda, sportsLiquids include fruit juice, soda, sports
drinks, energy drinks, liquid medicationsdrinks, energy drinks, liquid medications An acidic medium that further demineralizes An acidic medium that further demineralizes
the tooththe tooth Diet soft drinks contain added citric and phosphoric acidsDiet soft drinks contain added citric and phosphoric acids
Retentive CHOs include bakery items, crackers, Retentive CHOs include bakery items, crackers, potato chips, pretzelspotato chips, pretzels
Slowly dissolving CHOs include antacids, cough Slowly dissolving CHOs include antacids, cough drops, breath mintsdrops, breath mints
1414Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
Major Factors in the Dental Caries Major Factors in the Dental Caries ProcessProcess
Frequency of intakeFrequency of intakeLinear relationship between caries rate and number Linear relationship between caries rate and number
of meals and/or snacks consumedof meals and/or snacks consumed Each time a food containing carbohydrates is eaten, the Each time a food containing carbohydrates is eaten, the
salivary pH drops below the critical level for approximately salivary pH drops below the critical level for approximately 40 minutes 40 minutes
Enamel demineralization occursEnamel demineralization occurs Acid exposure is additive throughout the day Acid exposure is additive throughout the day Eventually demineralization progresses to the point at which Eventually demineralization progresses to the point at which
decay may be detected clinicallydecay may be detected clinically The calcium and phosphorus in saliva need time to The calcium and phosphorus in saliva need time to
remineralize the tooth between meals/snacksremineralize the tooth between meals/snacks
1515Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
Major Factors in the Dental Caries Major Factors in the Dental Caries ProcessProcess
Timing and sequence in a mealTiming and sequence in a mealAmount of acid is reduced if a fermentable Amount of acid is reduced if a fermentable
carbohydrate food is eaten before or between other carbohydrate food is eaten before or between other noncariogenic foods noncariogenic foods Dairy products, such as cheese, reduce demineralization of Dairy products, such as cheese, reduce demineralization of
the tooth and help buffer acids produced by the bacteriathe tooth and help buffer acids produced by the bacteria Sialagogues, like sugar-free chewing Sialagogues, like sugar-free chewing
gum, stimulate the saliva and gum, stimulate the saliva and promote buffering of acids promote buffering of acids produced by bacteria and aidproduced by bacteria and aidin oral clearance of the foodin oral clearance of the food
Coffee with sugar after a meal decreases pH which increases Coffee with sugar after a meal decreases pH which increases cariogenicitycariogenicity
1616Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
Major Factors in the Dental Caries Major Factors in the Dental Caries ProcessProcess
Dental hygiene considerationsDental hygiene considerationsReview diet history for patterns of fermentable Review diet history for patterns of fermentable
carbohydrate consumption, frequency, and formcarbohydrate consumption, frequency, and formConsume fermentable carbohydrates within a meal or Consume fermentable carbohydrates within a meal or
eat a noncariogenic food at the endeat a noncariogenic food at the endNoncariogenic snacks include raw fruits and Noncariogenic snacks include raw fruits and
vegetables; low-fat cheese, milk, and yogurt; nuts; vegetables; low-fat cheese, milk, and yogurt; nuts; popcorn; seeds; pizza and tacospopcorn; seeds; pizza and tacos
Encourage limiting of soft drinks and sports/energy Encourage limiting of soft drinks and sports/energy drinksdrinks
1717Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
Dental Hygiene PlanDental Hygiene PlanAssessmentAssessment
Gather information about the quality of the patient’s meal Gather information about the quality of the patient’s meal pattern and eating habits with a 24-hour diet recall or 3- pattern and eating habits with a 24-hour diet recall or 3- to 7-day food record to 7-day food record
Use MyPyramid as a guide to assess adequacy of food Use MyPyramid as a guide to assess adequacy of food intake with cooperation of the patientintake with cooperation of the patient
Have the patient highlight all the fermentable Have the patient highlight all the fermentable carbohydrates and note form, frequency, and when eaten carbohydrates and note form, frequency, and when eaten Estimate amount of time teeth are exposed to cariogenic foodsEstimate amount of time teeth are exposed to cariogenic foods More than 2 hours of acid exposure generally considered highMore than 2 hours of acid exposure generally considered high
1818Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
Dental Hygiene PlanDental Hygiene PlanGoalsGoals
Help patient develop realistic goalsHelp patient develop realistic goalsGoals need to be flexible to meet the patient’s needs, Goals need to be flexible to meet the patient’s needs,
preferences, and lifestylepreferences, and lifestyle
EducationEducationEducation alone does not guarantee behavioral Education alone does not guarantee behavioral
changechangeAssessment and goals are the basis for any Assessment and goals are the basis for any
recommendationsrecommendationsDispel myths, redirect inappropriate habits, and Dispel myths, redirect inappropriate habits, and
provide new ideasprovide new ideas