100% preventable: dental caries and other oral diseases

100% preventable: dental caries and other oral diseases

Start by eating right and end by cleaning right. 


The role of diet in caries aetiology :

  • While some authors have emphasised the importance of the dental biofilm and others dietary sugars, both are essential primary etiological factors driving caries expression, and one cannot cause caries in the absence of the other. 
  • Diets high in proteins and fats favour a more neutral biofilm pH. High-protein diets increase the urea concentration of saliva which can be converted by ureolytic bacteria to ammonia; this raises the biofilm pH and is associated with decreased caries risk. 
  • Frequent and prolonged lowering of biofilm pH as a result of excessive consumption of dietary sugars favours the growth of the more acid-tolerant (aciduric) bacteria, such as S. mutans and lactobacilli, which are also highly acidogenic. Therefore, the frequent consumption of sugar- containing foods and beverages gives a selective advantage to these cariogenic bacteria, allowing them to increase in number at the expense of other acid-sensitive biofilm bacteria that are less pathogenic. 
  • Coarse diets (high-fibre) stimulate salivary gland function, whereas a soft or liquid diet leads to atrophy (decline in effect) of the salivary glands and diminished salivary gland function. 
  • The longer a food containing fermentable carbohydrate is retained
    in the mouth, the longer there is substrate for acid formation and for this reason the retentive properties of food is considered an important factor its cariogenic potential
  • Complex carbohydrates (starches) are considered less cariogenic than the simple sugars (sucrose, glucose, fructose), with sucrose being the most cariogenic because of its unique role in the production of extracellular glucans. 
  • Starches are not readily soluble in oral fluids and have a low diffusion rate into the dental biofilm. They also must be broken down to maltose by salivary amylase before biofilm bacteria can use them. 
  • Most starch is cleared from the mouth before it can be broken down. However, most all modern processed foods contain a combination of starch and sugar and can be highly cariogenic due to prolonged retention in the mouth. 
  • Sucrose represents the main source of sugar in the diet and has been implicated as an important determinant of dental caries.
  • Similar to other simple sugars (glucose, fructose, maltose), sucrose is freely diffusible in dental plaque biofilm and readily metabolised by oral bacteria. 
  • However, sucrose has the unique property in that it is the main dietary substrate involved in the synthesis of soluble and insoluble extracellular glucan by glucosyltransferases (GTFs) from S. mutans. There are several mechanisms to explain the role of extracellular glucans as the major caries- associated microbial virulence factor. There is evidence that their presence in plaque promotes bacterial adherence to the tooth surface and contributes to the structural integrity of dental biofilms. Studies using an in situ caries model have shown that the presence of insoluble glucan markedly enhanced demineralisation potential of S. mutans test plaques. The effect has been attributed to an alteration of the diffusion properties of plaque, allowing deeper penetration of dietary carbohydrates.
  • A recent systematic review has concluded that caries is much less likely to occur in the absence of dietary free sugar intake above a threshold of
    5% of energy intake.

((PAPER:  Caries Prevention Partnership: White Paper on Dental Caries Prevention and Management))

Diet :

  • The frequency of meal and property of food influences the cariogenicity of patient’s diet. The consistency and temperature of food can affect the oral clearance from the mouth. Oral sugar clearance is the reduction in the concentration of sugars in saliva and is known as the strong predictors of the prevalence of dental caries. 
  • Clinicians should realise that patients eating or dietary habits are dependent on many factors such as socioeconomic status, cultural ethnicity, cost and availability of food.
  • At a minimum level, clinicians should asses for diet risk factors such as amount and frequency of the sugars and fermentable carbohydrates intakes and promote consumption of sugar substitute and health promoting snacks and meals.
  • Recommendation of healthy snacks related to oral health will also help patient in reducing their risk level.

    ((PAPER: Caries management strategies by risk assessment-prevention and treatment))

  • The main cause of tooth loss is dental caries in which diet plays an important role.

The impact of dental diseases on quality of life :

  • Despite a low mortality rate associated with dental diseases, they have a considerable impact on self-esteem, eating ability, nutrition and health both in childhood and older age.
  • In modern society, the most important role of teeth is to enhance appearance; facial appearance is very important in determining an individual’s integration into society. Teeth also play an important role in speech and communication. The second International Collaborative Study of Oral Health Systems (ICSII)7 revealed that in all countries covered by the survey substantial numbers of children and adults reported impaired social functioning due to oral disease, such as avoiding laughing or smiling due to poor perceived appearance of teeth. Throughout the world, children frequently reported apprehension about meeting others because of the appearance of their teeth or that others made jokes about their teeth. In addition, dental diseases cause considerable pain and anxiety. These factors are likely to be exacerbated in less developed societies where pain control and treatment are not readily available. For example, in Thailand, half the children of age 12 claimed pain or discomfort from teeth and 40% of children had tooth extraction at their last visit to the dentist. Similar patterns are observed in other countries such as China, Jordan & Madagascar. 
  • Dental decay also results in tooth loss, which reduces the ability to eat a varied diet (Deficiencies of vitamin D, vitamin A and protein energy malnutrition (PEM) have been associated with enamel hypoplasia. PEM and vitamin A deficiency are also associated with salivary gland atrophy which subsequently reduces the mouth’s defence against infection and its ability to buffer plaque acids. ) 
  • Tooth loss may, therefore, impede the achievement of dietary goals related to the consumption of fruits, vegetables and NSP. Tooth loss has also been associated with loss of enjoyment of food and confidence to socialise.

Dental caries :

  • The deciduous teeth erupt from 6 months and are lost by the early teens. The permanent dentition replaces the deciduous dentition from the age of 6 years and is complete by age 21. 
  • Teeth are most susceptible to dental caries soon after they erupt; therefore, the peak ages for dental caries are 2 – 5 years for the deciduous dentition and early adolescence for the permanent dentition. 
  • In the absence of dietary sugars, undernutrition is not associated with dental caries. Undernutrition coupled with daily increased amount and/or frequency of sugars results in levels of caries greater than expected for the level of sugars intake. 
  • Saliva promotes remineralisation. Saliva is super-saturated with calcium and phosphate at pH 7; this favours the deposition of calcium. If a demineralised lesion is formed it will be remineralised; although this is a slow process that competes with factors that cause demineralisation. If the pH in the mouth remains high enough for sufficient time then complete remineralisation of enamel may occur. 

(( PAPER: Diet, nutrition and the prevention of dental diseases))

  • In general, evidence suggests that the use of sugar-free chewing gum immediately after meals reduces carious lesion progression; That the use of chewing gum containing xylitol should be part of a strategy for carious lesion control in schools and that the provision of xylitol-containing gummy bear snacks is feasible. 
  • The last can be implemented, with good compliance from both children and parents, in a caries-control regimen at schools. Although the consumption of xylitol-based candies and lozenges favours a reduction in carious lesion increment, in general, this effect is not seen on approximal (in-between) tooth surfaces. 
  • A side-effect of sugar-free candies and gums is their potential to cause dental erosion due to acidic flavouring agents.

((PAPER: Minimal intervention dentistry for managing dental caries – a review ))

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