Diet and Dental Caries

Presented by : Dr Pawan Raj M.D.S II nd year

Definations Introduction Diet and Dental Caries Major factors in dental caries process Stephens curve Factors affecting caries process Dietry constituents and cariogenicity Food guide pyramid Sugar clocks Epidemiological human studies 1.Interventional human studies 2.Non interventional human studies Starch and Dental caries Cariogenicity of Food Can food be ranked acc to cariogenic potential

contents
Role of fats ,proteins &vitamins in dental caries

Artificial sweetners for reduction of dental caries

Soft drinks and beverages in dental caries Trace elements and its mechanism References

Definations
Diet :
Total oral intake of a substance that provides nourishment and energy (Nizel,1989)

Balanced Diet

It is one which contains varities of foods in such quantities & proportion that the need for amino acids,vitamins,fats,carbohydrates &other nutrients is adequetly met for maintaining health ,vitality & general well-being and also makes provision for a short duration of leaness(Chauliac,1984)

 Child diet

Combination of food consumed and the nutrients contained there in, which have a profound ability to influence cognition, behavior and emotional development in addition to ultimate physical growth & development (DCNA 2003)

Dental caries:
Dental caries is an irreversible microbial disease of the calcified tissues of the teeth, characterized by demineralization of the inorganic portion and destruction of the organic substance of the tooth , which often leads to cavitation

Introduction
Diet :plays imp role in which contribute to development
of caries
Dietry sugar : Most imp etiology of Dental Caries

Todays diet contains :

Multifaced

a) Fermentable carbohydrate b) High pronounced starch containing food c) Novel synthetic carbohydrate(oligofruct ose,sucrose,glucose d) Non cariogenic sweetners

strategy for caries control:

a) Oral hygiene

b) Use of flouride
c) Diet control

Diet and Dental caries

Frequent consumption of carbohydrate associated with prevalence of dental caries
Overall imp factor the events Dental Caries & Food consumption are that occur in evidently diff time periods

To determine the effect of diet :assessment of form & frequency of carbohydrate should be made earlier than clinical examination of caries 2nd problem :evaluating diet & caries in large intra individually and inter individually

Dietary sugars and caries

SUCROSE-ARCH CRIMINAL (Newbrun 1969) Effect on plaque substrate for cariogenic microflora Sucrose polymers bulk of plaque attachment of bacteria High free energy, high specificity of enzymes SUGARS THE ARCH CRIMINAL (zero 2004)

Diet
Extracelllular Storage polysaccharides

Sucrose + other carbohydrates Glycolytic metabolism

Adhesive Extracelluar polymers

Intracellular storage polysaccharides

ATP Lactic acid Co2 production production fixation

growth Biosynthesis of toxic macromolecules Plaque accumulation

Dental caries

Periodontal disease

 Diet and dental caries have several background factors:

a) b) c) d) e) f) Intake pattern Total food intake Salivary secretion rate Plaque composition Use of flouride Socioeconomic variable

Estimation of consumption based on supply data do not

take in account factors such as ; Age distribution Socioeconomic Ethnic Cultural differences

Relation of starch to Dental Caries ----> controversial

 Lingstrom et al 2000:
When evaluating starch in animal human plaque ph response in situ caries model studies Results: Processed food starches in mordern diet posses a significant cariogenic potential

Lingstrom et al 2000 studies on human provide unequivocal data on actual cariogenicity historical data->starch has low caries effect Moredern sources->starch contribute to caries development

Major factors in the dental caries process

Five Dental and oral environment factors :
1. 2. 3. 4. 5. Tooth chemistry Amount of salivary flow Types of Dental Plaque bacteria Type of fermentable carbohydrate eaten Frequency of daily food intake, especially the between meal snacks, are causative agents concerned with initiation and extension of dental caries

 Dental caries is caused by interaction between oral bacteria, their access to fermentable carbohydrates and vulnerable parts of the tooth. Classic graph which bears Stephan's name, shows the rapid drop in plaque pH after a glucose rinse The drop in pH is the result of fermentation of carbohydrates by some plaque bacteria. The gradual return of the pH is the result of buffers present in plaque and saliva. Provided the pH does not drop below 5.3 the enamel remains intact, but below this critical level, crystals of apatite dissolve (demineralise).

Stephens curve

 Fortunately both plaque and saliva are saturated with calcium and phosphate ions, so that if the pH returns fairly rapidly above the 5.3 level, ions will go back into the enamel and recrystallise (remineralise). Acid environments favour demineralisation and occur when there is a plaque biofilm, a supply of sugar for them and little saliva. Neutral or alkali environments favour emineralisation and occur when there is good oral hygiene, no sugar and plenty of saliva. The presence of fluoride ions in the tooth or in the plaque also help remineralisation to take place.

Factors affecting caries process

Caries results from a dietary disorder, the damage to the tooth is not done directly by the excess of sugar but a combination of factors which result from the excess. These include the effect of sugar on bacterial activity, time and the tooth environment

Dietary Constituents and Cariogenicity

Constituents :Polysaccharides & Sugars Starch

Glucose

4 sugars

sucrose

Fructose

Main polysaccharidestarch (not highly cariogenic)(cariogenic in some circumstances Japan & italy known to consume high amount of starch caries rate relatively low Studiesexcessive & frequent use of highly fermentable mono & disaccharides correalted with high caries rates

 Glucose,fructose,lactose and mannose-cariogenic bt minor constituents in human food Sucrose commenest dietary sugar

Physical properties of food and cariogenicity

Some important physical properties that determine food texture are: 1. Mechanical properties Hardness Cohesiveness Viscosity Adhesiveness 2. Geometric properties Particle size Shape 3. Others Moisture Fat content

Texture of food
Caldwell,1970 Texture of food & subjective descriptions of
food items by the use of terms as soft-hard,crumbly-brittle,tendertough,sticky-gooey,gritty-coarse,dry-moist arise from physical properties

Mcgregor,1958-physical properties of food have significance

by affecting food retention,food clearence,solubility & oral hygiene

Fibrous fruits & vegetables

High fibrous,cellulose content of plant food exerts a mechanical cleansing action on teeth &eating raw fruits & vegetables has long been recommended an aid to oral hygiene & caries preventive measure

 Slack and martin,1958-study on effect of apples & dental health gave indications of caries reduction other fibrous vegetables a celery also exerts mechanical cleansing effects & not strongly acidic as apples.

Physical texture and chemical composition

Effect salivary flow rates Flowing saliva more alkaline than resting saliva & more supersaturated with calcium & phosphate thus more caries inhibitory Those properties that improve cleansing action & reduce the retention of food within oral cavity & increases saliva flow encouraged everyday

Natural v/s processed foods

Natural,unrefined foods contain protective factors against dental caries. Studies showed-saliva incubated with refined foods caused a greater dissolution of tooth enamel than when incubated with unrefined foods. Mixtures that included bran,wheat germ & unrefined treacle & cane juice contained protective factors

Jenkins ,1966
Protective substance in cereals-PHYTATE a polyphosphate PHYTATE=when applied to tooth enamel reduces solubility & has caries inhibiting effect

Acidity of Foods
Acidic diet usually affect in transient manner ,ph in plaque and saliva. Natural foods such as lemons,apples,fruit juices and carbonated beverages sufficiently acidic demineraliztion of enamel Above items in normal dietary usage no influence on dental caries process Excessive usage of foods and beverages causes etching of enamel and cavitation Reports of excessive frequency of consumption of carbonated beverages,having a low ph ,continuous chewing & habitual sucking of lemons causes dental erosion

Food guide pyramid

Pictorial representation of UNITED STATES DEPT OF AGRICULTURES DAILY FOOD GUIDE Commonly used tool for planning healthful diet User friendly and offers people flexibility in planning a daily diet Varitions of the food guide pyramid exist over various populations such as elderly,vegetarian & peoplelderly ,vegetarian & people of diff ethnicities

Sugar clocks (S S Fuller & M Harding)

British Dental Journal 170, 414 - 416 (1991)

Important factor in the prevention of dental caries is limiting the number of times in a day that sugar enters the mouth.
simply illustrated by using the sugar clock.

Frequent eating Acid formation

The effectiveness of this as a technique for teaching 9-11year-old children the importance of limiting frequency of sugar intakes was tested in a controlled study.
Four weeks and 4 months after sugar clocks were used with a study group of children, they showed a significant increase over baseline in the number of correct answers given to a questionnaire. A control group showed no significant increase.

No acid formation

It was concluded that the sugar clock is an effective method of teaching the importance of limiting frequency of sugar intake to this age group

Epidemiological Human Studies

Shift towards habits & diets associated with urban living led to increase in dental caries Food consumed by mordern society compared with earlier periods charaterized as

a. Manufactured and more processed food

Primitive way Urban living

b. High take of refined flour c. Softer food consistency

 Starch consumed during earlier periods differ from highly gelatinized processed starch today constitute majority of mordern diet.

Rugg-gunn,1986 studies point out low caries prevalence during starch Schamschula ,1978
ed caries has been observed in relation to certain starches such as diet consisting frequent consumption of sago starch in grps of people in new guinea
Caries prevalence fall

Reduced refined carbohydrate

 toverud,1951
marked changes in intake of refined carbohydrate in europe and japan

In short Hopewood study Lonngitudnal study (australian children)

Reduction in sugar and sugary products

Diet given: lactovegetarian with minimum sugar and refined flour

Showed low caries prevalence as compared to control group Caries ed when children left home

Reduction in caries

 Newbrun et al,1980
a. 17 human subjects ,the sugar intake was 2.5g for H & 48.2g for control grp. Corresponding DMFT index 2.1 & 14.3 Both grps ate high levels of starch(160g/day in H grp & 140g/day in cntrl grp)

b. c.

Result consumption of starch did not appear to be conductive to caries development

INTERVENTIONAL STUDIES VIPEHOLM STUDY HOPEHOOD HOUSE STUDY TURKU SUGAR STUDY EXPERIMENTAL CARIES STUDY NON INTERVENTIONAL STUDIES EPIDEMIOLOGICAL STUDIES CROSS- SECTIONAL STUDIES OBSERVATIONAL STUDIES

Interventional studies
1) Vipeholm study, Lund (Sweden) 1945- 1954 1930,Hojer and Maunsbach, Gustafson 1954 Purpose- to determine the effects of frequency and quantity of sugar intake on the formation of caries. Institutionalized patients (436- 32yrs) were divided into 6 experimental and 1control group Poor oral hygiene, twice normal sugar

Seven groups
Control group - low sugar diet only at meals Sucrose group - high- sugar diet (300g) mostly in drinks with meals Bread group - sweetened bread at meals (sugar- or equal to normal) Caramel group- 22 sticky candies 2 portions at meals (carbohydrate study I) 4 portions between meals (carbohydrate study II) 8- toffee group 24-toffee group- throughout day, twice normal total intake of sugar Chocolate group- milk chocolate- 4 portions bet meals( CSII)

Studies were divided into 3 phases 1. clinical experimental studies of the relation bet diet and caries 2. Supplementary studies 3. Special studies (Hojer and Maunsbach 1954) Preparatory period (1945- 1946)

pts were selected, recording methods

I Clinical experimental studies

1) Vitamin study (1945-1946)
Vit A,C,D, 1mg Fl tab Basic diet- sugar (1/2) + starch = low caries

2) Carbohydrate study
To examine how caries activity was influenced by the ingestion of carbohydrates under controlled conditions

Study 1 (1947- 49)

SUGAR - solution/ sticky form at (new bread) /bet meals( toffees)

Study 2 (1949- 51)

Types of sweets were similar

Preparatory and vitamin period- low sugar= 0.34 carious lesions/pt/yr Carbohydrate I- twice the normal amt of sugar, only at meals Carbohydrate II- normal amt of sugar only at meals/ at and bet meals

Results
Little effect- sweet drinks with meals bread sugar in non sticky

Moderate increase in carieschocolate (4times) bet meals Dramatic increase- 22 caramels 8 / 24 toffees bet or after meals

Effect of frequency and CHO intake (Davies 1955)

3

NEW CARIOUS SURFACES /PERSON/YEAR

0 A B C D E

CONTROL GROUP The effect of frequency and form of carbohydrate intake on dental caries activity

Influence of carbohydrate type and frequency on Dental Caries

5 4.5 4 3.5 3 2.5 2 1.5 1 0.5 0

Coronal caries

Cementum caries

to ffe e8

Sugar with meals

ch oc ol at e ca ra m el 22

sugar with and bet meals

to ffe e2 4 po st st ud y

pr es tu dy

co nt ro l

br ea d

br ea d

su ga r

II Supplementary and special studies Supplementary study

Quensal et al 1954 reliability of the method in determination of caries, caries activity was statistically significant in all groups (sticky)

Special studies 1) Biochemical studies

(Lundquist 1952, Swenander lanke 1957) sugar content of blood and urine, pH viscosity, buffer capacity, cap conc in saliva and oral sugar clearance.

2) Microbiological studies
(Grubb and Krasse 1953, 1954) Differences in lactobacilli and carbohydrate caries promoting diet=>caries, high LB count

Other studies
a) Consumption of sweets and caries activity in school children an Hungarian farm workers-showed increase in caries with increase in high sucrose diet b) Studies on the inhibition of acid production by substance produced by chocolate bean showed significant decrease in caries and streptococcous mutans

3) Genetic study (Book and Grahnen 1953)

Parents and siblings of caries free recruits - low caries prevalence, no diff bet oral hygiene and dietary habits.

IMPLICATIONS All the sweets you like but only once a week sugar substitutes Malmo study 1976- consumption of sugar (sticky) form bet meals= >caries incidence + high LB count Vipeholm study - Citation classic

Conclusion
Increase avg sugar consumption(30-330g/day) showed very little increase in caries(0.27-0.43 cs/yr) provided additional sugar was consumed at meals in solution In patients with poor oral hygiene - caries Varies from person to person Subsides- withdrawal of sugar containing foods Great risk Sugar (retained on tooth surf) Greatest risk- bet meals, form Increase in duration of Sugar clearance from the saliva

Limitations
No possibility of matching the age Initial caries Mentally handicapped- instructions Dietary regimes of various groups

Hopewood study in Bowral, N.S.W, Australia

1942, 80 children, 7-14 yrs (10yr period) Vegetarian diet- carbohydrates (whole meal bread, whole meal porridge, biscuits, wheat germ, fruits ,vegetables, dairy products) 1948- 49 meat Vitamin concentrates, nuts and honey Unfavorable oral hygiene, insignificant fl, meals controlled = Toothsome diet

Results- 13yr old (DMF) -1.6(53%) HH

-10.7(0.4%) general

Heredity fructose intolerance

1st described in 1956 Autosomal recessive disorder of fructose metabolism associated with reduced activity of fructose 1 phosphate aldolase by 2.5%liver ,renal cortex & small bowel Following fructose intake,patient experiences nausea vomiting,excessive sweating,malaise ,coma & convulsions Patients tend to avoid all sweets and most of the fruits Patient able to take glucose ,galactose,lactose & starch containing foods Patient usually have teeth with extraordinary good condition

Caries if present limited to pits & fissures & usually not in smooth surfaces Indicative of starchy foods do not produce decay sugary foods do

Turku sugar study, Finland

(Scheinen and Makinen 1975)
AIM - To compare the cariogenecity of sucrose, fructose and xylitol. (1972-1974) BASIS- Xylitol is a sweet substance not metabolised by plaque organisms. 125 subjects (115), 27.6yrs (15-45yr) 3 groups sucrose (S), fructose (F) and xylitol (X) Examination- clinically, radiographically Precavitational and cavitational lesions primary and secondary caries

Results 1) Early white spot lesions Sucrose group- DMFS- 3.6 After 1 yr- sucrose and fructose= equal xylitol= no caries 2nd year- sucrose- increase fructose- unchanged Xylitol- zero Xylitol- non cariogenic / anticariogenic

2) Cavitation- low DMFS xylitol than sucrose and fructose.

Development of primary and secondary caries (24 mon)

Primary secondary

S- 7.2
F- 3.8 X- 0.0

10.5
6.1 0.9

Conclusion
Substitution of xylitol for sucrose in normal Finnish diet resulted in low caries incidence. Reduced the number of most microorganism

second 1yr trial

to test the effects of xylitol gum 102 subjects- 22.2yrs 2 groups (chewing gum) 1) sucrose (4.2 sticks/day) 2) xylitol (4.9 sticks/day) Saliva- remineralistion Xylitol- anticariogenic effect

IV. Experimental Caries Study

Von der fehr 1970-buccogingival enamel caries
23 days,50% sucrose solution (9 timesdaily) After 30 days- oral hygiene and fl rinses. Critical factor- duration and frequency

Loe et al 1972- 3 weeks, chemical plaque control twice daily

(CHX) but no Fl, no caries

Conclusion
Sugar is modifying risk factor Dental plaque is a etiological factor Clean teeth- no caries

Non interventional human studies

Subjects are free to choose whatever diet they please, correlation bet caries increment and dietary factor is low.

Based on dietary recall

No control over amount/ frequency of sugar intake

I. Epidemiological studies
Sugar consumption in selected countries in1977
Australia Finland Iceland Japan Canada China Cuba USSR Sweden Switzerland USA England

10

20

30

40

50

Consumption (kg/y) / person

Sugar consumption in Sweden 1960-1990

120 100 80 60 40 20 0 1960 1970 1980 1990

 During world war II in Europe and Japan wartime food restrictions 15kg- 0.2kg nutrition Marthaler 1967 (1941-1946)- less decay Sreenby 1982 international data 6yr (23 nations), 12yr (43 nations) <50gms- <3 DMFT

II. Cross sectional studies

Goose1967, Goose and Gittus 1968, James et al 1957, Winter et al 1966, 1971 labial incisor caries and sugared pacifiers

Granath et al 1976,1978- level of sugar-controoled, Fl was given Oral hygiene (6yr, 4yr)-result low caries prevalence
Hausen et al 1981 2000 finish school children, least caries prevalence- sugar exposure Marthaler 1990- sugar main threat Wendt et al 1995,1996- 700 infants,1-3yr Bottle fed/breast fed>12mon Less fl toothpaste Oral hygiene and diet-result :high caries prevalence

III. Observational studies

Axelsson and El Tabakk 2000- 685, 12yr old (period of
2yrs) with poor oral hygiene, sugar diet.

Rugg- Gunn et al (1984) North thumberland, England and

Burt et al 1988 in Michigan Assessed frequency and grouping of foods North Michigan thumberland
Duration age subjects Frequency of eating Diet diary Total sugars Caries incidence 2yr 11.5 456 6.8 t/d 15 day diary 118g/d 1.21 DMFS/Y 3yr 11-15 499 4.3t/d 3-10 day 142g/d 0.97 DMFS/Y

Starch and dental caries

Swenander lanke 1957 Dietary starch - mixture of starch products with apparently widely varying potentials to serve as substrates for bacterial acidogenesis in plaque and hence induce cariogenesis.

a) Intraoral bioavailability of starch Polymers of glucose Starch molecules- starch granules (grains and vegetables) Gelatinization (8-100 c)
Salivary

Starch

Bacterial amylase

Maltose + maltriose

dextrin and glucose (mormann and muhleman1981) Modifiers starch protein, starch lipid interactions

b) Applications to cariology
1)Starch consumption, frequency and retention
Stickiness of starches in human mouth
(Bibby etal 1957,Gustafson 1953,Caldwell 1975)

Kashket et al 1991 increased starch food particles related to increased caries Lingstorm et al 1997 high cariogenic potential

2) Studies of starch caries issues with humans

Classic vipeholm study Hopewood house experiments Turku sugar studies HFI individual study

Draw backs 1) Frequency of consumption 2) plaque pH lowering potential 3) bioavailability

Hopewood house study

Lacto vegetarian diet 3 meals with milk upon rising and milk/fruit after dinner Low caries Vs and HHS not caries inducive

Turku sugar study 3 groups- sucrose, fructose, xylitol Xylitol- little / no caries

Newbrun et al 1980
HFI (hereditary fructose tolerance)= little caries Little sucrose(2.5g/d), total carbohydrate (160g/d)

Rugg gun et al 1987 (2yr)

High starch/ low sugar diet- no reduction caries

Sreenby 1983, 1996- 12yr children

Various starches + little sucrose=low

Schamschula et al 1978 Starch diet+ sugar + frequency= caries

Studies of starch caries issue with animals

classic animal model (van Houte 1980,1994)

MS free rats fed with high sucrose diet sucrose replaced by starch fissure caries

Bowen et al 1980- starch sucrose diet

Processed starches Amylopectin and amylose Result - increased caries prevalence Firestone et al 1984- cooked wheat starches
pH remained low for longer periods

Starch and dental caries???

Non cariogenic or cariogenic Non cariogenic
Starch products can be , but frequently are not, as effective as sucrose in inducing enamel caries 1) lower bioavailability of starches 2) diminished delivery of glucose and maltose to plaque bacteria.

Enhanced retentiveness of starchy foods

It is premature to consider starches in modern diet as safe for teeth

Cariogenecity of foods

(ADA 1985)

Cariogenic potential- a foods ability to foster

caries in humans under conditions conducive to caries formation. (Stamm et al 1986) Diet counselling methods to assess Animal models, plaque acidity models, demineralization and in vitro models.

Influenced by- sugar content, protective factors,

consumption pattern and frequency (Bowen et al 1980)= CPI

Edgar 1985-

food factors- Amt and type of CHO, food

pH, buffer, consistency , retention in mouth, eating pattern, factors modifying enamel solubility.

Cultural and economic factorsavailability and distribution

Can foods be ranked according to their cariogenic potential??

Foods 2 categories ( Switzerland ) acidogenic / non- acidogenic 1. Cheddar cheese 2. non fat dry milk solution 3. 10% sucrose solution, fruit beverage 4. caramel. cracker, potato chip. SLS 5. Milk chocolate, sugar cookie, corn and wheat flake.

ch ee s e

m ilk be ve ra ge

su cr os e

ca ra m el

cr ac ke r

ch ip s

S LA S m ilk ch oc

co co

ok i rn f la w he a

ke tfl a

Minimum pH obtained with reference foods (schachtele and Jensen)

ke

Caries promoting potential

categories 1) Simple sugars Disaccharides Sucrose maltose 2) lactose Fermentable CHOpolysaccharides- starch examples Dextrin, corn syrup, fruit sugar, powdered sugar, honey CPP yes details Carbonated and bottle drinks, vegetables and processed foods with added sugars Galactose? Gelatinized

Milk sugar Cooked potatoes, rice, legumes, grains, cornstarch and bananas Cellulose, pectin, gums Sorbitol, mannitol, xylitol Lactitol,maltitol, HSH aspartame Saccharin Acesulfame sucralose

low yes

Non fermentable 1) fiber 2) Sugar alcohols High intensity sweetners 1)nuritive 2) Non nutritive

no

Grains, fruits, vegetables 30-90% sweet

no no

Food additives in desserts >200-700 times

Snack foods Acidogenic potential Edgar 1981

Group1 Least Acidogenic Beverages 1) Milk Fruit etc peanuts Baked goods sweets Sugarless gum

2) Chocolate

milk

apple

Bread , butter

Caramels Sugared gum Chocolate Orange jellies

3) Carbonated beverages

banana

Cream filled cakes ,sandwich cookies

4) Apple/orange juice

Dates Bread jam Raisins Sweet biscuits Sweetened cereal Apple pie Clear mints Fruit gums Fruit lollipops

5) 6)

Cariogenecity of foods
Based on acidogenic potential
Raw vegetables<nuts<milk<corn chips<fresh fruit<ice cream<French fries<dried fruit.

Retention
High sugar foods- caramel, chocolate bars Sucrose+ cooked starch

Cariogenecity- food composition, texture, solubility, retentiveness, and rate of salivary clearance than sucrose alone

Role of vitamins in dental caries

Vitamin B1- thiamine Caries promoting effect Vitamin B6 (pyridoxine) Cole et al 1980 reduce caries in rats High doses - drug (pregnant women and children) Local effect? Affect growth rates, metabolism and microbial composition of dental plaque (by stimulating/ inhibiting microbial species)

Role of fats in dental caries

Post eruptive consumption- reduce caries Mechanism ?? Protects the enamel surface by fatty film Reduces the contact bet CHO and bacteria Antimicrobial action? (Williams et al 1982) Replace carbohydrates (Michigan 1994) Rapid clearance of carbohydrates from oral cavity.

Role of proteins in dental caries

Shaw 1970 and Navia 1979protein deficiency during dental development in rats caries susceptibility Experimental and control rat pups on cariogenic diet Mechanism? Posteruptively direct action on plaque met Short exposure time in mouth Replace CHO weak proteolytic activity in mouth

xylitol
Metabolism by microorganisms- lacks enzyme to utilize xylitol Frequency 3 times a day Timing- long term

Caries prevention
Turku 1975- 90% reduced Gallium 1981- 70%- candies Isokangas 1987- gum Makinen et al 1995 (Belize study) pellet and sticky gums

sorbitol
Fermented by microorganisms (Slow- SM) Substrate for microorganisms Diffuses out acid Slack et al 1964- 48% reduction Birkhed and bar 1991- acidogenecity reduced Glass et al 1983,szoke et al 2001- gum Von loveran 2004- between /after meal

sweeteners
Non caloric Not fermented by oral microorganisms

Saccharin- (Grenby et al 1991) active cariostatic property Inhibit bacterial growth

Aspartame (NutraSweet)- reduce caries

SOFT DRINKS AND CARIES Potentially cariogenic 10% sucrose Carbonic and phosphoric acids- pH 2.4-2.5 (transitory) Oral sugar clearance is rapid Apple and orange juice- heavily buffered

Protective food components

Fluoride Phosphates- capo4 toothpaste, ACP-CPP Fatty acids- replace carbohydrates (Michigan 1994) Arginine rich peptides and pyridoxine (basic) Calcium lactate Dietary acids and flavors (foods and beverages) Tea and starch Aged cheddar cheese- antiacidogenic effect Chocolate ad extracts, glycyrrhizin/ liquorice Sugar substitutes

Trace elements
Trace elements in diet can be cariostatic or caries promoting Grpd in to a. Cariostatic Fl,P b. Midly cariostatic Mo,V,Cu,Sr,B,Li,Au,Fe c. Doubtful cariostatic-Be,Co,Mn,Sn,Zn,Br,I,Y d. Caries inert Ba,Al,Ni,Pd,Ti e. Caries promoting Se,Mg,Cd,Pt,Pb,Si

Trace elements divided in to 2 categories 1.Those that have well defined human requirements,namely iron,zinc,iodine,copper,flourine 2.Those that are integral constituents or activators of enzymes namely manganese ,molybdenum,selenium,chromium ,cobalt

Possible mechanism of trace elements

Altering the resistance of the tooth itself or modifying the local environment at plaque-tooth enamel interface

Acts like flouride ,other elements can modify the physical and chemical composition of the teeth thus affecting the soluability of the enamel to acid attacks

References
Understanding dental caries-Niki foruk Dental caries-The disease and its clinical management-Ole Fejerskov & Edwina Kidd Nutrition in clinical dentistry 3rd edition-Athena Papas(nizel) Textbook of Pedodontics 2nd edition Shobha Tandon Laura M.Romito.Nutrition and oral health .The Dental clinics of North America2003 vol 47(2) S S Fuller & M Harding The use of the sugar clock in dental health education British Dental Journal 170, 414 - 416 (1991)

Applied Oral Physiology - The Ecology of the Mouth chap 4