Cariology Exam One [Diets and Caries Marshall]

What is the difference between sugar and sugars

Sugar refers to sucrose

Sugars refers to monosaccharides and disaccarides

What is the difference between nutritive and non-nutritive

Nutritive = Ones you get calories from

Non-Nutritive = Ones you don't get calories from

Define Refine

to bring to a pure state; free of impurities

EX/

Field corn

- Cornmeal

-- Cornstarch

--- Corn syrup

---- HFCS

In each processing step of refining

We remove fiber and nutrients and we concentrate the simple sugars

With respect to caries: Each step of refining

Decrease the workload for the bacteria. Increasing the bioavailability of the sugar or starch

Make easier for them to ferment the carbohydrates

Modified starches

modified for a specific function/ quality for food products - very intentional by food industry

Used as

- Thickeners

- Stabilizers

- Binders

- Emulsifiers

Modified starches: How did we modify

- Oxidized, hydrolyzed by acid, gelatinized

- Chemical structure changed

- Effectively reduced the number of steps before the "starch" is cariogenic

Observational studies

The investigator watches whats going on. There is no intervention

In observational studies the focus is mainly on sugar (Ie. change in sugar intake). But it may not just be the sugar because

other things may be going on in the patients environment

DMFT

Decayed missing filled teeth

DMFS

Decayed missing filled surfaces

STUDY: Sugar intake vs caries prevalence

Design:

- Comparison of sugar availability and the DMFT scores of 12 year old children by country

- Left hand side we see sugar supply

- Right hand side DMFT

We see:

- As you increase sugar you see an increase in the DMFT scores

Supports the hypothesis one may see more caries

STUDY: Caries prevalence before and after sugar introduction

Design:

3 Inuit communities

- 2 (Point Ley and Point Hope) had sugar and white flour prior to 1950

- Anaktuvuk- Sugar and white flour were introduced in 1953

Two things to look at here

- Anaktuvuk that recently got the sugar introduced had lower caries (DMFT) for all ages in 1955/57 then the other two areas

- With time and that sugar exposure their caries increase to a comparable amount to the other sites

Takeaway:

1. Individuals moving to the states from developing countries and adapting our diets are at a higher risk of caries then they were at their home country

2. Developing countries where we export our highly processes foods we are exporting caries and obesity

STUDY: Caries prevalence before and after sugar introduction

Design:

Tristan Da Cunha

- Island store began carrying sugar and refined flour in 1940

- Mean daily sugar/flour consumption increased from 4.2 g/day (1938) to 350 g/day (1966)

All groups you can see an increase in DMFT with time and exposure

Concern with diets where we introduce sugar is we get entire cultural changes. Hard to tease out sugar from overall diet processing as well as lifestyle factors

STUDY: Caries prevalence on diets low in sugar: population living within "westernized cultures"

Hopewood house, South Wales, Australia

Design:

- Birth-12 years: lactovegetarian diet emphasizing whole grains, raw vegetables and minimal sugar or white flour

- 12 years: "westernized" diet of local community

*definitely important for exam*

While they were at Hopewood house with very little sugar or flour (0-10) the Hopewood house had significantly less DMFT (lack of exposure was protective)

at age 12 they moved and adapted the diet of their peers: Their caries rate paralleled their peers.

Takeaway:

- The limited exposure to sugar and refined flour was protective while it wasn't there but it did not offer lifelong protection of caries

STUDY: Caries prevalence on diets low in sugar: populations living within "westernized" cultures

Hereditary fructose intolerance

- Inborn error of metabolism- can't split fructose

Image shows individuals who have the disorder and their DMFT scores

- Kids typically avoid sugar and results in less DMFT.

- Some of the results are from individuals who were forced to eat sugar as kids

Caries prevalence on diets high in sugar

- Employees of the confection industry

Sweets industry vs Textile industry

Sweets industry: In time there is an increase in caries prevalence

Textiles industry: No real increase in caries over time and also is less then those in the sweets industry

Frequency of any food or beverage intake on caries outcome

- Contemporary society

- Hour intervals

STUDY: Cross sectional

Young kids who were either caries free or had severe early childhood caries requiring surgical treatment

Takeaway:

With increasing number of exposures we see an increasing number of children with early childhood caries and a decreasing in those without early childhood caries

Cross Sectional study:

Sugar Sweetened Beverages and Early Childhood caries

Subjects:

2-6 year old, healthy children

- caries free

- SECC: 3+ smooth surface lesions with 1+ pulpal involvement

Exposure:

Tools: 24 hour recall and Block FFQ

- 100% fruit juice

- SSB

- Eating occasions

Outcome

- Caries

Takeaway:

Regardless of how they looked at it the factor that increased caries risk was the sugar sweetened beverages (SSB)

Did not see a major impact from the fruit juice or the eating events

STUDY: Dr. Levy's IFS data (longitudinal/cohort)

Strength: Having exposure data before outcome

Caries at 17 years: lifelong impact of beverages - fluoride- toothbrushing

Objective:

Investigate associations between childhood and adolescent beverage intakes and age 17 caries experience, while adjusting for fluoride and toothbrushing

Exposure:

- Beverage intakes

- Toothbrushing events

- Fluoride

Outcome:

- Caries experience adjusted for surfaces

-- DFSAR

Data before adjustments

Takeaway:

The juice and the water seemed to protect against the caries where the SSB increased the risk of caries

Levy's study: After adjusting for all the other stuff

Adjusted for:

- Beverage intake

- Total fluoride excluding ssb

- Toothbrushing

- Sex and SES

Takeaway:

- The SSB increases caries

Why was juice protective

- Nobody knows

OBSERVATIONAL STUDY SUMMARY: Sugar consumption is

positively associated with caries incidence

OBSERVATIONAL STUDY SUMMARY: Diets high in _________ offer current, but not future, protection against caries

unrefined carbohydrates

OBSERVATIONAL STUDY SUMMARY: Consumption _______ is positively associated with caries risk

frequency

OBSERVATIONAL STUDY SUMMARY: Added sugar sweetened beverages are _______ associated with caries risk

positively

Clinical studies

- Clinical= humans were involved

- Clinical studies are a type of experimental study.

- Experimental implies that the investigator is in charge- there's an intervention or a challenge of some sort

STUDY

Vipeholm, Sweden

Objective:

Determine how caries incidence is influenced by

- Mealtime exposure to non-retentive sugars

- Mealtime exposure to retentive sugars

- Between meal exposures to retentive sugars

Design:

- 960

- Mental hospital with 12 wards (4 wings and 3 floors); diets assigned by ward (no sharing)

*Definitely on exam*

Total DMFT scores including existing lesions

Straight lines: at and between meal exposures

Dotted line: meal exposures

Takeaway:

- When you have the at and between the slope is much higher than when just exposures during meals. This suggests that:

1. Between and at meals increase risk

2) At meals only not so much

Vipeholm but only looking at new lesions

Again

Just at meals not as much of an increase as between and at meals

Big summary of Vipeholm study

1. Sugar at meals- minimal impact on lesions

2. Sugar at and between meals- major impact on caries

3. (not shown) but not everyone gets caries and a few get caries with minimal carbohydrate exposures

STUDY

Turku, Finland

Objective

To determine the effect of total substitution of fructose or xylitol for sucrose on dental caries

Design:

- Volunteer, adult subjects

- Secondary gum trial

Image depicts sugar intake according to diet over a two year period

at the beginning every ate a lot

Takeaway:

Sucrose/fructose higher than xylitol because xylitol tastes not as good and Gi tolerance is not as good

Takeaway

Turku Finland DMFT

Those who received the sucrose and fructose diets had much higher DMFS scores than those on xylitol

Technically there is no difference between sucrose and fructose

Turku gum trial

- Because Xylitol had less caries wanted to see if it was protective

Design:

- Chewing four sticks of gum per day

- Either sucrose or xylitol gum

Sucrose: Definitely see increase in caries

Xylitol: See a slight decrease in caries (is it due to remin??? we don't know yet)

CLINICAL STUDIES SUMMARY: Sugar consumption with meals is associated with

a slight increase in caries

CLINICAL STUDIES SUMMARY: sugar consumption with and between meals is associated with a

substantial increase in caries

CLINICAL STUDIES SUMMARY: Individual variability in caries susceptibility

exists

CLINICAL STUDIES SUMMARY: Increased caries incidence disappears with

sugar removal

CLINICAL STUDIES SUMMARY: caries do occur

without sugar

CLINICAL STUDIES SUMMARY: substitution of sucrose by sugar alcohols is associated with

reduced caries incidence

CLINICAL STUDIES SUMMARY: Substitution of sucrose by other sugars

does not reduce caries

Animal studies

Also an experimental study but uses animals instead of humans

Advantages:

- More invasive

- Shorter lifespans

STUDY:

Research questions:

1) Is exposure of the teeth/plaque to the substrate required for caries formation

- Local vs systemic

2) Does the presence or absence of saliva impact the process

Design:

- Cariogenic diet by mouth or GI tube

- Removed salivary glands

Points to note:

- Tube feeding = 0 caries (localized effect not systemic)

- Decreased saliva = increase severity of caries (saliva is protective)

STUDY

Research question:

- Can you produce caries in a germ-free environment

Design

- Cariogenic diet with no bacteria in the system

- Normal rats

- Germ free rats

- Compare the rats

Take home:

- No bacteria = no caries

- Have to have cariogenic bacteria for caries

STUDY

Research question:

- How does the frequency (number of exposures) of feeding and the volume of intake affect caries development?

Design:

- Fed rats ad lib or at set volumes at specific time of the day

- Restrict the intake the rats they will eat it all at once

- If you feed plenty theyll nibble throughout the day

Takeaway:

- Same amount consumed but increasing frequency of exposure = increased caries

- Saturated effect at 24 exposures

STUDY

Research question:

- Is the concentration of sugar associated with caries formation

Design:

- Provided diets with different sugar concentrations in the presence of bacteria

Circle = smooth surface caries

Squares = pit and fissure

^^^ not important^^^

Takeaway:

- Increase the concentration of sugar = increase in caries for both types of lesions.

ANIMAL STUDIES SUMMARY: Effects of dietary sugar are

local, not systemic

ANIMAL STUDIES SUMMARY: Feeding frequency is _______ associated with caries incidence

positively

ANIMAL STUDIES SUMMARY: Sugar concentration is __________ associated with caries incidence

positively

ANIMAL STUDIES SUMMARY: All sugars are

highly cariogenic

Enamel slab experiments (also called in situ)

- Not quite clinical studies and allow more flexibility from an ethical perspective

- Individuals wear appliances containing enamel from extracted teeth in their mouths (or other test material)

- The enamel is then exposed to experimental conditions

PROS and CONS of Enamel slab experiments

Pro:

- mimics life

- intra oral environment

- ethics

- Not damaging real teeth

Cons:

- Not quite in vivo

ENAMEL SLAB EXPERIEMENTS SUMMARY: Fermentable sugars cause:

Non-fermentable sugars

Fermentable sugars cause demineralization

Non-fermentable sugars aid remineralization

ENAMEL SLAB EXPERIEMENTS SUMMARY: Sugar concentrations and exposure frequency increase

demineralization

Plaque pH Studies

Experimental clinical study

Micro electrodes are placed in the mouth at the tooth surface and pH changes are measured in response to a challenge (food, meal, nutrients)

Stephan Curve

*Important for exam*

Plot of the pH of plaque vs time

1. Fall of pH representing speed of sugar metabolism (acid production)

2. Rise in pH represents removal of acids

- Salivary clearance

- Saliva buffering

- Acid leaching from plaque

3. pH then returns to normal

4. 5.5 (dotted line) is the critical pH where demineralization begins

- there is individual variance as to exact pH where things change

How food impacts pH:

E = sugared coffee alone

F = Sugared coffee and 2 nonacidogenic foods (eggs and non crisp bread)

Takaway:

- The drop was blunted when nonacidogenic food was consumed with the acidic coffee

How food impacts pH-

A = Sugared Coffee immediately followed by egg and toast

D= Sugared coffee with egg and toast after 5 minute wait

Takeaway:

- Delay in solid food delays pH rise

- How one eats impacts acid production and length of time below the curve

PLAQUE pH STUDIES SUMMARY: The acidogenicity, not _____, of various foods, drinks and meal patterns has been determined

cariogenicity

PLAQUE pH STUDIES SUMMARY The critical pH is

5.0-5.5

Incubation studies

- In vitro

- Experimental

- Assess the ability of microorganisms to ferment food (produce acid)

- Test food incubated with plaque/saliva in test tube

- Results consistent with other science

INCUBATION STUDIES SUMMARY: All fermentable sugars can be fermented by

plaque microorganisms

FOOD AND CARIES

FOOD AND CARIES

Fat, protein, non-nutritive sweeteners are not

substrates for bacteria -- will not result in acid production and thus no caries risk

STUDY

Palmer: Diet and ECC

Subjects:

2-6 year old, healthy children, Boston Area

- Caries free

- Severe early childhood caries

Exposure:

24 hour recall: meal patterns, food intake

Outcome:

Caries

Design:

Foods grouped by composition:

- protective (nuts cheese xylitol)

- non-cariogenic (protein and fats)

- Low cariogenicity (starches, fruits, vegies, milk)

- Liquids (sugared beverages)

- Solid/ retentive (bread, chips, cereal, cookies)

Estimated cariogenicity scores/foods and beverages

Takaway:

1. Kids with ECC had more

- Sugared liquids

- Solid/retentive foods - highly processed

2. Total number foods higher in kids with ECC

3. More frequent exposure

Sugared beverages and your processed snacks increase your risk for caries

CARIES RISK BASED ON FOOD COMPOSITION SUMMARY

If a food has Carbohydrates:

But also has Protein/ fat:

- Worst case is it will be neutral

- If calcium = protective

But also has Starch:

- Complex = Neutral

- Processed = significant risk

But also has sugar:

- High risk

Risk is associated with susceptibility but note eating habits (frequency) increase risk

Food sugars

- Mono/Disaccharides

Fructose

Glucose

Sucrose

Lactose

Maltose

Starches

-Polysaccharides

Raw, Cooked (fine)

vs

Baked with sugars (bad)

Processed starches

- Not quite sugars (oligosaccharides):

Dextrins

HFCS

Maltodextrin

Modified starches

Natural/ Food sugars

Honey

Raw sugar

In respect to natural sugars bacteria

could not care where the sugar came from

STUDY: Starch intake and caries

Design:

- Longitudinal (11 year follow-up)

- Had a huge distribution of starch intake per day so were able to look at a big difference

Subjects:

- Finish adults (30-88)

Exposure:

- Starch

- Starch-rich foods (potatoes, tubers, pasta, etc)

Outcome:

- DMFT score

Takeaway:

Weather they looked at the starch (g/day) or the percent energy they found that:

Starch is not associated with dental caries (this is your unprocessed starch products)

Caries risk by food group

Basically the more bioavailable the CHO

the more cariogenic

4 factors that impact the bioavailability

+- CHO

+- protein/fat

Level of processing

Sugar concentration

Risk ratio when having a higher intake of ultra processed foods

71% increase risk of caries

Clearance time impacts

Oral motor skills

- Individual coordination

Food's physical properties

- Retentive/sticky

- Liquid

- Readily dissolved

Resting salivary rate

Induced salivary rate

Self Cleansing foods

Foods that clean the teeth (apples/celery/carrots)

- Plaque accumulation: fibrous foods do help prevent accumulation. Tend to see increase in plaque on soft/liquid diets

- Salivary flow: decrease plaque accumulation

- Mastication demands: decrease plaque accumulation

Do self cleansing foods remove plaque

No sir: you have to brush your silly little teeth to remove plaque

Buffering agents

Saliva (need adequate nutrients to produce healthy saliva)

- anything chewy will stimulate saliva

Peanuts and cheese: High fat and cheese has Calcium

Sugarless gum vs Sugared gum

- Increase pH with sugarless gum

- Fairly blunted fall with sugared gum

Takeaway:

- the chewing isn't really helping if you are constantly reapplying the sugar gum

Sequence of Foods

How we eat are food is important

Pears= control

- eat pears pH falls then returns to normal

If we follow a pear with sugared coffee the pH stays down longer before returning to normal

If we follow a pear with the cheese it won't fall as far because the cheese is protective

Takeaway:

- Combination of foods modify the cariogenicity of the pear

Composition of foods

Peanuts - no substrate

Chocolate- substrate and fat

Apple- substrate + chewing/friction

Coffee- only substrate

Mixed diets are thought to be protective against caries

STUDY: Sugared snacks followed by beverages

Objective:

Identify if plaque acidogenicity differed in response to different beverages after a sugary snack

Methods:

Clinical trial with 20 healthy adults

Design: Intervention #1

-- Fruit loops

-- 10% sucrose rinse

-- 10% sorbitol rinse

Outcome

- Plaque pH

Results:

Sorbitol: No impact on plaque pH

Sucrose: Fell but since it was just sucrose it was cleared relatively quickly

Fruit loops: with the starch still hanging out on the teeth and stayed longer

Design: Intervention #2

- Fruit loops

-- Whole milk

-- 100% apple juice

-- Tap water

Outcome

- Plaque pH

Results:

Water: pH increased a little after milk

Milk: pH increased faster (returned to normal quicker when you have the fat and calcium in milk)

Apple juice: pH stayed lower for longer (due to additional substrate)

Meal Patterns

The length and frequency of eating behavior results in more time in the demin vs the remin

Takeaway:

- Grazing/ snacking is bad and can increase caries

Non-nutritive sweeteners

No nutrients from them

STUDY: Sweeteners and acidogenicity

Objective:

In adults, compare change in interdental plaque pH after rinsing with:

Sugars

- sucrose

--fructose

Polyols

- Sorbitol

- Xylitol

High intensity sweeteners

- Aspartame

- Saccharin

- Acesulfame K

Takeaway:

Sugars spent a lot of time under the pH curve and increased demineralization

Sugar alcohols and sweeteners virtually no time in demineralization

pH response from Sugar Alcohols (polyols)

Xylitol and Sorbitol pH didn't fall so they are not cariogenic

pH response from high-intensity Sweeteners

Aspartame, Acesulfame K, and saccharin also had no cariogenicity

SUMMARY: Sugar alcohols are not

Acidogenic or Cariogenic

SUMMARY: High-intensity sweeteners are not

Acidogenic or Cariogenic (these are not carbohydrates and thus can't be fermented)

Monk Fruit and Stevia

Monk fruit sweetener

- 0 kcal

- Mogrosides provide sweetness

Stevia

- 0 kcal

- Steviol glycosides

No carbohydrates no kcal = no caries

Both products have Gras approval

Erythritol

- Sugar alcohol

-- 0.2 kcal/g

- Naturally in some fruits, fermented foods

- GI friendly compared to other sugar alcohols

- Bulking agent with stevia, other intense sweeteners

Oral health:

- Not cariogenic

- reduced plaque

Intrinsic sugars

Reside inside cellular structure

- Sugars within fruits, vegetables grains

Extrinsic sugars

Reside outside of cellular structure

- Added sugars

- Processed fruits, Vegetables (juice)

- Milk is outside of cellular structure but though "healthy"

Non-Milk Extrinsic sugars

Term used in Great Britain and the rest of Europe to categorize sugars as healthy

Nutrition labels ingredients are listed

Descending order by weight

Nutrient label evaluations of foods: Cariogenicity, systemic health

ingredients

Relative fat contents

Relative carbohydrate content

Relative sugar content

relative starch

Clearance

Nature of consumption

Food label

Total carbohydrates minus total sugars and dietary fibers = Starch

Ice Cream and cariogenicity

Ingredients in bold can be used by bacteria and cause caries

Takeaway:

- we are removing our sugars and replacing them with maltodextrin and polydextrose

Maltodextrin: is one of those highly processed starches with small chains in it. Its not really a sugar but in refining it we decreased the bacterial workload and thus she a cariogenic baddie

If we can digest it and get calories from it we can get cavities

Does soda-pop cause cavities

Takeaway:

Higher pop consumption among those with rampant caries