DIET AND DENTAL CARIES

Definitions
Oral Dental Caries Periodontal Tooth Enamel of the mouth tooth decay gum the hard outer layer of teeth made from hydroxypatite which contains calcium and phosphate Plaque a colourless film called mucin forms on teeth, bacteria collect on this and form plaque Cariogenic causing tooth decay Demineralisation release of calcium and phosphate from teeth. Remineralisation the replacement of calcium and phosphate in teeth Fermentable carbohydrate sweet tasting compounds eg sugars and cooked starches, in order of sweetness: fructose, sucrose, glucose, lactose, maltose, dextrose.

While much literature emphasises the role of sucrose in tooth decay, it needs to be understood that all sugars can be fermented into acids by decay producing bacteria found in plaque. Sucrose is of particular concern for many people because of the emphasis that it receives in their diets and the frequency of eating sugary foods between meals.

Dental caries - a health issue

Dental caries and periodontal disease are still common in Australia. The incidence of caries for the population as a whole has reduced over the past decades, mainly due to improved nutrition, fluoridated water supplies improved dental hygiene However there are still large numbers of Australian children and adults who experience caries and many older adults experience periodontal disease. Of particular concern is caries in very young children - referred to as nursing bottle tooth decay. This mainly occurs as a result of babies and toddlers being given a bottle filled with something sweet to pacify them, or a dummy that has been dipped in honey or syrup. Children as young as 18 months suffer tooth decay.

Source: Australian Dairy Corporation

Optimal health through food variety and physical activity

Good oral health is necessary to prevent dental caries and to achieve normal growth and development of the oral cavity (mouth) and teeth. Strong teeth and a healthy mouth make eating more effective and enjoyable. Oral health depends heavily on nutritional status and dental hygiene, therefore it is important to eat a wide variety of foods each day and to clean teeth after eating.

Tooth care, the same for everyone

Clean your teeth as soon as possible after eating, especially after eating sugary foods such as cakes, biscuits, jams and sweets. Snack on raw fruit and vegetables to stimulate the flow of saliva and help to clean food debris from the mouth. Cheese is a tooth friendly snack which helps to protect tooth enamel. Avoid sticky sweet foods, potato chips, biscuits and raisins as between meal snacks. Have your teeth and gums checked regularly. Eat the Healthy Eating Pyramid way. Maintain thorough dental hygiene.

Optimal health through food variety and physical activity

Who is at risk?
People who consume fermentable carbohydrate foods and snack frequently on sticky, sugary foods and do not regularly eat dairy foods. Persons who do not use fluoride toothpaste, brush regularly and correctly and do not seek regular professional dental care. In children from conception to approximately 11 years, if nutrition is inadequate, the formation of enamel can be affected, this causes pits and areas of roughness which can be more susceptible to dental caries. Infants and toddlers who are put to bed with dummies dipped in syrup or with bottles containing Source: Australian Dairy Corporation fluids other than water. Persons who suffer from eating disorders such as anorexia and bulimia, where vomiting is induced so causing abnormal oral acid - an environment for decay. Some older people are at risk due to higher incidence of chronic diseases and multiple drug (usually prescribed) use, inadequate oral hygiene and lack of food variety, all of which lead to poor dental health. Persons with diabetes are at a higher risk, potential causes include increased salivary glucose levels in inadequately controlled diabetes, decreased salivary flow and dry mouth. Persons living in a community without a fluoridated water supply. Fluoride decreases the caries rate due to its effect on the tooth surface - it reverses the demineralising effect of acids produced by plaque.

Dental caries is the result of complex interactions involving the individual (nutrition, genetics, behaviour, race, age), plaque bacteria, saliva flow and composition and the environment. Diet has been shown to be one very important element of the environment that can be 'at risk' and so contribute to dental caries as the following information will illustrate: Dental caries incidence in native populations (Australian Aborigines, the Bantu of Africa, Maoris of New Zealand and the Inuit of Greenland) was very low prior to the introduction of the modern diet, but increased dramatically following exposure to North American and European cultures. The children of the world's most remote island community Tristan da Cunha, Southern Atlantic, were remarkably free of caries in 1937 when their foods were mainly potatoes, fish, sea birds and their eggs, as well as some beef, mutton, apples and berries. But, since they began to adopt the modern diet and life style they suffered from caries. When consumption of refined carbohydrates and sugar were rationed during World War 2, snacking decreased and so did the incidence of caries. Following the war the caries rate rose as sugar restrictions were lifted. The measurable differences were most significant in England, Norway and Japan.

(Source:Diet and Dental Caries, Stephen Wei in the Asia Pacific Journal of Clinical Nutrition, 1995,4, Suppl 1, 45-50)

Optimal health through food variety and physical activity

Teeth and nutrition

Teeth are unusual in that nutritional influences are exerted primarily during their formation, unlike bone and other tissues that change constantly and respond readily to nutritional changes. Inadequate nutrition in the period from conception to approximately 11 years of age can affect the formation of enamel, causing pits and areas of roughness and these can be more susceptible to decay. Medical conditions such as vitamin D deficiency (rare in Australia) can also lead to malformation of tooth enamel making tooth decay more likely. Once a tooth has grown through the gum, saliva becomes important in tooth health. For example, fluoride that is consumed is secreted into the saliva and provides a protective effect through its direct contact with the tooth surface. If the consumption of foods containing sugars is limited to mealtimes, and calcium rich foods are included with meals, teeth will have time to remineralise between meals. Frequent consumption of foods containing sugars, especially between meals, results in continuing high levels of acidity on plaque this inhibits the remineralisation process.

Cariogenic foods
Sweet and acid foods contribute to dental caries. Specific examples are cakes, sweets biscuits, lollies, toffees, sweetened cereals, muesli bars, jams, fruits canned in sweetened syrups, acidic fruits such as plums and citrus fruits, coffee and tea with sugar. Dried fruit and honey should not be eaten frequently. Although they do not contain added sugars, the natural sugars are highly concentrated and sticky and tend to stay on teeth for long periods of time. Soft drinks, sport drinks and fruit juice drinks, particularly when consumed between meals, can be a major cause of tooth decay, due to their sweetness and acidity.

How does a tooth decay?

Consumption of fermentable carbohydrates contributes to dental caries, however the frequency of intake is much more significant than the amount consumed. Dental caries is a demineralisation disease. A colourless film called mucin forms on teeth. Bacteria collect on the mucin and form plaque. These bacteria need food. They feed on the food, fermentable carbohydrates in particular, that gathers on and in-between teeth. As they feed they produce an acid which causes the demineralisation of enamel, this in turn leads to holes (caries) in teeth. The longer the period of time that the teeth are exposed to sugars the more acid is formed and the more detrimental to the teeth. For example eating a lolly in 3 minutes will be less detrimental than sipping a sweetened drink over a period of 15 minutes or chewing a sticky fruit or cereal bar that stick between the teeth for a longer period.

Optimal health through food variety and physical activity

The role of fluoride

Fluoride helps to maintain the hardness of bones and teeth. Fluoride occurs in water, plants, seafood and animal foods. Community water fluoridation is extremely important in the prevention of dental caries for children, teenagers and adults. The use of fluoride toothpaste supplements its availability in food and water. Fluoride is widely distributed in the environment, and all natural water supplies contain fluoride in various amounts. The purpose of community water fluoridation is to adjust the natural fluoride content of the drinking water to the optimum level in order to promote sound teeth. Fluoride is incorporated into the structure of teeth as they form in children. Fluoride continues to be important in the remineralisation of teeth throughout life: pitted surfaces that are vulnerable to decay are remineralised (repaired) by continuous exposure to low levels of fluoride in the mouth. This slow, ongoing process occurs particularly around the margins of existing fillings. fluoride is incorporated into the structure of the root surface, making it more caries resistant if it becomes exposed as the result of gum line recession, a problem relevant to older adults. A major advantage of community fluoridation as a disease preventive measure is that it does not require conscious behaviour by individuals in order for them to gain benefits. The benefits are gained simply by drinking fluoridated water.

The role of calcium

The major nutrient that is important for tooth health is calcium. The best food source of calcium is milk and its by-products such as cheese and yoghurt. The calcium in milk is particularly well absorbed because of the ratio of calcium to phosphorous which enhances absorption. Other good sources include fish with edible bones such as canned sardines and salmon. The amount of calcium needed per day depends on a number of factors: Calcium needs are high during periods of rapid growth (as is the need for many other nutrients) hence requirements are great during adolescence, pregnancy, infancy and childhood. A common misconception has been that calcium is not really necessary after bones and teeth have stopped growing. It is necessary throughout life. Our calcium requirements can be achieved by eating a wide variety of foods each day, the Healthy Eating Pyramid way.

From mid-teens to adulthood we require 3 serves of dairy, or 800mg calcium, each day. One serve = one cup, or 250mL of milk one 200g tub of yoghurt 40g of cheese.

Optimal health through food variety and physical activity

Dairy foods
Dairy foods are the richest dietary source of calcium and other nutrients needed for energy, growth and development. Just three serves each day provide around 70% of the calcium needed to build strength and growth in bones and teeth and to help prevent tooth decay. They also supply around one fifth of the daily intake of protein, riboflavin (vitamin B2) and vitamin A.

Dairy foods, calcium and more

There are several ways in which dairy foods such as cheese and milk may protect dental health. These include stimulation of the flow of saliva which, in turn, increases plaque ph (ie more alkaline, less acid), prevents enamel demineralisation, and helps clear fermentable carbohydrates from the mouth. Nutrients in cheese and milk such as protein, fats, calcium, phosphorus, magnesium, vitamin D and others may contribute to the beneficial effects on dental health. These nutrients support the development of teeth and gums in young children, which may help to protect against dental caries. Calcium may have a role in protecting against periodontal (gum) disease in adults and it is thought that calcium deficiency may increase periodontitis (ie. Inflammatory changes in the bone supporting teeth). The high calcium and phosphorus content of cheese and milk may contribute to the anti-cariogenic (decay preventing) effect of these foods. Cheese may be protective by increasing calcium and phosphorus concentrations in dental plaque. This concentration encourages remineralisation.

Looking at our Life Span

Babies
Babies do not need drinks other than breastmilk or formula, although water or diluted juices can be offered after the age of 6 months, or in very hot weather. Juices should not be put in a bottle nor should baby be put to bed with a bottle of milk or juice to suck. This long term bathing of teeth in sweet/acid solution causes tooth decay, which can result in loss of teeth. This will effect the growth of healthy permanent or 'second' teeth. Juice should be diluted with 1 to 2 times as much water and served in a babys cup. Once baby can sit alone and can make chewing movements it is time to encourage chewing and biting, even if baby does not have any teeth. This will help with teething and with talking. Foods high in sugar can contribute to tooth decay. Sweet foods should not be used as a rewardit is best to use lots of cuddles and attention or a special toy instead. Sugary foods such as honey should NEVER be put on baby's dummy.

Optimal health through food variety and physical activity

Childhood
This is an important time to develop tooth care habits Use a fluoride toothpaste and a soft tooth brush to clean teeth. Clean teeth twice daily after breakfast, before going to school and after the evening meal, before going to bed. Use a soft tooth brush and children's low fluoride toothpaste. Visit the dentist regularly. For between meal snacks choose fruit, raw vegetables or cheese. While at school swish the mouth out with fresh water after snacking and after having lunch. Avoid sugary snacks. The Healthy Eating Pyramid is a good guide to food intake and aids in limiting the amount of foods high in sugar.

Adolescence
It is normal for young people to supplement their meals with snacks. The frequent intake of foods and drinks high in sugar continually supplies the plaque bacteria with food and increases the amount of decay causing acid that is produced. It takes up to 40 minutes for the plaque acid to return to a healthy level therefore it is preferable for the type of snack foods eaten to be fruits, vegetables or cheeses and milk or water. Regular visits to the dentist, good dental hygiene including flossing and the use of fluoride toothpaste will help young people to maintain healthy teeth into adulthood. A great smile and fresh breath help to make a confident person. This in turn contributes to personality and sex appeal!

Adults
All the points recommended for children and adolescents are important. Cheese is a very important food for caries prevention. It has been shown that cheese may reduce the risk of root caries - many adults are at high risk of root caries. For many years it was thought that the dental benefits of fluoride, both in water supplies and in toothpaste, were primarily for children and adolescents, due to the incorporation of fluoride into the structure of their teeth as they formed. The incorporation of fluoride into the enamel results in tooth surfaces being more resistant to the acid attack which is part of the process of dental caries. However we now know that there are dental benefits for adults also. For more details see section on 'The role of fluoride' above.

Optimal health through food variety and physical activity

Older persons
All the points recommended for children, adolescents and adults remain important. More older people are retaining their teeth than ever before however, probably due to this longer retention, there has been an increase in tooth decay and periodontal (gum) disease. For the enjoyment of food and healthy eating habits it is important to maintain healthy teeth, gums and supporting bone tissue throughout life.

Dental caries are usually associated with the crown of the tooth, but some older people can suffer from root caries as well (see note above on the importance of fluoride). This is due to the gradual loss of supporting bone causing gum recession (long in the tooth). Because the roots are not protected by enamel (the hard covering of the crowns) they decay more easily. See note about cheese and root caries in the adult section above.

Dentures
clean well daily (plaque also forms on dentures) brush gums, tongue and palate with a soft brush have regular check ups: the gum ridges on which the denture rests will change and dentures will not fit well, chewing ability will be lessened, speech can be hampered and there can be facial alterations.

Summary Guidelines to protect oral health

Eat a wide variety of foods each day by following the Healthy Eating Pyramid Limit between meal snacks. If you do snack, choose nutritious foods such as cheese, plain yoghurt, fruit, or raw vegetables. Consume cariogenic foods (eg biscuits) with non-cariogenic foods (eg milk and cheese). Drink plenty of water. Visit your dentist at least once every six months, brush with fluoride containing toothpaste at least twice daily and preferably after every meal and floss daily. Never allow babies and toddlers to fall asleep with a bottle containing fluids other than water.

Optimal health through food variety and physical activity

Further information about Dairy foods can be obtained by contacting: The Australian Dairy Corporation PO Box 467 Port Melbourne 3207 Telephone: 1800 817 736 www.dairycorp.com.au/nutrition

Acknowledgments
The Australian Nutrition Foundation wishes to acknowledge the work of Lucinda Dobson, Ruth Riddell and the Australian Dairy Corporation for their work in the preparation of the manuscript for this publication. Published by The Australian Nutrition Foundation Inc. 2001

Disclaimer
This material is provided on the basis that it constitutes advice of a general nature only and on the basis that The Australian Nutrition Foundation Inc. will not be liable for any loss or damage occasioned from the use (either directly or indirectly) of this material no matter howsoever such loss or damage is caused. Readers should take advice as appropriate from an accredited practising dietitian on all specific situations and conditions of concern to them. The Australian Nutrition Foundation Inc. 2001 This publication is copyright. Apart from any fair dealing for the purpose of private study, research, criticism or review, as permitted under the Copyright Act, no part may be reproduced by any process without the written permission of the publisher. Enquiries should be made in writing to the publisher.

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