1. NUTRITIONAL ASPECTS OFNUTRITIONAL 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.

2. 2Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
PrevalencePrevalence
Nutrients have topical and systemic effects thatNutrients have topical and systemic effects that
can be primary or secondary factors in thecan be primary or secondary factors in the
development of dental cariesdevelopment of dental caries
National Call to Action to Promote Oral HealthNational Call to Action to Promote Oral Health
stresses preventionstresses prevention
Dental caries remain the most common chronicDental caries remain the most common chronic
childhood diseasechildhood disease
Certain racial, ethnic, and lower-income populationsCertain racial, ethnic, and lower-income populations
suffer disproportionately higher rates of cariessuffer disproportionately higher rates of caries

3. 3Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
PrevalencePrevalence
Caries rates rise with ageCaries rates rise with age
28% of children ages 2–5 years28% of children ages 2–5 years
49% of children ages 6–11 years49% of children ages 6–11 years
68% of adolescents 12–19 years68% of adolescents 12–19 years
75% of adults75% of adults
Prevalence of root caries also rises with agePrevalence of root caries also rises with age
9.4% among persons ages 20–39 years9.4% among persons ages 20–39 years
17.8% among those ages 40–59 years17.8% among those ages 40–59 years
31.6% among those ages31.6% among those ages >>60 years60 years
From Bird DL, Robinson DS: Torres and EhlrlichFrom 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.

4. 4Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
Major Factors in the Dental CariesMajor Factors in the Dental Caries
ProcessProcess
Caries results from a combinationCaries results from a combination
of factorsof factors
Susceptible host or tooth surfaceSusceptible host or tooth surface
Sufficient quantity of cariogenicSufficient quantity of cariogenic
microorganisms in the mouthmicroorganisms in the mouth
Presence of fermentablePresence of fermentable
carbohydratescarbohydrates
Particular composition or flow ofParticular composition or flow of
salivasaliva
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.

5. 5Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
Major Factors in the Dental CariesMajor Factors in the Dental Caries
ProcessProcess
Tooth structureTooth structure
Resistance againstResistance against
demineralization beginsdemineralization begins
in pre-eruptive phasein pre-eruptive phase
with adequate intakeswith adequate intakes
of calcium;of calcium;
phosphorus; vitaminsphosphorus; vitamins
A, C, and D; fluoride;A, C, and D; fluoride;
and proteinand protein
Deep pits and fissuresDeep pits and fissures
increase susceptibilityincrease susceptibility
Host factorsHost factors
Food selection andFood selection and
dietary patternsdietary patterns
Oral hygiene habitsOral hygiene habits
GeneticsGenetics
Race or ethnic groupRace or ethnic group
AgeAge
SES (socioeconomicSES (socioeconomic
status)status)

6. 6Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
Major Factors in the Dental CariesMajor Factors in the Dental Caries
ProcessProcessSalivaSaliva
Availability of essentialAvailability of essential
nutrients duringnutrients during
development of salivarydevelopment of salivary
glandsglands
Protection provided byProtection provided by
adequate salivary flowadequate salivary flow
and saliva’s bufferingand saliva’s buffering
capacitycapacity
Plaque biofilmPlaque biofilm
Composition of plaque isComposition of plaque is
altered and stronglyaltered and strongly
influenced by dietinfluenced by diet
By-products of sucroseBy-products of sucrose
and glucose metabolismand glucose metabolism
produce acids; lowers pHproduce acids; lowers pH
to create environment forto create environment for
growth of bacteria, suchgrowth of bacteria, such
asas S. mutansS. mutans
From Fehrenbach MJ, Herring SW: Illustrated AnatomyFrom Fehrenbach MJ, Herring SW: Illustrated Anatomy
of the Head and Neck, ed 3. St. Louis: Saunders, 2007.of the Head and Neck, ed 3. St. Louis: Saunders, 2007.

7. 7Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
Major Factors in the Dental CariesMajor Factors in the Dental Caries
ProcessProcess
Cariogenic foodsCariogenic foods
Salivary amylase breaks down oral mono- andSalivary amylase breaks down oral mono- and
disaccharidesdisaccharides
Sucrose is used to produce glucans that facilitateSucrose is used to produce glucans that facilitate
adherence of bacteria (adherence of bacteria (S. mutans)S. mutans) to the dentalto the dental
pelliclepellicle
Processed starches (instant oatmeal) are often moreProcessed starches (instant oatmeal) are often more
fermentable than their nonprocessed counterparts duefermentable than their nonprocessed counterparts due
to partial hydrolysis or diminution of particle sizeto partial hydrolysis or diminution of particle size
High concentration of fructose found in juices isHigh concentration of fructose found in juices is
potential source of substratepotential source of substrate

8. 8Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
Major Factors in the Dental CariesMajor Factors in the Dental Caries
ProcessProcess
Anticariogenic properties of foodAnticariogenic properties of food
Sugar alcoholsSugar alcohols
 Fermented more slowly than mono- and disaccharides;Fermented more slowly than mono- and disaccharides;
therefore, buffering effects of saliva neutralize destructive acidstherefore, 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
Nonnutritive sweetenersNonnutritive sweeteners
 Not metabolized by microorganisms; do not promote cariesNot metabolized by microorganisms; do not promote caries

9. 9Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
Major Factors in the Dental CariesMajor Factors in the Dental Caries
ProcessProcess
Protein and fatProtein and fat
 Considered cariostatic because do not lowerConsidered cariostatic because do not lower
plaque pHplaque pH
Phosphorus and calciumPhosphorus and calcium
 Provide a buffering effect in the salivaProvide a buffering effect in the saliva
Dairy productsDairy products
 Protein,Protein, caseincasein (principal protein in milk), phosphorus,(principal protein in milk), phosphorus,
calcium are ingredients of anticariogenic or evencalcium 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 ofAlthough lactose is cariogenic (but the least cariogenic of
all saccharides), these other elements in milk and milkall saccharides), these other elements in milk and milk
products decrease risk of dental cariesproducts decrease risk of dental caries

10. 10Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
Major Factors in the Dental CariesMajor Factors in the Dental Caries
ProcessProcess
Other foods with protective factorsOther foods with protective factors
Constituent in chocolate, known as theConstituent in chocolate, known as the
cocoa factor, has shown anticariogeniccocoa factor, has shown anticariogenic
properties in Vipeholm studyproperties in Vipeholm study
Glycyrrhiza, the active ingredient inGlycyrrhiza, the active ingredient in
licorice, also anticariogeniclicorice, also anticariogenic

11. 11Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
Major Factors in the Dental CariesMajor Factors in the Dental Caries
ProcessProcess
Dental hygiene considerationsDental hygiene considerations
Encourage meticulous oral self-care, regularEncourage meticulous oral self-care, regular
preventive dental visitspreventive dental visits
Promote sealants for deep pits and fissuresPromote sealants for deep pits and fissures
In high-risk patients encourage use of aIn high-risk patients encourage use of a
chlorhexidine, fluoride, xylitol protocolchlorhexidine, fluoride, xylitol protocol
Encourage healthy eating habits with minimalEncourage healthy eating habits with minimal
fermentable CHO intake between mealsfermentable CHO intake between meals
Eating low-fat cheese as snack or at end of a mealEating 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 ModernTorres and Ehlrlich Modern
Dental Assisting, ed 9. St. Louis:Dental Assisting, ed 9. St. Louis:
Saunders, 2009.Saunders, 2009.

12. 12Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
Major Factors in the Dental CariesMajor Factors in the Dental Caries
ProcessProcess
Dietary factorsDietary factors mustmust be modified to reduce thebe modified to reduce the
risk of caries. Dietary recommendations needrisk 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 snacks
Oral retentiveness of foodsOral retentiveness of foods
Sequence of food consumptionSequence of food consumption
Amount of fermentable carbohydrate consumedAmount of fermentable carbohydrate consumed
Sugar concentration of the food or drink itemSugar concentration of the food or drink item
Physical form of the carbohydratePhysical form of the carbohydrate
Proximity of eating to bedtimeProximity of eating to bedtime

13. 13Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
Major Factors in the Dental CariesMajor Factors in the Dental Caries
ProcessProcess
Physical formPhysical form
Liquids include fruit juice, soda, sportsLiquids include fruit juice, soda, sports
drinks, energy drinks, liquid medicationsdrinks, energy drinks, liquid medications
 An acidic medium that further demineralizesAn 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, coughSlowly dissolving CHOs include antacids, cough
drops, breath mintsdrops, breath mints

14. 14Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
Major Factors in the Dental CariesMajor Factors in the Dental Caries
ProcessProcess
Frequency of intakeFrequency of intake
Linear relationship between caries rate and numberLinear 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, theEach time a food containing carbohydrates is eaten, the
salivary pH drops below the critical level for approximatelysalivary pH drops below the critical level for approximately
40 minutes40 minutes
 Enamel demineralization occursEnamel demineralization occurs
 Acid exposure is additive throughout the dayAcid exposure is additive throughout the day
 Eventually demineralization progresses to the point at whichEventually demineralization progresses to the point at which
decay may be detected clinicallydecay may be detected clinically
 The calcium and phosphorus in saliva need time toThe calcium and phosphorus in saliva need time to
remineralize the tooth between meals/snacksremineralize the tooth between meals/snacks

15. 15Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
Major Factors in the Dental CariesMajor Factors in the Dental Caries
ProcessProcess
Timing and sequence in a mealTiming and sequence in a meal
Amount of acid is reduced if a fermentableAmount of acid is reduced if a fermentable
carbohydrate food is eaten before or between othercarbohydrate food is eaten before or between other
noncariogenic foodsnoncariogenic foods
 Dairy products, such as cheese, reduce demineralization ofDairy 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 chewingSialagogues, like sugar-free chewing
gum, stimulate the saliva andgum, stimulate the saliva and
promote buffering of acidspromote buffering of acids
produced by bacteria and aidproduced by bacteria and aid
in oral clearance of the foodin oral clearance of the food

16. 16Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
Major Factors in the Dental CariesMajor Factors in the Dental Caries
ProcessProcess
Dental hygiene considerationsDental hygiene considerations
Review diet history for patterns of fermentableReview diet history for patterns of fermentable
carbohydrate consumption, frequency, and formcarbohydrate consumption, frequency, and form
Consume fermentable carbohydrates within a meal orConsume fermentable carbohydrates within a meal or
eat a noncariogenic food at the endeat a noncariogenic food at the end
Noncariogenic snacks include raw fruits andNoncariogenic 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/energyEncourage limiting of soft drinks and sports/energy
drinksdrinks

17. 17Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
Dental Hygiene PlanDental Hygiene Plan
AssessmentAssessment
Gather information about the quality of the patient’s mealGather 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 recordto 7-day food record
Use MyPyramid as a guide to assess adequacy of foodUse 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 fermentableHave the patient highlight all the fermentable
carbohydrates and note form, frequency, and when eatencarbohydrates 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

18. 18Copyright © 2010, 2005, 1998 by Saunders, an imprint of Elsevier Inc.
Dental Hygiene PlanDental Hygiene Plan
GoalsGoals
Help patient develop realistic goalsHelp patient develop realistic goals
Goals 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
EducationEducation
Education alone does not guarantee behavioralEducation alone does not guarantee behavioral
changechange
Assessment and goals are the basis for anyAssessment and goals are the basis for any
recommendationsrecommendations
Dispel myths, redirect inappropriate habits, andDispel myths, redirect inappropriate habits, and
provide new ideasprovide new ideas