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									   International Dental Journal (2000) 50, 162–174

   Diet and oral health
   K.G. König
   Nijmegen, The Netherlands

   This review paper looks at the effects of diet on oral health and is                            Diet and nutrition in relation to
   concerned mainly with the effects of localised attacks on the dental                            oral health and disease
   hard tissues. In analysing the epidemiological evidence, the paper
                                                                                                   A review of nutritional influences on
   draws distinctions between the rates of disease entities in developed and
                                                                                                   oral health requires consideration of
   developing countries. The author concludes that oral health risks do not
                                                                                                   three groups of oral tissues with
   necessitate dietary recommendations in addition to, or other than, those
                                                                                                   different structure, morphology
   required for maintenance of general health. The paper indicates an
                                                                                                   metabolism and pathologic response:
   increasing need for evidence-based, individual tailor-made counselling
                                                                                                   • the hard tissues of the teeth (with
   and for specific programmes directed towards defined, high-risk groups
                                                                                                       implications for dental health)
   or populations whose oral health problems have been carefully studied
                                                                                                   • the supporting structures of teeth
   and identified.
                                                                                                       (with implications for periodon-
                                                                                                       tal health)
                                                                                                   • the oral mucosa (with implica-
   General remark. The author has cited several passages from an earlier publication by König
                                                                                                       tions for mucosal health).
   K G and Navia J M: Nutritional role of sugars in oral health. Am J Clin Nutr 1995 62(suppl):        Dental and periodontal health will
   275S–283S. In this article also Figures 2–4 have been published, however, copyright for these   be dealt with in more detail than
   is held by S. Karger Publishers, Basel, publisher of the Journal of Caries Research.            mucosal health because of the high
                                                                                                   prevalence of pathology of hard
                                                                                                   tissues and periodontal structures.

                                                                                                   Nutritional systemic vs. dietary
                                                                                                   local effects
                                                                                                   In the relation of nutritional factors to
                                                                                                   oral health, there is a peculiarity to be
                                                                                                   considered regarding the dental hard
                                                                                                   tissues. Once formed, tooth enamel is
                                                                                                   no longer subject to systemic nutri-
                                                                                                   tional influences, however, it is subject
                                                                                                   to dynamic exchange of ions as well as
                                                                                                   organic molecules and particles with
                                                                                                   its oral environment. The role of
                                                                                                   nutrition in general on the growth,
                                                                                                   development and maintenance of oral
                                                                                                   tissues has been discussed in a wide
                                                                                                   context1 and two major groups of
                                                                                                   effects are clear: one systemic/nutri-
                                                                                                   tional and the other local and dietary.
                                                                                                       The main result of nutrition is
                                                                                                   the systemic effect of the absorbed
                                                                                                   nutrients on growth, development
                                                                                                   and maintenance of tissues and
                                                                                                   organs and their specific functions.
                                                                                                   Local dietary side effects are of great
                                                                                                   practical importance in the oral
                                                                                                   cavity. Dental enamel after eruption
Correspondence to: Professor Klaus G. König, The University Medical Faculty, Preventive            is particularly subject to local side
and Community Dentistry, Nijmegen, The Netherlands.
                                                                                                   effects from whatever may enter the
© 2000 FDI/World Dental Press

mouth. Dietary components not only           therefore, the other effect we see later   ment and life-long integrity as well
provide essential nutrients for tissues      on, that is fewer and smaller carious      as functioning are associated with
of the host, but also for bacteria in        lesions, will likewise be due to the       systemic molecular and cellular reac-
the oral cavity which use them as            pre-eruptive deposition of fluoride. It    tions to variables associated with
substrates if readily available. Besides     took decades before the paramount          nutrition and medication, some of
‘indirect side effects’ of e.g. bacteri-     importance of life-long topical            them interacting with oral factors and
ally metabolised sugars and of amino         fluoride availability was clearly recog-   bacterial antigens. Tooth enamel, in
acids, there are ‘direct side effects’       nised and dental science agreed that       contrast, is subject to systemic influ-
of nutrients exerted by their ion            pre-eruptive administration of fluoride    ences on its development before
content, (erosive) acidity and physi-        was less important. In 1990 the epide-     eruption only; after eruption it inter-
cal properties.                              miological results of the US survey        acts exclusively with local (topical)
                                             completed in 1987 were published2.         environmental factors.
Pre-eruptive vs. post-eruptive               The authors describe the findings in           Because of the importance of
influences                                   large representative samples of 5- to      local effects in controlling deminer-
It is important in a discussion of           17-year-old individuals residing life-     alisation of teeth and inflammation
oral health and its relation to nutri-       long in areas with or without fluori-      of periodontal structures, which are
tional factors that we differentiate         dated drinking water. The difference       the major risks to oral health, this
between formative nutritional and            in caries experience between people        review deals with side effects of
post-eruptive local influences. The          from non-fluoridated areas compared        diet rather than with metabolic
effect of nutrition on formation is in       with those from fluoridated areas (50–     nutritional aspects. In any event,
general constructive. In contrast, the       60 per cent less with optimum              nutritional advice during develop-
influence of diet and its local side         concentration of fluoride in all           ment is the field of the medical
effects are more likely to be damag-         pioneering fluoridation studies            practitioner, and not of the dentist.
ing than stabilising: the mouth is the       between 1945 and 1970) had fallen          For the maintenance of periodontal
port of entry for all food and drink,        off to an average of 18 per cent; in       and mucosal health, systemic nutri-
regularly accepting either very cold,        certain regions the difference was         tional factors are more relevant than
hot, aggressive and/or very hard             much lower, and in region III, around      for maintenance of tooth structures,
components eliciting enormous                and south of the Great Lakes, it was       but even in this case, absence of
mechanical forces. Since the tissues         even slightly reversed: mean DMFS          local bacterial and cytotoxic irritants
lining the oral cavity are part of           under life-long exposure to fluoridated    requires much more attention than
the surface of our body, they are            water 2.86, vs. no exposure to fluori-     do systemic nutritional factors.
colonised by numerous species of             dated water with DMFS 2.69. The
micro-organisms interacting with the         authors comment that ‘because of the
                                             multifactorial etiology of caries, it is   Dental health and caries risk factors
food passing, and/or with the
underlying structures.                       doubtful that an unequivocal explana-      Caries is a bacterial plaque-depend-
    If integrity is maintained, it will be   tion for this trend can be found,          ent disease that is characterised by
the result of a continuous interaction       though there can be little argument        an intermittent demineralisation of
of protective and destructive influ-         that the ubiquity of fluoride in the       enamel, dentine and/or cementum.
ences. The difficulty is that nutritive as   environment has been a dominant            Oral micro-organisms, when organ-
well as local dietary protective and         factor’. The most plausible explana-       ised in voluminous masses as in
destructive factors both act on the same     tion, by our present knowledge, is the     dental plaque on tooth surfaces,
tissues, and their respective effects        increasing popularity of personal oral     hydrolyze starches and metabolise
cannot be differentiated readily and         hygiene and the use of fluoride tooth-     sugars to form weak acids (mainly
assessed separately. The fact that           paste. The same conclusion was drawn       lactic acid) which slowly and inter-
formative influences are effective in        from observations after the fluorida-      mittently demineralise the hard
an early distinct period of develop-         tion of drinking water had been            tissue underneath.
ment, and destructive influences             stopped in Tiel (The Netherlands3) and         This utilisation of some food
usually do not start before exposure         in Kuopio (Finland4). These studies as     components such as sugars by bacte-
and functioning, does not solve the          well as the US sample illustrate the       ria is a local side effect in the mouth
difficulty. A well-known example of          fact that systemic fluoride may not be     during food passage, in contrast to
this is the question of the mechanism        necessary, at least for the permanent      the systemic effect of carbohydrates
of effect of water-borne fluoride.           dentition, if local fluoride (mainly in    as a source of energy for the host.
When fluoride in drinking water in           toothpaste) is available from eruption     Carious demineralisation is the result
the US was first discovered to be the        of teeth onwards.                          of a side effect, namely acid forma-
cause of mottling of teeth, and later                                                   tion from sugars in the bacterial plaque
also identified to be the protective         Special position of enamel                 on the teeth. The sugars and other
factor against caries, the conclusion        among the oral structures                  carbohydrates per se exert no direct
was rapidly drawn: Fluoride does have        With respect to the tissues of bone,       damaging effect on the teeth. During
an effect on teeth during formation          periodontium, mucosa, salivary             sleep and when no food is available,
that shows as mottling after eruption;       glands, dentine and pulp, develop-         the acidogenic plaque bacteria can
                                                                                                          König: Diet and oral health

(slowly) metabolise and survive on a
minimum supply of substrate derived
from carbohydrate sidechains of sali-
vary mucins. At these low substrate
concentrations, no cariogenic amounts
of acid are formed. However, oral
acidogenic bacteria can handle
substrate concentrations of a very large
range from very low to very high, and
to high concentrations of sugars they
react with acid formation immediately.
    For quite some time in the early
phases of acid attack on hard dental
tissues, the demineralisation is a diffu-
sion-controlled process resulting in an
increase in pore volume only, without
disintegration of the mineralised
tissues; supply and access of saliva
are important for remineralisation
between acid attacks because saliva
contains buffering systems, and trans-
ports mineral and fluoride ions to the
tooth-environment interface.
    Both processes, that is the attacks,
resulting in demineralisation and                  Figure 1. Acid production in aged bacterial dental plaque before cleansing (A) and after
remineralisation resulting in repair, are          cleansing on the left side (C). From Stephan and Miller 19435.
modified by a number of variables.
The most important factor on the side
of attack is presence of plaque, its               1950s on inmates of the Vipeholm              experimental dietary regimes consis-
thickness and bacterial composition;               asylum in Sweden7. Analysis of later          ted of mentally retarded, severely
there is a good reason for not listing             (mostly not controlled, but epidemio-         handicapped subjects who were
carbohydrates such as sugars in the                logical) studies conducted in the             unable to perform any oral hygiene
first place: if there is no mature plaque          1960s and 1970s confirmed this                technique. There were no dental
present, that is there are no more than            relationship8. The Vipeholm Study             hygienists available at that time to
thin layers of bacteria, no appreciable            was the first to reveal the distinction       do regular professional cleaning,
amount of acid is formed. This had                 between the effects of amount of              and cariostatic fluoride was not
been shown by Stephan and Miller5                  sugars eaten, versus the frequency of         available; a similar condition prevailed
who measured acid formation on the                 sugar intake. The experiment showed           in normal populations even in
teeth after rinsing with sugar solutions.          that restriction of sugar intake to four      developed countries up until the
They found immediate pH drops                      main meals daily did not significantly        seventies, because regular oral
when thick plaque was present,                     increase the (low) baseline caries            hygiene was only performed by a
whereas after removal of the plaque                activity, even if large amounts of            minority, and toothbrushing was
no dangerous acidity could be detected             sugar (300g/day) were given. On the           particularly unpopular among chil-
on the cleaned surface (Figure 1). The             other hand, when 8 or 24 between-             dren at school age, on which nearly
same phenomenon was reported from                  meal sugar-containing snacks were             all the caries epidemiology was done.
a number of laboratories where pH                  given daily, caries incidence rose                 This has changed conspicuously
telemetry is used to measure the                   dramatically. The reason is that              during the last 20 years, starting and
acidogenic potential of carbohydrate-              plaque bacteria after exposure to             being observed first in hygiene-
containing foodstuffs: if the experi-              sugar produce acid only for about             conscious populations such as in the
menter does not let plaque grow for                0.5h (Figure 1). Consequently, the            US, Scandinavia, Switzerland and The
at least two days, no acid formation               total demineralisation time is 2h per         Netherlands where toothbrushing
can be observed6.                                  day if 4 meals are taken, but 12h if          among children became a habit,
                                                   24 sugar exposures occur. With                keeping plaque accumulation low.
Dietary sugars and caries                          increasing frequency therefore the
experience, and the role of                        caries risk increases.                        Modern caries epidemiology vs.
eating habits in the development                       However, it is necessary to               findings in the pre-hygiene era
of dental caries                                   analyse and consider the conditions           It has been mentioned in the theo-
An association between intake of                   under which the Vipeholm Study7               retical part of this paper and shown
sugars and dental caries was first                 was conducted: the 436 Vipeholm               in Figure 1 that sugars do not give
studied experimentally in the early                inmates exposed to the various                rise to production of dangerous
International Dental Journal (2000) Vol. 50/No.3

amounts of acid in the oral cavity         tices should not be dismissed lightly.     and only 8.2 per cent of the subjects
when plaque is absent or only              In that study, frequency of sugar          had a quality level of 5, which is the
present in thin layers. Therefore, it is   consumption, although significant,         minimal recommendation of Cana-
feasible to separate modern epide-         had a much lower correlation value         da’s Food Guide for the use of the
miological research from early             (+0.099) with caries than the weight       four essential food groups. While
findings accumulated in the pre-           of sugary foods consumed (+0.143).         there was a trend toward a decreased
hygiene era. This is the more impor-           The study done in the US was a         caries increment with improved
tant because during the same time          longer, three-year investigation of 499    nutritional quality of the diet,
span in which oral hygiene practice        children aged 11–15 years in a non-        analysis of variance did not show
developed, the sale of toothpastes         fluoridated community in the state         statistical significance for this trend.
containing fluoride in caries-inhibit-     of Michigan. These American chil-          Furthermore, no significant associa-
ing concentrations rose from zero          dren consumed on the average 142g          tion was observed between frequency
up to more than 90 per cent in the         of sugar per day (51kg/year) and sug-      of consumption of sugary foods and
countries mentioned above.                 ars accounted for 26.5 per cent of         increments in caries.
                                           their total daily energy intake. In this        It is obvious that while dietary
Findings based on single cross-            study, pit and fissure caries were not     sugars are a determinant of caries
sectional sampling and short               found to be correlated with any            risk, they are not the only factor in
observations                               aspect of sugar consumption, but           the aetiology of the disease. This
Walker and Cleaton-Jones9 without          increments in approximal caries were       understanding is highlighted in
ignoring the caries risk associated        observed to be related to dietary          studies done with special populations
with intake of sugars, have identified     sugar intake parameters. While             such as mentally retarded children14
a number of situations in caries           children who consumed a high               where again, the frequent consump-
epidemiology reported in the litera-       proportion of their energy intake as       tion of candy did not seem to be a
ture where sugar intake alone does         sugar had the higher increments of         significant determinant of caries, but
not explain the caries status of the       approximal caries, there was no rela-      rather, poor oral hygiene status
consumers. A study of diet, oral           tionship between the caries scores         appeared to be a more important
hygiene and dental caries in 457           and the average frequency of eating        caries risk factor. Similar conclusions
Canadian children has not revealed         during the day or the average number       concerning the importance of oral
meaningful correlations between            of sugary snacks consumed between          hygiene vs. diet were reached in a
independent and dependent variables10.     meals. Results of this study did not       study 15 evaluating oral health of
    There have been many attempts          differ much from those obtained in         Latin-American preschool children
to study in humans the specific rela-      the study done in England, and             living in Malmö: children with a
tionship between sugar intake, dietary     suggested that while sugar continues       sound gingiva due to good oral
and nutritional parameters and             to be a clear aetiologic component         hygiene had only 1.1 tooth surfaces
dental caries, but three studies con-      of the carious process and a high          either carious or restored with
ducted using English11, American12,        frequency of sugar consumption in-         fillings, while those with gingival
and Canadian13 children deserve            creases the risk of the disease, the       inflammation due to poor oral
special consideration. The English         dietary behaviour of the populations       hygiene had 6.2 surfaces carious or
study involved 405 children who had        in these two sites was not sufficiently    filled. Another study16 examining the
an initial average age of 11.6 years       caries-promoting to make a major           oral health status of Greek immi-
and were followed for two years.           difference in their caries experience.     grant (GI) children in comparison
Evaluation of the data indicated that          A third study was done in Canada,      with Swedish (S) and rural Greek
the average consumption was 118g           using 232, 11-year-old students to         (G) children, illustrated the complex-
of sugars per day (43kg/year) which        evaluate the association between           ity inherent in the evaluation of
also accounted for 21 per cent of          dietary patterns and dental caries.        determinants of oral health. The
the total energy intake. Sugar intake      Nutritional data were collected using      carbohydrate content of the diet
explained only 4 per cent of the           a quality index based on the eating        consumed by these three groups was
variance in caries increment and 94        frequency recommended in food              about the same, however, children
per cent of the variance remained          guides and divided into eight levels       in the G group had only 15 per cent
unexplained by the factors under           (with 1 being the worst nutrition and      caries free primary teeth, as well as a
consideration in the study. The            8 being the rank given to the group        higher incidence of decayed and
authors believed that a large propor-      that best complied with nutritional        filled tooth surfaces in primary and
tion of the variance was due to            recommendations). They also consi-         permanent teeth than the other two
methodological inaccuracies, such as       dered the frequency of sugary food         groups. There was also a similar
those related to dietary assessment,       consumption at meal time and               distribution of mutans streptococci
and a large intra-subject variability      between meals. Results of the study        and lactobacilli in the three groups,
that could mask a true relationship.       indicated that the nutritional status      and this indicates a potential risk for
While this may be the case, other          of these children was compromised;         any of the children, if other caries
aetiological factors such as saliva,       almost 50 per cent of the children         conducive conditions are increased.
plaque, fluoride/oral hygiene prac-        had a nutritional quality level of 3       The availability of health services for
                                                                                                        König: Diet and oral health

children living in Sweden (S and GI)                      Table 1 Percentages of 6-year-old children with intact dentition (from Truin
was made evident by the increased                           et al., 199020) and eating habits of samples from the same populations
                                                           (Meulmeester, 198819); average consumption (g/day) of food and snacks
use of toothbrushes and improved                                    possibly relevant as determinants of oral health/ill health.
oral hygiene of these groups compared
to children in the G group and this                                                   NL (low SES)        Turkish        Moroccan
could have been an important deter-                          % caries-free children       43                 20              22
minant of their oral health status.                          Bread                       149                128             142
    Gibson and Williams17 have pub-                          Vegetables
lished the results of a careful re-evalu-                    Sweet pastry                 25                  9              12
ation and advanced statistical analysis                      Sweet beverages             256                 80             121
of the data collected in a representa-                       Sweets                       21                 13              10
tive sample of 1,450 pre-school                              Jam                          17                 11              11

children. They had been studied in
the course of the British National Diet            Secular trends found by sampling               ride availability will decrease caries
and Nutrition Survey (NDNS)                        over long periods of time                      prevalence. The relative effect of the
conducted in 1992/93. The original                 While most dental epidemiological              two inhibitory factors can be judged
report published in 1995 included the              results are based on a study of single         considering percentages of caries-
statement that ‘overall, the benefits of           cross-sectional samples or on obser-           free children in Basel, Switzerland,
frequent brushing of teeth did not                 vation periods not longer than a few           subsequently under pre-war, wartime,
appear to outweigh the damaging                    years, there are also a number of              and post-war sugar supplies (Figure
effect of frequent sugar consump-                  observations over time, covering               223). Before and during the first year
tion’ 18. The results of the recent                secular changes in caries prevalence           of the war – with an unlimited sugar
multivariate analysis17 applying three             over some decades. One of the                  supply, poor oral hygiene and no
series of stepwise logistic regression             pioneers in discovering secular                fluoride available – the percentage
models do not support this conclu-                 changes in the prevalence of caries,           of caries-free, 7-year-old children did
sion. Besides revealing age and social             R.L. Glass, in 1981 published a                not exceed 2–3 per cent.
class as strong predictors of caries               classic paper on epidemiological                   Wartime restrictions reduced
experience, the influence of tooth-                findings between 1958 and 1978 in              sugar supply from about 40 to
brushing frequency was also highly                 two non-fluoridated Massachusetts              16kg/person/year, with a resulting
significant (probability of error                  towns21. He seems to have been the             increase in the number of caries-free
P<0.001). Based on the lacking or                  first to suggest that the decrease of          children to about 15 per cent. This
weak association of caries with eating             caries experience could be due to              improvement of oral health tended
sugar and sugary foods, the authors                increasing use of fluoride-containing          to disappear when sugar became
conclude with the ‘hypothesis that                 toothpastes, and increased awareness           again freely available after the war.
regular brushing (twice a day) with a              of the importance of oral health.              At that time the war-time improve-
fluoride toothpaste may have greater                   Other series of observations,              ment seemed impressive, but it was
impact on caries in young children                 although published later, have been            dwarfed by the upcoming modern
than restricting sugary foods’.                    dug up from old records and were in            preventive tools. Fluoride tablets and
    In the Netherlands the caries                  addition based on a continuation of            fluoride toothpastes became gradu-
experience of Turkish and Moroc-                   examinations by epidemiologists                ally available, oral hygiene lessons at
can children is significantly higher               working in the same area and                   school were introduced, and water
than that of native ones of the same               according to the same traditions. For          fluoridation started in 1962: although
age. A comparative study of the                    instance, reductions in availability           sugar consumption rose rapidly after
dietary habits of 8-year-old immigrant             and intake of sugar as was seen                the war and has varied around 45kg
and native children19 revealed that                in Europe during the war, were                 per capita during the last 40 years, by
inferior nutrition can be ruled out as             accompanied by a decrease in caries            1989 the number of caries free
the cause of higher caries rates in                prevalence in populations involved             schoolchildren 7 to 15 years of age
Turkish and Moroccan children; it                  in such dietary changes, but these             had risen to 65 per cent, and the
was found that the latter consumed                 effects were not permanent – they              DMFT index of 12-year-olds had
much less potentially cariogenic                   disappeared when the imposed                   decreased to 1.023.
sugary food, snacks and drinks, as                 drastic dietary changes were reversed.             The Netherlands is one of the
well as more vegetables than the                   Caries experience of individuals who           industrialised countries where caries
native children with significantly                 had to reduce their sugar intake               prevalence within the last 25 years
lower caries experience. In Table 1 the            during the war years showed that               has decreased rapidly20,24,25. An aver-
dietary findings are presented together            there was no long lasting beneficial           age DMFT of 1 in 12-year-old
with percentages of caries free chil-              effect when they were exposed once             children was reached in the mid
dren from another sample, 6-year-old               more to a caries-challenging situa-            1990s. The percentage of caries free
low-SES native (NL), Turkish and                   tion during the post-war period22.             children is still increasing although
Moroccan children examined in The                      It is obvious that both severe             sugar consumption was still more
Hague one year later.                              sugar restriction and optimum fluo-            than 90 per cent of that which it was
International Dental Journal (2000) Vol. 50/No.3

                                                                                         shortly after Walker and Cleaton-
                                                                                         Jones9, came to the confirmatory
                                                                                         conclusion that in many highly
                                                                                         developed industrialised countries
                                                                                         there was a ‘lack of correlation
                                                                                         between the decline of caries
                                                                                         prevalence and average sugar
                                                                                         consumption’. This is a comforting
                                                                                         statement, however, there are still
                                                                                         high-risk populations who force us
                                                                                         to keep alert. These are found in
                                                                                         developing countries, or in sub-
                                                                                         populations (mostly ethnic minority
                                                                                         groups) even in the highly developed
                                                                                         ‘low-caries countries’. Appropriate
                                                                                         alertness does not mean that we
                                                                                         should continue issuing the same
                                                                                         general recommendations for every-
                                                                                         body as during the past decades when
                                                                                         the high caries experience of nearly
                                                                                         100 per cent of the people was clearly
                                                                                         sugar dependent. A specific analysis
                                                                                         of risk factor(s) per risk group is
                                                                                         necessary, and a specific package
                                                                                         of preventive measures should be
                                                                                         Cariogenicity of diets rich in
                                                                                         carbohydrates other than sucrose
                                                                                         Up to this section caries data have
                                                                                         been presented of populations feed-
                                                                                         ing on diets containing sucrose as
Figure 2. Percentages of caries-free first grade (7-year-old) schoolchildren in Basel,   the preponderant carbohydrate,
Switzerland, between 1933 and 1982. From König 199024.                                   although these diets eaten in highly
                                                                                         developed countries also contain a
in 1965 (38.5kg/p.p./per year in 1985        where nevertheless regular epidemio-        great variety of sugars other than
and in 199224,25; Figure 3). Fluorida-       logical monitoring of caries data has       sucrose and also high-molecular-
tion of drinking water stopped after         shown that the caries prevalence in         weight carbohydrates. Because of
a Supreme Court decision in 1973,            children continued to decrease: these       the special situations in developing
but as a consequence of the public-          are Sweden26, Norway27, and New             countries, it seems appropriate also
ity around this event many people            Zealand24. The situation is illustrated     to consider constellations in which
became aware of the great impor-             in Figure 4.                                the cariogenic potential of certain
tance of individual self-care. The                                                       foodstuffs can be isolated because
most plausible explanation for the           A secular change in the                     they are the ones preponderantly, or
decreasing caries prevalence in the          association between sugar                   even solely used.
Netherlands seems to be a combina-           consumption and caries
tion of factors, the most important          When Sreebny in 1982 published his          Milk
being the improved personal hygiene          analysis of the sugar-caries relation-      Lactose has repeatedly been reported
habits. Most children are now                ship, he had based it on caries data        to stand out among the major
clinically plaque-free and are using a       in deciduous dentitions from 23             dietary sugars as being of markedly
fluoride-containing toothpaste; some,        countries and on data in permanent          lower cariogenicity. One must keep
especially high-SES children get             dentitions from 47 countries8. He           in mind, however, that this conclu-
occasional topical fluoride applica-         found that every 20g of increased           sion was based on laboratory
tions. In addition, more than 50 per         sugar consumed per person per year          studies, and many animal tests with
cent of the chewing gum sold,                resulted in 0.5 dmft increase for           this sugar have been run with ad libi-
contains xylitol and/or sorbitol in          5- to 6-year-old children, and an           tum feeding. Since rats do not toler-
place of sucrose (see below).                increase of 1 DMFT for 12-year-olds.        ate lactose very well and tend to eat
    There are some countries where           Since then, much has changed.               less, and less frequently, on lactose
between 1982 and 1985 sugar                      In his analysis of the secular          diets than on control diets with other
consumption has increased, but               trends published in 1990, Marthaler28,      sugars, the lower caries activity on
                                                                                                          König: Diet and oral health

                                                                                            sugar-sweetened contents. Fortu-
                                                                                            nately, if the permanent teeth erupt
                                                                                            into a much less sugar-swamped oral
                                                                                            environment, they usually remain

                                                                                            Sugars in fresh fruits
                                                                                            There are a number of studies which
                                                                                            seem to confirm that the popular
                                                                                            saying ‘an apple a day keeps the
                                                                                            doctor away’ may also apply to
                                                                                            ‘...keeping the dentist away’11,36.
                                                                                            However, these findings do not
                                                                                            provide direct evidence of low cario-
                                                                                            genicity of fruit-borne sugars since
Figure 3. Average number of decayed, missing and filled teeth (DMFT) of 12-year-old
children in the Netherlands between 1965 and 1993, and per capita sugar disappearance
                                                                                            individuals who consume relatively
per year in the Netherlands, corrected for import and export of sugar products. From        high amounts of fresh fruit may
König 199024 and Truin et al., 199425.                                                      differ in a number of other dietary
                                                                                            and oral hygiene variables which +
                                                                                            affect caries activity.
                                                                                                 Indeed, findings in several groups
                                                                                            of South African farm workers show
                                                                                            the high risk associated with frequent
                                                                                            fruit eating37. The caries experience
                                                                                            of 120 farm workers was analysed.
                                                                                            The purpose was to determine the
                                                                                            effect of a high intake of citrus
                                                                                            fruit or of different varieties, in
                                                                                            comparison with the diet of a grain-
                                                                                            producing (control) group. The mean
                                                                                            daily intake of added sugars (exclud-
                                                                                            ing that from the specific fruits to be
                                                                                            investigated), was the highest for the
                                                                                            control group, however, they had the
                                                                                            lowest caries experience, DMFT 9.9,
                                                                                            significantly different from the
                                                                                            citrus group with DMFT 24.8 and
                                                                                            the ‘mixed variety’ fruit group with
                                                                                            DMFT 22.7 (P<0.0001). This
                                                                                            suggests that sugars contained in
                                                                                            fruits may be even more cariogenic
Figure 4. Average DMFT in 12-year-old children (s) and per capita sugar disappearance       than extrinsic sugars.
in Norway, New Zealand and Sweden between 1970 and 1985. Norway: l = sugar data                  Some fruits tend to cause only
uncorrected, l = corrected for import/export. New Zealand: l = sugar data, corrected.
Sweden: n = sugar incorporated in industrial products, m = sugar for household and other
                                                                                            moderate falls in plaque pH6,38,39.
use. From König 199024.                                                                     Apples, however, besides containing
                                                                                            sometimes high concentrations of
lactose diets may in part be an                    the high cariogenicity of milk in this   free acids, by virtue of their sugars
unspecific effect29. It does not seem              situation is the habit of ad libitum     content, can also give rise to forma-
justified to regard lactose as a                   feeding. Infants are not only breast-    tion of acid in plaque6,40–42. A host of
virtually non-cariogenic food, a                   fed upon demand frequently during        information with a reliable pH-
conclusion which was drawn from                    daytime, but also are allowed to sleep   telemetry method has been gathered
the publication by Storey30. Several               beside their mother with the nipple      by Imfeld6, including direct compari-
papers on observations, referred to                of a breast in their mouth, suckling     sons of acidity generated by intrinsic
above, in babies breast-fed over                   even at night as often as they tend to   sugars from fruits and sucrose. An
periods of a year or longer, as it is              wake up. The caries prevalence in        apple for instance contains 9 to 11
common practice in Central African                 the deciduous dentition of these         per cent sugars, mostly fructose.
Countries, have shown that lactose                 children is very high. This practice     There are favourable factors in an
in milk can be highly cariogenic when              has the same effect as continuous        apple that are missing in a 10 per
drunk frequently30–35. The reason for              availability of a nursing bottle with    cent sucrose solution: fresh apples
International Dental Journal (2000) Vol. 50/No.3

are fibrous and crisp which makes            may not, in principle, be as hazard-     fore it is highly questionable whether
them self-cleansing, a considerable          ous for dental health as sugars.         a recommendation to use complex
part of the sugars is likely to remain           Starches cannot directly serve as    carbohydrates in place of sugars
in the bolus up until it is swallowed,       substrates for bacterial fermentation,   would decrease the caries risk in
and the citric acid in the apple is a        but hydrolysis to maltose, isomaltose    particular since many starch-contain-
good stimulant for neutralising              and glucose is no problem in the         ing types of food contain sucrose
saliva. Nevertheless not only dried          oral cavity. Both salivary and bacte-    and other sugars as well.
dates and raisins with high content          rial hydrolases can accomplish this,
of sugars, but also apples and               and it has been shown that after the
                                                                                      The role and functions of non-
bananas in Imfeld’s studies gave rise        chewing of crackers, potato chips
                                                                                      fermentable sweeteners in
to dangerously strong acidity. It is         and so forth, glucose clearance is
                                                                                      relation to dental caries
interesting to note that the pH turned       prolonged due to the intermediate
and remained low not only in plaque,         starch degradation products malto-       Sugar alcohols or polyols, with the
but also in the oral fluid in which the      triose and maltose51. Acid formation     pentitol xylitol and the hexitols sorbi-
pH was monitored concomitantly.              can start surprisingly quickly after     tol and mannitol are sweet, but not
What is surprising is a lack of accel-       starchy food has got in contact with     cariogenic (in the case of xylitol) or
eration of the oral sugar clearance in       dental plaque. Pollard et al.52 have     much less cariogenic than sugars
the case of the apple; the pH in the         tested the acidogenicity of white        (in the case of hexitols). Numerous
oral fluid stayed low even longer than       bread, cooked spaghetti, cooked          articles on original clinical research,
in plaque. The conclusion from these         long-grain rice and many other starch    among them the Turku Sugar
studies is that there is no difference       products with and without added          Studies 55, the ‘Michigan Xylitol
in acidogenicity of fruit-borne and          sugar. Paired t-tests of the minimum     Programme (1986–1995)’56, the
dissolved or soluble sugars, although        pH values measured with indwelling       Belize City chewing gum trial57 and
some properties of fruits appear             electrodes showed that none of           review papers58,59 have firmly estab-
favourable in theory.                        the test products was significantly      lished the caries preventive effect of
    The limited studies of caries in         different from 10 per cent sucrose       these sugar substitutes, especially of
rats fed various fruits indicate that        solution. So there is no doubt that      xylitol. The stimulating effect on sali-
apples, bananas, and grapes can give         starches are acidogenic in the mouth;    vary glands is unequivocally estab-
rise to appreciable levels of caries,        how cariogenic starch products are,      lished, and of xylitol it is well known
sometimes as much or more than               depends on many factors. In cases        that it can be taken up by oral bacte-
sucrose itself43–46. Moreover, it has        of impaction of starchy food in          ria, but because in the cells it has the
been demonstrated that fruit, espe-          retentive fissures and interdental       form of a toxic xylitol phosphate it
cially citrus fruits, carry a risk of acid   spaces, especially when the starch has   cannot be further metabolised. Only
erosion of tooth enamel 47–50. It            been industrially processed, this may    a few questions are still open: does
would appear that fresh fruits when          give rise to considerable amounts of     xylitol reduce (initial) caries because
consumed infrequently in a normal            acid and their cariogenic potential      it stimulates salivary flow, or has it a
varied diet do not contribute                must be considered high. Observa-        specific remineralising power of its
detectably to caries activity, but they      tions in individuals with hereditary     own? Does xylitol change the plaque
possess a cariogenic potential which         fructose intolerance (HFI) due to an     flora60? There is no doubt that under
may become manifest when they are            enzyme defect tended to show that        certain growth conditions xylitol-
consumed frequently. Regarding               complete lack of fructose and            resistant mutants of mutans strepto-
dried fruits, plaque pH measurements         sucrose in a human diet resulted in      cocci can emerge, but not all strains
and animal feeding studies clearly           low caries experience53. However,        of these species show this phenom-
indicate a high cariogenic potential38,43.   these individuals, who tolerate          enon61. If such a mutation occurs,
                                             unlimited amounts of starches, are a     the cell is unable to synthesise a
                                             very limited, special group, and all     cellwall transferase system necessary
Complex carbohydrates (starches)
                                             normal populations eating prepon-        to transport the xylitol molecules
Most national dietary surveys in highly      derantly starches eat them in cooked     inside. At the same time these resist-
developed countries result in recom-         or baked form and besides also eat       ant mutants of mutans streptococci
mendations to eat more food with             much food containing sugars as well.     seem to be less virulent which may
complex carbohydrates. The idea              Imfeld6 refers to a large number of      result in a less cariogenic plaque flora.
behind this is to reduce fat intake;         animal experiments showing that          The uncertainty as to whether xylitol
because of the caries risk associated        cooked starch cannot be considered       changes the plaque composition
with consumption of sugars, sugars           a non-cariogenic dietary component,      favourably may be due to the
are not recommended as energy-               and Lingström et al.54 have shown        inconsistency of strains to develop
providing substitutes for fats. Whether      with three different pH-measurement      resistant mutants. As a matter of fact,
this is justified need not be discussed      systems that acid formation in plaque    these open questions do not limit
further at this stage, but for the sake      after chewing soft bread or potato       the general use of polyols, especially
of fact-finding, it is necessary in this     chips is more intense and lasts longer   xylitol, because safety and the over-
context to examine whether starches          than after intake of sucrose. There-     all caries preventive effect are firmly
                                                                                                         König: Diet and oral health

established. Recently, two reports                 away whatever mineral substance at         the sequelae of environmental pollu-
have been published indicating that                the interface, only loosened by the        tion, and to make sure one gets all
xylitol can, besides the inhibiting                acid, that otherwise might have a          essential nutrients, vitamins and
effect on dental caries, also prevent              slight chance to remineralise.             minerals.
acute otitis media in children62,63.                   Regular removal of plaque is
    All polyols when eaten in                      essential for prevention of caries and     Conclusions from observations
amounts of 20–40g or more do have                  periodontal disease, but it increases      on dental health determinants
the side effect of causing osmotic                 the susceptibility of tooth surfaces       Although a relationship between
diarrhoea, however, in small confec-               to erosion. Therefore it is a very         sugars and dental caries is accepted
tionery such as chewing gum with                   important task of dental profession-       by all clinicians and researchers work-
amounts of 2g or less per piece, very              als to instruct patients regarding the     ing in the dental field, the degree of
few children have problems. On the                 correct time for daily oral hygiene        emphasis on the importance of this
positive side the reduction of the                 practice, and to instruct the most         factor in prevention and control of
number of sucrose contacts when                    gentle and efficient manner of cleans-     the disease varies. The information
polyol gum is used in place of                     ing. Not only acid in fruit and drinks     we have available today, based on
sucrose gum can substantially reduce               is erosive, but all individuals addicted   studies into the situation in the 1990s,
the total time of acid attack on teeth,            to eating raw vegetables and other         should stimulate a sober scientific
and thereby reduce the caries risk64.              unprocessed food run a very high           and rational approach to the role of
    A special group which will profit              risk of erosion66. In contrast to          fermentable carbohydrates in dental
from the beneficial effect of a polyol,            former assumptions, yoghurt and            caries. If one intended to advise in
especially xylitol chewing gum, are                fresh cheese are not erosive due to        principle against consumption of all
elderly people. Besides the saliva                 the high mineral content and absence       cariogenic food, it would be irrational
stimulation which is necessary in                  of aggressive chelating citric acid67.     to advise only against consumption
many cases of xerostomia, dentate                  Larsen and Nyvad68 found that              of sucrose. The same applies to sugar
individuals with recession and high                otherwise erosive orange juice, pH         substitution in food and snacks;
risk of root caries will profit65.                 4.0, when supplemented with                regarding this issue, Rugg-Gunn64
    Modern ‘non-caloric’ artificial                40mmol/l calcium and 30mmol/l              wrote a comment on a recent review
sweeteners such as aspartame or                    phosphate was not erosive any more         article on the beneficial effects of
cyclamate are not carbohydrates and                because the supplements saturated          sugar substitutes58. It starts with the
therefore do not give rise to cariogenic           the juice with respect to apatite. Such    sentence, ‘Substitution of non-sugar
acid formation in plaque, however,                 a drink has already been launched          sweeteners for non-milk extrinsic
they can only correct the low sweet-               commercially as a ‘functional food’        sugars in the diet is an important
ness of some polyols but not provide               intended to counteract osteoporosis        means of preventing caries’. While
the necessary bulk which sucrose                   – another hint that medical indica-        the statement concerning the useful-
or polyols have to deliver in sweets.              tions are stronger arguments than          ness of sugar substitutes is correct,
                                                   dental ones.                               the sentence nevertheless implicitly
Dietary components increasing                          A good source of original infor-       also contains two misleading state-
the risk of erosive loss of hard                   mation and references to erosion           ments.
tissues                                            literature are the proceedings of the          Firstly, to suggest replacing
Caries lesions are caused slowly by                workshop on ‘Etiology, Mechanisms          extrinsic sugars only would imply that
diffusion of protons of weak bacterial             and Implications of Dental Erosion’        intrinsic sugars such as in fruits are
acids into enamel, thus protonising                published in 199669.                       non-cariogenic; that is not true – all
the phosphate in apatite which then                    In an affluent society with the        sugars are potentially cariogenic.
releases calcium; the pore volume in               possibility to choose from a host of       Secondly, to replace non-milk extrin-
this pre-carious hard tissue increases             exotic and indiginous varieties of fruit   sic sugars only would imply that the
until finally it is weakened to a degree           it seems unlikely that the modern          lactose in milk is non-cariogenic; this
that the layer above the carious                   trend to eat them will be ignored.         also is not the case.
subsurface porosity collapses, and a               Considering the positive health                The choice of sugar-free, espe-
carious cavity is formed.                          effect of fruit and vegetables it would    cially xylitol-containing chewing gum
    In contrast to the diffusion-                  moreover not be feasible to advise         is a welcome preventive possibility.
controlled caries development,                     against consuming them. The best           If the reports on the prevention of
erosion is due to strong acids such                compromise seems to advise people          acute otitis media by xylitol chewing
as citric acid in fruit and acid bever-            to avoid eating the same fruits every      gum are further confirmed, doctors
ages. Contact of a strong acid with                day; not always grapefruit for break-      in well-baby clinics, paediatricians and
the tooth causes an immediate                      fast, but also banana or pear for a        oto-rhino-laryngologists are the
stormy dissolution of the surface                  change – variation in the choice of        professionals to recommend it as a
layer, and mechanical friction after-              diet is the best general health advice     preventive measure with positive
wards (toothbrushing after a break-                possible not only in order to avoid        general health effects in childhood.
fast with grapefruit or apple) whisks              erosion of teeth, but also to avoid        Moreover, any dentist should

International Dental Journal (2000) Vol. 50/No.3

recommend it individually, especially     countries, preventive measures            oranges and lemons. This observa-
to mothers with children and elderly      requiring expensive professionals         tion strongly biased investigators for
people with salivary deficiencies.        may be too costly. In order to achieve    more than 200 years, due to the
However, if issued as a message as        the best possible cost-benefit ratio,     striking evidence that periodontal
to what a healthy diet should consist     the special problems of each high-        disease seemed to be a systemic
of, it is doubtful whether this would     risk population should be studied         disease caused by nutritional deficien-
be understood as dietary counselling      and analysed70. The results of the        cies. Today it seems more likely that
in the traditional sense of the word.     analysis should be the basis of an        Lind saw cases of acute necrotising
It would be more efficient to stimu-      appropriate specific approach to the      ulcerative gingivitis and periodonti-
late the manufacturers of chewing         problem in a developing country; it       tis of bacterial causation rather than
gum to promote products contain-          should not only take into account         scurvy, or at least in addition to
ing xylitol preferentially.               the causes of a high risk (which may      scurvy.
    As a general health message           well be high sugar consumption), but          Before Löe and his team pub-
from the medical side, the recom-         also the economic and cultural back-      lished their clinical-experimental
mendation of a varied diet seems          ground. It may be useful to keep in       work on the bacterial causation of
appropriate from the medical as well      mind that the studies in The Nether-      gingivitis in 196571 nutritional and
as the dental point of view, supple-      lands have shown that despite a           other systemic factors were assumed
mented by the dental recommenda-          continuing high sugar consumption         to be virtually exclusively responsi-
tions and instructions regarding oral     the basic ‘personal prevention pack-      ble for periodontal disease(s), even
hygiene and fluoride use. Detailed        age’ of oral hygiene habits – cleaning    when it was becoming clear that
instruction of patients in gentle,        with a toothbrush and using fluoride      vitamin C deficiency could only
systematic cleansing with a soft brush    toothpaste – seems to have been suf-      explain a small segment of the
and a minimum of pressure is of           ficient to keep more than 80 per cent     problem.
paramount importance since there is       of adolescents caries free. In most
a definite trend to consume more          of the subjects who are not caries        Non-nutritional factors
fruit and more varieties, many of         free, the number of carious lesions       Up until about 1960 nearly every-
them with erosive potential.              has become very low; the problem          body believed that periodontitis was
    The most important observation        of the few with high caries experi-       a systemic disease. This explains why
emerging from recent epidemio-            ence is not that they could not profit    scientists up until the early 1960s
logical studies and reviews on            from personal preventive measures         were still looking mainly for systemic
epidemiological studies is that           and additional professional help: their   disturbances associated with loss of
populations in industrialised coun-       problem is that they do not (yet)         bone and connective tissue. Research
tries are characterised by a very low     react to any advice, and do not seek      was directed towards malnutrition,
caries experience in the younger          any kind of professional help.            hormonal disturbances, occlusal
generation, in general independent            In short, dental health problems      trauma, genetic factors, nutritional
from intake of sugars and other           do not require any dietary recom-         deficiencies and systemic dysfunc-
carbohydrates. The main conclusion        mendations in addition to, or other       tions. American epidemiologists and
is that we should question the neces-     than, those required for maintenance      nutritionists conducted a study on
sity of dietary counselling from what     of general health.                        21,559 subjects in eight areas around
has become a specifically dental point                                              the world: Alaska, Ethiopia, Ecua-
of view, focusing predominantly on        Periodontal health                        dor, Vietnam, Chile, Colombia,
restrictions of sugars in the diet. The                                             Thailand and Lebanon72. Surprisingly,
currently emerging view underscores       Maintenance of periodontal health         this tremendous and important study
the need to adopt a more equili-          is achieved by preventing chronic         tends to be largely ignored nowa-
brated, general-health conscious          inflammation of the gingiva, the peri-    days. It was carried out by a
preventive approach. It should            odontal connective tissues and the        multidisciplinary research team of
recognise the importance of a good        supporting alveolar bone.                 nutritionists, biochemists, physicians
diet, but dietary recommendations                                                   and dentists. The dental epidemiolo-
should be based primarily on medi-        Nutritional factors                       gists included, among the items to
cal and general health considerations     One of the oldest observations on         be studied, a number of local factors
and arguments. Prevention of dental       nutrition and periodontal health is       such as oral hygienic status. Russell
diseases is possible with other, more     James Lind’s account of scurvy in         in 196372 reported on the oral find-
direct measures and should concen-        the first controlled therapeutic trial    ings. As far as dental caries was
trate on achieving better personal oral   conducted in 1747; he experimented        concerned, the Russell study
hygiene and appropriate use of            on sailors suffering from general         confirmed the caries-preventive
fluoride. Where fluoridation of drink-    weakness and putrid periodontal           effect of fluoride in drinking water;
ing water is not feasible, fluoridating   inflammation on board the ship,           furthermore it corroborated the
domestic salt is an alternative dietary   Salisbury. He subjected them to a         earlier finding that people who did
preventive measure.                       number of different treatments, but       not have more to eat than was suffi-
    For the situation in developing       the only effective one was eating         cient for one or two meals per day
                                                                                                      König: Diet and oral health

had lower numbers of carious teeth                 Pre-cancerous lesions and oral                             Community Dent Oral Epidemiol 1977 5: 227–
than well-nourished people.                        cancer develop upon inherited                              230.
   Regarding periodontal health the                predisposition and a variety of envi-                11.   Rugg-Gunn A J, Hackett A F, Appleton
results of the Russell study were, at              ronmental agents, notably alcohol in                       D R, Jenkins G N, Eastoe J E. Relation-
                                                                                                              ship between dietary habits and caries
that time, quite unexpected. The                   high concentrations and tobacco, but
                                                                                                              increments assessed over two years in
research team found periodontitis                  also nutritional/dietary components.                       405 English adolescent school children.
strongly dependent on age in all                       In the case of risk to mucosal                         Archs Oral Biol 1984 29: 983–992.
populations studied, the severity                  health, medical rather than dental                   12.   Burt B A, Eklund S A, Morgan K J, Larkin
increasing with age in all populations             advice is appropriate. In addition to                      F E, Guire K E, Brown J L O, Weintraub
examined. However, periodontitis                   this question of competence, there                         J A. The effects of sugars intake and fre-
was much more closely associated                   is a practical aspect: the risk to                         quency of ingestion on dental caries incre-
with another factor: 12 per cent of                develop pathology originating from                         ment in a three-year longitudinal study. J
the variance could be explained by                 the oral mucosa is high in elderly                         Dent Res 1988 67: 1422–1429.
age, 66 per cent by lack of oral                   people, and due to the high percent-                 13.   Lachapelle D, Couture C, Brodeur J M,
hygiene. In contrast the influence                 age of edentates among them it is                          Servigny J. The effects of nutritional
                                                                                                              quality and frequency of consumption of
of the only nutritional influence                  most likely that they see a doctor
                                                                                                              sugary foods on dental caries increment.
detected, deficiency of vitamin A,                 more often than a dentist.                                 Canadian J Pub Hlth 1990 81: 370–375.
was negligible: 1 per cent of the total                                                                 14.   Palin-Palokas T, Hausen H, Heinonen O.
variance.                                                                                                     Relative importance of caries risk factors
   Although Russell in the discus-                                                                            in Finnish mentally retarded children.
sion section of his paper uttered the              References
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                                                                                                                               König: Diet and oral health

        Diet Working Groups                        Consensus Statement on Diet
Albert Bär        Switzerland
Nino Binns                UK                       The relationship between                 The importance of non-
Richard Cottrell          UK                       fluoride, diet, eating patterns          fermentable sweeteners on oral
R S Levine                UK                       and oral health                          health
Stephen Odusanya          UK                       The bulk of evidence suggests that,      Non-fermentable sweeteners have a
Haim Sarnat             Israel                     where the prevalence of caries has       definite role to play in the promo-
Jorge Sintes             USA                       declined over recent decades, this is    tion of oral health.
Ms van der                                         primarily due to exposure to fluo-           Non-fermentable sweeteners can
Sanden-Stoelinga  Netherlands                      rides rather than due to changes in      be used for the production of non-
Christine Wight           UK                       diet. Carbohydrates are a required       cariogenic soft drinks and low
Susanne Ziesenitz   Germany                        component of a balanced diet. The        volume/high frequency food prod-
Steve Charnock            UK                       fluoride ion is essential for good       ucts e.g. chewing gum and mints.
Maureen Edmondson         UK                       oral health. It is required to protect   Their consumption should be
Bodil Fredberg      Denmark                        against the negative effects of the      encouraged where this helps reduce
Nathalie Henin       Belgium                       bacterial fermentation of carbohy-       the frequency of intake of sugars
Cor Van Loveren   Netherlands                      drates.                                  and other fermentable carbohydrates.
A Ratnanesan         Malaysia                          Where adequate oral hygiene and      These sweeteners can be particularly
Wayne Richards            UK                       fluoride are present daily, diet has     recommended to high risk patients.
John Rogers         Australia                      become a lesser factor in caries
Harold Sgan-Cohen       Israel                     prevention. Without sufficient fluo-
Heung-Ryul Yoon        Korea                       ride and hygiene, diet becomes more
                                                                                            The role of the medical and dental
                                                                                            team in dietary counselling
                                                   important. It is the frequency of
                                                   consumption of all carbohydrate-         Dental health professionals have a
                                                   containing foods and drinks that         primary role in explaining the rela-
                                                   constitute the risk rather than the      tion between diet and oral health.
Workshop issues
                                                   amount.                                      When giving dietary advice related
• The relationship between fluo-                       To minimise the risk of caries       to oral health, account should be
  ride, diet and caries.                           and erosion:                             taken of other health issues relevant
• The significance of diet and eat-                1. Brush twice daily with fluoride       to the patient. Equally, oral health
  ing patterns on oral health.                         containing toothpaste.               issues must be considered when gen-
• The importance of non-ferment-                   2. Manage the frequency of carbo-        eral dietary advice is given to indi-
  able sweeteners on oral health.                      hydrate-containing and acid-con-     viduals.
• The role of the medical and                          taining foods and drinks.                In post-natal clinics health pro-
  dental professionals in dietary and              3. Particularly, discourage continu-     fessionals should play a key role in
  nutritional counselling.                             ous eating and drinking.             oral health promotion.

International Dental Journal (2000) Vol. 50/No.3

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