Longitudinal Relationships between

Nutrition and Oral Health

ATHENA S. PAPAS," CAROLE A. PALMER,"
MAUREEN C. ROUNDS," JOAB HERMAN,"
ROBERT B. MCGANDY,~STUART c. HARTZ,~
ROBERT M. RUSSELL,b AND
PAUL DEPAOLA'
"School of Dental Medicine
Tufts University
Boston, Massachusetts 02111
bHuman Nutrition Research Center on Aging
United States Department of Agriculture
Boston, Massachusetts 02111
'Forsyth Dental Research Center
Boston, Massachusetts 02115

INTRODUCTION

Poor oral health can profoundly decrease appetite and the ability to eat, which
in turn may lead to poor nutrition. Compromised nutritional status may result in
an impaired immune response and resistance to infection, retarded wound heal-
ing, poor oral health, and, ultimately, general ill health.
The recently completed National Dental Survey of Oral Health of United
States Adults' indicates that 42% of those attending senior centers are edentulous.
The average number of teeth in those retaining natural teeth was only 17. Al-
though these figures indicate an improvement since past national surveys, they
are still not indicative of good oral health, nor are they indicative of what the oral
health is of the inner city poor who do not attend senior centers. Of the elderly
who retained some of their teeth, 22% exhibited signs of periodontal disease as
defined by at least one periodontal pocket with a depth of at least 4 mm. Eighty-
eight percent had gingival recession in at least one site, exposing roots to the oral
environment and thus root caries. The mean number of decayed or filled teeth was
7.6. Ninety-one percent of the tooth surfaces designated as decayed or filled were
filled. Only 37.5% of the seniors had received dental care within the past year.

LOCAL FOOD EFFECTS ON CORONAL CARIES

Local food factors have been recognized since the time of Aristotle as contrib-
uting to the development of caries.* Over the past century, many epidemiological
and clinical studies have established the causal relationship between the con-
sumption of fermentable carbohydrates and caries development. TABLE1 lists the
major studies that have investigated the relationships between dietary patterns
and cariogenicity. These studies have identified several factors that are associated
l24
PAPAS et 01.: NUTRITION AND ORAL HEALTH us
with caries incidence. These factors, which will be investigated further, are listed
below:
1. Amount of carbohydrate consumed.
2. Sugar concentration of food item.
3. Physical form of carbohydrate.
4. Oral retentiveness (length of time teeth are exposed to decreased plaque
pH).
5 . Length of interval between eating times.
6 . Frequency of eating of meals and snacks.
7. Sequence of food consumption.
8. Pattern of food consumption.
Other problems exist, however, that make studies in this area difficult, such as
the existence of the many variables that affect cariogenisity and the great inter-

TABLE 1. Selected Epidemiological Studies on Diet and Caries

Subject of Study References
Wartime dietary restrictions Toverudss
Takeuchi6
Unusual dietary patterns“ Holloway et aL7
Fishers
Vegetarian, sugar-restricted dietsh Lilienthal et u I . ~
Sullivan and Hamslo
Sucrose-free diets‘ Marthaler and Froeschii
Relationships between dental caries Gustafsson et a / .
and dietary patterns Zita et al.I3
Weiss and TrithartI4
Duany et ~ 1 . ‘ ~
Hankin et al. l6
Kohler and Holsti7
Clancy et al.’*
Burt and c o - w o r k e r ~ ~ ~ ~ ~
Rug-Gunn and c o - ~ o r k e r s ~ ~ - ~ ’
I~mail~~
Burt et U I . ~
Studies of primitive societies that changed to Western diets.
Studies of children at Hopewood House.
Studies of people with hereditary fructose intolerance-an inborn metabolic flaw requir-
ing a virtually sucrose-free diet.

and intraindividual variability in food intake. Also, the sequence of eating is

important, as foods are mixed with other foods before and during ingestion (for
example, if cheese or peanuts are eaten after a sugar exposure, the duration of the
pH drop is reduced).2628 Time of day (for example, fermentable carbohydrate
consumption before bedtime), length of intervals between eating, rate of inges-
tion, variations in food form and composition, and effects of cariostatic factors-
all effect the rate of cariogenicity.
Information about the effective cariogenicity of food (the total exposure time
of teeth to fermentable carbohydrate challenges) and the identification of foods
that are “friendly to teeth” would be important. The Consensus Conference on
CariogenicityZ9concluded that confirmatory results of any two studies (for exam-
126 ANNALS NEW YORK ACADEMY OF SCIENCES

ple, animal studies, in uitro studies, or interproximal plaque pH studies) could be

used to determine whether a food is noncariogenic. The sucrose content of food is
not related to acidogenic potential, nor is acid production necessarily related to
the amount of enamel dissolved.30
Using human studies, investigators are able to identify dietary patterns that
tend to increase the risk of oral disease; however, investigators cannot rank foods
in order of ~ariogenicity.~’ Ethical considerations do not allow studies that use
cariogenic diets in humans. The fluoridation of water supplies has resulted in a
lower caries rate."^^*-^^ The high level of “hidden sugars” in the diet may mask
possible differences between dietary patterns. All of these factors add to the
complexity of such investigations.
Burt et al.35have conducted a longitudinal study on a teenage cohort. They
reported that the average daily consumption of sugar was strongly related to
proximal and smooth-surface caries and weakly related to total caries incidence.
Children who developed two or more carious lesions reported more snacking on
at least one high-sugar food and consumed more snack carbohydrates and more
calories after 9:OO P.M. When high- and low-sugar groups were compared for
caries, there were statistically significant differences in DMFS (decayed, missing,
and filled surfaces) and smooth-surface caries between the groups. The average
number of eating occasions was not significant. Rugg-Gunn et a/.*’ also found that
the total amount of sugar consumed was more strongly associated with canes
incidence than frequency of consumption.
Because sugar consumption has been observed to rise again in older Ameri-
cans (males and females in the 65-74 age group consumed 53% and 47% more
sugar-containing foods than young adults in the 19-24 age group26),it is important
that caries incidence and dietary patterns be observed in the older adult as well as
the adolescent.

EFFECT OF STARCH ON CARIOGENICITY

Other carbohydrates such as starch can affect cariogenicity. Therefore, total

fermentable carbohydrates as well as sucrose alone should be measured. There is
a large amount of evidence from various sources suggesting that mixing a starch
with sugars increases cariogenicity . In the Vipeholm Study, sugar-rich bread at
meals was found to be more cariogenic than sugar in liquid form.’Z Several animal
~ J ’ have shown that a starch base can
studies have confirmed these r e ~ u l t s ~ and
actually enhance cariogenicity by increasing the retentiveness of fermentable
~ ~ . ~ ~ et a1.40also observed a trend for
carbohydrates in the oral c a ~ i t y . Rugg-Gunn
starches to increase caries in his study of children.

EVIDENCE FOR DAIRY PRODUCTS SERVING AS PROTECTIVE

FACTORS

It has been suggested that diets containing dairy products (especially cheese)
are anticariogenic. Many mechanisms for this protective effect have been pro-
posed. Dairy products may affect caries incidence in several ways. They can
lower the critical pH of plaque through the diffusion of calcium and phosphate
into plaque. Lipids derived from dairy products coat the tooth surface, but the
inhibition of bacterial growth by fatty acids has not been verified. Proteins can
PAPAS et 01.: NUTRITION AND ORAL HEALTH u7

reduce demineralization by absorption onto the tooth surface. Caseinates and

other organic phosphates found in milk products have been found to help reduce
enamel in uitro demineralization by augmenting the action of the acquired pellicle
and inhibiting adhesion of normal microbial flora.4148Acid buffering and common
ion effects may be present with phosphates, calcium, calcium lactate, calcium
propionate, or fluoride. Dairy products may also stimulate salivary secretion rate
and composition, thus increasing oral clearance and buffer capacity.49Further
lipids derived from dairy products may coat the tooth surface.
Schachtele has shown that the consumption of cheeses after the consumption
of an item offering a cariogenic challenge can totally obliterate any cariogenic
effect of that item. Silva et found that cheese extracts reduce acid demineral-
ization in uitro and in intraoral plaque pH studies.
In uitro plaque pH studies,51studies on experimental a n i r n a l ~ , ~demineral-
”~~
ization studies,5s7-day intraoral cariogenicity tests,56and epidemiological obser-
vations of human subjectss7suggest that diets containing dairy products (espe-
cially cheese) exert caries-protective effects or anticariogenic effects or both.

OTHER FACTORS AFFECTING CARIOGENICITY

Other dietary factors may play a role in mitigating or increasing cariogenic

potential. Most fermentable carbohydrates are found in foods in association with
other constituents, including nonfermentable carbohydrates such as dietary fiber,
protein, fats and oils, water, and vitamins and minerals (of which calcium, phos-
phate, and fluoride may be especially important). The presence of these other
factors can alter the cariogenicity of the ~ a r b o h y d r a t eFor
. ~ ~ example, fats may
coat teeth, physically decreasing the amount of fermentable carbohydrate re-
tained and preventing the acid from reaching plaque; that is, fats may be bacterio-
~ i d a l . Bicarbonate,
*~ sialin, argenine, urea, and phosphate have all been demon-
strated in uitro and in animal studies to be caries-protective but have not been
demonstrated to be effective in human s t u d i e ~ . ~Salty
~ . ’ ~or acidic food stimulates
salivary flow. Lectins, tannins, and other compounds that are less well character-
ized may affect microbial metabolism and adhesion. Boron, aluminum, molybde-
num, vanadium, strontium, and iron are caries-inhibiting, whereas copper, sele-
nium, lead, manganese, and cadmium are caries-accelerating.m Substances
affecting the physical nature of food (nuts, granular substances) speed removal,
probably by increasing salivary flow. Flavoring agents such as licorice retard the
dissolution of enamel. Crude fiber is harder to chew and is nonretentive; conse-
quently, it increases salivary flow, and could make fermentable carbohydrate
relatively unavailable to plaque.

DIETARY FACTORS IN THE ETIOLOGY OF ROOT CARIES

Recent surveys show a broad range of root caries prevalence values, ranging
from 15% in military personnel who have good dental care, to 83% in nursing
home residents. Prevalences of root caries run much higher in the elderly than
among younger adults: 67% of the males and 61% of the females from a senior
center population included in a 1985 survey by the National Institutes of Dental
Research1 had root caries. Also, those who have more exposed root surfaces are
at higher risk; 89 percent of the patients suffering advanced periodontal disease
TABLE 2. Relationships between the Presence of Root Caries and Selected Variables in Multivariate Studies"

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a Each of the column headings indicates the principal author or coauthors of a multivariate study. These column headings correspond to the
3
followingreference citations: Hiu and O'Leary62; Schamschula et al."@; Ravald et aLa; El-Hadary et a1.&; Sumney et al.67;Lohse et al.@;DePaola
et a1.*; Burt et aL7';Vehkalahti and P a ~ n i oand
~ ~Vehkalahti7'; Beck et aL7'; Banting et a1.l'; and Kitamura et aL76
PAPAS el ol.: NUTRITION AND ORAL HEALTH 129

had root caries.61 Risk factors for root caries now being investigated are listed in
TABLE2.
Dietary factors have been implicated in the incidence of root caries. Studies of
primitive tribes, New Guineans and aborigine^,^.^^.^ and observations of ancient
have shown that people whose diets were high in complex carbohydrates
did not have a high prevalence of coronal caries but did have root caries. Hix and
O'Leary62 and Ravald et al.,65who conducted dietary studies on patients with
periodontal disease, found statistically significant correlations between the fre-
quency of consumption of fermentable carbohydrates and root caries. Similar
findings have also been found by our g r o ~ pand ~ ~by, Vehkalahti
~ ~ and P a ~ n i o . ~ ~

NUTRITION AND PERIODONTAL DISEASE

The influence of nutritional factors on susceptibility to and progression of

periodontal disease has been difficult to determine. This is in part due to the
methodological difficulties inherent in clinical nutritional studies. Nevertheless,
several recent studies in both humans and laboratory animals have targeted sev-
eral areas of interest.
Vitamin A is necessary to maintain the integrity of epithelial tissues. Vitamin
A in sufficiently high doses causes mucous metaplasia of keratinizing epithe-
Vitamin A deficiency produces squamous metaplasia, xerophthalmia, fol-
licular hyperkeratosis, and atrophy of sebaceous glands.70 In salivary gland duct
cells, the squamous metaplasia and associated keratin production can eventually
lead to xerostomia because of occlusion of duct lamina.81*82
Several nutrients have been identified tentatively as contributing to the pro-
gression of periodontal disease. Nutritional status may be impaired by inadequate
dietary intakes in the elderly and by common medications that alter folk acid
metabolism. A substantial percentage of the American elderly population appears
to be at risk for folate d e f i ~ i e n c y . ~Folate
' , ~ ~ deficiency results in impaired sulcular
epithelial barrier function.84 In monkeys, folate deficiency decreases host im-
munocompetence and causes severe mucosal inflammati~n.~' Controlled human
studies by Vogel and Deasyg6 have shown that supplementation with folate can
significantly reduce gingival fluid flow and the bleeding index.
Ascorbic acid has also been studied extensively with contradictory findings
because of its role in collagen synthesis. Studies of monkeys have shown that
even marginal ascorbic acid deficiencies can affect host defense to periodontal
i r r i t a t i ~ n . In
~ ~animals
. ~ ~ with suboptimal ascorbic acid intake, but without clinical
signs of ascorbate deficiency or spontaneous gingivitis, experimentally induced
periodontitis resulted in significantly greater pocket depth and gingival index
scores when compared to a controlled group. Increased collagen formation and
significant decreases in sulcular epithelial permeability in humans were also asso-
ciated with one gram/day supplementation of diets already adequate in vitamin C.
In other controlled human studies,89 statistically significant inverse correlations
were found between epithelial permeability and the concentration of ascorbic acid
in the sulcular epithelium. Ismail et al." found low correlation between low
vitamin C levels and periodontal disease.
Tissue levels of zinc, a nutrient that is often found to be lower than the
Recommended Dietary Allowance in the diet of elderly persons, may also be able
to modify periodontal defense levels. Zinc deficiencies can inhibit leukocyte activ-
ity9I and increase sulcular epithelial permeability, thus increasing gingival fluids
130 ANNALS NEW YORK ACADEMY OF SCIENCES

and gingival i n f l a m m a t i ~ nBecause

.~~ there is controversy over the current Rec-
ommended Dietary Allowances for zinc and the adequacy of food composition
data on zinc, it is difficult to interpret the results of these studies.

STUDIES CONDUCTED BY THE TUFTS SCHOOL OF DENTAL

MEDICINE ON DENTATE STATUS AND NUTRIENT QUALITY OF
DIET

The relationship between dentate status and nutrient quality of the diet has
been studied in 181 free-living volunteers (1 14 females and 67 males) over 60 years
of age. This study population is a subset of the Nutritional Status Survey (NSS) of
691 free-living subjects, aged 60-98 years, conducted by the United States De-
partment of Agriculture-Human Nutrition Resource Center (HNRC) at Tufts
University.

FIGURE 1. Caloric intake for males and females: rop panel: calories; borrorn panel: calo-
ries/kg.
PAPAS ef 01.: NUTRITION AND ORAL HEALTH 131

W Male
0 Female

p = 0.021

FIGURE 2. Crude fiber intakes for males and females.

Data obtained by the HNRC on each NSS subject included the following: a
blood chemistry analysis; a 3-day food diary; a modified physical examination;
anthropometric measures; a medical history; information on medication use; liv-
ing, shopping, and cooking arrangements; tobacco and alcohol consumption; age,
sex, and education level. Additional information obtained by the Tufts University
School of Dental Medicine substudy was information on each subject's dental
knowledge attitudes and behaviors determined by administration of a question-
naire. The following oral health parameters were also measured: root caries,
coronal caries, periodontal status, plaque debris index, and calculus index.
The NSS population is characterized by a high educational level and is 98%
Caucasian (despite the fact that an attempt was made to recruit a more diverse
population reflective of minorities). Nutritional data revealed low intakes of cer-
tain nutrients between both males and females: vitamins D, B6, and Blz as well as
folate, zinc, and calcium. Three life-style characteristics were found to affect food
intake and dietary quality adversely: low educational attainment, low median
family income, and wearing dentures (either partial or full).
Subjects were divided into four groups according to dentate status. In group 1
( N = 48), each subject had two full dentures. In group 2 ( N = 23), each subject
had one full denture; the mean number of teeth was seven; and 24% of the
subjects had periodontal pockets deeper than 4 mm. In group 3 (N = 47), each
subject had partial denture(s); the mean number of teeth was 18; and 15% of the
subjects had periodontal pockets deeper than 4 mm. In group 4 ( N = 63), each
subject had teeth and no dentures: the mean number of teeth was 23; and 15% of
the subjects had periodontal pockets that were at least 4 mm deep.
Analysis of total calories and 19 nutrients showed a statistically significant
drop in the nutritional quality of the diets of those who had one or two full
dentures as compared to those who had teeth and no dentures, or partial dentures
(FIGS.1-5). This drop was approximately 20% for most nutrients. In this popula-
tion, these findings were independent of demographic factors such as education.
In a geriatric population, which would not have a large margin of safety and would
include subjects whose nutritional status was marginal, this could result in nutri-
tional deficiency. Similar findings were found in a study of 75 Veterans Adminis-
tration Dental Longitudinal Study participant^.^^ In order to determine whether
this decrease in the nutrient quality of the diet was due to tooth loss, longitudinal
data collected over an extended period of time would have to be examined.
132 ANNALS NEW YORK ACADEMY OF SCIENCES

215 ..............................................
250
O1 225
k
200 .................................. .................................
Y 175
Y
..................................................
2 150 ..............................................................
1125
c
g 100
'i 75
;
Y
50
25
0 2D I D PD T 2 D I D PD T
2D I D PD T 2 0 I D PD 1
Protein Total fat Total CHO Mono t Disaccharides

FIGURE 3. Protein, total fat, total carbohydrate, and mono- and disaccharide intakes for
males and females.

3500
..................................................................

9 3000
2500
.................................................................. ..........................................................

,g
c
2000
.........................................................................................................................................................

....................................................................
1500

'
..................................................................
W
0 1000 fi p = 0 002
............................
500

0 '
T 20 I D PD T ' 2D I D PD T
Calcium Phosphorus Magnesium Potassium

FIGURE 4. Calcium, phosphorus, magnesium, and potassium intakes for males and fe-
males.

275
250
225
200
175
150
125
100
75
50
25
0
Thiamin Niacin Vitamin 86 Vitamin C Vitamin D Folic Acid

FIGURE 5. Nutrient intakes as percentages of the Recommended Daily Allowances.

PAPAS el ol.: NUTRITION AND ORAL HEALTH 133

NUTRITION AND ORAL HEALTH STUDY

Three hundred seventy middle-aged to elderly adults living independently

were recruited from the NSS and from the community. A special group of subjects
with histories of use of prescription drugs and medications causing xerostomia
were included for separate analysis. Care was taken during the screening process
to keep the percentage of these participants low. Because there are at least 400
relatively common drugs and medications that have been reported in the Physi-
cian's Desk Reference to produce xerostomia as a side effect, it is not possible to
prevent all such subjects from participating, especially in the geriatric population.
Also, this is a subgroup that is likely to develop caries more rapidly.

DATA OBTAINED BY THE TUFTS UNIVERSITY SCHOOL OF DENTAL

MEDICINE

Standardization and Calibration of Measures

At the beginning of the study, training exercises were performed with Doctor
Soparkar, the examiner for the Forsyth Root Caries Study; Doctor Papas, the
principal investigator; and Doctor Giunta, the examiner for the Nutrition and Oral
Health Survey. Following these initial sessions, annual standardization and cali-
bration sessions are being conducted with Doctor Soparkar supervising. The
maintenance of measurement methods are being reconfirmed by conducting addi-
tional calibration sessions once every two months with Doctor Soparkar super-
vising.

Oral Examinations
All of the oral parameters recommended by the National Institute of Dental
Research' were included as well as additional ones important to this study. The
additional parameters were as follows:
1. Erosion, abrasion, and attrition.
2. Periodontal examination of mesial, distal, buccal, and lingual sites.
3. Silness and low plaque index.93

Diet Records
Participants were asked to measure all foods with common household mea-
sures. We considered the possibility of obtaining weighed food intakes; however,
in our previous experience, we had found that this greatly reduces response rates.
The food diaries were analyzed using two systems:
1. To evaluate the diet diaries for nutrients, we purchased the CBORD system
adaptation of the Nutrient Data Bank at Case Western Reserve University.
2. To assess the diets for cariogenic potential, a food grouping system for
potential diet cariogenicity devised at the Tufts University School of Dental
Medicine and pretested at Tufts and the Forsyth Dental Research Center
were used.
134 ANNALS NEW YORK ACADEMY OF SCIENCES

The food records were used to assess patterns of eating potentially cariogenic
foods that were analyzed in reference to specific oral health indices. Diet records
are being collected twice annually. They are planned to include at least one
weekend day as well as weekdays.

TABLE 3. Palmer Classification of Cariogenicity"

Classification
Type of Food Code Specific Foods
Not Cariogenic
NI Eggs, bacon, sausage, nuts, peanut butter, butter,
gravies, margarine, salad dressing, club soda,
water, coffee, tea, cream, artificial sweetener,
nonlegume vegetables, meat, fish, poultry, soups
N2 Antacid tablets

Sliehtly Cariogenic or Possibly Cariostatic

Ci Cheese
D1 Milk, yogurt, buttermilk
LI Fruit juicesb

Moderately Cariogenic
Starchy S1 Cooked starch (tortilla, rice, noodles, macaroni,
spaghetti), potatoes, cooked cereal, popcorn,
legumes, corn
s2 Plain cereal
s3 Crackers
s4 Bread, rolls, cornbread

Highly Cariogenic
sugary' FI Soft drinks, mixed drinks, fruit drinks, sugar or
honey in beverages (coffee or tea), nondairy
creamer, cocoa, Kool-Aid, lemonade, breakfast
drinks, tonic water
F2 Ice cream, ice milk, frozen desserts, applesauce,
puddings, custard, gelatin desserts, sherbert,
flavored yogurt, whipped cream
F3 Donuts, cookies, cakes, sweetened cereals, pies,
pastries, sweet rolls, sweet bread, chocolate
candy, canned fruit, Pop Tarts, wheat flakes, soda
crackers, snack crackers, pretzels, chips, cara-
mels, muffins, coffee cake
F4 Dried fruits, marshmallows, toffee, sticky candy,
jelly, jam, syrup, molasses, bananas, gum
F5 Breath mints, cough drops, hard candy
a The most frequently eaten carbohydrate-containing foods are derived from Block; the
highly cariogenic foods are derived from the dental literature.
Sialagogues.
The sugary foods are listed in order of oral retention: F1: liquid sugars; F2: semisolid
sugars; F3: solid sugars; F4: sticky sugars; F5: slowly dissolving sugars.

The use of dietary records for individual dietary assessment has recently been
reviewed by B i t ~ g h a r n For
. ~ ~ most purposes, 6-9 days of diet records should
suffice to obtain stable estimates of habitual (usual) nutrient intakes. According to
Hackett et uI.,~'with two 3-day food diaries we should have a reliability of 58%.
PAPAS ef ul.: NUTRITION AND ORAL HEALTH 135

In our previous studies, we have found that this number of days will suffice for
assessing food consistency and food use patterns that are associated with ca-
riogenicity. Six days of records per year should also provide enough information
to assess differences in a variety of foods.
Because some of these products are cariogenic, subjects were also asked to
record medications, supplements, and other consumables (such as cough drops
and breath mints) used during the specific 3-day periods (including a weekend
day). ‘They were asked to record the specific order in which foods and beverages
were consumed during meals and between meals, and the time and duration of
each eating/drinking period. This is important for estimated total cariogenic expo-
sure times. They were also asked to record their bedtime in order to determine
whether a snack was eaten prior to retiring. The number of foods was determined
for an estimate of variety of food.
The dietary history was analyzed by the Palmer and Papas scoring method,
which incorporates timing and physical form and retention characteristics of the
ingestion. Palmer and Papas devised an improved and abbreviated cariogenicity
scale (TABLE3). This improved scale, which is based upon prior scales, rates
foods according to potential oral retentiveness. The index assigns the 50 most
commonly consumed carbohydrate-containing foods (according to food consump-
tion surveys conducted by the U.S. Department of Agriculture), and assigns
additional items known to be potentially cariogenic in the U.S. diet to one of nine
groups based on their physical characteristics.
Briefly, all carbohydrates listed in the 3-day food diaries were scored using the
Palmer scoring system for frequency of use of potentially cariogenic foods having
various degrees of oral retentiveness. The frequency of ingestion of water and
noncariogenic liquid and the frequency of consumption of cheeses known to be
cariostatic were also tallied and incorporated into the Palmer index. From this
information, it is possible to determine whether patterns of eating in general and
patterns of eating foods of specific types and with constituents such as carbohy-
drates are associated with the oral conditions being studied.

FOOD FREQUENCY QUESTIONNAIRE

No valid and reliable short questionnaire covering all of the variables known to
influence the cariogenic potential of food and diets is yet available. Burt’s group
developed a questionnaire that addresses some (but not all) of these issues; how-
ever, after discussions with him, he did not believe it had been sufficiently vali-
dated for use in this study. Schroeder’s instrument, which is based on Swedish
diets, was also inappropriate. By using the Block% questionnaire and by adding
the list of frequently consumed carbohydrates to it, we were able to find that the
correlation coefficient between the data from the 5-6-day food diaries and the
data from the food frequency questionnaire for fermentable carbohydrates was
0.69.

PRELIMINARY RESULTS

Initial analysis of the data obtained demonstrates several correlations between

the intake of fermentable carbohydrates and both root and coronal caries. Statisti-
cally significantly higher intakes of solid fermentable carbohydrates (that is, cakes
and cookies) and breakfast cereals were found in participants who were in the
highest quintile as opposed to those who had no root caries (TABLE4). Similarly,
l36 ANNALS NEW YORK ACADEMY OF SCIENCES

TABLE 4. Relationship of Solid Fermentable Carbohydrates to Coronal Caries"

Mean Statistical Data
Breakfast cereals
Subjects with no cariesb 0.27 r = 2.066; p < .05
Subjects with 6-28 caries' 0.80 I = 2 . 0 6 6 ; ~< 5 0
Solid fermentable carbohydrates
Subjects with no cariesb 3.71 t = 2 . 5 2 8 ; ~< .025
Subjects with 6-28 cariesc ' 5.50 t = 2.528; p < .025
All data are taken from the Nutrition and Oral Health Study.
b The mean was calculated for all of the subjects in this subpopulation ( N = 135).
'The mean was calculated for the highest quintile of subjects in this subpopulation
( N = 20).

TABLE 5. Weekly Frequency of Food Consumption by Root Caries Status"

~~

Root Caries Statusb

Diseased Healthv Mixed
Fruits and fruit juices 12.03 15.78 17.77
Noncariogenic foods 36.60 46.05 36.80
Cheese 2.07 3.16 2.85
Other dairy products 6.42 8.01 7.87
Liquid sugars 21.02 11.14 15. 11
Semisolid sugars 3.46 2.52 2.66
Solid sugars 12.77 9.54 11.77
Sticky sugars 6.80 6.12 6.41
Slowly dissolving sugars 6.21 6.28 4.01

Total 50.26 35.60 39.96

~~

All data are taken from the Forsyth Root Caries Study ( N = 275).
The three categories for root caries status are as follows: diseased, at least one root
surface lesion; healthy, no root surface lesions or fillings; mixed, no root surface lesions but
may have fillings.

TABLE 6.Patterns of Consumption of Fermentable Carbohydrates for the Caries

Incidence and Caries Prevalence Groups"
Number of Times a Food Item
Was Consumed
Group from the Group from the
Food Item Incidence Study* Prevalence Study'
~ ~~ ~~ ~~

Liquid sugars 5.22 4.00

Semisold sugars 2.39 3.56
Solid sugars 5.69 6.46
Sticky sugars 4.25 4.00
Slowly dissolving sugars 0.99 2.00

Total 21.44 20.02

All data are from 3-day food records.
The subjects in this group developed root caries.
The subjects in this group were from the highest quintile of subjects having 6-28 canes.
PAPAS el a/.: NUTRITION AND ORAL HEALTH l37

there was a statistically significant association between higher intake of sugary

liquids, solid fermentable carbohydrates, and starches in those who presented
with root caries as compared to those who were free of root caries in the Forsyth
study. Additionally, those who were free of root caries consumed 50% more
cheese and 25% more milk than those participants who had root canes (TABLE5 ) .
Although the analysis of our year 2 data is in progress, the group that devel-
oped root caries had similar fermentable carbohydrate consumption patterns to
those for the group that included subjects who were in the highest quintile in at the
initial visit (TABLE6). The caries incidence observed in our study was found to be
similar to that found in a representative sample of 451 rural, free-living Iowans in
the same age group (TABLE7).97

TABLE 7. Coronal Canes and Root Caries Incidence

~~

Incidence
Coronal Caries Root Caries
Papas" Beckb Papas" Beckb
Initial 1.14 1.15 0.78 0.76
Recurrent 0.16 0.15 0.14 0.09
Net 1.30 2 2.68 1.30 0.92 2 1.59 0.85
(' Number of subjects: 142; time period: 12 months.
'' Number of subjects: 451; time period: 18 months.

DISCUSSION

Several problems exist with the methodologies of dietary studies of caries.

Most critically, they have usually attempted to associate lifetime caries experi-
ence with a short-term dietary survey. A 40-year-old person, for example, may
have developed most of his DMFS by the age of 20, but in such studies his dental
history is matched against a food diary or food frequency questionnaire that
reflects habitual diet at age 40 only. To overcome this problem, we planned a
semilongitudinal 3-year study in which both nutritional factors and local food
factors were studied over time to enable us to observe dietary patterns as the
canes develop.
In conclusion, those participants with root caries consumed more sugary items
and less dairy products than those who were free of root caries, at levels that were
statistically significant. In our longitudinal study, those who had developed root
caries at the end of 14-16 months consumed sugary foods in amounts similar to
those consumed by the group that included subjects who had a high canes level
(upper quintile) at the initial visit. A preventive program of nutritional counseling
and fluoride treatment for 1 month decreased the caries incidence threefold in our
small prevention group. Thus, as in coronal caries, sugar is involved in the devel-
opment of root caries. There is suggestive data that starch is also involved in the
root canes process. Initial data also suggest that dairy products may have a
caries-protective function. It is our opinion that preventive measures, such as
nutritional counseling, preventive dental education, and fluoride therapy, may
l38 ANNALS NEW YORK ACADEMY OF SCIENCES

help reduce the risk of root and coronal canes. If the preliminary results demon-
strating that dentate status can affect nutritional status are borne out by longitudi-
nal studies, more active educational programs will have to be instituted to teach
elders the importance of maintaining their dental health. Further studies are in
progress.

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