DIET AND DENTAL

CARIES
CONTENTS
★ Introduction
★ Definition
★ Role of diet in caries process
★ Cariogenicity of diet
★ Classification of sugars
★ Sugar substitutes
★ Importance of diet and
nutrition in pediatric dentistry
★ Dietary screening and
education in the dental
practice
★ Objectives of counselling
★ Diet counselling
★ Steps involved in diet
counselling
★ Role of carbohydrates in caries
★ Studies on groups have low
sugar diet
★ Role of minerals in dental caries
★ AAPD recommendations
★ Conclusion
★ Reference
INTRODUCTION

❖ Dental caries is the result of complex interactions involving the individual

(nutrition, genetics, behaviour, race & age), plaque bacteria, saliva flow &
composition and the environment

❖ Promotion of sound dietary practices is an essential component of caries

management, along with fluoride exposure and oral hygiene practices
DEFINITION
According to E. Newbrun,
“Diet refers to the customary allowance of food and drink taken by any
person from day to day”
ROLE OF DIET IN CARIES PROCESS

❖ Diet exerts a profound effect on dental caries locally

in the mouth by reacting with enamel surface and by
serving as substrate for cariogenic micro-organisms
which produce acid thereby reducing the pH and
causing dissolution of tooth surface.
ROLE OF NUTRITION IN ORAL TISSUES
PRE ERUPTIVE EFFECTS

❖ Causes irreversible changes.

❖ Enamel maturation, physical and chemical composition, time of
eruption, tooth morphology and size are all affected by pre eruptive
nutrient intake.
❖ The dental dysplasias associated with malnutrition are:

.
● Odontoclasia in deciduous dentition
● A yellow teeth in permanent teeth
● Infantile melanodontia in deciduous
teeth
● A linear hypoplasia of deciduous
incisor teeth occurs due to
deficiency in ascorbic acid or
vitamin A or neonatal infection

Shoban peter. Essentials of Public Health Dentistry, 5th edition

POST ERUPTIVE EFFECTS

❖ Decreased salivary lysozyme and secretory IgA levels.

❖ Changes in salivary peroxidase, lactoferrin, lysozyme and other proteins can reduce
the host defence mechanism to cariogenic organisms.
❖ In children with protein calorie malnutrition, IgA is reduced in the secretions thereby
increasing caries suspectibility.
CARIOGENICITY OF DIET
❖ Cariogenic potential : a food’s ability to foster caries in humans under
conditions conductive to caries formation

❖ Cariogenicity : the true cariogenicity of a food can only be established by

experimentally determining in humans the extend of tooth decay associated
with a given food” .- Stamm JW et al.1986
In order to evaluate the cariogenicity of the diet, the balance between the other
causative as well as protective factors should be taken into consideration

➔ Nature of the diet

➔ Retention & oral clearance time of dietary components
➔ Intake frequency
➔ Chemical composition
➔ Protective components in the diet

When the causative factors overpower the protective factors in the diet , it is termed
cariogenic.
Nature of the diet
❖ The form of fermentable carbohydrate directly influences
the duration of exposure and retention of the food on the
teeth.
❖ Liquid sugars pass through the oral cavity quickly with
limited contact time or adherence to the tooth surface
❖ Holding sugar containing beverages in the oral cavity for a
prolonged time increases the risk of caries
❖ Long lasting sources of sugars (hard candies, lollipops)
have extended exposure time because the sugars are
gradually released during consumption.
Retention and oral clearance time of dietary components

❖ It vary by individual person and depend on metabolism

by micro organisms, adsorption onto oral surfaces,
degradation by plaque, salivary enzymes , flow, and
swallowing
❖ Retentiveness of foods is not the same as stickiness
❖ A caramel or jellybean may be sticky but its retentive
properties are fairly low and they are cleared from the
oral cavity faster than retentive foods such as cookies
or chips
Intake frequency

❖ Significant contributor to the cariogenicity of the diet

❖ Higher frequency means more demineralization and less remineralization
❖ The duration of the decrease in the pH after intake of a cariogenic food is an
important confounder.
Chemical composition

❖ Earlier it was thought that consumption of sugars mainly sucrose was the
key factor in the development of tooth decay
❖ But processed cooked food combined with refined sugars also contribute to
dental caries
❖ Diet and nutrition may favor remineralization when their content is high in
calcium , phosphate and protein.
❖ The acidity of individual foods can precipitate erosion. This depends on the
oral buffer systems to neutralize the food
❖ Because the critical pH of enamel dissolution is 5.5,
any food with low pH may stimulate erosion
❖ This can be minimized by adequate salivary flow and
good oral hygiene habits
❖ Large doses of chewable vitamin c may also cause
decrease in pH because of its citric acid content,
which contributes to tooth erosion
Protective component in the diet

❖ Some components of food are caries inhibiting and have been called protective ,
especially products that are rich in calcium and phosphates

They act by :

❖ Reducing the rate of dissolution of hydroxyapatite

❖ Reducing the fall in plaque pH by buffering acids produced by fermentation
❖ Enhancing remineralization
❖ Modifying formation and composition of pellicle and plaque
 SUGARS
❖ Sugars are types of soluble carbohydrates that provide energy in the diet.
❖ Compared with other types of carbohydrates, they are quickly absorbed into
the body and are less filling.
ROLE OF SUGARS IN DENTAL CARIES
❖ Sugars are used to enhance the flavours of food and drink, and can be
added by the consumer or by the food and drink industry.
❖ Sometimes it is known as ‘hidden sugar’ as the consumer may not know
the presence of sugar.
❖ Sugars can be intrinsic or extrinsic .
❖ Intrinsic sugars occur naturally within the cellular structure of a food e.g) sugars in
whole fruit.
❖ Extrinsic sugars, on the other hand, include milk sugars (lactose) and so-called ‘free
sugars’.
❖ It is these free sugars that can be added to food and drink by the consumer or by
the food industry.
❖ While intrinsic sugars doesn’t have any adverse effect on general health or dental
health, free sugars can be detrimental and contribute to dental caries .
❖ The term sugar is
generally intended to ❖ The term added sugars are all mono-
mean all “dietary and disaccharides added to food by the
sugars,” whether added manufacturer, cook, or consumer —
to foods or naturally which will therefore include white,
occurring (Cummings brown, raw, manufactured, corn
and Stephens 2007). syrups, high fructose corn syrup, and so
on.

❖ The term free sugars, as used by the WHO (2015) in its sugar report,
encompasses “all mono and disaccharides added to food by manufacturer,
cook or consumer plus those sugars naturally present in honey, syrups and
fruit juices and concentrates”
SUGAR SUBSTITUTES
Classification of sugar substitutes

Sugar substitutes are classified

❖ Based on them being caloric/noncaloric

❖ Based on their origin .

Their sweetness is high as compared to sucrose

Caloric sugar substitutes

❖ Caloric sugar substitutes are group of sweeteners consisting of ingredients that can
substitute for both the physical bulk and sweetness of sugar.
❖ Products of this type, sometimes called “sugar replacers” or “bulk sweeteners,”
include the sugar alcohols (“polyols”) such as

Sorbitol
Erythritol, Hydrogenated starch
Mannitol
Lactitol, Hydrolysates
Xylitol
Maltitol, Hydrogenated glucose
Isomalt
syrups.
❖ Two new sweeteners, trehalose and tagatose, are similar in function to the polyols
although they are actually sugars rather than sugar alcohols.

❖ Polyols and other bulk sweeteners are used in food products in which the volume
and texture of sugar, as well as its sweetness, are important such as sugar-free
candies, cookies, and chewing gum.
Xylitol

❖ Alcohol form of xylose and made by extracting the carbohydrate from corn cobs
or birch wood.
❖ It is 60% as sweet as sucrose but does not raise blood sugar
❖ It has the ability to reduce bacteria in saliva
❖ The ability of xylitol chewing gum and candy to reduce S. mutans in plaque and
shows promise in control of dental caries
❖ Xylitol is available in many forms (e.g., gums, mints, chewable tablets, lozenges,
toothpastes, mouthwashes, cough mixtures, oral wipes, nutraceutical products).
❖ The chewing process enhances the caries inhibitory effect, which may be a significant
confounding factor for the efficacy of xylitol gum
❖ Xylitol intake ranging from 4 to 15 grams per day divided into three to seven
consumption periods
❖ Abdominal distress and osmotic diarrhea have been reported following the ingestion of
xylitol

American Academy of Pediatric Dentistry. Policy on use of xylitol in pediatric dentistry. The Reference
Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry; 2020:70-1.
Sorbitol
❖ Also called glucitol, made by adding hydrogen to glucose
❖ Most sorbitol are made from corn syrup but can be found naturally in prunes,
apples, peaches and pears
❖ It draws water into the large intestines for a laxative effect
❖ Chewing gum with sorbitol has shown anti caries properties
 Non caloric sugar substitutes

❖ Also called as alternative, artificial, high- intensity, or nonnutritive sweeteners,

which can replace the sweetness of sugar while providing few or no calories.

❖ In addition to the calorie savings, these sugar substitutes have the advantage of
not promoting tooth decay, and they are useful in dietary planning for people
who are coping with obesity or diabetes.
❖ Sugar substitutes (artificial sweeteners) provide little or no calories or
carbohydrates and do not increase blood sugar.
❖ Therefore, choosing sugar substitutes can assist with controlling carbohydrate
and energy intake.
 Acesulfame K
Aspartame
Neotame
Non-caloric sugar substitutes approved by the FDA: Saccharin
Stevia
Sucralose

❖ These sugar substitutes offer a sweet taste without increasing blood glucose or
calories. Choosing sugar substitutes is a one way to assist you with limiting
carbohydrate intake.
❖ If one chooses to use sugar substitutes or foods and drinks with less sugar, one may
have more room to eat a variety of other healthy carbohydrates.
Artificial sugar substitutes

1. Acesulfame potassium—200 × sweetness (by weight)

2. Aspartame—200 × sweetness (by weight)
3. Cyclamate—30 × sweetness (by weight)
4. Neotame—8000 × sweetness (by weight)
5. Saccharin—300 - 400 × sweetness (by weight)
Importance of diet and nutrition in pediatric dentistry

❖ Optimal growth and development - primary objectives of

pediatric nutrition.

❖ A child’s diet, defined as the combination of foods consumed

and the nutrients contained, therein has the profound ability
to influence cognition, behavior, and emotional development
in addition to ultimate physical growth and development.
❖ Food is merely a vehicle for nutrient delivery; the
nutrients provide energy for growth, serve as
structural components, and participate in all
metabolic functions of the body.

❖ Food, however, is more than just nutrients: sensory,

emotional, social, and cultural associations influence
food choices.
Dietary screening and education in the dental practice

❖ Dental professionals should routinely screen patients to

assess the role of diet in caries risk and management.
❖ Dentists are not trained to conduct a complete nutritional
assessment but they can use dietary screening, assessment,
and analysis to provide nutrition and dietary education and
referral to registered dietitians for more in-depth nutrition
counseling.
❖ Screening activities should include assessment of
determinants of dietary intake and behaviors that
are associated with dental health status and caries
risk.
❖ Rather than labeling foods as “allowable” or “to
be avoided,” nutrition messages need to be
offered that promote health but respect the
strong influence that taste has on food choices.
Objectives of counseling

❖ The main objective is caries prevention.

❖ If prevention is indeed the objective, then diet assessment and preventive
recommendations must begin at an early age, prior to visible signs of the carious
process.
■ Diet counseling aims to help parents change their and
their children’s dietary behaviors so that they choose
diets with low or non cariogenic snacks, limit sweet
foods to mealtimes, and perform toothbrushing after
sugar exposures.
❖ Objectives of diet counseling are as follows:

Correction of diet imbalance that could affect the

patient’s general and oral health.

Modification of dietary habits,

Dietary recommendations must be realistic and always based

on current dietary behaviors of the family. It is pointless to
prescribe changes that a patient cannot or will not implement.
❖ Additionally, modifications to the diet can only be made over time, aided by
repetition and reinforcement.
❖ The goal must be to help caregivers develop lifelong dietary habits, which
promote general and oral health for themselves and for those whom they
influence
Art of counseling

● Counseling is One-One basis.

● To be effective, it should be in the form of dialogs.
Communication technique
• During a face-to-face interview, keeping eye contact with the patient is a persuasive
and powerful device for motivating behavioral change.
• Communication can be both verbal and nonverbal. Words transmit information. The
interviewer’s tone of voice, facial expression, and gestures convey sincerity,
enthusiasm, and empathy. The nonverbal actions can be influential in helping the
patient to change his or her behavior.
• Messages must be adopted to patients needs and level of understanding.
• To communicate with a patient, a combination of interviewing, teaching, counseling,
and motivating is used.
Nutrition education and counseling
• Reduce high-frequency exposures to sugars.
• Avoid frequent consumption of juice or other sugar-containing drinks.
• Discourage the behavior of a child sleeping with a bottle.
• Restrict sugar—containing snacks that are slowly eaten.
• Limit cariogenic foods to meal times while promoting snacking with non
cariogenic foods.
Rapidly clear cariogenic foods from the child’s oral cavity by toothbrushing or by
consumption of protective foods.
Prolonged Breastfeeding and Dental Caries In Children In the Third Year of Life (Hartwig et
al, 2019)

❖ Prolonged breastfeeding (>24 months) is associated with increased incidence of ECC ,

when compared with children who were not breastfed or were breastfed for less than
6 months
❖ Due to the presence of human milk in their mouth for longer periods when salivary
flow is decreased. This practice has been related to the development of dental caries
.
DIET COUNSELLING
Patient Selection
• Diet counseling will not succeed with every dental patient.
• Potential candidates for counseling should give high priority to
preventive dentistry and should be willing to expend long-term efforts to maintain
their natural dentition good health for a lifetime.
• In addition to a positive attitude, they should have a demonstrable need
for dietary improvement, based on their current food intake regimen.
Diet Diary

❖ Parents are asked to record every food item consumed, solid or liquid, during 6
consecutive days, and also food consumed at mealtime, between meals, at soda
fountain, or while watching television.
❖ They are also asked to record candies, chewing gum, and cough drops, the
approximate amount in household measures, such as 1 cup, 1 tablespoon, and 1
teaspoon, and the kind of food and how it was prepared, such as baked chicken, raw
apple, cooked cereal, etc.
❖ Additions to food in cooking or at the table, such as butter, sugar, cream, etc., are
also included.
FOOD PYRAMID

❖ The food guide pyramid can help to choose a variety of foods to help achieve a
balanced diet.
❖ Selecting foods from each group will provide many nutrients needed by the body.

Recommended dietary allowance (RDA) It is the amount of nutrients sufficient for

the maintenance of health in nearly all people.
The amounts recommended include:

❖ A minimal physiological requirement ( lack of which would eventually cause

deficiency disease)
❖ A margin of safety of 30-50% above actual physiological requirements to allow for
individual variation and to provide body stores for times of stress
Recommendations are:

❖ Dietary fat 20-30% of total daily intake

❖ Saturated fats not more than 10% of total energy intake
❖ Excessive consumption of refined carbohydrate to be avoided
❖ Energy rich sources such as fats and alcohols - consumption to be restricted
❖ Salt intake reduced to not more than 5gm/day
❖ Protein - 15-20% of daily intake
❖ Reduced consumption of colas, ketchups and other foods that supply empty calories
Calculation of Dental Health Diet Score

❖ It is a simple scoring procedure that can disclose a potential dietary

problem that is likely to adversely affect a patient’s dental health.
Dental Health Diet Score =
[FOOD SCORE (adequate intake of foods from each of the food groups) +
NUTRIENT SCORE (consuming foods from especially recommended groups of
ten nutrients)]
SWEET SCORE (ingestion of foods that are overtly sweet sugars)

Food RDA Number of servings points

Milk 3 X8

Meat 2 X 12 Food Group

Fruits & 1 X6 Score Table
vegetables (Highest
Vitamin C 1 X6
possible score
is 96)
others 2 X6

Bread & cereals 4 X6

Nutrient Score Table
Mark one score for each nutrient consumed

Protein and vitamin A Iron Folic acid Riboflavin Vitamin C

Cheese, dried peas, Beef, eggs, Cereals, Broccoli, Grapefruit, green

dried beans, liver, spinach, chicken peppers, oranges,
eggs, fish, meat, green leafy yeasts breasts, strawberries,
milk, apricot, butter, vegetables eggs, milk, tomatoes, Calcium
carrot, liver, milk mushrooms and Phosphorus—
and spinach cheese, eggs,
green leafy
vegetables, milk
Sweet Score Table
Classify the sweet by its nature and multiply according to severity
Liquid: (X 5)
Soft drinks, fruit drinks,
cocoa, sugar
and honey in beverages, ice
cream,
flavored yogurt, pudding,
custard
Solid and Sticky: (X 10) Slowly Dissolving: (X 15)
Cake, doughnuts, sweet rolls, Hard candies, breathe mints,
pastry, canned fruit in syrup, antacid tablets, cough drops
bananas, cookies, chocolate
candy,
caramel, chewing gum, dried
fruit,
marshmallows, jelly, jam
Assessment of Dental Health Diet Score

Score Result Interpretation

72-96 Excellent Counselling not required

64-72 adequate Educate the patient

56-64 Barely adequate Counselling required

56 or less Not adequate Counselling with diet

modifications
 Sugar clock
❖ Explain the parents the importance of abstaining

from frequent snacking throughout the day

❖ When considering the amount and frequency of
sugar, addition of sugar during meals is not as
detrimental as when sugary snacks are added in
between meals.

Dhingra S, Gupta A, Tandon S, et al. Sugar Clock: A Primordial Approach to Prevent Dental Caries. Int J Clin Pediatr
Dent 2020;13(2):174–175.
 ❖ This will decrease the amount of time the
pH of oral fluids remains below the critical
pH and thus fewer demineralization attacks
on the tooth
❖ Stephan and Miller, 1940 concluded that pH
drops within 30 minutes after a sugary
intake. So, any intake of sugar within these
30 minutes is less detrimental to oral health
than the intake after these 30 minutes.
Dhingra S, Gupta A, Tandon S, et al. Sugar Clock: A Primordial Approach to Prevent Dental Caries. Int J Clin Pediatr Dent 2020;13(2):174–175.
Steps involved in diet counseling

1. First visit

a. Select the patient

b. Give the patient food dairy

c. Give the patient salivary specimen bottle

2. Second and third visit

a. Elicit a personal and family history

Suggestions for modifying a patient’s diet:

• Stress the desirability of eating only 3 times a day and making last food a deterrent
or liquid.

• Emphasize the necessity for deleting from diet sweet food such as cookies, cakes,
candies, etc., particularly at the end of the meals.

• Suggest snack substitutes, such as raw fruits, raw vegetables, cheese, milk, and
desserts made with artificial sweeteners.

• Prescribe the day’s menu that will suit the patient’s needs, likes, and dislikes.
3. Fourth visit
a. The patient is asked to return his food dairy and saliva specimen for analysis.

❖ Counseling begins with the explanation of the process of dental decay and
the role of food in its etiology.
❖ The patient is asked to circle with a red pencil all the foods, beverages, or
sweets recorded in his diet that contains refined sugar.
❖ An additional form can be used for totaling the frequency of mealtime
versus between meal ingestion of such foods and beverages.
Discussion

❖ The patient selects Five “W” and one “H” of diet consultation.
❖ Six questions are to be made before making decision about which points will benefit
from diet counseling: WHO, WHAT, WHY, WHEN, WHERE, and HOW.

• WHO may be benefited?

• WHAT are the objectives of diet and nutrition
counseling?
• WHY is counseling beneficial?
• WHEN is counseling conducted?
• WHERE should the counseling occur?
• HOW to counsel?
❖ When providing dietary counseling in pediatrics, identification of the patient
requires careful Consideration
❖ Diet counseling will not succeed with every dental patient.
❖ Persons who need counseling must also want information about their potential
dental caries problem and must be willing to improve current undesirable food
selections and eating habits.
❖ Potential candidates for counseling should give high priority to preventive
dentistry and should be willing to expend long-term efforts to maintain their
natural dentition in good health for a lifetime.
Follow-up

• To determine the success of counseling service, a comparison should be made between

the initial and after 4 weeks of dietary modifications.

• Comparison should be made between the speeds of acid production at the first saliva
test and taken on 4 weeks later.

• Reinforcement is provided by praising the patient’s efforts.

Point out the improvements made in diet as well as in the test result.
Role of carbohydrates in caries

❖ According to Pierre Fauchard (1746), all sugary foods contribute to the destruction
of teeth and that those who like sucrose and use them frequently rarely have good
teeth.
❖ While William Robertson (1845) concluded that caries was caused by acids formed
from lodgment of food in certain places, pure sucrose has been strongly evidenced
as a decalcifying agent.
❖ Hence, Newbrun (1969) called for the specific elimination of sucrose and sucrose-
containing foods rather than restricting total carbohydrate consumption.
❖ Sheiham (2001) concluded that the sugars, particularly sucrose, are the
most important dietary cause of caries; the intake of extrinsic sugars
greater than 4 times a day increases caries risk; sugar consumption
should not exceed 60 g/day for teenagers and adults and proportionally
less for younger children
Studies on groups having low sugar diet

Hopewood house study

❖ This study was conducted on a group of 80 children of low socioeconomic status.

They were fed with a vegetarian diet rich in proteins, fats minerals, and vitamins.
❖ Sugar and refined carbohydrates were excluded from the diet.
❖ The authors of this study stated that caries could be reduced by dietary means alone
in spite of poor oral hygiene and low fluoride levels.
Hereditary fructose intolerance (HFI)

❖ It has been shown that dental caries prevalence of these subjects is extremely low.
❖ Newbrun tabulated the caries prevalence of 31 persons with HFI and, of the 27 for
whom dental status was known, 15 were found to be caries free, with the remaining
having extremely low DMFT scores.
Wartime studies

❖ Literature surveys made by Sognnaes (1948) covering 27 wartime studies from 11

European countries observed reduction in caries prevalence and severity
Human interventional studies

The Vipeholm study

❖ This study conducted in a mental institution in Sweden between 1945 and 1952
demonstrated that it was possible to increase the average sugar consumption with
very little increase in caries providing that the additional sugar was consumed at
mealtimes in solution.
❖ Sticky or adhesive forms of sucrose containing foods were more cariogenic.
Turku sugar studies in Finland

❖ The main objective of this study was to determine benefits from the use of
xylitol instead of sugar.
❖ Over a 2-year period of the study, there were practically no new lesions in
xylitol group, 4 per person in the fructose group and 7 in the sucrose group.
Turku 1-year xylitol chewing gum study (1975)

❖ In addition to normal diet subjects who chewed four sticks of gums containing
xylitol in addition to normal diet, control group subjects chewed sucrose
containing gums.
❖ After 1 year, the test group subjects averaged 0.3 new DMF surfaces compared
to 4 in control group.
Animal studies

❖ Kite et al. (1950) studied that when intact or desalivated rats were fed
adequate amounts of cariogenic diet by stomach tube, caries didn’t
develop.
❖ In contrast, caries occurred in normally fed rats, the severity being much
higher in desalivated animals.
Cariogenicity of sucrose

❖ Sucrose is the energy source of choice for the most cariogenic plaque bacteria.
❖ Availability of carbohydrates from dietary sources is intermittent so certain oral
microorganisms have a variety of enzyme systems to convert excess sugar to
storage material for later use.
❖ Glucosyl transferase and fructosyl transferase enzymes present in S. mutans and
S. sanguis produce glucans and levans present in plaque.
❖ These enzymes are highly specific for sucrose and will not utilize other sugars.
High energy of the link between C-1 of glucose and C-2 of fructose found in
sucrose causes it to have a high free energy of hydrolysis so that it can serve
directly as a glucosyl donor.
Other disaccharides, such as maltose and lactose have low free energy of hydrolysis
and cannot serve directly as glucosyl donor
Role of minerals in dental caries

Calcium: Reduced levels of calcium in diet can result in increase in caries.

Phosphates: Cariostatic action of phosphates has been demonstrated when added to

cariogenic diet of rats.

Magnesium: It was reported that cariostatic effect of F was enhanced when Mg is added
to drinking water.

Iron: It has been claimed that phosphate on enamel surface can chemically bound to
ferric ion. This affects the rate of dissolution of apatite and hence increases enamel
solubility.
Barium: Is chemically similar to strontium and exerts cariostatic effect. Topical effect
of St and Ba appears to be more effective than systemic effect.

Molybdenum: Alder (1964) concluded that Mo is a cariostatic agent. Mo

synergistically enhances the reaction of fluoride.

Zinc: Animal studies have shown that Zn reduces the incidence of caries by
depressing the growth of S. mutans and by rehardening the enamel during
remineralization phenomenon.
AAPD on Dietary Recommendations for Infants,Children, and
Adolescents
- 2017
❖ The recommendation of national and international organizations to reduce the
consumption of sugar to less than 10 percent of total energy intake and, to
reduce children’s risk of weight gain and dental caries, sugar intake should be
less than five percent of total energy intake (less than 16 grams of sugar for
children aged 4-8).
❖ Breast-feeding of infants prior to 12 months of age to ensure the best possible
health and developmental and psychosocial outcomes for infants.
❖ 2017 recommendation of the Committee on Nutrition of the American
Academy of Pediatrics (AAP) include: juice should not be introduced to infants
before one year of age; intake of juice should be limited to four ounces a day for
children ages 1-3 years of age; 4-6 ounces for children 4-6 years of age; eight
ounces for children 7-18 years of age; toddlers should not be given juice in
containers that foster easy consumption; and toddlers should not be given juice
at bedtime.
❖ Education of health professionals and parents regarding daily sugar-consumption
recommendations, as well as the sugar content of foods, beverages and oral liquid
medications.
❖ Dental professionals becoming more engaged in identifying children who consume
frequent or large quantities of sugar-containing foods and beverages, and who are
at risk for dental caries and obesity.
❖ Dental professionals’ engagement in nutrition education and provision, when
necessary, of appropriate referral for dietary counseling from pediatrician or
nutritional specialist.
Conclusion
A pediatric dentist is in a unique position to promote good nutrition in
their patients and their families as they treating a disease to which diet
contributes dramatically to both etiology and treatment.
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Journal of Clinical Pediatric Dentistry, 2019 ; 43(2):1-6

Sheiham A, James WP. Diet and Dental Caries: The Pivotal Role of Free Sugars
Reemphasized. J Dent Res. 2015 Oct;94(10):1341-7
Soban Peter. Essentials of Public Health Dentistry 5th edition
Academy of Pediatric Dentistry; 2020:84-6.
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Dhingra S, Gupta A, Tandon S, et al. Sugar Clock: A Primordial Approach to Prevent Dental Caries. Int J Clin
Pediatr Dent 2020;13(2):174–175.
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Dentistry; 2020:84-6.
Sroda R. Nutrition for dental health, 3rd edition.

AmericanAcademy of Pediatric Dentistry. Policy on use of xylitol in pediatric dentistry. The Reference
Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry; 2020:70-1.