Nutrition

Lecturer 3
Nutrition for Oral and Dental Health
nutritionist Clinical /Dr. Hamas Swiaed
Oral health is integral and essential to general health
Oral health means more than good teeth; it is integral to general health and
essential for well-being. It implies being free of chronic Oro-facial pain, oral and
pharyngeal (throat) cancer, oral tissue lesions, birth defects such as cleft lip and
palate, and other diseases and disorders that affect the oral, dental and
craniofacial tissues, collectively known as the craniofacial complex.

Oral health is a determinant factor for quality of life

The craniofacial complex allows us to speak, smile, kiss, touch, smell, taste, chew,
swallow, and to cry out in pain. It provides protection against microbial infections
and environmental threats. Oral diseases restrict activities in school, at work and
at home causing millions of school and work hours to be lost each year the world
over. Moreover, the psychosocial impact of these diseases often significantly
diminishes quality of life.

NUTRITION FOR TOOTH DEVELOPMENT

Primary tooth development begins at 2 to 3 months’ gestation. Mineralization begins at approximately 4
months 'gestation.
and continues through the preteen years. Therefore, maternal nutrition must supply the presumptive teeth
with then appropriate.
building materials. Inadequate maternal nutrition consequently affects tooth development. Teeth are
formed by the mineralization of a protein matrix. In dentin, protein is present as collagen, which depends on
vitamin C for normal synthesis. Vitamin D is essential to the process by which calcium and phosphorus are
deposited in crystals of hydroxyapatite, a naturally occurring form of calcium and phosphorus that is the
mineral component of enamel and dentin. Fluoride added to the hydroxyapatite provides unique caries-
resistant properties to teeth in prenatal and postnatal developmental periods. Diet and nutrition are
important in all phases of tooth development, eruption, and maintenance Post eruption diet and nutrient
intake continue to affect tooth development and mineralization, enamel development and strength, and
eruption patterns of the remaining teeth. The local effects of diet, particularly fermentable carbohydrates
and eating frequency, affect the production of organic acids by oral bacteria and the rate of tooth decay as
described later in this chapter. Diet and nutrition play key roles in tooth development,
Diet and nutrition play key roles in tooth development, integrity of the gingiva (gums) and mucosa, bone
strength, and the prevention and management of diseases of the oral cavity. Diet has a local effect on tooth
integrity; the type, form, and frequency of foods and beverages consumed have a direct effect on the oral pH
and microbial activity, which may promote dental decay. Nutrition systemically affects the development,
maintenance, and repair of teeth and oral tissues.
 Other Oral diseases
Oral diseases extend beyond dental caries. Deficiencies of several vitamins (riboflavin, folate, B12, and C)
and minerals (iron and zinc) may be detected first in the oral cavity because of the rapid tissue turnover of
the oral mucosa. Periodontal disease is a local and systemic disease. Select nutrients play a role, including
vitamins A, C, E; folate; beta-carotene; and the minerals calcium, phosphorus, and zinc. Oral cancer, often a
result of tobacco and alcohol use, can have a significant effect on eating ability and nutritional status. This
problem is compounded by the increased caloric and nutrient needs of persons with oral carcinomas. In
addition, surgery, radiation therapy, and chemotherapy are modalities used to treat oral cancer that also can
affect dietary intake, appetite, and the integrity of the oral
cavity. Some but not all problems affecting the oral cavity are discussed here with relevant nutrition care.
Patients may try over the-counter natural products to prevent or treat oral disease or conditions.

DENTAL CARIES
Dental caries is an oral infectious disease in which organic acid metabolites lead to gradual
demineralization of tooth enamel, followed by rapid proteolytic destruction of the tooth structure. Caries
can occur on any tooth surface. The cause of dental caries involves many factors. Four factors must be
present simultaneously:
(1) a susceptible host or tooth surface;
(2) microorganisms such as Streptococcus or Lactobacillus in the dental plaque or oral cavity;
(3) fermentable carbohydrates in the diet, which serve as the substrate for bacteria; and
(4) time (duration) in the mouth for bacteria to metabolize the fermentable carbohydrates, produce acids,
and cause a drop in salivary pH to less than 5.5. Once the pH is acidic, which can occur within minutes, oral
bacteria can initiate the demineralization process.
Early childhood caries
often called “baby-bottle tooth decay,” describes a caries pattern in the maxillary anterior teeth
of infants and young children. Characteristics include rapidly developing carious lesions in the primary
anterior teeth and the presence of lesions on tooth surfaces not usually associated with a high caries risk.
Because tooth decay remains a common oral disease of childhood, caries are a primary marker for a child’s
oral health. Good behavioral habits and child nutrition patterns must be encouraged, beginning in infancy.
Pathophysiology
Often ECC follows prolonged bottle-feeding, especially at night, of juice, milk, formula, or other sweetened
beverages. The extended contact time with the fermentable carbohydrate– containing beverages, coupled
with the position of the tongue against the nipple, which causes pooling of the liquid around the maxillary
incisors, particularly during sleep, contributes to the decay processes. The mandibular anterior teeth usually
are spared because of the protective position of the lip and tongue and the presence of a salivary duct in the
floor of the mouth. In general, children from low-income
families and minority populations experience the greatest amount of oral disease, the most extensive
disease, and the most frequent use of dental services for pain relief; yet these children have the fewest
overall dental visits

Caries Promotion by Individual Foods

It is important to differentiate between cariogenic, cariostatic, and anticariogenic foods.
Cariogenic foods are those that contain fermentable carbohydrates, which, when in contact with
microorganisms in the mouth, can cause a drop in salivary pH to 5.5 or less and stimulate the caries process.
Cariostatic foods do not contribute to decay, are not metabolized by microorganisms, and do not cause a
drop in salivary pH to 5.5 or less within 30 minutes. Examples of cariostatic foods are protein foods such as
eggs, fish, meat, and poultry; most vegetables; fats; and sugarless gums. Sugarless gum may help to reduce
decay potential because of its ability to increase saliva flow and because it uses noncarbohydrate
sweeteners.
Anticariogenic foods are those that, when eaten before an acidogenic food, prevent plaque from
recognizing the acidogenic food. Examples are aged cheddar, Monterey Jack, and Swiss because of the
casein, calcium, and phosphate in the cheese. The five-carbon sugar alcohol.
xylitol, is considered anticariogenic because bacteria cannot metabolize five-carbon sugars in the same way
as six-carbon sugars such as glucose, sucrose, and fructose. It is not broken down by salivary amylase and is
not subject to bacterial degradation. Salivary stimulation leads to increased buffering activity of the saliva
and subsequent increased clearance of fermentable carbohydrates from tooth surfaces.
Another anticariogenic mechanism of xylitol gum is that it replaces fermentable carbohydrates in the diet. S.
mutans cannot metabolize xylitol and is inhibited by it. The antimicrobial activity against S. mutans and the
effect of gum chewing on salivary stimulation are protective. Consumers should be advised to look for
chewing gum in which xylitol is listed as the first ingredient.

Factors Affecting Carcinogenicity of Food

Carcinogenicity also is influenced by the volume and quality of saliva; the sequence, consistency, and
nutrient composition of the foods eaten; dental plaque buildup; and the genetic predisposition of the host to
decay.
Form and Consistency
The form and consistency of a food have a significant effect on its cariogenic potential and pH-reducing or
buffering capacity. Food form determines the duration of exposure or retention time of a food in the mouth,
which, in turn, affects how long the decrease in pH or the acid-producing activity will last.

Nutrient Composition
Nutrient composition contributes to the ability of a substrate to produce acid and to the duration of acid
exposure. Dairy products, by virtue of their calcium- and phosphorus-buffering potential, are considered to
have low cariogenic potential. Evidence suggests that cheese and milk, when consumed with cariogenic
foods, help to buffer the acid pH produced by the cariogenic foods.
Sequence and Frequency of Eating
Eating sequence and combination of foods also affect the caries potential of the substrate. Bananas, which
are cariogenic because of their fermentable carbohydrate content and adherence capability, have less
potential to contribute to decay when eaten with cereal and milk than when eaten alone as a snack. Milk, as
a liquid, reduces the adherence capability of the fruit.
1-Periodontal disease
is an inflammation of the gingiva with infection caused by oral bacteria and subsequent destruction of
the tooth attachment apparatus. Untreated disease results in a gradual loss of tooth attachment to the bone.
The primary causal factor in the development of periodontal disease is plaque. Plaque in the gingival
sulcus, a shallow, V-shaped space around the tooth, produces toxins that destroy tissue and permit
loosening of the teeth.
Nutritional Care
Deficiencies of vitamin C, folate, and zinc increase the permeability of the gingival barrier at the gingival
sulcus, increasing susceptibility to periodontal disease. Severe deterioration of the gingiva is seen in
individuals with scurvy or vitamin C deficiency.
Although other nutrients, including vitamins A, E, beta carotene, and protein, have a role in maintaining
gingival and
immune system integrity, no scientific data support supplemental uses of any of these nutrients to treat
periodontal disease.
2-Diabetes Mellitus
Diabetes is associated with several oral manifestations, many of which occur only in periods of poor glucose
control. These include burning mouth syndrome, periodontal disease, candidiasis, dental caries, and
xerostomia. The microangiopathic conditions seen in diabetes, along with altered responses to infection,
contribute to risk of periodontal disease in affected persons. Tooth infection, more common in those with
diabetes, leads to deterioration of diabetes control in addition to blood glucose control, dietary management
for people with diabetes after any oral surgery procedures or placement of dentures should include
modifications in the consistency, temperature, and texture of food to increase eating comfort, reduce oral
pain, and prevent infections or decay
3-Fungal Infections
Oropharyngeal fungal infections may cause a burning, painful mouth and dysphagia. The ulcers that
accompany viral infections such as herpes simplex and cytomegalovirus cause pain and can lead to reduced
oral intake. Very hot and cold foods or beverages, spices, and sour or tart foods may cause pain and should
be avoided. Consumption of temperate, moist foods without added spices should be encouraged. Small,
frequent meals followed by rinsing with lukewarm water or brushing to reduce the risk of dental caries are
helpful. Once the type and extent of oral manifestations are identified, a nutrition care plan can be
developed. Oral high calorie–high protein supplements in liquid or pudding form may be needed to meet
nutrient needs and optimize healing.
4-Head and Neck Cancers
Head, neck, and oral cancers can alter eating ability and nutrition status because of the surgeries and
therapies used to treat these cancers. Surgery, depending on the location and extent, may alter eating or
swallowing ability, as well as the capacity to produce saliva. Radiation therapy of the head and neck area and
chemotherapeutic agents can affect the quantity and quality of
5-Xerostomia
Xerostomia (dry mouth) is seen in poorly controlled diabetes mellitus, other autoimmune diseases, and as
a consequence of radiation therapy and certain medications Xerostomia from radiation therapy may be
more permanent than that from other causes. Radiation therapy procedures to spare the parotid gland
should be implemented, when possible, to reduce the damage to the salivary gland. Efforts to stimulate
saliva production using pilocarpine and citrus-flavored, sugar-free candies may ease eating difficulty.
increases the risk of dental caries and infections.
Nutrition care
Dietary guidelines focus on the use of moist foods without added spices, increased fluid consumption with
and between all meals and snacks, and judicious food choices. Problems with chewy (steak), crumbly (cake,
crackers, rice), dry (chips, crackers), and sticky (peanut butter) foods are common in persons with severe
xerostomia. Alternatives should be suggested, or the foods should be avoided to avert dysphagia risk.
Drinking water with a lemon or lime twist or citrus-flavored seltzers or sucking on frozen tart grapes, berries,
or sugar-free candies may help. Because these foods or beverages may contain fermentable carbohydrate or
contribute to reduced pH, good oral hygiene habits are important in reducing the risk of tooth decay and
should be practiced after all meals and snacks.
Roles of Saliva reduce the risk of caries.
Salivary flow clears food from around the teeth as a means to reduce the risk of caries. The bicarbonate-
carbonic acid system, calcium, and phosphorus in saliva also provide buffering action to neutralize bacterial
acid metabolism. Once buffering action has restored pH above the critical point, remineralization can occur.
If fluoride is present in the saliva, the minerals are deposited in the form of fluorapatite, which is resistant to
erosion. Salivary production decreases as a result of diseases affecting salivary gland function (e.g., Sy green
syndrome); as a side effect of fasting; as a result of radiation therapy to the head and neck involving the
parotid gland; normally during sleep and aging;
with the use of medications associated with reduced salivary flow; or with xerostomia, dry mouth caused by
inadequate saliva production. An estimated 400 to 500 medications currently available by prescription or
over the counter may cause dry mouth. The degree of xerostomia may vary but may be caused by
medications such as those to treat depression, hypertension, anxiety, human immunodeficiency virus (HIV),
and allergies.
Fluoride There are four primary mechanisms of fluoride action on teeth:
(1) when incorporated into enamel and dentin along with calcium and phosphorus, it forms fluorapatites, a
compound more resistant to acid challenge than hydroxyapatite
(2) it promotes repair and remineralization of tooth surfaces with early signs of decay (incipient carious
lesions);
(3) it helps to reverse the decay process while promoting the development of a tooth surface that has
increased resistance to decay.
(4) helps to deter the harmful effects of bacteria in the oral cavity by interfering
with the formation and function of microorganisms and prevention of dental caries.
.
CARIES PREVENTION
1. -Caries prevention programs focus on a balanced diet, modification of the sources and quantities of
fermentable carbohydrates, and the integration of oral hygiene practices into individual lifestyles.
Meals and snacks should be followed with brushing, rinsing the mouth vigorously with water, or
chewing sugarless gum for 15 to 20 minutes, preferably gum that contains xylitol.
2-Positive habits should be encouraged, including snacking on anticariogenic or cariostatic foods,
chewing sugarless gum after eating or drinking cariogenic items, and having sweets with meals rather
than as snacks. Despite the potential for a diet that is based on the dietary guidelines to be cariogenic,
with proper planning and good oral hygiene a balanced diet low in cariogenic risk.
3-Practices to avoid include sipping sugar-sweetened and low pH beverages for extended periods. Adding
lemon and other fruits to water has become a common practice but this lower
the pH and in general should be avoided. Frequent snacking and harboring candy, sugared breath mints, or
hard candies in the mouth for extended periods are discouraged. Over-the-counter
4-chewable or liquid medications and vitamin preparations, such as chewable vitamin C or liquid cough
syrup, may contain sugar and contribute to caries risk. Patients with dysphagia may use thickening agents in
beverages or liquid foods (soups) to reduce the risk of aspiration.
5-Good oral hygiene should be emphasized in these situations because the thickening agent may contain
fermentable carbohydrate, and the type of dysphagia may contribute to inadequate clearing of food from the
oral cavity.
TOOTH LOSS AND DENTURES
Tooth loss (edentulism) and removable prostheses (dentures) can have a significant effect on dietary habits,
masticatory function,
olfaction, and nutritional adequacy. As dentition status declines, masticatory performance is compromised
and may have a negative effect on food choices, resulting in decreased intake of meat, whole grains, fruits,
and vegetables.
bone over time possibly may alter the fit of the dentures. This is a common problem in the elderly that
interferes with eating. Counseling
on appropriate food choices and textures is advocated.
Nutrition Care
Guidelines should be provided for cutting and preparing fruits and vegetables to minimize the need for
biting and reduce the amount of chewing. The importance of positive eating habits must be stressed as a
component of total health. Overall, guidelines that reinforce the importance of a balanced diet should be
part of the routine counseling given.

Nutrition tips related to oral health for 3 - to 10- years-old children

Nutrition tips Rationale

Starchy, sticky, or sugary foods The pH will rise if a non-sugary
should be eaten with non-sugary item that stimulates saliva is
foods. eaten immediately before,
during, or after a challenge.
Combine dairy products with a Dairy products (nonfat milk,
meal or snack. yogurt) enhance remineralization
and contain calcium.
Combine chewy foods such as Chewy, fibrous foods induce
fresh fruits and vegetables with saliva production and buffering
fermentable carbohydrates. capacity.
Space eating occasions at least Fermentable carbohydrates eaten
2 hours apart and limit snack sequentially one after another
time to 15 to 30 minutes. promote demineralization.
Limit bedtime snacks Saliva production declines during
sleep.
Limit consumption of acidic Acidic foods promote tooth erosion
foods such as sports drinks, that increases risk for caries.
juices, and sodas.
Combine proteins with Proteins act as buffers and are
carbohydrates cariostatic.
in snacks.
Examples: tuna and crackers,
apples and cheese