DENTAL CARIES (2)

BY Dr. SYED MUZZAMIL ALI

SHAH
AETIOLOGY OF DENTAL CARIES
Four factors are necessary to produce
dental caries:
1.Dental plaque.
2.Suitable carbohydrate.
3.Susceptible tooth surface.
4.Time.
 MAJOR EPIDEMIOLOGICAL STUDIES
ESTABLISHING RELATIONSHIP OF DIET
& CARIES.
Diet has a clear influence on caries development. In
particular the relation between the intake of refined
carbohydrates, especially sugars , and the prevalence
and severity of caries is so strong that sugars are clearly
a major etiological factor in the causation of caries.
Some major studies which established the relationship
between diet & caries are:
1.WW2 studies.
2. Tristan da Cunha.
3. Hopewood house.
4. Anthropologic studies.
5. Vipeholm study.
6. Turku study.
Vipeholm study:
This study investigated the effects of consuming sugary
foods of varying stickiness( i.e different oral retention times)
and at different times through out the day on the
development of caries by measuring caries increments in
subjects who consumed:
Refined sugars with a slight tendency to be retained in the
mouth at meal times only ( e.g sucrose solution, chocolate).
Refined sugars with a strong tendency to be retained in the
mouth at meal times only( sweetened bread).
Refined sugars with a strong tendency to be retained in the
mouth, in between meals ( e.g toffees). The subjects were
divided into 6 groups ( and groups were sub divided into
male & female)
Dietary regimes were given in two periods.
The first carbohydrate period was between
1947 & 1949 and the second carbohydrate
period in which regime were changed
slightly ran between 1949 & 1951.
CONCLUSION:
Sugar intake, even when consumed in large amounts,
had little effect on caries increment if it was ingested up
to a maximum of four times a day at meal times only.
Consumption of sugar in between meals was associated
with a marked increase in dental caries.
The increase in dental caries activity disappears on
withdrawal of sugar-rich foods.
Dental caries experience showed wide individual
variations.
 FLAWS IN THE STUDY
This study had a complicated design and
subjects were not randomly assigned to groups.
The study was conducted on adults in a situation
where it was possible to prescribe dietary
regimen, the subjects may have been more
resistant to caries (as enamel is fully
mineralized).
The Fluoride concentration in drinking water was
0.4 ppm and the study was done before use of
fluoride in dentrifices.
TURKU SUGAR STUDY:
This was a longitudinal study conducted in Finland in
1970s. The study investigated the effect of almost total
substitutions of sucrose in a normal diet with either
fructose or xylitol on development of caries.
Three groups of subjects aged btw 12-53 years, with
65% in their twenties, consumed a diet sweetened with
sucrose, fructose or xylitol for a period of 25 months and
dental caries increment was monitored blind at six
months intervals by one person throughout the study &
both carious cavities & pre cavitations lesions were
monitored.
The xylitol group consumed xylitol-
containing foods significantly less
frequently than the sucrose or fructose
groups consumed their sweetened foods &
the overall intake of xylitol in the xylitol
group was lower then that of fructose or
sucrose in the other groups. An 85%
reduction in dental caries was observed in
the xylitol group who had removed sugar
from their diet.
CONCLUSION:
Substitutions of sucrose with xylitol
resulted in a markedly lower dental
caries increment in both cavities & at
the pre cavitation stage.
HEREDITY FRUCTOSE INTOLERENCE:
Studies done on rare disease of HFI in which
person suffering from it have to minimize their
sugar intake on life long basis. HFI is a
congenital deficiency of fructose -1-phosphate
aldolase and consumption of fructose results in
nausea and hypoglycemia; hence all food
containing fructose & sucrose are excluded from
the diet. Studies showed that the participants
with disease had low caries experience
compared to subject with HFI.
ANTHROPOLGIC STUDIES:
Studies conducted in Polynesia, Ghana,
Greenland & Australian aborigines reported
rapid increase in caries experience. This has
largely been associated with change in life style
& diet in these remote communities when they
come in contact with developed world. The
changes are so profound & abrupt that it’s
difficult to be sure that all changes in caries
prevalence are due to diet, there is little question
that the dietary factors are important.
HOPEWOOD HOUSE STUDY:
This study was done for the period of 15 years
on a group of children living on a basically
vegetarian diet with severely restricted sucrose
intake, however oral hygiene was virtually
absent & fluoride exposure was low. Dental
caries level were much lower in the participants
than in children of the same age &
socioeconomic background. 46% of 12 year old
in hope wood house were caries free compared
with 1% of the children from state schools.
However after the age of 12 when the
children’s association with the home
ended, the rate of caries increased to a
level observed in children from the state
school.
WORLD WAR 2:
In studies done at pre & post war era in Japan &
Norway found that the dental caries rate were
dramatically reduced during the war which was
largely attributed to rationing of sugar during war
time but change was observed as soon as the
war ended & the DMFT returned back to the pre
war era, hence establishing a strong relationship
of diet & caries.
TRISTAN DA CUNHA:
This study was conducted on the community
living on this remote island of south Atlantic.
Temporary evacuation of the whole community
to UK was done in 1960’s due to a volcanic
eruption. Data showed that after evacuation
there DMFT increased abruptly when there diet
pattern was changed towards processed food
compared to pre evacuation era.
 GLOBAL DISTRIBUITION OF
CARIES.
In the beginning of twentieth century
caries was seen as a disease of the high
income countries while low prevalence in
poorer country. The prime reason for this
trend was attributed to DIET. Specifically
high levels of consumption of refined
carbohydrates in the wealthier countries
led to selective proliferation of cariogenic
bacteria.
 While on the other hand poorer countries/
societies had a diet dependent upon subsistence
farming & in some cultures by hunting , both of
which provided diets low in fermentable
carbohydrates.
However a change was noticed in the trend of
dental caries in the late twentieth century:
a) In some low income countries especially those
in Asia-Pacific, the caries Incidence has
increased sharply in the years after WW2,
however this change was not universal
 & this trend was not observed in other low
income regions like AFRICA, where the
caries incidence was still relatively low.
b) The second change which was observed
was the marked reduction in caries
experience among children & young adults
in high income countries.
This trend is also evident in WHO global oral
health data bank, In most of the developed (high
income) countries decline in dental caries has
been witnessed but limited to some countries
only where the preventive measures are well
practiced & established.
On the other hand in middle income countries,
this trend was only limited in two countries ,
Cuba which has a well established school dental
services for years and Estonia, where caries
levels where very high.
 SUMMARY
There is strong evidence to suggest that both
the frequency of intake of sugars and sugars-
rich foods and drinks ( total amount of sugars
consumed are related to dental caries) & these
two variables are strongly associated ( meaning
that efforts to control one are likely to control the
other).
It’s public health policy to reduce the amount of
sugars consumed.
At Individual level, it’s more pragmatic to advise
to reduce the frequency of consumption.
ANY QUESTIONS?