Nutrition and Diet Flashcards
what are the NICE Guideline NG30
- “give all patients (or parents or carers) advice during dental examination based on the oral health messages in Public Health England’s ‘Delivering Better Oral Health’ evidence based toolkit (2017)
- “Ensure that advice is tailored to suit individual needs using appropriate behavioural change techniques, goals, planning monitoring and feedback”
- Tailor information to patients
why is nutrition and diet important
• Diet and general health, current dietary guidelines
• Nutrients and tooth development- in utero nutrition
• The post-eruptive affect of diet on teeth
• Diet and other oral conditions
– Diet and tooth loss
– Diet and periodontal disease
– Diet and dental erosion
• Dietary advice in dental practice
what the main nutrient classes
macronutrients
- proteins
- carbs
- fats
micronutrients
- vitamins
- minerals
- trace elements
what is energy measured in
• Energy is measured in kcal or kJ (kilocalories/ kilojoules)
how much energy is in fats carbs protein alcohol
- Fat has 9 kcal / gram consumed
- Carbohydrate has 4 kcal / gram
- Protein has 4 kcal / gram
- Alcohol has 7 kcal / gram
what is Estimated Average (Energy) Requirement (EAR)
the average dietary energy intake that is predicted to maintain energy balance in healthy, normal weight individuals of a defined age, gender, weight, height, and level of physical activity consistent with good:
• Voluntary activity
Maintenance of life
• Brain function
why is energy needed for • Maintenance of life
- Body temperature
- Breathing
- Heart beat
why is energy needed for brain function
- Growth
- Children
- Pregnancy and lactation
- Body builders- increase body mass
• In the UK a healthy Body Mass Index is between what
18.5 and 24.9 kg/m2 (calculated as weight/height 2)
what does Requirement for energy depend on
• Body size and composition- weight/ height
• Age- elderly need less
• Activity- low activity, low energy
• Basal Metabolic Rate (BMR) is estimated using equations based on metabolic studies
- the Henry equations are used to estimate BMR (Henry, 2005)
- can work out BMR
what is the Henry Equations for estimating BMR
BMR = weight coefficient x weight (kg) + height coefficient x height (m) + constant
given values (differ for male and female)
– weight coefficient
– height coefficient
– constant
how can Estimated energy requirements (EAR) be calulated using BMR
physical activity level (PAL) x BMR
The median PAL for adults is 1.63
what are some examples of Estimated Average Requirements (EAR) for different individuals
- 12 month old boy: 718 kcal
- 12 month old girl: 646 kcal
- Adult men: 2772 kcal
- Adult women: 2079 kcal
- For pregnant women in third trimester add 191kcal per day
- For lactating women for first 6 months of breastfeeding add 335kcal per day- more than this they will put weight on
what are the features of Dietary fats
- Composed of glycerol and fatty acids
- Fatty acids are saturated (single bonds) , mono-unsaturated (single bonds, one double bond) or polyunsaturated.
- Saturated (no double bonds) are mostly found in animal and dairy fats
- Monounsaturated (MUFA) (one double bond) are found in olives and nuts
- Polyunsaturated (PUFA) (several double bonds) are found in plant oils, seed oils and fish oils
what are the Functions of dietary fats
• Provision of energy- energy dense goods
• Component of membranes- lipid bilayers in plasma membranes
• Precursors of prostaglandins (inflammatory response)
• Precursor of cholesterol (digestion and absorption of fat- chylomicron)
• Absorption of fat soluble vitamins- A, D, E, K (lack of these is not good)
• Essential fatty acids- not produced in on body. MUST be consumed
– Linoleic- plant oils omega 3 (3 soluble bounds before methyl end)
what are the features of Omega 3 fatty acids
- Double bond 3 carbons from methyl end of fatty acid chain
- α-Linolenic (converts to EPA in body)
- Eicosapentanoic acid (EPA) – essential, found by consuming consuming alpha-linolenic acid from plant oil or EPA from fish oil
- Docosahexanoic acid (DHA)- omega 3 but 6 double bonds. Found in fish oil
- Form prostaglandins of the 3 series that alleviate inflammation
- Eat lots of these - Negative association with cardiovascular disease
- Possible role in preventing periodontal disease (inflammatory disease- prostagloanding involved in reducing prostaglanding)
- Oily fish are the richest source of DHA and EPA
what are Trans fatty acids
• Double bonds may be ‘cis’ or ‘trans’
• Hydrogenated oils contain trans fatty acids
- Processed oils – processed foods where we need solid fats as its much cheaper than animal sources
• Intake is strongly linked with cardiovascular disease and possible colon cancer
what the association between Dietary fats and cardiovascular disease, how can this be overcome by MUFA and PUFA
Negative associations: Accumulation of cholesterol-rich lipid in arterial walls
• Convincing evidence that saturated fat (myristic and palmitic) increase LDL cholesterol- in arterial walls it will increase CVD
• Trans fatty acids increase LDL cholesterol and decrease HDL cholesterol
• Dietary cholesterol probably increases LDL cholesterol
However
• Substituting saturated fat with PUFA (especially linoleic) decreases cholesterol
• Substituting saturated fat with MUFA has similar but lesser effect
what is • Eicosapentanoic acid (EPA) and how is it formed
Essential, found by consuming alpha-linolenic acid from plant oil or EPA from fish oil
α-Linolenic (converts to EPA in body)
• Form prostaglandins of the 3 series that alleviate inflammation
• Docosahexanoic acid (DHA)
omega 3 but 6 double bonds. Found in fish oil
• Form prostaglandins of the 3 series that alleviate inflammation
what is the link between Dietary fats and cardiovascular disease
Thrombosis: platelet aggregation at site of narrowing artery
EPA and DHA reduce aggregation
Lots of fish
what do Plant sterols do and what is an ex, where are they present
prevent cholesterol absorption and thereby lower serum LDL cholesterol
Benecol’ reduces cholesterol absorption by ~14%
Plant sterols and stanols are naturally present in low levels in fruits, vegetables, vegetable oil, nuts, seeds and cereals.
• Plant stanols work the same way
what are other food cholesterol and why
• Oat fibre reduces cholesterol absorption (beta glucan binds cholesterol in gut)
- May be due to beta glucan that will bind to cholesterol and render it un-transportable across the membrane in GI tracts
• Soya protein (soya milk, tofu etc) also reduces cholesterol absorption
what is the association between Dietary fat and cancer
- Dietary factors account for 30 % of cancers
- High fat intake (energy dense diet) is associated with obesity
- Convincing evidence that obesity is linked to some cancers
- Possible that high intake of animal fat is associated with cancers of the bowel, pancreas and prostate.
what are the different Carbohydrates
Sugars
Starches
Oligosaccharides
oGlucose polymers
oNon-digestible oligosaccharides
Fibre and non-starch polysaccharides
what are ex of sugars
• Monosaccharides (one sugar molecule) o glucose, fructose & galactose • Disaccharides (two sugar molecules) o sucrose (glucose + fructose) o maltose (glucose + glucose) o lactose (glucose + galactose)
what is an oligosaccahride
• Chains of 3+ are called oligosaccharides and are not classified as sugars but polysaccharides
what are Sugar alcohols or polyols
sorbitol, mannitol, xylitol (sweetener) & lactitol bulk sweeteners called bulk as theyre not as sweet as sugar hence need to put more in xylitol can lower dental caries risk (futile cycle)
what are sugars needed ro form and why
how much energy do they give per g consumed
• Energy 4.0 kcal /g
Glycoproteins: sugar needed to form glycoproteins. Proteins esterified to one or more oligosaccharides containing sugars. The CHO content varies 1-85% e.g. albumin, collagen, peptide hormones and enzymes, fibrinogen, immunoglobulins
Glycosaminoglycans and proteoglycans e.g. hyaluronic acid, chondroitin sulfates (in cartilage), heparin
what are Sources of sugars:
confectionery, soft drinks, table sugar, biscuits and cakes, breakfast cereals, puddings and preserves.
what are the Health effects of sugars
• Contribute to excess energy intakes – obesity and weight gain
• May cause hyperlipidemia (?) in 10-15% population
- Increase in fat
• Diabetics must restrict intake- TII
• High intake of energy dense foods high in sugars and fats contribute to obesity, diabetes and cardiovascular disease
what are free sugars
OUTSIDE THE CELL
include all sugars added by manufacturer, cook and consumer, plus sugars in syrups, honey, fresh fruit juices and fruit juice concentrates. anything that is added
Fruit isn’t classed as a free sugar / fruit juice is: sugar in fruit is intrinsic sugar (in cell)
Advised not to eat free sugar between meals
what is intrinsic sugar
INSIDE THE CELL
can be consumed as much as you want, it already exists e.g. lactose in milk and fruits (all natural)
what can Dried fruits be classified as
bit of both as drying process breaks some cells releasing intrinsic sugar
what is Starch and what the 2 major forms, what are good sources
a-glucan polysaccharides (lots of glucose molecules joined by glucan links)
Amylose (straight chain of glucose with 1,4 bonds) and amylopectin (branched)
- Good sources include bread, potatoes, pasta, rice and cereals
- No adverse general health effects
- No deficiency states
what are Glucose polymers and ex
oligosaccharides
maltodextrins and glucose syrups
how are Glucose polymers made
- Made from hydrolysis of starches
* Chains of glucose 3 units and above with some mono and di saccharides (3- oligosaccharides)
what are glucose monomers used as
• Used as energy supplements, sports drinks and infant milk/foods
- Lactose intolerant babies milk replaced with glucose polymers as they still need sugar (more cariogenic than lactose)
• Are potentially cariogenic
what are The 3 classes of non-digestible (non-glycemic) carbohydrate in dietary fibre
- Non-starch polysaccharide (NSP) - skeletal remnants of plants that resists human digestion.
- Resistant starch
- Resistant oligosaccharides
what are Non-starch Polysaccharide
- Consists of cellulose, hemicelluloses, pectins, gums and mucilages
- Not digested in upper gastrointestinal tract so passes to colon where some undergo anaerobic microbial fermentation (healthy bacteria)
- NSP adds to stool bulk and stimulates peristalsis
- Soluble NSP attenuates post-prandial increase in blood lipids and glucose so important for glucose homeostasis and lipid metabolism
- Insoluble forms are more resistant to fermentation but bind water and increase stool mass which aids peristalsis and reduces toxin concentration
- NSP increases satiety and is useful in weight loss plans
what is Resistant starch
starch that is not digested e.g. physically enclosed in cell walls or un-gelatinised starch (e.g. green bananas)
what are 3) Resistant oligosaccharides
- Naturally occurring and synthetic
- Resistant or partially resistant to digestion in upper GI tract (non-digestible oligosaccharides (NDO))
- Resistant oligosaccharides include: fructo-; isomalto-; galactosyl-; gluco-oligosaccharides can be cariogenic.
- NDO encourage growth of bifidobacteria and lactobacilli in colon which metabolise NDOs (may prevent cancer)- can ferment this bacteria in the mouth
- NDO potentially cariogenic as dental plaque contains bifidobacteria and lactobacilli
- May be labelled as dietary fibre
what is the SACN for total carbohydrate
- Total carbohydrate intake appears to be neither detrimental nor beneficial to cardio-metabolic health, colo-rectal health and oral health
- The hypothesis that diets higher in total carbohydrate cause weight gain is not supported by the evidence from randomised controlled trials
- A small number of studies suggest that higher consumption of potatoes is associated with a risk of type 2 diabetes mellitus, but it is not possible to exclude confounding by other dietary variables e.g. cooking methods for potatoes such as frying. There is insufficient evidence to draw a conclusion on the association between starch intake and weight gain
- It is recommended that the dietary reference value for total carbohydrate should be maintained at an average population intake of approximately 50% of total dietary energy (starch)
what is the SACN for free sugars
• No more than 5% of total dietary energy should come from free sugars from 2 years upwards
what literature suggests for the statement “No more than 5% of total dietary energy should come from free sugars from 2 years upwards”. refer to
- prospective cohort studies
- randomised controlled trials
- Prospective cohort studies indicate that greater consumption of sugars-sweetened beverages is associated with increased risk of type 2 diabetes mellitus
- Randomised controlled trials conducted in adults indicate that increasing or decreasing the percentage of total dietary energy as sugars when consuming an ad libitum diet leads to a corresponding increase or decrease in energy intake.
- Randomised controlled trials conducted in children and adolescents indicate that consumption of sugars-sweetened beverages, as compared with non-calorically sweetened beverages, results in greater weight gain and increases in body mass index
- With the proposed reduction in the population intake of free sugars, their contribution toward recommended total carbohydrate intake should be replaced by starches, sugars contained within the cellular structure of foods and, for those who consume dairy products, by lactose naturally present in milk and milk products
- The complete replacement of energy derived from free sugars by these carbohydrate sources would only apply to those people who are a healthy BMI and in energy balance
- In those who are overweight, the reduction of free sugars would be part of a strategy to decrease energy intake”
Are we meeting the DRVs for Free sugars?
- The National Diet and Nutrition Survey published in 2014, shows that mean intake of NMES (same as free sugar) exceeded the DVR in all age groups!
- 11-18 year olds consumed the greatest amount of NMES, getting 15.6% of energy from NMES, compared to their recommended amount of under 5%
- So if on average 11-18 year olds are getting 15.6% of their energy from NMES
- 312 calories per day 78g free sugar per day
- This means in a year that’s 28,470g of free sugar (3 times more than the recommendation!)
- (29 extra bags of sugar!!!!)
what are the Main sources of free sugars consumed by 11-18 year olds
40% of free sugars came from non-alcoholic beverages:
– Fruit juices
– Fizzy drinks
– Sports drinks
19-22% came from sugar, preserves and confectionary
– Added sugar
– Chocolate
– Biscuits
what is the SACN for fibre
• Increased intakes of total dietary fibre, and particularly cereal fibre and wholegrain are associated with a lower risk of cardio-metabolic disease and colo-rectal cancer
- Adults should get around 30g/day of fibre
- 2 to 5 years -15g/day
- 5 to 11 years 20g/day
- 11 to 16 years 25 g/day
- 16 to 18 years 30g/day
• No quantitative recommendations are made for <2 years, due to the absence of information, but from about six months of age, gradual diversification of the diet to provide increasing amounts of whole grains, pulses, fruits and vegetables is encouraged
what literature suggests for the statement “Increased intakes of total dietary fibre, and particularly cereal fibre and wholegrain are associated with a lower risk of cardio-metabolic disease and colo-rectal cancer”. refer to
- prospective cohort studies
- randomised controlled trials
- Randomised controlled trials indicate that total dietary fibre, wheat fibre and other cereal fibres increase faecal mass and decrease intestinal transit times
- Randomised controlled trials also indicate that higher intake of oat bran and isolated β-glucans leads to lower total cholesterol, LDL cholesterol and triacylglycerol concentrations and lower blood pressure
what is the function of Dietary proteins and sources
• Growth and repair
• Maintenance of muscle and other tissues
• Hormones and enzymes
• Sources include
o Animal - meat, fish & dairy products
o Vegetable - pulses, quorn, bread, nuts & quinoa
what are the Protein requirements
- The amount of protein needed to be in nitrogen balance
- Nitrogen intake = nitrogen output
- 6.25g protein = 1 g N
- Body protein is continually undergoing turnover
- Positive N-balance in growth/pregnancy
- Negative N-balance in starvation/trauma
- Guidance for intake 0.75-1.5g/kg body weight (12% calorie intake)
what are the Requirements in terms of food for proteins
• 70 kg man • 1g / kg = 70g (= 280 kcal) • Protein usually provides around 12% of kcal o 30g meat - 7g o 30g fish - 5g o 1 pint milk - 20g o 30g cheese - 7g o 1slice bread 2g
- Your patient is a 60kg woman
* What is the range of her protein requirement?
45-90g
• Your patient is a 60kg woman
Assuming she consumes the middle value from this range, what percentage of her energy would this provide if she consumed 2000 calories a day?
12% =60kg/day * 4(kcal/gram) = 240
240/2000 *100 = 12%
what is Marasmus
extreme protein energy malnutrition
• Both protein and energy are limited
• Severe muscle wasting
• Decreased insulin (anabolic): glucagon (catabolic)
• Muscle proteins used in liver to make albumin which prevents oedema
what is Kwashiorkor
- Protein is deficient, but energy intake is maintained
- High insulin: glucagon
- Reduced amino acids for albumin synthesis causes oedema
- Water babies’ or ‘sugar babies bloated even though are not fed
what is NOMA
- Increased risk of NOMA (cancrum oris) in protein-energy malnutrition
- Ulcerating stomatitis of upper gum and underlying maxilla and face and ulceration of cheeks
- Occurs in malnourished impoverished children
- Results in irreversible disfiguration can be fatal
outline DRVs (Dietary ref values )summary with ref to % of total energy from the following macronutrients
fat
free sugar
proteins
balance
fat <35% (<10% saturated)
free sugar 5%
protein 12-15%
balance- from starch, milk sugar and intrinsic sugar
what do • Carbohydrates (CHO) include
sugars, oligosaccharides, starch, glucose polymers and fibre (non-starch polysaccharides, resistant starch and resistant oligosaccharides)
what are the Dietary reference values (DRVs)
series of estimates of the amount of energy and nutrients needed by different groups of healthy people in the UK population. (not individual)
what is the reference nutrient intake (RNI)
the amount of a nutrient that is enough to ensure that the needs of nearly all the population (97.5%) are being met
If everyone consumes this much we can say 97.5 % of population will be getting enough of that nutrient
what is The Estimated Average Requirement (EARs)
an estimate of the average requirement for energy or a nutrient. Approximately 50% of the population will need less energy or the nutrient and 50% of the population will need more.
what is the Lower Reference Nutrient Intake (LRNI)
the amount of a nutrient that is enough for only the small number of people who have low requirements (2.5%). The majority of the population will need more.
Some people (2.5% population) will be okay on this however the rest will be below of what is needed for a healthy balanced life.
in summary what are the following used for :
EAR
RNI
LRNI
EAR is used for energy
RNI is often used as a reference amount for population groups.
LRNI is a useful measure of nutritional inadequacy.
what are the DRVs for fat, free sugar, protein, balance
fat <35% (<10% saturated)
free sugar (5%)
protein (12-15%)
Other 45% should comes form starch, milk sugar, fibrous foods, intrinsic sugars (sugars present naturally in fruits)
what are the practical steps PHE are providing to help people lower their sugars intake
- They have produced ‘Sugar why 5%?’ - a summary of SACN recommendations for professionals and non professionals
- Visualise in cubes and teaspoons
BUT!!! How many teaspoons? Heaped teaspoons, flat teaspoons • 7 x 4g per teaspoon = 28g flat • 7 x 6g per teaspoon = 42g heaped • 12 g per day more!
what does The Eatwell Guide outline
The Eatwell Guide does not include references to frequency of serving and recommended portion sizes, except for:
• fruit and vegetables: at least 5 portions of a variety of fruit and vegetables a day
• fish: eat 2 portions a week, 1 of which should be oily
• red and processed meat: limit to less than 70g per day if you usually consume more than 90g every day
• fluids: 6-8 glasses a day
• Limits for juices and dried fruit are also given (contain free sugar)
This is consistent with government advice and is in accordance with the available evidence.
what is the advice on Bread, rice, potatoes, pasta and other starchy foods
• Eat lots • Eat wholegrain if possible • Avoid frying (e.g. chips) • Avoid adding fat, rich sauces or dressings • This group includes: o Breakfast cereals o Pasta o Rice o Oats o Noodles o All types of bread
what is the advice on Milk and dairy foods
- Eat or drink moderate amounts
- Choose lower fat varieties wherever possible
- This groups doesn’t include butter eggs and cream
- This group includes milk, cheese, yogurt and fromage frais
what is the advice on Meat, fish, eggs, beans and other non-dairy sources of protein
• Eat moderate amounts • Choose lower fat versions if possible e.g cut skin off chicken, cook without oil, avoid fish in batter • Beans and pulses are good alternatives • This group includes o Meat o Poultry and game o Fish o Eggs o Nuts, beans and pulses o Quorn and soya
what is enamel hypoplasia
structural defect in which the enamel present is HARD but DEFICIENT in amount- caused by a defective ENAMEL MATRIX formation . This alters the shape during development; pits, grooves
what is enamel hypomineralisation
enamel matrix has been formed, but its mineralisation is suboptimal leading to opacities due to reduced mineral content and softer enamel. enamel chips post-eruptively
what are the causes of Enamel Hypoplasia and Hypomineralisation
developmental defects with many causes including dietary deficiencies and difficulty during birth (neonatal line)
what are the pre and post eruptive effects of enamel hypoplasia
pre- pits, grooves, larger areas of missing enamel
post- enamel may become stained on eruption from diet
what are the Nutrient deficiencies in the aetiology of hypoplasia
- Protein – protein energy malnutrition (PEM)
- Calcium - hypocalcaemia
- Vitamin D – deficiency
- Vitamin A – deficiency
Nutritional deficiencies usually occur in undernourished communities or due to metabolic disturbances (which don’t allow nutrient absorption)
discuss evidence for the link between protein deficiency and enamel defects
• Study of Guatemalan children (1977)
• 43% with moderate malnutrition had hypoplasia
• 73% with severe malnutrition had hypoplasia
• Later research showed that a protein supplement did not reduce the incidence of hypoplasia
• Feeding rat dams a protein deficient diet during pregnancy and lactation resulted in:
- Poor quality and quantity of milk
- Increased dental caries in pups (compared with a control group)
Protein deficiency causes developmental defects and salivary gland atrophy (saliva not produced sufficiently – xerostomia patients increased caries risk)
discuss evidence for the link between Hypocalcaemia and risk of developmental defects of enamel:
- 53 children with disturbances of calcium and phosphate metabolism were studied
- Vitamin D dependent rickets – Low Ca, low P – hypoplysia
- Hypophosphataemia – normal Ca, low P – no hypopysia
- Hypoparathyroidism – low Ca, high P – hypolysia
- Therefore, low blood calcium level is associated with developmental defects in enamel
- Hypocalcaemia is also common in malnourished children (diarrhoea)
a low serum calcium concentration during enamel formation is a specific determinant of enamel hypoplasia
Discuss the link between Vitamin A deficiency and pre eruptive effect on dental caries risk- mention why
- Rare in industrialised countries
- Often associated with PEM
- Linked (alongside PEM) with enamel defects
- In experiments in rats fed a cariogenic diet: Gp with vitamin A deficiency had higher levels of dental caries when compared with well-nourished rats…
- Deficiency of vitamin A causes salivary gland atrophy causing less/poorer quality saliva
outline the effects of vitamin D deficient on teeth that were also seen in children
- Delayed development of teeth
- Delayed eruption
- Poorly aligned
- Defects of enamel & dentine
outline evidence for The Association Between Enamel Hypoplasia and Dental Caries
everyone who had hypoplasia had caries
only 25% without hypoplasia had caries
what is the link between vitD supplements are caries
- lower initiation and spread of caries
- greater hardening of pre-carious lesions
• 2-year trial in Birmingham children’s home
deficiency is ONE OF the causative factors- dental caries is multifactorial
why were War-time diets better for teeth
- Improvement children’s teeth in the UK between 1939 and 1944 – sugar wasn’t freely available
- Cheap milk (calcium and vitamin D)
- Cod liver oil free to pregnant and breat-feeding mothers, infants and children
- Vitamins A and D were added to margarine
- Calcium carbonate was added to flour
what is the link between vitamin D deficiency and studies carried out in India - how does it show that vit D does have an effect
- Gross enamel hypoplasia - more common in India due to diarrhoea induced hypocalcaemia
- Mild enamel hypoplasia - Similar prevalence in both countries due to the sunshine in India (vitamin D) overriding the effects of a poorer diet- sun does make difference
what can Deficiency of vitamin D during the development of the teeth cause
defects in the enamel that render the tooth more susceptible to dental caries
outline the conclusions of some studies relating to the risk of dental caries with vitD deficiency
Low certainty conclusion that Vitamin D may decrease incidence of dental caries- (Hujoel, 2013)- Significant publication bias
Improving vitamin D status is an additional preventive consideration to reduce caries risk
• (Schroth et al., 2016)
what was the advice fromPublic Health England 2016 about vitD
- Adults, and children over the age of 1y should have 10 micrograms of vitamin D per day
- Many would need a supplement to achieve this
- NB: 10 micrograms is the amount in 5 sardines!
- NB: in North of England the angle of the sun in the sky between October and May is too low to enable synthesis of vitamin D via the skin
how does Under Nutrition Increases Susceptibility to Dental Caries- relate this between uk and developing countries
- UK – good diet but high sugars
* Developing countries – poor diet but low sugars = cariesUK
what does undernutrition result in
**Under nutrition = lack of energy and protein
- Under nutrition results in developmental defects rendering teeth caries prone
- Under nutrition causes salivary gland atrophy (post-eruptive effect)
what does malnutrition result in
delays eruption of teeth which affects caries- just delays the caries some would say
how does Excess Fluoride Ingestion Affects Mineralisation of Enamel:
- During enamel maturation, an excess of F- ions:
- Alters the rate at which matrix proteins (amelogenins) are enzymatically broken down
- Alters the rate at which the subsequent breakdown products are removed.
- Fluoride may also indirectly alter the action of protease via a decrease in the availability of free calcium ions in the mineralisation environment.
- Lower enamel mineralisation. Hypomineralised enamel has altered optical properties and appears opaque and lustreless relative to normal enamel.
what are the different fluorosis
very mild
mild
moderate
severe
what is teh accepted amount of water flourosis found by The Research of H Trendley Dean in the 1930s:
• Continued use of water with 1ppm F caused mild mottling in 10% of cases- anticaries effect accepted amount
Continued use of water with 1.7 ppm F caused mild mottling in 40-50% of cases
where is Artificially Fluoridated Water found
- Newcastle & area artificially fluoridated to 1ppm NaF 1969 Birmingham artificially fluoridated to 1ppm NaF since 1963
- Later research in the UK in the 1980’s showed permanent teeth:
- Birmingham – 1ppm NAF in water = 59% children no mottling
- Leeds – low F in water = 68% no mottling
does • Low plasma phosphate results in dental hypoplasia
no because:
• Vitamin D dependent rickets – Low Ca, low P – hypoplysia
• Hypophosphataemia – normal Ca, low P – no hypopysia
•
• List three ways in which malnutrition can impact of levels of dental caries at age 12
delays eruption of teeth which delays caries
developmental defects rendering teeth caries prone- hypoplasia ad hypomineralisation
salivary gland atrophy (post-eruptive effect)
what nutritional deficiencies can cause hypoplasia
calcium - hypocalcemia showed hypoplasia in study with phosphate
PEM- hypoplasia increased with protein deficiency severity, but supplement did not decrease this. also causes salivary gland atrophy
Vit A- linked alongside PEM with enamel defects
VitD- mild hypoplasia was the same in india and UK due to vitD from sun in india which balanced out the effects of poor diet
what nutritional deficiencies can cause caries
vitD- defiecny can render teeth more succeptibe to caries (hypomineralisation). vit D is preventative for caries
vitA- PRE-ERUPTIVE effect on caries- Gp with vitamin A deficiency had higher levels of dental caries when compared with well-nourished rats. linked with PEM on enamel defects
what deficiencies cause salivary gland atrophy thus increase dental caries risk
Protein deficiency
Vitamin A deficiency
what are the Sources of Fluoride Exposure
Diet
o Natural sources- black tea/ green tea, seafood/fish (seawater contains fluoride)
o Added: water, milk, salt
o Manufacturing of foods can influence how much water is in foods (processing)
Dental products o Toothpastes (topical) o Mouthwashes (topical) o May be swallowed by children so can be systemic intake of fluoride
F-supplements
o Tablets
outline Fluoride ingestion and excretion
- 90% of F is absorbed mainly in stomach as HF (passes easily across membrane)
- Rapid absorption
- 99% of F in body is in calcified tissues
- 10% excreted in urine or faeces
outline the differences in Fluoride ingestion and excretion in diifferent diets (high fat, vegetarian)
high fat diet slows digestion and reduced rate of gastric emptying to F is in stomach for longer so absorption is increased. Positive F balance (more than 90%) - dental/skeletal fluorosis
Vegetarian diet- increase pH of renal tubule so more alkali which will increase urinary excretion so more elimation of fluoride so negative F balance – potential increase in caries Trivalent cation (copper/zinc) will form complexes with other divalent cations in GI tract
outline Importance of fluoride in caries prevention
- Exposure to F is most reasonable explanation for the decline in caries
- Excess F fluorosis of enamel- results in mottling/opacities. Skeletal fluorosis – can end up with brittle bones.
- Optimising the use of F for maximum caries prevention and minimal fluorosis is crucial
outline the Action of fluoride
- Historically, thought to act by improving tooth structure (systemic effect)
- The local/intra-oral action is now considered more important
- Fluoride aids (re)mineralisation
- Fluoride inhibits anaerobic glycolysis and subsequent acid production by oral bacteria
what is the Modern Understanding of Dental Caries
The early stages of dental caries can be prevented, reversed or arrested, primary through the elimination or modification of aetiological factors (dietary, microbial) and/or by enhancing protective factors (fluoride, sealants and salivary stimulation).
Increased sugars in the diet utilized by bacteria to produce acid increasing caries risk.
Topically applying fluoride can help with remineralization thus reducing the risk of dental caries
outline acute Fluoride toxicity (what are the lethal and safe tolerated doses)
• sudden ingestion of large dose- fluoride poisoning
• causes nausea, vomiting, diarrhoea and
abdominal pain
• Certain lethal dose is ~ 32-64mg/F/kg
• Safe tolerated dose is 8-16 mg F/kg
outline chronic Fluoride toxicity
- More common
- smaller dose over long time-
- affects teeth while still forming: up to 6 years, incisors up to 3 years
- affects bone continually
what is the Optimum safe daily dose of F- for dental health benefits is
0.05-0.07 mg/kg body weight per/day in children <12 years of age
o Even If we go up to 0.1 mg/kg we will increase dental caries via fluorosis/ mottling of teeth
outline Systemic & topical Fluoride therapy
Public water fluoridation School water fluoridation Fluoridised salt (self-select, but high salt not good Fluoridised milk Fluoride drops/tablets
outline Topical Fluoride therapy
Topical application
Fluoride mouth rinse & Fluoride toothpaste
outline studies that show the Evidence of effectiveness of F
H Trendley Dean (in the 1940’s)
• 7,000, 12-14 year olds from 21 cities in US states
• Investigated relationship between F level in water and prevalence of dental decay – J shaped curve
• Showed that water fluoridation at 1 ppm was the best balance between caries and fluorosis
• Resulted in artificial fluoridation of water
• Low fluoride – high risk of caries
Weaver 1941
• Dentist in Lake District
• Reduced dental caries in those children from South shields (1.4ppmF naturally) than those in the west and North shields
• DMFT was higher in those in north shields with no water fluoridation
outline Newcastle fluoridation studies
- There has been a decrease in caries over the last few decades
- However, caries has been consistently lower in those from fluoridated areas
- This shows water fluoridation has a positive effect even when there is exposure to fluoride from other sources, eg. Toothpaste
outline Fluoridation of social class
- Occurrence of dental caries shows a social class trend with lower social classes at greatest risk
- Water fluoridation has a positive effect on caries levels in all social class groups but as the lower social classes have higher caries the effect is greatest in this group
outline Water fluoride: systematic reviews
- Systematic reviews locate, appraise and synthesize evidence from scientific literature
- No association between water fluoridation and mortality from any cancer was found
- Stopping water fluoridation ↑ caries to levels higher than non-fluoridated areas
- Water fluoridation is effective, despite exposure to fluoride from other sources
- Fluoridation of water ↓ social class trends in dental caries
what are the benefits and drawbacks of Fluoridised salt
Allows individual to control when they have fluoride- consumer choice – politically advantageous.
but
- Negative systemic effects
- Is this positive as a public health measure?? As then not everyone exposed
- Salt increases blood preassure
what are the benefits and drawbacks of Fluoridised milk
- Targeted at children when their teeth are developing
- Milk is nutritious
- Considered a good vehicle for fluoride
but
- Can cause mild fluorosis
- Binding of F to calcium or protein may ↓ topical effect
- Cessation of milk fluoridation associated with worsening dental health
- less good evidence than for water fluoridation (But not as many people exposed so less numbers)
outline Systematic reviews of effectiveness of milk fluoridation programmes
Yeung et al 2008:
• Considered RCT only
• Two RCTs – for primary dentition
Some individuals expose to fluoridated milk and some just to milk
Onlt 2 studies
one study showed a significant reduction in DMFT (31.3%) after 3 years
o One did not
• Concluded insufficient studies with good quality evidence to show effectiveness
• HOWEVER: need to look at totality of evidence
Systematic Review by Australian National Health & Medical Research Council 2007
• Is intentional milk fluoridation more efficacious that no milk fluoridation in the prevention of dental caries?
• Considered evidence from cohort and cross sectional epidemiological studies
o Milk fluoridation is beneficial – though less good evidence than for water fluoridation (But not as many people exposed so less numbers)
o Cessation of milk fluoridation associated with worsening dental health
o Milk F may lead to increased mild fluorosis – not considered to be of aesthetic concern rather than problematic
what are the benefits and drawbacks of Public water supply fluoride
Low cost per head
Free for consumers
but
- Individuals have no say (mass medication)
- Not widespread in UK
where are Fluoridadated milk schemes
• There are many fluoridated milk schemes in Thailand, Chile, UK, Bulgaria and Russia, which are primarily school-based
• Fluoridated milk studies in China, Chile, Hungary,Bulgaria and Scotland have shown F milk to be effective in reducing the incidence of dental caries in young children.
• Have used doses ranging from 0.5-1.5mg F per drink (daily drink)
o Fluoride ingestion due to swallowing toothpaste as opposed to from the milk
how can carbohydrates be classified
according to their chemistry
according to their digestion and absorption
how can carbohydrates be classified according to their chemistry and what is the issue with this
- Sugars (monosaccharides and disaccharides)
- Polyols
- Oligosaccharides (malto-oligosaccharides and non-digestible oligosaccharides)
- Polysaccharides (starch and non-starch polysaccharides).
× This classification does not allow a simple translation into nutritional effects since each class of carbohydrates has overlapping physiological properties and effects on health.
what is ‘Dietary fibre’
There is no universal definition of the term ‘dietary fibre’.
• Broadly speaking, it refers to some or all of the constituents of non-digestible carbohydrates and may also include other quantitatively minor components (e.g. lignin) that are associated with non-digestible carbohydrates in plant cell walls.
what is the Classification of sugars for dental health
intrinsic- fruit, veg and grains
milk sugars- naturally present in milk and milk products (ensure parents are talking about plain milk not milk shakes)
Free sugars- added sugars, plus sugars in honey, syrups, fruit juices, and fruit juice concetrates
what are Free sugars
• Free sugars are sugars (monosaccharides and disaccharides) that have been added by a food manufacturer, cook or consumer to a food and include those sugars naturally found in fruit juice, honey and syrups.
- Pure fruit better than a fruit smoothie – blending it changes composition etc. so important to ask
• They do not include sugars naturally found in milk and milk products, nor in fruit and vegetables.
Why do we differentiate between types of sugars?
- High levels of sugar consumption are associated with a greater risk of tooth decay- leads to negative outcome
- The higher the proportion of sugar in the diet, the greater the risk of high energy intake.
- Drinking high-sugar beverages results in weight gain and increases in BMI in teenagers and children.
- Higher BMI the higher the risk of anaesthetic
- Consuming too many high-sugar beverages increases the risk of developing type 2 diabetes
what is the impact of sugars on dental diseases
- Cost to health services
- Multiple extractions of teeth due to caries is the main reason for hospitalisation young children in England
- Self esteem
- Pain and anxiety
- Time lost from school/work
- Tooth loss and impaired health
- 44% of worlds population have untreated dental caries!
outline Children’s dental health: 5 year olds
- 31% of 5 year old children have obvious decay experience
* Mean number of teeth affected is 0.7
outline Dental caries: UK
- 30% of dentate adults have dental caries
- 11% of 55-66 year olds have root caries – difficult to manage (seen in elderly due to drymouth
- 20% of 75-84 year olds have root caries- ageing population
what do the Scientific Advisory Committee on Nutrition recommend at a population level for sugars
- Dietary recommendations at a population level:
- Free sugars should account for no more than 5% daily dietary energy intake.
- The term free sugars is adopted, replacing the terms Non Milk Extrinsic Sugars (NMES) and added sugars.
- The consumption of sugar-sweetened beverages (e.g. fizzy drinks, soft drinks and squash) should be minimised by both children and adults.
- Education- are parents aware between no added sugar and sugar free difference
what are the WHO Guideline for free sugars- recommendations
• WHO recommends reduced intake of free sugars throughout the life-course (strong recommendation).
• In both adults and children, WHO recommends that intake of free sugars not exceed 10% of total energy (strong recommendation).
• WHO suggests further reduction to below 5% of total energy (conditional recommendation).
- Based on healthy BMI
Remarks
what are the WHO Guideline for free sugars- remarks
- For countries with low free sugars intake, levels should not be increased
- The recommendation to further limit free sugars intake to less than 5% of total energy is further based on the recognition that dental caries tracks from childhood to adulthood; in order to minimize lifelong risk of dental caries, the consumption of free sugars should be as low as possible
• It is recommended that the dietary reference value for total carbohydrate should be maintained at ….
an average population intake of approximately 50% of total dietary energy
free sugars, recommended total carbohydrate intake should be replaced by:
- starches
- sugars contained within the cellular structure of foods
- lactose naturally present in milk and milk products.
- In those who are overweight, the reduction of free sugars would be part of a strategy to decrease energy intake.
Consider:
- Milk intolerance
- Vegan diet
outline Recent : Change4Life free sugars maximum
- PHE is aiming to provide practical steps to help people lower their sugars intake
- They have produced ‘Sugar why 5%?’- a summary of SACN recommendations for professionals and non professionals
- They have set new Change 4 Life - new maximum sugar intake figures
outline role of honey in dental caries
Does protect against dental caries
- Propolis (Bee glue) contains flavonoids and esters that decrease dissolution of enamel
what are the Types of evidence- what is the gold standard
Human intervention studies
- Randomised controlled trials (gold standard) but Not realistic for dental caries
- non-randomised intervention studies – open to bias
Human observational studies
- Cohort studies – strongest data after RCT
- Population ecological studies – use per capita sugars data
- Cross sectional studies – measure one point in time only
- Case studies – weak evidence only suggestive
what are Weaker forms of evidence
- Animal experiments
- Enamel slab experiments (in vivo)
- Plaque pH studies
- Laboratory experiments (in vitro)
- Alone provide insufficient evidence unless supported by data from epidemiological studies
why should Cross sectional studies be interpreted with caution
- Dental caries takes several years to develop.
- It is the diet several years earlier that is likely to be responsible to decay levels. Consider: working parents, children and students who may have changed eating habits
- Those with dental decay may have changed habits
outline World wide ecological studies
- Compare sugar availability and dental data using data from dental surveys and per-capita data on sugars availability e.g. from Food and Agricultural Organization (FAO)
- Sreebny 1982: Studied data from 42 countries and showed that sugar availability accounted for 52 % of variation in caries in children aged 12 years
outline Population based studies within countries
• Compare population averages for levels of dental caries with sugars (sucrose) availability at the population level (per capita) over time e.g. before and after a change in sugars availability
outline Observational studies: dental caries following a change in diet
• Populations that have experienced a marked increase in dental caries on adopting a ‘westernised’ diet - • Tristan da Cunha
why is sugar intake More variable factors as age increases
e.g. transition from primary school to secondary school (increased access to tuk shops)
what is involved in Intervention studies and why are they diffucult to carry out (ethically) in the UK - have any RCTs been carried out in systematic reviews
- Change diet in one group (intervention group) and monitor dental caries increment compared with a control group
- Ideally participants should be randomised into intervention and control groups
- The person assessing dental health and diet should be blind to the participants group identity
Difficult to get permission for- may be possible if child has a restricted diet for a health reason. Impossible to tell one group to have less than 5% and other to have more.
In the systematic review NO RCT were identified. Only non-randomised trials exist for the relationship between sugars intake and development of dental caries
what did the Turku Sugar Studies indicate
- The effect of total substitution of sucrose in the diet with xylitol or fructose
- Xylitol resulted in an 85% reduction in caries
what do Cohort studies measure - given an example
- Measure change in dental caries levels in a study cohort over time
- Relate the change in dental caries levels to dietary sugars intake
- Easy to do but ethics difficult
5 studies enabled dental caries development to be compared when sugars intake was above vs. below 10% of energy – all showed lower dental caries with sugars intake <10% energy
what is the relationship between Frequency of sugars vs amount- what studies show this
pH in mouth not recalibrated when consumed frequently
- The SACN carbohydrate review concluded there was insufficient evidence on frequency of sugars intake and risk of dental caries
- There is convincing evidence that frequency and amount of sugar intake are correlated
- Frequency – useful at chairside
- Amount – essential for dietary guidelines and policy
• But Reducing frequency alone will not impact on other NCD associated with a too high intake of free sugars
outline the cariogenicity of Different types of sugars
cariogenicity of mono- and di- saccharides is similar EXCEPT for lactose
(Animal studies and plaque pH studies show lactose is less cariogenic)
- Turku Sugar Study showed no significant difference between development of cavities between fructose and sucrose – but there were more pre-cavity lesions with sucrose compared with fructose
- Some animal studies show sucrose to be more cariogenic
Is sucrose relatively more cariogenic compared with other sugars?
- Sucrose is the sole substrate for extracellular glucan synthesis
- Clinical evidence suggests that glucans enhance Streptococcus mutans in plaque by increasing plaque porosity which results in increased acid accumulation at the enamel surface
The WHO consider all free sugars to be a risk for dental caries (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)
what is the The influence of fluoride on caries
- Fluoride reduces caries by up to 50% but does not eliminate caries
- A relationship between sugars and caries exists in populations exposed to fluoride
- Where there is good exposure to fluoride, sugars consumption is a moderate risk factor for caries in most people and so preventing consumption of excess sugars is a justifiable part of caries prevention if not the most crucial for aspect for most people
- On its own wont solve issue- need diet improvements
Method
- Fluoride varnish – high risk caries children
- Get them to use correct tooth pastes (age specific) – are they putting on the right amount?
• The evidence for an association between amount of sugars intake comes from many different study types with the strongest evidence coming from…
cohort studies
why are Even low levels of caries in childhood are of significant
dental caries is progressive and the effects of sugars on the dentition are lifelong
Summarise the evidence for an association between free sugars and dental caries for intervention studies LEARN
Turku sugar study (removing sugar from diet and replacing it with xylitol over a 2 year
period)
- 85% caries reduction in adults.
The Vipeholm (consumption of – sugars inbetween meals)
- it increased caries.
- Sugars up to 4 times with meals only had lesser effect. - Withdrawing sugars stopped caries activity.
Summarise the evidence for an association between free sugars and dental caries for cohort studies LEARN
8 cohort studies show higher caries with higher sugars.
5 cohort studies show lower caries when intake of free sugars is<10% energy.
Some low levels of dental caries occurs at <10% sugars.
Summarise the evidence for an association between free sugars and dental caries for Ecological studies LEARN
These provide data to show that dental caries is lower when the sugars availability is below 5% or energy compared with above 5 but below 10%.
outline the limitations of the following study types to outline a Relationship between dietary sugars and dental caries:
Plaque pH
indirect measuremnet of dental caries as only measures acidogenicity
outline the limitations of the following study types to outline a Relationship between dietary sugars and dental caries:
Animal experiments
Differences in tooth morphology and salivary composition – so need caution when extrapolating findings to humans
outline the limitations of the following study types to outline a Relationship between dietary sugars and dental caries:
Cross sectional
epidemiological studies
measure ONE POINT in time only
Current diet may be different from diet several years previously when dental caries
was initiated. Only measure disease and diet at one time point
outline the limitations of the following study types to outline a Relationship between dietary sugars and dental caries:
Population based ecological studies
Do not account for confounding factors and use per capita sugars data that assumes equal consumption across population – e,g, all age groups
outline the limitations of the following study types to outline a Relationship between dietary sugars and dental caries:
Cohort studies
Do not provide such strong data as RCT. No all have controlled for confounding factors such as fluoride exposure, oral hygiene.
outline Starchy staple foods
- Bread- 50/50 or translation to wholemeal
- Potatoes
- Unsweetened cereals
- Rice
- Pasta
- Bulgar wheat
- Millet
outline Highly processed starchy foods
- Sweetened breakfast cereals
- Biscuits
- Cakes
- Processed corn and potato snacks
- Sweetened popcorn
outline Starch & dental caries: animal studies- what have they shown (what is a limitation)
- Raw starch in not cariogenic
- cooked starch can cause caries but less so than sucrose
- mixes of cooked starch and sugar can cause levels of caries equal to that seen with sugars alone
- All diets provided in powdered form
• Differences in tooth morphology and salivary composition compared with humans
TAKE HOME MESSAGE - Starch is not the problem- free sugars are
outline Starch & dental caries clinical experimental studies
- Laboratory incubation studies show crisps, pretzels, breadsticks, crackers and cornflakes can be hydrolysed to glucose which is metabolised to lactic acid
- Enamel slab experiments show that processed starchy foods causes approximately ¼ the demineralisation seen with sugars
outline Starch and dental caries: Plaque pH studies
• Highly processed starch foods containing sugars produced as much acid as high sucrose products (Studies by Lingstrom and Kashket):
• Breakfast cereals, bread, rice and pasta reduced plaque pH but not below critical pH and significantly less so than sucrose (studies by Pollard et al)
- Depends on breakfast cereals
what evidence shows that starch doesnt effected caries- mention studies
when starch intake in unaltereted or even decreased and sugars decrease- caries declines
Population based studies
• Starch intake increased in Japan and Norway
• Dental caries decreased in all three countries
Children with Hereditary Fructose Intolerance compared with controls have:
• Low caries
• Low intake of sucrose and fructose
• Normal or higher intake of starch
Turku Sugars studies (a non randomised intervention study see ND8/9)
• Intake of starch was unaltered over a 2 year period and dental caries decreased when sucrose was removed from the diet
Northumberland study:
High starch- low sugar diet better- however not be eating as much
what was the WHO conclusion for starchy staple foods and dental caries
- The WHO concluded there was convincing evidence that starch rich staple foods showed no relationship with caries (WHO/FAO 2003)
- Reduce frequency of free sugars- take at meal times s
outline Epidemiological data relating to highly processed starches
Iowa Fluoride Study (US)
• Cohort study of children studies between 5 and 8 years
association between consumption of foods high in PROCESSED starch (e.g. potato crisps etc.) as snacks and development of new cavities was found
-Some crisps have erosive potential (salt and vinegar), prawn cocktail (sweet)
No association was found between the intake of NON-PROCESSED starchy (boiled potato, bread, rice) staple foods and dental caries
when can ,starch cause caries- but the amount is much less than that caused by sugars
- If finely ground, heat-treated and eaten frequently
- The addition of sugars increases the cariogenicity of cooked starchy foods. Foods containing baked starch and substantial amounts of sucrose appear to be as cariogenic and a similar amount of sucrose
Based on the findings of research into starch and dental caries, what would you advise your patient with respect to starch in the diet?
- Advice to patient is to consume plenty starchy rich staples as not linked to caries and good for general health.
- Avoid highly processed starch foods esp. those to which sugars added.
what is the Relationship between fruit and dental caries
- Fresh fruit and erosion may be more prominent than fruit and caries - Unstable occlusion if erosion
- Plaque pH – fruit consumption decreases pH but not to below critical
- DEPENDS on type Fresh fruit or as a juice (orange juice)
- Epidemiological studies show fruit consumption is associated with low levels of caries
- S.African fruit farmer study showed higher levels of caries than grain farmers but intake was very high – 3 bunches of grapes a day.
what should be the Advice to parents for fruit and dental caries
fresh whole fruit is a healthy snack for children to consume (aim for 5+ fruit and vegetable portions per day). Fruit juices are high in free sugars and if consumed should be limited to one 150ml portion per day.
what is the impliaction of Dried fruits on dental caries - whens the best to consume
• Not all dried fruits are dried the same way
- Some in honey (caries reduction) or other things added
- Fresh fruits better to recommend
• Traditional whole dried fruits (raisins, prunes, apricots)
• Fruits where syrup and or sugar is added during the drying process (cranberries, dates, mango)
• Fruit ‘leathers’ – highly processed dried fruit with added sugars
• Dried fruits are not classified as free sugars.
• Dried fruits are a concentrated form of natural sugars
• Some claim dried fruit is retentive in the mouth – but there is not firm evidence to support this
• Dried fruits are an excellent source of micronutrients and fibre
• Best to consume at mealtimes
what is the Lactose content in milk- why does this mean milk may not be cariogenic depite it containing a common dietary sugar - what else does it contain
- Human = 7g/100g
- Cow’s milk = 5g/100g
Milk could be classified as cariogenic BUT lactose is the least cariogenic of the common dietary sugars- not overly worried
• Also contain calcium and phosphorous which help prevent dissolution of enamel.
what is the implication of breast fead Milk on caries
- Children breastfed >12 months have an increased risk of caries when compared with children breastfed <12 months
- Amongst children breastfed >12 months, those fed nocturnally or more frequently had a further increased caries risk.
- A meta-analysis of cross-sectional studies showed that breastfed children were less affected by dental caries than bottle fed children
what is the department of health advice on dietary sugars and human disease
greatest gain if sweetners used to replace sugars in food ingested frequently
food manufacturers produce low sugars alternatives to existing sugar rich products, especially those for children
what are bulk sweetners and examples
composed of the polyols, which are derivatives of normal sugars and exhibit carbohydrate-like structure - they are sweeter than sugar but only a few times. Need to put a lot in to get effect and often used in combination.
- Sorbitol
- Mannitol
- Lycasin
- Isomalt
- Xylitol
- Lactitol
- Maltitol
- Sucralose
what are intense sweetners and examples
range of chemical structures and are very much sweeter than sugar. Much sweeter than sugar (x200), tiny amounts needed • Acesulfame potassium • Thaumatin • Aspartame – Canderell – Nutra sweet • Saccharin • Stevia
what are the types of experiments that can be carried out to test sweetness
- Plaque pH studies- in vitro (test tube) – measure pH drop when sugar added to plaque
- Animal experiments- not humans, don’t have same tooth anatomy
- Intervention studies (clinical trials)- most realistic/comparable to the population
- Enamel slab experiments
what are the results of the experiments been carried out on Sorbitol and Mannitol (Bulk sweeteners)
- 0.5 and 0.7 times as sweet as sucrose respectively
- Incubation studies: fermented slowly (how quickly they ferment)
- Plaque pH studies: slight decrease in pH (not as severe as pH drop which sucrose)
- Animal studies: caries occurs in rats but to a much lesser extent than with sucrose (rats don’t consume similar diet)
- Enamel slab experiments: 45% extent of demineralisation caused by sucrose (nothing for sorbitol and mannitol)
- Clinical trials: sorbitol is non-cariogenic
outline Sorbitol/mannitol: intervention studies
- Half the group has intervention and half do nothing
- Three trials have compared sorbitol and mannitol containing gum on caries risk compared with no gum
• Trial 1
– 3 sticks per day had no effect on 2.5 year caries increment in permanent dentition (children) Finn et al 1978
• Trial 2
– 3 sticks per day -6 % reduction in 2 year increment and 8% reduction in 3 year increment in permanent dentition (Beiswanger et al 1998)
• Trial 3
– 3 sticks per day 33% reduction in 2 year caries increment with sorbitol
– (Szoke et al 2001)
Chewing sorbitol and mannitol will reduce caries risk compared to no gum? No. May be due to chewing action itself increasing saliva therefore increasing pH.
Can oral bacteria adapt to using sorbitol and mannitol? Hogg & Rugg Gunn
Frequent or long term use of sorbitol is unlikely to increase caries in normal people- dietary advice is its fine to chew.
they dont get better at acid production
what is Xylitol and what do experiments show about the cariogeinicity
• As sweet as sucrose
Turku study- almost total substitution of sugar with xylitol for 2 years cause 85% less caries development
Clinical trials of xylitol gum have shown it to be anti-cariogenic- but is this due to saliva flow from chewing? no as tests with lozenges were also carried out
what is Sucralose (Splenda)- bulk sweetener
- 1’,4’,6’ trideoxy-trichloro-galactosucrose
- A chlorinated derivative of sucrose
- Manufactured as ‘Splenda’
- Widely available as a sugar alternative
- Non-cariogenic in rats (Bowen et al 1990)
what is Aspartame
Intense sweetener
- 200 x as sweet as sucrose
- Non cariogenic
- Uses are widespread, especially frozen
- Contains phenylalanine (and aspartic acid) so cannot be used in phenylketonuria (PKU)
what is saccharin
Intense sweeteners
500 times as sweet as sucrose
• Inhibits bacterial growth/metabolism by enzyme inhibition- positive effect?
• Used in table top sweeteners, gums and drinks
what is Acesulfame potassium
Intense sweeteners
• 130 times as sweet as sucrose
• Non-cariogenic but doesn’t inhibit caries (like xylitol)
• Used in boiled sweets and preserves (withstands high temperatures)
what did the Acesulfame/saccharine intervention study which measured 3 year DMFS increment, including non-cavitation lesions conclude
• Acesulfame/saccharin gum (5 sticks per day) reduced dental caries compared with no gum
but No significant difference between effectiveness of acesulfame/saccharine gum and sorbitol and xylitol gums
what is Stevia
- Stevia is a sweetener extracted from the leaves of the plant species Stevia rebaudiana
- The active compounds are steviol glycosides
- 150 times as sweet as sugar- don’t need to add a lot
- heat-stable
- pH-stable
- non fermentable- bacteria cant grow (can reduce sugar)
- Some of its extracts may have a bitter or liquorice aftertaste at high concentrations
Sugar substitutes what should we advise for a 12 year olds diet
Replace sugar with sweetener e.g canderel?
Replace coke to diet cokes then work on changing behaviour to different drink
Fruit yoghurt- low sugar alternative yoghurt
Low sugar polo mint
what can cause Tooth wear (tooth surface loss)
Attrition
Abrasion
Erosion
what is Erosion
Tooth wear is described as the irreversible loss of dental hard tissues from mechanisms other than bacteria or trauma (Bartlett & Smith 2000)
Erosion is the chemical dissolution of tooth structure by acids other than those caused by bacteria
what is a (BEWE) and what do the different scores mean
Basic Erosive Wear Examination
0- no erosive tooth wear
1- initial loss of surface texture
2- distinct defect, hard tissue loss <50 % of surface area
3- hard tissue loss >50 % of surface (irreversible tooth loss
This will become pathological due to pulpal exposure)
guidance is offered depending on the different risk factors
what is Pathological wear
Loss of function
Serious aesthetic deterioration
The tooth won’t survive the rate of wear
Pain
what is the Impact of erosive wear
Tooth destruction
Costly restorative treatment
Aesthetics
Sensitivity/pain
Psychological
what are some intrinsic acids that contribute to the aetiology of tooth wear
intrinsic
Gastro-oesophageal reflux disease (GORD)
– Pregnancy
- Impairments
Frequent vomiting
- Pregnancy
- Alcoholics
- Eating disorders
hydrochloric acid is the issue
what are some extrinsic acids that contribute to the aetiology of tooth wear
Diet
Medicines
what are some Dietary acids
Carbonic
Citric
Vitamin C Bubbles in beverages Citrus fruits & juices Apples Cola beverages Rhubarb Grapes
what are Acidic Foods and Drinks
Carbonated drinks Fruit squashes/cordials Fresh fruit juices Wine Alcopops Pickles and vinegar Chewable vitamin C tablets Fruit Fruit flavourings/ fruit teas Adding slices of fruit Tomato and chilli based foods
what are the Different acids can work in different ways
Hydrogen ions are dissociated from the acids when dissolved in water.
Cause dissolution by either combining with the carbonate or phosphate ions in HA releasing all the ions from that region of the crystal.
how do citric acids and hydrochloric acids have different erosive potential
HCL= hydrogen ions directly dissolve the mineral surface, but there is no effect from the chloride ions
CA=hydrogen ion directly dissolves the mineral surface and citrate anion may interact with calcium removing it from the crystal surface
- Citric acid (CA) can have double effect
what is the Erosive potential affected by
pH value (the H+ ion concentration)
titratable acidity (the total available H+ ions as the pH value changes)
calcium chelation properties
buffering capacity (the ability to maintain a pH at the current value)
mineral content (specifically calcium and phosphate levels)- Adding minerals can reduce erosive potential
what are the Risk factors for erosive wear
Quantity- more fruit/coke more erosion
Frequency-between meals is bad
Habits- longer you spend eating/ drinking = more tooth wear. swishing, sipping
temperature- higher temps= higher erosive potential
what are Groups potentially at increased risk of erosion
Sportsmen Eating disorders Alcoholics Drug addicts/users of recreational drugs Pregnant women ‘Dieters’ Wine tasters Impairments
what are Questions to ask patients when you suspect dietary erosive tooth wear
How many dietary acids are being consumed on a daily basis
How many of these are between meals?
Is greater than 10 minutes being spent consuming any dietary acid at a single sitting?
Do they sip, swish, hold or rinse the dietary acid in their mouths prior to swallowing?
Do they consume dietary acids at an increased temperature eg hot water with lemon
Food diary can be done
What do I need to do as an oral health care professional?
Identify Inform Counsel/support Prevent Treat
Good management of dental erosion
Early diagnosis
Control of aetiological factors
Good baseline records
Ongoing monitoring
Take a good case history Dietary habits Gastric disturbances Drug therapy, radiotherapy Salivary gland dysfunction Oral hygiene habits
what Dietary advice can be given to reduce erosive wear
Drink water or milk only
Limit the amount and frequency
If consumed drinks should be
Consumed quickly and do not swish around the mouth
Drank through a straw with the straw well back in the mouth
Not consumed close to bedtime
Avoid brushing directly after an acid attack
Immediately following an acid attack with, a remineralising (fluoride mouthwash/tablets as tooth paste abrasive) or a neutralising agent (sugar free antacids)
why is dairy milk a Protective factors for erosion and caries
Contains sugar but non cariogenic due to protective factors and low cariogenic sugars (lactose)
why is dairy cheese a Protective factors for erosion and caries
Cheese is high in saturated fatty acids
Only need small amount of cheese for it to have a protective factor - can advise as fat content is neglible
what are the factors in cheese and milk that are caries and erosive protective
Calcium, phosphate, casein
what is the association between tooth loss and chewing function and what does this lead to
reduced ability to chewing and biting with dentures- less ability to exert force- leads to avoidance of foods that need chewing (apples, celery) -may also avoid foods with pips (grapes, tomatoes)
how does tooth loss lead to low intake of dietary fibre
tooth loss
reduced chewing function
selective food avoidance (fruit and veg- tough meat)
low intake of fruit, veg, and fibrous foods
low intake of dietary fibre
compare the intake of dietary fibres in dentate and edentulous persons
Intake of dietary fibre (non-starch polysaccharide) was compared between dentate and edentulous adults- higher number of edentulous patients with a very low fibre intake
Test group: 30 full-denture wearers aged 40-60 years
Control group: 30 dentate (20 + natural teeth) adults aged 40-60 years
what do edentulous have a lower intake of, and what do they have higher intakes of
- Fibre
- b-carotene
- Fruits and vegetables
- vit C
Edentulous had higher intakes of saturated fat
Does retention of dentition play a role in preventing undernutrition in older people?
- MNA score was lowest for edentulous with 1 or 0 denture
* MNA (nutritional assessment) score was highest for those with 2 dentures
does prosthetic rehabilitation increase food choice and nutrient intake
Prosthetic rehabilitation improves chewing function but does not provide sufficient drive to change what people eat
dietary advice should be given, and it must be tailored e.g. if they’re vegetarian can’t tell them to eat meat
outline the impact of having implanted dentures as opposed to conventional ones on saturated fat and fibre
both groups gave a high saturated fat intake- implanted patients their fat intake decreased (dietary advice)
fibre intake increases for implant patients- dietary advice and increased confidence
outline the impact of dentures on eating - what should dentists be doing
loss of enjoyment of eating- negative social impact
less healthy diet consumed with respect to fruits, veg, fibre and macronutrients
dentist adjust denture rather than diet to overcome eating problems- patients receive little advice on what to eat
dentists should support patients to change dietary behaviour- but they feel like they’ve not had adequate training to do this
- lack of personal experience of wearing denture underpins dentists and DCPs reluctance
how could the edentulous increase fruit and veg
– Smoothies – Mushy peas/ mashed – Grate in salads – Soup – Stewed fruit – One 150ml portion of fresh fruit juice per day
how could the edentulous increase fibre
– Weetabix with milk – Porridge – Lentil soup – Pease pudding – Dhal
how could the edentulous increase intake of foods from meat and alternatives group
– Fish is easier to chew
– Minced meats e.g. turkey, chicken beef
– Stews and slow cooked tender meat
– Cooked pulses (dhal, soups, pease pudding, mushy peas, bean pate)
what some factors that should be considered when giving advice to the edentulous
- Who buys the food?
- Who prepares the food?
- What basic cookery skills do they have?
- How long does it take to eat a meal?
- How appetising does food look?
- What about the social aspects of eating?
what are the Aetiological factors in PD
Initiated by microorganisms in plaque – biofilm is major mediator
Interaction between plaque biofilm and host immune system
outline the disease process of PD
microbial dysbiosis
indvidual patient
hyper-inflammatory host response
microbial dysbiosis bacterial biofilm can be normal and protective – conditions lead to biofilm becoming dysbiotic – lead to change in biofilm which promotes changes towards disease-> inflammation and tissue breakdown
Bacterial cells important but process is driven by hyper-inflammatory host response
What are SOME of the risk factors for periodontal disease?
nutrition!!
microbial
oral hygiene
mediation
so many more!
why would there be significantly larger amount of plaque in students who’s diet included sucrose over glucose
extracellular polysaccharides such as glucans can be harnessed from sucrose
what is the impact of malnutrition on immune function
impairs host innate and adaptive defences such as phagocytic function, cell mediated immunity, complement system, secretory antibody and cytokine production and function
depletion of antioxidants in cells promotes immunosuppression
what are Suspected causative factors of malnutrition
increased oral burden of free glucocorticoids (immunosuppression)
impaired host defence of saliva
what is the effect of undernutrition of the immune response
impairs normal immune response
‘Rapidly progressing (aggressive) forms of periodontitis and gingivitis are most prevalent/severe in impoverished communities’
what is Cancrum Oris / Noma and the risk factors
Severe gangrenous disease that causes a rapid necrotising destruction of soft and hard tissue of the face, including bone.
Risk factors:
Malnutrition
Poor oral hygiene
Compromised immune system – infection with measles, malaria or HIV
what is impact of calcium and vitD deficiency on periodontal health
resorption of cementum and bone (animal studies)
exacerbated bone loss
females have ‘54% increased risk of periodontal disease if Ca <499mg and 27% more risk if Ca<799 mg/d compared to >800mg per day’
(Nishada et al. 2000)
what is the role of vitD in diet
Essential for cell development, neuromuscular functioning, bone development and inflammation control
what are the sources of vitD
Major source of Vitamin D is the conversion of 7-dehydrocholesterol to Vitamin D3 via exposure of skin to UVB radiation
food
- oily fish
- egg yolks, butter, beef
- cheese, mushrooms
- fortified foods
what is the role of Folic acid in inflammation
Gingival tissues have high folic acid requirements due to high cellular turnover rate
Clinical trials of folic acid supplementation (systemic and topical) demonstrate reduced inflammation
Low serum folate was independently associated with periodontal disease (Yu et al. 2007)
what is the role of Vitamin C (Ascorbic acid) periodontal health
Severe Vitamin C deficiency causes scurvy
–Swollen bleeding gums & tooth loss
Collagen synthesis
- Periodontal ligament
- Bone matrix
- Blood vessel walls
Immune function - phagocytosis and wound healing
Powerful antioxidant
Epidemiological studies (observational) have shown weak negative association between Vitamin C status and chronic periodontitis
what is the role of Vitamin B in periodontal health
that low B12 levels were associated with a worsening of the periodontal status of teeth and an increased tooth loss rate (Zong et., 2016)
Deficiency of vitB in the vegan diet
what are Reactive oxygen species
free radicals that act as host immune defence to bacterial antigens (PMLs) - however when not regulated can damage healthy tissues
what is oxidative stress
the imbalance between damaging reactive oxygen species (ROS) and protective antioxidant (AOX) compounds
Oxidative stress highlighted as having a central role in the pathogenesis of chronic inflammatory diseases
what is the role of Reactive oxygen species in periodontitis
Reactive oxygen species (ROS) are produced in periodontitis
Oxidative damage to gingival tissue, periodontal ligament and alveolar bone
ROS have been implicated in the periodontal tissue destruction - both directly and indirectly via cytokine production
ROS cause lipid peroxidation, protein degradation, DNA mutations and bone resorption
Antioxidants buffer ROS and protect against tissue damage
Low levels of antioxidants implicated in the susceptibility and progression of
periodontal disease
what are Antioxidants
Defined as molecules capable of slowing or preventing the oxidation of other molecules
Exist as vitamins, minerals and other compounds in food
May help to prevent disease by resisting free radicals
Thought to influence periodontal disease onset, progression and wound healing
what are the Antioxidants in food
Lycopene Vitamin A Vitamin E Vitamin C Carotenoids Glutathione Iron Copper
veg- sweet potato fruits- apricots, mango nuts- Brazil nuts seeds- sunflower oily fish meat- beef, chicken brocolli dark choc
what is the function of Vitamin E and its role in periodontal disease
anti-oxidant
stabilise the membrane structure by terminating the free radical chain reaction
Found in non-citrus fruits, nuts and seeds
Suggested impact on prevention periodontal inflammation and collagen breakdown
what is the link between antioxidant and periodontitis
Initial studies show antioxidant levels in gingival crevicular fluid (GCF) and in serum are compromised in periodontitis
Niigata Study: A higher intake of dietary antioxidants was inversely related to number of teeth with periodontal disease
what is the link between obesity and PD
Periodontal disease is associated with low grade systemic inflammation (Janket et al., 2003)
Obesity is associated with increased risk of adult periodontitis
Adipocytes secrete pro-inflammatory adipokines e.g. TNF-a, IL-6 which up-regulate acute phase proteins seen in inflammation
other studies
Body Mass Index >30 significantly associated with risk of periodontitis in Japanese adults - obesity was second risk factor after smoking (Saito et al., 1998)
NHANES data: significant relationship between BMI and waist hip ratio and
periodontitis (Wood et al., 2003)
Maintaining a normal BMI associated with lower risk of periodontal disease (Al-Zahrani
et al., 2005)
outline the Model of the nutritional impact on periodontal disease
undernutrition and antioxidants play a role in tissue damage and the immune response
obesity is linked to gingivitis/periodontitis
outline the role of Omega 3 fatty acids and periodontal disease
Eicosapentanoic acid (EPA) and decosahexanoic acid (DHA) have lesser inflammatory effects compared with omega 6 fatty acids
EPA found in fish can block this inflammatory pathway
EPA can also stimulate the Lypooxygenase pathway for leukotriene B5 which has less inflammatory effect than B4
what are the Epidemiological studies of omega 3 fatty acids
The composition of fatty acids in inflamed gingival tissue differs from healthy tissue
Those with alveolar bone loss had lower serum omega 3 fatty acids
(Cicek et al., 2005)
Progression of periodontal disease lower in men with a higher intake of docosahexanoic acid
(Iwasaki, Yoshihara, Moynihan et al., 2009)
what is the Niigata Study: relationship between fish oils (EPA/DHA) and periodontal disease
Odds ratio for periodontal disease events in middle omega 3 consumers lower than the ‘low group’ when compared with highest tertile (reference group)
what is the role of dental professions and diet
diet
- reduce sugars and sat fats
- increase fruit and veg, lean protein, nuts, seeds, oily fish and wholegrain
prevention
medical history
lifestyle
what are the benefits of breast feeding outline by WHO
Breastfeeding and appropriate complementary feeding can reduce mortality in children <5 years by 19%
Breast feeding could prevent 37% of deaths in the second year of life (continue breastfeeding into second year of life)
what are the WHO recommendations for feeding infants and young children, what are these recommendations based on
WHO recommends: Immediate initiation of BF
- Exclusive breast feeding for 6 months
- Complementary feeding with continued breast feeding up to 2 years
- Appropriate use of micronutrient supplements (e.g. Vitamin A, Iron, Zinc, Iodine)
The recommendations are based on systematic review of the evidence for the effects of breastfeeding on infant and maternal health
discuss the evidence for the statement : “bottle fed children have more dental caries in primary dentition than breastfed children”
what does current evidence suggest
Systematic review and meta-analysis
4 studies showed formula fed had higher caries and 3 showed no difference
Meta-analysis of cross sectional studies (lowest quality evidence) showed breastfed children had fewer caries
But All studies were susceptible to residual confounding (oral hygiene, sugars in bottle/diet, water F, preventive dental visits, on demand nocturnal feeding).
Examiner may not have been blind to feeding practice
CURRENT EVIDENCE suggests that breastfeeding has a greater protective effect against dental caries than bottle feeding BUT
- Further cohort studies are needed to strengthen evidence- where data on confounders can be collected and included in multivariate models.
- We need studies that think about confounding factors
outline a Systematic review and meta-analysis for the effect of breast feeding and bottle fed on dental caries - is there a need for more studies?? if so on who?
12 months breastfeeding had fewer dental caries than <12 months but >12 months has increased caries risk when compared to <12 months
Amongst children breastfed >12 months, those fed nocturnally or more frequently had a further increased caries risk
There is a need for studies on children aged >12 months assessing caries risk in breastfed, bottle-fed and children not bottle or breastfed, with simultaneous data on all potential confounders
-Breastfeeding only protects to a certain time, after this we don’t know
what are the Key questions of relevance to breastfeeding and risk of early childhood caries?
- Why are babies breast-fed after 12 months?
- Are they any benefits of nocturnal breastfeeding?
- Are there any nutritional advantages of on-demand infant feeding?
Why are babies breastfed after 12 months? are these results reliable
delayed maternal menses
reduced risk of diarrhoea
Contributes to nutrition when there is a lack of adequate complementary foods
helps hydration where there is a lack of clean water - WHO advice to continue breastfeeding up to 2 in developing countries
results are mixed, methodologies weak and not all studies control for confounding
Are there any benefits of nocturnal breastfeeding? (Pan American Health Organisation)
Improves milk supply- nocturnal prolactin levels higher
Contraceptive effect
Reduced SIDS risk
Helps ensure adequate intake
Important for babies with faltering weight
Promotes sleep (serotonin)
Are there any nutritional advantages in on-demand infant feeding? is it recommended by WHO
recommended by WHO and American Association of Pediatrics (AAP)
Nutritional adequacy- increases milk flow
tailored intake
Hunger upsets and stresses the baby
some evidence that it can regulate the baby’s body temperature and blood glucose
what is Hypoallergenic infant formula milk used for - what is it made with - what is the implications of this upon the baby
cows’ milk protein intolerant/ lactose intolerant infants, or babies allergic to lactose
made with fully hydrolysed protein (for reasons above) and partially hydrolysed protein (atopy history)
Contain maltodextrins or glucose syrups (cariogenic) as a replacement to lactose
• Can contain sucrose and fructose (up to 20% of total CHO)
Babies more exposed to (fruit) sugars compared to breastfeed/bottle fed (only exposed to milk sugars)
what are some other formal milks , what should parents be advised
LOW OR LACTOSE FREE FORMULA - lactose free and does not contain casein.
- contain glucose syrups and sucrose (caries)
NUTRIENT ENRICHED POST DISCHARGE FORMULA - nutrient enriched formula for pre-term infants post discharge
SOYA FORMULA- use for vegan infants and contain soya protein with vegetable fats- doesn’t have lactose sugars, has glucose polymers (increased caries risk)
Parents should be advised that because free sugars are present in these infant milks that good weaning practice and oral hygiene are needed to safeguard teeth
what is soya formula not recommended
phytoestrogens (risk reduced from 6 months)
what is the issue with many formula milks containing oligosaccharides (pre-biotics
carbohydrate which passes to large bowel which is fermented by commensal bacteria
what is follow on formula and what are the issues with it
- For infants over 6 months of age
- Contain more protein, micronutrients (e.g. iron) and energy than infant formula
but can get Good source of iron during weaning
Not as regulated as those before 6 months - can contain maltodextrins and other oligosaccharides
Use of follow on formula has led to a decline in cow’s milk being the main milk before 12 months
No reason for follow on formula as WHO recommend breastfeeding up to 12 months so why are we changing the formula for over 6 months when breast milk doesn’t change?
what was the European Food Standards Agency issued guidance in 2014 for Follow on formula
Carbohydrate content from can range from 36-53% of energy
Sucrose and fructose should provide no more than 20% total CHO
This means no more than 10.6% of energy can come from sucrose and fructose
what the Recommendations for use of follow on formula milk by WHO and SACN 2008
WHO: Follow-on formula is unnecessary and is unsuitable as a replacement for breast milk after 6 months
SACN 2008: no published evidence that the use of any follow –on formula offers any nutritional health advantage over the use of whey based infant formula among infants artificially fed’
what is the guidance on cow milk
• Not before 6 months at all (risk of allergy & too high in minerals)
• Not as main milk before 12 months (low iron)
• Semi-skimmed from 2 years if overweight
- Children need fat soluble vitamins
• Skimmed milk – not before age 5 years
• Children under 5 years need more calories from fat than older children do
what do Cohort studies in Italy, Australia, Japan, India, Kosovo, China and the UK show about the association of sugar and ECC
children aged 1-5 years bottle feeding and sugar in bottle at night was associated with increased dental caries
Several birth cohort studies show sugars in bottles is a factor associated with increased dental caries
Sweetened milk or juice in bottles is associated with increased dental caries
Why do parents add sugars to infant feeds? what are alternatives to this
Treat constipation: a practice that goes back centuries.
<6 months cooled boiled water 1-2 a day is just as effective
For >6 months prunes/pear/peach/plums/apricots/peas (soften stools) not banana/apple.
Aid digestion: no theory or evidence to support
Help the baby sleep/reduce pain (e.g. colic, gas): sugar water can relieve pain, however, human breastmilk also provides pain relief
outline the association between Night bottle time feeding and caries
Sleeping with a bottle increases caries
oData from cohort studies show that use of a bottle during sleep is predictive of dental caries risk in children aged 3-4 years
oPre-school children. Sleeping with a bottle was associated with increased dental caries
oSugars in bottle given at night is associated with dental caries
what is WHOs advice on complementary feeding
Complementary feeding - all foods and liquids other than breast milk or infant formula
Infants should be breastfed for the first 6 months of life to achieve optimal growth, development and health.
Infants should receive nutritionally adequate/safe complementary foods while breast feeding continues for up to two years of age or beyond
In some countries micronutrient supplements are recommended from the time complementary foods are introduced - in UK vitamins A C & D from 6 months to 5 years recommended by Dept Health
Non-breastfed infants need at least 400-600ml extra fluids in a temperate and 800-1200 in a hot climate
outline Complementary feeding and oral health
• Sugars should not be added to complementary foods
• Should be low in free sugars including sugars derived from fruit juices or concentrates
• Unsweetened cereals, fruits and vegetables, and unsweetened yoghurts should be encouraged
• There is absolutely no advantage to dental health if sucrose is replaced by other sugars such as fruit juices or fructose
- Natural sugar just the same as caries risk as sucrose
outline Complementary feeding drinks and oral health
- Milk and water should constitute most drinks.
- From six months infants should be introduced to drinking from a cup
- From one-year drinking from a bottle should be discouraged
- Tap water when cooled and boiled is safe for infants
- Bottled mineral water may vary in composition and may be too high in some minerals and trace elements
- Sugars sweetened beverages should not be given - drinks contribute little to nutrient intake and may spoil the appetite
- Fruit juices and herbal drinks including those designed specifically for infants are totally unnecessary from a nutritional standpoint
- Drinks containing sugar substitutes are not recommended for infants and children under 3 years as they contain artificial sweeteners
outline Dietary advice for children <5 years
- Appetites are small so frequent intake may be necessary
- > 5% energy from free sugars (3 cubes or LEVEL teaspoons) WHO
- 50% energy from fat gradually reducing to 35% by age 5
- Diets with too little fat are common in those who consume fruit juices – can lead to failure to thrive (as well as dental caries risk)
- Very high fibre is NOT recommended
- Vitamin supplements may be advised (e.g vitamins A, D, C, iron, iodine may be recommended) - ensure sugars free.
In the UK what dietary advice do we recommend for children <5 years
- 5 small fruit and vegetable portions per day
- Starch rich carbohydrate at all meals and snacks
- 3 portions of dairy foods per day
- 2-3 portions of meat and alternatives or 3-4 if vegetarian (eggs, nuts, pulses)
- Public Health England recommend a max of 19g/d free sugars or 4 cubes for children aged 4-6 years
what is evidence from cohort studies about Dietary sugars and ECC
increased amount and frequency of sugared soft drinks (soda) is associated with increased early childhood caries in the US (Trinidad – 3 years & Brazil 18-42 months)
• In children aged 2-6 years increased frequency of consumption sugars-containing food was associated with increased caries
• In children aged 6-36 months increased sugars in the diet was associated with increased caries in children in Uganda
• An increased frequency of intake of sweet snacks was associated with increased caries at age 3 years old in Trinidad
• In children aged 18-42 months in Brazil, in low income areas increased sugars intake was associated with increased caries
what are Sources of dietary sugars in the diets of young children
- Sugar sweetened beverages
- Confectionery
- Sweet pastries
- Fruit juices
- Sucrose
- Sweetened sauces
- Sweetened milks – condensed milk
what are some Hidden sugars
- Invert sugar
- Sucrose
- Glucose
- Glucose syrup
- Corn starch/starch solids
maltodextrin
maple syrup
fruit juice
what are Strategies that can be given by dentists to reduce sugars intake
Advise to eat less
what are Suggested actions to reduce free sugars intake
- National policies on free sugars in line with WHO Guideline
- Taxing foods high in free sugars e.g. sugar sweetened drinks
- Improved nutritional labelling of foods for sugars content
- Advertising and marketing restrictions on foods and drinks high in free sugars
- Reformulation of food products to reduce free sugars content
- Clear food based dietary guidelines
what are Fiscal pricing policies- how can manufacturers get around this
• Taxing of sugars sweetened beverages exists in several countries (Mexico, France, UK from 2018, S. Africa)
• Policy simulations have shown that a tax would achieve highest reduction in sugars intake in high SSB consumers - despite high consumers having less elastic demand for SSB (up to 8g per day reduction)
• Imposing a tax on a high sugar product sends a health message out to consumers
Sugar free products may contain maltodextrin (mixes with salivary amylase glucose)
Sugar free products may contain maltodextrin (mixes with salivary amylase to produce glucose)
it is a polysaccharide; thus, it does not inherently contribute to the added sugars declaration (although one could argue that because it is easily hydrolyzed in the digestive tract that it ought to
are Family based dietary intervention studies useful- e.g. motivational interviewing session
- One-time motivational interviewing session to change mothers diet and oral hygiene behaviour immediately after birth of child.
- After 5 years a case control analysis showed children whose mothers had participated in the intervention had significantly lower caries experience than controls
are targeted dietary practices using posters and leaflets
Intervention group received targeted dietary practices using posters and leaflets
ECC was not lower in intervention group – however:
- Lower ECC was observed in children of mothers who remained exclusively at same health centre using it as their source of feeding advice (sub-group analysis)
- Continuous access to dietary information may protect against ECC
can the ten steps of healthy feeding (no use of bottle or pacifier, avoid adding sugars, juices, avoid sugars sweetened beverages and sweets) delivered in home visits help ECC
Controlled trial of an intervention for first 2 years of life, delivered in home visits
Home counseling reduced incidence of ECC by 22% and severe ECC by 32% by age 4
what are the main sources of sugars in children diet
soft drinks and sweets
Teenagers get 22% of their daily added sugar from soft drinks and DON’T forget ACID intake!
what is the recommended free sugars per day for >11 year olds
no more than 30g
what are the Main aims for reducing free sugars and acidic foods
- Decrease FREQUENCY of consumption- drip feeding means pH in mouth is constantly below critical pH
- Decrease AMOUNT consumed
- Cut out IN-BETWEEN meal sugars and acidic drinks
- Do not consume free sugars or acidic foods within ONE HOUR of bedtime (saliva flow decreases)
- Chew SUGAR FREE GUM or a piece of cheese after each meal or snack – helps improve saliva production
what are the Different levels of advice/intervention for for reducing free sugars and acidic foods
- Individual advice – general with or without leaflet
- Individually tailored advice (according to diet diary)
- Group work (schools, care homes)
- Campaigns and displays in the practice
- School initiatives
- Campaigning at a national level for change- sugar tax
outline an Individual dietary intervention- what are the 3 Ps this should be based around
• Screening: identification of those who need to change
• Assessment: are they ready to change/motivated?
– discuss motivation and explore barriers to change.
– assess current diet – provide feedback
• Desired changes:
– Negotiate 2-3 changes (even if there are several more that you want to change)
– Identify misconceptions
– Plan in stages
• Set goals for next time and write in notes (patient centred)
• Monitor progress and provide feedback
The three Ps: Personal, practical & positive
how should Agenda and goal setting be when giving patients dietary advice
Agneda:
Collaborative Patient-led Flexible Individually tailored Facilitated not driven (choice of whether to change rests with the patient)- we cannot change the patient, we must jus facilitate change
Goal setting:
Collaborative
Patient-Directed
Clinican Facilitated
what should Smart goals be
- Specific
- Measurable- have they done it or not
- Achievable
- Realistic
- Timed- e.g what time of day will you do this
what are usually reasons why people dont change
Snags:
•Yes, but…….
- Lack of confidence to change
- Lack of motivation to change
- Plans for change not put into practice
why is the Readiness to Change of a patient useful when discussing dietary advice
- Useful to tailor approach to the patient’s readiness to change.
- Action talk will be counterproductive for the >80% of people who are not ready-
- Role of dental professional is to facilitate change or movement in attitude towards change.
- Decision to change (or not) stays with the patient.
why is a rapport important when Talking about the need for change
- Probably the most important aspect.
- Attitude open and curious.
- Friendly body language and voice tone.
- Reflections.
- Open questions.
- Important to keep relationship going well
why is a change talk important when Talking about the need for change- what are some examples
- Invitation not demand.
- People are influenced by what THEY say, not what you say.
- Communicate in a way that encourages change talk by the patient.
- Good rapport and respect is more important than pushing the change agenda.
- Patient will change when they are ready, not before
‘Food and drink is really important for healthy teeth. Is this something you would be happy to talk about today?’ I they say no you must respect that
‘Reducing the amount of sugar, you eat could protect your teeth from decay. Perhaps we could talk about some changes that would help?’
what is linked to the Readiness to Change of the patient- how can we ask questions to asses this
importance and confidence
How important do you think it is to make this change now
How confident are you that you would be able to change
What are the pro’s and cons to sticking with things as they are
how can facilitate change talk
- Reflections
- Open questions
- Scaling questions
- Roll with resistance
what is Reflection - what does it aim to do
- This is where you repeat back what the person has said
- Simple or ‘between the lines’
- Aim is to show you are listening and encourage them to say more.
what are Open questions - what do they aim to do
• Ask questions that allow the person to express their considered opinion.
• Can be preceeded by a closed question.
- Do you have any concerns about your diet?- if they answer no then this is an issue
• What concerns do you have? -more likely to encourage talk
what are Scaling questions:
- Ask about importance or confidence of a particular behaviour change.
- On a scale of 0 to 10, where 0 is not at all important and 10 is the most important, how important is it to you to cut down on the sugar you eat?
what follow up qs could you ask if the answer to a scaling qs is:
1- If 5 or more
2- for any number
3- if 7 or more
If 5 or more- What is it that makes that a 6 for you rather than a 1?- they will likely say their reasons for change
for any number- What would have to change for the importance to go up a bit – say from a 6 to an 8?
if 7 or more- It sounds like this is quite important for you. How confident are you that you could make a change? Would you like to talk about what you could do?
outline why Roll with Resistance is important - what is the benefit of this
For people at the contemplation / ambivalent stage (likely to be the majority of patients).
Rationale is that they will have plenty of experience or thinking through both sides of the argument.
- Therefore in a conversation they will take the ‘other side’.
Acknowledging there resistance e.g. ‘it sounds like it would just be too hard for you to think of making a change right now’
-Can help keep the relationship solid
‘on balance maybe now just isn’t the time to change anything’
Keeps relationship positive and leaves the door open to future conversations
outline why Discussing and Negotiating Change is important
- Don’t direct – facilitate
- Discuss possible change – positive first
- Too much too soon will confuse
- If a particular aspect is difficult let it pass, don’t force the issue
- Remember – change takes time!
what is Patient-centred Decision Making
- Having discussed options for change, ask the patient which they would like to agree to change
- Ask them to choose 2-3 changes they think are achievable by the next visit
- Write these in the notes and give patient a copy so they can be revised at next visit
what are the Dietary Intervention at NDH- five stages
- Giving out a food diary- limit advice before diary so its accurate
- Collecting and validate what is written
- Analyse the diary – e.g. free sugar intakes, snack intakes, anything in an hour of bed, food groups
- Negotiate changes
- Monitor changes
Remember the three Ps!
