Nutritional Aspects of Dental Caries & Dietary Analysis PDF

Nutritional Aspects of Dental Caries & Dietary Analysis Module 3 Image courtesy of: https://jigsaw.vitalsource.com/books/9780133560954/epub/OPS/images/f0054-01.png Module Three: Learning Objectives 1) Explain the roles of fermentable carbohydrates in the caries process. 2...

Nutritional Aspects of Dental Caries & Dietary Analysis Module 3 Image courtesy of: https://jigsaw.vitalsource.com/books/9780133560954/epub/OPS/images/f0054-01.png Module Three: Learning Objectives 1) Explain the roles of fermentable carbohydrates in the caries process. 2) Define sugar alcohols and list the benefits of xylitol. 3) Identify the sugar substitutes permitted in Canadian foods. 4) Describe various factors that affect the cariogenicity of carbohydrates. 5) Discuss the scientific evidence as it relates to diet and dental caries. 6) Identify cariogenic foods and caries-protective foods. 7) Utilize a one-day dietary record for nutritional assessment. 8) Analyze a one-day dietary record for cariogenicity with respect to exposure, frequency, and form of fermentable carbohydrates. 9) With a focus on nutritional counselling, describe preventive strategies related to both diet-related and oral self-care behaviours that will decrease the dietary risk for caries (e.g., that neutralize acids). 10) Describe how to incorporate the Healthy Eating Recommendations from Canada’s Food Guide into nutritional counselling. Fermentable Carbohydrates ØThey are carbohydrates that can be metabolized by bacteria in biofilm Includes all sugars (mono/disaccharides), cooked/processed starches, and oligosaccharides Metabolism of fermentable carbohydrates produces acid that can cause demineralization of enamel/dentin/cementum once critical pH is reached Sucrose promotes production of polysaccharides (glucans) by Streptococcus mutans (S. mutans), which facilitates adherence of biofilm to teeth (“slime layer”) Glucose, available from sucrose or any other carbohydrate food, can be used for energy by oral bacteria in biofilm *Laboratory tests have demonstrated that the rate at which fructose and glucose lowers biofilm pH is similar to that of sucrose – they are considered as cariogenic as sucrose *Lactose is less cariogenic than other sugars Metabolism of Starch Starches are composed of many long-chain or branched glucose units Most food sources of complex carbohydrates are in the form of starch; found in cereal grains, roots, vegetables, and legumes Found in salty snacks, cakes, cookies (*fermentable carbohydrates) In digestion, starch is broken down into dextrin and then glucose ØRetentive high-starch foods (e.g., potato chips/crackers) might be more acidogenic than high-sugar foods that are rapidly eliminated from the mouth Reminder: Oligosaccharides found in legumes (beans) are also fermentable carbohydrates. Image courtesy of: The dental hygienist's guide to nutritional care (5th ed.). Fig. 4.3 Sugar Alcohols (Polyols) Currently used as sugar substitutes due to their sweet taste They are not sugars; *not considered cariogenic Each molecule resembles a sugar, with the exception that an alcohol group (OH-) is attached to each carbon in the molecule They can be derived from different mono/di/polysaccharides Incomplete absorption causes laxative effect Sorbitol—half as sweet as sucrose; slowly fermented by S. mutans; natural in fruits/berries; commercially produced for chewing gum, chocolate, jam, ice cream Mannitol—metabolized very slowly; natural in seaweed; produced from mannose and added to chewing gum and powdered foods *Xylitol—almost same sweetness as sucrose; non-fermentable; found in birch bark and produced from corncobs/sugar cane fibres; added to chewing gum, lozenges, toothpastes, syrup, and hard candy Benefits of Xylitol Decreases bacterial metabolism; produces less dramatic pH drop Reduces amount of supragingival biofilm due to reduced production of extracellular polysaccharides (glucans) Stimulates salivary secretion For therapeutic benefit (caries prevention): 1) Consume 6 to 10 grams per day (divided into four doses) 2) Exposure time of at least five to ten minutes per dose CAMBRA Recommendations (2019) Other Sugar Substitutes (Non-Nutritive) The practice of flavouring foods without additional calories is one of many approaches to the problems of excess energy intake and a sedentary lifestyle Add sweetness but contain no/minimal carbohydrates (or energy) and do not raise blood glucose level Most are synthesized compounds from fruits, herbs, or sugar itself All products on the market have been extensively researched and are considered safe by Health Canada, if consumed in moderation (except for aspartame) ØAspartame should not be consumed by individuals who have phenylketonuria (inability to metabolize the amino acid phenylalanine) Use of sugar substitutes is an option for between-meal snacks to decrease tooth exposure to sugar Are not fermentable (not cariogenic) ØSaccharin and aspartame exhibit microbial inhibition and caries suppression Sugar Substitutes The dental hygienist’s guide to nutritional care (5th ed.). Table 4.6 https://www.canada.ca/en/health- canada/services/food-nutrition/food-safety/food- additives/lists-permitted/9-sweeteners.html Click on the link above to see a list of sugar substitutes that are permitted in Canada, along with the foods that they may be found in. The dental hygienist’s guide to nutritional care (5th ed.). Table 4.7  Canada’s Food Guide: Resources for Health Professionals and Policy Makers – Guideline 2 To help reduce the intake of free sugars, the majority of total sugars intake should come from nutritious foods, such as intact or cut fruit and vegetables, and unsweetened milk While sugar substitutes are considered *safe, Health Canada indicates that reducing intake of free sugars can be accomplished without using sugar substitutes Ø For example: drink water and eat whole fruit instead of drinking fruit juice Canada’s Food Guide: Resources for health professionals and policy makers (Section 2). https://food-guide.canada.ca/en/guidelines/section-2-foods-and-beverages-undermine-healthy-eating/ Research on Dental Caries and Diet Animal Studies Human Trials Many undertaken in the Two large landmark studies in 1950s the 1950s furthered the Proved that: results of the animal studies in humans: 1) Microbes are necessary 2) Fermentable carbohydrates, ingested 1) Vipeholm study orally, are necessary 2) Hopewood Home study 3) Saliva influences caries process Vipeholm and Homewood Studies Vipeholm Study (1945-1953) Completed at a mental health hospital in Sweden; 436 patients were used as participants Looked at relationship between frequency of sugar intake and dental caries Homewood Study (1948-1963) Completed at an orphanage in Australia; 82 children were used as participants The study was done to determine if the significantly different diet of the children living at the home (as compared to that of the children in the average Australian family household) would affect dental caries activity Recorded data included: oral conditions, lactobacillus counts and their relation to dental caries, the diet, and general pattern of life Note: Currently, neither of these studies would be replicated as they would NOT be accepted by an Ethics Review Board. There was no informed consent and the studies may have harmed the participants. Other Factors Influencing Cariogenicity Physical form of fermentable carbohydrate (liquid vs. solid) including the retentiveness of the food on the tooth surface Frequency of intake Timing and sequence in which foods are consumed (e.g., cheese eaten before a sweet food limits pH drop; likewise, cheese eaten after a sweet increases pH quickly) Presence of minerals in a food (see Week 5 notes on minerals that are important for hard tissues) *Physical Form of Fermentable Carbohydrate How quickly a cariogenic food is cleared from the mouth is a factor related to caries development A solid, sticky, and retentive carbohydrate (e.g., chewy fruit snacks) remains in contact with the enamel surface for a longer period than sweetened fluids Slow oral clearance of fermentable carbohydrate means longer exposure of the tooth to acid attack Fermentable carbohydrates that are chewy, such as caramels, adhere to teeth, BUT the additional mastication required to process these foods stimulates saliva flow, making them less retentive and less damaging than dry, sticky foods, such as pretzels *The quantity of fermentable carbohydrates has a limited impact ØThe retentiveness and the frequency of consumption are most important *Frequency of Intake of FC Longer periods of oral exposure to a fermentable carbohydrate lead to a greater risk of demineralization and less opportunity for teeth to remineralize If two people eat equal amounts of fermentable carbohydrates, the person who eats more frequently throughout the day has the greatest potential for caries With each exposure, a decrease in pH begins within 2 to 4 minutes At a pH of 5.5 or less (the critical pH for enamel), enamel demineralization occurs Within 40 minutes, the pH has increased to its initial value (this depends on saliva) Stephan Curve shows the pH changes of biofilm after rinsing with a sugar solution The dental hygienist’s guide to nutritional care (5th ed.). Fig. 18.4 Frequency of Intake Example a) Person A eats a candy bar within a 5-minute period. The teeth would be exposed to a critical pH that lasts for approximately 40 minutes before the pH returns to the original level. b) Person B eats the same candy bar in five bites, but only takes a bite every hour, the total acid exposure would be approximately 200 minutes (5 bites × 40 minutes = 200 minutes of acid exposure). *Frequent between-meal snacking on sugar or processed starch-containing foods has the same effect. Timing and Sequence of Consumption Timing: Another consideration is whether the cariogenic food is eaten with meals or between meals Participants in the Vipeholm study who ate foods high in sugar between meals in addition to mealtime had a significantly higher caries rate than participants who consumed these foods at mealtime only Despite these results, recommendations to eliminate snacks are not always realistic ØChildren cannot eat enough food in three meals to get all the nutrients they need; snacks are warranted *Foods chosen for snacks should produce little or no acid, and oral self-care should follow a snack Sequence: Sugar should NOT be consumed at the end of the meal. Protein or fat eaten after the sugar enables pH to increase faster. (Eating proteins and fats before the sugar is helpful for limiting the pH drop when sugar is consumed afterward, BUT sugary foods should not be the last food eaten during a meal.) Cariogenic Foods The dental hygienist’s guide to nutritional care (5th ed.). Box 18.1 Caries-Protective Foods Proteins, fats, phosphorus, and calcium inhibit caries Aged natural cheeses have been shown to be cariostatic ØWhen cheese is eaten after a sucrose rinse, the biofilm pH remains higher and enamel demineralization is lower than when no cheese follows a sucrose rinse ØThe protective effect of cheeses is attributed to their texture, which stimulates salivary flow, and their protein, calcium, and phosphate content, which neutralizes biofilm acids Many dairy products such as some yogurts are now fortified with live probiotic Lactobacillus rhamnosus GG, which also has been shown to have an inhibitory affect on a wide range of bacteria including Streptococcus species Lipids seem to accelerate oral clearance of food particles ØSome fatty acids, linoleic and oleic, in low concentration inhibit growth of Streptococcus mutans Lectins (proteins found in plants) appear to interfere with microbial colonization and might affect salivary function More Dietary Suggestions If snacks are needed when oral self-care cannot be performed, suggest low-fat milk products, aged cheese, plain yogurt, or chew xylitol-containing gum Xylitol and erythritol may cause less gastrointestinal distress than other sugar alcohols Complete and permanent elimination of sweets is unrealistic. The best advice is to (a) use sugar in moderation, (b) limit the frequency of sugar exposure, (c) consume sweets with a meal, and (d) brush the teeth after consuming sugar-containing products Encourage clients to brush their teeth before consuming acidic foods and chew sugar-free gum afterward as brushing their teeth afterward may increase dental erosion More Dietary Suggestions (cont’d) Eat fibrous vegetables such as celery and carrots that will stimulate saliva when chewing, and help neutralize acid Replace potentially cariogenic snacks with foods such as fresh fruits and vegetables; low-fat cottage cheese cheese, and yogurt (flavoured with nutmeg, cinnamon, or fresh fruit); peanuts Use a straw with beverages such as carbonated drinks or lemonade to reduce contact with teeth Consumption of sugar-sweetened beverages (SSBs) should not be consumed regularly Specific Diet Suggestions for Caries Prevention Primary preventive dentistry (8th ed.). Table 17-7. In-Between Meal (Snack) Suggestions The dental hygienist’s guide to nutritional care (5th ed.). Box 18.2 *Diet and Dental Erosion Dental erosion can occur with frequent exposure to acidic liquids Citrus juices contain citric acid, which is especially damaging to tooth enamel; the citrate binds with calcium in saliva, reducing its potential to remineralize the tooth Deleterious effects of 100% fruit juices can be minimized with chemical modification or calcium fortification Sour sweets and acidic products, even if they are sugar free, may increase the probability of dental erosion Energy drinks, sports drinks, carbonated beverages, chewable Vitamin C tablets, salad dressing, fruits, and fruit juices increase erosion occurrence; in contrast, milk and yogurt have a protective effect The extent of enamel erosion caused by various beverages occurs in the following order (from greatest to least): energy drinks, sports drinks, regular soda, and diet soda Note: It is important to differentiate this type of erosion/demineralization from the caries process in which cariogenic bacteria cause demineralization Ø We will use two different indices for this: FCRA and AERA (see following slides) Lemon Sucking Habit Image courtesy of: https://i0.wp.com/www.bauersmiles.com/wp- content/uploads/2013/08/IMG_1213-2.jpg?resize=640%2C409&ssl=1 Acidic Beverages The dental hygienist’s guide to nutritional care (5th ed.). Table 4.7 Nutritional Assessment The systematic collection of information to identify the need for nutritional counselling (an intervention in the DHCP) and make the appropriate recommendations and referrals The assessment is comprehensive, taking a client’s medical, oral health and social histories into consideration Client’s personal history can reveal information regarding educational, cultural, financial, and environmental influences on food intake The health and pharmacologic histories identify health factors and medications that interfere with an individual's ability to eat or the body's ability to absorb nutrients The oral health history provides information about caries susceptibility, fluoride use, and dentition concerns that may affect food intake Dietary Record A dietary record may consist of a one- day, three-day, five-day, or seven-day where the client records all food and drinks consumed within the defined timeframe To improve accuracy, the record is meant to be filled out by the client at home as they consume foods and beverages The record, once completed, helps determine a client’s USUAL intake over the time period It is a screening tool to identify those in need of nutritional counselling GBC DH 1-Day (24 hr) Dietary Record One-Day (24 hour) Dietary Record Strengths This is a tool we can use chairside that allows us to collect data easily on food consumed in a single day We usually ask the client (or guardian) to list intake from the previous day (ideally, we want a “regular” day) *Snacking and spacing of meals is also gathered Weaknesses A single day may not be a typical representation of dietary intake; multiple day reports are generally better for analysis Clients sometime provide us with “fictitious” data which is easier to do for a single day than multiple days Clients sometimes have difficulty recalling what they ate and drank the day before Fermentable Carbohydrate Risk Assessment Assesses the cariogenic potential of the diet (gives a risk score based on the frequency and form of FC exposure) (FCRA) Details the number and type of fermentable carbohydrate exposures Start by circling each fermentable carbohydrate exposure in RED, and then categorize each exposure (each of the 3 types of FC exposures has a point value): Fermentable carbohydrate-LIQUID = 1 point Fermentable carbohydrate-SOLID AND STICKY = 2 points What is the Fermentable carbohydrate-SLOWLY DISSOLVING = 3 points FCRA score Multiply the number of exposures in each category by its point value; then add and what is the risk level? up all the points in each category to get a FCRA risk score which will be LOW (0-3 points), MODERATE (4-7 points), HIGH (≥8 points) This data is entered into axiUm Assessment Summary form inside the DH Care Plan. This assessment data will be used to form a diagnostic statement, goal, and intervention. Acid Exposure Risk Assessment (AERA) Assesses the acid erosion potential of the diet (gives a risk score based on the frequency and form of acid exposure) Details the number and type of acid exposures Start by circling each sugar exposure in GREEN, and then categorize the exposure (each of the 3 types of acid exposures has a minute value): Ø Acid exposure-LIQUID = 20 minutes What is the AERA Ø Acid exposure-SOLID AND STICKY = 40 minutes score and what is the risk level? Ø Acid exposure-SLOWLY DISSOLVING = 40 minutes Multiply the number of exposures in each category by its minute value; then add up all the minutes in each category to get an AERA risk score which will then be given a risk of LOW (0-59 minutes), MODERATE (60-119 minutes), HIGH (≥120 minutes) The AERA is a more comprehensive analytic tool for determining caries risk. The time the mouth is in acidogenic conditions is more indicative of caries risk. This data is entered into the axiUm Assessment Summary form inside the “DH Care Plan” area of the EHR. This assessment data will be used to form a diagnostic statement, goal, and intervention. axiUm Dietary Analysis Summary See previous slide See previous slide Refer to the document posted on Brightspace for a detailed description of foods in each category, for how to analyze the 1-day (24 hour) dietary record, and how to calculate the FRCA and AERA scores. Note: 1) During one meal, if two or more FCs are eaten, you only include points for the higher risk exposure. 2) Similarly, if during one meal, there are two or more acidic exposures, you only include the minutes for the higher risk exposure. 3) *Additionally, if a cariogenic or acidic food is consumed and a fat or protein food is eaten immediately afterward, the cariogenic or acidic exposures are not counted. Healthy Eating Recommendations As health professionals, dental hygienists should incorporate the Healthy Eating Recommendations into nutritional counselling. The following questions can be asked to gather information about your client’s diet. Recommendations can be given once the client provides the answer to each question. Canada’s Dietary Guidelines for Health Professionals and Policy Makers. (2019). Healthy eating recommendations. https://publications.gc.ca/collections/collection_2019/sc-hc/H164-231-2019-eng.pdf Questions to Ask Your Client 1) Are you mindful of your eating habits? Do you take time to eat? Do you notice when you are hungry and when you are full? 2) Do you cook more often? Do you plan what you eat? Do you involve others in planning and preparing meals? 3) Do you enjoy your food? 4) Do you eat meals with others? 5) Do you eat plenty of vegetables and fruits, whole grain foods, and protein foods? Do most of your protein foods come from plant-based sources? Do you choose foods with healthy (unsaturated) fats instead of saturated fats? Questions to Ask Your Client 6) Do you limit highly processed foods? If you choose these foods, eat them less often and in small amounts. Do you prepare meals and snacks using ingredients that have little to no added sodium, sugars or saturated fat? Do you choose healthier menu options when eating out? 7) Do you make water your drink of choice? 8) Do you use food labels? 9) Are you aware that food marketing can influence your choices? Review Questions 1) Define fermentable carbohydrate. Are all the different carbohydrates considered fermentable carbohydrates? 2) What are sugar alcohols? List the sugar alcohol that is MOST beneficial for preventing caries? Critical thinking: Which levels of prevention could it be used for (see levels discussed in Week One)? 3) Thoroughly describe the factors that affect cariogenicity of fermentable carbohydrates (form, frequency, timing and sequence). Which factor is the most important? *Vipeholm study 4) Why does CAMBRA list in-between meal fermentable carbohydrates as a caries risk factor? (Relate the required amount of FC for risk stated by CAMBRA with the Stephan Curve.) 5) What role do fats and proteins in food play with regard to caries? 6) Develop a list of caries-protective foods that you might recommend to a client. 7) Become comfortable categorizing cariogenic foods and acidic foods into their three categories for determining the FCRA and AERA score, and incorporating the scores and related recommendations into nutritional counselling. 8) Become comfortable incorporating the Health Eating Recommendations from Canada’s Food Guide in nutritional counselling. References Government of Canada. (2019). Canada’s dietary guidelines for health professionals and policy makers. https://publications.gc.ca/collections/collection_2019/sc-hc/H164-231- 2019-eng.pdf Government of Canada. (2023, September 15). Canada’s food guide. https://food-guide.canada.ca/en/ Harris, N., Garcia-Godoy, F., & Nielsen Nathe, C. (2014.) Primary preventive dentistry (8th ed.). Pearson Education Inc. Sroda, R., & Reinhard, T. (2018). Nutrition for dental health (3rd ed.). Jones & Barlett Learning.