A Few SoundBites on

Diet, Nutrition and Oral Health,

Carole A Palmer EdD RDCarole A. Palmer EdD, RD

Tufts University:

S h l f D t l M di iSchool of Dental MedicineFriedman School of Nutrition

Science and Policy

Conflict of Interest DisclosureConflict of Interest Disclosure

Advisor Board Member – unpaid

Mouthwatchers Inc. : an oral health th t kcare company that makes

toothbrushes, develops oral health promotion programs andhealth promotion programs, and makes xylitol lollypops

Myth: Teeth are NOT yt eet a e Oimportant

Diamante DriverDiamante Driver

Health Implications of OralHealth Implications of Oral Problems

• Severe caries in children requires surgery under general anesthesia

• Severe caries in adults due to radiation/chemo can result in osteoradionecrosis

• Poor oral hygiene can cause VAP (ventilator-associated pneumonia)pneumonia)

• Periodontal disease is assoc. with preemies

• Edentulousness is major risk for choking and malnutrition

•Oral health means•Oral health isintegral to

much more thanhealthy teeth

integral togeneral health

2000 Department of Health and Human Services

Surgeon General’s Reportg p

•Children lose about 632,000 school days

•Adults lose about 3.6 million workdays/year from oral health pain and suffering.

• Dental disease can result in profound behavioral consequences:

Loss of self-esteem, Social avoidanceLoss of self-confidence,

di i i h d bilit t f ti i i tdiminished ability to function in society

From: NIDCR(www.nih.nidcr.gov) 1999 and Surgeon General’s Report, 2000.

Dental Caries: one of the mostcommon diseases in 5- to 17-year-olds

Significant Relationship betweenSignificant Relationship between Periodontal Disease

and Heart Disease in Humans*and Heart Disease in Humans

This relationshipThis relationship has long been known in dogsknown in dogs

Loesche, Compendium 15 (8) l994

Teeth ShouldTeeth ShouldTeeth Should Teeth Should Last a LifetimeLast a Lifetime

D t l bl t bl !!!Dental problems are preventable !!!

Overlapping dental/medical and pp gnutrition issues

• Increasing Child and Teen dental cariescaries

• Childhood obesity• Childhood obesity

• RelationshipsRelationships between periodontal and

i disystemic disease

Oral ProblemsOral ProblemsOral ProblemsOral Problems

Dental CariesPeriodontal

disease Tooth Loss Dental Caries (tooth decay)

(gum disease)

Nutrition/Oral HealthNutrition/Oral Health Interrelationships

Eating impairment

Diet/nutrition problems

Oral soft tissue bone problems

oror

Tooth problems

UndernutritionUndernutritionl l affects the Oraffects the Oral Cavityal Cavity

B & S ft TiB & S ft TiTeeth: PreTeeth: Pre--eruptiveeruptive Bone & Soft Tissue Bone & Soft Tissue over the Lifetime over the Lifetime

Teeth: PreTeeth: Pre--eruptive eruptive malnutrition can result in malnutrition can result in enamel defectsenamel defects

– Slowed healing/rapid tissue turnover rate

– Decreased resistance to oral infections

– Ultimately may result in increased tooth loss

OverNUTRITIONff t th O l C itl C itcan affect the Oral Cavityal Cavity

• Overnutrition (supplements)

- developmental defects p(vitamin D toxicity)

– tissue regenerationtissue regeneration (vitamin A toxicity)

- Fluorosis

Child Obesity???

How Diet Effects Teeth:How Diet Effects Teeth: Like politics: all effects are local

Demineralization: Demineralization: most most common with common with xerostomiaxerostomia • Regular & diet sodas

both causeboth cause demineralization

(• (sugar content not relevant)

• acid: lemons– acid bevs: soda &

diet soda

• non-colas & iced tea were worst

– vitamin C tablets– eating disorders

Von Fraunhofer, General Dentistry July-August 2004, pp.308-312

Dental Caries Process• Bacterial plaque colonize in

protected areas

• Metabolize simple sugars to acid

• Acid demineralizes enamel

•Bacteria and acid invade d tidentin

• Bacteria can invade pulp and migrate throughout the bodymigrate throughout the body

Abscess

What is What is CariogenicCariogenic ? ?•• AllAll simple sugars can be cariogenic. simple sugars can be cariogenic.

(glucose, fructose, lactose, maltose, sucrose, honey,(glucose, fructose, lactose, maltose, sucrose, honey,hi h f t )hi h f t ) high fructose corn syrup ) high fructose corn syrup )

•• StarchStarch can be cariogenic under some circumstancescan be cariogenic under some circumstancesStarchStarch can be cariogenic under some circumstances can be cariogenic under some circumstances(amylase)(amylase)

•• Sugars are rarely eaten alone, but rather with other foodSugars are rarely eaten alone, but rather with other foodcomponents and other foods which can affect their cariogeniccomponents and other foods which can affect their cariogenicpotentialpotential

•• Cariogenic for Cariogenic for MEME may may not benot be cariogenic for cariogenic for YOUYOU

The AMOUNT of sugarsgeaten or drunk (drank,

drinked??)drinked??)

is NOTthe most important factorthe most important factor

““the relative cariogenicity of a food is NOT correlated with its carbohydrate content” (Kandelman, D 1997)

What Determines C i i P i l Cariogenic Potential

of Diet?of Diet?

• Factors Increasing • Factors DecreasingRisk Risk

• Eaten or sipped often

• Eaten or sipped for prolonged i d

• Consumed infrequently

• Consumed fast periods

• Highly retentive in mouth• Liquid or fast removal from

mouth

• No rinsing or brushing after

X t i

• Oral hygiene after

N t i• Xerostomia • No xerostomia

P t ti ll C i i P t ti ll C i i F dF dPotentially Cariogenic Potentially Cariogenic FoodsFoodsHi hl C i niHi hl C i ni L CL CHighly CariogenicHighly Cariogenic

•• dried fruitsdried fruits•• candy, hard candycandy, hard candy

Low CariogenicityLow Cariogenicity•• raw vegetables raw vegetables•• raw fruits raw fruitsy, yy, y

•• cake, cookies, piecake, cookies, pie•• crackerscrackers•• chipschips

raw fruits raw fruits•• milk milk

Non-cariogenicNon-cariogenic•• chipschips

Moderately CariogenicModerately Cariogenic•• fruit juicefruit juice

gg•• meatmeat,, fish, poultry fish, poultry•• fats and oils fats and oilsfruit juicefruit juice

•• sweetened, canned fruitsweetened, canned fruit•• soft drinkssoft drinks

breadsbreads

CariostaticCariostatic•• cheesescheeses•• nuts nuts•• breadsbreads •• nuts nuts•• xylitol xylitol

Which is More Cariogenic ?

OR sodahard candy

Whi h i M C i i ?Which is More Cariogenic ?

OR • one soda• one hard candy OR• consumed slowly

y

• consumed slowly

k • every day• once a week

Snacking cartoon

AdultsAdultsRoot Caries & Periodontal Disease

• Multiple meds =xerostomia

• Smoking cessationg

• Hard candies and breath lozengeslozenges

Caries Protective Foods

Xylitol Gum

Xylitol interferes with StrepMutans: inhibits their ability toinhibits their ability to produce acids.

Interferes with their ability to colonize and stick to oralcolonize and stick to oral tissues.

chewing action stimulates salivary fflow

SugarSugar Free GumFree GumSugarSugar--Free GumFree Gum

Stimulates salivary flowStimulates salivary flow

Considered Caries-Safe MealConsidered Caries Safe Meal Pattern

• 3 meals N th 3 k• No more than 3 snacks

• Sweets as dessert not between • No constant sipping

Van loveren,Duggal, Caries Research: vol 38 (suppl 1),2004

What we What we DON’TDON’T know know

•• caries-“safe” diet for individuals caries-“safe” diet for individuals(Some say 3 meals/2 snacks)(Some say 3 meals/2 snacks)

•• extent of protection of other food components extent of protection of other food components (Ca, P, cocoa, etc.)(Ca, P, cocoa, etc.)( , , , )( , , , )

•• protective mechanisms ofprotective mechanisms of cariostaticcariostatic foods:foods:•• protective mechanisms of protective mechanisms of cariostaticcariostatic foods:foods:••e.g. salivary stimulation,e.g. salivary stimulation, remin remin., etc.., etc.

Life Cycle IssuesLife Cycle Issues

Early Childhood Caries

•Immature dentitionImmature dentition

•Plaque-filled mouth

L li•Low saliva

•Long bottle contact

The “Sippy” & Juice IssueThe Sippy & Juice Issue

••Consumed constantly,Consumed constantly,••Considered nutritiousConsidered nutritious••Considered nutritiousConsidered nutritious••Contributes to ECCContributes to ECCC t ib t t hildh dC t ib t t hildh d••Contributes to childhood Contributes to childhood

obesityobesity

Diet Patterns and ECCDiet Patterns and ECC

S-ECC children:• more total food/ beverage items

daily (p=0.0029),• ate/drank more frequently (p= 0 005)• ate/drank more frequently (p= 0.005), • more cariogenic foods more often

(p<0.0001) •more: juice, particularly between meals

(p<0.007), •non-juice cariogenic liquids (p<0.01), j g q (p ),•solid retentive foods (p<0.0005).•more bedtime snacks (p=0.002).

•Palmer , Tanner, et. al. JDent.Res 2010

How Periodontal Disease How Periodontal Disease occursoccurs

• Also called gingivitis, pyorrhea

• Plaque bacteria infect gumsg

• Gums recede

• Bacteria infect jaw bone

• Jaw bone recedes

Elders: Dentate Status

• Tooth loss affects dietary lit d t i tquality and nutrient

intake

• Tooth loss risk of low b d i d dbody mass index and weight loss, among vulnerable populationsvulnerable populations

I l ti b t• Inverse correlation between vitamin C levels and occlusal pairs

Active Research • Child Obesity assoc. with early tooth eruption =

early risk for dental caries and increased risk of malocclusions. (Must , Obesity, 2012 )

• Vitamin D insufficiency (serum 25[OH]D <75 nmol/l)• Vitamin D insufficiency (serum 25[OH]D <75 nmol/l) is associated with maternal periodontal disease during pregnancy (Boggess, JPeriodontol. 2011)

• Low calcium intake is related to increased risk of tooth loss in men (Adegbove, Jnutr, 2010)

• Green tea is associated with decreased odds of tooth loss ( Koyanna, Prev.Med, 2010)tooth loss ( Koyanna, Prev.Med, 2010)

Active Research • Green and Black tea: may have

anti-plaque bacterial effect (via catechins)1

Calcium & Vit. D: may clinical attachment loss and tooth loss2attachment loss and tooth loss

Dentate Status affects Nutritional Status3

Antioxidant intake may modulate both periodontal disease and systemic disease (such as CVD, cancer stroke) 4cancer, stroke)

1. Czajka-Jakuboswka et al. Chemistry in Britain, 20022.. Krall, Dent. Clin. Of NA ## Sahyoun,Krall, JADiet A, 20033. Krall, Annals of Perio, 2001 , Nishida J, J Periodontol. 20004. Ritchie et al. Critical Rev. Oral Biol Med 13 (3): 291-300, 2002.

Summary: Common MythsSummary: Common Myths Debunked

• Tooth loss is inevitable• Only sucrose causes tooth decay• How much sugar you eat is the most• How much sugar you eat is the most

important factorDi t i t i t t i i d t l• Diet is not important in periodontal disease

•

Research Needs

• Making cariogenic foods less cariogeniccariogenic

• Learning oral effects of nutrients and phytochemicals to prevent periodontal disease and mitigate oral infections

Ancient History

h l P !!Sh l P i !!Shameless Promotion !!Shameless Promotion !!

Dental Caries:Preventable

Fluoride Anti-microbial rinses

SystemicSystemic nutrition

Nutrition & Perio DiseaseNutrition & Perio Disease Significant associationsSignificant associations

between tooth loss and bone loss

Vitamin C: collagen and antioxidant

Those eating < 60 mg vit. C/day had 1 1/2x chance of having gingivitis than those with 180 mg/daywith 180 mg/day

low Calcium &low Calcium & VitVit. D. D: may: maylow Calcium & low Calcium & VitVit. D. D: may : may increase clinical attachment increase clinical attachment loss and tooth lossloss and tooth loss