DIET AND ORAL HEALTH

Abstract

Oral health is related to diet in many ways. The objective of this paper is to review the evidence for an association between nutrition, diet and dental diseases and to recommend proper diet for their prevention. Nutrition affects the teeth during development and malnutrition may exacerbate periodontal and oral infectious diseases. However, the most significant effect of nutrition on teeth is the local action of diet in the mouth on the development of dental caries and enamel erosion. Dental erosion is increasing and is associated with dietary acids, a major source of which is soft drinks. There is convincing evidence, for an association between the amount and frequency of free sugars intake and dental caries. Although other fermentable carbohydrates may not be totally blameless, epidemiological studies show that consumption of starchy staple foods and fresh fruit are associated with low levels of dental caries. In addition, the frequency of consumption of foods containing free sugars should be limited to a maximum of 4 times per day. It is the responsibility of national authorities to ensure implementation of feasible fluoride programs.

Full text

DIET, NUTRITION AND ORAL HEALTH
Volume 2 Issue 1
February 2011
175
Review
DIET AND ORAL HEALTH
Dr Jayaprasad Anekar MDS
Professor, Dept. Oral Medicine and Radiology, KVG Dental College and hospital
Sullia
Abstract:
Oral health is related to diet in many ways. The objective of this paper is
to review the evidence for an association between nutrition, diet and
dental diseases and to recommend proper diet for their prevention.
Nutrition affects the teeth during development and malnutrition may
exacerbate periodontal and oral infectious diseases. However, the most
significant effect of nutrition on teeth is the local action of diet in the
mouth on the development of dental caries and enamel erosion. Dental
erosion is increasing and is associated with dietary acids, a major source
of which is soft drinks. There is convincing evidence, for an association
between the amount and frequency of free sugars intake and dental
caries. Although other fermentable carbohydrates may not be totally
blameless, epidemiological studies show that consumption of starchy
staple foods and fresh fruit are associated with low levels of dental
caries. In addition, the frequency of consumption of foods containing free
sugars should be limited to a maximum of 4 times per day. It is the
responsibility of national authorities to ensure implementation of feasible
fluoride programs.
Journal of Dental Sciences and Research: Volume 2 Issue 1 Pages 175-182
Introduction
In most animals, teeth are
essential for survival. They are
necessary tools for preparing food
for ingestion and a weapon for
defense or attack. In most human
societies now, by far the most
important role for teeth is to
enhance appearance. The one
more attribute of teeth is their
role in speech. Teeth are also
essential for making certain
sounds. These teeth are prone to
injury and disease. Diet has a
great influence on the etiology
and control of dental and oral
diseases.1
Diet and nutrition in relation
to oral health and disease
The study of nutritional
influence on oral health requires
consideration of three groups of
oral tissues with different
structure, morphology,
metabolism and pathologic
response.1
1. The hard tissues (with
implication for dental health)
2. The supporting structures of
teeth (with implications for
periodontal health)
3. The oral mucosa (with
implications for mucosal health)

DIET, NUTRITION AND ORAL HEALTH
Volume 2 Issue 1
February 2011
176
Nutritional systemic Vs
dietary local effects2
In their relationships, there
is a peculiarity to be considered
regarding the dental hard tissues
and nutrition. Once the enamel is
formed, it is no longer subject to
systemic nutritional influence;
however it is subject to dynamic
exchange of jaws as well as
organic molecules and particles
with its oral environment.
The main result of nutrition
is the systemic effect of the
absorbed nutrients on growth,
development and maintenance of
tissues and organs and their
specific functions. Local dietary
side effects are of great practical
importance in the oral cavity.
Dental enamel, after eruption is
particularly subject to local side
effect from whatever may enter
the mouth. Dietary components
not only provide essential
nutrients for tissues of the host,
but also for bacteria in the oral
cavity which use them as
substrates if readily available.
Besides indirect side effects,
there are ‘direct side effect’ of
nutrients exerted by their ion
content, acidity and physical
properties.
Pre-eruptive Vs Post-eruptive
influences2
It is important to
differentiate between formative
nutritional and post eruptive local
influences. The effect of nutrition
on formation is generally
constructive. Since the tissues
lining the oral cavity are part of
the surface of our body, they are
colonized by numerous species of
micro organisms interacting with
the food passing, and / or with
the underlying structures.
If integrity is maintained, it
will be the result of a continuous
interaction of protective and
destructive influences. The
difficulty is that nutritive as well
as local dietary protective and
destructive factors both act on
the same tissues and their
respective effects can not be
differentiated readily and
assessed separately.
The fact is that the
formative influences are effective
in an early distinct period of
development, and destructive
influences usually do not start
before exposure and functioning.
Special position of Enamel
among the oral structures2
With respect to the tissues
of bone, periodontium, dentin and
pulp, development and lifelong
integrity as well as functioning
are associated with systemic
molecular and cellular reactions
to variables associated with
nutrition and medication, some of
them interacting with oral factors
and bacterial antigens. Teeth
enamel, in contrast, is subject to
systemic influences on its
development before eruption
only; after eruption it interacts
exclusively with local (topical)
environmental factors.
Dental Health and Caries risk
factors2, 10
Dental caries is a bacterial
plaque - dependent disease that
is characterized by an
intermittent demineralization of

DIET, NUTRITION AND ORAL HEALTH
Volume 2 Issue 1
February 2011
177
enamel, dentin and / or
cementum. To be more specific, it
is the microbial disease which
causes the demineralization of
the inorganic and destruction of
the organic structures of the
teeth. Oral micro organisms,
when organized in voluminous
masses as in dental plaque on
tooth surfaces, hydrolyze and
metabolize sugars to form weak
acids (mainly lactic acid) which
slowly and intermittently
demineralize the hard tissues
underneath.
This utilization of some food
components such as sugars by
bacteria is a local side effect in
the mouth during food passage,
in contrast to the systemic effect
of carbohydrates as a source of
energy for the host. Carious
demineralization is the result of a
side effect.
The sugar and other
carbohydrates exert no direct
damaging effect on the teeth.
During sleep and when no food is
available, the acidogenic plaque
bacteria can slowly metabolize
and survive on a minimum supply
of substrate derived form
carbohydrate side chains of
salivary mucins. At these low
substrate concentrations, no
cariogenic amounts of acid are
formed. However oral acidogenic
bacteria can handle substrate
concentrations of a very large
range from very low to very high,
and to very high concentrations of
sugars they react with acid
formation immediately.
The demineralization is a
diffusion controlled process
resulting in an increase in pore
volume only, without
disintegration of the mineralized
tissues, supply and access of
saliva are important for
remineralization between acid
attacks because saliva contains
buffering systems, and transports
minerals and fluoride ions to the
tooth - environment interface
The attacks resulting in
demineralization and
remineralization resulting in
repair are modified by a number
of variables. The most important
factor is the plaque, its thickness
and bacterial composition. If
there is no mature plaque
present, there are no more than
thin layers bacteria and no
appreciable amount of acid
formation.
This had been showed by
Stephan and Millar as early as in
1943 who measured the acid
formation on the teeth after
rinsing with sugar solutions. They
found immediate pH drop when
thick plaque was present, no
dangerous acidity could be
detected on the cleaned surface.
Dietary sugars and caries
experience and the role of
eating habits in the
development of dental caries
An association between
intake of sugars and dental caries
was first studied experimentally
in the early 1950s in inmates of
the Vipeholm asylum in Sweden.
Studies conducted in 1960 sand
1970 s confirmed this
relationship. The experiments
showed that restriction of sugar
intake to four main meals daily
did not significantly increase the

DIET, NUTRITION AND ORAL HEALTH
Volume 2 Issue 1
February 2011
178
baseline caries activity even if
large amounts of sugar were
given, whereas when between -
meal sugar containing snacks
were given daily, caries incidence
rose dramatically.3,4,5
Cariogenicity of diets rich in
carbohydrates other than
sucrose6
Because of the special
situations in developing countries,
it seems appropriate also to
consider constellations in which
the cariogenic potential of certain
foodstuffs can be isolated
because they are the once
preponderantly, or even solely
used.
Milk
Lactose has repeatedly
been reported to stand out
among the major dietary sugars
as being of markedly lower
cariogenicity. One must keep in
mind that this is based on the
laboratory studies. Several papers
on observations and in babies
breast - fed over periods of a
year or longer have shown that
lactose in milk can be highly
cariogenic when drunk
frequently.7
Sugars in fresh fruits
The saying ‘an apple a day keeps
the doctor away’ may also apply
to ‘keeping the dentist away’.
However, these findings do not
provide direct evidence of low
cariogenicity of fruit - borne
sugars since individuals who
consume relatively high amounts
of fresh fruit may differ in a
number of other dietary and other
hygiene variable which affect
caries activity. The studies
suggest that sugars contained in
fruits may be even more
cariogenic than extrinsic sugars.5
Some fruits tend to cause
only moderate falls in plaque pH.
Apples, however, besides
containing sometimes high
concentrations of free acids, by
virtue of their sugar content, can
also give rise to formation of
acids in the plaque. An apple
contains 9 - 11 % sugar, mostly
fructose. It is interesting to note
that the pH turned and remained
low not only in plaque, but also in
oral fluid in which the pH was
monitored concomitantly. The
studies suggest that there is no
difference in acidogenicity of fruit
- borne and dissolved or soluble
sugars, although same properties
of fruits appear favorable in
theory. Some studies of caries in
rats fed various fruits indicate
that, apples, bananas and grapes
can give rise to appreciable levels
of caries, sometimes as much as
or more than sucrose itself.
Moreover, it has been
demonstrated that fruit,
especially citrus fruit, carry a risk
of acid erosion of tooth enamel.
Complex carbohydrates
(starches) 8, 9
The idea behind
recommendations to eat more
food with complex carbohydrates
is to reduce fat intake, because of
the caries risk associated with
consumption of sugars, sugars

DIET, NUTRITION AND ORAL HEALTH
Volume 2 Issue 1
February 2011
179
are not recommended as energy
providing substitutes for fat.
Acid formation can start
surprisingly quickly after starchy
food has got in contact with the
dental plaque. Pollard et al, in
1993 tested the acidogencity of
white bread, cooked spaghetti,
cooked long - grain rice and many
other starch products with and
without added sugar. This showed
that none of the test products
was significantly different from 10
per cent sucrose solution. So
there is no doubt that starches
are acidogenic in the mouth.
Imfeld in 1983 referred to a large
number of animals experiments
showing that cooked starch
cannot be considered a non -
cariogenic dietary component.
The role and functions of non -
fermentable sweeteners in
relation to dental caries1, 2
Sugar alcohols or polyols,
with the pentitol xylitol and the
hexitols sorbitol and mannitol are
sweet, but not cariogenic or much
less cariogenic than sugars. The
stimulating effect of xylitol on
salivary glands is established and
it is well known that it can be
taken up by oral bacteria, but
because in the cells it has the
form of a toxic xylitol phosphate
it can not be further metabolized.
Under certain growth conditions
xylitol resistant mutants of
mutans streptococci can emerge,
but not all strains of these species
show this phenomenon. If such a
mutation occurs, the cell is unable
to synthesise a cell wall
transferase system necessary to
transport the xylitol molecules
inside. At the same time these
resistant mutants of mutans
streptococci seem to be less
virulent which may result in a less
cariogenic plaque flora. Modern
‘non - caloric’ artificial sweetners
such as asp-artame or cyclamate
are not carbohydrates and
therefore do not give rise to
cariogenic acid formation in
plaque.
Dietary components
increasing the risk of erosive
loss of hard tissues2
Erosion is due to strong
acid such as citric acid in fruit and
acid beverages. Contact of the
strong acid with teeth causes an
immediate strong dissolution of
the surface and mechanical fiction
afterwards (teeth brushing after
eating grape fruit or apple).
Regular removal of plaque
even though is essential for
prevention of caries and
periodontal diseases; it increases
the susceptibility of teeth surface
to erosion. So it is important for
the dental surgeon to instruct the
patients regarding the correct
time for daily oral hygiene
practice. Not only the acid in the
fruit and drinks is erosive, but all
individuals addicted to eating raw
vegetables and other unprocessed
food run a very high risk of
erosion.
Considering the positive
health effect of fruit and
vegetables it would not be
feasible to advice against
consuming them. The best
compromise seems to advice
people to avoid eating the same
fruits every day. This is not only

DIET, NUTRITION AND ORAL HEALTH
Volume 2 Issue 1
February 2011
180
in order to avoid erosion of teeth
but also to make sure one gets all
essential nutrients, vitamins and
minerals.
Nutrition and Periodontal
disease11, 12
Periodontal disease is likely
to be the main cause of tooth loss
in the world. In Periodontal
disease there is downward
migration of the epithelial
attachment of gingiva to tooth,
loss of fibres of the periodontal
ligament, and resorption of the
crest of the alveolar bone. This
progresses down the root surface,
so that more and more of the
support for the tooth are lost.
The essential role of plaque
in the etiology of gingivitis was
clearly demonstrated by Loe et al
in 1965 and Theilade in 1966. The
transition of gingivitis to
periodontal disease, which
involves the breakdown of the
periodontal tissues, has been
demonstrated experimentally in
humans.
The first step in the
development of gingivitis is
changes in the epithelium, which
allows toxins produced by plaque
organisms to permeate through
the junctional epithelium and
initiate an inflammatory response
in the gingival connective tissue.
As a result of this there will be:
1. Loss of connective tissue
fibres between tooth,
gingiva and bone.
2. Migration of crevicular
epithelium down the root
surface.
3. Resorption of the crest of
the alveolar bone
4. Pocket formation which
allows plaque and calculus
to spread further down the
tooth root and become
inaccessible to mechanical
methods of removal.
Relevance of nutrition
A number of ways in which diet
and nutrition may affect the
disease can be identified.
Factors concerned with the
pathogenesis of periodontal
disease which may be influenced
by diet and nutrition:
- Dental plaque
- Epithelial integrity
- Immune response
- Collagen formation and repair
- Bone formation and repair
- Food consistency (fibrous or
soft)
Physical character of the Diet
Numerous experiments in
animals have shown that the
physical character of the diet may
play some role in the
accumulation of plaque and the
development of gingivitis. Soft
diets, although nutritionally
adequate, may lead to plaque and
calculus formation. Hard and
fibrous foods provide surface
cleansing action and stimulation,
which result in less plaque and
gingivitis even if the diet in
nutritionally inadequate.7
There are nutritional
deficiencies that produce changes
in the oral cavity including
periodontal tissues, but there are
no nutritional deficiencies that by
themselves can cause gingivitis or

DIET, NUTRITION AND ORAL HEALTH
Volume 2 Issue 1
February 2011
181
periodontitis, or pockets. There
are however nutritional
deficiencies that can affect the
condition of the periodontium and
thereby aggravate the injurious
effects of local irritants and
excessive occlusal forces.
Theoretically, it can be assumed
that there may be a “border
zone” in which local irritants of
insufficient severity could cause
gingival and periodontal disorders
if their effects upon the
periodontium were aggravated by
nutritional deficiencies. However,
regarding the relationship
between nutrition and periodontal
health, it can be concluded as,
periodontal diseases are caused
by local inflammatory irritation
due to overgrowth and
differentiation of dental plaque,
and not by systemic nutritional
deficiencies. Therefore the
rational method of prevention is
regular cleaning of teeth and not
dietary measure.8
Mucosal Health
Diet and nutrition can affect
the soft tissue by influencing
plaque bacteria, and to some
extent the immunological
response as well as healing and
repair. However in contrast to the
retentive morphology of the teeth
and periodontal structures, the
mucosa self - cleans by
desquamation of peripheral
epithelial cells. This continuously
minimizes the antigenic load of
bacteria and food residues.
Nevertheless, inflammatory
reactions to bacterial colonization
and / or infections occur, and
soluble food components can
cause irritations.13
Precancerous lesions and
oral cancer develop upon
inherited predisposition and a
variety of environmental agents,
notably alcohol in high
concentrations and tobacco, but
also nutritional / dietary
components.
CONCLUSION
In case of risk to mucosal
health, medical rather than dental
advice is appropriate. In addition
to this question of competence,
there is a practical aspect; the
risk to develop pathology
originating from the oral mucosa
is high in elderly people and due
to the high percentage of
edentulates among them it is
most likely that they see a
medical doctor more often than a
dentist.
REFERENCES
1. König KG. Diet and Oral
Health. Int Dent J. 2000
June; 50(3):162-74.
2. A.J. Rugg – Gunn. Nutrition
& Dental Health; 1993
Oxford University Press.
3. Tinanoff N, Palmer CA.
Dietary determinants of
dental caries and dietary
recommendations for
preschool children. Refuat
Hapeh Vehashinayim. 2003
Apr; 20(2):8-23, 78.
4. Marshall TA, Levy SM,
Broffitt B, et al. Dental
caries and beverage
consumption in young
children. Pediatrics. 2003
Sep; 112(3 Pt 1):e184-91.

DIET, NUTRITION AND ORAL HEALTH
Volume 2 Issue 1
February 2011
182
5. Marshall TA, Broffitt B, et
al. The roles of meal, snack,
and daily total food and
beverage exposures on
caries experience in young
children. J Public Health
Dent. 2005
Summer;65(3):166-73.
6. Burt BA, Eklund SA, et al.
The effects of sugars intake
and frequency of ingestion
on dental caries increment
in a three-year longitudinal
study. J Dent Res. 1988
Nov; 67(11):1422-9.
7. Stefano Petti, Roberto
Simonetti et al. The effect
of milk and sucrose
consumption on caries in 6-
to-11-year-old Italian
schoolchildren. European
Journal of Epidemiology.
1997;13(6): 659-664.
8. Moynihan P, Petersen PE.
Diet, nutrition and the
prevention of dental
diseases. Public Health
Nutr. 2004 Feb; 7(1A):201-
26.
9. Moynihan PJ. The role of
diet and nutrition in the
etiology and prevention of
oral diseases. Bull World
Health Organ. 2005 Sep;
83(9):694-9. Epub 2005
Sep 30.
10. Sheiham A. Dietary
effects on dental diseases.
Public Health Nutr. 2001
Apr; 4(2B):569-91.
11. Branch-Mays GL,
Dawson DR, et al. The
effects of a calorie-reduced
diet on periodontal
inflammation and disease in
a non-human primate
model. J Periodontol. 2008
Jul; 79(7):1184-91.
12. Michael G. Newman,
Henry Takei, Fermin A.
Carranza, Dr. Odont
Carranza's Clinical
Periodontology, 9th Edition.
2001. Saunders.
13. Shafer, Hine, Lery &
Tomich. A Testbook of oral
pathology. 4th edition
1983; WB Saunders
Company