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The Study of Cariogenicity of Raw Sugarcane in 12-year-old Children in Punjab, India

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There is laboratory evidence that refined carbohydrates are more cariogenic compared with unrefined carbohydrates. It was reported that sugarcane workers in South Africa, who consumed large quantities of raw sugarcane daily, had a low caries experience. However, other epidemiologic studies of this relationship, both in Africa and elsewhere, have given mixed results and to date the question concerning the cariogenicity of raw sugarcane remains equivocal. Objective The purpose of the present study was to investigate further the hypothesis that children who reside in a sugarcane growing region have a lower caries experience than those residing in an otherwise comparable environment outside of the sugarcane growing region. Method A total of 404 Children aged 12 years were selected from government run schools in both sugarcane region which was close to the town of Mehta and non-sugarcane region which was close to attari in Amritsar district in the state of Punjab, India, and were given consent to participate in the survey. Data on the eating habits of the children were obtained by questionnaire and caries experience was determined during a clinical examination. The drinking water in both regions contained fluoride at less than 0.5 ppm. Results The mean DMFT scores for the sugarcane and non-sugarcane groups were 0.41 and 0.70, respectively (p<0.002). In a multivariable logistic regression analysis of risk factors for a caries experience, residence area alone was the sole significant predictor of experiencing one or more DMFT. Children residing in the sugarcane growing region were 49% less likely to have decayed teeth (OR=0.51; 95%CI= 0.33, 0.78). Conclusion The null hypothesis is rejected; the results of this study support the hypothesis that the chewing of raw sugarcane is associated with reduced dental caries experience.
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JOHCD www.johcd.org January 2013;7(1) 37
The Study of Cariogenicity of Raw
Sugarcane in 12-year-old Children in
Punjab, India
1NIMS Dental College,
NIMS University, Jaipur,Rajasthan, India
2SGT Dental College Gurgaon, Haryana (India)
3Manav Rachna Dental College,
Faridabad, Haryana (India)
ABSTRACT
There is laboratory evidence that refined carbohydrates are more cariogenic compared with unrefined carbohydrates.
It was reported that sugarcane workers in South Africa, who consumed large quantities of raw sugarcane daily, had a
low caries experience. However, other epidemiologic studies of this relationship, both in Africa and elsewhere, have
given mixed results and to date the question concerning the cariogenicity of raw sugarcane remains equivocal.
Objective: The purpose of the present study was to investigate further the hypothesis that children who reside in a
sugarcane growing region have a lower caries experience than those residing in an otherwise comparable environment
outside of the sugarcane growing region.
Method: A total of 404 Children aged 12 years were selected from government run schools in both sugarcane region
which was close to the town of Mehta and non-sugarcane region which was close to attari in Amritsar district in the
state of Punjab, India, and were given consent to participate in the survey. Data on the eating habits of the children
were obtained by questionnaire and caries experience was determined during a clinical examination. The drinking water
in both regions contained fluoride at less than 0.5 ppm.
Results: The mean DMFT scores for the sugarcane and non-sugarcane groups were 0.41 and 0.70, respectively
(p<0.002). In a multivariable logistic regression analysis of risk factors for a caries experience, residence area alone was
the sole significant predictor of experiencing one or more DMFT. Children residing in the sugarcane growing region
were 49% less likely to have decayed teeth (OR=0.51; 95%CI= 0.33, 0.78).
Conclusion: The null hypothesis is rejected; the results of this study support the hypothesis that the chewing of raw
sugarcane is associated with reduced dental caries experience.
Keywords: Caries, coronal, Diet
ORIGINAL ARTICLE
INTRODUCTION
On the basis of an examination of
skulls dating from the bronze-
age onwards, Hardwick demon-
strated that dental caries was rare in Eng-
land and that its prevalence fluctuated with
rises and falls in cereal production (1). At
that time, lesions were confined mainly to
cervical margins whereas coronal caries did
not generally occur until sugar came into
common usage in the 17th century. Several
20th century studies of remote hunting
communities have detailed dramatic rises
Journal of Oral Health
Community Dentistry
&
Singh A1, Grover H2, Bhatia HP3
in caries experience coinciding with diet
changes following a sudden exposure to
foodstuffs containing flour and sugar (2,
3).
Prior to the development of an understand-
ing of the role of fluoride in caries preven-
tion, research on caries aetiology and man-
agement strategies centred on the diet-car-
ies relationship and confirmed that the
upsurge in sugar consumption was mainly
responsible for the caries pandemic that
swept western cultures during the first half
Contact Author
Dr. Amandeep Singh
exljatt@yahoo.com
J Oral Health Comm Dent 2013;7(1)37-43
38 JOHCJOHCD www.johcd.org January 2013;7(1)
of the 20th century (4). The acid theory of
dental caries aetiology was first postulated
by Miller (1890), who demonstrated that
when extracted teeth were incubated in a
mixture of saliva and carbohydrate, they
were subject to demineralization (5). In
1937, Osborne and Noriskin (6) reported
on the low caries experience of sugarcane
cutters in South Africa in a region where
the fluoride concentration in the drinking
water was less than 0.1 mg/L. These work-
ers chewed up several sugarcane sticks daily
and consumed large quantities of
sugarcane juice. On average, they consumed
4.5kg of sugarcane daily (500gm sucrose)
(7). Osborn et al. (8) demonstrated via in
vitro studies that the incubation of mix-
tures of saliva and pure sucrose readily re-
sults in the production of organic acids
and that the addition of teeth or calcium
phosphate to these mixtures results in their
dissolution. On the other hand, when such
experiments are repeated in which pure
sucrose is replaced with raw sugarcane juice,
the dissolution does not occur despite the
acidic environment. It was postulated that
phosphates, which are removed during the
sugar refining process, are protective against
dental caries (9), yet it was later shown that,
in fact, the acid yield on fermentation of
unrefined carbohydrate was about double
that derived from the refined products (10).
At the same time, the greater quantity of
acid produced did not correspond with a
greater capacity to demineralise tooth
enamel.
Animal studies demonstrate that dietary
phosphate additives are protective against
experimentally induced caries (11), but epi-
demiologic studies of caries experience in
sugarcane chewers (Table 1), that have been
cited in relation to the hypothesis that con-
sumption of raw sugarcane is protective
against caries, give mixed results (12).
Possible support for a protective effect was
reported more recently among 100 Tanza-
nian 12-year-olds living on a sugarcane es-
tate (13). Caries experience there was re-
ported to be similar to that of other rural
and urban Tanzanian children examined
by the same authors (14, 15), but it was
also reported that workers at the sugarcane
estate received refined sugar as a work in-
centive, and that refined sugar consump-
tion by the estate population was six times
higher than the national average. Had it
not been for the possible protective effect
of sugarcane chewing, it might have been
expected that the caries experience of the
estate children would be higher than
among children from elsewhere.
Support for a sugarcane-related protective
effect was shown in Australia (16) where a
controlled cohort study was conducted
among 399 boarding school children to
investigate the effect of supplementing
dietary sugar with calcium sucrose phos-
phate, the organic phosphate which is pre-
sumed to be removed from sugarcane dur-
ing the refining process. Children attend-
ing the control schools followed their usual
diet while those belonging to the experi-
mental schools were exposed to a diet in
which the added sugar was supplemented
with calcium sucrose phosphate. After three
years, the DMFT, DMFS, and proximal
surface DMFS were 15.3, 17.9, and 29.5%
less in the experimental children aged 9-13
years compared with the control children
of the same age. While these results ap-
pear impressive, Craig (17) reported that
during the course of the study, the groups
became unbalanced and that the results
could be biased. A more recent in vivo study
of Kenyan children, aged 7-14 years, with
cavitated teeth confirmed the anti-cari-
ogenic potential of chewing sugarcane (18).
On one day, they rinsed with 10% pure
sucrose and on the next day they chewed
sugarcane for 3 minutes. Measurements at
interproximal sites on both days showed
that pH falls following sucrose rinses were
deeper than those following the chewing
of sugarcane. Further, the depressed pH,
induced by the sucrose exposure, took
longer than 30 minutes to return to base-
line levels compared with return times of
5-10 minutes following sugarcane chew-
ing. It was concluded, however, that the
result was probably not due to a protective
factor derived from the sugarcane but that
the rapid pH rise was a natural result of an
increased saliva flow rate which was stimu-
lated by the combination of the sweet
sugarcane juice and the vigorous chewing
action required to masticate the tough cane.
On the other hand, in Cuba (19), where
brown sugar is used extensively in cooking
and for food seasoning, extensive caries
experience and tooth loss was reported
among sugarcane workers. This study did
not, however, include non-sugarcane eat-
ing controls, nor was the dietary added
sugar controlled for. The results of another
cross sectional study of sugarcane con-
sumption among Tanzanian children aged
7 to 15 years failed to demonstrate a corre-
lation with caries experience, however it is
not clear whether either age-related con-
sumption of sugarcane or age-related car-
ies experience was controlled for in this
study (20). In yet another controlled cross
sectional study of adults, also conducted
in Tanzania, a caries protective effect among
77 cane cutters was not evident (21). In
this study, the caries experience of 68 sisal
labourers was also investigated. Although
the ratio of sugarcane consumption by the
cane cutters and the sisal labourers was 10:1,
the diets of both groups were otherwise
said to be comparable and low in refined
carbohydrates. The respective mean DMFS
scores of the sugarcane and sisal workers
were 13.9 and 7.8.
The purpose of the present study was to
investigate further the hypothesis that chil-
dren who reside in a sugarcane-growing
region have a lower caries experience than
those residing in an otherwise comparable
environment outside of the cane-growing
region.
METHODS
The chewing of sugarcane by children in
the state of Punjab, India, occurs during
two periods each year totalling about 6
months when the cane is harvested. This
survey of 12-year-old children attending
government run schools was conducted in
the Amritsar District of Punjab. The se-
lected schools were located in villages sur-
rounding a sugar mill, close to the town
of Mehta in the sugarcane belt along the
Beas River. Parents of children attending
the seven largest government run village
schools in this area were requested to give
consent for their 12-year-olds to participate.
THE STUDY OF CARIOGENICITY OF RAW SUGARCANE IN 12-YEAR-OLD CHILDREN IN PUNJAB, INDIA
JOHCD www.johcd.org January 2013;7(1) 39
Table 1: Summary of studies investigating the possible anticariogenic effect of raw sugarcane chewing
First author Study type Location Method and results Support1Comment
Osborn (7) In vitro South Africa 32 teeth were added to each of mixtures of Yes
saliva and (a) crude sugarcane juice (15%
sucrose) and (b) refined pure sugar solution
(15% sucrose). After 8 weeks incubation,
3 and 15 teeth in solutions (a) and (b)
respectively were decalicifed
Driesen (18) Cross sectional Cuba Study of 147 sugarcane cutters who chewed No No control for non-cane
and drank large quantities of sugarcane juice cutters and other sugar
daily. Crude brown sugar was also used use
extensively in cooking and for food seasoning.
Mean DMFT was 15.1, 10 were edentuolous,
and 1 was caries free.
Jenkins (22) In vitro United 50 mg calcium phosphate mixed with 7 ml saliva Yes
Kingdom was added to each of 5 mls of (a) sugarcane
juice (20% sucrose) and (b) pure sucrose
solution (20% sucrose). After incubation for
24 hours, the concentration of phosphate in
solutions (a) and (b) increased by 9 and 79
micrograms/ml, respectively.
Harris R (15) Controlled Australia Boarding school children aged 9-13 years were Yes
cohort exposed to (a) diet in which calcium sucrose
phosphate was substituted for dietary
sugar and (b) normal diet. Comapred with children
on diet (b) scores for DMFT, DMFS, and DMFS
(proximal surfaces) were less by 15.3%,17.9%
and 29.5%, respectively.
Harris S (6) Cross sectional South Africa Study of 98 male and female sugarcane chewers Yes High intake of sucrose
aged 14->60 years. Their daily mean consumption and low caries experince
of sugarcane was 4.5kg (500gm sucrose) hints at protective effect.
Normal diet comprised maize, legumes, meat, and
water (< 0.1 ppm F). DMFT scores for adolescents,
young adults, middle and old age groups were:
0.9, 3.1, 6.0, and 8.1, respectively.
Nörmark (19) Cross sectional Tanzania Study of 399 children aged 7-15 years. The No No control for age.
distribution of DMFS by sugarcane was random
Frencken (20) Cross sectional Tanzania Study of (a) 77 sugarcane cutters and (b) 68 sisal No
controlled labourers. Diets,said to be comparable, included
4gm of refined sugar daily. The ratio of daily
sugarcane eaten (a):(b) was 8.1:0.8. DMFS
for (a) and (b) were 13.9 and 7.8, respectively.
Rugarambu(12)Cross Tanzania Study of 100 sugarcane estate children aged Possible Sugarcane chewing
sectional 12 years, where estate consumption of refined may have counter-acted
sugar was 6 times higher than the national the effect of exposure
average. Mean DMFT of 0.48 was comparable to to refined sugar.
scores of 0.51 and 0.67 for other rural and urban
12-year-olds, respectively.
Fejerskov (17) Experimental Kenya Study of children aged 7-14 years with 2 or more Yes
cross over open cavities . On day 1, they rinsed with 10%
sucrose solution, and on day 2, chewed sugar
cane for 3 minutes. Plaque pH was measured
at non-carious proximal sites before and up to
30 minutes following both rinsing and chewing.
After rinsing with sucrose solution, pH values
recovered after 30 minutes, but fell less and
recovered in 5-10 minutes following chewing
sugarcane.
1. Support for hypothesis that raw sugarcane chewing is anticariogenic.
THE STUDY OF CARIOGENICITY OF RAW SUGARCANE IN 12-YEAR-OLD CHILDREN IN PUNJAB, INDIA
40 JOHCJOHCD www.johcd.org January 2013;7(1)
Similarly, consent was obtained from par-
ents of the reference children who attended
the six largest government run schools in
villages around Attari, a non-sugarcane
growing region. Attari is a small town, 50
km southwest of Mehta, near the border
with Pakistan. Apart from the difference in
exposure to sugarcane, the population sam-
ples were similar in other respects. Only
children of lower socio-economic groups
attend government run schools in Punjab.
In both areas, the fluoride concentration
in the drinking water was less than 0.5 mg/
L. Families subsist on their land from one
generation to the next, so that the children
examined were life-long residents of their
respective areas. Although the children in
both regions were either Sikhs (the major-
ity) or Hindus, they live in rural villages
and share the same cultural beliefs and prac-
tises; in particular, their diets are the same.
At the selected schools, the children were
interviewed using a structured question-
naire to obtain information on their diet
and tooth brushing habits. This was fol-
lowed by clinical examinations which were
conducted outside in natural daylight by a
single examiner who had been calibrated
before the survey. The children, none of
whom had experienced previous dental
care, were seated on a chair and their teeth
were examined with the aid of a wooden
spatula but without drying. Caries was di-
agnosed by visual inspection alone whereby
teeth were recorded as decayed on the evi-
dence of presence of cavitation (22). The
data were later entered into an electronic
database for subsequent statistical analy-
sis. Intra-examiner calibration was carried
out during return visits to two schools in
each region where randomly selected chil-
dren were re-examined under the same con-
ditions as previously.
Following data checking, the mean DMFT
scores of children in the two locations were
calculated and compared. The effect of
potential confounding variables on the re-
lationship between sugarcane chewing and
dental caries experience was assessed. Firstly,
the univariate association of each of the
potential confounders (total added dietary
sugar, lollie consumption, mealtime con-
sumption of sugar-containing beverages,
tooth brushing frequency, and use of
fluoridated toothpaste) with DMFT was
assessed. Secondly, the potential
confounders that were shown to be sig-
nificantly associated with differences in
DMFT scores were included in a multiple
variable regression analysis. As the data
were highly skewed (the majority of the
children were caries free) a logistic regres-
sion model (caries experience was
dichotomised as DMFT = 0 or 1+) was
developed using the backward stepwise
selection option. The analyses were carried
out using SAS statistical software, Release
8.2.
Ethics approval for this study was granted
by the Human Research Ethics
Committee,The University of NIMS.
RESULTS
A total of 404 12-year-olds participated in
the study. The children living in the
sugarcane belt chewed around three to four
sticks of sugarcane daily during the cane
harvesting seasons. Since none of the chil-
dren in either area had received dental care,
the DMFT scores reflected decayed or miss-
ing teeth only. Caries experience in both
areas was confined almost exclusively to
the first permanent molars (Table 2). The
mean DMFT of the non-sugarcane group
was 0.70 (sd=1.17) compared with 0.41
(sd=0.96) in sugarcane group. That is, the
mean DMFT score was 71% higher in the
non-sugarcane group and further, the pro-
portion of children who had one or more
DMFT was 62% higher in the non-
sugarcane group. The kappa value relating
to diagnostic reliability, based on 51 dupli-
cate examinations, was 0.73. The distribu-
tion of mealtime risk factors for caries ex-
perience, namely sugar-containing bever-
ages, which are consumed at breakfast, tiffin
(lunch), and dinnertime, is shown in Table
3. Except for yoghurt (12% versus 3.9%),
the consumption of all other sugar-con-
taining beverages at breakfast was greater
in the sugarcane group than in the non-
sugarcane group (p<0.001). At tiffin
(lunch), more milk with added-sugar was
Table 2: Caries experience by residential location
Mean DMFT = 0 DMFT = 1+
n DMFT (sd) n % n % p-value*
Non-sugarcane 200 0.70 1.17 127 63.5 73 36.5 0.002
Sugarcane 204 0.41 0.96 158 77.5 46 22.5
*Chi-square = 9.45, DF = 1
Table 3: Mealtime intake of water and sugar-containing beverages
Water Milk Tea Yoghurt
Meal Residential location n % n % n % n % Total p-value*
Breakfast Non-sugarcane 84 42.0 5 2.5 87 43.5 24 12.0 200 <0.001
Sugarcane 78 38.2 22 10.8 96 47.1 8 3.9 204
Tiffin Non-sugarcane 21 10.5 86 43.0 86 43.0 7 3.5 200 <0.001
Sugarcane 56 27.5 39 19.1 102 50.0 7 3.4 204
Dinner Non-sugarcane 32 16.0 32 16.0 112 56.0 24 12.0 200 <0.001
Sugarcane 56 27.5 25 12.3 56 27.5 67 32.8 204
THE STUDY OF CARIOGENICITY OF RAW SUGARCANE IN 12-YEAR-OLD CHILDREN IN PUNJAB, INDIA
JOHCD www.johcd.org January 2013;7(1) 41
consumed by the non-sugarcane group
(43% versus 19%) and at dinnertime, more
sweetened tea was consumed by the non-
sugarcane group (56% versus 27.5%)
(p<0.001).
Table 4 shows the distribution of expo-
sure to additional caries risk factors, namely
tooth brushing habits, lollie consumption,
and total daily added-sugar to children in
both residential locations. Both groups had
almost identical tooth brushing habits re-
garding brushing frequency and use of fluo-
ride toothpaste. One quarter of the chil-
dren reported that they brushed daily and
60% reported that they used fluoridated
toothpaste. More children in the non-
sugarcane group (88% versus 70%) con-
sumed 4 or more lollies per day than in the
sugarcane group (p<0.001). An almost
identical amount of total daily added-sugar
was consumed by both groups; the me-
dian amount was 8 teaspoons per day. This
amount included sugar that is eaten by it-
self, as a sweet, directly after a meal. The
mean DMFT scores were lower in sugarcane
group in relation to each of the risk/pro-
tective factors.
In the multivariable logistic regression
analysis of risk factors for a caries experi-
ence (Table 5), all but one of the factors
were dropped from the model, leaving resi-
dential location area alone as the sole sig-
nificant predictor of experiencing one or
more DMFT. Compared with children in
the non-cane region, the children residing
in the sugarcane growing region were 49%
less likely to have decayed teeth (OR=0.51;
95%CI= 0.33, 0.78)
DISCUSSION
Although overall caries experience of chil-
dren in both regions was low, a clear cut
association between exposure to raw
sugarcane and caries experience was evident.
The important question is: whether or not
this association is causal. In this parallel
cross-sectional study, the caries experience
outcome was measured directly on the day
of the survey, while exposures to the risk
factors of interest were inferred on the ba-
sis of the current habits of the children.
The weakness of this research design is the
assumption that measures of exposure,
based on current habits, may be biased es-
timates of previous habits. Hence, the in-
ference we have drawn on the basis of the
exposure estimate can only be interpreted
as suggestive of a causal link, rather than
proof of one. To prove causation, the ideal
research design would be that of a control-
led cohort study in which children would
be followed for a period, throughout which
their exposure to sugarcane and relevant
confounding factors, would be assessed at
regular intervals. In this way, the exposures
could be better quantified.
The explanation of the effect of sugarcane
on caries incidence is problematic. Both
organic and inorganic phosphates have
been investigated in this regard. A review
of more than 100 experiments showed
conclusively that the addition of inorganic
phosphates to cariogenic diets reduced the
caries experience in animals (23). However,
in a human clinical trial in which sweets
supplemented with dicalcium phosphate
were provided to school children over a
three year period, no reduction in caries in-
cidence was observed (24). The potential
anti-cariogenic effect of the organic phos-
phate, calcium sucrose phosphate, already
referred to, is to raise both calcium and
Table 4: Exposure of the children to protective/risk factors for dental caries and their caries experience
byresidence location
Sugarcane Non-sugarcane Mean DMFT (SD)
Risk/protective factor Exposure n % n % p value Sugarcane Non-sugarcan p value
Toothbrushing frequency Daily 54 26.5 53 26.5 0.916 0.48 (1.04) 0.77 (1.14) 0.168
Weekly 150 73.5 147 73.5 0.39 (0.93) 0.67 (1.19) 0.021
Toothpaste use Fluoride 116 56.5 119 59.5 0.590 0.45 (1.04) 0.53 (0.84) 0.601
Non-fluoride 88 43.1 81 40.5 0.38 (0.91) 0.82 (1.35) 0.004
Lollies 2 per day 64 30.0 23 12.0 <0.001 0.39 (0.95) 0.65 (1.15) 0.280
4 per day 140 70.0 177 88.0 0.42 (0.97) 0.71 (1.18) 0.021
Total daily added sugar 0 - 4 21 10.3 12 6.00 0.383 0.28 (0.64) 0.58 (0.80) 0.249
(number of teaspoons) 5 - 6 42 20.6 45 22.5 0.55 (0.83) 0.57 (1.03) 0.881
7 - 8 79 38.7 74 37.0 0.38 (1.04) 0.73 (1.39) 0.078
9+ 62 30.4 69 34.5 0.40 (1.03) 0.77 (1.07) 0.049
Table 5: Odds ratio from best fitting multiple variable logistic regression model (using the backward stepwise
selection method) of risk factors* for dental caries experience**
Explanatory variable Variable category Odds ratio 95% CI p value
Residential area Sugarcane area 0.507 0.327, 0.784 0.0023
Non-sugarcane area (reference category)
* The effects of sugar consumption at breakfast, tiffin (lunch) and dinner, and the effect of lollie consumption were dismissed
(p > 0.05) during successive steps.
** Dichotomised as DMFT = 0 or 1+
THE STUDY OF CARIOGENICITY OF RAW SUGARCANE IN 12-YEAR-OLD CHILDREN IN PUNJAB, INDIA
42 JOHCJOHCD www.johcd.org January 2013;7(1)
phosphate levels in plaque and saliva and
its anti-cariogenic effectiveness is reportedly
due to its ability to adsorb firmly to enamel
surfaces and thus prevent its dissolution.
In this regard, phytate, derived from
unrefined cereals was identified as being
more active than calcium sucrose phosphate
(25). Wilson and Ashley (26) have reported
on studies that have shown a strong rela-
tionship between levels of calcium and
phosphate in plaque and caries incidence in
adolescents. The increased concentration of
calcium and phosphate in saliva reduces
the likelihood of enamel dissolution as
pH falls (27). However, more recently, in a
2-year cohort study of children aged 12
years, Pearce et al. (28) demonstrated that
while plaque calcium and phosphate were
highly correlated with each other, when a
set of confounding variables were taken
into account, only calcium, and not phos-
phate, was significantly associated with a
caries incidence of three or more DMFS.
On the other hand, the Indian diet is rich
in milk, yoghurt, and cheese. In 1975,
Rugg-Gunn reported that eating cheese
after a sugar-containing snack returns plaque
pH to a safe level within 5 minutes (29). It
has been proposed that this effect could be
due to the stimulation of salivary flow
which causes pH rise, or to the raising of
calcium concentrations in plaque, or to in-
creasing alkaline substances in plaque, or
finally, due to the adsorption of a protec-
tive protein, such as casein (a phosphor-
protein), on the enamel surface, thereby
physically slowing the dental caries process
(29, 30). In a more recent review of the
anti-cariogenicity of dairy products, it was
reported that in rat caries models, caries
incidence is reduced significantly by the ad-
dition of soluble caseinate to drinking water
or confectionery (31). Although not meas-
ured directly in this study, it is assumed
that exposure to dairy products was the
same in both areas.
In summary, the lower caries experience
observed in the sugarcane group may be
due to the protective effect of an organic
phosphate, such as calcium sucrose phos-
phate, however, as already noted, the chew-
ing of sugarcane stimulates saliva produc-
tion, the rinsing effect of which reduces
the potential for the sucrose to depress pH.
Alternatively, the chewing effect itself, on
saliva stimulation, may be the protective
factor, since the pH fall associated with
chewing on sucrose-sweetened gum is nei-
ther deep nor long lasting as compared
with the fall which follows a sucrose expo-
sure alone (32). A low caries experience was
observed in both groups of children, de-
spite their very high consumption of
added sugar; sugar which is added, two
spoonfuls at a time, to beverages includ-
ing milk and yoghurt. In addition, for good
measure, a spoonful of sugar is eaten by
itself frequently, at the end of a meal. In
other environments, this is a recipe for high
caries experience. These observations indi-
cate that our understanding of the rela-
tionship between caries and refined carbo-
hydrates remains rudimentary.
CONCLUSION
It is concluded that the lower caries experi-
ence of Punjabi children, who chew large
quantities of sugarcane daily during a pe-
riod of about six months per year, is sup-
portive of the hypothesis that raw sugarcane
is associated with a caries protective effect.
The protective factor may be intrinsic to
the sugarcane such as an organic phosphate,
or extrinsic, such as a saliva factor that is
associated with vigorous chewing.
ACKNOWLEDGEMENTS
We are grateful to the school principals,
parents, and children for their co-operation
during the survey, and we thank the water
engineers for data on the fluoride concen-
tration in the water supplies in the survey
regions.
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THE STUDY OF CARIOGENICITY OF RAW SUGARCANE IN 12-YEAR-OLD CHILDREN IN PUNJAB, INDIA
... However, in contrast to plaque, debris could disappear just by rinsing the mouth, while the plaque is firmly attached to the surface of the teeth. Research in India found that chewing raw sugar cane affected the decreased caries experience in 12 years old children [7]. However, with the high sugar content in sugar cane, further investigation about the effect of sugar cane mastication on plaque formation is needed. ...
Article
In 5 rural Kenyan children, the effect of sugarcane chewing on plaque pH was compared with the effect of a mouthrinse with 10% sucrose at various intraoral sites. They all had poor oral hygiene and at least two carious cavities in occlusal surfaces of molars. pH measurements were conducted under field conditions using paladium touch microelectrodes connected to a battery-operated pH meter. There was a marked difference in pH response of non-carious approximal sites between maxilla and mandible, with the lowest values in the maxilla. However, the pH recovery following the instantaneous drop occurred in parallel even if most pH values had not returned to baseline values 30 min after the sucrose rinse. Following the sugarcane chewing, the pH fall was less pronounced on all sites, and within 5-10 min the values had returned to resting pH and even exceeded this. In carious cavities, a similar pattern was observed, although the acidity in these sites was more pronounced, also reflected in a lower resting mean pH. The main conclusion from this study is that sugarcane chewing yields a less pronounced pH drop and a quicker pH recovery in dental plaque than is seen following a mouthrinse with 10% sucrose. This difference probably results from stimulation of salivary flow associated with the chewing.