Sugar The Arch Criminal of Dental Caries

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ammad on Jul 14, 2009 Says :

hi i m dentist in pak.i did my sp in prosthodontics. i m interested in dental implants.

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Slide 1 :

1 SUGARS – THE ARCH CRIMINAL? Presented at the 50th Anniversary Congress of the European Organization of Caries Research (ORCA): Cariology in the 21st Century, State of the Art and Future Perspectives, Konstanz, Germany Caries Res 38:277-285 2004. Domenick T. Zero, DDS, MSDepartment of Preventive and Community DentistryIndiana University School of Dentistry

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2 Nomenclature Monosaccharies Glucose (dextrose) Fructose (fruit sugar) Galactose Invert sugar (1:1 glucose and fructose) Disaccharides Sucrose (table sugar) Maltose Lactose (milk sugar) Trehalose (mushroom sugar) Natural and Manufactured Oligosaccharides (3-10 units) Polysaccharides (> 10 units) Starch (Moynihan, 1998)

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3 Sucrose arch criminal of dental caries. (Newbrun,1969)

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4 Outline Brief overview of existing evidence Classic Human Evidence National Surveys Epidemiology Studies (cohort, case-control and cross-sectional) Indirect Evidence from model systems In vitro Animal Human plaque acidity In situ demin/remin Special Role of Sucrose Where are we now? Future Research Summary and Implications

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5 Review Articles

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6 Review Articles (Cont.)

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7 Classic Human Evidence

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8 Classic Human Evidence (Cont.)

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9 Vipeholm Study (Gustafsson et al., 1954)

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10 Conclusions Based on the Vipeholm Study The amount of sugar eaten is not as important as the form in which it is eaten. Sticky sugar products which tend to be retained on teeth have a greater caries potential than sugar consumed in a liquid form. The more frequent sugar is consumed the greater the risk. Sugar consumed between meals has much greater caries potential than when consumed during a meal. (Gustafsson et al., 1954)

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11 Data From National Surverys

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12 Methodological Challenges Low level of caries and high level of sugar consumption with small variation in industrialized countries Lack of consistency in how sugar consumption is reported among different countries sugar intake, sucrose intake, added sugar, and non-milk extrinsic sugar, calculated as grams/person/day, kilograms/person/year, or sugar intake as % of total energy intake. Reliability of caries scores calibration treatment effects

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13 Sugar and Caries Risk Burt & Pai (2001) conducted a systematic review that specifically addressed the question: “In the modern age of extensive fluoride exposure, do individuals with a high level of sugar intake experience greater caries severity relative to those with a lower level of intake?” J Dent Res 65:1017-1023, 2001

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15 (Burt & Pai, 2001) Strong: risk ratio (odds ratio or relative risk) = 2.5 Moderate: risk ratio between 1.5 and 2.4 Weak: risk ratio = 1.4

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16 Based this systematic review the authors concluded “that while the relationship between sugar consumption and caries is not as strong as it was in the pre-fluoride era, restriction of sugar consumption still has an important role in caries prevention.” (Burt & Pai, 2001)

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17 Research Challenges Limitations of dietary surveys Complexity of foods Behavioral factors associated with eating foods Controlling other confounders

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18 Methods of Testing the Cariogenic Potential of Foods In vitro Microbial Caries Models – acid production, microbial shifts, enamel demineralization Human Plaque Acidity Models Animal Caries Models In situ Demineralization/Remineralization Models

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19 San Antonio Scientific Consensus Conference on Methods of Assessment of the Cariogenic Potential of Foods, 1985 Integration of Methods – Working Group Consensus Report Cariogenicity – “The true cariogenicity of a food can only be established by experimentally determining in humans the extent of tooth decay associated with a given food.” Cariogenic potential – “ a food’s ability to foster caries in humans under conditions conducive to caries formation”. (Stamm et al., 1996)

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20 The cariogenic potential of a particular food or beverage is influenced by its properties, most importantly the sugar content and the presence of protective factors, and the consumption pattern, most importantly the frequency of consumption. (Bowen et al., 1980)

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21 Possible Factors that Can Influence the Cariogenicity of Foods Food factors amount and type of carbohydrate food pH and buffering power consistency, retention in the mouth eating pattern factors influencing the oral flora factors modifying enamel solubility sialogogue properties other substrates for bacterial metabolism Cultural and economic factors availability and distribution selection, marketing Edgar (1985)

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22 Recommendations for Ranking Foods Bowen et al. (1980) ranking based on a sucrose standard Combination of tests (Matsukubo et al., 1985) plaque-forming ability acid-producing ability ingestion time clearance time

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23 Limitations of Testing Cariogenic Potential Some methods appear to be too sensitive Does not account for how foods are actually consumed frequency of ingestion patterns of ingestion relationship to dietary intake of other foods Does not account for the actual susceptibility of the individual to caries composition of the oral flora amount and composition of saliva How should we use the information?

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24 Is sucrose “the arch criminal of dental caries” ? ? (Newbrun,1969)

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25 Easily Fermentable Carbohydrates Sucrose Fructose Maltose Glucose ACID DEMIN

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26 Evidence of Cariogenic Properties of Sucrose Sucrose sole substrate for synthesis of extracellular glucan by S. mutans (Newbrun, 1967) Glucan can be a major component of the extracellular matrix of plaque (Guggenheim, 1970) Synthesis of glucan favors accumulation of MS in plaque (Gibbons, 1983) May be more cariogenic than other sugars in some animal models, mainly smooth surfaces (van Houte and Russo, 1986)

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27 Evidence of Cariogenic Properties of Sucrose (Cont.) Limited data suggests that replacement of sucrose by monosaccharides may reduce proximal- and smooth-surface caries (Burt, 1993). Sucrose-mediated synthesis of glucans increases the porosity of plaque, permitting deeper penetration of dietary carbohydrates into the biofilm (Dibdin and Shellis, 1988; van Houte et al., 1989; Zero, 1993) and enhance the demineralization potential of plaque (Zero et al. 1986; Cury et al. 2000) Glucan synthesis by MS may be more important than their levels in plaque (Mattos-Graner et al., 2000; Nobre dos Santos et al., 2002)

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28 Where are we now?

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29 Relationship Between Sucrose and Caries (Newbrun, 1982)

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30 Relationship Between Sucrose and Caries

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31 Fluoride Era Has everything changed? And if so, has it changed for everybody?

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32 Future Research Biologic and behavioral factors that influence caries risk Relationship between cariogenic (sugar) challenge and level of fluoride intervention Specific cariogenicity of sucrose relative to other sugars Impact of soft drinks targeted a adolescent Root caries in aging individuals Food additives to reduce cariogenicity

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33 Summary and Implications

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34 Population Level Industrialized countries - measures to educate the public on the dangers of frequent sugar consumption (especially foods with high sugar concentration) in conjunction with recommendations for proper oral hygiene and fluoride use are still warranted. Developing countries - strategies need to be developed to ensure that educational resources and dental public health manpower are available before the dental health problem manifests.

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35 Individual Basis Dietary counseling is still highly recommended for patients that show signs of caries activity and/or are at high caries risk (hyposalivation, iatrogenic factors, i.e. orthodontic brackets).

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36 Low pH Adjacent to Tooth Surface

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