Dental Caries and Nutrition revised Essay NUTR150

BACKGROUND According to the United States Surgeon’s General Report, dental caries is the most common chronic childhood disease. It is five times more common than asthma and seven times more common than hay fever1. Poor dietary choices and poor nutritional intake are associated with an increased risk for dental caries. According to the American Dietetic Association, “nutrition is an integral component of oral health.” Oral health and nutrition have a synergistic relation. Nutrition and diet affects the integrity of the oral cavity and act as a source for progression of many dental diseases2. More than 50% of children of age 5 to 9 years are affected with caries which increases to 78% in adolescents. Children of age below 5 years are also affected but the proportion is half when compared to that in middle childhood. Poor oral health has numerous effects on child’s nutrition, growth and development. Untreated cavities may lead to pain and inability to eat thereby affecting the overall growth and development. In addition, it has an effect on child’s nutritional intake leading to malnutrition in major cases. Dental caries in primary teeth of 2 to 11 years age group children has been declining since 1970s. But the most recent National Health and Nutrition Examination Survey reported that there has been reverse trend after 1990. Although small, a significant increase has been observed3. According to the data and statistics, it can be inferred that there exists many disparities in oral health and particularly caries. Disparities by family income shows striking features. Children of low income group suffers from cavities more when compared to peers of other income groups. Social factors like race, ethnicity, age, sex also show disparities in prevalence of caries. Also, people without insurance coverage have more oral problems when compared to people with insurance or Medicaid. Healthy People 2020, a ten-year agenda to improve the health of all Americans, identifies priorities for health improvement along with measurable goals and objectives applicable at national, state, and local levels. Objective OH-1 is “Reduce the proportion of children and adolescents who have dental caries experience in their primary or permanent teeth,” with a target of a 10 percent improvement4. In the U.S. from : 54% of children aged 6-9 years of age had dental caries experience in at least one primary or permanent tooth. 54% of adolescents aged 13-15 years of age had dental caries experience in at least one permanent tooth. Dental disease still remains a common problem in Ohio. Fifty-one percent of children have experienced tooth decay by third grade. Overall, 19 percent of Ohio’s children were found to have untreated cavities, which has decreased when compared to 26% before five years. Dental care remains the most common unmet health care need for nearly 157,400 children in Ohio. Almost 486,000 (19 percent) of Ohio’s children are without dental insurance. Almost 340,000 children in Ohio have never been to the dentist. Striking disparities in Ohio include: Children in Appalachian counties suffer more than twice than children living in other counties in Ohio. Children from low-income families have more cavities and toothaches and are less likely to have dental insurance than children from middle or upper-income families. Black children have significantly less number of visits to dentist when compared to White children5. Even though there has been progress in reducing dental caries over the past 25 to 30 years, still it remained to be a serious problem. In addition to poverty, race, ethnicity and geography, poor nutritional intake and the availability of unhealthy eating choices contribute to the presence of dental caries among school-aged children. ETIOPATHOGENESIS The relation between diet and nutrition and oral health and disease is said to be synergistic two-way street because any oral disease decreases the ability to eat and affects dietary intake and nutritional status. Similarly, inadequate diet and nutrition affects the development of efficient oral cavity and may result in oral diseases. Diet has a local effect on oral health affecting teeth, pH, and composition of the saliva and plaque. On the other side, nutrition has a systemic effect on the tissues like teeth, periodontium, oral mucosa, and alveolar bone2. Dental caries is caused by the demineralization of calcified tissues of tooth like enamel and dentine by the acids produced when food particularly, sugars are acted upon by bacteria. It was first described in Miller’s chemo-parasitic theory in 1890. Three factors are said to be responsible for initiation of dental caries which includes susceptible tooth, dietary factors and dental plaque and microflora2. Since, diet and nutrition constitute major part of caries initiation, numerous studies were conducted to identify the relationship of diet and nutrition with dental caries. In addition to regular sugars, added sugars pose major risk for caries. Intake of sugars in the United States increased significantly in the latter part of the 20th century; per capita consumption of added sugars increased by 23% from 1970 to 1996. Intake of added sugars increased from to , representing an increase from 13.2% to 15.8% of total energy intake. The USDA Dietary Guidelines 2010 recommended that added sugars should constitute about no more than 5 – 15% total energy intake6. In 2000, the most frequently reported form of added sugars in the US diet was beverages, which accounts up to one-third of regular sugar intake. An increase in the availability of added sugars in the diet at home, restaurants, and even in school contributes to the rising intake of these foods. A study on intake of sweetened beverages in children during 10-12 months of age has resulted in caries incidence by about 6 years of age7. Caries pattern in children, adults, and elderly vary, as do eating patterns. In all age groups, form, eating frequency, clearance and nutrient properties of food play a role in determining caries risk. Form of sugar has an effect on caries. For example, liquids foods does not have more contact time with tooth and are not adhered to the tooth surface for a long period of time. On the contrary, foods for example, sticky in form can have a long contact period resulting in more acid production leading to loss of calcified tissues. Oral clearance of foods depends on many factors like saliva flow, enzymes and bacterial activity rate. A study by Kashket et al showed that foods with high starch content like cookies need more time to be cleared when compared to foods with low starch like chocolates. Clearance depends on the retentive capacity of food. So, foods which are more retentive are responsible for increasing caries risk8. Frequency and amount of sugars play a major role in initiating risk for caries. Studies show that caries rate increases with increase in frequency and amount of carbohydrate intake. Hopewood House study was a longitudinal study conducted for about 10 years on 82 children between 3 and 14 years of age at Hopewood House in Australia. The principal features of their diet was absence of meat and restriction of refined carbohydrates. Snacking was limited to fruits and vegetables except on weekends. Whole meal bread, soya beans, wheat germ, oats, rice and potatoes were the main sources of carbohydrates. Fluoride content in the water and meals and snacks were taken with great regularity. The prevalence of dental caries in those children was almost negligible when compared to other children of same age group in Australia. At the start of the study, 78% of the children were caries-free, and 53% continued to be caries-free at age 13. Children on normal diet tend to be affected with caries 5-6 times more common than children at Hopewood house. When the children from Hopewood House were relocated as they became older, they no longer adhered to their strict diet. The result was a steep increase in caries increment, similar to that found in other children, indicating that teeth do not acquire any permanent resistance to dental caries. This study shows that caries can be reduced by restricting sugar intake even with minimum oral hygiene and fluoride9. Figure 4 The number of decayed, missing or filled (DMF) teeth with caries in the general population compared to children in Hopewood House. Vipeholm Study was conducted for about five years at the Vipeholm Hospital in Lund, Sweden, an institute for the mentally-deficient in 1954. The aim of this study was to determine the relationship between diet, frequency of sugar intake and dental caries. 436 patients were divided into one control group and six main test groups. Sugars were given either at mealtime or between meals. The conclusion of the study include increase in caries activity with increase in carbohydrate and frequency of sugar intake. There is high risk if sugars are taken in between meals and are retentive on tooth for a long period of time. The increase in caries activity disappeared when sugar-rich foods were reduced or removed from the diet. Thus, Vipeholm study clearly showed that physical form of carbohydrates and frequency of intake was important in cariogenicity10.