Oral health is directly related to diet and nutrition. Dental decay (caries) remains the most significant dental health problem in the UK, and concerns have been expressed about the rising prevalence of erosion. Both these factors are related to dietary factors, and we dentists have an increasing role to play in educating patients to support appropriate dietary habits. Although scientific evidence is clear and there is international agreement, media coverage frequently highlights findings of controversial and isolated studies.

The standard classification of sugars is based on where the sugar molecules are located within the food or drink.  INTRINSIC sugars are found within the cell structure of unprocessed foodstuffs like fruit and vegetables and are usually Fructose, Glucose and Sucrose. EXTRINSIC sugars are found outside the cell wall and are divided into two types; milk and non milk extrinsic sugars  (NMES).  Extrinsic milk sugars include Lactose found in milk and dairy products.  NMES are found in table sugar, confectionery, soft drinks, biscuits, honey and fruit juice.

 Guidelines for consumption are as follows:

2. Limit NMES to a maximum of four times per day

An example of tooth erosion on the backs of these top front teeth caused by excessive  fizzy drinks intake.

Intake within one hour of bedtime is very damaging.

There should not be an increase of saturated fats, or fatty snacks like crisps.

After the second war there was a marked increase in the consumption of NMES following the lifting of rationing, but this has reduced in recent times. However the main source to-day is by hidden sugars in processed and manufactured foods and drinks. Examples of the sugar content of a few popular examples is shown in the table below. The average UK daily intake is above the 60 g per day, and is of particular concern amongst pre-school children and adolescents, and in older members of the population as more retain some natural teeth.

A selection of alternative foods and snacks.

DENTURE CARE

Brush - Soak - Brush

When you take out your dentures at night, brush them clean with a non abrasive cleaning paste. Toothpaste for natural teeth is too rough on the plastic which will wear prematurely. Soak them in a proprietary cleaner (non bleach) overnight, then brush them again in the morning is the preferred programme. For those patients who cannot leave their dentures out at night, it is essential that they thoroughly clean both their natural teeth AND their denture.

Denture cleanliness is more important these days because many more patients are retaining some teeth all their lives. A contaminated denture will encourage plaque retention not only to the plastic surfaces of the denture, but also on the natural teeth and gums. This will result in poor gum health, and perhaps the premature loss of more of the remaining natural teeth.

XEROSTOMIA   DRY MOUTH

There are many reasons for suffering from a dry mouth, and this is now perhaps more frequent due not only to the increasing number of older patients in the population, but also to the number of prescribed drugs used which may cause this problem.

Causes may be separated into temporary and permanent. Temporary causes include stress and anxiety which unfortunately is often treated with drugs which themselves worsen the problem. Blockage of a duct will cause dryness on the affected side as well as pain and swelling from the salivary gland. Infections like mumps. Drug therapy can affect secretions and some are listed below; Drugs producing a dry mouth as a recognised side effect include the following; 

Antidepressants           Tricyclics  eg. amitriptyline

Antihistamines             early ones like  promethazine

Antihypertensives         like beta blockers

Diuretics                      like bendrofluazide

Permanent causes include the congenital absence of salivary glands, Sjogrens syndrome which is usually in combination with dry eyes and rheumatoid arthritis especially in women over 40 years of age. Uncontrolled diabetes mellitus, Parkinson's disease, cystic fibrosis and some vitamin deficiencies, anaemia and HIV infection. Radiotherapy, especially for tumors in the head and neck and surgical treatment or trauma can also cause permanent loss of function.

The mouth will often feel dry and painful. These problems will be heightened if dentures are worn, and the lack of saliva will mean more plaque will build up quicker round natural teeth. It is therefore important that regular visits to the dentist and  hygienist are maintained, together with improved diet and oral hygiene measures.

Treatment Options include:

Elimination of drug therapy if at all possible, promotion of salivary flow by chewing sugar-free gum or citric flavoured boiled sweets for those wearing full dentures, and the use of saliva substitutes and sipping iced water.

CARBOHYDRATE FREQUENCY AND FLUORIDE

It is now accepted that the frequency of carbohydrate intake has a more important influence on dental caries ( tooth decay ) than the amount consumed. Epidemiological studies have suggested that even the influence of frequency  fades when fluoride toothpaste is taken into account, although this relationship has NOT been studied experimentally.

Researchers asked volunteers to wear an oral device containing a piece of human tooth enamel that had been weakened by introducing a white spot lesion. The mineral content of the enamel was measured before and after five days in which the volunteers consumed 500ml of a drink containing 60g of sucrose. Frequency of consumption was varied by splitting the intake into one, three, five, seven or ten occasions per day. The whole procedure was repeated twice; once using a fluoride toothpaste and once using a non-fluoride toothpaste when tooth brushing.

The results showed that there was only a significant demineralisation of the enamel when using fluoride toothpaste when the frequency of intake was TEN times per day. However, with non-fluoride toothpaste there was significant demineralisation when the intake was only three times per day.

As can be seen in the picture above, there is early caries (tooth decay) in the tops of these three teeth caused by frequent snacks of sweets, biscuits and drinks during a busy day at work. There are small dark holes in the front two, and early darkening in the fissures on the back tooth. All these now need some drilling and filling.

THE VALUE OF SCHOOL TOOTHBRUSHING

Caries levels (tooth decay) are higher in children who live in deprived communities. Experts believe that part of the problem is poor standards of oral hygiene, although collecting accurate data on toothbrushing is difficult.

Researchers have recently carried out a two year clinical trial to determine if daily  toothbrushing in a school setting improves the dental health of low income children.

Five year old children from a deprived area in Scotland were supervised in their toothbrushing activities at a school and given supplies of fluoride toothpaste and brushes for the holidays.

There were two groups; one was a control with no action taken and the active group who had benefited from toothbrushing supervision and the toothpaste and brushes supplied. Both groups were given dental assessments every six months.

After the two year period the children in the intervention group had developed fewer cavities due to dental decay in their permanent molars than the control group.

This study shows that there is an improvement in dental health with a reduction in dental caries in a high risk population when oral hygiene is improved and fluoride toothpaste used.

From a paper by Currow M et al (2000)

YOUR GUMS AND YOUR HEART

LIP AND TONGUE PIERCING

Did you know of the DANGERS?

Many of the 18 to 30 year olds subject themselves to the  fashion craze of body piercing and tattoos. I am too old to be impressed by this, and will not dwell on the need to ensure that the salon used has properly qualified personnel who will display certificates of training, nor the obvious need to check that they operate under strict hygiene and cross infection controls. Too many people say  "yes" under the encouragement of friends whilst under the influence of the sun, sea and a few too many drinks. "It seemed like a good idea at the time" comes to mind, which you can remove if piercing was done, but tattoos are for life!

Lip and tongue piercing involves the insertion of either a bar bell or ball and flat disc type stud. The former is more likely to cause damage to teeth and dentistry due to its weight and bulbous design. There have been several cases reported where either teeth have been chipped, or some of the porcelain chipped off crowns, bridges or veneers. All of these problems will cause some distress, and possibly high costs to replace or repair the damage which may be far in excess of the cost of the piercing. My only point is to raise the issue of possible dental damage as a consequence of your bravado which may be something that may not have been considered beforehand.

NURSING  CARIES

Nursing caries is a specific form of tooth decay affecting the "baby teeth". It can result in considerable suffering and disfigurement and frequently compromises the future adult set of teeth.

Often known as "nursing caries", or "baby bottle caries" it is the upper front teeth that are affected most, but all can be involved if the decay process continues for long enough. Initially a white band round the gum level of the tooth starts, progressing to holes then a brown or black collar. Finally the tooth may snap off leaving decayed root stumps behind.

The main causes are a combination of long-lasting consumption of carbohydrates as drinks ( especially when sleeping or on demand bottle or breast feeding ), colonization of the mouth by decay-producing bacteria, poor oral hygiene and poor parenting. There are three stages ; 1) infection with the bacteria 2) rapid high build-up in the number of these bacteria through frequent ingestion of carbohydrates 3) the demineralization of the teeth. As the bacteria can come from the mother, it is recommended that the mother to be ensures that she has any decay and gum problems resolved during pregnancy and so reduce the risk of infecting her new baby.

Nursing caries affects approximately 3-5% of infants and young children, and is best prevented by educating prospective parents and new parents and by identifying "high risk" children.

Prevention measures:

a)    Start to clean your baby's teeth as soon as they appear

b)    Use a small toothbrush with flexible nylon bristles

c)    Only use a small (pea size) amount of fluoride toothpaste

d)    When brushing use  a circular motion and pay particular attention to the inner surfaces and the spaces between the teeth

e)    Make sure that your child is relaxed. It is usually better to stand or sit behind your child whilst brushing their teeth.

THE EROSIVE POTENTIAL OF DRINKS

There is an increasing number of children seen in the practice who suffer from varying degrees of "tooth surface loss" caused by the consumption of acidic foods, and drinks in particular. Erosion has been found to be present in a staggering 37% of eleven to thirteen year old children, and so is far from a small problem. This may cause a reaction from the patient or parent, and may result from either pain or sensitivity, difficulty in eating or concern about their appearance (aesthetics).

See the article above on Sugars as there is a photo of the type of damaged that can be done especially to the inside surfaces of the top front teeth by drinking "pop" or juices, dissolving away the hard enamel surface. This can result in sensitivity, increased wear and decay. 

These x-rays show the dark areas at the contact points between teeth, especially in the lower jaw, that indicates tooth decay. The patient snacked between meals regularly on crisps, sweets and pop.

Another interesting issue relating to how corrosive a drink will be is the temperature at which it is drunk. As the dissolving of the enamel is a chemical process, it will be speeded up by an increase in temperature, and the reverse is also true. So, if the drink is taken ice cold with ice cubes too, the dissolving power of the drink is reduced. It is for this reason that there is much less erosion of teeth, say in North America, where traditionally soft drinks are consumed chilled with ice cubes that will also dilute the beverage.

Drinking through a straw will also reduce the risk to the teeth.

Do NOT brush your teeth for a least 40 minutes after softening the enamel with acidic drinks as this will markedly increase the tooth wear. Sugar free chewing gum, milk, cheese or water will all dilute the acidity without wearing the tooth away. 

http://www.bite.uk.com     for further information

EROSION UPDATE

Listed below are some erosion comparisons with modern drinks. Note that RED WINE is not mentioned, so in moderation may be regarded as tooth and heart kind!  Obviously  fruit based drinks are bad for teeth as is CAVA, the Spanish cheap sparkling white wine favoured by many. 

The power of the acidity and therefore the damage potential is related to the ph value. please note the LOWER the number the WORSE (more damaging) the drink.

Organic Acid content of some fruits ( mg per 100 gm )

Erosion data for Hooch

Hooch is generally BAD FOR TEETH!