Diet, Fluoride, and
Dental Caries
Wendell Evans BDS MDS DDSc FICD
Population Oral Health
The University of Sydney
Dental caries was ranked as the highest
diet-related disease in Australia in terms of
both total costs and health care costs
(Crowley et al 1992).
Crowley S, Antioch K, Carter R, Waters AM, Conway L,
Mathers C (1992). The cost of diet related disease in
Australia. Canberra: AIHW and NHMRC.
Annual sugar use (kg)
Age 11-12 years
DMF* Teeth
*Decayed, Missing, Filled
FAO (Food and Agriculture Organsiation - United Nations 1960
10% glucose rinse
Dental
plaque pH
Critical pH for tooth
enamel dissolution
Minutes
Jenkins GN. The physiology and biochemistry of the mouth, 4th Edition. Oxford: Blackwell Scientific
Publications, 1978. Page 388.
Jenkins GN. The physiology and biochemistry of the mouth, 4th Edition. Oxford:
Blackwell Scientific Publications, 1978. Page 389.
The Vipeholm Study of
Diet and Dental Caries
Gustafsson et al. (1954). The Vipeholm dental caries
study. Acta Odontlogica Scandinavica 11:232-364.
Gustafsson et al. (1954). The Vipeholm dental caries
study. Acta Odontlogica Scandinavica 11:232-364.
4
300
3
200
New
DMFT
per
year
Sugar
consumed
gm per day
100
0
1
Liquid
Gustafsson et al. (1954). The Vipeholm dental caries
study. Acta Odontlogica Scandinavica 11:232-364.
24
toffees
0
The Dental Caries Experience
of the Children of
Hopewood House
Bowral, NSW
Lilienthal et al Med J Aust, June 1953
Hopewood House
82 Children aged 4-9 years
Investigators
Findings
Paediatricians
• well nourished
• healthy
Dental scientists • very poor oral hygiene
• no dental caries
Lilienthal et al Med J Aust, June 1953
12
10
HOPEWOOD HOUSE
8
BOWRAL, NSW
6
DMFT of children
aged 6 – 9 years
4
2
0
New
Sydney
Zealand
Lilienthal et al Med J Aust, June 1953
Bowral
Lilienthal et al Med J Aust, June 1953
The Tennessee Study
Weiss RL, Trithart. Between meal eating habits and dental caries experience in preschool children.
American Journal of Public Health 50:1097-1104, 1960.
Weiss RL, Trithart. Between meal eating habits and dental caries experience in preschool children.
American Journal of Public Health 50:1097-1104, 1960.
Weiss RL, Trithart. Between meal eating habits and dental caries experience in preschool children.
American Journal of Public Health 50:1097-1104, 1960.
The cariogenicity of
refined carbohydrates
Beck DJ, Bibby BG. Acid production during the fermentation of starches by saliva. Journal of Dental
Research 40:486-491, 1961.
Calcium sucrose phosphate
Harris et al. Observations on the cariostatic effect on a group of children aged 5-17 years. Australian Dental
Journal 12:105-113, 1967.
Harris et al. Observations on the cariostatic effect on a group of children aged 5-17 years. Australian Dental
Journal 12:105-113, 1967.
Relationship between dietary habits
and caries increment assessed over
two years in 405 adolescent school
children in Northeast England.
Rugg-Gunn et al (1984). Archives of Oral Biology
29:983-992.
.
•
•
•
•
•
2 year study
children initially aged 11.5 years
3 day diet diary on 5 occasions
annual bitewings
non-fluoridated environment
Rugg-Gunn et al. Archives of Oral Biology 29:983-992, 1884.
Rugg-Gunn et al. Archives of Oral Biology 29:983-992, 1884.
Rugg-Gunn et al. Archives of Oral Biology 29:983-992, 1884.
Rugg-Gunn et al. Archives of Oral Biology 29:983-992, 1884.
The effects of sugars intake and
frequency of ingestion of dental
caries increment in a three-year
longitudinal study – Michigan, USA
Burt et al. Journal of Dental Research 67:1422-1429, 1988.
Michigan, USA
● 3 year study of 499 children
● initially aged 11-15 years
● 24 hour diet interviews on 3-4
occasions
● non-fluoridated environment
● annual bitewings
Burt et al. Journal of Dental Research 67:1422-1429, 1988.
(3 years)
Burt et al. Journal of Dental Research 67:1422-1429, 1988.
(3 years)
Burt et al. Journal of Dental Research 67:1422-1429, 1988.
Summary of findings
Caries incidence was not related to total
sugar intake nor to frequency of eating
occasions.
Rugg-Gunn et al. Archives of Oral Biology 29:983-992, 1884.
The Melbourne Study
Pit and fissure surface caries risk estimates
Effect of cheese
Eating cheese following consumption of a sugary
snack (pears in sugary syrup) prevented the
depression of plaque pH whereas drinking
sugared coffee following pears consumption
further depressed pH.
Rugg-Gunn et al. The effect of different meal patterns upon plaque pH n human subjects. British Dental
Journal 139:151-156, 1975.
Effect of war time diet
During WW2, severe rationing of sugar occurred.
Caries incidence in both Scandinavia and Japan
was correlated with sugar consumption.
Most recently, United Nations imposed sanctions
against Iraq was associated with a dramatic
decline in caries incidence.
These data show the potential for health promotion
(at the population level) to target dietary sugar
restriction. The common risk factor approach.
Toverud G (1957). The influence of war and post-war conditions on the teeth of Norwegian children. In:
Rugg-Gunn AJ. Nutrition and Dental Health. Oxford: Oxford University Press, 1993, 129.
DMFT in Iraq before and
after United Nations
Sanctions (UNS)
Jamel H, Plasschaert A, Sheiham A. Dental caries experience and availabilit of sugars in Iraqi children before
and after the United Nations sanction. International Dental Journal 54: 21-25, 2004
Fluorine
☻ 13th most abundant element in the earths crust
☻
☻
☻
☻
☻
☻
(WHO,1984)
most electronegative of the elements
emitted from volcanoes as gaseous fluorine which
reacts immediately with water to form HF
mainly found in rock and soil in various forms of
barely soluble calcium fluorides
concentration in seawater about 1.2 mg/L (ppm)
concentration in fresh water ranges from near
zero to 25 ppm (in the Rift Valley, Tanzania)
world-wide fresh water fluoride concentrations
are generally less than 0.1 ppm but commonly up
to 2 ppm in some areas
0.0 ppm
0.0 ppm
1.2 ppm
Source: McClure FJ. Water fluoridation: The search and the victory. Bethesda: National
Institute of Dental Research, 1970.
0.1 ppm
1.0 ppm
1.2 ppm
Permanent teeth DMF reductions at Grand Rapids
after 10 and 15 years of fluoridation.
Source: McClure FJ. Water fluoridation: The search and the victory. Bethesda: National Institute of Dental Research, 1970.
Percent caries reduction in 113 studies into the effectiveness
of water fluoridation in 23 countries.
Source: Murray JJ, Naylor MN. Fluorides and dental caries. In: Murray JJ (Editor). Prevention of oral
disease 3rd edition. Oxford: Oxford University Press, 38, 1996.
Australian
12-year-olds
The effect of water
fluoridation
The combined effect of water
fluoridation and fluoridated toothpaste
Victorian 12-year-olds
Source: Spencer AJ, Slade GD, Davies M. Water fluoridation in Australia. Community
Dental Health 46:188-198,1986
Water fluoridation in the
Blue Mountains reduces risk
of tooth decay
RW Evans1, A Hsiau1, PJ Dennison1, A Paterson2,
and B.Jalaludin2
Australian Dental Journal 54: 368-373, 2009
Primary teeth
Caries experience of lifelong
residents aged 6 – 8 years
3
2.5
Blue Mountains
2.58a
Hawkesbury
2
Mean
dmft
1.5
1
1.10
0.69b
0.5
0
1993
2003
a = 135% more than Hawkesbury at baseline
b = 73% less than Hawkesbury at baseline
A=
RW Evans1, A Hsiau1, PJ Dennison1, A Paterson2, and B.Jalaludin2
1Community Oral Health and Epidemiology, 2Formerly NSW Health
0.71
Primary teeth
Percent of lifelong residents
aged 6 – 8 years with no decay
100
90
80
70
72%
60
71%
62%
50
40
30
38%
20
10
0
1993
Blue Mountains
Hawkesbury
RW Evans1, A Hsiau1, PJ Dennison1, A Paterson2, and B.Jalaludin2
1Community Oral Health and Epidemiology, 2Formerly NSW Health
2003
PERMANENT TEETH
Caries experience of lifelong
residents aged 9 – 11 years
1
0.9
0.8
Blue Mountains
0.87a
Hawkesbury
0.7
Mean
DMFT
0.6
0.5
0.58
0.4
0.36
0.3
0.2
0.22b
0.1
0
1993
a = 50% more than Hawkesbury at baseline
b = 75% less than Hawkesbury at baseline
RW Evans1, A Hsiau1, PJ Dennison1, A Paterson2, and B.Jalaludin2
1Community Oral Health and Epidemiology, 2Formerly NSW Health
2003
PERMANENT TEETH
Percent of lifelong residents
aged 9 – 11 years with no decay
100
90
87%
80
70
60
50
81%
71%
61%
40
30
20
10
0
1993
Blue Mountains
Hawkesbury
RW Evans1, A Hsiau1, PJ Dennison1, A Paterson2, and B.Jalaludin2
1Community Oral Health and Epidemiology, 2Formerly NSW Health
2003
Fluoride toothpaste
The Cochrane Database of Systematic Reviews
Fluoride toothpastes for preventing
dental caries in children and adolescents
Marinho VCC, Higgins JPT, Sheiham A, Logan S
Date of Most Recent Substantive Update:
3 September 2002
The overall caries-inhibiting effect (that is preventive
fraction, %PF) derived from the pooled results of 70 trials
was 24% (95% CI, 21 to 28%).
This effect was independent of background domestic
drinking water fluoride status.
The caries increments ranged from 1.14 to 7.66 D(M)FS per
year.
In addition there was:
☻ a 14% increase in the PF moving from once to twice
daily tooth brushing
☻ an 8% increase in the PF per 1000 ppm increase in the
fluoride concentration
Fluoride varnish
The Cochrane Database of Systematic Reviews
Fluoride varnishes for preventing dental
caries in children and adolescents
Marinho VCC, Higgins JPT, Logan S, Sheiham A.
29 May 2002
Nine studies were included in this meta-analysis, involving
2709 children.
For the seven studies that contributed data for the main
meta-analysis, the D(M)FS pooled prevented fraction
estimate was 46% (95% CI, 30% to 63%; p<0.0001).
The pooled d(e/m)fs prevented fraction estimate was 33%
(95% CI, 19% to 48%; p<0.0001).
The role of diet in caries prevention
– an ecological model
Dietary
challenge
Caries
risk
For a given dietary challenge, risk of caries at any tooth site will depend
on (1) fluoride exposure, (2) plaque bulk, and (3) access to saliva.
Loveren C van, Duggal MS. The role of diet in caries
prevention. International Dental Journal 51:399-406,2001.
Better use of fluorides
Better oral
hygiene
Dietary
challenge
Caries
risk
Better access to saliva
For a given dietary challenge, risk of caries at any tooth site will depend
on (1) fluoride exposure, (2) plaque bulk, and (3) access to saliva.
Loveren C van, Duggal MS. The role of diet in caries
prevention. International Dental Journal 51:399-406,2001.
Better use of fluorides
Betteroral
Better
hygiene
For reduced
dietary
challenge
Betteraccess
accessto
tosaliva
saliva
Better
For a given dietary challenge, risk of caries at any tooth site will depend
on (1) fluoride exposure, (2) plaque bulk, and (3) access to saliva.
Loveren C van, Duggal MS. The role of diet in caries
prevention. International Dental Journal 51:399-406,2001.
Better use
Better use of fluorides
Betteroral
Better
hygiene
For reduced
dietary
challenge
Scope to
reduce caries
risk is limited
Betteraccess
accessto
tosaliva
saliva
Better
For a given dietary challenge, risk of caries at any tooth site will depend
on (1) fluoride exposure, (2) plaque bulk, and (3) access to saliva.
Loveren C van, Duggal MS. The role of diet in caries
prevention. International Dental Journal 51:399-406,2001.