Introduction
Maintaining optimal oral health involves more than just brushing and flossing. The foods and beverages we consume play a crucial role in the health of our teeth and gums. Dental caries, or tooth decay, arises when the demineralization of tooth enamel surpasses its remineralization capacity. This dynamic process involves susceptible tooth surfaces, cariogenic bacteria (mainly Streptococcus mutans), and a fermentable carbohydrate source. A well-informed dietary approach, often referred to as the "dental diet," is essential for preventing dental caries and promoting overall oral well-being. This article explores the principles of a dental diet, including which foods to embrace and which to avoid, to help you achieve and maintain a healthy, radiant smile.
Understanding Dental Caries
Dental caries is a multifactorial disease with dietary sugars providing the substrate for cariogenic bacteria to flourish and generate enamel-demineralizing acids. It occurs when bacteria in dental plaque metabolize fermentable carbohydrates, especially sucrose, leading to the production of organic acids and a drop in pH. When the pH falls below 5.5 (the critical pH), demineralization of enamel occurs. This process happens every time fermentable carbohydrates are consumed.
Several factors contribute to the development of dental caries, including poor oral hygiene, salivary gland hypofunction, socioeconomic status, parenting practices, and genetics. However, nutrition is a modifiable parameter that plays a crucial role in preventing dental caries since sugar is required for the disease to occur.
The Role of Sugars and Carbohydrates
Sucrose and Cariogenicity
Sucrose, the most common dietary sugar, is considered the most cariogenic carbohydrate. Past and modern studies have demonstrated the distinctive cariogenic potential of each type of dietary sugar; among these, sucrose is the most cariogenic. It is obtained from sugar cane and beets and is also present in fruits. Frequent consumption of carbohydrates, particularly simple sugars, increases the risk of dental caries. Enamel is demineralized every time sugar is consumed, and the demineralization increases with the frequency of such episodes. Moreover, the amount of sugar consumed also influences the severity of dental caries. Free sugar intake between meals is also associated with higher caries rates.
Starches and Dental Caries
Dietary starches, found in foods like bread, pasta, potatoes, rice, oats, and breakfast cereals, also contribute to the development of dental caries. Bacteria in the dental plaque metabolize fermentable carbohydrates from the diet, particularly sucrose. As a result of this process, organic acids are produced, causing a drop in the pH. It has been hypothesized that when the pH is lower than 5.5, demineralization of the enamel occurs, known as the critical pH. This process occurs every time fermentable carbohydrates are consumed.
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Frequency vs. Amount of Sugar Intake
Several studies evaluate the association between the amount and frequency of sugar intake and dental caries. It is hard to establish if the amount of sugar intake is more important than the frequency or vice versa, as these two variables are hard to analyze separately. The risk of caries increases with more frequent and higher free sugar intake and consumption of food, with a tendency to be retained in the oral tissues for longer. The frequency of sugar intake is a major determinant of caries risk. Caries risk is the greatest if sugar is consumed at high frequency, more so when the sugar is in a form that is retained in the mouth for long periods of time. Sipping sugar-containing beverages provides repeated hits of sugar on the teeth. Most sugary beverages are highly acidic, which promotes demineralization.
Free Sugars: A Closer Look
The term "free sugar" includes all sugars added to food and beverages, as well as naturally occurring sugars found in fruit juices and concentrates, honey, and natural syrups. In addition to the type of sugar consumed, the amount consumed may affect caries development. There is ongoing research to determine strategies to decrease the consumption of sugar-sweetened beverages (SSBs), as they are a significant contributor to free sugar consumption. A tax on SSBs is one strategy that has been attempted; studies suggest that taxation of SSBs may decrease SSB consumption, caries incidence, and caries-related costs.
Sugar Substitutes and Their Role
Sugar substitutes pose numerous benefits for preventing and controlling diabetes mellitus, weight, and dental caries. Sweeteners are substances that provide sweetness to food and drinks and are classified into two main types according to their caloric potential: caloric (carbohydrate-based) and non-caloric (non-carbohydrate based). Sugar alcohols, such as xylitol or erythritol, don’t seem to influence oral health. As for stevia, it doesn’t appear to have negative effects on oral health.
Xylitol: A Non-Cariogenic Sweetener
Xylitol is a non-cariogenic and antibacterial sugar alcohol with a similar sweetness to sugar and a pleasant taste. It is added to various products for caries prevention, including chewing gum, chewable tablets, lozenges, mouthwashes, toothpaste, and cough mixtures. Xylitol is believed to have an antimicrobial action on the biofilm. Postulated mechanisms by which xylitol may reduce caries risk include simple substituting for fermentable carbohydrates, reducing the acidogenic potential, inhibiting the growth of Streptococcus mutans, or just increasing salivary flow (especially in the case of sugar-free chewing gums). Although non-sugar sweetened gum is eligible for application to the ADA Seal of Acceptance, the ADA does not have a policy on the use of xylitol for caries prevention.
Other Non-Caloric Sweeteners
The Food and Drug Administration (FDA) approves the following non-caloric chemically synthesized sweeteners to be consumed in the United States: aspartame, saccharin, acesulfame potassium, and neotame. Stevia, a plant-derived sweetener, has also been approved for consumption.
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Foods That Harm Dental Health
Sugary Foods and Drinks
Sugary foods and drinks are among the most significant contributors to tooth decay. When you consume sugar, the bacteria in your mouth convert it into acid, which then attacks the enamel, the hard outer layer of your teeth. Refined foods and fermentable carbohydrates increase the risk of dental disease. Empty calorie foods such as candy (especially hard or sticky candies like lollipops, mints, taffy and caramel), sweets like cookies, cakes and muffins, and snack foods like chips are a cause for dental concern, not only because they offer no nutritional value, but because the amount and type of sugar that they contain that can adhere to teeth. Sugar-containing drinks-soda, lemonade, juice and sweetened coffee or tea (iced or hot)-are particularly harmful because sipping them causes a constant sugar bath over teeth, which promotes tooth decay.
Acidic Foods and Drinks
Acidic foods and beverages can also pose a risk to your teeth by eroding enamel. Common culprits include citrus fruits, tomatoes, and sodas. Acidic food and drinks can cause dental erosion - the gradual dissolving of the tooth enamel. Anything with a pH value lower than 5.5 may cause erosion. Eating and drinking foods containing sugar and acids naturally weakens the enamel on your teeth.
Sticky and Starchy Foods
Sticky sweets and snacks, such as caramel, candies, and dried fruits, are particularly harmful because they cling to your teeth, providing a long-lasting source of sugar for bacteria to thrive on. Sticky and Starchy Foods: Items like dried fruit and potato chips can adhere to teeth, fostering decay.
Foods That Promote Dental Health
Calcium and Phosphorus
These minerals are essential for keeping your teeth and bones strong. Calcium can be found in abundance in dairy products like milk, cheese, and yogurt, as well as in leafy green vegetables, almonds, and fortified foods.
Vitamin D
Vitamin D is essential for the body’s ability to absorb calcium, making it crucial for strong teeth and bones.
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Vitamin C
This vitamin is important for the health of your gums. It supports the production of collagen, which helps keep your gums strong and resilient.
Antioxidants
Antioxidants help protect your gums from damage caused by bacteria and inflammation.
Water
Keeping hydrated is crucial for sustaining a healthy mouth. Water assists in washing away food particles and bacteria, which helps lower the risk of cavities and gum disease.
High-Fiber Foods
Eating foods that stimulate saliva production, such as high-fiber fruits and vegetables like apples, carrots, and celery, can help keep your mouth healthy.
Other Cariostatic Foods
Foods such as milk and dairy products, apples, cranberries, tea, and high-fiber foods have been suggested to have cariostatic properties (i.e., inhibiting the development of caries). It has been postulated that the calcium in dairy products offsets some of the cariogenic properties of lactose by limiting enamel undersaturation during acidogenesis. As mentioned above, lactose fermentation also results in a smaller reduction in pH compared with other simple sugars.
Dietary Recommendations for Preventing Dental Caries
Limit Sugary and Acidic Foods
Try to reduce your intake of sugary snacks and acidic beverages. The World Health Organization suggests that no more than 10% of total energy intake should come from added sugars. It is better for your teeth and general health if you eat 3 meals a day instead of having 7 to 10 snacks. To help reduce tooth decay, cut down on how often you have sugary foods and drinks and try to have sugar-free varieties.
Choose Healthy Snacks
Opt for snacks that are low in sugar and high in nutrients, such as fresh fruits, vegetables, nuts, and cheese. Non-cariogenic or low-cariogenic snacks must be available at home and provided in school lunchboxes, e.g., cheese, plain milk, vegetables, fruits, and whole grain products.
Stay Hydrated
Maintaining hydration by drinking ample water throughout the day helps to keep your mouth moist and removes food particles and bacteria. Still water and milk are good choices.
Balance Your Meals
Make sure your diet includes a variety of nutrient-rich foods to ensure you’re getting the vitamins and minerals your teeth need. A diet that is rich in vitamins, minerals and fresh fruit and vegetables can help to prevent gum disease. Eat mostly whole, nutrient-dense foods that provide plenty of calcium, phosphorus, magnesium, vitamin K (especially K2) and vitamin D. Foods like leafy green vegetables, nuts, seeds, hard aged cheeses, plain yogurt, meats, natto, beans, mushrooms, fish, eggs, and organ meats all work here.
Promote Regular Eating Patterns
Continuing to promote regular eating patterns. Promoting eating cariogenic foods only with meals. Dietary recommendations to prevent dental caries include: Offering non-cariogenic or low-cariogenic snacks, like cheese and fruits. Avoiding sugar-containing foods that are sticky or slowly eaten.
Be Mindful of Snacking
During this period, children begin to be more independent, make their own food choices, and increase food snacking between meals. Sugary snacks that tend to be retained in the mouth for extended periods should be discouraged, like candies and lollipops. If you do need to snack between meals, choose foods that do not contain sugar.
Dilute Drinks
It is better for your teeth if you drink fruit juices just at meal times. Diluted sugar-free fruit drinks are the safest alternative to water and milk. If you make these, be sure that the drink is diluted 1 part fruit drink to 10 parts water.
Consider Chewing Gum
Chewing gum makes your mouth produce more saliva, which helps to cancel out the acid in your mouth after eating or drinking. It has been proven that using sugar-free chewing gum after meals can prevent tooth decay. Chew xylitol gum after meals. Xylitol increases saliva production and prevents the bacteria in your mouth from producing the acids that cause cavities.
Other Tips and Recommendations
- Eat some raw, crunchy fruits and vegetables every day. Raw veggies clean your teeth to a degree (apples, carrots, bell peppers, etc). Eating an apple as dessert after lunch will help to remove material that has adhered to the surface of your teeth.
- Limit added sugars from both foods and beverages. This includes soda, fruit juice, energy drinks, candies, etc. Energy drinks are particularly damaging as they combine a high sugar load with an incredibly acidic pH.
- Increase the amount of arginine in your diet.
- Remember, it is not the amount of sugar you eat or drink, but how often you do it.
Special Considerations
Oral Health in Children
Mothers and caregivers influence their children's diet and oral hygiene. Pregnant women have a unique opportunity to receive appropriate information about healthy dietary habits and general oral hygiene to prevent early childhood caries in their children. Furthermore, maintaining good oral hygiene must be emphasized, as mothers and caregivers are the sources of cariogenic bacteria in their children. Mothers should also be advised to limit sugar consumption and snacking on sugary products between meals. Establishing a healthy eating pattern at a young age benefits oral and general health. Children would prefer foods high in sugar and calories if exposed to repeated consumption of such foods early in infancy. Parents must make sure that regular eating patterns are already inculcated by this age and continue to encourage them.
Breastfeeding is strongly recommended in the first year of life because of its nutritional and immunological benefits. Breast milk is insignificant in the development of early childhood caries as compared to night-time bottle feeding, which should be discouraged. Breast milk is low in fluoride. Systemic fluoride supplementation can be indicated for infants more than six months of age if the fluoride levels are insufficient in the area where they live. However, clinicians must corroborate that the fluoride levels are low in the local drinking water before supplementing a child because of the risk of dental fluorosis.
Early childhood caries (ECC) is the presence of one or more decayed, missing, or filled tooth surface in children under 6 years of age. ECC was formerly referred to as “baby bottle tooth decay” and is primarily due to prolonged exposure of the enamel to sweetened liquids causing caries in small children.
Children up to three years old should use a toothpaste with a fluoride level of at least 1000ppm (parts per million).
Pregnancy and Oral Health
Poor nutrition in pregnant women may result in developmental anomalies in the infants' teeth. Enamel hypoplasia has been associated with poor prenatal nutrition and increased caries risk. The first few years after birth are critical since there is a massive dietary shift from exclusive milk and liquid diet to a modified adult diet.
Malnutrition and Oral Health
Malnutrition, especially in children, results from improper dietary behaviors and feeding practices in infancy and childhood. It is usually related to limited access to fresh and nutritious food, which is replaced with low-cost and high in sugars food. Poor nutrition, especially during the early years of development, increases the risk of dental and periodontal disease.
Besides dental caries, nutrition may contribute to developing other dental and oral mucosa pathologies. Delayed tooth eruption and salivary gland dysfunction may be linked to protein deficiencies. Vitamin A deficiency leads to impaired epithelial tissue development, tooth formation, and enamel hypoplasia. Vitamin D and calcium deficiency cause hypo-mineralization, delayed eruption, the absence of lamina dura, and abnormal alveolar bone patterns. Delayed wound healing, dentin malformations, bleeding gums, and defective collagen formation may result from vitamin C deficiency. Angular cheilosis and periodontal diseases are associated with a lack of vitamin B.
Obesity and Oral Health
It’s clear that controlling inflammation is important for oral health, and obesity is correlated with inflammation. This is why obesity is the second biggest risk factor for inflammation in the mouth. Because high blood sugar, AGEs, changes in salivary pH, and pro-inflammatory compounds all tend to be present in those who are over-fat. People who are over-fat are also at greater risk for diabetes, and diabetes, in turn, is associated with poor oral health. This is probably due to elevated blood sugar and its associated effects. Maintain a lean/healthy body composition. Get regular exercise.
The Impact of Aging
Our risk of periodontal disease goes up as we age. It’s not clear what exactly causes oral disease with age. What is clear is that taking good care of our teeth and gums at every age is important.
The Importance of Oral Hygiene
Maintaining good oral hygiene is essential for preventing dental caries and promoting overall oral health. In addition to eating a healthy diet, it’s important to stick to a consistent dental hygiene routine. Every time you eat or drink anything sugary, your teeth are under acid attack for up to one hour. This is because the sugar will react with the bacteria in plaque (the sticky coating on your teeth) and produce harmful acids. Acidic foods and drinks can be just as harmful. The acid ‘erodes' or dissolves the enamel, exposing the dentine underneath.
Key Oral Hygiene Practices
- Brush your teeth at least twice a day, especially before bed. It is especially important to brush before bed.
- Use a toothpaste with fluoride. Brush your teeth, not only with fluoride-based toothpaste, but also baking soda-based toothpaste.
- Floss daily to remove plaque and food particles from between your teeth. Are you flossing yet?
- Visit your dentist regularly for check-ups and cleanings.
Enhancing Healthcare Team Outcomes
The incidence of dental caries has increased significantly over the past few decades, partly due to the excess intake of added sugars. Dental caries is associated with increased morbidity: dental pain, infection, and cosmetic disfigurement, ultimately leading to premature loss of teeth. An interdisciplinary team of dentists, general practitioners, nurses, and dieticians must work together to ensure patients are well informed of the connection between proper nutrition and oral health and receive dietary advice to prevent dental caries and other systemic conditions related to poor nutrition. Healthcare professionals must also perform basic nutrition screening and assess patients' diets. Furthermore, dental hygienists can also provide dietary advice along with oral hygiene instructions. Collaboration between all these health care providers will greatly improve patients' outcomes.
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