Dietary carbohydrates: their role in cariogenicity

Comparative Evaluation of Changes in Salivary pH and Streptococcus mutans Count in Saliva by Natural Sugar Substitutes: An In Vivo Study

Aim

The purpose of this study was to compare the effect of natural sugar substitutes-stevia, jaggery, and honey on salivary pH and Streptococcus mutans (S. mutans) count in saliva.

Materials and methods

Children aged between 7 and 12 years with no active carious lesion were selected. A total of 80 subjects were randomly selected and divided into three experimental groups and one control group, with 20 subjects in each group. Prior to rinsing with the respective solutions, the baseline pH and S. mutans count were evaluated for each individual. All solutions were freshly prepared whenever required. After rinsing with the respective solutions, saliva samples were collected to evaluate pH and S. mutans count. The pH was analyzed at different time intervals, that is, 0 (immediately after rinsing), 15, and 30 minutes. The S. mutans count was analyzed after 30 minutes of rinsing with the respective solutions.

Results

The results were tabulated and statistically analyzed using one-way analysis of variance (ANOVA) and post hoc tests. The results depicted that group I (stevia) showed a maximum increase in salivary pH, followed by group III (honey) and group III (jaggery) at different time intervals (0, 15, and 30 minutes). The maximum number of subjects who had shown a decrease in S. mutans count were from group III (honey), followed by group I (stevia), and group II (jaggery) after 30 minutes of rinsing with the respective solutions when compared to baseline S. mutans count.

Clinical significance

It is a universally known fact that dental caries is a multifactorial disease process, one of the key factors of which is the consumption of sugar. Of all the fermentable carbohydrates, sucrose is considered the archcriminal in the carious process. Hence, this advocates the need for developing suitable sugar substitutes that help in controlling dental caries. An ideal sugar substitute should not only minimize the risk of dental caries but also should have nutritional benefits.

Conclusion

Natural sugar substitutes (stevia, jaggery, and honey) have the ability to reduce caries risk in children.

How to cite this article

Sharma W, Bhola M, Bajaj N, et al. Comparative Evaluation of Changes in Salivary pH and Streptococcus mutans Count in Saliva by Natural Sugar Substitutes: An In Vivo Study. Int J Clin Pediatr Dent 2023;16(5):728-733.

The caries environment: saliva, pellicle, diet, and hard tissue ultrastructure

The pathogenicity of the dental biofilm is modified by salivary and dietary factors, as well as by the characteristics of the tooth structure. The composition of the acquired pellicle can modify the mineral homeostasis of the tooth surfaces and the attachment of bacteria for the development of the biofilm. The substitution of sucrose from the diet by other less cariogenic sugars and/or sugar substitutes can contribute to reducing the pathogenicity of the biofilm. Saliva clears, dilutes, neutralizes, and buffers acids produced by the biofilm. In addition, saliva provides the biofilm/tooth structure with Ca(2+) PO(4)(3-) and F(-) ions, which can positively affect the equilibrium between demineralization-remineralization toward the remineralization and modify the susceptibility of the tooth structure to caries progression.

Evaluation of the association of demographics and beverage consumption with dental caries

There is much speculation about the role of carbonated soft drinks in the development of dental caries. We examine the relationships between certain demographic variables, beverage consumption, and professional dental care and their contribution to the number of decayed, missing, and filled surfaces (DMFS). The National Health and Nutrition Examination Survey III (NHANES III) conducted by the National Center for Health Statistics was used to examine DMFS among four age groups: 17-24 yr, 25-40 yr, 41-60 yr, and over 60 yr. Age has a strong, positive relationship with DMFS. About 15% of young adults aged 17-24 yr have no DMFS, and the average DMFS is only 10.4 in this age group. Less than 1% of adults over age 40 have a DMFS score of 0, and nearly one in five has the maximum of 128 DMFS. Controlling for other factors, whites have more DMFS than do blacks and Hispanics. Beverages have a weak, but statistically significant, relationship with DMFS among the older age groups only. Regular professional dental care was associated with lower DMFS among the older age groups. Age and ethnicity are the strongest predictors of DMFS. Young adults have fewer DMFS regardless of dietary factors. This study suggests that carbonated soft drinks are not associated with poor dental health. Useful strategies to reduce dental caries involve good personal dental hygiene, regular use of fluoridated toothpastes and mouthwashes, and regular care by dental professionals.

Caries-risk assessment

Dental caries has a multifactorial aetiology in which there is an interplay of three principal factors: the host (saliva and teeth), the microflora (plaque), and the substrate (diet), and a fourth factor: time. There is no single test that takes into consideration all these factors and can accurately predict an individual's susceptibility to caries. The risk of dental caries can be evaluated by analysing and integrating several causative factors. These include caries experience (initial caries lesions and established caries defects, secondary caries and present caries activity), fluoride use, extent of plaque present, diet, bacterial and salivary activity and social and behavioural factors.

Sociodemographic and dietary factors in relation to dental health among Greek adolescents

In the context of a project aiming to assess risk factors affecting health status of Greek adolescents, 380 adolescents aged 12-17 years were randomly selected from two rural high schools of similar socioeconomic status, and from two urban schools of different socioeconomic level, namely urban/lower and urban/ higher. Dental examinations were carried out according to WHO diagnostic criteria; oral hygiene habits were recorded through personal interviews; and diet was assessed through interviewer-administered, semi-quantitative food frequency questionnaires. The percentage of caries-free adolescents varied from 24.3 in the age group of 12-13 years to 13.2 in the age group 16-17 years; mean (SE) DMFT values were 3.7 (0.3) in the younger age group and 5.9 (0.4) in the older age group whereas mean (SE) DMFS values were respectively 5.6 (0.5) and 9.9 (0.9). Multiple regression analysis-derived results showed that dental health, measured through either DMFT or DMFS indices, was significantly better among younger and male adolescents; among higher socioeconomic class urban residents; among those brushing their teeth at least once per day; and among those who had better school performance. There was evidence that intake of vegetables and milk products was associated with lower DMFS and DMFT indices, whereas there was a non-significant tendency for sugar intake to be associated with higher values of these indices. In contemporary Greek society there are substantial social inequalities with respect to dental health; these are due, in part, to differences in oral hygiene habits and patterns of dietary intakes. High risk groups should be identified among the underprivileged for targeted health education efforts and delivery of more intensive dental care services.

Dental caries, sugar consumption and restorative dental care in 12-13-year-old children in Riyadh, Saudi Arabia

A 3-day dietary history was obtained from 363 Riyadh schoolchildren aged 12-13 yr, after which their dentitions were examined for dental caries. About 16-31% of the children were caries-free and the mean DMFT varied between 1.67 and 2.43. However, in those with at least one tooth decayed, missing or filled, the mean DMFT remained constant at about 3, irrespective of age or gender; and most of the carious teeth were unrestored. There was a statistically significant relationship between DFS and the frequency of sugar consumption on the first 2 days of the dietary diary. It is suggested that the management of dental caries in the children must include the control of dietary sugar.

Effects of Weight Watchers' diet on salivary secretion rate, buffer effect and numbers of mutans streptococci and lactobacilli

The aim of this investigation was to study how a change to the dietary regimen of the Weight Watchers' (WW) affected salivary secretion rate, buffer effect and number of cariogenic bacteria. Thirty-three women joining the WW were saliva sampled at the evening prior the day of the start of the dietary regimen and after 4 and 8 wk on the dietary regimen. No significant changes were found regarding saliva secretion rate and buffer effect. A significant decrease of salivary numbers of mutans streptococci and lactobacilli occurred. Between the 4th and 8th wk of dietary regimen an increase of cariogenic bacteria occurred but not back to the baseline values. At baseline 15 of the WW carried Streptococcus sobrinus in addition to Streptococcus mutans. The total number of salivary mutans streptococci and lactobacilli was significantly higher in those subjects. In conclusion the dietary regimen of the WW, based on food choice and distributions of meals in agreement with a non-cariogenic diet, reduced the number of cariogenic bacteria in most subjects, but not in all, while the secretion rate and buffer effect remained the same.

Food cariogenicity in Americans aged from 9 to 29 years assessed in a national cross-sectional survey, 1971-74

The purpose of this study was to investigate the association between the probability of having high DMFT scores and reported consumption of eight food groups. The sample included Americans (aged from 9 to 29 years) examined during the first National Health and Nutrition Examination Survey conducted between 1971 and 1974. Analysis was restricted to comparing those individuals having DMFT scores equal to or above the 80th percentile of the DMFT distribution with those having scores equal to or below the 20th percentile of the distribution. The strongest discriminator between the low- and high-DMFT groups was the between-meal consumption of table sugars and syrups. The between-meal consumption of sugary desserts was also significantly associated with high DMFT scores. Foods to which table sugars are usually added before consumption, such as coffee, chocolate, and tea drinks, were associated with high DMFT scores in the bivariate analysis. When the same-day consumption of table sugars and syrups was accounted for, the associations became nonsignificant. The reported consumption of breakfast cereals, bread, fruit juices, ice cream, and nuts and crackers was not associated with high DMFT scores, perhaps because they were consumed only infrequently.

Epidemiologic study of dental emergencies among utilizers in an insured population in Washington, USA

This is a study of the epidemiology of dental emergencies based on information abstracted from the microfilmed dental claim forms of a large American insurance program in 1981-82. Overall, about 4% of all dental visits were classifiable as emergencies. There were significant seasonal and age variations in dental emergencies. There was no variation with respect to geographic regions in the State of Washington (USA) or sex. Paradoxically, residents in regions having fluoridated water supplies were at equal risk of developing dental emergencies due to dental caries, relative to those residing in non-fluoridated regions. There was also no difference in risk associated with insurance deductibles, although generally deductibles are thought to deter first-contact visits.

The cariogenicity of soft drinks in the United States

The cariogenicity of soft drinks was evaluated in 3,194 Americans aged 9 to 29 years who were examined during the NHANES I survey conducted from 1971 to 1974. A significant positive association was found between the frequencies of at- and between-meal consumption of soft drinks and high DMFT scores. These associations remained even after accounting for the reported concurrent consumption of other sugary foods and other confounding variables. The results of this study underscore the need for further evaluation of the relation between adhesiveness of sugary foods and dental caries and more research of the cariogenicity (or lack of it) of diet drinks. "Pure cariogenicity" is suggested as a term to apply to gram-for-gram comparisons, whereas "effective cariogenicity" also considers amount and frequency of consumption. Dentists and auxiliaries, in their dental health education, should not imply that sugary solutions are less cariogenic than sticky snacks, for there may be no difference in effective cariogenicity in modern American society.

Dental health education by "barefoot doctors"

In an insurance company 18 out of 507 employees were trained as dental health educators. They then informed their fellow workers about prevention of caries and periodontal disease in groups of about 10 persons. Two information meetings were held during a period of 10 months. Eighty-nine percent of the employees were positive to this educational programme. Twenty-two percent said that they had reduced the intake of sucrose after the first meeting. Even more persons reduced their sucrose intake later. Saliva secretion rate and buffer capacity were analyzed and the number of lactobacilli and Streptococcus mutans were determined before and after the information meetings. A significant reduction in the number of lactobacilli was found, confirming the change in carbohydrate intake. The information raised the level of knowledge about dental health among the employees. It was suggested that this type of educational programme should be used in other health areas.

Sugars and dental decay

Sugar is the principal cause of the most common disease in industrialised countries, dental caries. The sugars implicated in dental caries, in decreasing order of cariogenicity, are sucrose, glucose, and fructose; brown sugars are as cariogenic as white. The level of sugar consumption at which most of the population will not get dental caries is 15 kg/person/year. The goal should therefore be to reduce consumption to this level and below. The following policies should be introduced to achieve this goal: sugars should not be added to dietary items such as baby foods; a range of acceptable sugar-free snacks and drinks should be developed; non-cariogenic sweeteners should be substituted for added sucrose and glucose in foods, confections, and drinks; sugar-containing foods should be modified to make them less cariogenic; and the levels of added sugars in commonly used foods should be reduced. The transmission to the public of information on sugars and dental health should be improved.

Sugar and dental caries: a review of human studies

Studies of special population groups, epidemiological surveys, controlled longitudinal studies of humans, and longitudinal studies on the effect of sugar substitutes indicate that frequent or high intake of sugary foods predisposes to dental decay. The relation is not always clear-cut, and most studies have important methodological problems and limitations. Longitudinal measurements of caries increments combined with multiple dietary histories are needed to clarity the association between caries and eating habits. The relative cariogenicity of specific foods can be assessed by a combination of in vitro tests, human in vivo tests, and experimental caries in animals. Human diets, however, vary in food items eaten and the frequency and sequence of eating, and these factors can affect the cariogenicity of a food. Therefore, reported correlations must be interpreted with caution.

Nutritional Assessment

An abundant food supply has brought with it problems of overnutrition in Australia, but has not precluded problems of undernutrition and, indeed, overnutrition and undernutrition may coexist. "Dysnutrition" accounts for, or is associated with considerable morbidity and mortality in Australia. Nutritional assessment, therefore, is as important as other components of patient assessment. The approaches to nutritional assessment include: (i) identification of the individual at risk; (ii) eliciting relevant symptoms and signs; (iii) ascertaining to patients' food and nutrition knowledge and beliefs; (iv) establishing recent and remote food intake patterns: (v) anthropometry; and (vi) various laboratory investigations. The early recognition of excessive adiposity is likely to be a valuable contribution to preventive medicine. In hospital practice, the early recognition of protein energy malnutrition is likely to reduce the duration of hospital stay and morbidity and mortality rates.

Dental caries in South African black and white high school pupils in relation to sugar intake and snack habits

DMFT scores, total sugar intakes and snacks habits were determined in 1918 South African Black pupils (923 rural, 995 urban) and 724 White pupils (English and Afrikaans speaking) aged 16-18 years inclusive. Mean DMFT scores of school groups of Black pupils (both sexes) ranged from 0.9 and 2.0 in rural areas, to 4.2-6.7 in urban areas (where data were far higher than such obtained 7 years ago), and were 9.2 and 10.2 for White pupils. Corresponding mean daily sugar intake were - rural Blacks, 69 g and 97 g, urban Blacks 118-141 g, respectively (all slightly higher than previously); and Whites 102 g and 123 g. Mean DMFT scores of girls were higher than those of boys; yet while mean sugar intakes of Blacks girls and boys were somewhat similar, White girls' intakes were much lower than those of White boys. In the ethnic-sex groups studied, mean DMFT scores for pupils in upper, compared with lower, third of sugar intake, were higher in nine of the 14 sub-groups. Mean DMFT scores in upper, compared with lower, third of exposure to snack practices were higher in 11 of the 14 groups. However, most of the differences were slight. In further research, more intensive enquiries should be pursued on roles of ethnic and familial factors, as well as on roles of inter-acting dietary components additional to sugar and sugar-containing foods.

Comparison of dietary habits and dental health of subjects with hereditary fructose intolerance and control subjects

Persons with HFI follow a lifelong, self-imposed, sucrose-restricted diet in which foods containing sucrose are consumed infrequently. Our subjects with HFI had a total sucrose intake that was approximately 5% that of control subjects and had a caries score (DMFS) that was less than 10% that of control subjects. No significant differences were found in the oral hygiene status (plaque or oral hygiene indexes) of the two groups. Foods containing starch, in the absence of sucrose, are not articularly inducive to caries. The daily intake of sucrose of the control group was less than expected. Consumption of sucrose is, therefore, less than estimates calculated by per capita sucrose disappearance. We consider that caries is initiated when the sucrose content of the diet and the frequency of ingestion exceed a low limit.

Microflora and chemical composition of dental plaque from subjects with hereditary fructose intolerance

We compared the microbiological and chemical composition of dental plaque from subjects with hereditary fructose intolerance who restrict their dietary sugar intake with that of control subjects who do not. The two groups showed no significant differences in chemical composition of plaque: the mean protein, carbohydrate, calcium, magnesium, and phosphate contents were similar. Dental plaque from both groups contained similar numbers of total colony-forming units per microgram of plaque protein, and Streptococcus sanguis, an indigenous nonpathogen, was isolated with equal frequency from plaque samples of both groups. However, potentially odontopathic Streptococcus mutans and Lactobacillus were isolated three to four times more frequently from plaque samples of control subjects than from plaque samples of subjects with hereditary fructose intolerance. Clearly, diet (sucrose in particular) influences the colonization and multiplication of specific cariogenic organisms in dental plaque.