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Diet, Fluoride, and Dental Caries Wendell Evans BDS MDS DDSc FICD Population Oral Health 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 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 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 p. H Critical p. H for tooth enamel dissolution 10% glucose rinse Dental plaque p. H Critical p. H for tooth enamel dissolution Minutes Jenkins GN. The physiology and biochemistry of the mouth, 4 th Edition. Oxford: Blackwell Scientific Publications, 1978. Page 388.

 Jenkins GN. The physiology and biochemistry of the mouth, 4 th Edition. Oxford: Jenkins GN. The physiology and biochemistry of the mouth, 4 th Edition. Oxford: Blackwell Scientific Publications, 1978. Page 389.

The Vipeholm Study of Diet and Dental Caries Gustafsson et al. (1954). The Vipeholm 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 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 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 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 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 2 0 Lilienthal et al Med J Aust, June 1953 12 10 HOPEWOOD HOUSE 2 0 Lilienthal et al Med J Aust, June 1953 4 DMFT of children aged 6 – 9 years 6 BOWRAL, NSW 8 New Sydney Zealand Bowral

Lilienthal et al Med J Aust, June 1953 Lilienthal et al Med J Aust, June 1953

The Tennessee Study Weiss RL, Trithart. Between meal eating habits and dental caries experience 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. 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. 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 The cariogenicity of refined carbohydrates

Beck DJ, Bibby BG. Acid production during the fermentation of starches by saliva. Journal 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 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 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 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 • 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. 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 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 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.

(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 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 The Melbourne Study

Pit and fissure surface caries risk estimates Pit and fissure surface caries risk estimates

Effect of cheese Eating cheese following consumption of a sugary snack (pears in sugary Effect of cheese Eating cheese following consumption of a sugary snack (pears in sugary syrup) prevented the depression of plaque p. H whereas drinking sugared coffee following pears consumption further depressed p. H.

Rugg-Gunn et al. The effect of different meal patterns upon plaque p. H n Rugg-Gunn et al. The effect of different meal patterns upon plaque p. H n human subjects. British Dental Journal 139: 151 -156, 1975.

Effect of war time diet During WW 2, severe rationing of sugar occurred. Caries Effect of war time diet During WW 2, 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 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, 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 ☻ 13 th most abundant element in the earths crust (WHO, 1984) ☻ Fluorine ☻ 13 th 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 1. 2 ppm Source: Mc. Clure FJ. Water fluoridation: The search 0. 0 ppm 1. 2 ppm Source: Mc. Clure 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 0. 1 ppm 1. 0 ppm 1. 2 ppm Permanent teeth DMF reductions at Grand Rapids after 10 and 15 years of fluoridation. Source: Mc. Clure 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 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 3 rd edition. Oxford: Oxford University Press, 38, 1996.

Australian 12 -year-olds Australian 12 -year-olds

The effect of water fluoridation The combined effect of water fluoridation and fluoridated toothpaste 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 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 Evans 1, Water fluoridation in the Blue Mountains reduces risk of tooth decay RW Evans 1, A Hsiau 1, PJ Dennison 1, A Paterson 2, and B. Jalaludin 2 Australian Dental Journal 54: 368 -373, 2009

Primary teeth Caries experience of lifelong residents aged 6 – 8 years Blue Mountains Primary teeth Caries experience of lifelong residents aged 6 – 8 years Blue Mountains 2. 58 a Hawkesbury Mean dmft 1. 10 0. 69 b 1993 2003 a = 135% more than Hawkesbury at baseline b = 73% less than Hawkesbury at baseline A = RW Evans 1, A Hsiau 1, PJ Dennison 1, A Paterson 2, and B. Jalaludin 2 1 Community Oral Health and Epidemiology, 2 Formerly NSW Health 0. 71

Primary teeth Percent of lifelong residents aged 6 – 8 years with no decay Primary teeth Percent of lifelong residents aged 6 – 8 years with no decay 72% 71% 62% 38% 1993 Blue Mountains Hawkesbury RW Evans 1, A Hsiau 1, PJ Dennison 1, A Paterson 2, and B. Jalaludin 2 1 Community Oral Health and Epidemiology, 2 Formerly NSW Health 2003

PERMANENT TEETH Caries experience of lifelong residents aged 9 – 11 years Blue Mountains PERMANENT TEETH Caries experience of lifelong residents aged 9 – 11 years Blue Mountains 0. 87 a Mean DMFT Hawkesbury 0. 58 0. 36 0. 22 b 1993 a = 50% more than Hawkesbury at baseline b = 75% less than Hawkesbury at baseline RW Evans 1, A Hsiau 1, PJ Dennison 1, A Paterson 2, and B. Jalaludin 2 1 Community Oral Health and Epidemiology, 2 Formerly NSW Health 2003

PERMANENT TEETH Percent of lifelong residents aged 9 – 11 years with no decay PERMANENT TEETH Percent of lifelong residents aged 9 – 11 years with no decay 87% 81% 71% 61% 1993 Blue Mountains Hawkesbury RW Evans 1, A Hsiau 1, PJ Dennison 1, A Paterson 2, and B. Jalaludin 2 1 Community Oral Health and Epidemiology, 2 Formerly NSW Health 2003

Fluoride toothpaste Fluoride toothpaste

The Cochrane Database of Systematic Reviews Fluoride toothpastes for preventing dental caries in children 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 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 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 Fluoride varnish

The Cochrane Database of Systematic Reviews Fluoride varnishes for preventing dental caries in children 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 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 The role of diet in caries prevention – an ecological model

Dietary challenge Caries risk For a given dietary challenge, risk of caries at any 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 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 Better oral hygiene For reduced dietary challenge Better access to Better use of fluorides Better oral hygiene For reduced dietary challenge 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 Better oral hygiene For reduced dietary challenge Scope to reduce Better use of fluorides Better oral hygiene For reduced dietary challenge Scope to reduce caries risk is limited 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.