Oral diseases: a global public health challenge

Oral health is related to diet in many ways, for example, nutritional influences on craniofacial development, oral cancer and oral infectious diseases. Dental diseases impact considerably on self-esteem and quality of life and are expensive to treat. The objective of this paper is to review the evidence for an association between nutrition, diet and dental diseases and to present dietary recommendations for their prevention. Nutrition affects the teeth during development and malnutrition may exacerbate periodontal and oral infectious diseases. However, the most significant effect of nutrition on teeth is the local action of diet in the mouth on the development of dental caries and enamel erosion. Dental erosion is increasing and is associated with dietary acids, a major source of which is soft drinks. Despite improved trends in levels of dental caries in developed countries, dental caries remains prevalent and is increasing in some developing countries undergoing nutrition transition. There is convincing evidence, collectively from human intervention studies, epidemiological studies, animal studies and experimental studies, for an association between the amount and frequency of free sugars intake and dental caries. Although other fermentable carbohydrates may not be totally blameless, epidemiological studies show that consumption of starchy staple foods and fresh fruit are associated with low levels of dental caries. Fluoride reduces caries risk but has not eliminated dental caries and many countries do not have adequate exposure to fluoride. It is important that countries with a low intake of free sugars do not increase intake, as the available evidence shows that when free sugars consumption is ,15‐20 kg/yr (,6‐10% energy intake), dental caries is low. For countries with high consumption levels it is recommended that national health authorities and decision-makers formulate country-specific and community-specific goals for reducing the amount of free sugars aiming towards the recommended maximum of no more than 10% of energy intake. In addition, the frequency of consumption of foods containing free sugars should be limited to a maximum of 4 times per day. It is the responsibility of national authorities to ensure implementation of feasible fluoride programmes for their country.

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Diet, nutrition and the prevention of dental diseases

Objective: The purpose of this review was to study the prevalence and incidence of edentulism and tooth loss in European countries.

Material and method: A literature search was performed by means of Medline/PubMed using various combinations of keywords concerning prevalence and incidence of tooth loss and edentulism, complemented by a hand search. Inclusion criteria were cross-sectional and longitudinal clinical and questionnaire studies of representative or random samples of ≥100 subjects at the initial examination. Sixty articles were identified; the hand search gave 13 more references.

Results: This literature review demonstrated that there is a lack of epidemiological studies on edentulism and tooth loss in many countries in Europe. The quality of available data varied considerably. There is a documented decline of edentulism with still great differences in prevalence between countries, between geographical regions within countries and between groups with various backgrounds. The mean number of lost teeth increases with age. In several countries many dentate subjects aged 60 years and over still have reduced dentitions possibly needing prosthodontic treatment. The incidence of tooth loss is low but with geographical variation between age groups, and there is a trend for decreasing incidence over the last decades. A great number of variables are associated with tooth loss, and there is no consensus whether dental disease related or socio-behavioural factors are the most important risk factors. Institutionalised elderly people have, in general, more compromised oral health, including fewer teeth, than those at the same age living freely.

Conclusion: Tooth loss and edentulism are declining at least in those European countries where reliable data are available. However, the WHO goal of retaining at least 20 teeth at the age of 80 years has not yet been met but is being approached in some countries.

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What are the prevalence and incidence of tooth loss in the adult and elderly population in Europe

 Define evidence based medicine.  Identify the grades of the hierarchy of evidence.  Identify some of the topics included in the toolkit for prevention.  Identify advice that should be given to prevent caries in under 3 year olds.  Identify advice that should be given to prevent caries from aged 7 and young adults.  Identify key points of good dietary advice.  Identify risk factors of periodontal disease.  Identify sources of acid that may lead to tooth wear.  Pass an assessment, scoring over 70%.

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Delivering better oral health: an evidence-based toolkit for prevention

Dental caries is a highly prevalent chronic disease and its consequences cause a lot of pain and suffering. Sugars, particularly sucrose, are the most important dietary aetiological cause of caries. Both the frequency of consumption and total amount of sugars is important in the aetiology of caries. The evidence establishing sugars as an aetiological factor in dental caries is overwhelming. The foundation of this lies in the multiplicity of studies rather than the power of any one. That statement by the British Nutrition Foundation's Task Force on Oral Health, Diet and Other Factors, sums up the relationship between sugars and caries in Europe. There is no evidence that sugars naturally incorporated in the cellular structure of foods (intrinsic sugars) or lactose in milk or milk products (milk sugars) have adverse effects on health. Foods rich in starch, without the addition of sugars, play a small role in coronal dental caries. The intake of extrinsic sugars beyond four times a day leads to an increase risk of dental caries. The current dose-response relationship between caries and extrinsic sugars suggests that the sugars levels above 60 g/person/day for teenagers and adults increases the rate of caries. For pre-school and young children the intakes should be proportional to those for teenagers; about 30 g/person/day for pre-school children. Fluoride, particularly in toothpastes, is a very important preventive agent against dental caries. Toothbrushing without fluorides has little effect on caries. As additional fluoride to that currently available in toothpaste does not appear to be benefiting the teeth of the majority of people, the main strategy to further reduce the levels of caries, is reducing the frequency of sugars intakes in the diet. Dental erosion rates are considered to be increasing. The aetiology is acids in foods and drinks and to a much lesser extent from regurgitation.

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Dietary effects on dental diseases.

Adult dental health survey

The 1998 Adult Dental Health Survey, published this year, showed that the number of people without teeth should fall over the next three decades, to only 4% of the UK population. Patterns of tooth loss and retention are also changing. This article, the first of a series on the interpretation of the Adult Dental Health Survey, discusses the implications of these trends for dentistry.

Total tooth loss in the United Kingdom in 1998 and implications for the future.

Knowledge of the extent of dental disease gives a clinical indication of the experience of dental problems but it does not necessarily reflect the problems that people experience as a result of their dentition. It is becoming increasingly appreciated that the way a disease affects people's lives is just as important as epidemiological measures of its prevalence or incidence. The 1998 Adult Dental Health survey is the first of the decennial series of UK adult dental health surveys to use and report a measure of the self-perceived impact on people of the dental and periodontal diseases and other oral conditions. Over half (51%) of dentate adults said they had been affected in some way by their oral health, and in 8% of cases the impact was sufficient to have reduced their quality of life.

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The impact of oral health on people in the UK in 1998

CHILDREN'S SURVEY Background The 2003 Children's Dental Health Survey is the fourth in a series of decennial national children's dental health surveys. Aims This paper reports the survey-derived estimates of dentinal caries experience of children aged five, eight, 12 and 15 years, considering the trends over recent decades and the position in 2003 following changes in disease presentation and the use of additional criteria. Methodology A representative UK sample of children in the four specified age groups were invited to participate in a clinical dental examination in school. A total of 12,698 children were sampled and 10,381 were examined (82%). Examinations were undertaken in school by trained and calibrated examining teams using reclining chairs and portable lights, the criteria were visual, limited to dentine caries and no diagnostic aids were employed. In order to compare trend data with 1993 and earlier surveys the criteria allowed the re-classification of the full 2003a results (those including cavities and visual dentine caries - D3cvMFT/d3cvmft) according to the previous criteria to produce results labelled 2003b (those restricted to dentinal cavities - D3cMFT/d3cmft). Results and conclusions The experience of obvious dentinal caries in children within the UK has continued to change over the last decade and patterns are different for the two dentitions. While continuing overall improvements are evident for permanent teeth across the UK (D3c for 15-year-old children falling from 42% in 1983, via 30% in 1993 to 13% in 2003 for example), trends amongst those experiencing dentinal caries are more concerning and there have been no statistically significant improvements for primary teeth (the mean number of teeth with obvious dentine decay (d3c) at age five years being 1.3 in 1983 and 1.4 in both 1993 and 2003). The inclusion in the criteria of visual dentinal caries resulted in higher estimates of mean caries and mean caries experience in the permanent dentition (at age 15 years D3 increasing from 0.2 to 0.8, D3MFT increasing from 1.6 to 2.0 for example) but not the primary dentition (where the estimates for % d3mft at age five years were identical at 43%). Geographic variations also persist across the UK (% with D3cvMFT at 12 years being 41% for England, 54% Wales, 73% Northern Ireland and 43% for the UK; % with d3cvmft at age 5 years: 41% for England, 52% Wales, 61% Northern Ireland and 43% for the UK). These survey results have implications for planning and for daily practice, but must be interpreted carefully acknowledging the specific survey conditions and diagnostic criteria employed.

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The dentinal caries experience of children in the United Kingdom, 2003.

The latest of the decennial surveys of the United Kingdom was undertaken in 1998 by the Office of National Statistics in collaboration with the dental schools of the Universities of Birmingham, Dundee, Newcastle and Wales. Dentate adults in 1998 have fewer missing teeth and more sound and untreated teeth on average than in 1978. The average number of decayed teeth has dropped significantly from 1.9 in 1978 to 1.1 in 1998. The average number of filled teeth has remained fairly constant over the same time but its distribution has changed quite markedly towards older adults having more filled teeth than people of a similar age in the past whilst the reverse is true for younger adults. The overall trends are encouraging, but there is a need to review the way disease is managed in adults in the United Kingdom.

Jan Steele

Papers

Adult dental health survey

Total tooth loss in the United Kingdom in 1998 and implications for the future.

The impact of oral health on people in the UK in 1998

The dentinal caries experience of children in the United Kingdom, 2003.

The condition of teeth in the UK in 1998 and implications for the future.