Dental Tribune Nordic Edition No. 3, 2016

09 Dental Tribune Nordic Edition | 3/2016 TRENDS & APPLICATIONS Worldwide, 60 to 90 per cent of schoolchildren and nearly 100 per cent of adults have dental caries, making untreated tooth decay the most common oral condition.1, 2 Caries and periodontal disease share many risk factors with non-communicable diseases, in- cluding tobacco use, high sugar intake and lack of exercise.3 Therefore, behavioural changes are needed to decrease the risk of de- veloping these diseases. For caries specifically, the frequency and amount of sucrose consumption should be reduced.4 This improve- ment in dietary habits would be beneficial to general health as well. In some cases, such as studies on food intake, body weight maintenance,glycaemicresponse, serum lipid profiles, blood pres- sure and the effects of sucrose- containing medication, sucrose or sucrose-containing products are still used as a comparator in clinical studies.5, 6 In dental caries- related randomised clinical trials, the use of sucrose as a comparator can be considered unethical, as the correlation between sucrose consumption and caries incidence is well established. Consequently, many of the studies investigating the association between sucrose consumption and caries are cross- sectional or population studies. To date, there are few non- randomised interventions and cohort studies that have evalu- ated this. A recent meta-analysis on studies from as early as the 1950sfoundthatcollectivelythese studies showed that oral health outcomes improved as sucrose consumption was reduced.4 Diet and nutrition can affect tooth de- and remineralisation in both protective and destructive ways. Frequentconsumptionofferment- able carbohydrates increases acid production and favours aciduric bacteria and thus caries develop- ment, but a healthy diet, low in added sucrose and high in cal- cium, fluoride and phosphate, can benefit mineralisation.7 Therefore, in addition to clin- ical trials evaluating the cario- genicity of foods using compara- tors other than sucrose, different ways of estimating the cariogenic- ity of foods or food ingredients are needed. These include animal trials, enamel slab experiments, plaque pH evaluation and labo- ratory methods.8 Animal, mostly rat, caries experiments provide the means to control diet or single food ingredients carefully.9 Animal studies have been used to evaluate frequency and amount of sucrose consumption, starch and milk cariogenicity, and frequency of fruit consumption in relation to caries.10 If possible, it is suggested that animal trials should be combined with plaque pH or intra-oral methods to gain more information.8 Intra-oral or enamel slab models utilise ap- pliances with real or modelled enamel or dentine that are kept in the oral cavity by volunteers. Periodically, the appliances are placed in experimental solutions, and then caries development re- lated factors are measured.9 The benefits of enamel slab experi- ments include the presence of saliva, oral microbiota and masti- cation, in addition to test prod- ucts. The cariogenicity of foods like cheese, starch and cookies has been evaluated using enamel slab methods.8 The plaque pH method, which is a means of following the pH of the plaque during and after eating, is another useful tool for evaluating acidogenicity of food items.9 It should be noted that acidogenicity is not equal to cario- genicity, as foods or food ingre- dients may also have possible protective factors.10 In addition to all the above- mentioned methods, laboratory models of varying degrees of complexity exist. In these models, depending on the research ques- tion, there may be no bacteria present or they may be pure cul- ture studies or multispecies mod- els or use salivary microbes in the model. These models cannot evaluate caries development per se, but factors that increase the risk of caries, including demin- eralisation, acid production, oral pathogen growth and microbial dysbiosis. Studies on determining the cariogenicity of foods and food ingredients are limited. Most re- search has focused on sucrose, var- ious sucrose-containing products, starch and alternative sweeteners, such as polyols. Evaluations of dairy products and fruits have been performed too.10 Among the polyols, xylitol has received inter- est since the 1970s when the Turku sugar studies were performed.11 Xylitol is used widely as a sugar substitute. It is not metabolised by mutans streptococci, thus substi- tuting sucrose with xylitol reduces the substrate for acid-producing Evaluating the cariogenicity of food ingredients By Krista Salli, Finland Figs. 1a & b:(a) Schematic diagram of the dental simulator.28 1. Reservoir for artificial saliva/artificial saliva with test substances. 2. Inlet pump. 3. Simulation vessel with constant stirring and added bacteria. 4. Sample collection during simulation. 5. Outlet pump. 6. Waste. (b) Photograph of the dental simulator. +4 °C +37 °C 2 1 5 6 3 4 A. Fig. 2: The author presenting her latest research at the FDI Annual World Dental Congress in Pozna´ n in Poland. “Diet and nutrition can affect tooth de- and remineralisation in both protective and destructive ways.” 2 1a 1b 34

Dental Tribune Nordic Edition No. 3, 2016

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