Nutrition and Diet Flashcards

Question

what are the different Carbohydrates

Answer 1

Sugars Starches Oligosaccharides oGlucose polymers oNon-digestible oligosaccharides Fibre and non-starch polysaccharides

Answer 2

``` • Monosaccharides (one sugar molecule) o glucose, fructose & galactose • Disaccharides (two sugar molecules) o sucrose (glucose + fructose) o maltose (glucose + glucose) o lactose (glucose + galactose) ```

Answer 3

• Chains of 3+ are called oligosaccharides and are not classified as sugars but polysaccharides

Answer 4

sorbitol, mannitol, xylitol (sweetener) & lactitol  bulk sweeteners  called bulk as theyre not as sweet as sugar hence need to put more in  xylitol can lower dental caries risk (futile cycle)

Answer 5

• Energy 4.0 kcal /g Glycoproteins: sugar needed to form glycoproteins. Proteins esterified to one or more oligosaccharides containing sugars. The CHO content varies 1-85% e.g. albumin, collagen, peptide hormones and enzymes, fibrinogen, immunoglobulins Glycosaminoglycans and proteoglycans e.g. hyaluronic acid, chondroitin sulfates (in cartilage), heparin

Answer 6

confectionery, soft drinks, table sugar, biscuits and cakes, breakfast cereals, puddings and preserves.

Answer 7

• Contribute to excess energy intakes – obesity and weight gain • May cause hyperlipidemia (?) in 10-15% population - Increase in fat • Diabetics must restrict intake- TII • High intake of energy dense foods high in sugars and fats contribute to obesity, diabetes and cardiovascular disease

Answer 8

OUTSIDE THE CELL include all sugars added by manufacturer, cook and consumer, plus sugars in syrups, honey, fresh fruit juices and fruit juice concentrates. anything that is added Fruit isn’t classed as a free sugar / fruit juice is: sugar in fruit is intrinsic sugar (in cell) Advised not to eat free sugar between meals

Answer 9

INSIDE THE CELL can be consumed as much as you want, it already exists e.g. lactose in milk and fruits (all natural)

Answer 10

bit of both as drying process breaks some cells releasing intrinsic sugar

Answer 11

a-glucan polysaccharides (lots of glucose molecules joined by glucan links) Amylose (straight chain of glucose with 1,4 bonds) and amylopectin (branched) * Good sources include bread, potatoes, pasta, rice and cereals * No adverse general health effects * No deficiency states

Answer 12

oligosaccharides maltodextrins and glucose syrups

Answer 13

* Made from hydrolysis of starches | * Chains of glucose 3 units and above with some mono and di saccharides (3- oligosaccharides)

Answer 14

• Used as energy supplements, sports drinks and infant milk/foods - Lactose intolerant babies milk replaced with glucose polymers as they still need sugar (more cariogenic than lactose) • Are potentially cariogenic

Answer 15

1. Non-starch polysaccharide (NSP) - skeletal remnants of plants that resists human digestion. 2. Resistant starch 3. Resistant oligosaccharides

Answer 16

* Consists of cellulose, hemicelluloses, pectins, gums and mucilages * Not digested in upper gastrointestinal tract so passes to colon where some undergo anaerobic microbial fermentation (healthy bacteria) * NSP adds to stool bulk and stimulates peristalsis * Soluble NSP attenuates post-prandial increase in blood lipids and glucose so important for glucose homeostasis and lipid metabolism * Insoluble forms are more resistant to fermentation but bind water and increase stool mass which aids peristalsis and reduces toxin concentration * NSP increases satiety and is useful in weight loss plans

Answer 17

starch that is not digested e.g. physically enclosed in cell walls or un-gelatinised starch (e.g. green bananas)

Answer 18

* Naturally occurring and synthetic * Resistant or partially resistant to digestion in upper GI tract (non-digestible oligosaccharides (NDO)) * Resistant oligosaccharides include: fructo-; isomalto-; galactosyl-; gluco-oligosaccharides can be cariogenic. * NDO encourage growth of bifidobacteria and lactobacilli in colon which metabolise NDOs (may prevent cancer)- can ferment this bacteria in the mouth * NDO potentially cariogenic as dental plaque contains bifidobacteria and lactobacilli * May be labelled as dietary fibre

Answer 19

* Total carbohydrate intake appears to be neither detrimental nor beneficial to cardio-metabolic health, colo-rectal health and oral health * The hypothesis that diets higher in total carbohydrate cause weight gain is not supported by the evidence from randomised controlled trials * A small number of studies suggest that higher consumption of potatoes is associated with a risk of type 2 diabetes mellitus, but it is not possible to exclude confounding by other dietary variables e.g. cooking methods for potatoes such as frying. There is insufficient evidence to draw a conclusion on the association between starch intake and weight gain * It is recommended that the dietary reference value for total carbohydrate should be maintained at an average population intake of approximately 50% of total dietary energy (starch)

Answer 20

• No more than 5% of total dietary energy should come from free sugars from 2 years upwards

Answer 21

* Prospective cohort studies indicate that greater consumption of sugars-sweetened beverages is associated with increased risk of type 2 diabetes mellitus * Randomised controlled trials conducted in adults indicate that increasing or decreasing the percentage of total dietary energy as sugars when consuming an ad libitum diet leads to a corresponding increase or decrease in energy intake. * Randomised controlled trials conducted in children and adolescents indicate that consumption of sugars-sweetened beverages, as compared with non-calorically sweetened beverages, results in greater weight gain and increases in body mass index * With the proposed reduction in the population intake of free sugars, their contribution toward recommended total carbohydrate intake should be replaced by starches, sugars contained within the cellular structure of foods and, for those who consume dairy products, by lactose naturally present in milk and milk products * The complete replacement of energy derived from free sugars by these carbohydrate sources would only apply to those people who are a healthy BMI and in energy balance * In those who are overweight, the reduction of free sugars would be part of a strategy to decrease energy intake”

Answer 22

* The National Diet and Nutrition Survey published in 2014, shows that mean intake of NMES (same as free sugar) exceeded the DVR in all age groups! * 11-18 year olds consumed the greatest amount of NMES, getting 15.6% of energy from NMES, compared to their recommended amount of under 5% * So if on average 11-18 year olds are getting 15.6% of their energy from NMES * 312 calories per day 78g free sugar per day * This means in a year that’s 28,470g of free sugar (3 times more than the recommendation!) * (29 extra bags of sugar!!!!)

Answer 23

40% of free sugars came from non-alcoholic beverages: – Fruit juices – Fizzy drinks – Sports drinks 19-22% came from sugar, preserves and confectionary – Added sugar – Chocolate – Biscuits

Answer 24

• Increased intakes of total dietary fibre, and particularly cereal fibre and wholegrain are associated with a lower risk of cardio-metabolic disease and colo-rectal cancer * Adults should get around 30g/day of fibre * 2 to 5 years -15g/day * 5 to 11 years 20g/day * 11 to 16 years 25 g/day * 16 to 18 years 30g/day • No quantitative recommendations are made for <2 years, due to the absence of information, but from about six months of age, gradual diversification of the diet to provide increasing amounts of whole grains, pulses, fruits and vegetables is encouraged

Answer 25

* Randomised controlled trials indicate that total dietary fibre, wheat fibre and other cereal fibres increase faecal mass and decrease intestinal transit times * Randomised controlled trials also indicate that higher intake of oat bran and isolated β-glucans leads to lower total cholesterol, LDL cholesterol and triacylglycerol concentrations and lower blood pressure

Answer 26

• Growth and repair • Maintenance of muscle and other tissues • Hormones and enzymes • Sources include o Animal - meat, fish & dairy products o Vegetable - pulses, quorn, bread, nuts & quinoa

Answer 27

* The amount of protein needed to be in nitrogen balance * Nitrogen intake = nitrogen output * 6.25g protein = 1 g N * Body protein is continually undergoing turnover * Positive N-balance in growth/pregnancy * Negative N-balance in starvation/trauma * Guidance for intake 0.75-1.5g/kg body weight (12% calorie intake)

Answer 28

``` • 70 kg man • 1g / kg = 70g (= 280 kcal) • Protein usually provides around 12% of kcal o 30g meat - 7g o 30g fish - 5g o 1 pint milk - 20g o 30g cheese - 7g o 1slice bread 2g ```

Answer 29

12% =60kg/day * 4(kcal/gram) = 240 | 240/2000 *100 = 12%

Answer 30

extreme protein energy malnutrition • Both protein and energy are limited • Severe muscle wasting • Decreased insulin (anabolic): glucagon (catabolic) • Muscle proteins used in liver to make albumin which prevents oedema

Answer 31

* Protein is deficient, but energy intake is maintained * High insulin: glucagon * Reduced amino acids for albumin synthesis causes oedema * Water babies’ or ‘sugar babies  bloated even though are not fed

Answer 32

* Increased risk of NOMA (cancrum oris) in protein-energy malnutrition * Ulcerating stomatitis of upper gum and underlying maxilla and face and ulceration of cheeks * Occurs in malnourished impoverished children * Results in irreversible disfiguration  can be fatal

Answer 33

fat <35% (<10% saturated) free sugar 5% protein 12-15% balance- from starch, milk sugar and intrinsic sugar

Answer 34

sugars, oligosaccharides, starch, glucose polymers and fibre (non-starch polysaccharides, resistant starch and resistant oligosaccharides)

Answer 35

series of estimates of the amount of energy and nutrients needed by different groups of healthy people in the UK population. (not individual)

Answer 36

the amount of a nutrient that is enough to ensure that the needs of nearly all the population (97.5%) are being met If everyone consumes this much we can say 97.5 % of population will be getting enough of that nutrient

Answer 37

an estimate of the average requirement for energy or a nutrient. Approximately 50% of the population will need less energy or the nutrient and 50% of the population will need more.

Answer 38

the amount of a nutrient that is enough for only the small number of people who have low requirements (2.5%). The majority of the population will need more. Some people (2.5% population) will be okay on this however the rest will be below of what is needed for a healthy balanced life.

Answer 39

EAR is used for energy RNI is often used as a reference amount for population groups. LRNI is a useful measure of nutritional inadequacy.

Answer 40

fat <35% (<10% saturated) free sugar (5%) protein (12-15%) Other 45% should comes form starch, milk sugar, fibrous foods, intrinsic sugars (sugars present naturally in fruits)

Answer 41

* They have produced ‘Sugar why 5%?’ - a summary of SACN recommendations for professionals and non professionals * Visualise in cubes and teaspoons ``` BUT!!! How many teaspoons? Heaped teaspoons, flat teaspoons • 7 x 4g per teaspoon = 28g  flat • 7 x 6g per teaspoon = 42g  heaped • 12 g per day more! ```

Answer 42

The Eatwell Guide does not include references to frequency of serving and recommended portion sizes, except for: • fruit and vegetables: at least 5 portions of a variety of fruit and vegetables a day • fish: eat 2 portions a week, 1 of which should be oily • red and processed meat: limit to less than 70g per day if you usually consume more than 90g every day • fluids: 6-8 glasses a day • Limits for juices and dried fruit are also given (contain free sugar) This is consistent with government advice and is in accordance with the available evidence.

Answer 43

``` • Eat lots • Eat wholegrain if possible • Avoid frying (e.g. chips) • Avoid adding fat, rich sauces or dressings • This group includes: o Breakfast cereals o Pasta o Rice o Oats o Noodles o All types of bread ```

Answer 44

* Eat or drink moderate amounts * Choose lower fat varieties wherever possible * This groups doesn’t include butter eggs and cream * This group includes milk, cheese, yogurt and fromage frais

Answer 45

``` • Eat moderate amounts • Choose lower fat versions if possible e.g cut skin off chicken, cook without oil, avoid fish in batter • Beans and pulses are good alternatives • This group includes o Meat o Poultry and game o Fish o Eggs o Nuts, beans and pulses o Quorn and soya ```

Answer 46

structural defect in which the enamel present is HARD but DEFICIENT in amount- caused by a defective ENAMEL MATRIX formation . This alters the shape during development; pits, grooves

Answer 47

enamel matrix has been formed, but its mineralisation is suboptimal leading to opacities due to reduced mineral content and softer enamel. enamel chips post-eruptively

Answer 48

developmental defects with many causes including dietary deficiencies and difficulty during birth (neonatal line)

Answer 49

pre- pits, grooves, larger areas of missing enamel post- enamel may become stained on eruption from diet

Answer 50

* Protein – protein energy malnutrition (PEM) * Calcium - hypocalcaemia * Vitamin D – deficiency * Vitamin A – deficiency Nutritional deficiencies usually occur in undernourished communities or due to metabolic disturbances (which don’t allow nutrient absorption)

Answer 51

• Study of Guatemalan children (1977) • 43% with moderate malnutrition had hypoplasia • 73% with severe malnutrition had hypoplasia • Later research showed that a protein supplement did not reduce the incidence of hypoplasia • Feeding rat dams a protein deficient diet during pregnancy and lactation resulted in: - Poor quality and quantity of milk - Increased dental caries in pups (compared with a control group) Protein deficiency causes developmental defects and salivary gland atrophy (saliva not produced sufficiently – xerostomia patients increased caries risk)

Answer 52

* 53 children with disturbances of calcium and phosphate metabolism were studied * Vitamin D dependent rickets – Low Ca, low P – hypoplysia * Hypophosphataemia – normal Ca, low P – no hypopysia * Hypoparathyroidism – low Ca, high P – hypolysia * Therefore, low blood calcium level is associated with developmental defects in enamel * Hypocalcaemia is also common in malnourished children (diarrhoea) a low serum calcium concentration during enamel formation is a specific determinant of enamel hypoplasia

Answer 53

* Rare in industrialised countries * Often associated with PEM * Linked (alongside PEM) with enamel defects * In experiments in rats fed a cariogenic diet: Gp with vitamin A deficiency had higher levels of dental caries when compared with well-nourished rats… * Deficiency of vitamin A causes salivary gland atrophy causing less/poorer quality saliva

Answer 54

* Delayed development of teeth * Delayed eruption * Poorly aligned * Defects of enamel & dentine

Answer 55

everyone who had hypoplasia had caries | only 25% without hypoplasia had caries

Answer 56

- lower initiation and spread of caries - greater hardening of pre-carious lesions • 2-year trial in Birmingham children’s home deficiency is ONE OF the causative factors- dental caries is multifactorial

Answer 57

* Improvement children’s teeth in the UK between 1939 and 1944 – sugar wasn’t freely available * Cheap milk (calcium and vitamin D) * Cod liver oil free to pregnant and breat-feeding mothers, infants and children * Vitamins A and D were added to margarine * Calcium carbonate was added to flour

Answer 58

* Gross enamel hypoplasia - more common in India due to diarrhoea induced hypocalcaemia * Mild enamel hypoplasia - Similar prevalence in both countries due to the sunshine in India (vitamin D) overriding the effects of a poorer diet- sun does make difference

Answer 59

defects in the enamel that render the tooth more susceptible to dental caries

Answer 60

Low certainty conclusion that Vitamin D may decrease incidence of dental caries- (Hujoel, 2013)- Significant publication bias Improving vitamin D status is an additional preventive consideration to reduce caries risk • (Schroth et al., 2016)

Answer 61

* Adults, and children over the age of 1y should have 10 micrograms of vitamin D per day * Many would need a supplement to achieve this * NB: 10 micrograms is the amount in 5 sardines! * NB: in North of England the angle of the sun in the sky between October and May is too low to enable synthesis of vitamin D via the skin

Answer 62

* UK – good diet but high sugars | * Developing countries – poor diet but low sugars = cariesUK

Answer 63

* Under nutrition results in developmental defects rendering teeth caries prone * Under nutrition causes salivary gland atrophy (post-eruptive effect)

Answer 64

delays eruption of teeth which affects caries- just delays the caries some would say

Answer 65

* During enamel maturation, an excess of F- ions: * Alters the rate at which matrix proteins (amelogenins) are enzymatically broken down * Alters the rate at which the subsequent breakdown products are removed. * Fluoride may also indirectly alter the action of protease via a decrease in the availability of free calcium ions in the mineralisation environment. * Lower enamel mineralisation. Hypomineralised enamel has altered optical properties and appears opaque and lustreless relative to normal enamel.

Answer 66

very mild mild moderate severe

Answer 67

• Continued use of water with 1ppm F caused mild mottling in 10% of cases- anticaries effect  accepted amount Continued use of water with 1.7 ppm F caused mild mottling in 40-50% of cases

Answer 68

* Newcastle & area artificially fluoridated to 1ppm NaF 1969 Birmingham artificially fluoridated to 1ppm NaF since 1963 * Later research in the UK in the 1980’s showed permanent teeth: * Birmingham – 1ppm NAF in water = 59% children no mottling * Leeds – low F in water = 68% no mottling

Answer 69

no because: • Vitamin D dependent rickets – Low Ca, low P – hypoplysia • Hypophosphataemia – normal Ca, low P – no hypopysia •

Answer 70

delays eruption of teeth which delays caries developmental defects rendering teeth caries prone- hypoplasia ad hypomineralisation salivary gland atrophy (post-eruptive effect)

Answer 71

calcium - hypocalcemia showed hypoplasia in study with phosphate PEM- hypoplasia increased with protein deficiency severity, but supplement did not decrease this. also causes salivary gland atrophy Vit A- linked alongside PEM with enamel defects VitD- mild hypoplasia was the same in india and UK due to vitD from sun in india which balanced out the effects of poor diet

Answer 72

vitD- defiecny can render teeth more succeptibe to caries (hypomineralisation). vit D is preventative for caries vitA- PRE-ERUPTIVE effect on caries- Gp with vitamin A deficiency had higher levels of dental caries when compared with well-nourished rats. linked with PEM on enamel defects

Answer 73

Protein deficiency | Vitamin A deficiency

Answer 74

Diet o Natural sources- black tea/ green tea, seafood/fish (seawater contains fluoride) o Added: water, milk, salt o Manufacturing of foods can influence how much water is in foods (processing) ``` Dental products o Toothpastes (topical) o Mouthwashes (topical) o May be swallowed by children so can be systemic intake of fluoride ``` F-supplements o Tablets

Answer 75

* 90% of F is absorbed mainly in stomach as HF (passes easily across membrane) * Rapid absorption * 99% of F in body is in calcified tissues * 10% excreted in urine or faeces

Answer 76

high fat diet slows digestion and reduced rate of gastric emptying to F is in stomach for longer so absorption is increased. Positive F balance (more than 90%) - dental/skeletal fluorosis ``` Vegetarian diet- increase pH of renal tubule so more alkali which will increase urinary excretion so more elimation of fluoride so negative F balance – potential increase in caries Trivalent cation (copper/zinc) will form complexes with other divalent cations in GI tract ```

Answer 77

* Exposure to F is most reasonable explanation for the decline in caries * Excess F  fluorosis of enamel- results in mottling/opacities. Skeletal fluorosis – can end up with brittle bones. * Optimising the use of F for maximum caries prevention and minimal fluorosis is crucial

Answer 78

* Historically, thought to act by improving tooth structure (systemic effect) * The local/intra-oral action is now considered more important * Fluoride aids (re)mineralisation * Fluoride inhibits anaerobic glycolysis and subsequent acid production by oral bacteria

Answer 79

The early stages of dental caries can be prevented, reversed or arrested, primary through the elimination or modification of aetiological factors (dietary, microbial) and/or by enhancing protective factors (fluoride, sealants and salivary stimulation). Increased sugars in the diet utilized by bacteria to produce acid increasing caries risk. Topically applying fluoride can help with remineralization thus reducing the risk of dental caries

Answer 80

• sudden ingestion of large dose- fluoride poisoning • causes nausea, vomiting, diarrhoea and abdominal pain • Certain lethal dose is ~ 32-64mg/F/kg • Safe tolerated dose is 8-16 mg F/kg

Answer 81

* More common * smaller dose over long time- * affects teeth while still forming: up to 6 years, incisors up to 3 years * affects bone continually

Answer 82

0.05-0.07 mg/kg body weight per/day in children <12 years of age o Even If we go up to 0.1 mg/kg we will increase dental caries via fluorosis/ mottling of teeth

Answer 83

``` Public water fluoridation School water fluoridation Fluoridised salt (self-select, but high salt not good Fluoridised milk Fluoride drops/tablets ```

Answer 84

Topical application | Fluoride mouth rinse & Fluoride toothpaste

Answer 85

H Trendley Dean (in the 1940’s) • 7,000, 12-14 year olds from 21 cities in US states • Investigated relationship between F level in water and prevalence of dental decay – J shaped curve • Showed that water fluoridation at 1 ppm was the best balance between caries and fluorosis • Resulted in artificial fluoridation of water • Low fluoride – high risk of caries Weaver 1941 • Dentist in Lake District • Reduced dental caries in those children from South shields (1.4ppmF naturally) than those in the west and North shields • DMFT was higher in those in north shields with no water fluoridation

Answer 86

* There has been a decrease in caries over the last few decades * However, caries has been consistently lower in those from fluoridated areas * This shows water fluoridation has a positive effect even when there is exposure to fluoride from other sources, eg. Toothpaste

Answer 87

* Occurrence of dental caries shows a social class trend with lower social classes at greatest risk * Water fluoridation has a positive effect on caries levels in all social class groups but as the lower social classes have higher caries the effect is greatest in this group

Answer 88

* Systematic reviews locate, appraise and synthesize evidence from scientific literature * No association between water fluoridation and mortality from any cancer was found * Stopping water fluoridation ↑ caries to levels higher than non-fluoridated areas * Water fluoridation is effective, despite exposure to fluoride from other sources * Fluoridation of water ↓ social class trends in dental caries

Answer 89

Allows individual to control when they have fluoride- consumer choice – politically advantageous. but - Negative systemic effects - Is this positive as a public health measure?? As then not everyone exposed - Salt increases blood preassure

Answer 90

- Targeted at children when their teeth are developing - Milk is nutritious - Considered a good vehicle for fluoride but - Can cause mild fluorosis - Binding of F to calcium or protein may ↓ topical effect - Cessation of milk fluoridation associated with worsening dental health - less good evidence than for water fluoridation (But not as many people exposed so less numbers)

Answer 91

Yeung et al 2008: • Considered RCT only • Two RCTs – for primary dentition  Some individuals expose to fluoridated milk and some just to milk  Onlt 2 studies  one study showed a significant reduction in DMFT (31.3%) after 3 years o One did not • Concluded insufficient studies with good quality evidence to show effectiveness • HOWEVER: need to look at totality of evidence Systematic Review by Australian National Health & Medical Research Council 2007 • Is intentional milk fluoridation more efficacious that no milk fluoridation in the prevention of dental caries? • Considered evidence from cohort and cross sectional epidemiological studies o Milk fluoridation is beneficial – though less good evidence than for water fluoridation (But not as many people exposed so less numbers) o Cessation of milk fluoridation associated with worsening dental health o Milk F may lead to increased mild fluorosis – not considered to be of aesthetic concern rather than problematic

Answer 92

Low cost per head Free for consumers but - Individuals have no say (mass medication) - Not widespread in UK

Answer 93

• There are many fluoridated milk schemes in Thailand, Chile, UK, Bulgaria and Russia, which are primarily school-based • Fluoridated milk studies in China, Chile, Hungary,Bulgaria and Scotland have shown F milk to be effective in reducing the incidence of dental caries in young children. • Have used doses ranging from 0.5-1.5mg F per drink (daily drink) o Fluoride ingestion due to swallowing toothpaste as opposed to from the milk

Answer 94

according to their chemistry according to their digestion and absorption

Answer 95

* Sugars (monosaccharides and disaccharides) * Polyols * Oligosaccharides (malto-oligosaccharides and non-digestible oligosaccharides) * Polysaccharides (starch and non-starch polysaccharides). × This classification does not allow a simple translation into nutritional effects since each class of carbohydrates has overlapping physiological properties and effects on health.

Answer 96

There is no universal definition of the term ‘dietary fibre’. • Broadly speaking, it refers to some or all of the constituents of non-digestible carbohydrates and may also include other quantitatively minor components (e.g. lignin) that are associated with non-digestible carbohydrates in plant cell walls.

Answer 97

intrinsic- fruit, veg and grains milk sugars- naturally present in milk and milk products (ensure parents are talking about plain milk not milk shakes) Free sugars- added sugars, plus sugars in honey, syrups, fruit juices, and fruit juice concetrates

Answer 98

• Free sugars are sugars (monosaccharides and disaccharides) that have been added by a food manufacturer, cook or consumer to a food and include those sugars naturally found in fruit juice, honey and syrups. - Pure fruit better than a fruit smoothie – blending it changes composition etc. so important to ask • They do not include sugars naturally found in milk and milk products, nor in fruit and vegetables.

Answer 99

* High levels of sugar consumption are associated with a greater risk of tooth decay- leads to negative outcome * The higher the proportion of sugar in the diet, the greater the risk of high energy intake. * Drinking high-sugar beverages results in weight gain and increases in BMI in teenagers and children. * Higher BMI the higher the risk of anaesthetic * Consuming too many high-sugar beverages increases the risk of developing type 2 diabetes

Answer 100

* Cost to health services * Multiple extractions of teeth due to caries is the main reason for hospitalisation young children in England * Self esteem * Pain and anxiety * Time lost from school/work * Tooth loss and impaired health * 44% of worlds population have untreated dental caries!

Answer 101

* 31% of 5 year old children have obvious decay experience | * Mean number of teeth affected is 0.7

Answer 102

* 30% of dentate adults have dental caries * 11% of 55-66 year olds have root caries – difficult to manage (seen in elderly due to drymouth * 20% of 75-84 year olds have root caries- ageing population

Answer 103

* Dietary recommendations at a population level: * Free sugars should account for no more than 5% daily dietary energy intake. * The term free sugars is adopted, replacing the terms Non Milk Extrinsic Sugars (NMES) and added sugars. * The consumption of sugar-sweetened beverages (e.g. fizzy drinks, soft drinks and squash) should be minimised by both children and adults. * Education- are parents aware between no added sugar and sugar free difference

Answer 104

• WHO recommends reduced intake of free sugars throughout the life-course (strong recommendation). • In both adults and children, WHO recommends that intake of free sugars not exceed 10% of total energy (strong recommendation). • WHO suggests further reduction to below 5% of total energy (conditional recommendation). - Based on healthy BMI Remarks

Answer 105

* For countries with low free sugars intake, levels should not be increased * The recommendation to further limit free sugars intake to less than 5% of total energy is further based on the recognition that dental caries tracks from childhood to adulthood; in order to minimize lifelong risk of dental caries, the consumption of free sugars should be as low as possible

Answer 106

an average population intake of approximately 50% of total dietary energy

Answer 107

* starches * sugars contained within the cellular structure of foods * lactose naturally present in milk and milk products. * In those who are overweight, the reduction of free sugars would be part of a strategy to decrease energy intake. Consider: - Milk intolerance - Vegan diet

Answer 108

* PHE is aiming to provide practical steps to help people lower their sugars intake * They have produced ‘Sugar why 5%?’- a summary of SACN recommendations for professionals and non professionals * They have set new Change 4 Life - new maximum sugar intake figures

Answer 109

Does protect against dental caries | - Propolis (Bee glue) contains flavonoids and esters that decrease dissolution of enamel

Answer 110

Human intervention studies - Randomised controlled trials (gold standard) but Not realistic for dental caries - non-randomised intervention studies – open to bias Human observational studies - Cohort studies – strongest data after RCT - Population ecological studies – use per capita sugars data - Cross sectional studies – measure one point in time only - Case studies – weak evidence only suggestive

Answer 111

* Animal experiments * Enamel slab experiments (in vivo) * Plaque pH studies * Laboratory experiments (in vitro) * Alone provide insufficient evidence unless supported by data from epidemiological studies

Answer 112

* Dental caries takes several years to develop. * It is the diet several years earlier that is likely to be responsible to decay levels. Consider: working parents, children and students who may have changed eating habits * Those with dental decay may have changed habits

Answer 113

* Compare sugar availability and dental data using data from dental surveys and per-capita data on sugars availability e.g. from Food and Agricultural Organization (FAO) * Sreebny 1982: Studied data from 42 countries and showed that sugar availability accounted for 52 % of variation in caries in children aged 12 years

Answer 114

• Compare population averages for levels of dental caries with sugars (sucrose) availability at the population level (per capita) over time e.g. before and after a change in sugars availability

Answer 115

• Populations that have experienced a marked increase in dental caries on adopting a ‘westernised’ diet - • Tristan da Cunha

Answer 116

e.g. transition from primary school to secondary school (increased access to tuk shops)

Answer 117

* Change diet in one group (intervention group) and monitor dental caries increment compared with a control group * Ideally participants should be randomised into intervention and control groups * The person assessing dental health and diet should be blind to the participants group identity Difficult to get permission for- may be possible if child has a restricted diet for a health reason. Impossible to tell one group to have less than 5% and other to have more. In the systematic review NO RCT were identified. Only non-randomised trials exist for the relationship between sugars intake and development of dental caries

Answer 118

* The effect of total substitution of sucrose in the diet with xylitol or fructose * Xylitol resulted in an 85% reduction in caries

Answer 119

* Measure change in dental caries levels in a study cohort over time * Relate the change in dental caries levels to dietary sugars intake * Easy to do but ethics difficult 5 studies enabled dental caries development to be compared when sugars intake was above vs. below 10% of energy – all showed lower dental caries with sugars intake <10% energy

Answer 120

pH in mouth not recalibrated when consumed frequently * The SACN carbohydrate review concluded there was insufficient evidence on frequency of sugars intake and risk of dental caries * There is convincing evidence that frequency and amount of sugar intake are correlated - Frequency – useful at chairside - Amount – essential for dietary guidelines and policy • But Reducing frequency alone will not impact on other NCD associated with a too high intake of free sugars

Answer 121

cariogenicity of mono- and di- saccharides is similar EXCEPT for lactose (Animal studies and plaque pH studies show lactose is less cariogenic) * Turku Sugar Study showed no significant difference between development of cavities between fructose and sucrose – but there were more pre-cavity lesions with sucrose compared with fructose * Some animal studies show sucrose to be more cariogenic

Answer 122

* Sucrose is the sole substrate for extracellular glucan synthesis * Clinical evidence suggests that glucans enhance Streptococcus mutans in plaque by increasing plaque porosity which results in increased acid accumulation at the enamel surface The WHO consider all free sugars to be a risk for dental caries (all mono and disaccharides added to food by manufacturer, cook or consumer, plus those sugars naturally present in honey, syrups and fruit juices and concentrates)

Answer 123

* Fluoride reduces caries by up to 50% but does not eliminate caries * A relationship between sugars and caries exists in populations exposed to fluoride * Where there is good exposure to fluoride, sugars consumption is a moderate risk factor for caries in most people and so preventing consumption of excess sugars is a justifiable part of caries prevention if not the most crucial for aspect for most people * On its own wont solve issue- need diet improvements Method - Fluoride varnish – high risk caries children - Get them to use correct tooth pastes (age specific) – are they putting on the right amount?

Answer 124

cohort studies

Answer 125

dental caries is progressive and the effects of sugars on the dentition are lifelong

Answer 126

Turku sugar study (removing sugar from diet and replacing it with xylitol over a 2 year period) - 85% caries reduction in adults. The Vipeholm (consumption of – sugars inbetween meals) - it increased caries. - Sugars up to 4 times with meals only had lesser effect. - Withdrawing sugars stopped caries activity.

Answer 127

8 cohort studies show higher caries with higher sugars. 5 cohort studies show lower caries when intake of free sugars is<10% energy. Some low levels of dental caries occurs at <10% sugars.

Answer 128

These provide data to show that dental caries is lower when the sugars availability is below 5% or energy compared with above 5 but below 10%.

Answer 129

indirect measuremnet of dental caries as only measures acidogenicity

Answer 130

Differences in tooth morphology and salivary composition – so need caution when extrapolating findings to humans

Answer 131

measure ONE POINT in time only Current diet may be different from diet several years previously when dental caries was initiated. Only measure disease and diet at one time point

Answer 132

Do not account for confounding factors and use per capita sugars data that assumes equal consumption across population – e,g, all age groups

Answer 133

Do not provide such strong data as RCT. No all have controlled for confounding factors such as fluoride exposure, oral hygiene.

Answer 134

* Bread- 50/50 or translation to wholemeal * Potatoes * Unsweetened cereals * Rice * Pasta * Bulgar wheat * Millet

Answer 135

* Sweetened breakfast cereals * Biscuits * Cakes * Processed corn and potato snacks * Sweetened popcorn

Answer 136

* Raw starch in not cariogenic * cooked starch can cause caries but less so than sucrose * mixes of cooked starch and sugar can cause levels of caries equal to that seen with sugars alone * All diets provided in powdered form • Differences in tooth morphology and salivary composition compared with humans TAKE HOME MESSAGE - Starch is not the problem- free sugars are

Answer 137

* Laboratory incubation studies show crisps, pretzels, breadsticks, crackers and cornflakes can be hydrolysed to glucose which is metabolised to lactic acid * Enamel slab experiments show that processed starchy foods causes approximately ¼ the demineralisation seen with sugars

Answer 138

• Highly processed starch foods containing sugars produced as much acid as high sucrose products (Studies by Lingstrom and Kashket): • Breakfast cereals, bread, rice and pasta reduced plaque pH but not below critical pH and significantly less so than sucrose (studies by Pollard et al) - Depends on breakfast cereals

Answer 139

when starch intake in unaltereted or even decreased and sugars decrease- caries declines Population based studies • Starch intake increased in Japan and Norway • Dental caries decreased in all three countries Children with Hereditary Fructose Intolerance compared with controls have: • Low caries • Low intake of sucrose and fructose • Normal or higher intake of starch Turku Sugars studies (a non randomised intervention study see ND8/9) • Intake of starch was unaltered over a 2 year period and dental caries decreased when sucrose was removed from the diet Northumberland study: High starch- low sugar diet better- however not be eating as much

Answer 140

* The WHO concluded there was convincing evidence that starch rich staple foods showed no relationship with caries (WHO/FAO 2003) * Reduce frequency of free sugars- take at meal times s

Answer 141

Iowa Fluoride Study (US) • Cohort study of children studies between 5 and 8 years association between consumption of foods high in PROCESSED starch (e.g. potato crisps etc.) as snacks and development of new cavities was found -Some crisps have erosive potential (salt and vinegar), prawn cocktail (sweet) No association was found between the intake of NON-PROCESSED starchy (boiled potato, bread, rice) staple foods and dental caries

Answer 142

* If finely ground, heat-treated and eaten frequently * The addition of sugars increases the cariogenicity of cooked starchy foods. Foods containing baked starch and substantial amounts of sucrose appear to be as cariogenic and a similar amount of sucrose

Answer 143

* Advice to patient is to consume plenty starchy rich staples as not linked to caries and good for general health. * Avoid highly processed starch foods esp. those to which sugars added.

Answer 144

* Fresh fruit and erosion may be more prominent than fruit and caries - Unstable occlusion if erosion * Plaque pH – fruit consumption decreases pH but not to below critical * DEPENDS on type Fresh fruit or as a juice (orange juice) * Epidemiological studies show fruit consumption is associated with low levels of caries * S.African fruit farmer study showed higher levels of caries than grain farmers but intake was very high – 3 bunches of grapes a day.

Answer 145

fresh whole fruit is a healthy snack for children to consume (aim for 5+ fruit and vegetable portions per day). Fruit juices are high in free sugars and if consumed should be limited to one 150ml portion per day.

Answer 146

• Not all dried fruits are dried the same way - Some in honey (caries reduction) or other things added - Fresh fruits better to recommend • Traditional whole dried fruits (raisins, prunes, apricots) • Fruits where syrup and or sugar is added during the drying process (cranberries, dates, mango) • Fruit ‘leathers’ – highly processed dried fruit with added sugars • Dried fruits are not classified as free sugars. • Dried fruits are a concentrated form of natural sugars • Some claim dried fruit is retentive in the mouth – but there is not firm evidence to support this • Dried fruits are an excellent source of micronutrients and fibre • Best to consume at mealtimes

Answer 147

* Human = 7g/100g * Cow’s milk = 5g/100g Milk could be classified as cariogenic BUT lactose is the least cariogenic of the common dietary sugars- not overly worried • Also contain calcium and phosphorous which help prevent dissolution of enamel.

Answer 148

* Children breastfed >12 months have an increased risk of caries when compared with children breastfed <12 months * Amongst children breastfed >12 months, those fed nocturnally or more frequently had a further increased caries risk. * A meta-analysis of cross-sectional studies showed that breastfed children were less affected by dental caries than bottle fed children

Answer 149

greatest gain if sweetners used to replace sugars in food ingested frequently food manufacturers produce low sugars alternatives to existing sugar rich products, especially those for children

Answer 150

composed of the polyols, which are derivatives of normal sugars and exhibit carbohydrate-like structure - they are sweeter than sugar but only a few times. Need to put a lot in to get effect and often used in combination. * Sorbitol * Mannitol * Lycasin * Isomalt * Xylitol * Lactitol * Maltitol * Sucralose

Answer 151

``` range of chemical structures and are very much sweeter than sugar. Much sweeter than sugar (x200), tiny amounts needed • Acesulfame potassium • Thaumatin • Aspartame – Canderell – Nutra sweet • Saccharin • Stevia ```

Answer 152

* Plaque pH studies- in vitro (test tube) – measure pH drop when sugar added to plaque * Animal experiments- not humans, don’t have same tooth anatomy * Intervention studies (clinical trials)- most realistic/comparable to the population * Enamel slab experiments

Answer 153

* 0.5 and 0.7 times as sweet as sucrose respectively * Incubation studies: fermented slowly (how quickly they ferment) * Plaque pH studies: slight decrease in pH (not as severe as pH drop which sucrose) * Animal studies: caries occurs in rats but to a much lesser extent than with sucrose (rats don’t consume similar diet) * Enamel slab experiments: 45% extent of demineralisation caused by sucrose (nothing for sorbitol and mannitol) * Clinical trials: sorbitol is non-cariogenic

Answer 154

* Half the group has intervention and half do nothing * Three trials have compared sorbitol and mannitol containing gum on caries risk compared with no gum • Trial 1 – 3 sticks per day had no effect on 2.5 year caries increment in permanent dentition (children) Finn et al 1978 • Trial 2 – 3 sticks per day -6 % reduction in 2 year increment and 8% reduction in 3 year increment in permanent dentition (Beiswanger et al 1998) • Trial 3 – 3 sticks per day 33% reduction in 2 year caries increment with sorbitol – (Szoke et al 2001) Chewing sorbitol and mannitol will reduce caries risk compared to no gum? No. May be due to chewing action itself increasing saliva therefore increasing pH.

Answer 155

Frequent or long term use of sorbitol is unlikely to increase caries in normal people- dietary advice is its fine to chew. they dont get better at acid production

Answer 156

• As sweet as sucrose Turku study- almost total substitution of sugar with xylitol for 2 years cause 85% less caries development Clinical trials of xylitol gum have shown it to be anti-cariogenic- but is this due to saliva flow from chewing? no as tests with lozenges were also carried out

Answer 157

* 1’,4’,6’ trideoxy-trichloro-galactosucrose * A chlorinated derivative of sucrose * Manufactured as ‘Splenda’ * Widely available as a sugar alternative * Non-cariogenic in rats (Bowen et al 1990)

Answer 158

Intense sweetener * 200 x as sweet as sucrose * Non cariogenic * Uses are widespread, especially frozen * Contains phenylalanine (and aspartic acid) so cannot be used in phenylketonuria (PKU)

Answer 159

Intense sweeteners 500 times as sweet as sucrose • Inhibits bacterial growth/metabolism by enzyme inhibition- positive effect? • Used in table top sweeteners, gums and drinks

Answer 160

Intense sweeteners • 130 times as sweet as sucrose • Non-cariogenic but doesn’t inhibit caries (like xylitol) • Used in boiled sweets and preserves (withstands high temperatures)

Answer 161

• Acesulfame/saccharin gum (5 sticks per day) reduced dental caries compared with no gum but No significant difference between effectiveness of acesulfame/saccharine gum and sorbitol and xylitol gums

Answer 162

* Stevia is a sweetener extracted from the leaves of the plant species Stevia rebaudiana * The active compounds are steviol glycosides * 150 times as sweet as sugar- don’t need to add a lot * heat-stable * pH-stable * non fermentable- bacteria cant grow (can reduce sugar) * Some of its extracts may have a bitter or liquorice aftertaste at high concentrations

Answer 163

Replace sugar with sweetener e.g canderel? Replace coke to diet cokes then work on changing behaviour to different drink Fruit yoghurt- low sugar alternative yoghurt Low sugar polo mint

Answer 164

Attrition Abrasion Erosion

Answer 165

Tooth wear is described as the irreversible loss of dental hard tissues from mechanisms other than bacteria or trauma (Bartlett & Smith 2000) Erosion is the chemical dissolution of tooth structure by acids other than those caused by bacteria

Answer 166

Basic Erosive Wear Examination 0- no erosive tooth wear 1- initial loss of surface texture 2- distinct defect, hard tissue loss <50 % of surface area 3- hard tissue loss >50 % of surface (irreversible tooth loss This will become pathological due to pulpal exposure) guidance is offered depending on the different risk factors

Answer 167

Loss of function Serious aesthetic deterioration The tooth won’t survive the rate of wear Pain

Answer 168

Tooth destruction Costly restorative treatment Aesthetics Sensitivity/pain Psychological

Answer 169

intrinsic Gastro-oesophageal reflux disease (GORD) – Pregnancy - Impairments Frequent vomiting - Pregnancy - Alcoholics - Eating disorders hydrochloric acid is the issue

Answer 170

Diet | Medicines

Answer 171

Carbonic Citric ``` Vitamin C Bubbles in beverages Citrus fruits & juices Apples Cola beverages Rhubarb Grapes ```

Answer 172

``` Carbonated drinks Fruit squashes/cordials Fresh fruit juices Wine Alcopops Pickles and vinegar Chewable vitamin C tablets Fruit Fruit flavourings/ fruit teas Adding slices of fruit Tomato and chilli based foods ```

Answer 173

Hydrogen ions are dissociated from the acids when dissolved in water. Cause dissolution by either combining with the carbonate or phosphate ions in HA releasing all the ions from that region of the crystal.

Answer 174

HCL= hydrogen ions directly dissolve the mineral surface, but there is no effect from the chloride ions CA=hydrogen ion directly dissolves the mineral surface and citrate anion may interact with calcium removing it from the crystal surface - Citric acid (CA) can have double effect

Answer 175

pH value (the H+ ion concentration) titratable acidity (the total available H+ ions as the pH value changes) calcium chelation properties buffering capacity (the ability to maintain a pH at the current value) mineral content (specifically calcium and phosphate levels)- Adding minerals can reduce erosive potential

Answer 176

Quantity- more fruit/coke more erosion Frequency-between meals is bad Habits- longer you spend eating/ drinking = more tooth wear. swishing, sipping temperature- higher temps= higher erosive potential

Answer 177

``` Sportsmen Eating disorders Alcoholics Drug addicts/users of recreational drugs Pregnant women ‘Dieters’ Wine tasters Impairments ```

Answer 178

How many dietary acids are being consumed on a daily basis How many of these are between meals? Is greater than 10 minutes being spent consuming any dietary acid at a single sitting? Do they sip, swish, hold or rinse the dietary acid in their mouths prior to swallowing? Do they consume dietary acids at an increased temperature eg hot water with lemon Food diary can be done

Answer 179

``` Identify Inform Counsel/support Prevent Treat ```

Answer 180

Early diagnosis Control of aetiological factors Good baseline records Ongoing monitoring ``` Take a good case history Dietary habits Gastric disturbances Drug therapy, radiotherapy Salivary gland dysfunction Oral hygiene habits ```

Answer 181

Drink water or milk only Limit the amount and frequency If consumed drinks should be Consumed quickly and do not swish around the mouth Drank through a straw with the straw well back in the mouth Not consumed close to bedtime Avoid brushing directly after an acid attack Immediately following an acid attack with, a remineralising (fluoride mouthwash/tablets as tooth paste abrasive) or a neutralising agent (sugar free antacids)

Answer 182

Contains sugar but non cariogenic due to protective factors and low cariogenic sugars (lactose)

Answer 183

Cheese is high in saturated fatty acids Only need small amount of cheese for it to have a protective factor - can advise as fat content is neglible

Answer 184

Calcium, phosphate, casein

Answer 185

reduced ability to chewing and biting with dentures- less ability to exert force- leads to avoidance of foods that need chewing (apples, celery) -may also avoid foods with pips (grapes, tomatoes)

Answer 186

tooth loss reduced chewing function selective food avoidance (fruit and veg- tough meat) low intake of fruit, veg, and fibrous foods low intake of dietary fibre

Answer 187

Intake of dietary fibre (non-starch polysaccharide) was compared between dentate and edentulous adults- higher number of edentulous patients with a very low fibre intake Test group: 30 full-denture wearers aged 40-60 years Control group: 30 dentate (20 + natural teeth) adults aged 40-60 years

Answer 188

- Fibre - b-carotene - Fruits and vegetables - vit C Edentulous had higher intakes of saturated fat

Answer 189

* MNA score was lowest for edentulous with 1 or 0 denture | * MNA (nutritional assessment) score was highest for those with 2 dentures

Answer 190

Prosthetic rehabilitation improves chewing function but does not provide sufficient drive to change what people eat dietary advice should be given, and it must be tailored e.g. if they're vegetarian can't tell them to eat meat

Answer 191

both groups gave a high saturated fat intake- implanted patients their fat intake decreased (dietary advice) fibre intake increases for implant patients- dietary advice and increased confidence

Answer 192

loss of enjoyment of eating- negative social impact less healthy diet consumed with respect to fruits, veg, fibre and macronutrients dentist adjust denture rather than diet to overcome eating problems- patients receive little advice on what to eat dentists should support patients to change dietary behaviour- but they feel like they've not had adequate training to do this - lack of personal experience of wearing denture underpins dentists and DCPs reluctance

Answer 193

``` – Smoothies – Mushy peas/ mashed – Grate in salads – Soup – Stewed fruit – One 150ml portion of fresh fruit juice per day ```

Answer 194

``` – Weetabix with milk – Porridge – Lentil soup – Pease pudding – Dhal ```

Answer 195

– Fish is easier to chew – Minced meats e.g. turkey, chicken beef – Stews and slow cooked tender meat – Cooked pulses (dhal, soups, pease pudding, mushy peas, bean pate)

Answer 196

* Who buys the food? * Who prepares the food? * What basic cookery skills do they have? * How long does it take to eat a meal? * How appetising does food look? * What about the social aspects of eating?

Answer 197

Initiated by microorganisms in plaque – biofilm is major mediator Interaction between plaque biofilm and host immune system

Answer 198

microbial dysbiosis indvidual patient hyper-inflammatory host response microbial dysbiosis bacterial biofilm can be normal and protective – conditions lead to biofilm becoming dysbiotic – lead to change in biofilm which promotes changes towards disease-> inflammation and tissue breakdown Bacterial cells important but process is driven by hyper-inflammatory host response

Answer 199

nutrition!! microbial oral hygiene mediation so many more!

Answer 200

extracellular polysaccharides such as glucans can be harnessed from sucrose

Answer 201

impairs host innate and adaptive defences such as phagocytic function, cell mediated immunity, complement system, secretory antibody and cytokine production and function depletion of antioxidants in cells promotes immunosuppression

Answer 202

increased oral burden of free glucocorticoids (immunosuppression) impaired host defence of saliva

Answer 203

impairs normal immune response 'Rapidly progressing (aggressive) forms of periodontitis and gingivitis are most prevalent/severe in impoverished communities'

Answer 204

Severe gangrenous disease that causes a rapid necrotising destruction of soft and hard tissue of the face, including bone. Risk factors: Malnutrition Poor oral hygiene Compromised immune system – infection with measles, malaria or HIV

Answer 205

resorption of cementum and bone (animal studies) exacerbated bone loss females have '54% increased risk of periodontal disease if Ca <499mg and 27% more risk if Ca<799 mg/d compared to >800mg per day' (Nishada et al. 2000)

Answer 206

Essential for cell development, neuromuscular functioning, bone development and inflammation control

Answer 207

Major source of Vitamin D is the conversion of 7-dehydrocholesterol to Vitamin D3 via exposure of skin to UVB radiation food - oily fish - egg yolks, butter, beef - cheese, mushrooms - fortified foods

Answer 208

Gingival tissues have high folic acid requirements due to high cellular turnover rate Clinical trials of folic acid supplementation (systemic and topical) demonstrate reduced inflammation Low serum folate was independently associated with periodontal disease (Yu et al. 2007)

Answer 209

Severe Vitamin C deficiency causes scurvy –Swollen bleeding gums & tooth loss Collagen synthesis - Periodontal ligament - Bone matrix - Blood vessel walls Immune function - phagocytosis and wound healing Powerful antioxidant Epidemiological studies (observational) have shown weak negative association between Vitamin C status and chronic periodontitis

Answer 210

that low B12 levels were associated with a worsening of the periodontal status of teeth and an increased tooth loss rate (Zong et., 2016) Deficiency of vitB in the vegan diet

Answer 211

free radicals that act as host immune defence to bacterial antigens (PMLs) - however when not regulated can damage healthy tissues

Answer 212

the imbalance between damaging reactive oxygen species (ROS) and protective antioxidant (AOX) compounds Oxidative stress highlighted as having a central role in the pathogenesis of chronic inflammatory diseases

Answer 213

Reactive oxygen species (ROS) are produced in periodontitis Oxidative damage to gingival tissue, periodontal ligament and alveolar bone ROS have been implicated in the periodontal tissue destruction - both directly and indirectly via cytokine production ROS cause lipid peroxidation, protein degradation, DNA mutations and bone resorption Antioxidants buffer ROS and protect against tissue damage Low levels of antioxidants implicated in the susceptibility and progression of periodontal disease

Answer 214

Defined as molecules capable of slowing or preventing the oxidation of other molecules Exist as vitamins, minerals and other compounds in food May help to prevent disease by resisting free radicals Thought to influence periodontal disease onset, progression and wound healing

Answer 215

``` Lycopene Vitamin A Vitamin E Vitamin C Carotenoids Glutathione Iron Copper ``` ``` veg- sweet potato fruits- apricots, mango nuts- Brazil nuts seeds- sunflower oily fish meat- beef, chicken brocolli dark choc ```

Answer 216

anti-oxidant stabilise the membrane structure by terminating the free radical chain reaction Found in non-citrus fruits, nuts and seeds Suggested impact on prevention periodontal inflammation and collagen breakdown

Answer 217

Initial studies show antioxidant levels in gingival crevicular fluid (GCF) and in serum are compromised in periodontitis Niigata Study: A higher intake of dietary antioxidants was inversely related to number of teeth with periodontal disease

Answer 218

Periodontal disease is associated with low grade systemic inflammation (Janket et al., 2003) Obesity is associated with increased risk of adult periodontitis Adipocytes secrete pro-inflammatory adipokines e.g. TNF-a, IL-6 which up-regulate acute phase proteins seen in inflammation other studies Body Mass Index >30 significantly associated with risk of periodontitis in Japanese adults - obesity was second risk factor after smoking (Saito et al., 1998) NHANES data: significant relationship between BMI and waist hip ratio and periodontitis (Wood et al., 2003) Maintaining a normal BMI associated with lower risk of periodontal disease (Al-Zahrani et al., 2005)

Answer 219

undernutrition and antioxidants play a role in tissue damage and the immune response obesity is linked to gingivitis/periodontitis

Answer 220

Eicosapentanoic acid (EPA) and decosahexanoic acid (DHA) have lesser inflammatory effects compared with omega 6 fatty acids EPA found in fish can block this inflammatory pathway EPA can also stimulate the Lypooxygenase pathway for leukotriene B5 which has less inflammatory effect than B4

Answer 221

The composition of fatty acids in inflamed gingival tissue differs from healthy tissue Those with alveolar bone loss had lower serum omega 3 fatty acids (Cicek et al., 2005) Progression of periodontal disease lower in men with a higher intake of docosahexanoic acid (Iwasaki, Yoshihara, Moynihan et al., 2009)

Answer 222

Odds ratio for periodontal disease events in middle omega 3 consumers lower than the 'low group' when compared with highest tertile (reference group)

Answer 223

diet - reduce sugars and sat fats - increase fruit and veg, lean protein, nuts, seeds, oily fish and wholegrain prevention medical history lifestyle

Answer 224

Breastfeeding and appropriate complementary feeding can reduce mortality in children <5 years by 19% Breast feeding could prevent 37% of deaths in the second year of life (continue breastfeeding into second year of life)

Answer 225

WHO recommends: Immediate initiation of BF - Exclusive breast feeding for 6 months - Complementary feeding with continued breast feeding up to 2 years - Appropriate use of micronutrient supplements (e.g. Vitamin A, Iron, Zinc, Iodine) The recommendations are based on systematic review of the evidence for the effects of breastfeeding on infant and maternal health

Answer 226

Systematic review and meta-analysis 4 studies showed formula fed had higher caries and 3 showed no difference Meta-analysis of cross sectional studies (lowest quality evidence) showed breastfed children had fewer caries But All studies were susceptible to residual confounding (oral hygiene, sugars in bottle/diet, water F, preventive dental visits, on demand nocturnal feeding). Examiner may not have been blind to feeding practice CURRENT EVIDENCE suggests that breastfeeding has a greater protective effect against dental caries than bottle feeding BUT - Further cohort studies are needed to strengthen evidence- where data on confounders can be collected and included in multivariate models. - We need studies that think about confounding factors

Answer 227

12 months breastfeeding had fewer dental caries than <12 months but >12 months has increased caries risk when compared to <12 months Amongst children breastfed >12 months, those fed nocturnally or more frequently had a further increased caries risk There is a need for studies on children aged >12 months assessing caries risk in breastfed, bottle-fed and children not bottle or breastfed, with simultaneous data on all potential confounders -Breastfeeding only protects to a certain time, after this we don’t know

Answer 228

* Why are babies breast-fed after 12 months? * Are they any benefits of nocturnal breastfeeding? * Are there any nutritional advantages of on-demand infant feeding?

Answer 229

delayed maternal menses reduced risk of diarrhoea Contributes to nutrition when there is a lack of adequate complementary foods helps hydration where there is a lack of clean water - WHO advice to continue breastfeeding up to 2 in developing countries results are mixed, methodologies weak and not all studies control for confounding

Answer 230

Improves milk supply- nocturnal prolactin levels higher Contraceptive effect Reduced SIDS risk Helps ensure adequate intake Important for babies with faltering weight Promotes sleep (serotonin)

Answer 231

recommended by WHO and American Association of Pediatrics (AAP) Nutritional adequacy- increases milk flow tailored intake Hunger upsets and stresses the baby some evidence that it can regulate the baby’s body temperature and blood glucose

Answer 232

cows’ milk protein intolerant/ lactose intolerant infants, or babies allergic to lactose made with fully hydrolysed protein (for reasons above) and partially hydrolysed protein (atopy history) Contain maltodextrins or glucose syrups (cariogenic) as a replacement to lactose • Can contain sucrose and fructose (up to 20% of total CHO) Babies more exposed to (fruit) sugars compared to breastfeed/bottle fed (only exposed to milk sugars)

Answer 233

LOW OR LACTOSE FREE FORMULA - lactose free and does not contain casein. - contain glucose syrups and sucrose (caries) NUTRIENT ENRICHED POST DISCHARGE FORMULA - nutrient enriched formula for pre-term infants post discharge SOYA FORMULA- use for vegan infants and contain soya protein with vegetable fats- doesn’t have lactose sugars, has glucose polymers (increased caries risk) Parents should be advised that because free sugars are present in these infant milks that good weaning practice and oral hygiene are needed to safeguard teeth

Answer 234

phytoestrogens (risk reduced from 6 months)

Answer 235

carbohydrate which passes to large bowel which is fermented by commensal bacteria

Answer 236

* For infants over 6 months of age * Contain more protein, micronutrients (e.g. iron) and energy than infant formula but can get Good source of iron during weaning Not as regulated as those before 6 months - can contain maltodextrins and other oligosaccharides Use of follow on formula has led to a decline in cow’s milk being the main milk before 12 months No reason for follow on formula as WHO recommend breastfeeding up to 12 months so why are we changing the formula for over 6 months when breast milk doesn’t change?

Answer 237

Carbohydrate content from can range from 36-53% of energy Sucrose and fructose should provide no more than 20% total CHO This means no more than 10.6% of energy can come from sucrose and fructose

Answer 238

WHO: Follow-on formula is unnecessary and is unsuitable as a replacement for breast milk after 6 months SACN 2008: no published evidence that the use of any follow –on formula offers any nutritional health advantage over the use of whey based infant formula among infants artificially fed’

Answer 239

• Not before 6 months at all (risk of allergy & too high in minerals) • Not as main milk before 12 months (low iron) • Semi-skimmed from 2 years if overweight - Children need fat soluble vitamins • Skimmed milk – not before age 5 years • Children under 5 years need more calories from fat than older children do

Answer 240

children aged 1-5 years bottle feeding and sugar in bottle at night was associated with increased dental caries Several birth cohort studies show sugars in bottles is a factor associated with increased dental caries Sweetened milk or juice in bottles is associated with increased dental caries

Answer 241

Treat constipation: a practice that goes back centuries. <6 months cooled boiled water 1-2 a day is just as effective For >6 months prunes/pear/peach/plums/apricots/peas (soften stools) not banana/apple. Aid digestion: no theory or evidence to support Help the baby sleep/reduce pain (e.g. colic, gas): sugar water can relieve pain, however, human breastmilk also provides pain relief

Answer 242

Sleeping with a bottle increases caries oData from cohort studies show that use of a bottle during sleep is predictive of dental caries risk in children aged 3-4 years oPre-school children. Sleeping with a bottle was associated with increased dental caries oSugars in bottle given at night is associated with dental caries

Answer 243

Complementary feeding - all foods and liquids other than breast milk or infant formula Infants should be breastfed for the first 6 months of life to achieve optimal growth, development and health. Infants should receive nutritionally adequate/safe complementary foods while breast feeding continues for up to two years of age or beyond In some countries micronutrient supplements are recommended from the time complementary foods are introduced - in UK vitamins A C & D from 6 months to 5 years recommended by Dept Health Non-breastfed infants need at least 400-600ml extra fluids in a temperate and 800-1200 in a hot climate

Answer 244

• Sugars should not be added to complementary foods • Should be low in free sugars including sugars derived from fruit juices or concentrates • Unsweetened cereals, fruits and vegetables, and unsweetened yoghurts should be encouraged • There is absolutely no advantage to dental health if sucrose is replaced by other sugars such as fruit juices or fructose - Natural sugar just the same as caries risk as sucrose

Answer 245

* Milk and water should constitute most drinks. * From six months infants should be introduced to drinking from a cup * From one-year drinking from a bottle should be discouraged * Tap water when cooled and boiled is safe for infants * Bottled mineral water may vary in composition and may be too high in some minerals and trace elements * Sugars sweetened beverages should not be given - drinks contribute little to nutrient intake and may spoil the appetite * Fruit juices and herbal drinks including those designed specifically for infants are totally unnecessary from a nutritional standpoint * Drinks containing sugar substitutes are not recommended for infants and children under 3 years as they contain artificial sweeteners

Answer 246

* Appetites are small so frequent intake may be necessary * >5% energy from free sugars (3 cubes or LEVEL teaspoons) WHO * 50% energy from fat gradually reducing to 35% by age 5 * Diets with too little fat are common in those who consume fruit juices – can lead to failure to thrive (as well as dental caries risk) * Very high fibre is NOT recommended * Vitamin supplements may be advised (e.g vitamins A, D, C, iron, iodine may be recommended) - ensure sugars free.

Answer 247

* 5 small fruit and vegetable portions per day * Starch rich carbohydrate at all meals and snacks * 3 portions of dairy foods per day * 2-3 portions of meat and alternatives or 3-4 if vegetarian (eggs, nuts, pulses) * Public Health England recommend a max of 19g/d free sugars or 4 cubes for children aged 4-6 years

Answer 248

increased amount and frequency of sugared soft drinks (soda) is associated with increased early childhood caries in the US (Trinidad – 3 years & Brazil  18-42 months) • In children aged 2-6 years increased frequency of consumption sugars-containing food was associated with increased caries • In children aged 6-36 months increased sugars in the diet was associated with increased caries in children in Uganda • An increased frequency of intake of sweet snacks was associated with increased caries at age 3 years old in Trinidad • In children aged 18-42 months in Brazil, in low income areas increased sugars intake was associated with increased caries

Answer 249

* Sugar sweetened beverages * Confectionery * Sweet pastries * Fruit juices * Sucrose * Sweetened sauces * Sweetened milks – condensed milk

Answer 250

* Invert sugar * Sucrose * Glucose * Glucose syrup * Corn starch/starch solids maltodextrin maple syrup fruit juice

Answer 251

Advise to eat less

Answer 252

* National policies on free sugars in line with WHO Guideline * Taxing foods high in free sugars e.g. sugar sweetened drinks * Improved nutritional labelling of foods for sugars content * Advertising and marketing restrictions on foods and drinks high in free sugars * Reformulation of food products to reduce free sugars content * Clear food based dietary guidelines

Answer 253

• Taxing of sugars sweetened beverages exists in several countries (Mexico, France, UK from 2018, S. Africa) • Policy simulations have shown that a tax would achieve highest reduction in sugars intake in high SSB consumers - despite high consumers having less elastic demand for SSB (up to 8g per day reduction) • Imposing a tax on a high sugar product sends a health message out to consumers Sugar free products may contain maltodextrin (mixes with salivary amylase  glucose) Sugar free products may contain maltodextrin (mixes with salivary amylase to produce glucose) it is a polysaccharide; thus, it does not inherently contribute to the added sugars declaration (although one could argue that because it is easily hydrolyzed in the digestive tract that it ought to

Answer 254

* One-time motivational interviewing session to change mothers diet and oral hygiene behaviour immediately after birth of child. * After 5 years a case control analysis showed children whose mothers had participated in the intervention had significantly lower caries experience than controls

Answer 255

Intervention group received targeted dietary practices using posters and leaflets ECC was not lower in intervention group – however: - Lower ECC was observed in children of mothers who remained exclusively at same health centre using it as their source of feeding advice (sub-group analysis) - Continuous access to dietary information may protect against ECC

Answer 256

Controlled trial of an intervention for first 2 years of life, delivered in home visits Home counseling reduced incidence of ECC by 22% and severe ECC by 32% by age 4

Answer 257

soft drinks and sweets Teenagers get 22% of their daily added sugar from soft drinks and DON’T forget ACID intake!

Answer 258

no more than 30g

Answer 259

* Decrease FREQUENCY of consumption- drip feeding means pH in mouth is constantly below critical pH * Decrease AMOUNT consumed * Cut out IN-BETWEEN meal sugars and acidic drinks * Do not consume free sugars or acidic foods within ONE HOUR of bedtime (saliva flow decreases) * Chew SUGAR FREE GUM or a piece of cheese after each meal or snack – helps improve saliva production

Answer 260

* Individual advice – general with or without leaflet * Individually tailored advice (according to diet diary) * Group work (schools, care homes) * Campaigns and displays in the practice * School initiatives * Campaigning at a national level for change- sugar tax

Answer 261

• Screening: identification of those who need to change • Assessment: are they ready to change/motivated? – discuss motivation and explore barriers to change. – assess current diet – provide feedback • Desired changes: – Negotiate 2-3 changes (even if there are several more that you want to change) – Identify misconceptions – Plan in stages • Set goals for next time and write in notes (patient centred) • Monitor progress and provide feedback The three Ps: Personal, practical & positive

Answer 262

Agneda: ``` Collaborative Patient-led Flexible Individually tailored Facilitated not driven (choice of whether to change rests with the patient)- we cannot change the patient, we must jus facilitate change ``` Goal setting: Collaborative Patient-Directed Clinican Facilitated

Answer 263

* Specific * Measurable- have they done it or not * Achievable * Realistic * Timed- e.g what time of day will you do this

Answer 264

Snags: •Yes, but……. - Lack of confidence to change - Lack of motivation to change - Plans for change not put into practice

Answer 265

* Useful to tailor approach to the patient’s readiness to change. * Action talk will be counterproductive for the >80% of people who are not ready- * Role of dental professional is to facilitate change or movement in attitude towards change. * Decision to change (or not) stays with the patient.

Answer 266

* Probably the most important aspect. * Attitude open and curious. * Friendly body language and voice tone. * Reflections. * Open questions. * Important to keep relationship going well

Answer 267

* Invitation not demand. * People are influenced by what THEY say, not what you say. * Communicate in a way that encourages change talk by the patient. * Good rapport and respect is more important than pushing the change agenda. * Patient will change when they are ready, not before ‘Food and drink is really important for healthy teeth. Is this something you would be happy to talk about today?’ I they say no you must respect that ‘Reducing the amount of sugar, you eat could protect your teeth from decay. Perhaps we could talk about some changes that would help?’

Answer 268

importance and confidence How important do you think it is to make this change now How confident are you that you would be able to change What are the pro’s and cons to sticking with things as they are

Answer 269

* Reflections * Open questions * Scaling questions * Roll with resistance

Answer 270

* This is where you repeat back what the person has said * Simple or ‘between the lines’ * Aim is to show you are listening and encourage them to say more.

Answer 271

• Ask questions that allow the person to express their considered opinion. • Can be preceeded by a closed question. - Do you have any concerns about your diet?- if they answer no then this is an issue • What concerns do you have? -more likely to encourage talk

Answer 272

* Ask about importance or confidence of a particular behaviour change. * On a scale of 0 to 10, where 0 is not at all important and 10 is the most important, how important is it to you to cut down on the sugar you eat?

Answer 273

If 5 or more- What is it that makes that a 6 for you rather than a 1?- they will likely say their reasons for change for any number- What would have to change for the importance to go up a bit – say from a 6 to an 8? if 7 or more- It sounds like this is quite important for you. How confident are you that you could make a change? Would you like to talk about what you could do?

Answer 274

For people at the contemplation / ambivalent stage (likely to be the majority of patients). Rationale is that they will have plenty of experience or thinking through both sides of the argument. - Therefore in a conversation they will take the ‘other side’. Acknowledging there resistance e.g. ‘it sounds like it would just be too hard for you to think of making a change right now’ -Can help keep the relationship solid ‘on balance maybe now just isn’t the time to change anything’ Keeps relationship positive and leaves the door open to future conversations

Answer 275

* Don’t direct – facilitate * Discuss possible change – positive first * Too much too soon will confuse * If a particular aspect is difficult let it pass, don’t force the issue * Remember – change takes time!

Answer 276

* Having discussed options for change, ask the patient which they would like to agree to change * Ask them to choose 2-3 changes they think are achievable by the next visit * Write these in the notes and give patient a copy so they can be revised at next visit

Answer 277

* Giving out a food diary- limit advice before diary so its accurate * Collecting and validate what is written * Analyse the diary – e.g. free sugar intakes, snack intakes, anything in an hour of bed, food groups * Negotiate changes * Monitor changes Remember the three Ps!

Nutrition and Diet Flashcards

(302 cards)