DENT 5302 TOPICS IN DENTAL BIOCHEMISTRY 30 March 2007 Dietary factors Cariogenic Aspects of Dental Plaque Objectives: • Role of diet in dental caries • Specific, non-specific, etiological plaque hypothesis • Metabolic activities of dental plaque related to dental caries
Outline • Diet and dental caries Sugars Dietary factors Caries-protecting food • Specific vs Non-specific vs Etiological plaque hypothesis • Acid production by dental plaque bacteria • Aciduricity • Production of intra- and extracellular polysaccharides • Alkali production in dental plaque • Methods to modify plaque acidity/cariogenicity
Diet and dental caries Dietary factors Fermentable carbohydrate: Sugars and starch Downer MC. Comm Dent Health 1999;16:18-21. sucrose Positive correlation between caries experience and sucrose consumption over 50 years
Currently, weaker relationship between sugar and caries? Industrialize nations: No relationship 90 nations: +ve relationship Woodward M, Walker AR. Br Dent J 1994;176:297-302. After ~ 1985, caries decreased more than sugar consumption The frequent use of fluoride Change the impact of sugars
Oligosaccharides Sugar alcohols Sugars and dental caries. Touger-Decker R, van Loveren C. American J Clin Nutr 2003;78(suppl):881S-92S.
Questions: Myth or Fact Honey is a natural product, you won’t get caries from it. Potatoes are non-cariogenic. Beer makes me drunk, but does not cause caries. I put Splenda in my coffee, so I am safe from both calories and caries. Cough syrup can cause tooth decay. ‘Baby bottle caries’ occurs when bedtime habits include lying with a bottle filed with milk.
Dietary factors Individual factors • Amount and type of carbohydrate • Consistency • Degree of retention • ‘Caries protective' factors • Eating pattern • Intake frequency The Vipeholm Study Institution…..ethic x • Sugar • Frequently • Between meals • Consistency (‘Sticky’) Gustafsson BE et al. Acta Odontol Scand 1954; 11:232-264.
Caries-protecting factors in food ‘Sialogogue’ Chewing gum stimulates saliva • Increase the clearance of sugars and fermentable carbohydrates • Buffering capacity Polyphenols Tannins (cocoa, coffee, tea) • Interfere glucosyltransfersase activity of MS reduce plaque Xylitol Sugar alcohol used in chewing gum • Stimulate salivary flow. • Antimicrobial action ? • Clinical studies: Xylitol vs Sorbitol Favoring remineralization Calcium, phosphate, protein: Cheese and dairy products
Elderly people that eat cheese several times per week had a lower incidence of root caries. Am J Clin Nutr 61:417S-422S, 1995 Remineralization of enamel was observed when cheese and milk were used as between meal snacks. Dairy products, except sweetened yogurt, generally reduced the amount of dentin demineralization. J Contemp Dent Prac 1:1-12, 2000 Children and adolescents with low incidence of dental caries drank more milk. Eur J Epidemiol 13:659-664, 1997 Com Dent Oral Epidemiol 24:307-311, 1996
Cariogenic aspects of dental plaque Paradigm change Discussion: (group of 6-8) Is dental cariesa transmittable, infectious disease? Yes, because………………. No, because……………….. Dental caries is a multifactorial disease resulting from an ecological shift in the tooth surface biofilm (dental plaque), leading to mineral imbalance between plaque fluid and tooth, hence net loss of tooth mineral. Fejerskov, 2004
Nonspecific Plaque Hypothesis ? Current ? Specific Plaque Hypothesis 1950 2000 plaque = pathogenic Should be eliminated animal + S. mutans Caries Other animals more plaque more disease Cariogenic bacteria: mutans streptococci (MS) lactobacilli 71% of carious fissures: > 10% MS 70% of ‘caries-free’ fissures: no detectable MS ?some plaque no caries? Rampant caries: MS & lactobacilli Preventive & treatment: eliminate specific infection Antibiotics and immunization Bacteria & number of caries lesions
? Current ? 2000 Ecologic Plaque Hypothesis Marsh PD, 1994 • MS & other microorganisms = endogenous bacteria (resident of oral cavity) • No caries: lower level & stability in plaque composition (microbial homeostasis) • Change in local environment Shift the balance of plaque microflora Frequent sugar intake Repeated low pH Favors growth of cariogenic species Dental caries High proportion of MS no caries / Caries developed without MS Contribution from other bacteria: S. mutans: final pH 3.95-4.1. S. mitis, S. salivarius, S. anginosus: final pH 4.05-4.5.
Role of cariogenic microorganisms 1. Produce acid rapidly from fermentable carbohydrate (Acidogenicity) 2. Survive and continue to produce acid at acidic pH (Aciduricity) 3. Produce extracellular polysaccharides from dietary sucrose to facilitate adherence to tooth surfaces and build-up of large bacterial deposits 4. Produceintracellular polysaccharides as storage components to prolong acid formation & acidic pH
Role of cariogenic bacteria Propionic Acetic Plaque Acids Formic Succinic Lactic Cariogenic bacteria Acidogenicity Ability of bacteria to produce organic acids from fermentable carbohydrates Glycolysis (fermentation): - Anaerobic catabolism of carbohydrates - Energy production Glucose 2 lactic acids + 2 ATPs Homofermentative bacteria Produce > 90% lactic acid Heterofermentative bacteria Produce a mixture of metabolites: • Organic acids - acetic, propionic, succinic, formic • Ethanol
Role of cariogenic bacteria Aciduricity Aciduricity = Ability of bacteria to live in a low pH environment “Dental caries is a consequence of successful adaptation by oral bacteria to survive and continue to produce acid at acidic pH” Ecologic plaque hypothesis: Beginning: - Low level of MS or lactobacilli - Other bacteria produce acid Frequent consumption of fermentable carbohydrate Best acid adaptation bacteria survive (MS & Lactobacilli) Increase level of MS & lactobacilli
Proton-translocating membrane ATPase pH more acid production Increase energy demand increased glycolysis How? Maintaining intracellular pH at optimum 1. Low proton permeability of the cell membrane: cell wall thickening 2. Production of bases 3. Buffering capacity of the cytoplasm 4. Active transport of proton out of cell Zero DT.Adaptation in Dental Plaque. Cariology for the Nineties. p 333-349.
Intra & extracellular polysaccharides formation Role of cariogenic bacteria 1 2 3 Pathways of sucrose metabolism Intracellular Extracellular
Intracellular polysaccharides (IPS) • Storage form of carbohydrate: glycogen-amylopectin • Energy production and acids (by-product) when dietary CHO is depleted • Excess nutrient: Up to 20% of sucrose converted to IPS • Produced by most plaque bacteria IPS as a virulence factor: • Contribute to acidogenicity • Caries-prone plaque has prolong production of acid (e.g., after meal) from IPS storage • Contribute to aciduricity IPS Energy for ATPase Drive protons out of cell Adapt to low pH environment
Major component of interbacterial matrix • Barrier to the outward diffusion of acids from plaque Glucans Extracellular polysaccharides (EPS) • Before sucrose enters the cells, <10% of sucrose glucans & fructans Diffuse into surrounding plaque Remain associated with cell glucan fructan EPS may serve as carbohydrate storage: Fructans – degrade rapidly within a few hours, Glucans – longer period
disaccharide bond energy Glucan-binding ligands sucrose glucose (S. mutans surface ) + glucan adherence & accumulation Sucrose(not other CHO) S. mutans Fructosyltransferase Glucosyltransferase Fructans Glucans Plaque accumulation Glucosyltransferase: Virulent factor of S.mutans
sucrose glucose Question (group of 3-4) Scanning electron micrograph of S. mutans grown in glucose broth (left), and sucrose (right). The amorphous material covering the colonies is extracellular polysaccharides. From your knowledge in the synthesis of EPS, what are the main points told by these micrographs? • Sucrose, not glucose, is necessary for the synthesis of EPS. • EPS permit the bacteria to accumulate on the surface.
Role of cariogenic bacteria Fluctuation of plaque pH • Acid diffusion • Buffering capacity • Alkali from bacterial metabolism Alkalinization phase Alkali generation: End products are ammonia and/or CO2 S. salivarius, A. naeslundii, haemophili use enzyme urease to hydrolyze urea in saliva. • Ureolysis Peptostreptococci oxidize proline in amino acids and reduce protons in plaque. • Strickland reaction • Arginine deiminase system (Major source of ammonia) S. gordonii, S. rattus, S. sanguis, lactobacilli, spirochetes use enzyme arginine deiminase to catabolize arginine in diet.
Methods to modify plaque acidity/cariogenicity 1. Stimulate salivary flow • chewing gum • bicarbonate (‘baking soda’) • ammonium salts 2. Increasing plaque pH • mechanical • enzyme 3. Disrupt plaque • plant extracts • chlorhexidine • xylitol • fluoride, stannous 4. Antimicrobial agent 5. Caries vaccine • reduce lactate producer • increase lactate user (Veillonella) • increase base producer 6. Modify microflora
Recommended references • Touger-Decker R, van Loveren C. Sugars and dental caries. Am J Clin Nutr 2003;78(suppl):881S-892S. • Zero DT. Sugars – The arch criminal? Caries Res 2004;38:277-285. • 3. Marsh PD. Microbiologic Aspects of Dental Plaque and Dental Caries. Dent Clin North Am 1999;43(4):599-614. • 4. Gordon Nikiforuk. Understanding Dental Caries 1. Etiology and Mechanisms, Basic and Clinical Aspects. Basel; New York: Karger 1985. Chapters 5 & 6. • 5. Burne RA, Marquis RE. Alkali production by oral bacteria and protection against dental caries. FEMS Microbiology Letters 2000;193:1-6. • 6. Fejerskov O. Changing paradigms in concepts of dental caries: Consequences for oral health care. Caries Res 2004;38:182-191. • 7. Twetman S. Antimicrobials in future caries control? Caries Res 2004;38:223-229.