第16章 P351

INTRODUCTION


The increase in dental caries prevalence among people ingesting moderate to high sucrose-containing diets is related to the bioavailability of sucrose to the plaque flora. Certain plaque organisms such as S. mutans and lactobacilli are able to exploit this bioavailability and progress from being supplemental members of the plaque flora to becoming indigenous members of this flora (See "Host-Parasite Interactions" in Chap. 4). The ascent of these organisms to numerical prominence in the plaque in most instances is synonymous with the transformation of the plaque from a noncariogenic plaque to a cariogenic plaque. An obvious treatment stratagem would be to prevent the emergence of these organisms. As this emergence appears to be sucrose dependent, then tactics which reduce sucrose bioavailability should be effective preventive and therapeutic measures. This treatment strategy was recognized and clinically verified some forty years ago. However, because of l) the difficulty in changing dietary habits, 2) the desirable characteristics of sucrose as a calorie source, 3) the obvious marketability of sucrose-containing products, 4) the safety regulations concerning foods, and 5) the hedonistic appeal of sucrose in food products, the control of dental caries by sucrose restriction has not been successful in clinical dentistry, except in rare instances. In this chapter we shall examine caries control measures based upon dietary approaches.

簡介

對於喜愛中等到高蔗糖含量的飲食會造成蛀牙的增加，這和蔗糖對於牙菌斑群的生物利用度有關。特定的牙菌斑微生物例如S. mutans和lactobacilli可利用這生物利用度，將牙菌斑群的supplemental members轉變成indigenous members (可見第四章的宿主-寄主交互作用)。在大部分例子中追溯這些微生物到站牙菌斑裡的大多數，是和將從非蛀牙的牙菌斑轉換成蛀牙牙菌斑是相同的。最直接的治療方法就是阻止這些微生物的出現。而這些微生物的出現看起來是和蔗糖有關，所以策略是要降低蔗糖的生物利用度且應具有有效之預防及治療較果。這治療政策應被認定和臨床上認定已四十年了。然而，因為1) 改善飲食習慣上困難 2) 蔗糖的理想特質被作為卡洛里的來源 3) 在市面上顯著的含蔗糖物質 4)食物之安全管理規定 5)快樂主義者易被食物裡的蔗糖所吸引，然而限制蔗糖攝取去控制蛀牙，除了少數例子外在牙科臨床上尚未成功。這這個章節我們會依據飲食來檢視控制蛀牙方法。



DIETARY COUNSELING

Dietary counseling to prevent and/or control any chronic disease such as dental caries, obesity, cardiovascular disease and diabetes, among others, has not been remarkably effective. The situation with dental caries is complicated by the youthful age of the patient and the ambiguous messages which the patient has already received concerning the "banned" sugar-containing items. He knows from personal experience that the high sucrose- containing products not only look good but are quite pleasant tasting. He may have been rewarded with such a sucrose item for good behavior or performance during the early formative years of his life. In fact, the sucrose eating pattern may have been acquired by (imposed on) the infant from the mother's sweet preferences (See Table 16-5). The older youngster perceives that sucrose is an energy food and certainly satisfying after exertion. The dentist's efforts to counteract all of these positive and immediate feelings concerning sugar with a distant threat of a toothache are essentially irrelevant to the patient. For at least these reasons, dietary counseling as a means of preventing decay in the average patient is not likely to be successful. Dietary counseling can be of therapeutic value, however, when the patient has clearly misused sucrose-containing foods and presents with a rampant caries situation

飲食諮詢

飲食諮詢去預防或是控制任何慢性疾病，例如蛀牙、肥胖、心臟血管疾病和糖尿病，對於這些並無明顯的有效性。蛀牙會因病人年幼的年紀而複雜化，還有病人已被輸入接受禁止吃含糖食物的含糊訊息。小朋友以個人經驗知道高糖分食物不僅外觀好看，而且有很好的口感。在年幼時有可能因行為或是表現良好因而接到含蔗糖的食物。事實上，蔗糖攝取形式可能是受母親喜愛吃甜食上所影響(見表16-5)。較年長的小朋友認為蔗糖是補給能量的來源並且會得到滿足感。而醫師所努力倡導，卻和吃甜食所得的正向快感背道而馳，而會蛀牙的威脅對病人無立即性的威脅。

因為上述這些原因，在一般病人身上，以飲食諮詢做為預防蛀牙是不太可成功的。飲食諮詢是有治療的價值，然而，當病人錯誤吃含蔗糖的食物，並表現出猛爆性蛀牙的情況。



Misuse of Food

Malnutrition is most often conceptualized to situations of under-nutrition. However, in modern industrialized societies malnutrition is more appropriately assigned to situations of over-nutrition. Thus we have health problems that relate to excesses of calorie intake, alcohol intake, sodium intake, fat intake and sucrose intake. Excessive sucrose intake has been linked to obesity, to cardiovascular disease and to mental disorders, but in no instance is the evidence for linkage as conclusive as in the relationship between dental caries and sucrose intake. (See "Nutritional Factors" in Chap. 11).

錯誤的飲食

錯誤的營養常被誤以為是營養不足。然而在現在這工業化社會錯誤的營養是指營養過剩。因此可能會因有攝取過多卡路里、酒精、鈉、脂肪和蔗糖，因而有健康的問題。過多蔗糖攝取會造成肥胖，心血管疾病和心理上缺失，然而這些關聯並不是絕對的，不像蛀牙和蔗糖攝取的關係(見11章的營養因素)



Yet even in regard to dental caries, the sucrose has to be misused. This misuse relates, 1) to the rapid replacement of traditional foods by high sucrose-containing foods, 2) to the increased frequency with which high sucrose-containing snack foods are eaten between meals, and 3) to the excessive indulgence in these snack foods for primarily hedonistic purposes. These misuses while not condoned by the food industry appear in certain instances to be encouraged by advertising practices.

即使會造成蛀牙，蔗糖依然被濫用。這樣濫用是因為1)用含高蔗糖食物來快速取代傳統食物，2)增加餐與餐之間吃高蔗糖含量的頻率，3) 為了當快樂主義者，過度沉溺於甜食中。這樣的濫用不會被食物公司所赦免反而還會用廣告來促銷。



Man evolved protective mechanisms against plaque acid production on the tooth surfaces that were within the context of food being consumed at a restricted frequency. Natural foods contain mostly macromolecular nutrients that are not rapidly degraded or solubilized in the oral cavity. The microbial acids that are formed as these nutrients pass through the oral cavity are diluted in the saliva, neutralized by salivary buffers and cleared from the mouth by swallowing. The efficacy of this protective system is verified by the low caries incidence of people who consume low-sucrose diets. These mechanisms can be overwhelmed when sucrose becomes the predominant nutrient in the food item. Thus the explosive epidemic of caries among nonindustrialized people who switched from natural foods to high-sucrose foods. (See "Nutritional Factors" in Chap. 11). This substitution is counterindicated in terms of dental health and would constitute a form of food misuse.

在食物上為了去對抗牙菌斑所產的酸，所發展出的保護機制是要去限制的頻率。天然食物含有大部分的大分子營養物，這樣才不會在口腔裡快速被分解或溶解。當這些營養物被唾液稀釋，並經過口腔被唾液中緩衝劑中和，並經吞嚥由口中清除。這個保護機制的效率可被吃低蔗糖食物的低蛀牙率族群所認同。而這些機制會隨蔗糖成為食物裡主要的營養物而被湮滅。在非工業性國家裡的人們，將天然食物轉成高蔗糖食物時，會有爆炸性蛀牙的發生(可見11章的營養因素)。這樣的取代危害到牙齒的健康並且造成食物上的濫用。





The Vipeholm study indicated that when high levels of sucrose were consumed at meal times, the caries incidence increased only slightly (Table 11-10). Accordingly, the argument can be made that sucrose when added to foods or when consumed with foods is not particularly cariogenic. This suggests that non-sucrose foods contain factors or elicit factors which minimize the access of sucrose to the plaque flora. Studies have shown that certain foods prevent or overcome the pH drop in plaque associated with exposure to sucrose (See "Foods Which Reduce Plaque Acid Production" in this chapter). These findings tend in some quarters to allay some of the concern associated with the industrial addition of sucrose to many food items that are consumed at mealtimes.

在Vipeholm的研究裡指出當在吃飯時間時吃含高蔗糖食物，其蛀牙發生率只有些微增加(表11-10)。 因此爭議點可以說當蔗糖添加在食物裡或是當我們所吃的食物不會特別容易引起蛀牙的發生。這建議非蔗糖性食物可包含或引起將低蔗糖接觸到牙菌斑群。研究指出當蔗糖暴露在牙菌斑時，在特定食物下可阻止酸鹼值的下降。這樣的發現使食品公司建議將這些含蔗糖的產品和吃飯時一起食用。

Sucrose-containing foods are so attractive and relatively inexpensive that they have evolved into a peculiarly unique modern food entity called a snack food. Snack foods apparently are devoid of food protective factors and as they are designed and promoted for frequent consumption, they are particularly cariogenic. Their acceptance in the American market is well documented by the multiplicity of such products. Desserts would comprise one class of high-sucrose foods that traditionally were consumed at the conclusion of a meal. In this location their potential cariogenicity could be muted by the salivary flow elicited by the mastication of the meal. In recent years desserts and other snack-type foods have been increasingly consumed between meals (Table 16-1). This temporal shift has transformed desserts into decidedly cariogenic food items and represents an example of food misuse.

含有蔗糖食物非常吸引人且又不貴，他們演進成現代的點心食物。現在的點心通常都缺乏保護因子並被設計成可經常攝取，這些都非常容易蛀牙的。這樣的食物因為其多樣性廣泛地被美國市場接受。甜點應該在餐點的最後才上。如此的安排才可以讓咀嚼食物的唾液中和這易蛀牙的特性。在這近幾年甜食和其他種類的零食食物在餐與餐之間攝取的頻率大大增加(表16-1)。這樣的轉變將甜食轉變成易蛀牙的食物，這也是食物錯誤使用的例子之一。



Snack foods are misused when a parent or other authority figure conditions, pacifies or rewards youngsters for any type of compliant behavior with the gift of a high-sucrose product. The milk-bottle baby syndrome represents a flagrant example of such. Children who are sent to bed with a bottle containing a high-sucrose beverage or with a high-sucrose snack often develop rampant caries. Some of this sucrose during its transit time in the mouth is sequestered by the plaque organisms forming both acids and polysaccharide polymers. Saliva flow decreases during sleep and actually appears to cease when the individual is in deep sleep. On the tooth surface the plaque organisms degrade the reserve polysaccharides, forming acid. This acid in the absence of saliva accumulates in the plaque causing the pH to fall to levels where the tooth mineral is solubilized. Under these conditions the plaque levels and proportions of S. mutans increase significantly. In this fashion bedtime ingestion of high-sucrose foods becomes particularly cariogenic. The situation is analogous to rampant caries secondary to xerostomia only in this instance, the xerostomia is physiologic due to sleep.

零食會誤用通常和用高蔗糖含量的食品來讚賞小朋友良好的行為有關。而乳牙的奶瓶性蛀牙即是很好的例子。小朋友若睡前喝高蔗糖含量的飲料或是點心通常會造成猛爆性蛀牙。在這段時間裡蔗糖在口內被牙菌斑物質分解成酸和polysaccharide polymers.唾液流量會在睡覺時減少或是在沉睡時停止分泌。在牙齒表面的牙菌斑微生物分解polysaccharide成酸性物質。這些酸性物質使酸鹼值往下降，使牙齒礦物質變成可溶解。在這樣形況下牙菌斑和S. mutans的量都上升。所以在睡前吃高蔗糖含量的食物會特別容易蛀牙。這樣的形況就像口乾症容易引起蛀牙，唯一不同的是口乾症是因睡覺所造成之生理性。







Sucrose has highly desirable taste characteristics, which accounts for its widespread ingestion by the public. In certain usages, such as the between-meal eating of candies, the sucrose consumption appears to be mainly for hedonistic purposes. Any overindulgence in high-sucrose foods for nonnutritional purposes usually predisposes to a rampant caries situation. This type of sucrose misuse can be identified by a diet history and corrective dietary therapy such as sucrose restriction and/or the appropriate usage of sucrose substitutes can be initiated (See Chap. 17).

蔗糖因有很好口感的特質，所以才可以廣為大眾所接受。在餐與餐之間吃甜食最主要是因為可得到快樂。任何過度沉溺於高蔗糖食物而不是以營養為主通常會造成猛冒蛀牙。這樣如此的濫用蔗糖可以從限制蔗糖或是適當地用蔗糖開始 (見17章)