Sucrose and starches are the predominant dietary carbohydrates in modern societies. While the causal relationship between sucrose and dental caries development is indisputable, the relationship between food starch and dental caries continues to be debated and is the topic of this review. The current view of dental caries etiology suggests that in-depth evaluation of the starch-caries relationship requires the consideration of several critical cariogenic determinants: (1) the intensity (i.e., the amount and frequency) of exposure of tooth surfaces to both sugars and starches, (2) the bioavailability of the starches, (3) the nature of the microbial flora of dental plaque, (4) the pH-lowering capacity of dental plaque, and (5) the flow rate of saliva. Studies of caries in animals, human plaque pH response, and enamel/dentin demineralization leave no doubt that processed food starches in modern human diets possess a significant cariogenic potential. However, the available studies with humans do not provide unequivocal data on their actual cariogenicity. In this regard, we found it helpful to distinguish between two types of situations. The first, exemplified by our forebears, people in developing countries, and special subject groups in more modern countries, is characterized by starch consumption in combination with a low sugar intake, an eating frequency which is essentially limited to two or three meals per day, and a low-to-negligible caries activity. The second, exemplified by people in the more modern societies, e.g., urban populations, is characterized by starch consumption in combination with significantly increased sugar consumption, an eating frequency of three or more times per day, and a significantly elevated caries activity. It is in the first situation that food starches do not appear to be particularly caries-inducive. However, their contribution to caries development in the second situation is uncertain and requires further clarification. Although food starches do not appear to be particularly caries inducive in the first situation, the possibility cannot be excluded that they contribute significantly to caries activity in modern human populations. The commonly used term "dietary starch content" is misleading, since it represents a large array of single manufactured and processed foods of widely varying composition and potential cariogenicity. Hence, increased focus on the cariogenicity of single starchy foods is warranted. Other aspects of starchy foods consumption, deserving greater attention, include the bioavailability of starches in processed foods, their retentive properties, also in relation to sugars present (starches as co-cariogens), their consumption frequency, the effect of hyposalivation on their cariogenicity, and their impact on root caries. The starch-caries issue is a very complex problem, and much remains uncertain. More focused studies are needed. At present, it appears premature to consider or promote food starches in modern diets as safe for teeth.

This communication reviews the effects of short-chain carboxylic acids on human cells of importance to the periodontium. The central hypothesis is that these acids can alter both cell function and gene expression, and thus contribute to the initiation and prolongation of gingival inflammation.Short-chain carboxylic acids [CH3-(CH2)x-COOH, x < 31 are metabolic intermediates with a broad range of apparently paradoxical biological effects. For example, lactic acid (CH3-CHOH-COOH), a 3-carbon alpha-hydroxy-substituted acid, is widely recognized for its cariogenicity. Lactic acid, however, also occurs in tropical fruits, and is the active ingredient in a variety of anti-wrinkle creams developed by dermatologists. In marked contrast, the unsubstituted 3-carbon propionic acid (CH3-CH2-COOH) is used as a food preservative and is the active principle for one class of non-steroidal anti-inflammatory agents. Interestingly, the addition of one carbon to propionic acid dramatically changes the biological effects. The unsubstituted 4-carbon butyric acid (CH3-CH2-CH 2-COOH) is used by hematologists as a de-differentiating agent for the treatment of sickle cell anemia, but by oncologists as a differentiating agent for cancer chemotherapy. Finally, acting either individually or in concert, these acids can increase vascular dilation. Clearly, these acids, while metabolically derived, have a number of very divergent activities which are cell-type-specific (Fig. 1).It may be telling that periodontal bacteria produce these acids in millimolar concentrations, and that these bacteria can be characterized by their acid production profiles. It is no less interesting that these acids occur in the gingival crevices of human subjects with severe periodontal disease at millimolar levels which are > 10-fold higher than those found in mildly diseased subjects, and are undetectable in healthy subjects. Further, when applied directly to healthy human gingiva, short-chain carboxylic acids stimulate a gingival inflammatory response and inflammatory cytokine release, At the cellular level, these acids inhibit proliferation of gingival epithelial and endothelial cells, and inhibit leukocyte apoptosis and function, but can stimulate leukocyte cytokine release. At the molecular level, these acids can stimulate neutrophil gene transcription, translation, and protein expression. Thus, the likelihood is high that these acids, in addition to their cariogenic activity, can promote and prolong gingival inflammation.Our challenge will be to identify the cell or cells of the periodontium which respond to short-chain carboxylic acids, to delineate their responses and the molecular mechanism(s) of these effects, and to categorize the aspects of the inflammatory components which damage and those which protect the host. With this information, it may be possible to begin to rationally identify and test pharmaceutical agents which diminish the harmful aspects, while enhancing the beneficial components, of the inflammatory response.

Tea decoctions prepared from a number of black and green teas inhibited amylase in human saliva. Black teas gave higher levels of inhibition than green teas, and removal of tea tannins with gelatin led to the loss of inhibitory activity from all decoctions. Streptococcal amylase was similarly inhibited by tea decoctions. Fluoride was without effect on amylase. Since salivary amylase hydrolyzes food starch to low molecular weight fermentable carbohydrates, experiments were carried out to determine whether tea decoctions would interfere with the release of maltose in food particles that became entrapped on the dentition. Subjects consumed salted crackers and rinsed subsequently for 30 s with black or green tea decoctions, or water. Maltose release was reduced by up to about 70% after rinsing with the teas. Black tea decoction was significantly more effective than green tea, in agreement with the in vitro data. The observations supported the hypothesis that tea consumption can be effective in reducing the cariogenic potential of starch-containing foods such as crackers and cakes. Tea may reduce the tendency for these foods to serve as slow-release sources of fermentable carbohydrate.

Earlier studies (Kashket et al., 1991) showed that particles of high-starch snack foods remained longer on the teeth than those of high-sucrose, low-starch foods. The question arose whether the prolonged presence of food particles enhances cariogenicity. A study was undertaken to measure sugars, starches, and metabolic acids in retained food particles. Subjects consumed portions of different foods, and particles were removed from all bicuspids and first molars at defined times after swallowing. Dry weights, sugars, and short-chain carboxylic acids were determined. High-sucrose foods were cleared rapidly from the teeth, while high-starch foods were retained for up to 20 min. Sucrose, glucose, and fructose persisted in the retained particles. Particles of high-starch foods accumulated maltose and maltotriose, presumably from the breakdown of starch by salivary amylase. At maximum, maltose plus maltotriose constituted 94% of total sugars in particles of potato chips; corresponding values in doughnuts, peanut butter cookies, and salted crackers were 43, 51, and 61%, respectively. Total fermentable sugars in the particles of high-starch foods were similar to those for the high-sucrose confectionery products. Carboxylic acids accumulated within the particles, presumably due to the fermentation of the sugars by entrapped salivary micro-organisms. At maximum (5 to 7 min), acetic, formic, lactic, and propionic acids rose 17-, 30-, 15-, and 1.3-fold, respectively, in doughnuts, and to smaller degrees in potato chips, salted crackers, and chocolate-caramel-peanut bars. In summary, the study demonstrated the persistence of sugars, the progressive accumulation of starch breakdown products, and the fermentation of the accumulated sugars in retained food particles. The findings support the view that high-starch foods contribute to the development of caries lesions.

When dental health professionals advise that sticky foods be avoided, it is left to the consumer to choose correctly among different foods. In this study, comparisons were made among consumer ratings of stickiness of 21 commercially available foods and objective measurements of tooth retention of each of the foods. No correlation was found between the two, and neither the rates of clearance of food particles from the teeth nor the rates of clearance of food-derived sugars from the saliva correlated with ratings of food stickiness. Cookies, crackers, and potato chips were most retentive, whereas caramels, jelly beans, raisins, and milk chocolate bars were among those poorly retained. Clearance rates appeared to vary inversely with initial retention. However, chocolate-caramel bars exhibited high initial retention and a very rapid rate of clearance from the teeth. The findings show that consumers cannot accurately assess the retentiveness of foods and, thus, the advise simply to avoid sticky ones is inadequate.