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et al. (1994) also showed that the levels of digestion and absorption of two sugar alcohols (sorbitol
and isomalt) were dose dependent, which can inluence digestive tolerance. A double-blind cross-
over study performed in 59 healthy volunteers has shown that an acute oral intake of 30 g of MTL
in milk chocolate resulted in no signiicant increase in reported digestive symptoms, except for mild
latulence (Koutsou et al. 1996).
In conclusion, it seems that the gastrointestinal intolerance of sweeteners exists and symptoms
and severity depend on a number of factors such as the type and amount of sweetener, the way of
administration (acute or continuous), or even the mode (solid or liquid) and time of ingestion. If all
these factors are considered, taking into account the individual characteristics of the person/patient,
the symptoms of carbohydrate malabsorption can be kept to a minimum.
11.3 DeNtaL heaLth
Diet plays an important role in preventing oral diseases, including dental caries, dental erosion,
developmental defects, oral mucosal diseases, and, to a lesser extent, periodontal disease. Moynihan
(2005a) provided an overview of the evidence for an association between diet, nutrition, and oral
diseases. Undernutrition increases the severity of oral mucosal and periodontal diseases and is a
contributing factor to life-threatening noma (a dehumanizing oro-facial gangrene). Undernutrition
is associated with developmental defects of the enamel, which increase susceptibility to dental car-
ies. Dental erosion is perceived to be increasing. Evidence suggests that soft drinks, a major source
of acids in the diet in developed countries, are a signiicant causative factor (Moynihan 2005a). This
section will focus on dietary and behavioral factors as well as on sugar-replacing substances that
inluence the incidence of dental caries.
11.3.1 Dental Caries
Dental caries occurs because of the demineralization of enamel and dentine by organic acids
formed by bacteria in dental plaque through the anaerobic metabolism of dietary sugars (Moynihan
and Petersen 2004). Convincing evidence from experimental, animal, human observational, and
human intervention studies shows that sugars are the main dietary factor associated with dental car-
ies. Despite the indisputable role of luoride in the prevention of caries, it has not eliminated dental
caries, and many communities are not exposed to optimal quantities of luoride. The risk of dental
caries increases with the intake of nutritive sweeteners; however, this risk does not work indepen-
dent of oral hygiene and luoridation (Navia 1994). The classic evidence supporting the role of sugar
in dental caries in humans includes studies that are readily recognizable by name—the Vipeholm
Study, the Turku Sugar Study, World War II Food Rationing, the Hopewood House Study, Tristan
da Cunha, Hereditary Fructose Intolerance, Experimental Caries in Man, and Stephan Plaque pH
Response. The Vipeholm Study remains one of the most important contributions in the dental lit-
erature and deinitively established that the more frequently sugar is consumed, the greater the risk
becomes and that sugar consumed between meals has a much greater caries potential than when
consumed during a meal (Zero 2004).
The extent of dental decay is measured using the primary/permanent-dentition decayed, miss-
ing, and illed teeth (dmft/DMFT) index. This is a count of the number of teeth in a person's mouth
that are decayed, illed, or extracted. The dmft/DMFT indices are widely used for the indication of
the prevalence of dental caries and the severity of dental caries experience in populations. Dental
diseases—caries and periodontal disease—result in tooth loss, and therefore, the dental status of a
population may also be assessed by looking at the proportion of the population who are edentulous
(have no natural teeth; Moynihan and Petersen 2004). In 1982, the World Health Organization
(WHO) and the Fédération Dentaire Internationale (FDI) jointly set out global goals for oral health
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