I have a few patients on 3-month recare schedules who often present with white spot lesions, semi-tenacious supragingival calculus, and extrinsic stain. They all have good self-care, brush with a power toothbrush, floss, and use mouthrinse. Could diet cause these results?
Your theory that other factors may contribute to patients' caries risk, rapid calculus formation, and stain is correct. I suggest you ask each patient to share what he or she ate over the past 3 days. To see an example of a comprehensive food recording form, visit: tryon-nutrition.com/food_journal.pdf. With this information, you can analyze each meal and snack for fermentable carbohydrate intake and determine the average number of minutes the dentition is exposed to acid. Consumption of liquids generally allows for 20 minutes of acid exposure, while solid consumption can lead to 40 minutes of acid exposure. Two hours of acid exposure per day is considered high.
Frequent consumption of carbohydrates can enhance supragingival plaque biofilm formation, and foods that stick to the tooth surface attract plaque biofilms. Increased caries risk is also a concern. All carbohydrates are fermentable; however, not all carbohydrates or eating events are cariogenic. Simple carbohydrates (eg, sucrose, fructose, lactose) have more cariogenic potential than complex carbohydrates, such as starchy foods. Unless combined with a simple carbohydrate (eg, sugar-frosted cereals) or a processed starch, as is the case with instant oatmeal, the protective nature of saliva readily neutralizes acids produced by most complex carbohydrates.1
Fruits, which are carbohydrates, have the potential to be cariogenic. Consider the infant who sips on a bottle filled with fruit juice or milk during the night or the child who carries a sippy cup through the day. Both are at risk for early childhood caries. Thus, even juice and sugar-containing milk might be cariogenic when the dentition is exposed to these liquids for long periods. Dairy products, however, also contain anticariogenic properties—including protein, phosphorus, and calcium—that protect against demineralization. In addition, consumption of hard fruits can stimulate saliva flow. In other words, when an individual consumes a glass of juice or milk or eats a whole pear, it is not cariogenic. Exceptions are sticky fruits, such as dried fruits or bananas, which can increase the risk of decay.1
The timing and sequence of intake must be considered as well. Cariogenic food or drinks consumed with a meal or snack containing a noncariogenic or cariostatic food (eg, protein, fat) will help keep the plaque pH neutral.1 Providing patients with alternate meal or snack ideas may prove helpful.1 Some of my favorite snack ideas that have low or no cariogenicity include: sugarfree gelatin or pudding; Greek yogurt; yogurt cheese; cheese and crackers; raw vegetables with a low-fat dip or hummus; fresh, frozen, or canned fruit with no sugar added or in light syrup; popcorn sprinkled with salt-free seasoning blends; nuts; and low-fat cottage cheese with berries.1
In regards to extrinsic stain, taking a liquid iron supplement or a high consumption of tea and/or coffee may contribute to greater stain accumulation. There is no evidence to support the idea that vitamin/mineral supplements or herbs encourage plaque biofilm or calculus formation. The only exception would be "gummy" or chewable versions that contain sugar.1
Stegeman CA, Davis JR. The Dental Hygienist's Guide to Nutritional Care. 4th ed. Philadelphia; Elsevier: February 2014. In press.