664 BRITISH DENTAL JOURNAL, VOLUME 187, NO.

12, DECEMBER 25 1999

RESEARCH
dental caries
reduced the enamel demineralisation caused by sucrose rinses.
3
More recently, a study of 179 children aged 7 to 9 years, showed that
consumption of 5 g of cheese following breakfast for a period of
2 years was effective in reducing caries.
9
In one extensive dietary
survey it was shown that children who were caries-free consumed sig-
nificantly more cheese than children who were more caries-prone.
10
Cheese is a good gustatory stimulant of salivary flow: consump-
tion of a lump of cheese following a sugary snack almost abolishes
the usual fall in plaque pH which follows sugar consumption.
1,11,12
However, the gustatory effect of cheese on saliva flow only partially
accounts for its cariostatic action because the caries-reducing prop-
erty of cheese is effective in desalivated animals.
13
The calcium concentration of dental plaque is an important
determinant of the balance between enamel de- and remineralisa-
tion because the rate of dissolution of the enamel hydroxyapatite is
determined chiefly by the level of saturation with calcium and phos-
phate ions of the environment of the tooth. Increasing the calcium
concentration of the environment of the tooth disfavours de- and
favours remineralisation. The calcium, but not the phosphate con-
centration of dental plaque increase significantly following the con-
sumption of uncooked cheese on its own.
13
These observations
suggest that changes in the calcium concentration of plaque follow-
ing cheese consumption are one measure of the effectiveness of the
cheese in reducing enamel demineralisation.
14
Calcium would be
expected to diffuse most readily into plaques with a low calcium
concentration because the concentration gradient between saliva
and plaque is greater than with plaques high in calcium. This possi-
bility warrants investigation because individuals who are prone to
caries tend to have low mean plaque calcium concentration
14
so,
if the calcium entering plaque from cheese is a factor affecting
caries, cheese might be most effective on those most caries-prone.
Evidence supports the theory that the release of calcium ions
from cheese and the diffusion of these ions into plaque is a major
cause of the protective effect of cheese, by preventing demineralisa-
tion or by promoting the remineralisation of enamel.
The data reported on the cariostatic properties of cheese refer to
the effect of uncooked cheese on its own, following a meal or snack.
The aims of the present study were:
To investigate if cheese-containing cooked meals are effective in
increasing plaque calcium concentration
To compare the relative effect on plaque calcium concentration
of: cheese-containing cooked meals; cheese-free control meals;
and cheese consumed alone
To compare any changes in plaque calcium concentration between
ObjectiveEating cheese by itself increases plaque calcium
concentration which is probably one mechanism of the well-
established action of cheese in reducing experimental caries. The
objective of the present study was to determine whether
consumption of cheese as part of a cooked, mixed meal (ie as it is
habitually consumed) is able to increase plaque calcium
concentration.
Design Plaque samples were obtained from 16 adult volunteers
before and 5 minutes after consumption of either a 15 g cube of
cheese, one of two cheese-containing test meals, or one of two
control meals. Each subject tested each of the four meals on a
separate occasion. Plaque calcium concentration was measured
using atomic absorption spectrophotometry.
Results The test meals increased plaque calcium concentrations
to a significantly greater magnitude than the control meals
(P < 0.05). A non-significant trend was observed towards a larger
magnitude of change in plaque calcium concentration in the
8 subjects with the lowest, compared with the 8 subjects with the
highest baseline concentration.
Conclusion The findings suggest that cheese-containing meals
increase plaque calcium concentration and thus probably protect
against dental caries.
Several lines of evidence have shown that consumption of a cube of
cheese following carbohydrate foods may protect against dental
caries, probably by increasing the plaque calcium concentration
14
and the pH of plaque.
1
However, cheese is not usually consumed
alone following a meal and it is not known whether cheese, as it is
habitually consumed, as part of a cooked mixed meal, is protective.
Further information on the cariostatic potential of cheese in a
mixed meal is required to enable dental health professionals to give
sound, consistent advice on the role of cheese in caries prevention.
The first evidence for a cariostatic effect of cheese showed that
feeding cheese to rats resulted in reduced caries.
58
The intra-oral
cariogenicity test (ICT), in which subjects wear appliances contain-
ing enamel slabs, have also shown that chewing of cheese or dipping
the appliances into an aqueous cheese extract, several times per day,
1
Lecturer in Nutrition,
2
Senior House Officer,
3
Emeritus Professor of Oral
Physiology, The Dental School, Framlington Place, Newcastle upon Tyne NE2 4BW
REFEREED PAPER
Received 03.03.99; accepted 04.08.99
British Dental Journal 1999; 187: 664667
The cariostatic potential of cheese:
cooked cheese-containing meals
increase plaque calcium
concentration
P. J. Moynihan,
1
S. Ferrier,
2
and G. N. Jenkins,
3
BRITISH DENTAL JOURNAL, VOLUME 187, NO. 12, DECEMBER 25 1999 665
RESEARCH
dental caries
those subjects with low compared with high baseline calcium con-
centrations. The overall aim was therefore to investigate if cheese
consumed in the usual way, cooked and mixed with other foods is
effective in increasing plaque calcium concentration
Method
Subjects
Ethical consent for the study was obtained and written consent was
obtained from all participants. Sixteen adult volunteers (eight males
and eight females) aged 19 to 21 years, were recruited from the
undergraduate students in Nutrition and in Dentistry. Before each
experimental session, subjects were asked to refrain from oral
hygiene for 48 hours to enable dental plaque to collect on tooth sur-
faces. Subjects fasted for 2 hours prior to each experiment to ensure
a near neutral oral pH at baseline.
Test and control meals
The cheese-containing test meals were:
Pasta in cheese sauce
Chicken breast rolled and filled with cheese and ham.
The corresponding control meals were:
Pasta in mushroom sauce
Chicken breast rolled and filled with mushrooms and ham.
The meals included a standard weighed portion of green salad,
garlic bread and unsweetened tea or coffee, containing 20 ml
of milk.
A 15 g cube of Red Leicester cheese (chosen because its dark
orange colour enables it to be distinguished from plaque) was eaten
on one occasion by each subject as a positive control. All meals were
prepared the evening before the experiment and were stored refrig-
erated and re-heated in a microwave for 3 minutes prior to con-
sumption. All ingredients and meal components were weighed to
the nearest gram to ensure each portion was as far as possible, iden-
tical in composition. The total weight of each meal was calculated to
enable the calcium concentration and content of each meal to be
determined using the values presented in 5th edition of Mc Cance
and Widdowsons The Composition of Foods.
15
All test meals con-
tained 15 g of cheese per portion.
The pasta test meal had the highest calcium content, however, the
cheese cube had the highest calcium concentration. The pasta control
meal contained more calcium than the chicken test meal (Table 1).
Experimental procedure
A baseline plaque sample was collected by removing all visible plaque
from the upper right- and lower left-hand quadrants of the mouth
using a blunt ended spatula and avoiding obvious food debris. Plaque
was not collected from all four lower incisors as the plaque from this
region, being close to the salivary glands, has a very high calcium con-
centration and any small differences in the amount of plaque sampled
from this area in the pre-and post-meal samples could have a marked
influence on the results. Subjects then consumed one of the meals.
Immediately following consumption, a 250 ml glass of mineral water
(naturally containing 90 mg calcium/L) water was consumed to clear
food debris from the mouth. After 5 minutes, a second plaque sample
was collected from the lower right-hand and upper left-hand quad-
rants of the mouth. Samples were immediately placed in a pre-
weighed Eppendorf tube, which was sealed and quickly placed on ice.
At the end of the experimental session, all tubes were re-weighed and
stored frozen at 20C until analysis. All subjects tested the cheese
cube and each meal on five separate weekly occasions and the order in
which the subjects tested each meal was randomised.
Analysis of plaque calcium concentration
The wet plaque samples were freeze-dried and weighed. Dried
plaque samples were suspended in EDTA (sodium salt), with thor-
ough agitation on a vortex mixer, to give a final EDTA concentration
of 0.375%. A series of standards were prepared using calcium car-
bonate in distilled water which ranged in concentration from 5 to
20 g/ml. EDTA was added to standards to achieve a final EDTA
concentration of 0.375%.
Plaque calcium concentration was measured in duplicate on the
plaque suspension using an IL Atomic Absorption Spectropho-
tometer, with an Orion calcium lamp in an air settling mixture at a
wave length of 422.7 nm, as outlined in the manufacturers manual.
This method gives good within- and between-day reproducibility,
for which coefficients of variation of 4% and 5% were obtained,
respectively. Each run included a range of standards and blanks and
an internal standard prepared from a pooled plaque sample to
enable any between day variation of analysis to be corrected for.
Results were expressed as g calcium/mg dry weight plaque.
Statistical methods
Inspection of the results showed a non-Gaussian distribution for
the majority of the data and therefore non-parametric methods of
statistical analyses were used. The median (and range) pre- and
post-consumption plaque calcium concentrations were determined
for each meal and for cheese alone. Wilcoxon signed ranks test was
used to determine the significance of the differences between cal-
cium concentration in the pre-consumption and post-consump-
tion plaque samples. The Mann-Whitney two-sample test was used
to test the difference in change in plaque calcium concentrations
between the various meals. The magnitude of change in plaque cal-
cium concentration was compared between the eight subjects with
the highest and the eight subjects with the lowest baseline plaque
calcium concentrations using Mann-Whitney two-sample test. An
alpha level of 0.05 was set for all statistical tests.
Results
Table 2 presents the median (and range) plaque calcium concentra-
tions of the 16 subjects before and following consumption of the test
and control meals and for the cheese cube control. Baseline plaque
calcium concentrations ranged from 1.1 g/mg dry weight to
9.1 g/mg dry weight, and the median baseline value did not differ
significantly between the meals tested. Plaque calcium concentra-
tion significantly increased following consumption of the cheese
cube and the pasta (P = 0.001) and chicken (P = 0.004) test meals,
but did not increase significantly following consumption of either
of the control meals. On consumption of the cheese cube, 15 of the
16 subjects showed an increase in plaque calcium concentration and
one subject showed a decrease. Three of the subjects showed a
decrease in plaque calcium on consumption of the pasta test meal
and four of the subjects showed decreases in plaque calcium on con-
sumption of the chicken test meal. Ten subjects showed decreased
plaque calcium concentrations on consumption of the chicken con-
trol meal and five on consumption of the pasta control meal, with
no change in plaque calcium concentration for one subject.
The cheese cube appeared to have the most marked effect on
plaque calcium concentration, increase was 112% compared with
Table 1 The calcium content (mg/portion) and the calcium
concentration (mg/100 g) of the test and control meals and
of the 15 g neat cheese control
Meal Calcium content Calcium concentration
mg/portion mg/100 g
Cheese cube 108 720
Pasta with cheese sauce 395 97
Pasta with mushroom sauce 289 69
Chicken filled with cheese and ham 264 62
Chicken filled with mushroom and ham 157 36
Values calculated from food tables
15
666 BRITISH DENTAL JOURNAL, VOLUME 187, NO. 12, DECEMBER 25 1999
61% for the pasta test meal and 50% for the chicken test meal. How-
ever, the differences in the increase in plaque calcium on consump-
tion of the cheese cube compared with those of the pasta test meal or
the chicken test meal failed to reach statistical significance (P = 0.07
and P = 0.08 respectively).
The median value for change in plaque calcium concentration
was greater for the group of eight subjects with the low, compared
with the group of eight subjects with the high, baseline values for
both test meals. These differences, however, failed to reach statistical
significance, (Table 3).
Discussion
The critical point of this study was the finding that cooked cheese,
consumed diluted as part of a mixed meal was able to statistically
significantly increase plaque calcium concentration. Previous stud-
ies have investigated only the cariostatic properties of uncooked
cheese consumed alone.
In the present study, the increase in plaque calcium concentration
on consumption of a cheese cube was 112%, which is higher than
previously reported values.
2
However, this is probably accounted
for by the weight of the cheese cube consumed, which in some stud-
ies has been as low as 5 g.
2
The baseline values obtained for plaque calcium concentration
on the first visit made by the subjects (4.2 (1.17.4) g/mg dry
weight) are similar to those previously reported for students and
for children aged 11 years (4.5 g/mg and 3.8 g/mg dry weight
respectively)
18
and for children aged 11 to 14 years (5.5 g/mg
dry weight).
14
The range of baseline values obtained in the pre-
sent study is narrower than previously reported
14
which may
reflect the standardisation procedures employed (such as a period
of abstinence from oral hygiene and period of fasting prior to
each experiment).
The cheese cube gave the largest median increase in plaque
calcium concentration although this greater magnitude of increase
did not reach statistical significance. It is of note that, in the subjects
with the high baseline scores (Table 3), the cheese cube gave a
median increase in plaque calcium twice that observed with the
cheese meals. However, these differences failed to reach statistical
significance possibly because of the small sample size.
The findings of the present study show that even following sub-
stantial dilution of cheese with other meal components, and heat
treatment of cheese, cheese is still effective in significantly increas-
ing plaque calcium concentrations. It is recognised, however, that
only two cheese-containing meals were tested and it is possible that
some food components, other than those tested in the present study,
may reduce the ability of calcium from cheese to enter the plaque.
The only other study which has looked at the oral effects of diluting
cheese with another food stuff, compared the calcium release into
saliva following consumption of cheese on a biscuit with that fol-
lowing consumption of cheese alone. This study showed a non-
significant trend towards a higher calcium release from the cheese.
2
The increase in plaque calcium concentration did not appear to be
related to either calcium content, or concentration, of the meal. The
pasta control meal had a similar calcium content to the chicken test
meal but the former failed to have a significant effect on plaque cal-
cium concentration. This suggests that the calcium in cheese exists in
a readily available form for diffusion into the plaque. Another view is
that casein from cheese, or phosphopeptides from cheese, form
complexes which stabilise colloidal calcium phosphate and favour
their diffusion into plaque.
17,18
However, ICT experiments have
shown that a solution containing calcium and phosphate ions at the
same concentrations as found in a 25% w/v aqueous extract of
cheese, effectively reduces sucrose-induced demineralisation
suggesting a casein-independent action of these ions.
3
RESEARCH
dental caries
Table 2 Pre- and post- meal plaque calcium concentrations (g/mg dry weight) and the difference
between these values for 16 subjects. Median values (with ranges) and level of significance (P)
determined using the Wilcoxon one sample test
Meal Baseline calcium Post-meal calcium Pre-/post difference
Median (range) Median (range) Median (range) P
Cheese cube 4.2 (1.17.4) 9.0 (1.515.2) 4.5 (1.39.5) 0.001
Pasta with
cheese sauce 5.1 (2.49.1) 7.8 (4.212.3) 3.1 (2.68.4) 0.004
Pasta with
mushroom sauce 3.9 (1.26.5) 4.5 (1.410.2) 0.5 (2.46.3) 0.106
Chicken with
cheese/ham 4.6 (3.08.4) 6.9 (2.711.2) 2.3 (4.17.1) 0.014
Chicken with
mushroom/ham 3.8 (1.86.3) 3.8 (1.714.1) 0.2 (9.23.2) 0.959
Table 3 Change in plaque calcium concentration (g/mg dry weight), on consuming cheese
containing meals and control meals, in the eight subjects with the lowest baseline plaque
calcium concentrations compared with the eight subjects with the highest baseline plaque
calcium concentrations. Median values (with ranges)
Change in plaque calcium concentration
Low baseline High baseline Significance
n = 8 n = 8 P
Cheese cube 4.0 (0.49.1) 5.5 (1.39.5) 0.71
Pasta cheese sauce 3.3 (0.68.4) 2.1 (2.64.8) 0.09
Chicken with cheese/ham 3.6 (0.17.1) 1.0 (4.14.5) 0.10
Pasta mushroom sauce 0.7 (2.46.3) 0.4 (0.91.5) 0.09
Chicken with mushroom/ham 0.1 (1.12.7) 2.3 (3.29.2) 0.46
Differences failed to reject alpha at 0.05 using the Mann-Whitney two sample test
BRITISH DENTAL JOURNAL, VOLUME 187, NO. 12, DECEMBER 25 1999 667
A wide inter-subject variation in plaque calcium concentration
and its increase after cheese consumption has been reported
1,2,14
and is confirmed in the present work. No firm conclusions can be
drawn from the non-significant trend towards a greater increase in
plaque calcium concentration in those subjects with the lowest
baseline values. This observation was made to investigate the
hypothesis that cheese-containing meals may have a more marked
positive effect when baseline plaque calcium is low ie in what is
known to be a caries prone environment.
14
This hypothesis requires
clarification with larger numbers of subjects.
No significant differences in acid-extractable calcium have been
found between plaque samples taken from any two diagonal quad-
rants
1
so in the present study pre- and post- meal samples were col-
lected from opposite diagonal quadrants, avoiding the lower
anterior teeth. Despite precautions taken, the possibility that the
rise in plaque calcium was caused by minute particles of cheese
embedded in the plaque surface cannot be ruled out. However, if
this occurred these particles would constitute a reservoir of calcium
that may diffuse through the plaque.
Dental caries remains persistently high in children from deprived
social backgrounds. In the United Kingdom, 72% of 15-year-old
children from the lower social classes have decayed permanent
teeth.
19
The lower social classes are also least likely to visit the den-
tist and have the poorest oral hygiene.
19
Healthy eating messages of
the past two decades have failed to result in a fall in sugar consump-
tion,
20
however, advice to reduce sugars consumption is negative,
and it is known that positive messages are better received.
21
The
findings of this study provide the basis for a positive approach to
caries prevention, through the promotion of meals and snacks con-
taining cheese. The efficacy of promoting the consumption of
cheese-containing meals as a means of caries prevention warrants
further consideration. This work suggests that eating cheese may
reduce caries and it is hoped that more clinical data will become
available to clarify the hypothesis.
This investigation was supported by the National Dairy Council UK. The authors
would like to acknowledge the help of Mr G R Woods and Mr W G Wright with
this project.
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5 Knig K G. Caries induced in laboratory rats. Br Dent J 1967; 123: 585-589.
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dental caries