Toothless smiles—I see it in the village children, young men and women—the children, unabashed; the men, usually not caring; the women, reflexly covering their smiles with their fingers. I see the same toothlessness or varying degrees of missing teeth on masa TV shows as the cameras pan the audience.

Toothless might be an exaggeration. Indeed, some are. Others, seemingly so, with a few molars or premolars hanging on. More common are the bungi with missing front teeth and those with four to six active dental caries, unable to afford the dental visits, suffering the pain of continuing decay and recurring abscesses, self-medicating with analgesics and antibiotics, resigning to the inevitable outcome of falling teeth, extraction, or eventual toothlessness.

Easy to blame it simply on third-worldly deprivations, with dental health care way down in the concerns of day-to-day existence. But I have traveled most of the Third World countries—except for a few which I have vicariously traveled through CNN and National Geographic—and have not noticed toothlessness as bad as I have seen here in the Philippines.

Familiar with their stories of going to bed hungry and rice and salt diets, I surmised it was due to poverty related nutritional deficiency—chronic protein and calcium deprivation that starts as early as infancy, when mothers, low on breast milk, start bottle feeding babies with sweetened am (rice water) or just plain sugared water. I imagined electron microscopic examination of decayed, extracted, and fallen teeth would confirm my suspicion of mineral deprivation and nutritional deficiencies.

However, in my inquisitive fascination with rural culture, I stumbled upon stories that provided a simpler explanation. Although calcium or nutritional deprivation may contribute to the dental malady, the main culprit is an excess of a very common food item—sugar. Not the packaged sugary foods—cakes pastries, sweets and chocolates, ice cream or canned fruits swimming in syrup. In the boondocks, it's sugar—plain and brown, or in its many affordable candied one-peso treats.

Sugar in the boondocks
Time was, the usual sugary indulgences were the native delicacies, panucha or sangkaka, palitaw, suman rolled over sugar, even tubo—sugarcane freshly hacked from the fields, cut down to size to chew and suck the sugar from. Today, sugar is delivered mostly as fructose corn syrup buried under the countless guises of food and drink. But for the poor, in my part of the boondocks, the immediately available and preferred sugary indulgence is table sugar.

Sugared rice water: For infants, when breasts run dry or formula feeding is unaffordable, mothers resort to am (rice water) sweetened with table sugar; or easier still, just plain water heavy on sugar.

Lollipops as pacifier: From infancy on to early childhood, lollipops are used as pacifiers for crying babies. At bedtime, some mothers stick lollipops in the children's mouths, to sugar lull them to sleep, removing them when they're deep in sleep, lest they choke. For rural kids, it continues to be the affordable sugar treat, the one peso lollipop.

Sugary meals: Nothing to eat but rice? Problem solved if there's brown sugar to sprinkle on the rice. Sometimes, it's Milo over the rice, then brown sugar on top. Older children and adults would eat plain rice while taking occasional bites off sangkaka (Muscovado) cakes.

Veggie meals. . . Ugh!: Vegetables for lunch or dinner? No problem, the children push the veggies away, sprinkle their rice with brown sugar.

Spoonful of sugar: Nope, not the Mary Poppins song, but a sugary boondock treat. When hunger strikes, older children and adults go for a spoonful of brown sugar, holding it in the mouth to form a small salivary-sugary clump between the tongue and hard palate to deliver a few minutes of a slow sweet melt.

And when the budget allows, there are the sugared indulgences: Tang with added spoonfuls of sugar, coco jam (matamis-na-bao) on rice, fruits (bananas, coconut, melon, pineapple) and root crops (kamoteng kahoy, kamoting baging) dipped on sugar, and all the local delicacies delightfully rich in sugar. Sugar is the ubiquitous item in the marketing list, brown preferred because of cost, significantly cheaper than white sugar, but perhaps, also, because of the visually appealing contrast of brown sugar on white rice.

Of course, while sugar is the main etiologic culprit—there are other ingredients in the science of dental rot: acidity of foodstuff and drinks, interacton of pH with calcium, fluoride (whatever side of the debate you sit), other fermentable carbohydrates, salivary enzymes, plaque, bacteria, and in adults, the contribution of tobacco use to periodontal disease.

Studies have also added to the science of sugar that assures the battle is lost before it is even fought: sugar detectors on the taste buds, sugar sensors and sweet taste receptors on the tongue that get aroused by brain endocannabinoids in the brain to increase the appetite.

And for the poor in the boondocks, what is the point of science when there is no dental health awareness and no programs on oral hygiene, when fillings are unaffordable, and toothpaste, often, is a luxury. What more when the teeth are irrevocably lost. The cheapest dentures will run about P6,000. And for the poor, that is unthinkable luxury —about three sacks of rice, enough to last a family of four for three months.