Snacking Habits and Caries in Young Children

Dental caries is caused by a combination of infection and diet. This disease, if left untreated, may lead to pain, and impair the quality of life, nutritional status and development of young children. The objective was to investigate the association between snacking and caries in a population at high risk of dental caries. American preschool children (n = 1,206) were recruited in the offices of paediatricians. Data on sociodemographic characteristics, oral hygiene, breast-feeding, use of bottle and snacking were collected by questionnaire. Plaque presence, the number of teeth and their caries status (deft) were scored. The children sampled were 61% Black, 27% White and 10% Asian. Of the 1to 2-, 2to 3and 3to 4-year-old children, 93.8, 82.4 and 77.3% were caries free, and their mean caries scores were 0.16, 0.58 and 0.93, respectively. Multivariate partial least squares (PLS) modelling revealed plaque presence, lowest income, descriptors for tooth exposure time (number of teeth and age) and cariogenic challenge (total intake of sugar-containing snacks and chips/crisps, and chips intake with a sugar-containing Received: October 12, 2009 Accepted after revision: June 30, 2010 Published online: August 20, 2010 Ingegerd Johansson Department of Odontology , Umeå University SE–901 87 Umeå (Sweden) Tel. +46 90 785 6035, Fax +46 90 770 570 E-Mail ingegerd.johansson @ odont.umu.se © 2010 S. Karger AG, Basel Accessible online at: www.karger.com/cre Johansson /Lif Holgerson /Kressin /Nunn / Tanner Caries Res 2010;44:421–430 422 tato chips, fried potatoes, whole milk and fruit drinks, whereas those with higher incomes consumed more grain-based salty snacks, fruits, skim milk, soft drinks, coffee and tea [Briefel and Johnson, 2004]. The shifted dietary patterns have been associated with increased risk of endemic diseases such as type 2 diabetes, obesity and dental caries. Dental caries is a chronic infectious disease characterized by demineralization of tooth tissues at lowered pH following bacterial fermentation of dietary carbohydrates. The period of critically lowered pH needed for caries to occur is mainly a function of the type and frequency of carbohydrates consumed, the microbial composition of the tooth biofilm and salivary factors. Sucrose and monosaccharides induce a rapid and deep pH drop, and accordingly increase the risk of caries [Azevedo et al., 2005; Seow et al., 2009]. Energy-dense, low-nutrientdense foods are often characterized by a high content of added sugar, but several modern snack products such as chips (crisps), popcorn and shrimp crackers, while not sweet, are still potentially cariogenic due to their content of extensively hydrolysed starch [Lingström et al., 2000]. Snacking has gained an increasing role as a risk indicator for caries development in children [Milgrom and Reisine, 2000; Marshall, 2005], but so far the impact of products with extensively hydrolysed starch, such as potato chips, on caries risk has not been demonstrated in children or adults. Caries in young children, often referred to as early childhood caries [American Academy of Pediatric Dentistry, 2008], may, if left untreated, lead to pain, reduced quality of life and impaired eating, and may impair a child’s nutritional status and development. The prevalence of early childhood caries varies between communities but is frequently high in underprivileged communities and among disadvantaged immigrants [Grindefjord et al., 1993; Milnes, 1996; Petersen and Esheng, 1998; Wennhall et al., 2002; Jose and King, 2003; StecksenBlicks et al., 2004; Vachirarojpisan et al., 2004; BeltránAguilar et al., 2005; Schroth et al., 2005]. Understanding the role of lifestyle-associated risk indicators for dental caries in young children in groups prone to caries development forms the basis for targeted caries prevention programs. The aim of the present study has been to investigate the association between snacking habits and caries, considering oral hygiene and socioeconomics as possible confounders, in a cohort of young children living in a population at high risk of dental caries in an industrialized country (USA). Subjects and Methods Study Cohort Preschool children presenting for well-child visits at the paediatric clinics at Boston Medical Center, Boston University, and the Floating Hospital, Tufts Medical Center, Boston, USA, were recruited in a 12-month period in 2003–2005. These hospitals serve all racial and ethnic groups living in the Boston area but have a special mission for underserved groups [Kressin et al., 2009]. Inclusion criteria were that a child was 6 months to no more than 5 years of age, and that a parent or guardian was willing to consent to the child’s clinical examinations [Kressin et al., 2009]. Children with congenital diseases affecting the dentition were excluded. The study design, protocol, questionnaire and informed consent were approved by the institutional review boards of the institutions involved. Data Collection Data on sociodemographic characteristics (gender, family income, education level, race and ethnicity) and oral hygiene, feeding (breast-feeding or use of bottle) and snacking habits were obtained from parents or guardians, collected at the offices of paediatricians via a structured questionnaire [Kressin et al., 2009]. The number of teeth, and their status as sound, precavitated (white spot lesion), cavitated, filled or sealed was recorded [Drury et al., 1999], using good light, a disposable mirror and an explorer. For each child, the total number of decayed (d; non-cavitated and cavitated), filled (f; sealants not included) and extracted (e) primary teeth (t) was calculated. Visible plaque was recorded on a 0–3 scale (no plaque, and plaque covering a mean surface area of ! 1/3, 1/3 to ! 2/3 or 1 2/3 of the tooth) [Kanasi et al., 2010]. Data collection and oral examinations were performed by 2 specially research-trained dental hygienists. Data Analyses For descriptive data and associated univariate analyses, family income status was dichotomized as relatively high or low [equal to or higher than or below the median income in 2006 in the state of Massachusetts (USD 56,292 in 2008) according to the US Census Bureau news release (www.census.gov)], education to high (higher than high school) or low (equal to or lower than high school), and other variables as yes or no – for example, presence of caries (deft 6 1) or not (deft = 0), visible plaque (score 6 1) or no visible plaque (score 0), daily cleaning of teeth or not, and reporting eating a snack most days or not. Categorical data are presented as proportions (percent children), and distribution differences between groups were tested by a 2 test with p ! 0.01 considered statistically significant. Caries data (deft scores) are presented as means with 95% CI after standardization for age group or number of teeth in age-merged and age-stratified groups, respectively. Standardized least square means with 95% CI were calculated using the general linear model (GLM) procedure followed by the Bonferroni multiple mean test, with p ! 0.05 considered statistically significant. The SPSS software (version 16.0.1 for Windows; SPSS Inc., Chicago, Ill., USA) was used.