Table 2
delineates dietary factors that directly contribute to higher risk of caries development and the various studies from which we gathered the findings.
Factors | Study | Findings/Recommendations |
Fizzy drinks +/- sugar Sports drinks | Kolker J L et al. (16) explored low-income African-American children between the ages of 3–5 years (n = 436). Block Kids Food Questionnaires were utilised and caries measured using ICDAS. An estimated dmfs score was then allocated. Statistical analysis using SAS and SUDAAN. Sohn, W. et al. (17) analysed the impact of carbonated soft drinks on the primary dentition in 2–10 year olds using a 24-hour dietary recall interview. | Diets containing fizzy drinks (soda) with or without sugar produced a higher mean dmfs (p = 0.049). Sports drinks were positively associated with higher dmfs scores. High consumption of carbonated drinks were linked to a higher prevalence of ECC. 13% of those with a high consumption of carbonated drinks also had a significantly higher ECC in comparison to those that consumed non-carbonated drinks. NB: Children over the age of 6 were also included in this study. |
Sugar sweetened beverages (SSB) | Warren JJ et al. (18) completed a longitudinal study on children aged 6–24 months with a low socio-economic status (n = 212) and focused on the effects of beverage consumption (and plaque, mutans streptococci levels of mothers and fluoride use) on the prevalence of ECC. Lim, S. et al (19) carried out a longitudinal study looking at low-income African-American children in Detroit and their consumption of soft drinks (compared to milk and 100% fruit juice) and its association with ECC in 3–5 year olds, (n = 369). | Higher prevalence of ECC in children consuming sugar sweetened drinks (p = 0.04). SSBs are a significant predictor of ECC. NB: Study also reported on the effects of plaque, microbiology and fluoride use, however these results were excluded from our conclusion as they did not meet the PEO. Higher consumption of soft drinks increased the development of ECC in comparison to the consumption of milk and/or 100% fruit juice. Children that went from being low consumers of soft drinks to high consumers had a 1.75 times higher DMFT after 2 years. |
High frequency of snacking | AAPD (20) policy on ECC and preventive strategies. Yen, C. E. et al (21) studied the relationship between dietary intake and caries in children aged 3–6 years (n = 182) from day care centres in Taiwan. | Snacking in between meals and prolonged exposure to fermentable carbohydrates should be avoided where possible. Increased frequency of snacks in between meals caused an increased risk of ECC. |
Pre-bedtime feeding habits | AAPD (20) policy on ECC and preventive strategies. Rahman N.H.A et al (22) examined pre-bedtime milk (assumed to be cow’s milk) consumption and caries in children between 0–5 years old. | Ad libitum breastfeeding should be discouraged before bedtime after 6 months. ECC was most prevalent in children aged 4–5 years, likely due to a cumulative effect. Milk consumed directly pre-bedtime was associated with higher ECC. |
Mode of drinking in infants | AAPD (20) policy on ECC and preventive strategies | Bottles are actively discouraged at 12 months and older. Children should instead be encouraged to drink from a free flow cup. |
Formula milk | Erickson PR et al. (23) examined the oral pH changes and streptococcus sobrinus colonies after rinsing with infant formulas. The study also examined the buffering capacities of saliva against the formulas and their ability to demineralise enamel structures. | Some infant formulas were unable to significantly buffer acid, which in the oral cavity, may allow the plaque pH to drop more quickly, increasing the rate of ECC development. |
Breastmilk | Branger, B et al (24) conducted a review examining the impact of breastfeeding on caries development looking at meta-analyses on pubmed from 2009–2019. Hallonsten, A. L. (25) analysed breastfeeding habits and caries incidence in 18 month olds in Sweden (n = 3000). | Breastfeeding up to 12 months was not associated with an increased risk of ECC, and could even provide protection compared to feeding with formula milk. No conclusion for breastfeeding after 12 months has been made due to insufficient high grade research. Breastfeeding was found to be positively correlated with higher caries incidence in 18 month olds. There was also a statistically significant difference in breastfed vs not breastfed children and caries incidence. 19.7% of the breast-fed children had caries compared with 1.7% of the 2939 children not breast-fed. |
Milk consumption | Ghazal, T et al. (26) examined ECC in African American pre-school children aged 3–22 months consuming milk (n = 96 at start and n = 81 at final follow up). Yearly examinations were conducted up to 4 years after baseline record. Abbasoğlu, Z. et al (27) examined the mode of consumption of milk and resulting ECC in 2–5 year old children (n = 259). Petti, S. et al. (28) study on prediction factors for ECC in 3- to 5-year-old children in Rome, Italy (n = 2025) | 94.7% of children aged 0–4 years old with ECC consumed milk (41% of the children had their teeth brushed and 14% reportedly were permitted to brush their own teeth). NB: Other variables such as toothbrushing and fluoride exposure were commented on for the final conclusion. Use of milk bottles for prolonged periods of time was associated with higher prevalence of ECC, p = 0.431. NB: this study was conducted on children with genetic variants that resulted in enamel defects. Milk and yoghurt in the diet and low Plaque Index scores were inversely associated with ECC. |
Homemade weaning diet vs commercial formulas | Bhat S et al (29) study was aimed at infants 4–6 months being fed homemade weaning foods vs shop bought available weaning formulas, but research was conducted in vitro using extracted primary teeth incubated with test solutions of homemade and commercial weaning feeds for 6 weeks. | Lower prevalence of caries both clinically and histopathologically were seen in homemade feeds. |
Frequent consumption of 100% fruit juice | Ghazal, T et al. (26) examined ECC in African American pre-school children aged 3–22 months (n = 96 at start and n = 81 at the final follow-up). Yearly examinations were carried up to 4 years. | Daily frequency of consumption of 100% juices were associated with lower incidence of dental caries (p = 0.01). |
Frequent consumption of sugar sweetened foods (SSF) | Ghazal, T et al. (26) examined ECC in African American pre-school children aged 3–22 months (n = 96 at start and n = 81 at the final follow-up). Yearly examinations were carried up to 4 years. | Children who consumed a unit of SSF once more per day had ~ 9.2x chance of ECC in the 3-year incidence period than those who had one less unit of SSF per day (p = 0.003). |
Length of time of consumption of sugar | H Colak et al. (30) reviewed the diagnosis and management of ECC. | Sucrose was found to be removed fastest, while sorbitol persisted for up to one hour. |
Sweeteners sugar alcohols (e.g. xylitol, sorbitol, mannitol) synthetic sweeteners (e.g. aspartame, saccharin) and natural sweeteners (e.g. miracolin) | Roberts M.W. et al. (31) low calorie substitutes on caries and obesity. Mäkinen KK et al. (32) long term cohort studies on 6 year olds (n = 510) chewing gums containing xylitol and sorbitol, or their combinations) and the arrest of dentine caries. | Sugar alcohols are a non-cariogenic substitute for sucrose, glucose and fructose (which are often used in conventional foods). Xylitol consumption was associated with reduced plaque mass and lower dmft scores. Xylitol is not metabolised by oral microbes. Chewing high-xylitol gum may retard or arrest caries. |
Substantivity of carbohydrates (chocolate, fruit, dried fruit and bread) | Luke GA et al. (33) explored salivary removal of fermentable carbohydrates (glucose, fructose, sucrose, maltose, sorbitol, chocolate, white bread and bananas) in 5 subjects and analysis was performed by high-performance anion-exchange chromatography with pulsed amperometric detection. | Acids produced post-eating lasted 20–40 minutes in the oral cavity. Carbohydrate residues were still present in the mouth after 1 hour. Chocolate and fruit carbohydrates were cleared quicker than white bread. Dried fruit had a prolonged contact time to tooth surfaces compared to fresh fruit which contains bound sugars. |
Consistent foods that require good mastication e.g. fruit vegetables, milk, cheese | Butera, A et al. (34) narrative review of nutritional aspects and change in oral microflora (Streptococci spp., Lactobacilli spp., Candida albicans, Cryptococcus neoformans, and Candida sake) Yen, C. E. et al (35) studied the relationship between dietary intake and caries in children aged 3–6 (n = 182) from day care centres in Taiwan. | Foods that require more mastication stimulated higher salivary flow rates and have lower cariogenic potential than foods which require little mastication. Vegetable intake was significantly associated with lower ECC. |
Starchy, fibrous foods | Krasse, B. (36) using historical data, epidemiological surveys, laboratory and animal experiments, clinical studies and observations in ordinary dental practice. | More mastication, improved salivary secretion and faster oral food clearance, aids the maintenance of neutral pH, reducing caries progression. |
NB: dmfs and dmft are both quantitative measures of caries present using either the teeth (dmft) or tooth surfaces (dmfs)
Sucrose has been found to be twice as cariogenic as fructose (37) which is commonly found in western diets of children under 6 who are given foods containing sugar, maple syrup, dates and honey, to name a few.
The cariogenic potential of foods containing these sugars also depends on the substantivity and the frequency of consumption. It must also be noted that when eaten in conjunction with other foods, the cariogenic effects may be mitigated. Presence of cheese, cocoa, and xylitol among other foods, appears to reduce the cariogenic potential of a sucrose-containing meal in the mechanisms outlined in the third column of Table 2 (38). Imfeld, T et al. (39) recorded interdental plaque pH during different meal patterns using plaque pH telemetry. It was found that peanuts and cheddar cheese increase oral alkalinity, and cheese reduces pH drop (but the comparison used in the study was a sugar rinse) (40).
Similarly, Jensen, M.E et al. (41) discussed the acidogenic potential of a variety of foods by using short-term pH telemetry (30 min) on interdental plaque (n = 5)dairy sources such as; cheddar cheese and skimmed milk were less acidogenic than other common dietary foods.
Raw, unrefined cocoa without added sugar was shown to inhibit oral acidification with anti-plaque activity at the ADA conference in 2015 (38). From the findings that can be concluded from the studies collated in the table above, the necessity to consider the diet as a whole is further underlined.
It is prudent to consider the structure of the foods consumed. The cariogenic potential of an apple or a toffee varies even if the sugar content of both is equal. Aside from substantivity in the mouth, the water content, fibre and presence of minerals, such as calcium reduce the cariogenic potential of natural bound sugars such as those found in fruit. Furthermore, the mastication usually needed intra-orally during consumption of foods containing natural bound sugars mitigates the risk of developing dental caries by increasing salivary secretions and sugar clearance. The WHO has stated that it is the intake of free sugars that should be limited to prevent non-communicable diseases, including ECC (42). Interestingly, the research was conflicting but the majority of studies found that presence of fruit in the diet was inversely correlated with ECC, this may reflect socio-economic status or health behaviours of the parents but fruit, when eaten whole, should not be excluded in a child’s diet due to the sugar content. It must also be noted that different fruits have different substantivities, minerals, fibre content and thus varying degrees of cariogenicity.
WHO guidelines recommend that consumption of free sugars should provide ≤ 10% of energy intake, with a suggestion to further reduce intake to < 5% of total energy consumed with the aim to prevent dental decay (42). Although reducing intake of free sugars to less than 10% of total energy intake prominently reduces the risk of developing caries, it does not eliminate the risk entirely. Caries is a cumulative and ongoing disease which underlines the necessity to control all risk factors for the development of caries in paediatric patients, henceforth eradicating the potential to initiate a ceaseless restorative cycle.
The most prevalent dietary factors implicated in the development of ECC as seen in the current literature are frequent consumption of food and drinks containing fermentable carbohydrates as free sugars, particularly when consumed outside of mealtimes. As aforementioned, the cariogenic potential of these substances is in combination with time, host surface and biofilm formation, and is often exacerbated by non-dietary factors such as insufficient fluoride exposure, poor oral hygiene and a subsequent alteration of oral microflora (3).
Indirect Factors Increasing The Risk Of Ecc
Socioeconomic status of children belonging to ethnic and racial minorities have higher prevalence of malnourishment, leading to increased risk for enamel hypoplasia and insufficient fluoride exposure, combined with a greater inclination for a cheaper and more sugary diet (43). A similar pattern was seen in children born to single mothers (44).
Having parents earning low-income salaries put the child with a higher likelihood of having a DMFT/dmft score that was four times higher than those with parents earning high-income salaries (45, 46). Parents’ own lifestyles often dictate the diet and prognosis of their child’s health particularly in children under 6. Parents influence which foods are present in the house, the meals that are frequently consumed, as well as timings and feeding behaviours. High-energy and low-cost foods are more prevalent in households that are in the low-income category as they are generally more affordable. These high-energy foods are usually saturated with sugar and salt. Unfortunately, this often reduces the overall diet quality by providing energy without micronutrients. It can also be hypothesised that those from low-income households are often not advantaged enough to be provided education regarding good oral hygiene practices and are likely to access a dental care professional less frequently due to financial pressures which may be confounding factors. The research draws conclusions that children at either extremes of weight; either significantly underweight or overweight, have higher prevalence of caries, this finding resounded with low socioeconomic status families from deprived backgrounds presenting with more ECC.
It is important to note the use of sugar sweetened foods and beverages given as a reward to a child. Not forgetting the administration of cariogenic foods given by caregivers even after having a dental appointment. Paediatric patients will eagerly await their sugary snack from parents who are simply too exhausted to refuse, immediately relegating their child’s oral health secondary to management of the child’s emotional requests. Extensive literature has elucidated the addictive properties of sugar (47), hence it is unsurprising that when given regularly, rather than as a one off treat, an often painful cycle of deteriorating oral health commences.
Dietary acids are often overlooked in paediatric dietary analysis as sugar takes the main precedence. As described earlier, the pathogenesis of caries involves anaerobic metabolism of dietary substrates by acidogenic bacteria which demineralise the tooth surface in the presence of substrate and time. Direct extrinsic acids can also form an optimum environment for tooth decay to occur. Fortified when in combination with free sugars, an example would be coca cola, which has a pH of 2.6 owing to its phosphoric acid content. We know that enamel is demineralised at a critical pH less than 5.5, as delineated by Stephan’s curve (48).
Enamel defects and erosion are often exacerbated by dietary acids without bacterial aetiology. The weakening of the hexagonal enamel prisms due to effects from extrinsic acids leaves the tooth structure more susceptible to decay and breakdown. Thus it is integral to examine the combination of foods consumed in our patient’s meals and snacks and the timings of consumption.
Eating disorders will also weigh heavily on the development of caries due to the weakening of tooth structures, leaving the hydroxyapatite more likely to demineralise. However, illnesses such as anorexia and bulimia nervosa are significantly more pronounced in older paediatric patients, with a peak prevalence in puberty (49). It is rare to discover eating disorders in children under 6, likely due to reduced self-awareness, high activity levels and a large proportion of meals being supervised and provided by caregivers.