Dietary Impacts on Caries in Children

Dental caries is the most common childhood disease.¹ Early childhood caries (ECC) affects children younger than 6 and is defined as one or more decayed, missing or filled surface (dmfs) on any primary tooth.² Among children younger than 3, any smooth-surface caries is classified as severe early childhood caries (S-ECC), which is defined as a dmfs score of ≥4 for children age 3; ≥5 for children age 4; and ≥6 for children age 5.² If left untreated, ECC and S-ECC can lead to pain, infection, tooth loss, hospitalization, and greater likelihood of caries in the permanent teeth, which contributes to increased dental treatment costs, school absences and decreased quality of life.³

Based on 2011–2012 data from the National Center for Health Statistics, 23% of American children ages 2 years to 5 years have ECC.⁴ There are a number of demographic, behavioral and social factors associated with ECC.5 Certain subgroups of children are at increased risk, including racial and ethnic minorities, immigrants, children with developmental delays and special health care needs, uninsured children, and children living in low-income households.⁶

The three most important behaviors in ECC prevention are regular dental visits, consistent oral hygiene with exposure to fluorides, and a diet low in fermentable carbohydrates. Children without a dental home experience higher rates of ECC than those who receive regular oral health care.⁷ Toothbrushing with fluoride toothpaste helps to remineralize teeth and prevent ECC.⁸ The prenatal dietary behaviors of mothers and postnatal infant feeding habits are also relevant to ECC risk. Frequent intake of foods and beverages containing fermentable carbohydrates — particularly sugar-sweetened beverages such as fruit drinks and soda — can contribute to ECC.^9,10

Dental health professionals should provide parents and caregivers with evidence-based anticipatory guidance and education regarding diet. Population-based programs aimed at improving dietary behaviors among high-risk subgroups also need to be developed.

PRENATAL DIETARY FACTORS

A number of studies have examined the link between maternal prenatal dietary factors and ECC. Based on 2003 data from Japan, self-reported maternal prenatal intake of dairy products (milk, yogurt and cheese), milk only, and yogurt only were not significantly associated with ECC.¹¹ Maternal prenatal cheese intake, however, was associated with significantly lower ECC rates.¹¹ Another study found no ECC-related benefits associated with milk intake during pregnancy.¹² Any self-reported calcium supplementation was also associated with lower ECC rates.¹¹ Another study failed to detect a dose-dependent benefit associated with calcium intake, which raises questions on the effectiveness of prenatal calcium supplementation.¹²

In two studies, higher prenatal maternal vitamin D intake was associated with lower ECC rates for children age 1 year and those between 36 months and 46 months.^13,14 Vitamin D measurements were based on a dietary history questionnaire and measurements of blood serum levels of 25-hydroxyvitamin D. The latter study reported that mothers with blood serum vitamin D concentrations greater than 75 nmol/L had children with fewer decayed teeth.¹⁴

In summary, two maternal prenatal dietary factors may be associated with reduced ECC rates in children: cheese intake and vitamin D supplementation. There is less evidence on the benefits of maternal prenatal intake of other dairy products (such as milk and yogurt) and calcium supplementation.

INFANT FEEDING

Additional studies have examined the relationship between breastfeeding or bottlefeeding and ECC. Two Brazilian studies found significantly higher ECC rates among children who were never breastfed.^15,16 Another study found higher ECC rates among children who were exclusively bottlefed compared with those who were exclusively breastfed.¹⁷ A study based on U.S. National Health and Nutrition Examination Survey data, however, suggested no association between breastfeeding and ECC.¹⁸ The results of yet another study showed that children who were exclusively breastfed had significantly higher ECC rates.¹⁹ Collectively, the mixed results of these studies suggest that feeding modality either makes no difference, or may be overwhelmed by other associated behaviors that expose children to high levels of fermentable carbohydrates.

Three factors associated with feeding modality are relevant in preventing ECC. The first is feeding frequency. Research suggests that on-demand breastfeeding and high-frequency breastfeeding are associated with increased rates of ECC.²⁰ The second factor is nighttime feeding. Studies report that breastfeeding at night increases ECC risk, and is amplified by increased feeding frequency and on-demand breastfeeding.^21,22 The third factor is the age of weaning. Numerous studies report increased ECC rates associated with breastfeeding after children have reached 1 year^21,23,24 and 2 years.^21,25

In summation, when comparing ECC rates between children who are breastfed or bottlefed, mixed study findings suggest that associated feeding behaviors are more important in determining risk. On-demand feeding should be discouraged. Nighttime feedings should be minimized, and breastfeeding mothers should consider weaning children by age 2 to reduce ECC risk. After weaning, conventional, open-lid cups should be used rather than bottles or no-spill training cups to discourage nighttime feeding and constant sipping of beverages. If bottles or “sippy” cups are used, they should only be filled with water.

BEVERAGE CONSUMPTION

Carbonated soft drinks are strongly associated with increased ECC rates.^9,26 Sugar-sweetened beverages are positively associated with ECC and S-ECC.^10,20,27 Despite anecdotal claims that high volumes of 100% fruit juices increase ECC rates, studies based on parental self-reporting have so far not substantiated this association.^27,28 However, in the absence of adequate fluoride exposure and intake of other sugary beverages and foods, even 100% fruit juice can lead to ECC. Milk intake is negatively associated with ECC.^10,29,30 Water consumption also appears to help protect against ECC.¹⁰

In summary, young children should avoid carbonated soft drinks and other sugar-sweetened beverages. While the impact of drinking 100% fruit juices on ECC rates is not clear, their intake should be limited. Milk and water appear protective against ECC.

SOLID FOODS

Since the Vipeholm study was completed in the 1950s,³¹ it has been widely accepted that excess dietary carbohydrate intake is the primary behavioral etiology of dental caries. Recent research has found that both absolute (measured in grams) and relative (measured as a percentage of total energy) daily sucrose intake are associated with ECC.32 Example of foods associated with ECC are sweet snacks, confectionaries (e.g., candies, chocolate and toffee) and chips.^32,33 One study found confectionary intake to be associated with ECC only among children with poor oral hygiene (defined as brushing less than twice per day), which highlights the importance of both diet and hygiene in promoting optimal oral health.³⁴

In terms of breakfast items, marmalade, jams and honey are associated with increased ECC rates.³³ Among young children, yogurt is associated with lowered ECC risk and may confer additional benefits when consumed four or more times per week. The consumption of cheese and butter is not related to significantly lower ECC rates.³⁵ Sweetened or unsweetened cereals are not significant risk factors for ECC.³⁶

While the fermentable carbohydrate content of solid foods is important, frequency and timing of consumption are additional considerations when it comes to preventing ECC. A high snacking frequency is associated with ECC.³⁷ Another study found that children with two or more between-meal snacks per day had higher rates of ECC than subjects who snacked less frequently.³⁸ Eating at bedtime is also associated with increased risk of ECC.³⁹

In summation, sweet snacks are associated with increased risk of ECC and should be limited to no more than twice a day. The consumption of yogurt may be protective against ECC, but there is mixed evidence regarding cheese and ECC prevention. Bedtime eating should be discouraged.

DIETARY INTERVENTIONS

The goal of dietary interventions is to improve knowledge and self-efficacy of parents and caregivers in making healthy dietary decisions, encourage sustained healthy dietary behaviors, and reduce dental disease rates (Figure 1). A variety of interventions have been tested to improve the dietary knowledge of parents and caregivers of young children. One study of Korean American parents of children younger than 6 evaluated whether a community-level educational intervention based on bilingual educational flipcharts could help to improve parents’/caregivers’ oral health knowledge and self-efficacy (e.g., individuals’ beliefs in their abilities to engage in the behaviors necessary to reach health goals).⁴⁰ The intervention was a brief, five-minute session in which a student walked parents/caregivers through the flipchart. The results demonstrated significant improvements in knowledge and self-efficacy. This study suggests that brief, culturally tailored interventions have the potential to empower parents/caregivers and address any knowledge gaps on the dietary risk factors associated with ECC.

In addition, a number of studies have tested educational interventions that encourage healthy eating.^41–43 An Iranian study involved an education program in which staff at public health clinics received training on how to provide parents with dietary advice about sugary snacks.⁴⁰ The intervention lasted six months. Parents were randomly placed in one of three groups: a control group; an intervention group that was given five minutes of oral health education, an oral health pamphlet, and two phone call reminders about oral health instructions; and a third group that was only given an oral health pamphlet. Parents/caregivers in the intervention group reported significantly lower sugary snacking frequency than did parents of control children. Another intervention was conducted in Australia in which parents attended six, hour-long interactive group-counseling sessions with a dietitian and psychologist.⁴¹ Subsequently, significantly larger proportions of children in the intervention group reported liking fruits and were exposed to more vegetables than children in the control group.

In an educational intervention in Florida, teachers at a child care center were trained on how to talk to children about healthy eating, parents/caregivers participated in a monthly educational dinner, and the center modified its menus to encourage healthy eating.⁴² Staff at child care centers that served as controls provided similar levels of training on a nondietary topic. After six months, children in the intervention group consumed fewer junk food items, more fresh fruit and vegetables, and less juice during school time. In a fourth study, a 15-minute educational video based on the self-determination theory was shown to parents/caregivers of young children, significantly improving the children’s dietary behaviors⁴³ — at least in the short term. These studies indicate that educational interventions can encourage healthy eating among children.

A number of studies have also evaluated the capabilities of educational interventions to reduce ECC.^42–46 It appears, however, that single-episode educational interventions are ineffective at reducing ECC rates. A cluster-randomized intervention program in Brazil compared the ECC rates of children treated by health care workers who received an hour-long nutrition training session to the ECC rates of children treated by health care workers who did not receive nutrition training.⁴⁴ No significant differences were found in ECC rates between the two groups. Similarly, the previously mentioned video-based education for parents/caregivers did not improve ECC rates after six months.⁴³ Another study found that multiple interactions with parents based on motivational interviewing strategies over a six-month period resulted in significantly lower ECC rates.⁴⁵ A home-based, diet-focused intervention involving nine 30-minute visits by an undergraduate nutrition student who educated parents/caregivers about dietary behaviors was also found to significantly reduce ECC rates.⁴⁶

In summary, diet-focused educational interventions have the potential to improve knowledge, self-efficacy and healthy behaviors. To reduce ECC rates, interventions need to involve repeated interactions with parents/caregivers over time.

key takeaways

• If left untreated, early childhood caries (ECC) can raise the risk of caries in permanent teeth and contribute to increased dental costs, school absences and decreased quality of life.³
• Two maternal prenatal dietary factors may be associated with reduced ECC rates in children: cheese intake and vitamin D supplementation.
• Studies suggest that breastfeeding at night increases ECC risk, and is amplified by increased feeding frequency and on-demand breastfeeding.^21,22 In addition, breastfeeding mothers should consider weaning children by age 2 to reduce ECC risk.
• While the fermentable carbohydrate content of solid foods is important, frequency and timing of consumption are additional considerations in efforts to prevent ECC. A high snacking frequency is associated with ECC,³⁷ as is eating at bedtime.
• Dietary interventions should focus on the essential behavior changes needed to reduce ECC risk, and should be delivered by personnel who are culturally competent.⁴⁸

CLINICAL STRATEGIES

In terms of diet, clinicians should talk to pregnant women about the potential value of vitamin D supplementation to reduce ECC risk. For young children, clinicians should assess whether the child is breastfeeding and/or bottlefeeding. Breastfeeding should be encouraged, but on-demand breastfeeding may raise the risk of ECC. Once babies are old enough to no longer need feeding every three hours to four hours, nighttime breastfeeding should be minimized.

Children should not be given bottles filled with juice or other sugary beverages. Weaning by age 2 may help to reduce ECC risk. The use of bottles and no-spill training cups should be discontinued by age 12 months. Children should use an open cup when drinking liquids to discourage constant sipping.⁴⁷

Milk and plain water are preferred beverages for children. According to the American Academy of Pediatrics, 100% fruit juice should not be introduced to children until they are at least 1 year old, and intake should not exceed 4 ounces to 6 ounces per day.⁴⁸ Clinicians may need to show parents how little fluid is contained within 4 ounces to 6 ounces so they can visualize the appropriate amount. Furthermore, the consumption of 100% fruit juice should be done at mealtimes because increased salivary flow helps buffer the effects of sugars. For children who are eating solid foods, sugary snacks should be minimized and the number of between-meal snacks should be limited to two per day. Yogurt is worth encouraging, as it appears to provide protective benefits against ECC. Eating at bedtime should be discouraged.

PUBLIC HEALTH INTERVENTIONS

At the community level, efforts have been ongoing to help prevent or reduce ECC by improving parents’/caregivers’ and children’s dietary knowledge and behaviors. Such interventions should be aimed at high-risk subgroups, including low-income children, racial and ethnic minorities, and children with special health care needs. While improving parents’ and caregivers’ knowledge, skills and self-efficacy is important, the ultimate goal of such interventions is sustained improvements in dietary behaviors and disease prevention.

While brief interventions require fewer resources and may be easier to sustain, they do not typically lead to meaningful dietary behavior change or reduced ECC rates. Given the complexity of dietary risk factors and behaviors, effective interventions will likely require repeated interactions with parents and caregivers. These may take place in multiple locations in the community (e.g., clinics, daycare centers, schools, homes or stores). Home-based dietary interventions are particularly relevant, given that children generally receive most of their snacks, meals and beverages at home.

Dietary interventions should focus on the essential behavior changes needed to reduce ECC risk, and should be delivered by personnel who are culturally competent.⁴⁸ There is also a need to evaluate outcomes associated with community-based interventions to ensure effectiveness and acceptability by the communities, families and children. Intervention sustainability is also an important aspect of public health efforts that should be incorporated into every community’s health care structure.

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