intake of sweet drinks and sweet treats versus reported and observed caries experience

5European Archives of Paediatric Dentistry // 11 (Issue 1). 2010

Key words: Sweet drinks, sweet treats, reported caries, observed caries

Postal address: Emeritus Prof. L. B. Messer, Melbourne Dental School, The University of Melbourne, 720 Swanston Street, Victoria 3010 Australia.

Email: [email protected]

J.G. Lee, L.B. Messer Dept. Paediatric Dentistry, Melbourne Dental School, University of Melbourne, Victoria, Australia

Intake of sweet drinks and sweet treats versus reported and observed caries experience

AbstractAIM: This was to study the intakes of sweet drinks and sweet treats of children and their caries risk using the Paediatric Risk Assessment Tool (PRAT, 2003) and Caries-risk Assess-ment Tool (CAT, 2007-8). STUDY DESIGN: Parents of 266 healthy primary school children completed the PRAT ques-tionnaire during their child’s dental appointment at the Royal Dental Hospital of Melbourne, Australia, describing their fluid and sweet treat intakes in the past 24 hours, oral hygiene practices and past caries. A subgroup (n=100) was exam-ined clinically (CAT) for caries requiring restoration, visible plaque, gingivitis, orthodontic appliances, enamel defects, and use of dental care. RESULTS: The estimated mean daily fluid intake was 1.5±0.5L; fluids were consumed 3-5/day by 57% of children and 78% usually had evening/night drinks. Fluids consumed were: tap water by 90%, milk by 74%, juice by 50%, regular soft drink by 30%; sweet treats were consumed by 62% and confectionery by 25%. Most children (69%) brushed their teeth ≥2/day; 5% flossed daily. Parentally-reported caries was associated significantly with increasing treats frequency (p=0.006). In the subgroup, 81% were at high caries risk; 47% had irregular dental care; 21% had sweet drinks/foods frequently between meals; 49% had visible plaque/gingivitis, and 34% had enamel demineralisa-tion. Caries observed in the past 12 months was associated significantly with evening sweet drinks (p=0.004), and sub-optimal fluoride exposure (p=0.009). Caries observed in the past 24 months was associated significantly with treats frequency (p=0.006), intake of sweet drinks plus treats (p=0.000), enamel demineralisation (p=0.000) and irregular dental care (p=0.000). CONCLUSIONS: The PRAT and CAT are valuable tools in assessing children’s caries risk. The risk of caries from frequent intake of sweet drinks, either alone or in addition to sweet treats, must be emphasised to parents. All parents, and particularly those of children assessed at high risk from intakes of sweet drinks and sweet treats, sub-optimal fluoride exposure, or enamel demineralisation, must be encouraged to obtain regular dental care for their children.

Introduction An increase in dental caries in young children in Australia was reported recently by the School Dental Service (SDS). Since SDS data collection commenced in 1977, decreasing dmft/DMFT scores and improved dental health of Australian

children had been attributed to the introduction of commu-nity water fluoridation [AIHW, 1998]. However, increasing caries experience of 6 yr-old and 12 yr-old children has been reported from the mid to late 1990’s by the SDS [Armfield and Spencer, 2008]. In the most recent Australian child den-tal health survey conducted in 2002 and reported in 2007, 47.4% of 6 yr-olds had experienced caries in the primary dentition; the mean dmft was 1.96 (SD: 3.01), and the 10% of children with the greatest caries experience had more than nine cariously-affected teeth [Armfield et al., 2007]. For 12 yr-olds, over 40% had experienced caries in their permanent teeth; the mean DMFT was 1.02 (SD: 1.73) and the 10% of children with the greatest caries experience had nearly five cariously-affected teeth, exceeding the national average by almost five and a half-fold [Armfield et al., 2007]. Children liv-ing in low-fluoride areas had poorer dental health than those living in optimally-fluoridated areas, regardless of socioeco-nomic disadvantage [Armfield et al., 2007].

Speculation on the caries increase has focussed on fluid intakes, noting that societal changes such as expanding urbanisation and ready access to sweet drinks and fast and processed foods, have altered children’s diets in Australia and elsewhere [Sivaneswaran and Barnard, 1993; Ismail et al., 1997; Shenkin et al., 2003]. International reports indicate a common trend of increasing consumption of soft drinks by children. In 2000, the most frequently-reported form of added sugars in the USA diet was regular soft drink, accounting for one third of dietary sugar intake [Touger-Decker and van Louveren, 2003]. In the UK, soft drink intake in 11-12 yr-old children increased in the last 20 years [Tah-massebi et al., 2006; Rugg-Gunn et al., 2007]. A similar shift in fluid consumption towards sweet drinks may be occurring in Australia [NHMRC, 2008], and concerns over increasing childhood obesity in Australian children has led to the restric-tion of sales of sweet drinks in public schools [Sanigorski et al., 2006; Tam et al., 2006].

The intake of dairy products by Australian children appears to be decreasing. In 1998, the National Nutrition Survey (conducted in 1995) reported a low intake of dairy products in children, with about 30% of 2-18 yr-olds consuming less than one serving of dairy product daily, and a mean milk intake for 4-7 yr-olds of 0.38L and 0.39L for 8-11 yr-olds [ABS, 1999]. The Australian dietary guidelines recommend


J.G. Lee, L.B. Messer

2-3 servings/day of dairy products including milk for 4-11 yr-olds, and 3-5 serves/day for adolescents [NHMRC, 2008]. Due to the low milk intake, studies reporting increased intake of sweet drinks, without displacing milk, may reflect displacement of other fluids such as water, rather than the small volume of milk currently consumed.

A high consumption of non-milk extrinsic sugars is a risk for caries development [Sheiham, 2001]. A cross-sectional survey of 1,681 primary school-aged children in Victoria, Australia, reported one third were drinking water and another third were consuming juice or cordial while at school [San-igorski et al., 2005]. The high consumption of sweet drinks and low intake of dairy products amongst Australian children may be contributing to the recent caries increases.

Responding to apparent increases in soft drink intake and decreases in dairy consumption by USA children, a Paedi-atric Risk Assessment Tool (PRAT) was devised [Shenkin et al., 2003]. The PRAT questionnaire is completed by carers, recording fluid intake in the past 24 hours and the number of drinks per day, especially after the evening meal and during the night. Meal-time foods are not examined, but carbohy-drate intake between meals (confectionery, baked starches), fluoride exposure, oral hygiene practices and past caries experience are noted. The PRAT does not include a clinical examination.

Caries risk assessment is the standard of care in modern paediatric dentistry [Fontana and Zero, 2006; Trueblood et al., 2008], defining a child’s risk for developing caries at a given time; it should be reconsidered periodically throughout life [Selwitz et al., 2007]. Recently, a Caries-risk Assessment Tool (CAT) was developed by the American Academy of Pae-diatric Dentistry [AAPD, 2007-08]. The CAT records a child’s use of dental care, past caries, orthodontic appliances, diet cariogenicity, fluoride exposure, oral hygiene habits and the carer’s socio-economic status. A clinical examination records visible plaque, gingivitis, and enamel defects (dem-ineralisation, hypoplasia, molar-incisor hypomineralisation). Allowing utilisation of the CAT by other professionals, dental equipment and diagnostic tools (e.g., periodontal probe, radiographs, salivary or microbial tests) are not used, but dentists can add these in as a supplemental assessment. Caries risk is classified as high, moderate or low.

Using the PRAT and the CAT, this study examined intake of fluids and sweet treats, oral hygiene habits, reported caries and observed caries of as a convenience sample of primary school-aged children attending a public dental hospital in Melbourne, Australia.

Materials and Methods Ethics Approval and Selection of Subjects. The study was approved by the Human Research Ethics Committees of The University of Melbourne and the Department of Human Services Victoria, Australia. Children were selected from

those attending the Paediatric Dentistry Clinic, Royal Dental Hospital of Melbourne (RDHM), for preventive and restora-tive treatment between April 2007 and June 2008. All parents gave written informed consent for their child’s participation. Individuals receiving care at the RDHM hold a means-tested health care card or pension card. The two inclusion criteria were: (a) healthy child (ASA I or II), (b) living in and attending school in metropolitan Melbourne.

A convenience sample (253 parents of 290 children) was invited to participate; 24 parents declined (due to lack of time or uncertainty of their child’s diet); the remaining 229 parents (of 266 children) completed usable PRAT questionnaires free of uncertain responses. Clinical examinations (CAT) were conducted also for 100 of these children.

The PRAT Questionnaire. A preliminary questionnaire was trailed with 5 parents of 7-12 yr-old children during their child’s appointment (these children were not included in the study). Their comments were included in the final question-naire1 which was completed for each child by their parent during their appointment. One author (JL) answered queries and ensured completion of all questionnaire fields. Fluid and sweet treat intakes between meals were recorded for the previous 24 hours; parents indicated if these were typical. Questionnaires and consents were stored separately to pre-serve anonymity.

The CAT Examination. Subjects were categorised for 11 car-ies risk factors as follows:

● Use of a ‘dental home’: Low risk: regular attendance in an established ‘dental home’; moderate risk: irregular attend-ance; high risk: no usual source of care.

● Time elapsed since the last diagnosis or treatment of caries: Low risk: greater than 24 months; moderate risk: between 12-24 months ago and caries free in past 12 months; high risk: within the past 12 months.

● Current orthodontic appliance: Low risk: none worn; high risk: appliance worn.

● Daily between-meal exposures to simple sugars or foods strongly associated with caries initiation: Low risk: consumption primarily at meal times; moderate risk: occa-sional (1-2/day) exposures; high risk: frequent (3 or more/day) exposures.

● Fluoride exposure: Low risk: age-appropriate fluoride toothpaste used at least twice daily and fluoridated water consumed (i.e., optimal topical and systemic fluoride exposure); moderate risk: age-appropriate fluoride tooth-paste used at least twice daily and fluoridated water not usually consumed (i.e., optimal topical but suboptimal systemic fluoride exposure); high risk: fluoride toothpaste of inadequate strength for chronologic age and fluoridated water not usually consumed (i.e., suboptimal topical and systemic fluoride exposure).

1 A copy of the questionnaire is available from the corresponding author.


Sweet drinks and treats intake vs caries

● Times per day teeth are brushed: Low risk: brushes twice or more; moderate risk: brushes once; high risk: brushes less than once.

● Visible plaque on anterior teeth: Low risk: none; high risk: present.

● Gingivitis on anterior teeth: Low risk: none; high risk: present.

● Enamel demineralisation: Low risk: none; moderate risk: one demineralised area present; high risk: more than one demineralised area present.

● Enamel hypoplasia: Low risk: none; high risk; present.

● Molar-incisor hypomineralisation: Low risk: none; high risk: present.

Use of Dental Care. Dental care use was determined from patient records. The RDHM recall guidelines are between 6 and 24 months, depending on the child’s history, and are typically 12 months. Attendance at the child’s recommended intervals was denoted ‘regular use of dental care in an estab-lished dental home’; attendance at greater intervals was denoted ‘irregular use of dental care’; sporadic attendance was noted as ‘no usual source of dental care’.

Caries Histories. Patient records were reviewed for caries histories and available radiographs were examined for caries requiring restoration (radiographs were not taken for the pur-pose of this study). Fissure sealants were assumed to have been placed on non-carious pits and fissures. Past caries was diagnosed by noting restorations and treatment dates, categorising the child as follows:

● ‘Carious teeth in past 12 months’: Caries present at this examination, or caries diagnosed/restored within the past 12 months.

● ‘Carious teeth in past 12-24 months’: Caries diagnosed/restored between 12 and 24 months ago, but caries-free for the past 12 months.

● ‘No carious teeth in past 24 months’: No caries diagnosed/restored in the past 24 months and caries-free at this examination.

Available bitewing radiographs (n=26 subjects) were read blindly by the examiner (JL) on two occasions to determine intra-examiner reliability for caries diagnosis.

A mirror and explorer examination was conducted by one author (JL) using a dental light and triplex syringe. Carious teeth requiring restoration were diagnosed by WHO criteria [WHO, 1997], using an explorer instead of a CPI probe if diag-nosis needed light tactile sensation. Caries was diagnosed if visible dentinal cavitation was present or radiographs showed dentinal caries, and recorded as ‘carious teeth in past 12 months’. No further classification of individual teeth or tooth surfaces was undertaken.

Cariogenic Exposures. The child’s intake of cariogenic drinks and foods in the past 24 hours was assessed from the PRAT responses. The number of cariogenic exposures

was estimated; each glass of sweet drink was counted as one exposure and this number was added to the number of reported occasions of confectionery, cakes, biscuits and sugar-containing gum. Subjects were classified as follows:

● Consumption of simple sugars or foods strongly associ-ated with caries initiation primarily at mealtimes: Subjects with 0-2 total exposures.

● Occasional between-meal exposures to simple sugars or foods strongly associated with caries: Subjects with 3-4 total exposures.

● Frequent between meal exposures to simple sugars or foods strongly associated with caries: Subjects with 5 or more total exposures.

Fluoride Exposure. The child’s fluoride exposure was assessed from PRAT questions on use of fluoride toothpaste and fluoridated water. Current Australian guidelines deem use of non- or low-fluoride toothpaste in fluoridated areas by children aged over 6 years as suboptimal [ARCPOH, 2006]. The guidelines recommend ‘for people aged 6 years or more, the teeth should be cleaned twice a day or more with stand-ard fluoride toothpaste (1mgF/g)’; subjects brushing less than twice daily or using toothpaste without an age-appropriate fluoride concentration were recorded as ‘suboptimal topical fluoride exposure’, regardless of their intake of fluoridated water. The guidelines for optimum fluoride use in children aged 6 years and above include consumption of fluoridated water. Subjects meeting both criteria were recorded as receiving ‘optimal systemic and topical fluoride exposure’. Subjects under 6 years of age consuming fluoridated water and brushing twice daily with 400-500 ppmF toothpaste were recorded as receiving ‘optimal systemic and topical fluoride exposure’.

Oral Hygiene and Gingival Health. Visible plaque and gingi-vitis on anterior teeth were assessed by the Modified Plaque (MPI) and Gingival Inflammation (GII) Indices [Löe and Sil-ness, 1963; Silness and Löe, 1964]. An MPI score of 2 or 3 was denoted ‘visible plaque’; bleeding on probing was not recorded. For subjects with an MPI of 0 or 1, the GII was also used. A GII score of 1, 2 or 3 was recorded as ‘gingivitis present’. An MPI of 0 or 1 and GII of 0 were recorded as ‘no visible plaque or gingivitis’.

Enamel Demineralisation and Developmental Defects of Enamel. Air-dried teeth were inspected visually for enamel demineralisation using ICDAS II codes [Ismail et al., 2007], recording chalky opaque, white-brown lesions diagnosed in clinically-appropriate locations (ICDAS II codes 1, 2 or 3). Enamel hypoplasia was noted for non-carious enamel defects of reduced enamel thickness such as pitting [Winter and Brook, 1975]. For molar-incisor hypominer-alisation (MIH), permanent first molars and incisors were examined for white-brown opaque demarcated opacities, post-eruptive breakdown, and atypical restorations in the cuspal/incisal coronal one third [Weerheijm et al., 2003].


Caries Risk. Caries risk was determined from the 11 risk fac-tors, assessing risk based on the highest category assigned to any factor. One factor scored as high risk constituted ‘high caries risk’, regardless of status of other factors [AAPD, 2007-08]. For example, a child scored high risk for visible plaque, but low risk for all other factors, was classified as ‘high caries risk’ based solely on this risk factor. Subjects at ‘moderate caries risk’ had one or more factors scored as moderate with the remainder at low risk and none at high risk. A child scored at low risk for all factors was classified as ‘low caries risk’.

Data Management and Statistical Analysis. Observed caries categories were collapsed and compared as follows: ‘no carious teeth in past 12 months’ (subjects with no observed caries in the past 12-24 months + those with no observed caries in past 24 months) were compared with ‘carious teeth in past 12 months’ (subjects with caries observed currently or within the past 12 months); ‘no carious teeth in past 24 months’ (subjects with no observed caries in the past 12 months + those with no observed caries in the past 12-24 months) were compared with ‘carious teeth in past 24 months’ (subjects with observed current caries + those with observed caries in the past 12 months + those with observed caries in the past 12-24 months).

Data were entered into Excel spreadsheets (Microsoft Corp., Seattle, WA, USA) and analysed using the SPSS Graduate Pack 16.0 for Windows® (SPSS Inc., Chicago, IL, USA). The intra-examiner reliability (weighted Cohen Kappa co-efficient) was 1.0. Descriptive statistics were prepared for independent and dependent variables; categorical data were examined using Pearson Chi-squared tests. Noting the potential for inflating Type II errors (possibility of accept-ing a null hypothesis when the alternative hypothesis was true) in clinical data, Bonferroni adjustment of the p value for multiple comparisons was not applied [Perneger, 1998] and alpha was set conservatively at 0.01. A multiple risk fac-tor model was constructed using odds ratios for caries risk factors (binary logistic regression), and backward logistical regression using Chi-squared tests (p=0.1). Multi-variable modelling of independent variables (caries risk factors) was performed (backward elimination) until remaining variables were significant at p=0.05.

ResultsDistribution of Sample and Parental Report of Past Caries. The sample of 266 children (136 males, 130 females) com-pleting the PRAT were aged 56-152 months (mean: 110±23 months; Table 1). The subgroup (50 males, 50 females) also examined clinically (CAT) were aged 56-152 months (109±25). Most children (91%) were aged 72-143 months (6-12 years). Caries in the past 12 months was reported for 37.2% of the sample (subgroup: 36.0%); 29.7% (subgroup: 34%) reported no caries experience. A few parents (sam-ple: 5.6%; subgroup: 6.0%) were unsure of their child’s past

caries. The subgroup appeared representative of the sample for age, gender and past caries.

Oral Hygiene Habits. In the sample, 30.8% (82/266) of subjects (subgroup: 18.0%), brushed less than twice daily (Table 1). Most subjects (80.8%; subgroup: 82.9%) did not floss; daily flossing was rare (5.3%; 5.9%). All subjects used toothpaste, citing Colgate™ (Colgate Palmolive Pty Ltd., Sydney, Australia) products most frequently (sample: 88.3%; subgroup: 92%), in either child (400-500 ppmF) or adult strengths (1,000 ppmF). Some children used toothpastes of inappropriate fluoride concentration; among 4-7 yr-olds, adult strength (1,00 0ppmF) toothpaste was used inappro-priately by 16.5%, and 13.2% of 8-12 yr-olds used child strength (400-500 ppmF) toothpaste (not tabulated).

Fluid Consumption. Most children reported drinking 3-5 times/day, and over one third reported ≥6 occasions (Table 2). Most children (78.6%; 209/266) reported drinking fluids in the evening and/or night and for 86.1% (subgroup: 88.7%) these drinks included water. Of note, 35.9% (75/209) of children (subgroup: 35.2%, 25/71) reported drinking juices, cordials or soft drinks in the evening/night. Drinks without added sugars were consumed in the evening/night by 64.1% (subgroup: 64.8%). Of drinks consumed in the past 24 hours, tap water was the most popular, consumed by 90.2% (sub-group: 92%; Table 2). Few children (8.6%) reported drinking bottled, rain or mineral water. While 55.6% of the sample (subgroup: 52.0%) drank plain milk, 26.0% (subgroup: 25%) had not drunk milk in the past 24 hours. Almost half the sample (subgroup: 48.0%) drank juice, and 19.0% had drunk cordial. The intake of diet soft drink was lower than for regular soft drink (sample: 5.6% vs 30.5%).

Parental estimates of fluid consumed (number of glasses) in the past 24 hours are not tabulated. Milk consumption was low: less than one glass was consumed by 30.1% of the sample (subgroup: 28%), and two or more glasses were consumed by 31.1% (subgroup: 37%). Over half a glass of juice was consumed by 37.6% (subgroup: 43%). The intake of cordial was less frequent than juice: 18% had consumed over half a glass and 80% had not drunk cordial. More than half a glass of regular soft drink was consumed by 23.7% (subgroup: 17%), and a similar volume of diet soft drink was consumed by 4.9% (subgroup: 7%). Sports drinks or tea were rarely consumed.

Fluid volumes drunk in the past 24 hours were calculated from parental estimates of the number of 250mL glasses con-sumed (Table 3). The total fluid intake range was 0.25-3.25L (mean: 1.50 ± 0.50L) for the sample (subgroup: 0.50-3.00L; 1.50 ± 0.40L). The intake range for waters was 0-2.5L (0.82 ± 0.42L), and 0-1.25L (0.30 ± 0.24L) for milks.

The reported intakes of waters, milks and sweet drinks by 40, 4-7 yr-olds and 226, 8-12 yr-olds were estimated as proportions of their total fluid intakes (Table 4). Among 4-7 yr-olds, waters were 51-100% of fluid intake for 60% of



the sample (subgroup: 58.8%); milks were 26-75% of fluid intake for 42.5% (subgroup: 53%), and sweet drinks were 26-75% of fluid intake for 40% (subgroup: 47.1%). Among 8-12 yr-olds, waters were 51-100% of fluid intake for 54.9% of the sample (subgroup: 57.8%); milks were 26-75% of fluid intake for 28.3% (subgroup: 31.3%), and sweet drinks were 51-100% of fluid intake for 13.3% (subgroup: 13.2%). Par-ents of 87.0% of the sample (subgroup: 88%) reported that the responses for fluid consumption in the last 24 hours were typical of their child’s usual intake. The subgroup appeared representative of the sample for fluid intake.

24-hour Recall of Intakes of Confectionery, Baked Starches and Chewing Gum. The range in the number of treat occa-sions (excluding sugar-free gum) in the past 24 hours was 0-9 (1.1 ± 1.3) for the sample (subgroup: 0-4; 0.8 ± 0.9; Table 5). No treats were consumed by 38.3% (subgroup: 49%). One or two confectionery treats were consumed by 35% (subgroup: 34%), and one or two baked treats were eaten by 36.1% (subgroup: 27%). Very few children chewed either sugared (5.6%) or sugar-free gum (11.3%). Parents of 72.9% of the sample (subgroup: 83%) considered the reported treat intake for the past 24 hours was typical of their child’s usual intake.

Table 1: Distribution of primary school-aged Australian children in the sample population (N=266) and the subgroup (N=100) by age, gender, parentally-reported past caries experience and oral hygiene habits.

Age, past caries experience and oral hygiene habits

Distribution of children

Sample (N=266) n (%)

Subgroup (N=100) n (%)

Age (months) 56-95

96-131

132-152

Males Females Subtotal



Total males Total females

40 39

79 (29.7)

69 64

133 (49.9)

27 27

54 (20.4)

136 (50) 130 (50)

15 16

31 (31)

25 22

47 (47)

10 12

22 (22)

50 (50) 50 (50)

Parentally-reported past caries experience

None Over 2 years ago Between 12-24 months ago Within past 12 months Unsure

79 (29.7) 66 (24.8) 7 (2.6)

99 (37.2) 15 (5.6)

34 (34) 19 (19) 5 (5)

36 (36) 6 (6)

Frequency of tooth brushing Never/rarely Less than once per day Once per day Twice per day More than twice per day

7 (2.6) 6 (2.3)

69 (25.9) 176 (66.2)

8 (3.0)

1 (1.0) 4 (4.0)

13 (13.0) 77 (77.0) 5 (5.0)

Frequency of flossing Never/rarely Once per week Once per day

215 (80.8) 37 (13.9) 14 (5.3)

82 (82.9) 13 (13.9) 5 (5.9)

Type of toothpaste used Child strength fluoride Adult strength fluoride Fluoride-free

68 (25.6) 196 (73.7)

2 (0.8)

26 (26.0) 73 (73.0) 1 (1.0)




Table 2: Distribution of daily drinking frequency, pattern and drinks consumed in the evening/night and past 24 hours by the sample (W=266) population and a subgroup (N=100) of Australian children.

Daily drinking frequency, pattern and drinks consumed in the evening/night




No. of drink occasions per day

1-2 3-5 6-9 10 or more

15 (5.6) 152 (57.1) 82 (30.8) 17 (6.4)

3 (3.0) 61 (61.0) 32 (32.0) 4 (4.0)

Drinking pattern in evening/night

No drinks consumed Drinks in evening only Drinks in night only Drinks in evening and night

57 (21.4) 162 (60.9)

5 (1.9) 42 (15.8)

29 (29.0) 58 (58.0) 13 (13.9)

0

Drinksa consumed (evening/night)

Water (tap, rain, bottled, mineral) Milk (plain, flavoured, soy) Juice, cordial Soft drink (regular, diet)

180 (86.1) 98 (46.9) 47 (22.5) 24 (11.5)

63 (88.7) 33 (46.5) 18 (25.4) 8 (11.3)

Drinksa +/- added sugars consumed (evening/night)

Water, milkb , unsugared teaNon-milk drinks, sugars addedc

Drinks with added sugarsd

Drinks without added sugarse

204 (97.6) 58 (27.8) 75 (35.9)

134 (64.1)

71 (100.0) 21 (29.6) 25 (35.2) 46 (64.8)

Drinksa consumed (in past 24 hours)

Tap water Bottled water Rain water Mineral water

240 (90.2) 23 (8.6) 7 (2.6) 3 (1.1)

92 (92.0) 12 (12.0) 1 (1.0) 2 (2.0)

Milk (plain) Milk (flavoured) Milk (soy) No milks

148 (55.6) 64 (24.1) 3 (1.1)

70 (26.0)

52 (52.0) 32 (32.0)

0 25 (25.0)

Fruit juice Cordial Soft drink (regular) Soft drink (diet) Sports drink

115 (43.2) 50 (18.8) 81 (30.5) 15 (5.6) 3 (1.1)

48 (48.0) 19 (19.0) 22 (22.0) 7 (7.0) 3 (3.0)

a Multiple responses permitted; b One or more of the following: Water (tap, rain, bottled, mineral), milk (plain, flavoured, soy), unsugared tea; c One or more of the following: Juice, cordial, soft drink (regular, diet), sports drink, sugared tea; d One or more of the following: Juice, cordial, soft drink (regular, diet), sports drink, sugared tea, flavoured milk; e One or more of the following: Water (tap, rain, bottled, mineral), milk (plain, soy), unsugared tea.

Table 3: Distribution of fluids consumed as recalled for past 24 hours by sample population (W=266) and subgroup (W=100) of Australian children.

Fluids consumed in past 24 hours

Volume of fluid consumed (Litres)

Sample (N=266) Range (Mean ± SD)

Subgroup (N=100) Range (Mean ± SD)

Watersa

Milksb

Sweet drinks (excl. flavoured milk)c

Sweet drinks (incl. flavoured milk)d

Total fluid intake

0-2.50 (0.82 ± 0.42) 0-1.25 (0.30 ± 0.24) 0-1.5 (0.35 ± 0.32)

0-1.75 (0.42 ± 0.35) 0.25-3.25 (1.50 ± 0.50)

0-2.50 (0.84 ± 0.43) 0-1.25 (0.29 ± 0.24) 0-1.25 (0.32 ± 0.27) 0-1.25 (0.42 ± 0.31)

0.50-3.00 (1.50 ± 0.40)a Waters: tap, rain, bottled, mineral, unsugared tea; b Milks: plain, soy; c Sweet drinks: Juice, cordial, soft drink (regular, diet) sports drink, sugared tea; d Sweet drinks: Juice, cordial, soft drink (regular, diet), sugared tea, flavoured milk.


Table 4: Distribution of fluids consumed as a proportion of total fluid intake recalled for past 24 hours by sample population (N=266 children) and subgroup (N=100 children).

Proportion of total fluid intake (24 hour recall)

Distribution of fluids consumed

By 4 to 7-year-olds n (%)

By 8 to 12-year-olds n (%)

Watersa Milksb Sweet drinksc

Watersa Milksb Sweet drinksc

Sample (N=266)

0 1-25% 26-50% 51-75% 76-100%

Subtotal

0 1 (2.5)

15 (37.5) 15 (37.5) 9 (22.5)

40

14 (35.0) 9 (22.5) 15 (37.5) 2 (5.0)

0

40

14 (35.0) 10 (25.0) 13 (32.5) 3 (7.5)

0

40

12 (5.3) 9 (3.9)

81 (35.8 91 (40.3) 33 (14.6)

226

59 (26.1) 103 (45.6) 62 (27.4) 2 (0.9)

0

226

42 (18.6) 64 (28.3) 90 (39.8) 18 (8.0) 12 (5.3)

226

Subgroup (N=100)

0 1-25% 26-50% 51-75% 76-100%

Subtotal

0 0

7 (41.2) 7 (41.2) 3 (17.6)

17

3 (17.6) 5 (29.4) 8 (47.1) 1 (5.9)

0

17

5 (29.4) 4 (23.5) 6 (35.3) 2 (11.8)

0

17

3 (3.6) 3 (3.6)

29 (34.9) 39 (47.0) 9 (10.8)

83

22 (37.3) 35 (42.2) 25 (30.1) 1 (1.2)

0

83

11 (13.3) 28 (33.7) 33 (39.8) 8 (9.6) 3 (3.6)

83a Waters: Tap, rain, bottled, mineral, unsugared tea; b Milks: Plain, soy; c Sweet drinks: Juice, cordial, soft drink (regular, diet), sports drink, sugared tea, flavoured milk.

Table 5: Distribution of occasions when treats were used in the previous 24 hours for sample population (W=266) and subgroup of (N=1000) Australian children.

Number of treat occasions in previous 24 hours




Total treat occasions (excl. sugar-free chewing gum)

None 1 2 3-5 6-9

102 (38.3) 87 (32.7) 47 (17.7) 27 (10.2) 3 (1.1)

49 (49.0) 31 (31.0) 16 (16.0) 4 (4.0)

0

Occasions for sweets and/or chocolate

None 1 2 3-5

166 (62.4) 66 (24.8) 27 (10.2) 7 (2.7)

66 (66.0) 26 (26.0) 8 (8.0)

0

Occasions for biscuits and/or cake None 1 2 3-4

166 (62.4) 69 (25.9) 27 (10.2) 4 (1.6)

73 (73.0) 22 (22.0) 5 (5.0)

0

Occasions for sugared chewing gum

None 1 2

251 (94.4) 12 (4.5) 3 (1.1)

98 (98.0) 2 (2.0)

0

Occasions for sugar-free gum None 1 2-3

236 (88.7) 20 (7.5) 10 (3.8)

87 (87.0) 10 (10.0) 3 (3.0)




Table 6: Distribution of caries risk factors in subgroup of 100 Australian children.

Caries risk factors in Caries-risk Assessment Tool


Male (N=50)

Female (N=50)

Total children (N=100)

n (%)

Regular use of dental care, established ‘dental home’

Irregular use of dental care

No usual source of dental care

27

23

0

26

24

0

53 (53)

47 (47)

0

No carious teeth in the past 24 months

Carious teeth in the past 12-24 months

Carious teeth in the past 12 months

22

4

24

22

5

23

44 (44)

9 (9)

47 (47)

No orthodontic appliance worn

Orthodontic appliance worn

50

0

49

1

99 (99)

1 (1)

Consumption of simple sugars or foods strongly associated with caries initiation primarily at mealtimes

Occasional between-meal exposures to simple sugars or foods strongly associated with caries

Frequent between-meal exposures to simple sugars or foods strongly associated with caries

22

20

8

18

19

13

40 (40)

39 (39)

21 (21)

Tooth brushing 2 or more times/day

Tooth brushing once/day

Tooth brushing less than once/day

42

5

3

40

8

2

82 (82)

13 (13)

5 (5)

Optimal systemic and topical fluoride exposure

Optimal topical but suboptimal systemic fluoride exposure

Suboptimal topical fluoride exposure

33

1

16

39

4

7

72 (72)

5 (5)

23 (23)

No visible plaque or gingivitis

Gingivitis, and no visible plaque

Visible plaque on anterior teeth and gingivitis

24

10

16

27

4

19

51 (51)

14 (14)

35 (35)

No enamel demineralisation

One area of enamel demineralisation

More than one area of enamel demineralisation

32

2

16

34

1

15

66 (66)

3 (3)

31 (31)

No enamel hypoplasia present

Enamel hypoplasia present

48

2

49

1

97 (97)

3 (3)

No molar-incisor hypomineralisation

Molar hypomineralisation present

Molar and incisor hypomineralisation present

41

7

2

41

6

3

82 (82)

13 (13)

5 (5)


Table 7: Distribution of caries risk factors and categories of caries risk for subgroup (N=100) of Australian children.

Caries risk factors in caries-risk Assessment Tool (CAT)

Distribution of children by caries risk categories

Age 4 to 7 years (N=17) Age 8 to 12 years (N=83)

Low risk

n (%)

Moderate risk

n (%)

High risk

n (%)

Low risk

n (%)

Moderate risk

n (%)

High risk

n (%)

Use of ‘dental home’

Time since last caries diagnosis/ restoration

Currently wears orthodontic/ oral appliance/s

Daily between-meal exposures to cariogenic foods and drinks

Fluoride exposure

Times per day child’s teeth brushed

Visible plaque

Gingivitis

Areas of enamel demineralisation

Enamel hypoplasia

Molar-incisor hypomineralisation

7 (7)

5 (5)

17 (17)

5 (5)

9 (9)

12 (12)

11 (11)

10 (10)

9 (9)

17(17)

14 (14)

10 (10)

0

naa

9 (9)

0

5 (5)

na

na

0

na

na

0

12 (12)

0

3 (3)

8 (8)

0

6 (6)

7 (7)

8 (8)

0

3 (3)

46 (46)

39 (39)

82 (82)

35 (35)

63 (63)

70 (70)

54 (54)

41 (41)

57 (57)

80 (80)

68 (8)

37 (37)

9 (9)

na

30 (30)

5 (5)

8 (8)

na

na

3 (3)

na

na

0

35 (35)

1 (1)

18 (18)

15 (15)

5 (5)

29 (29)

42 (42)

23 (23)

3 (3)

15 (15)

Distribution of 4-7 yr-olds by caries risk category (n = 17)

2 (12) 1 (6) 14 (82) - - -

Distribution of 8-12 yr-olds by caries risk category (n = 83)

- - - 8 (10) 8 (10) 67 (81)

a na: No moderate category designated in the Caries-risk Assessment Tool

Caries Risk Factors and Categories. About half the subgroup examined clinically had regular dental care; 47% accessed dental care irregularly (Table 6). No child was without a usual source of dental care. Patient records and clinical examinations showed 47.0% of subjects had experienced caries in the past 12 months, and 44.0% were caries-free in the past 24 months. The consumption of simple sugars or foods primarily associated with caries initiation was typically at mealtimes for 40.0% of children; occasional between-meal exposures were noted for 39.0% and frequent between-meal exposures for 21.0%. While most subjects had optimal topical and systemic fluoride exposure, for 23.0% the topical fluoride exposure was suboptimal. Visible plaque on anterior teeth was seen in 35.0% of subjects and 49% had gingivitis. Areas of enamel demineralisation were present in 34% of subjects, enamel hypoplasia in 3%, and MIH in 5%. Except for fluoride exposure, risk factors were distributed similarly for both genders.

Parental report of past caries and the observed caries for their child were compared (not tabulated) and parental underestimates were noted: no carious teeth in the past 24 months: 53% subjects reported vs. 49% observed; carious teeth in the past 12-24 months: 5% vs. 9%; carious teeth in the past 24 months: 36% vs. 47%.

Children were categorized by caries risk (Table 7). In decreas-ing order, factors most likely to place a child at high risk were: gingivitis (affecting 42%), time since last caries diag-nosis/restoration (35%), visible plaque (29%), and enamel demineralisation (23%). The age groups were distributed similarly for caries risk: 4-7 yr-olds: 82% high, 6% moderate, 12% low; 8-12 yr-olds: 81% high, 10% moderate, 10% low. Collapsing age groups, 81% were at high risk, 9% moderate, and 10% at low risk.




Reported intake of fluids and sweet treats


Caries in past 12 months

Caries free

in past 12 months

Total Signif χ2 (df)

Past caries experi-ence or

in past 24 months

No past caries experi-ence or

caries free in past

24 months

Total Signif. χ2 (df)

Sample a

N=251No. treat occasions in past 24 hours:0 1-2 3 or more

32 55 12

65 70 17

97 125 29

2.824 (2) p=0.244

55 95 22

42 30 7

97 125 29

10.250 (2) p=0.006*

Subgroup b

N=100Sweet drinks (SwD) consumed in eve/night c

None SwD consumed

29 18

46 7

75 25

8.363 (1) p=0.004*

37 19

38 6

75 25

5.411 (1) p=0.020

No. treat occasions in past 24 hours:0 1 2 or more

16 15 16

33 16 4

49 31 20

12.816 (2) p=0.002*

21 18 17

28 13 3

49 31 20

10.315 (2) p=0.006*

Daily between-meal cariogenic foods & drinks:Mainly at meals Occasionally Frequently

10 23 14

30 16 7

40 39 21

13.278 (2) p=0.001*

13 27 16

27 12 5

40 39 21

15.210 (2) p=0.000*

Fluoride exposure:Optimal Suboptimal

28 19

44 9

72 28

6.791 (1) p=0.009*

37 19

35 9

72 28

2.219 (1) p=0.136

Enamel demineralisation:None Present

20 27

46 7

66 34

21.725 (1) p=0.000*

28 28

38 6

66 34

14.520 (1) p=0.000*

Dental visits:Regular Irregular

41 12

12 35

53 47

28.860 (1) p=0.000*

17 39

36 8

53 47

26.195 (1) p=0.000*

a PRAT questionnaire group; b PRAT questionnaire and CAT examination subgroup; c Sweet drinks: Juice, cordial, soft drink (regular, diet), sports drink, sugared tea, flavoured milk; * p<0.01

Reported Past Caries, Fluid Intakes and Treats. Associations between intakes of fluids and treats in the past 24 hours and reported caries of 251 children (15 subjects were excluded due to parental uncertainty of past caries) were examined. No significant associations were seen between reported caries in the past 12 mths, or reported past caries at any time, and the variables: drinking frequency, fluids (water, milk, sweet drinks) in the evening/night, number of glasses of fluids in the past 24 hrs, fluid intakes as proportion of total fluid intake, and frequency of daily tooth brushing. The association between treats (confectionery, baked starches, sugared chewing gum) in the past 24 hrs and reported past caries at any time was statistically significant (p=0.006), but not with caries in the past 12 mths (p=0.244) (Table 8).)

Observed Caries, Fluid Intakes, Treats and Caries Risk Fac-tors. Associations between intakes of fluids and treats in the past 24 hours, caries risk factors, and observed caries were examined for the subgroup. No significant associations were seen between observed caries in the past 12 months

and 24 months and the following variables: drinking fre-quency, fluids (waters, milks, sweet drinks) in the evening/night, number of glasses of fluids consumed in the past 24 hours, fluid intakes as proportion of total fluid intake, daily tooth brushing frequency, flossing, visible plaque/gingivitis, enamel defects, and MIH.

Statistically significant associations (Table 8) were seen between the following: sweet drinks in the evening/night and observed caries in the past 12 months (p=0.004); treats in the past 24 hours and observed caries in both the past 12 months and 24 months (p=0.002; p=0.006); daily between-meal exposure to sweet drinks/foods and observed caries in the past 12 months and 24 months (p=0.001; p=0.000); sub-optimal fluoride exposure and observed caries in the past 12 months (p=0.009); enamel demineralisation and observed caries in the past 12 months and 24 months (p=0.000; p=0.000); irregular dental care and observed caries in past 12 months and 24 months (p=0.000; p=0.000).

Table 8: Significant associations between fluid intake and treat occasions in past 24 hours and caries experience.


Multiple logistic regression and odds ratios of observed caries in the past 12 and 24 months and independent vari-ables. The final model for observed caries in the past 12 and 24 months showed statistically significant associations with these independent variables: in the past 12 months: increasing frequency of treats consumption in the previ-ous day, suboptimal fluoride exposure, presence of enamel demineralisation; in the past 24 months: presence of enamel demineralisation, irregular dental visitation (Table 9).

DiscussionThis study examining dental caries experience and intakes of fluids and sweet treats was conducted on a convenience sample of 266 primary school children aged 4-12 years. It is acknowledged that the sample size was small but it was within the range of similar clinical studies [Blum et al., 2005; Tam et al., 2006]. Parental recall of caries experience and of dietary intakes in the past 24 hours was intrinsic to the study. This method is commonly used in epidemiological studies, to provide an indication of overall fluid and treat intakes. Assessing response reliability, parents indicated the information given was typical of their child’s usual intake of fluids (for 87.0%) and treats (for 72.9%). However, a child’s diet may have changed since past diagnosis/restoration of caries, and the responding parent may have been unaware of their child’s caries history or diet.

The subgroup of 100 children examined clinically appeared similar to the sample population in many aspects, allow-ing generalizations to be made to the sample population. The subgroup appeared to be a representative subset of the sample with respect to age and gender distribution; frequency and pattern of fluid intake; types, volumes and distributions of fluids consumed; distribution and frequency of treats consumed; oral hygiene practices, and distribution of parentally-reported past caries.

The original PRAT questionnaire [Shenkin et al., 2003] was modified for the present study, expanding questions on fluid intake and omitting a scoring system for caries risk which was replaced with the CAT [AAPD, 2007-08]. The CAT includes socio-economic status (SES) as a risk factor; this factor was omitted as the sample population was limited to children of low SES parents holding health-care cards allowing care at a public dental hospital. Using the other CAT risk factors, the final caries risk status was similar for subjects aged 4-7 years and those aged 8-12 years: overall, 81% were categorized as high caries risk, 9% were moderate caries risk and 10% were low risk. However, if SES were included as a risk factor, all children in the study would be considered high caries risk.

In the last 24 hours, most children had consumed tap water and milk; a few drank bottled water; half drank fruit juice; and less than one third consumed soft drink. The mean fluid intake of 1.50 ± 0.50L was approximately 500mL higher than reported in other studies of similarly-aged children in Aus-tralia by the 1995 NNS survey [ABS, 1999] and others [Bell et al., 2005], and in the USA [Forshee and Storey, 2003]. This may reflect parental overestimation of volumes or fluid expo-sures, or differing approaches to estimations by researchers. Accurate measurement of fluid intake in such studies is only possible with direct observation, potentially altering intake patterns resulting in atypical observations.

The study was conducted in the fluoridated city of Melbourne. Water was the most popular drink consumed, with 90.2% of the sample drinking at least one glass of tap water in the past 24 hours. Information was not obtained on whether families filtered the reticulated water, potentially removing fluoride. The mean volume of water consumed (0.82 ± 0.42L) was higher than that reported in the 1995 NNS survey (0.54L for 4-7 yr-olds and 0.69L for 8-11 yr-olds) [ABS, 1999]. Although both studies obtained information by 24-hour recall, the dif-ference may be due to parental misinterpretation of volumes or number of drinks. The low intake of bottled water in the

Table 9: Logistic regression model for the occurrence of observed caries in subgroup (N=100 children) and association with independent variables.

Observed caries Independent variable Reference independent

variable

Com-parative

independent variable

OR (95% CI) p value Overall p value

In past 12 months Reported treat occasions in past 24 hours

0 1 0

1 ≥2≥2

3.50 (1.42, 8.62)4.41 (1.25, 15.63)5.88 (1.34, 25.64)

0.3280.019*0.002*

0.007*

Reported fluoride exposure

Optimal Suboptimal 3.02 (1.01, 9.07) 0.049* 0.049*

Enamel demineralisation None Present 8.42 (2.90, 24.47) 0.000* 0.000*

In past 24 months Enamel demineralisation None Present 4.17 (1.37, 12.66) 0.000* 0.000*

Dental visitation pattern Regular Irregular 8.00 (2.97, 21.74) 0.012* 0.012*

* significant p<0.05




past 24 hours (by 8.6% in the sample, 12% in the subgroup) suggests that these primary school children were not con-suming bottled water preferentially to fluoridated tap water.

The low mean milk intake for the sample (0.30 ± 0.24L) was similar to that reported in the 1995 NNS survey (0.28L for 4-7 yr-olds and 0.28L for 8-11 yr-olds) [ABS, 1999]. The Australian Dietary Guidelines recommend consuming two to three serves of dairy product per day, where one serving is equivalent to 0.25L of milk [NHMRC, 2008]. These findings of low milk intake over the past decade support reports of declining dairy consumption in children elsewhere [Ramper-saud et al., 2003; Friedman et al., 2007]. In the present study 26.0% of the sample had not drunk milk in the past 24 hours, but sweet drinks did not appear to be displacing milk intake as children who did or did not drink milk differed little in their proportional consumption of other fluids, agreeing with other reports of children in Australia [Tam et al., 2006] and the USA [Story et al., 2004].

Fruit juice was consumed in the previous 24 hours by almost half the sample population, with almost 90% drinking less than one glass. The mean juice intake of 0.13L was less than that reported by the 1995 NNS survey (0.31L for 4-7 yr-olds and 0.29L for 8-11 yr-olds) [ABS, 1999]. Juice intake per se was not associated significantly with either parentally-reported or observed caries, agreeing with the findings of a 1971-1974 USA national survey [Ismail, 1986]. Regular soft drink was consumed by 30.5% of the sample in the last 24 hours, approximating the proportion (29.7%) reported in a larger survey of children conducted in the same Australian state [Sanigorski et al., 2006]. In the present study, 76.3% of the sample had consumed less than half a glass of soft drink, with a mean intake of 0.12L. This was less than the mean intake of 0.17L calculated in the 1995 NNS survey for 7-11 yr-olds [ABS, 1999], but similar to the frequency of soft drink intake reported from a mail-in questionnaire survey of USA children [Grimm et al., 2004].

The significant association between observed caries in the past 12 months and the intake of sweet drinks at night cor-roborates an earlier report from a much larger study in the USA on the cariogenicity of sweet drinks in children [Ismail et al., 1984]. The latter study showed significant associations between the frequencies of intakes of sweet drinks between meals and with meals, and high DMFT scores [Ismail et al., 1984]. Parents may well be unaware of the cariogenic risk to the teeth of sweet fluids consumed overnight.

The number of treat occasions in the past 24 hours and parentally-reported past caries at any time were associated significantly. This was confirmed in the subgroup, where statistically significant associations were seen between the frequency of treat occasions in the past 24 hours and observed past caries, and between the frequency of intake of sweet drinks plus treats and observed caries. These find-ings support those of others [Ismail et al., 1984; Marshall et

al., 2003]. Of note, these significant findings were obtained from parental recall of past caries and 24 hour dietary recall, rather than direct observation, and with caries data recorded as either parental report or as simple binary data (i.e., clinical observation of caries/restorations present or absent). These findings suggest that the two tools used, the Paediatric Risk Assessment Tool and the Caries-risk Assessment Tool, can be valuable adjuncts in both clinical practice for dentists and as survey tools.

For the purposes of the CAT, caries was defined as a lesion requiring restoration, i.e., the end stage of the lesion. Enamel demineralisation and observed caries in the past 12 months and 24 months were associated significantly, as expected, since enamel demineralisation is the earliest visible sign of caries. In comparison with caries observed in the CAT exam-ination, parents of children in the subgroup underestimated their caries history. This is of note, as no significant associa-tions were found between parentally-reported caries in the sample and either fluid intake or oral hygiene habits. Given the close representation of the sample by the subgroup, it is likely that parentally-reported caries was also underesti-mated in the sample population.

Clinical examination showed 47.0% of the subgroup had experienced caries in the past 12 months, 9.0% had expe-rienced caries in the past 12-24 months, and 44.0% had no caries in the past 24 months. Strong associations between irregular dental care and increasing caries experience within the last 12 months and 24 months were found. These obser-vations highlight the importance of regular dental visits to identify early disease, review caries risk and educate par-ents in their role in caries prevention. Similar associations between caries and lack of dental visits in the last 12 months for young children in the USA were noted by others [Dye et al., 2004].

No significant associations were seen between oral hygiene habits and parentally-reported caries, in agreement with a USA study of low income children [Kolker et al., 2007]. How-ever, in the present study, observed caries in the subgroup in the past 12 months was associated significantly with subop-timal fluoride exposure. In the sample, 13.9% were using a lower fluoride concentration toothpaste than recommended by age, thereby receiving suboptimal fluoride exposure, and 16.7% used a higher fluoride concentration toothpaste than recommended in the Australian guidelines [ARCPOH, 2006]. Since it is not known for how long the children had been using these toothpastes, no conclusions can be drawn as to the level of caries protection afforded. The use of fluo-ride toothpaste of the appropriate concentration for age and caries risk should be addressed by dentists and dental aux-iliaries in clinical practice to ensure children are receiving the full benefits of fluoride. Dental professionals should also con-sider each child’s exposure to other fluoride modalities such as fluoridated water when recommending the appropriate fluoride toothpaste, in accordance with current guidelines.


ConclusionsThis retrospective study of the intakes of fluids and sweet treats of 266 primary school children aged 4-12 years, 81% of whom were deemed to be at high caries risk, draws three conclusions:

● The PRAT and CAT are valuable tools in assessing children’s caries risk.

● Noting that observed caries was associated significantly with suboptimal fluoride exposure, evening sweet drinks, frequency of treats, and frequency of sweet drinks plus sweet treats in the last 24 hours, the cariogenic risk of these intakes must be emphasised to parents.

● All parents, and particularly those of children assessed at high risk from intakes of sweet drinks and sweet treats, suboptimal fluoride exposure, or enamel demineralisation, must be encouraged to obtain regular dental care for their children.

ReferencesAAPD, American Academy of Pediatric Dentistry Council on Clinical Affairs.

Policy on use of a caries-risk assessment tool (CAT) for infants, children and adolescents. Pediatr Dent 2007-08;29:29-33.

Armfield J, Slade GD, Spencer AJ. Water fluoridation and children’s dental health: The child dental health survey. Australia 2002. Cat. No. DEN 170. Dental statistics and research series. No. 36. Canberra: Australian Insti-tute of Health and Welfare, 2007.

Armfield J, Spencer AJ. Quarter century of change: caries experience in Aus-tralian children, 1977-2002. Aust Dent J 2008;53:151-9.

ABS, Australian Bureau of Statistics. National Nutrition Survey Nutrient Intakes and Physical Measurements Australia 1995. Canberra, AGPS, 1999.

AIHW, Australian Institute for Health and Welfare. International health – how Australia compares, AIHW Cat. No. PHE 8. Canberra: AIHW 1998.

ARCPOH, Australian Research Centre for Population Oral Health. The use of fluorides in Australia. Aust Dent J 2006;61:195-9.

Bell A, Kremer PJ, Magarey AM, Swinburn BA. Contribution of ‘noncore’ foods and beverages to the energy intake and weight status of Australian chil-dren. Eur J Clin Nutr 2005;59: 639-45.

Blum J, Jacobsen D, Donnelly J. Beverage consumption patterns in elemen-tary school aged children across a two-year period. J Am Coll Nutr 2005;24: 93-8.

Dye B, Shenkin JD, Ogden CL, et al. The relationship between healthful eat-ing practices and dental caries in children aged 2-5 years in the United States, 1998-1994. J Am Dent Assoc 2004;135: 55-66.

Fontana M, Zero DT. Assessing patients’ caries risk. J Am Dent Assoc 2006;137:1231-9.

Forshee R, Storey M. Total beverage consumption and beverage choices among children and adolescents. Int J of Food Sciences and Nutrition 2003;54:297-307.

Friedman L, Snetselaar L, Stumbo P, et al. Influence of intervention on bever-age choices: trends in the Dietary Intervention Study in Children (DISC). J Am Diet Assoc 2007;107: 586-94.

Grimm G, Harnack L, Story M. Factors associated with soft drink consump-tion in school-aged children. J Am Diet Assoc 2004;104: 1244-9.

Ismail, A. Food cariogenicity in Americans aged from 9 to 29 years assessed in a national cross-sectional survey, 1971-74. J Dent Res 1986;65: 1435-40.

Ismail A, Burt BA, Eklund SA. The cariogenicity of soft drinks in the Unite States. J Amer Dent Assoc 1984;109:241-5

Ismail A, Tanzer JM, Dingle JL . Current trends of sugar consumption in devel-oping societies. Community Dent Oral Epidemiol 1997;25: 438-43.

Ismail A, Sohn W, Tellez M, Amaya A, Sen A, Hasson H, Pitts NB. The International Caries Detection and Assessment System (ICDAS): an inte-grated system for measuring dental caries. Comm Dent Oral Epidemiol 2007;35:170-8.

Kolker J, Yuan Y, Burt B, Sandretto A, Sohn W, Lang S, Ismail A. Dental car-ies and dietary patterns in low-income African American children. Pediatr Dent 2007;29: 457-64.

Löe H, Silness J. Periodontal disease in pregnancy: increased prevalence and severity. Acta Odontol Scand 1963;21:533-8.

Marshall T, Levy SM, Broffitt B, et al. Dental caries and beverage consumption in young children. Pediatrics 2003;112: 184-91.

NHMRC Dietary Guidelines for Children and Adolescents in Australia. Can-berra: Australian Government; 2003. Available at: http://www.nhmrc.gov.au/publications/synopses/_files/n34.pdf. Last accessed 16 July 2008.

Perneger T. What’s wrong with Bonferroni adjustments. Br Med J 1998;316:1236.

Rampersaud G, Bailey LB, Kauwell GP. National survey beverage consump-tion data for children and adolescents indicate the need to encourage a shift toward more nutritive beverages. J Am Diet Assoc 2003;103: 97-100.

Rugg-Gunn A, Fletcher ES, Matthews JNS, et al. Changes in consumption of sugars by English adolescents over 20 years. Public Health Nutr 2007;10: 354-63.

Sanigorski A, Bell AC, Kremer PJ, Swinburn, BA. Lunchbox contents of Australian school children: room for improvement. Eur J Clin Nutr 2005;59:1310-16.

Sanigorski, A., Bell AC, Swinburn, BA. Association of key foods and bev-erages with obesity in Australian schoolchildren. Public Health Nutr 2006;10: 152-7.

Selwitz R, Ismail AI, Pitts NB. Dental caries. Lancet 2007;369:51-9.Sheiham A. Dietary effects on dental diseases. Public Health Nutr

2001;4:569-91.Shenkin J, Heller KE, Warren JJ, Marshall TA. Soft drink consumption and

caries risk in children and adolescents. Gen Dent 2003; 51: 30-6.Silness J, Löe H. Periodontal disease in pregnancy II. Correlation between oral

hygiene and periodontal condition. Acta Odontol Scand 1964;22:121-35.Sivaneswaran A, Barnard PD. Changes in the pattern of sugar (sucrose)

consumption in Australia 1958-1988. Community Dent Health 1993; 10: 353-63.

Story M, Forshee RA, Anderson PA. Associations of adequate intake of cal-cium with diet, beverage consumption, and demographic characteristics among children and adolescents. J Am Coll Nutr 2004; 23: 18-33.

Tam C, Garnett SP, Cowell CT, Campbell K, Baur LA. Soft drink consumption and excess weight gain in Australian school students: results from the Nepean study. Int J Obes 2006;30: 1091-3.

Tahmassebi J, Duggal MS, Malik-Kotru G, Curzon MEJ. Soft drinks and dental health: A review of the current literature. J Dent 2006; 34: 2-11.

Touger-Decker R, van Louveren C. Sugars and dental caries. Am J Clin Nutr 2003; 78: 881S-892S.

Trueblood R, Kerins CA, Seale S. Caries risk assessment practices among Texas pediatric dentists. Pediatr Dent 2008;30:49-53.

Weerheijm K, Duggal M, Mejare I, et al. Judgement criteria for molar inci-sor hypomineralisation (MIH) in epidemiologic studies: a summary of the European meeting on MIH held in Athens, 2003. Eur J Paediatr Dent 2003;4:110-13.

Winter G, Brook AH. Enamel hypoplasia and anomalies of the enamel. Dent Clin North Am 1975;19:3-24.

World Health Organisation. Oral health surveys: Basic Methods. Geneva, World Health Organisation, 1997.


intake of sweet drinks and sweet treats versus reported and observed caries experience

Documents