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Brian A.Burt, B.D.S., Ph.D., M.P.H., and Satishchandra Pai, B.D.S., M.D.S., M.P.H.:

Is Sugar Consumption Still a Major Determinant Of Dental Caries? A Systematic Review

The recognition that sugars have an etiological role in dental caries has been with us for a long time. This relationship, however, may be changing. Per capita consumption of all sugars in the United States has risen over the last 25 years or so, while the incidence of caries in permanent teeth has declined. This changed relationship may be the result of widespread exposure to fluoride. The specific question to be examined in this review is: In the modern age of extensive fluoride exposure, do individuals with a high level of sugar intake, measured either as total amount or high frequency, experience greater caries severity relative to those with a lower level of intake?

Materials and Methods

Our review began with a search of the MEDLINE and EMBASE databases for papers on sugar and dental caries published between January, 1980, and July, 2000. The year 1980 was chosen as a reasonable starting point for the era of populationwide fluoride exposure in the United States. Only reports in English were considered for inclusion in the review. Other specific inclusion and exclusion criteria were applied, and an extensive search expression was developed with the assistance of an experienced librarian.

The initial search produced 809 reports. This set was divided into two halves alphabetically, and a different reader examined each half. The first assessment was based on each paper¹s title and abstract, and clearly irrelevant articles were discarded. This reduced the original 809 reports to 134. After those were read, another 65 papers were eliminated because they did not satisfy all inclusion/exclusion criteria. This left 69 papers, including 26 cohort studies, 4 case-control studies, and 39 cross-sectional studies.

Categories for scoring the individual papers were then established. The maximum score was 100, and the scores of the papers ranged from 12 to 79. In order to base the final results on papers of good quality, we included only those that scored 55 or higher, a total of 36. We then rated the risk of sugar-associated caries among the subjects of the papers according to the risk ratio correlation coefficient or beta coefficient given by the authors.

The Results

The two readers were acceptably uniform in their judgments of the papers. The correlations of readers¹ scores on five randomly-chosen papers was high (Pearson¹s r = 0.87), and there was no significant difference in mean scores (p = 0.56).

Table 1 shows the distribution of the reports that found a strong, a moderate, or a weak relation between sugars intake (any measure) and caries experience, and displays these relations by type of study design. By our criteria, only one report showed a strong relation. Nineteen papers found a moderate relationship between sugars intake and caries development, while the remaining 16 found the relationship to be weak-to-none.

Table 1. Distribution of 36 studies showing strong, moderate, and weak relation between sugars intake and dental caries by type of study design.

	Strong	Moderate	Weak	Total
Cohort studies	1	6	5	12
Case-control studies	0	1	0	1
Cross-sectional studies	1	9	13	23
Total	2	16	18	36

Discussion

The predominant design used in the papers was cross-sectional (23 of the 36), even though that was probably the weakest design with which to address the question. A cohort design would be strongest for this question, but such studies are expensive and include a number of inherent problems (e.g., nature of dietary records, definitions of meals and snacks). Of the remaining studies, 12 were cohort studies and only 1 was a case-control study.

Of the 23 cross-sectional studies, 16 studied the permanent dentition, as did 7 of the 12 cohort studies. Eight of those 12 were conducted for periods of 2 years or less, which may hardly be long enough to permit the true relationship to be discerned. Only 2 small-scale studies among the 36 dealt with root caries, and both concluded that a diet which promotes coronal caries also promotes root caries. With an aging population and greater retention of teeth, root caries is likely to grow as a public health issue.

Nearly all of the studies dealt with the relationship between the means of caries status and sugars exposure, rather than distributions. It seems likely that while the reduced risk of sugar consumption in the fluoride age has an overall population benefit, there are still some identifiable subgroups who do not benefit. Further research could focus on these differences.

The findings of our review are relevant to questions 2, 3, and 5 of the six conference questions:

2. What are the best indicators for an increased risk of dental caries?

Persons with high sugar consumption, whether measured in frequency or amount, usually have higher counts of cariogenic bacteria than people who have low consumption. This relationship is not always linear, however, and what constitutes "high" and "low" consumption is unclear; high bacterial counts do not by themselves always relate to a clinical caries outcome. Sugar consumption, however, is likely to be a more powerful indicator of risk of caries infection in persons who do not have regular exposure to fluoride.

3. What are the best methods available for primary prevention of dental caries initiation throughout life?

Where there is good exposure to fluoride, sugar consumption is a moderate-to-mild risk factor for caries in most people. Hence, avoiding consumption of excess sugar is a justifiable part of caries prevention, if not the most crucial aspect.

5. How should clinical decisions regarding prevention and/or treatment be affected by detection methods and risk assessment?

A patient assessed to be at high risk for caries needs to be aware that sugar consumption increases the risk. The clinician can therefore conduct a dietary assessment to identify how sugar consumption can reasonably be curtailed. For a patient assessed to be at low risk of caries, this procedure is probably unnecessary.

In conclusion, our findings are consistent with the view that restriction of sugar consumption still has a role to play in the prevention of caries, but this role is not as strong as it was in the prefluoride era.

Further Research Needs

• Research is needed to determine dietary risk factors for root caries in older people, balanced by the effect of daily fluoride in preventing root caries.

• Research is needed to identify the factors that render some children more susceptible than others to developing caries in the presence of a high-sugar diet. It may be that such individuals are not well-exposed to fluoride, or the explanation may be more complex.

• Studies are needed of how best to bring the benefits of reduced caries enjoyed by the majority of children to high-risk children (the poor, racial/ethnic minorities).

References

Burt BA, Eklund SA, Morgan KJ, Larkin FE, Quire KE, Brown LO, et al. The effects of sugars intake and frequency of ingestion on dental caries increment in a three-year longitudinal study. J Dent Res 1988;67:1422­9.

Gibson S, Williams S. Dental caries in pre-school children: associations with social class, toothbrushing habit and consumption of sugars and sugar-containing foods. Further analysis of data from the National Diet and Nutrition Survey of children aged 1.5-4.5 years. Caries Res 1999;33:101­13.

Kleemola-Kujala E, Rasanen L. Relationship of oral hygiene and sugar consumption to risk of caries in children. Community Dentistry Oral Epidemiol 1982;10:224­33.

Rugg-Gunn AJ, Hackett AF, Appleton DR, Jenkins GN, Eastoe JE. Relationship between dietary habits and caries increment assessed over two years in 405 English adolescent school children. Arch Oral Biol 1984;29:983­92.

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Index of Abstracts | Agenda.

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The main page for this site is located at http://www.lib.umich.edu/dentlib/nihcdc/ and is maintained by the University of Michigan Dentistry Library (dentistry.library@umich.edu) in partnership with the National Institutes of Health, National Institute of Dental and Craniofacial Research. Please see also the Consensus Development Program pages, and in particular the NIH Consensus Development Conference on Caries. Copyright © 2000 Regents of the University of Michigan. All rights reserved. URL of current page: http://www.lib.umich.edu/dentlib/nihcdc/abstracts/burt2.html Last Update: 10:32 AM EST on Monday, December 31, 2007

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