PEDIATRIC DENTAL JOURNAL 22(2): 117-124, 2012

Influences of diet on caries activities and caries-risk grouping

in children, and changes in parenting behavior
Michiko Nishimura, Omar M.M. Rodis , Seishi Matsumura" and Michiyo
Matsumoto-Nakano'
2

Pediatric Dentistry, Okayama University Hospital of Medicine and Dentistry

2-5-1 Shikata-cho, Kita-ku, Okayama 700-8525, JAPAN
Department of Pediatric Dentistry,
Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical
Sciences
2-5-1 Shikata-cho, Kita-ku, Okayama 700-8525, JAPAN

Abstract BACKGROUND: Dental caries incidence in

early childhood is known to influenced by the behavior of
parent with their children, and clinicians and dental staf
are advised to provide parents with efective oral health
instructions. The objectives of this study were to identify
the influence of diet of 18- and 24-month-old children on
caries activities and investigate changes related to the
behavior of their parents after receiving health
instructions regarding caries risk for 2-year-old children.
METHODS: The subjects were 1,206 child-parent pairs.
The children participated in 18-, 24-, and 42-month-old
health examinations at Kurashiki City Public Health Center
in Kurashiki City, Japan. Cariostat, a caries activity test
(Dentsply-Sankin Co., Tokyo), was conducted and the
children were then classified into 6 caries-risk groups
based on the 42-month-old predictive cutof points. Their
parents were given oral health instructions on caries
prevention by dental hygienists of the Kurashiki City Public
Health Center. In addition, a questionnaire regarding diet
was given to identify its influence on caries activities in 18and 24-month-old caries activities in 18- and 24-monthold children, as well as the influence of changes in
parenting behavior. RESULTS: A significant number of
children in the high-risk group received breast feeding or
bottle-feeding with liquids other than water at 18 months
of age. Also total time for sucrose- containing food intake
was significantly associated with increased caries activity
at 18 months of age. After giving oral health
instructions to parents of the 18-month-old children
dietary habits significantly correlated with the high-risk
group at 24 months of age were breast feeding or bottlefeeding with liquid other than water, total intake time of
sucrose-containing food, and frequency of sucrosecontaining foods intake. Furthermore, parents whose
children were in the higher caries-risk group at 18
months of age showed a lower level of change in
parenting behavior as compared to those with children in
the lower caries-risk group. CONCLUSION: It is important
to assess problematic dietary habits in accordance with

Key words
Caries activity,
Caries-risk
grouping,
Changes in
behavior,
Dietary habit,

Introduction

early prediction of caries-risk have been discussed

without giving too scientific or practical details .
Koch' emphasized the importance of early prediction The American
Academy of Pediatric Dentistry
and determination of caries-risk and the problems of
(AAPD) reported that
caries-risk assessment is an
*Correspondence to: Michiko Nishimura essential element of contemporary clinical
23)

11

118

Nishimura, M., Rodis, O.M.M.,

Matsumura, S. et al.
Oral examination by the
dentists of Kurashiki City
Dental Society

Oral examination by the

two pediatric dentists of
Okayama University

Questionnaires

Questionnaires

Oral hygiene instruction

Oral hygiene instruction

Cariostat testing

Cariostat testing

The subjects who were

18-month-old health examination

24-month old oral examination

42-month old health

born between Oct. 2000

from Apr. 2002 to Mar. 2003

from Oct. 2002 to Sep. 2003

from Apr. 2004 to

and Sep. 2001

Mar. 2005

Fig. 1 Time schedule of the investigation

18-, 24-, and 42-month-old examinations were carried out every month.

the concept of risk assessments . In our previous

2 Cariostat sampling
periods. 2) No Cariostat test
study ,we performed caries-risk assessment for very undertaken at 18 months
of age. As result, 1,206
young children using Cariostat, a caries activity test subjects were enlisted as
participants in this study.
(Dentsply-Sankin Co., Tokyo) and established 6 This study was performed
through Kurashiki City
caries-risk groups. We speculated the parent' comPublic Health Center
ethical committee's approval
pliance with oral health instructions was associated
and local city health
oficers completely sealed each
with caries-risk grouping of their children. Dental
subjects' private
information and released the data
caries is a multifactorial, chronic, and lifestyle-to us in coded form.
related disease. Hunter' considered diet, such as
sucrose intake, frequency of sucrose-containing
Methods
foods intake and total exposed time to such foods, Oral Examination
System of Kurashiki City
oral hygiene, and micro flora, to be as lifestyle Oral examinations of 18- and
42-month-old children
related factors while Reich et al. added child
are routinely performed
in Japan as part of governbehavior to that list. However, the lifestyles and
ment sanctioned national
dental check-up activities.
habits of children are primarily controlled by their In addition, a 24-monthold oral examination is conparents. Therefore, parent education, understanding ducted by Kurashiki City's
part of the community
of nutrition, socioeconomic status and behavior are
general health program.
Monthly programs for those
all related to prevention of dental caries in their ages began in 1975, 1961,
and 1980, respectively.
children .
In the present study, 2 pediatric dentists of Okayama
The objectives of this longitudinal study were
University performed
)

6)

8)

9-11)

CHILD DIETARY INFLUENCE AND CHANGES IN BEHAVIORS

119

42-month-old predicted cutoff based

on 24-month-old Cariostat scores
24-mo

18-mo

0.5

1.0

1.5

0
0.5
1.0
1.5

Low caries-risk

2.0
2.5
3.0

Moderate caries-risk
(MR)
n=261

n=538
n=145

(LR)

2.0

2.5

3.0

Progressive
border caries-risk
(PB)

Moderately high
caries-risk
(MHR)
n=60

Improved
border caries-risk
(IB) n=124

High caries-risk
(HR)

n=78

Fig. 2 Predicted caries-risk assessment at 42 months based on the 18- and 24-month cutof
points

Local city health oficers completely sealed and brush your child's teeth?
2) How many times
subjects private information and released the data
a day does your child
ingest sucrose-containing
to us in coded form.
foods? 3) Do you determine the total time of your
child's sucrose-containing foods intake? 4) Does
Six caries-risk groups
your child continue to breast feed or drink a liquids
The 42-month-old predicted cutof points based
other than water
through a bottle? These questionon the 18- and 24-month-old Cariostat test results
naires were sent to
individual subjects by mail along
were 1.5 and 2.0, respectively . The 6 caries-risk with a notification of their
examination date. The
groups used in the present study were as follows:
parents completed and
brought it to Kurashiki City
(1) Low risk (LR): children who had a Cariostat Public Health Center on
the day of their child's score at or lower than the 18-month-old cutof point,
scheduled examination.
and a score lower than the 24-month-old cutof
point. (2) Moderate risk (MR): children who had a Oral health
instructions
Cariostat score higher than the 18-month-old cutof The same Kurashiki
City public dental hygienists
point but had scores lower than the 24-month-old provided the parents with
instructions for caries
cutof point. (3) Progressive border (PB): children prevention. The results of
the oral examinations
who had a Cariostat score at or lower than the 18and the Cariostat tests
as well as completed quesmonth-old cutof point but reaching the 24-month- tionnaires were
computerized and provided to us as
old cutof point. (4) Improved border (I13): children coded data. These results
6)

120

Nishimura, M., Rodis, O.M.M., Matsumura, S. et al.

Table 1 Significant lifestyles changes at 18 months of ageTable 2 Significant lifestyles changes

at 24 months of age
L R M R P B I B M H R
LR MR PB IB MHR
HR
Q.3

LR

Q.3**

MR

Q.4***
Q.4*** Q.4*

Q.3*

PB
IB

Q.4***
Q.4*

LR
MR

Q.4**
Q.4*
Q.2*, Q.3*,
Q.4*

PB
IB

MHR

MHR

HR

HR

*: P<0.05, **: P<0.01, ***: P<0.001

*: P<0.05, **: P<0.01, ***: P<0.001

Q.1 Do you check and brush your child's teeth?Q.1 Do you check and brush your child's teeth?
Q.2 How many times a day does your child ingest sucroseQ.2 How many times a day
does your child ingest sucrosecontaining food?
containing food?
Q.3 Do you determine the total time of your child's sucroseQ.3 Do you determine the
total time of your child's sucrosecontaining foods intake?
containing foods intake?
Q.4 Does your child continue to breast feed or drink liquids
Q.4 Does your child continue to
breast feed or drink liquids
other than water through a bottle?
other than water through a bottle?

LR
n=

MR
n
261

PB

jjjj

n=
145

IB
n=1

MHR
n=
60

HR
n=
78

Less than 2 times

at both ages

100%
*: P<0.05, **: P<0.01, ***: P<0.001
From more than 3 times to From less than 2 times toMore than 3 times at both
l e s s t h a n 2 t i m e s m o r e t h a n 3 t i m e s ___ages

Fig. 3 Changes in patient behavior from 18 to 24 months old

used to investigate changes in behavior from 18 to results of the 18-month-old

children. Sugar-intake
24 months of age. A P-value of 0.05 was considered total time was related to
the 24-month-old cutof to be significant. point, as children belonging to the
MR, PB, and IB
groups had caries activities below the 42-month-old
Results
predictive cutof point based on the 18-month-old
cutof point (Cariostat test result of 1.5). Breast-

CHILD DIETARY INFLUENCE AND CHANGES IN BEHAVIORS

121
Q.3 Do you determine the total time of your child's sucrose-containing foods intake?

LR
(Yes or No)
n = 538

MR

n = 261

PB

n =145

IB
n

MH
R
n=

HR
n=
78

100%
*: P<0.05, **: P<0.01, ***: P<0.001

Yes at both

From no to

From yes to no No at both ages

Fig. 4 Changes in patient behavior from 18 to 24 months old

Table 2 shows the influence of lifestyle on Cariostat 4) Does your child continue
to breast feed or drink
test results of the 24-month-old children. Againliquids other than water
through a bottle?
breast-feeding or liquid intake other than water had Changes in the
behavior of children in HR group
a significant relationship with increased risk for were significantly worse as
compared to those in
caries, at 24 months old.
LR, MR, and PB groups from 18 to 24 months old.
Changes in behavior of children belonging to the IB
Changes in parent behavior from 18- to
and MR groups were significantly
worse as compared
24-month examination
to LR group from 18 to 24 months old. Changes in
1) Do you check and brush your child's teeth? children's behavior belonging
to moderate cariesThere were no data released from the Kurashiki City risk group were
significantly worse than children Public Health Center.belonging to low-cariesrisk group (Fig. 5).
2) How many times a day does your child ingest
sucrose-containing foods?
Discussion
Changes in the behavior of children in the HR group
were significantly worse as compared to those in the Caries is a multi-factorial
disease " and the most
LR, MR, PB, and IB groups from 18 to 24 months important dietary
component contributing to cariesold (Fig. 3).
risk without any doubt is ingestion of fermentable
.

122Nishimura, M., Rodis, O.M.M., Matsumura, S. et al.

Q.4 Does your child continue to breast feed or drink liquids other than water through a bottle?
(No or Yes)
L
n=5

MR

n=2
61

PB

n=1
45

**

TB

n=1
24

MH
R
n=

H
R

n=7

100%
*: P<0.05, **: P<0.01, ***:
P<0.001

0
No at both

"K
4

From yes
to no

From no to yes Yes at both ages

Fig. 5 Changes in patient behavior from 18 to 24 months old

children is still immature . Furthermore, thebrushing with their 24-monthold children.

mother's parenting behavior toward the child influ- In contrast, there were no
significant diferences
enced the child's caries status . In our previous in dietary habits among the
LR, MR, PB, and HR
study" , we reported that the 18-month-old caries groups, which showed the
importance of dietary
activity influenced the child's future oral conditions
habits in 18-month-old
children to prevent caries
compared to caries activity at more than 24 months initiation. Children in the
HR group did not signifiof age. This result supported Newbrun's conclusion" .cantly change their dietary
habits after the parent
Newbrun concluded as follows "In the clinicalreceived oral care instructions,
such as the frequency
situation, the accurate prediction of caries is not of sucrose-containing food
intake. On the other hand,
as important as the assessment of the individual
there were significant
diferences for the total time
caries risk and risk factors. Even with routinely of sucrose-containing food
intake among children
available clinical and sociodemographic information belonging to LR, MR,
PB, and IB groups whose
at clinical examination, a dentist can identify high
Cariostat scores were
below or at the predicted
caries risk subjects with good accuracy".
cutof point at age of 24 months.
Furthermore, there
1738)

19-21)

CHILD DIETARY INFLUENCE AND CHANGES IN BEHAVIORS

health instructions for parent, especially those with

very young children, are efective tools for caries
prevention. However, compliance by the parents to
early determination of

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