Dental Science - Case Report

Role of dietary habits and diet in caries

occurrence and severity among urban
adolescent school children
V. C. Punitha, A. Amudhan1, P. Sivaprakasam, V. Rathanaprabu2

Department of Community
Medicine, Meenakshi
Medical College and
Research Institute,
University of MAHER,
Kanchipuram, 1Department
of Oral Medicine and
Radiology, Balaji Dental
College and Hospitals,
Chennai, 2Department of
Dentistry, Kanchi Kamakoti
Child Trust Hospital,
Chennai, Tamil Nadu, India
Address for correspondence:
Dr. V. C. Punitha,
Email:drpunitha77@yahoo. Odds ratios were calculated for the same for frequency 4 times/day for confectionery and 4/week for
co.in
Received : 31-10-14
Review completed : 31-10-14
Accepted : 09-11-14
ABSTRACT
To identify the role of dietary habits (type of diet, skipping meals, snacking in-between meals and frequency of
visits to fast food restaurants) in caries occurrence and severity. To explore the correlation between frequency
of intake of selected foods and dental caries. A cross-sectional study was carried out on adolescent children
(n = 916) of age 13-19, following a two-stage random sampling technique. Data were collected using a
pretested questionnaire. Questionnaire included demographic details, dietary habits of children and food
frequency table that listed selected food items. The dependent variable-dental caries was measured using
the decayed, missing, filled teeth (DMFT) index. The prevalence of dental caries in this study population was
36.7% (95% confidence interval: 33.58-39.82). The mean DMFT was 1.01 (1.74). No statistically significant
difference found between caries occurrence and type of diet (P = 0.07), skipping meals (P = 0.86), frequency
of eating in fast food stalls (0.86) and snacking in between meals (0.08). Mean DMFT values were higher among
nonvegetarians and among children who had the habit of snacking in between meals. Frequency of intake of
selected food items showed that mean frequency intake of carbonated drinks and confectionery was higher
among children who presented with caries when compared to caries-free children (P = 0.000). Significant
correlation found between mean DMFT and mean frequency intake of carbonated drinks and confectionery.
carbonated drinks and results discussed. Frequent intake of carbonated drinks and confectionery is harmful
to oral health that eventually reflects on general health. Educating the adolescent children on healthy dietary
habits should be put in the forefront.
KEY WORDS: Carbonated drinks, confectionery, dental caries, dietary habits

Diet plays an important role in the nutritional status and
henceforth the development of an individual. When diet
and oral health is considered, Moynihan states that, Good
diet is essential for the development and maintenance of
healthy teeth, but healthy teeth are important in enabling the
consumption of a varied and health diet throughout life cycle,
thus emphasizing the twoway relationship between diet and
oral health.[1] Dental caries is a multifactorial disease with diet
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DOI:
10.4103/0975-7406.155963
being one of the contributing factors is well documented by
numerous studies.
Children and adolescents form the backbone of future
generation and many serious diseases in adulthood have their
roots in adolescence, for example, dietary habits and tobacco
usage.[2] Unhealthy lifestyle factors like skipping meals and food
choice leading to a poorer nutrient intake are common among
this vulnerable adolescent group.[3] Children and adolescents
are giving preferences for sweetened foods,[4] and soft drinks,[5]
that are rich in carbohydrate and thus are at risk for caries
development. With the known culture difference, where an
Indian diet is different from a western diet and with not many
studies addressing this issue there arises the need to explore
this concept of diet, and in recent decades with the western
culture influences in the urban sector especially in relation to
diet, there goes the need to study the Indian urban scenario.

How to cite this article: Punitha VC, Amudhan A, Sivaprakasam P, Rathanaprabu V. Role of dietary habits and diet in caries occurrence and severity among
urban adolescent school children. J Pharm Bioall Sci 2015;7:S296-300.

S296 Journal of Pharmacy and Bioallied Sciences April 2015 Vol 7 Supplement 1
 Punitha, etal.: Diet and dental caries among urban adolescents

Thus, this study was undertaken in the urban metropolitan
city of Chennai with the following objectives:(1) To identify
the role of dietary habits(type of diet, skipping meals,
snacking inbetween meals and frequency of visits to fast food
restaurants) in caries occurrence and severity.(2) To determine
the correlation between frequency of intake of selected food
items and dental caries(occurrence and severity).
Methodology
A crosssectional study was done on adolescent school children
of age 1319. Apilot study was carried out on a sample of
adolescent school children of similar age group(n=114). The
pilot study helped in identifying difficulties in the data collection
procedure and also helped in testing the questionnaire. The pilot
study pointed a prevalence of dental caries as 42.1%. So, the
sample size required under simple random sampling method
was 863(8% of prevalence was the variance allowed with at
5% level of significance). Adding 5% dropouts the total number
of children required for the study was 906.
and chocolates/day), fruits and vegetables(in a week), nuts and
pulses(frequency/week), nonvegetarian foods(frequency/week),
junk foods(frequency/week), carbonated drinks(frequency/week),
fresh fruit juices(frequency/week).
Food items were tabulated, and the children were instructed to
write down the number of times, on an average, they consume
a particular item in a day or week. If they do not consume a
particular item they were instructed to mark as 0, or if in case
they consume any particular item occasionally(>15days) they
would score it as occasionally. Oral examination included
screening the children for decayed, missing, filled teeth
index(DMFT) using the WHO guidelines.[7]
Data were analyzed using the IBM, SPSS(version 20.0, Armonk,
NY: IBM Corp). Independent samples ttest, Chisquare test,
oneway ANOVA, and correlation tests were carried out. P< 0.05
was considered significant.
Results

A twostage random sampling technique was followed wherein The prevalence of dental caries in this study population was
the first stage included random selection of schools from the 36.7%(95% confidence interval: 33.5839.82). The mean
list of schools in Chennai. Alist of higher secondary schools DMFT was 1.01(1.74).
in Chennai that included 448 schools was prepared from the
internet database.[6] By means of random sampling eight, schools Dietary habits and caries occurrence
were selected from the 448 schools. Second stage included
random selection of children in the specified age group of When type of diet was considered it was observed that caries
1319, from the selected schools by proportion to the population occurrence was found to be higher among nonvegetarians(38.4%)
sample(PPS) selection technique. With inclusion criteria of age when compared to vegetarians(31.6%). The results showed that
1319 for this present study, children of class 9th12th standard there was no statistically significant difference between caries
were the target population in each of the eight schools. List occurrence and type of diet(P=0.07), skipping meals(P=0.86),
of students in each school for the abovestated classes were frequency of eating in fast food stalls(P=0.86) and snacking
provided by the school head. After exclusion criteria, a total of in between meals(P=0.08)[Table1].
3806 children from all eight schools formed the sampling frame.
Using the PPS technique(proportion to population) the number Dietary habits and caries severity
of children to be included as study samples from each school
was calculated. These study children were randomly selected Mean DMFT values were higher among children who
from the list of total students studying in that particular school. are nonvegetarians(1.09) compared to vegetarians(0.80)
Thus, a total of 916(extra 10 children were sampled) adolescent with a statistical significant different between the two
schoolchildren of age 1319 formed our study sample.
Table1: Various dietary habits and its relation with caries
Permission was sought to the Principals in charge of the schools, occurrence
to carry out the study. Information was provided regarding the Variables Dental caries n(%) Total Significant
Present Absent n P
nature and the need of the study. The results discussed in this
article are part of the study, Effect of nutrition on dental caries Type of diet
and was cleared by the Institutional Ethical Committee. Vegetarian 77(31.6) 166(68.4) 243 0.07
Nonvegetarian 259(38.4) 414(61.6) 673
Skipping meals
Data collection Yes 90(37.3) 151(62.7) 241 0.86
No 246(36.4) 429(63.6) 675
Questions on frequency of visit to a fast food restaurant, habit Frequency of eating in fast
of skipping meals, and habit of snacking in between meals, type food stalls
Every week 111(37.2) 187(62.8) 298 0.86
of diet(vegetarian or nonvegetarian) was incorporated into the Once a month 84(35.5) 152(64.5) 236
questionnaire, considering them as possible risk indicators for Occasionally 141(36.9) 241(63.1) 382
dental caries. Afood frequency questionnaire was incorporated Snacking in between meals
with the help of a nutritionist. The frequency of intake of the Yes 97(32.6) 200(67.4) 297 0.08
following food items was taken up for the study: Sugar(number No 239(38.6) 380(61.4) 619
of spoons/day), milk(no of cups/day), confectionery(sweets P<0.05 considered significant

Journal of Pharmacy and Bioallied Sciences April 2015 Vol 7 Supplement 1 S297
 Punitha, etal.: Diet and dental caries among urban adolescents

groups(P=0.015). It was also observed that mean DMFT was is said to be significant to assess DMFT. The adequacy of the
higher among children who snacked in between meals(1.04) model is determined using ANOVA. If the significant value
compared to children who do not(0.96)(P=0.48). Table2 of Ftest used in ANOVA is<0.05 the model is said to be an
reveals that the mean DMFT values do not differ significantly adequate model. The efficiency of the model is determined based
between children who skip meals or not and among children on R2 value that is also known as coefficient of determination.
who visit fast food restaurants at different intervals. The high value of R2 indicates higher prediction levels of
the dependent variable(DMFT) based on the independent
Food frequency and caries occurrence and severity variable(confectionery and carbonated/soft drinks) used in the
It is observed that the mean frequency intake of carbonated model.
drinks was found to be higher among children who presented
with caries(3.16) compared to cariesfree children(1.79) and The result of our model indicates that the model is adequate as
there seems to be a statistically significant difference between the significant value of the Fstatistic used in ANOVA is<0.05.
the two groups with P=0.000. Similar results are also observed When the efficiency is considered, R2 is low, indicating that
in relation to intake of confectionery that includes sweets and the model if used for predicting DMFT, will correctly predict
chocolates. The results shown indicates that mean frequency to the tune of only 15%.
intake of confectionery was significantly higher among children
who had caries(3.13) compared to caries free group whose mean Table2: Dietary habits and caries severity(mean DMFT)
frequency was 1.44(P=0.000). When comparing other food
Variables DMFT Test Significant
groups, the mean frequency intake was almost similar among
Mean SD value P
children who were caries free or who presented with caries with
significant P>0.05[Table3]. It is concluded that frequent Type of diet
intake of confectionery and carbonated drinks is associated Vegetarian 0.80 1.47 2.451* 0.015
Nonvegetarian 1.09 1.82
with caries occurrence. Skipping meals
Yes 0.98 1.61 0.321* 0.749
Correlation between mean DMFT and mean frequency intake No 1.03 1.78
of food items was analyzed, and the results are tabulated in Frequency of eating in fast food stalls
Table4. It shows that DMFT is significantly correlated only Every week 0.96 1.42 0.419** 0.739
Once a month 0.96 1.74
with confectionery and carbonated drinks and not with items
Occasionally 1.08 1.78
like sugar, milk, fruits and vegetables, nonvegetarian foods, junk Snacking in between meals
food, or fresh fruit juices. Yes 1.04 1.71 0.700* 0.484
No 0.96 1.78
Estimating decayed, missing, filled teeth using frequency *Independent sample ttest, **Oneway ANOVA. DMFT: Decayed, missing,
of intake of confectionery and carbonated drinks filled teeth; SD: Standard deviation

Research question
Table3: Caries occurrence(present or absent) in relation to
Is it possible to assess DMFT, given the frequency of intake mean frequency intake of different food
of confectionery and carbonated drinks. Multiple regression Variables Decay Independent
analysis is used for this purpose, and the regression equation Present Absent samples ttest
is given by: Mean SD Mean SD t P
Sugar(number of spoons 3.46 2.03 3.33 1.72 0.940 0.348
Equation: DMFT = 0.208 + 0.213 confectionery perday)
+ 0.209 carbonated drinks Milk(number of cups per day) 2.02 1.24 2.03 1.34 0.056 0.955
Confectionery(frequency 3.13 2.54 1.44 0.92 10.641 0.000
perday)
tvalue for constant(significant Pvalue): 1.727(0.085);
Fruits and vegetables 12.19 5.33 12.58 5.41 0.937 0.349
tvalue for confectionery(significant Pvalue): 5.682(0.000); Nuts and pulses 5.05 3.33 5.50 3.28 1.706 0.089
tvalue for carbonated drinks(significant Pvalue): 5.483(0.000). Nonvegetarian foods 8.86 4.66 9.42 4.94 1.096 0.274
R2 value: 0.148 Fvalue: 49.401 significant: 0.000 Junk foods 5.63 3.77 5.99 5.70 0.806 0.421
Carbonated drinks 3.16 2.28 1.79 1.43 9.158 0.000
For assessing the significance of coefficients, ttest is being used. Fresh fruit juices 2.35 2.14 2.52 2.35 1.005 0.315
If the significant value of the ttest is<0.05, the coefficient SD: Standard deviation

Table4: Correlation between mean DMFT and mean frequency intake of food items
Sugar number of Milk number Confectionery Fruits and Nuts and Nonvegetarian Junk Carbonated Fresh fruit
spoons per day of cups per day per day vegetables pulses foods foods drinks juices
DMFT 0.016 0.004 0.343** 0.016 0.044 0.095 0.071 0.284** 0.036
**Correlation is significant at the 0.01 level(twotailed). DMFT: Decayed, missing, filled teeth; SD: Standard deviation

S298 Journal of Pharmacy and Bioallied Sciences April 2015 Vol 7 Supplement 1

Strength of association between intake of confectionery
and carbonated drinks and dental caries
Further calculation of odds ratio(OR) indicated that children
who eat confectionery4times a day are 19.67times at higher
risk of developing caries when compared to children who do
not eat confectionery at all(P=0.000). children who consume
carbonated drinks4 times a week were 7times at higher risk
of developing caries when compared to children who do not
take carbonated drinks at all(P=0.000)[Table5].
Discussion
Dietary habits
The dietary habits that were studied were consumption of
vegetarian and nonvegetarian diet, skipping of meals, snacking
in between meals and frequency of eating in fast food stalls.
None of the variables studies showed a significant difference
in caries occurrence. When caries severity was considered type
of diet(vegetarian/nonvegetarian) seemed to be significantly
associated with caries severity that is, less among children
who are on vegetarian diet. Vegetarian diet contains tannins
and phytins(green vegetables) which are cariostatic, [8]
but consumption of green vegetables in this age group is
questionable. Our study showed that the frequency of intake of
fruits and vegetables was same among children who presented
with caries or not[Table3]. Study by Venugopal etal. on Indian
children showed that caries prevalence was low in those taking
vegetarian type of diet. Frequency of sweet consumption was also
shown to be associated with prevalence of dental caries in their
study.[9] Almushayt etal. reported that increasing the frequency
of eating vegetables will lower the risk of caries(OR=0.7) than
those children who rarely eat vegetables.[10] Study by Yadav
etal. among 804 school children of age 512years reported
that nonvegetarians had lower prevalence of caries(59.46%) as
compared to vegetarians(65.5%) but this was not statistically
significant.[11]
In our study it was also observed that children who snacked in
between meals had slightly higher mean DMFT(1.04) value
when compared to those who do not(0.96) and this was not
statistically significant though. Bagramian and Russell had
reported no significant relationship between the consumption
of sucrose containing betweenmeal snacks and caries
experience.[12] But in this decade with snacking in between
Table5: Frequency of confectionery intake and carbonated drinks intake versus dental caries
Item Frequency Caries(+)
Confectionery =4 or > 108
1-3times/day 73
Occasionally 96
Not at all 59
Carbonated drinks =4 or > 120
1-3times/day 94
Occasionally 75
Not at all 47
*Ref: Reference values taken to compute OR. OR: Odds ratio; CI: Confidence interval
Journal of Pharmacy and Bioallied Sciences April 2015 Vol 7 Supplement 1 S299
Punitha, etal.: Diet and dental caries among urban adolescents
meals predominantly containing unhealthy junk food with high
carbohydrate content, studies have found a positive correlation
between snacking in between meals and caries occurrence. For
example, Marshall etal. in his study on the role of meal, snack
and daily total food and beverage exposures on caries experience
in young children found that higher exposure to sugar at snacks
increased caries risk.[13]
Our study did not investigate the intricacies of what types of
snacks were eaten in between meals(whether it contained
high carbohydrate content). But this present study has made
an observation that children who were in the habit of snacking
in between meals had higher DMFT values. This finding
would serve as an important input to oral health education
content on advising or educating the children about avoiding
inbetween unhealthy snacking behavior. Most children tend
to eat unhealthy snacks inbetween meals that are usually high
in carbohydrate and fat like chips, chocolates, sweets, burgers,
fried foods and sugared beverages, as DomjeanOrliaguet
etal.,[14] pointed that frequent eating of snack, sugar and cooked
starch between meals will increase risk of caries shown by OR
of 1.6. American Dental Association has recommended that
children and adults must limit eating and drinking between
meals and when they must snack, give preference to nutritious
foods identified by the US Department of Agriculture Dietary
Guidelines.[15] Our study also found that there was no difference
in caries occurrence or severity when the children skipped meals
or frequented eating in fast food stalls.
Diet and dental caries
When mean frequency intake of different food items was
analyzed, it was observed that intake of carbonated drinks and
confectionery(sweets and chocolates) had a significant association
with caries occurrence and severity. Children consuming sweets and
chocolates(confectionery) >4times a day were almost 20times
more likely to develop caries. The odds of developing caries was
7.00(OR=7.00) times higher among children who were in the habit
of drinking carbonated drinks frequently(>4times a week) when
compared to those who do not drink carbonated drinks. Almushayt
etal. study among preschool children showed that children who drink
soda drinks were 10.71(OR) times at high risk of caries compared to
children who do not.[10] Sohn etal. similarly found a strong significant
association of carbonated soft drinks with increased caries risk in the
primary dentition.[16] Marshall etal. in his longitudinal study also
concluded that higher intake of regular soda drinks was significantly
associated with increased odds of developing caries.[17]
Caries() OR 95% CI P
16 19.67 10.771-35.948 0.000
191 1.11 0.746-1.662 0.596
201 1.39 0.949-2.041 0.090
172 Ref*
47 7.00 4.359-11.264 0.000
224 1.15 0.763-1.738 0.501
180 1.14 0.744-1.756 0.539
129 Ref*
 Punitha, etal.: Diet and dental caries among urban adolescents
Conclusion
When food habits are considered, parents should advise
the children on the ill effects of frequent consumption of
carbonated drinks on their health and also the effect of frequent
consumption of confectionery on teeth. Teachers in school
also can contribute in educating the children on this. Health
education on healthy eating habits can bring about behavior
changes among these adolescent children that they would take
forward into their adult life.
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Source of Support: Nil, Conflict of Interest: None declared.
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