Sugar before bed: a simple dietary risk factor for caries experience

Systems mapping of multilevel factors contributing to dental caries in adolescents

Dental caries is a prevalent chronic disease among adolescents. Caries activity increases significantly during adolescence due to an increase in susceptible tooth surfaces, immature permanent tooth enamel, independence in pursuing self-care, and a tendency toward poor diet and oral hygiene. Dental caries in permanent teeth is more prevalent among adolescents in low-income families and racial/ethnic minority groups, and these disparities in adolescent dental caries experience have persisted for decades. Several conceptual and data-driven models have proposed unidirectional mechanisms that contribute to the extant disparities in adolescent dental caries experience. Our objective, using a literature review, is to provide an overview of risk factors contributing to adolescent dental caries. Specifically, we map the interactive relationships of multilevel factors that influence dental caries among adolescents. Such interactive multilevel relationships more closely reflect the complex nature of dental caries experience among the adolescent population. The methods that we use are two-fold: (1) a literature review using PubMed and Cochrane databases to find contributing factors; and (2) the system dynamics approach for mapping feedback mechanisms underlying adolescent dental caries through causal loop diagramming. The results of this study, based on the review of 138 articles, identified individual, family and community-level factors and their interactions contributing to dental caries experience in adolescents. Our results also provide hypotheses about the mechanisms underlying persistence of dental caries among adolescents.

Conclusions

Our findings may contribute to a deeper understanding of the multilevel and interconnected factors that shape the persistence of dental caries experience among adolescents.

Portrayal of oral hygiene and risk behaviours in animated movies

Background

Behaviours depicted in movies and TV shows can significantly affect one's behaviour. Children are particularly susceptible to these effects as their habits are still forming. Oral hygiene behaviours play a crucial role in preventing or slowing down the progression of dental diseases, which are among the most common yet preventable diseases in the world. Therefore, it is important to understand if popular movies include oral hygiene behaviours or risk-related behaviours, which can in effect influence children's behaviour.

Aim

The aim of this study is to review the top grossing animated movies of all time to record and collect on screen portrayals of oral hygiene practices and risk behaviours related to oral health.

Methodology

Top 30 highest grossing animated feature films (over 40 min duration) were coded using a structured coding instrument to capture oral hygiene and risk-related behaviours related to oral health. Two coders performed coding using the standardised instrument.

Results

Overall, 93% of behaviours were coded as a risk behaviour, with 7% coded as positive oral hygiene behaviour. Within the risk behaviour category, the majority (74%) were based around the consumption of sugar with risk behaviour occurring in 23 out of 30 movies (76%), while oral hygiene practices occurred in 6 out of 30 movies (20%); one movie depicted neither oral hygiene nor oral health risk behaviours. About 53% of behaviours were purely visual, 10% verbal, and 37% a combination of verbal and visual. Anthropomorphic characters and movie settings resulted in more behaviours related to oral health, either hygiene or mainly risk behaviours, depicted.

Conclusion

Despite their importance in shaping habits and attitudes, animated movies portrayed a significant number of risk behaviours related to oral health with depiction of beneficial behaviours remaining limited. Consideration should be given on how to best portray behaviours that promote and enhance optimal oral hygiene behaviours to achieve and sustain better oral health for children.

Evaluation of water fluoridation scheme in Cumbria: the CATFISH prospective longitudinal cohort study

Background

Water fluoridation was introduced in the UK against a background of high dental decay within the population. Levels of decay have dramatically reduced over the last 40 years following widespread use of fluoride toothpaste.

Objective

The aim of the CATFISH (Cumbrian Assessment of Teeth a Fluoride Intervention Study for Health) study was to address the question of whether or not the addition of fluoride to community drinking water, in a contemporary population, lead to a reduction in the number of children with caries and, if so, is this reduction cost-effective?

Design

A longitudinal prospective cohort design was used in two distinct recruited populations: (1) a birth cohort to assess systemic and topical effects of water fluoridation and (2) an older school cohort to assess the topical effects of drinking fluoridated water.

Setting

The study was conducted in Cumbria, UK. Broadly, the intervention group (i.e. individuals receiving fluoridated drinking water) were from the west of Cumbria and the control group were from the east of Cumbria.

Participants

Children who were lifetime residents of Cumbria were recruited. For the birth cohort, children were recruited at birth (2014–15), and followed until age 5 years. For the older school cohort, children were recruited at age 5 years (2013–14) and followed until the age of 11 years.

Intervention

The provision of a ‘reintroduced fluoridated water scheme’.

Main outcome measures

The primary outcome measure was the presence or absence of decay into dentine in the primary teeth (birth cohort) and permanent teeth (older school cohort). The cost per quality-adjusted life-year was also assessed.

Results

In the birth cohort (n = 1444), 17.4% of children in the intervention group had decay into dentine, compared with 21.4% of children in the control group. The evidence, after adjusting for deprivation, age and sex, with an adjusted odds ratio of 0.74 (95% confidence interval 0.56 to 0.98), suggested that water fluoridation was likely to have a modest beneficial effect. There was insufficient evidence of difference in the presence of decay in children in the older school cohort (n = 1192), with 19.1% of children in the intervention group having decay into dentine, compared with 21.9% of children in the control group (adjusted odds ratio 0.80, 95% confidence interval 0.58 to 1.09). The intervention was found to be likely to be cost-effective for both the birth cohort and the older school cohort at a willingness-to-pay threshold of £20,000 per quality-adjusted life-year. There was no significant difference in the performance of water fluoridation on caries experience across deprivation quintiles.

Conclusions

The prevalence of caries and the impact of water fluoridation was much smaller than previous studies have reported. The intervention was effective in the birth cohort group; however, the importance of the modest absolute reduction in caries (into dentine) needs to be considered against the use of other dental caries preventative measures. Longer-term follow-up will be required to fully understand the balance of benefits and potential risks (e.g. fluorosis) of water fluoridation in contemporary low-caries populations.

Limitations

The low response rates to the questionnaires reduced their value for generalisations. The observed numbers of children with decay and the postulated differences between the groups were far smaller than anticipated and, consequently, the power of the study was affected (i.e. increasing the uncertainty indicated in the confidence intervals).

Study registration

This study is registered as Integrated Research Application System 131824 and 149278.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 10, No. 11. See the NIHR Journals Library website for further project information.

Replacement of refined sugar by natural sweeteners: focus on potential health benefits

Refined sugar is a processed product containing 99% sucrose, which is obtained from sugarcane (70%) or sugar beet (30%). In modern societies, sugar continues to play a significant role in the diet, recognised not only for its flavour and special sweetening properties but also for its role in food preservation. On the other hand, a high consumption of refined sugar is associated with non-communicable diseases and many health issues such as a high risk of dental caries, overweight and neurodevelopmental disorders in children. Alternatives like unrefined sugars have generated a lot of interest as a healthy substitute due to their nutraceutical properties. This paper is aimed to review the beneficial effects of sugar derived from natural sources and highlight health problems that could be caused by refined processed sugar. Refined sugar is frequently used in variety of items including processed foods, soft drinks or ice creams although it is considered unhealthy due to its high salt and sugar content as well as added fats and artificial coloring. Natural sugars are preferred because they have a high nutritional value and a high concentration of healthy compounds, which offset the negative effects of refined sugar. Therefore, removing refined sugar or at least reducing its consumption should be promoted as a healthier option in food choices.

Infancy Dietary Patterns, Development, and Health: An Extensive Narrative Review

Correct dietary patterns are important for a child’s health from birth to adulthood. Understanding a child’s health as a state of entire physical, mental, and social well-being is essential. However, reaching adulthood in a complete health proper state is determined by feeding and dietary habits during preconception, pregnancy, or children infancy. Different factors, such as the mother’s lifestyle, culture, or socioeconomic status, are crucial during all these phases. In this review, we aimed to assess the long-term associations between infancy dietary patterns and health and their influence on development and growth. To reach this objective, a consensus critical review was carried out using primary sources such as scientific articles, and secondary bibliographic indexes, databases, and web pages. PubMed, SciELO, and Google Scholar were the tools used to complete this research. We found that high-income countries promote high-calorie foods and, consequently, obesity problems among children are rising. However, undernutrition is a global health issue concerning children in low- and middle-income countries; thus, parental socioeconomic status in early life is essential to children’s health and development, showing that biological, social, and environmental influences are increased risk factors for chronic diseases. This narrative review is aimed to collect evidence for early nutritional intervention and future disease prevention.

Factors Affecting Dental Caries Experience in 12-Year-Olds, Based on Data from Two Polish Provinces

(1) Background: Dental caries is a chronic disease that affects a child’s dentition from the first stages of life. Several factors contribute to the development of the disease, including an improper diet. This cross-sectional study aimed to identify risk factors of dental caries in 12-year-old adolescents from Greater Poland and Lubusz Provinces (Poland). (2) Material and methods: The research was conducted in adolescents from five primary schools. A questionnaire consisted of close-ended questions on socioeconomic characteristics on family, diet, and oral hygiene habits. An assessment of the dentition was carried out in accordance with World Health Organization (WHO) recommendations. In addition to cavitated carious lesions, incipient caries lesions were noted according to the International Caries Detection and Assessment System, adapted for epidemiological studies (ICDASepiDMFt). (3) Results: The mean number of teeth with untreated caries; removed due to caries; and restored because of caries (DMFt) was 1.52 ± 1.90, while the ICDASepiDMFt index amounted to 2.64 ± 2.55, respectively. Children who did not brush every day had significantly higher odds of having ICDASepiDMFt > 0 than children brushing at least once daily (OR = 10.32, 95% CI = 1.36−78.32, p = 0.0240). Adolescents who drank sweet carbonated drinks every day had significantly higher ICDASepiDMTt than children who drank sweet carbonated drinks less frequently (p = 0.0477). (4) Conclusions: The research revealed that dental caries indices of 12-year-old adolescents from Greater Poland and Lubusz Provinces depend mainly on oral hygiene behaviors. The only significant nutritional factor that differentiated the caries intensity was the daily consumption of sweet carbonated drinks.

Children's and Parents' Marburg Sugar Index (MSI) Values: Are They Comparable?

Studies on children’s nutritional behaviour (CNB) rarely compare children’s answers regarding the frequency of their sugar intake with the respective statements of their parents. Therefore, data from a prevention study were used to analyse this aspect, as well as a potential correlation between Marburg Sugar Index (MSI) values and caries experience of children. The present study based its questionnaire data on CNB and caries data. Pairs of questionnaires filled in separately by children and parents of the participating families were dichotomised by either having completed the diet section entirely (Group A) or in part (Group B). The MSI scores were calculated separately for children and parents. The statistical confidence level was set at α = 0.05 (two-sided). Furthermore, the Pearson correlation coefficient was calculated and tested for “r = 0”. Additionally, a test for equality of the correlations was applied. The number of available questionnaire pairs was 429 in Group A and 400 in Group B. In both groups, significant correlations between children’s and parents’ MSI scores (A: r = 0.301, p < 0.001; B: r = 0.226, p < 0.001) were found. Using Spearman’s Rho, a significant correlation between MSI scores and children’s caries experiences was observed in Group A. MSI scores based on dietary questionnaires can be used to obtain consistent information on children’s CNB provided by the children themselves or their parents. This is true even when the MSI score has to be calculated on the basis of incomplete questionnaires. Questionnaire-based CNB information can improve the effectiveness of individual or group preventive measures supplemented by individually adapted nutritional counselling.

Bedtime Routines Intervention for Children (BRIC) project: results from a non-randomised feasibility, proof-of concept study

BACKGROUND

Bedtime routines are highly recurrent family activities with implications for children's wellbeing, development and health.

AIMS

The objective of this study is to co-develop and test in a feasibility, proof-of-concept study a bedtime routines intervention using text messages aimed at first-time parents with young children.

METHODS

Fifty first-time parents with children aged 1-3 years were recruited for this study. Parents received a text message-based intervention for 7-consecutive nights which provided support and information on achieving optimal bedtime routines. Parents completed pre- and post-intervention questionnaires focusing on children's sleep, bedtime routines and parental mood disturbance. Feedback was provided at the end of the study.

RESULTS

Recruitment target and high retention with 98%, or 49 out of 50 participants completing the study were achieved. Pre- and post-intervention, there were improvements in total children's sleep with children sleeping longer and having less disrupted sleep overall (MD = - 7.77 (SD = 17.91), t(48) = - 3.03, p = .004, CI (- 12.91, - 2.63) and in overall quality of bedtime routines (MD = - 5.00, SD = 7.01, t(48) = - 4.98, p < .001, CI (- 7.01, - 2.98). Parental mood disturbance decreased pre- to post-intervention (MD = 5.87, SD = 15.43, t(48) = 2.66), p = .010, CI (1.44, 10.30). Parents provided positive feedback about the intervention and valued the support that was provided to them.

CONCLUSIONS

Bedtime routines were successfully altered with short-term benefits for children's sleep and parental mood. Future research will need to utilize a more robust, longitudinal approach for a definite exploration of sustained changes in bedtime routines and their long-term implications for children and parents.

Association between Insufficient Sleep and Dental Caries among Preschoolers in Japan: A Cross-Sectional Multicentre Study

Recently, sleeping status has attracted attention for its relationship with oral health. In the present study, we have investigated the association between early childhood caries and sleeping status. A multicentre observational cross-sectional study was conducted among 332 preschoolers (aged 3–6 years) and their parents in Chitose, Japan. Dental caries and sleeping status were assessed in the children and the sleep quality and health literacy of the parents were also assessed. Univariate and multivariate regression analyses were used in order to investigate the effect of the sleeping status of the parents and their children on dental caries. Among the children, the prevalence of dental caries experience was 12.7%. The children without caries slept significantly longer and their parents had a better Pittsburgh Sleep Quality Index (PSQI) score than those with caries experience. The sleeping status and the numbers of caries in the children were significantly correlated. Health literacy was better in those without caries experience. Parents’ PSQI was significantly positively correlated with the numbers of caries in the children (r = 0.19, p = 0.0004). The children’s sleep durations, screen time, and parental smoking status were independently associated with early childhood caries. Poor sleeping status of children and their parents is related to dental caries among preschoolers.

Dietary Patterns and Oral Health Behaviours Associated with Caries Development from 4 to 7 Years of Age

The association between modifiable risk factors and caries in children has been documented; however, most studies have been cross-sectional and have not considered the complexity of dietary factors and oral health habits. This study aimed to investigate the prospective association between dietary patterns and oral health behaviours at 4 years of age and the development of new decayed, missing, and filled teeth (d_3–6mft/D_3–6MFT) over a period of three years. Participants were children from the Generation XXI population-based birth cohort. At 4 years of age, diet patterns were assessed using a food frequency questionnaire, with three dietary patterns being identified. For the purpose of capturing the new development of caries between 4 and 7 years of age, two dental outcomes were defined in the mixed dentition: “dental caries development” and “severe dental caries development” in the mixed dentition. Bivariate analysis and multivariate logistic regression were used. From 4 to 7 years of age, 51.2% of the children had at least one new d_3–6mft/D_3–6MFT and 27.4% had more than two new d_3–6mft/D_3–6MFT. Children belonging to the “energy-dense foods” (OR = 2.19; 95% CI: 1.20–4.00) and “snacking” (OR = 2.19; 95% CI: 1.41–3.41) dietary patterns at 4 years old were associated with severe dental caries development three years later. Preventive strategies should be implemented in an attempt to reduce snacking and the consumption of energy-dense, micronutrient-poor foods to promote children’s oral health.

Bedtime Oral Hygiene Behaviours, Dietary Habits and Children's Dental Health

Background: Oral hygiene behaviours as well as dietary habits before bed can affect children's dental health resulting in higher prevalence of dental disease. Dental disease can affect children's health, development and even school performance. If left untreated, dental disease can progress and it can lead to extractions under general anaesthetic causing further distress for children and families. Consistent and appropriate oral hygiene behaviours and dietary habits can prevent dental diseases from occurring in the first place. Objective: This cross-sectional study examines the relationship between oral hygiene behaviours, dietary habits around bedtime and children's dental health. Methods: A total of 185 parents with children between the ages of 3 and 7 years from deprived areas participated in the study. Data on bedtime routine activities were collected using an automated text-survey system. Children's dental health status was established through examination of dental charts and dmft (decayed, missed, filled teeth) scores. Results: In total, 52.4% of parents reported that their children's teeth were brushed every night. The majority of children (58.9%) had dmft scores over zero. In total, 51 (46.7% of children with dmft score over 0 and 27.5% of all children) children had active decay. The mean dmft score for those experiencing decay was 2.96 (SD = 2.22) with an overall mean dmft score of 1.75 (SD = 2.24). There were significant correlations between frequency of tooth brushing, frequency of snacks/drinks before bed and dmft scores (r = -0.584, p < 0.001 and r = 0.547, p = 0.001 respectively). Finally, higher brushing frequency was associated with a lower likelihood of a dmft score greater than 0 (Exp(B) = 0.9). Conclusions: Despite families implementing oral hygiene behaviours as part of their bedtime routines those behaviours varied in their consistency. Results of this study highlight the need for additional studies that consider bedtime routine-related activities and especially the combined effects of oral hygiene practices and dietary habits due to their potentially important relationship with children's dental health.

Defining and measuring bedtime routines in families with young children-A DELPHI process for reaching wider consensus

INTRODUCTION

Bedtime routines are one of the most common family activities. They affect children' wellbeing, development and health. Despite their importance, there is limited evidence and agreement on what constitutes an optimal bedtime routine. This study aims to reach expert consensus on a definition of optimal bedtime routines and to propose a measurement for bedtime routines.

METHOD

Four-step DELPHI process completed between February and March 2020 with 59 experts from different scientific, health and social care backgrounds. The DELPHI process started with an expert discussion group and then continued with 3 formal DELPHI rounds during which different elements of the definition and measurement of bedtime routines were iteratively refined. The proposed measurement of bedtime routines was then validated against existing data following the end of the DELPHI process.

RESULTS

At the end of the four round DELPHI process and with a consistent 70% agreement level, a holistic definition of bedtime routines for families with young children between the ages of 2 and 8 years was achieved. Additionally, two approaches for measuring bedtime routines, one static (one-off) and one dynamic (over a 7-night period) are proposed following the end of the DELPHI process. A Bland-Altman difference plot was also calculated and visually examined showing agreement between the measurements that could allow them to be used interchangeably.

DISCUSSION

Both the definition and the proposed measurements of bedtime routines are an important, initial step towards capturing a behavioural determinant of important health and developmental outcomes in children.

Perceived Barriers and Facilitators for Bedtime Routines in Families with Young Children

Objectives: Bedtime routines are a highly recurrent family activity with important health, social and behavioural implications. This study examined perceived barriers to, and facilitators of, formulating, establishing, and maintaining optimal bedtime routines in families with young children. Design: Participants completed a semi-structured interview based on the Theoretical Domains Framework (TDF). Analysis followed a deductive approach. Participants: A total of 32 parents participated in the study. Most participants (N = 30) were females, were white (N = 25) and stay at home parents (N = 12). Results: Key barriers included lack of appropriate knowledge and sources of information, problematic skills development, social influences, cognitive overload, and lack of motivation for change. Facilitators included social role, access to resources, positive intentions, beliefs about consequences and reinforcement. In particular, optimal bedtime routines were less likely to be enacted when parents were tired/fatigued and there was a strong effect of habit, with suboptimal routines maintained over time due to past experiences and a lack of awareness about the importance of a good bedtime routine. Conclusions: Several theory-based, and potentially modifiable, determinants of optimal bedtime routines were identified in this study, providing important information for future interventions. Several of the key determinants identified were transient (tiredness) and/or non-conscious (habit), suggesting that future interventions may need to be deployed in real time, and should extend beyond conventional techniques.

Cross-Sectional Association between Behaviors Related to Sugar-Containing Foods and Dental Outcomes among Hispanic Immigrants

A cross-sectional, self-administered survey was used to gather information about dental outcomes, sugar-containing food behaviors and intake, and sociodemographic characteristics of adults of Mexican and Central-American (Guatemala, El Salvador, Honduras) origin (n = 517). Bivariate and multiple-variable logistic regressions were used to examine the associations of behaviors related to added sugar-containing foods/beverages (overall intake and consumption before bed) with dental outcomes. Outcome measures involved dental outcomes, dental self-care practices, and added sugar intake. Estimated daily added sugar intake among all participants was 98 (SD = 99) g, with no difference in consumption among participants from different countries. The majority of added sugar (63 (SD = 74) g) was provided by sugar-sweetened beverages. Participants who reported consuming sugar-containing foods or beverages within an hour before bed were more likely to report having a fair/poor/very poor condition of teeth and gums and having felt dental pain (p < 0.05 for all). The amount of sugar intake was associated with being prescribed medication for oral or dental problems (p = 0.008) and dental pain (p = 0.003). Findings support the association between sugar containing food–related behaviors and dental problems among Hispanic immigrants to the U.S. Health promotion and preventive interventions for this population should consider these behaviors as modifiable contributors to adverse dental outcomes.

Development of a Nutrition Questionnaire for Dental Caries Risk Factors

Background: Few existing tools quickly identify dietary behaviours related to dental caries. The objectives of this study were to (i) create a patient-generated questionnaire identifying these dietary behaviours, (ii) capture information on these dietary behaviours in two specific populations via questionnaire pilot testing and (iii) determine questionnaire test-retest reliability. Methods: After development, the questionnaire was reviewed by an expert panel. Cognitive interviewing was conducted, followed by pilot testing in a general university campus population (n = 80) and a university dental clinic (n = 10). Retesting was done with the general campus group (n = 53). Results: Most participants reported never receiving dietary advice from professionals regarding caries. Sugary foods were most often consumed as snacks in the evening or afternoon, then breakfast. In total, 41.3% of campus participants consumed high risk items at least a few times per week or more often. Weekly or more frequent consumption of “other” sugary drinks (e.g., iced tea) was common. In total, 77.6% of questionnaire items had a kappa value representing moderate agreement or greater. Conclusions: Dietary behaviours related to caries were common in this pilot study. Given the high prevalence of caries and low occurrence of prior dietary advice for the same, increased preventive efforts may be warranted.

Bedtime routines child wellbeing & development

Background

Bedtime routines has shown important associations with areas associated with child wellbeing and development. Research into bedtime routines is limited with studies mainly focusing on quality of sleep. The objectives of the present study were to examine the relationship between bedtime routines and a variety of factors associated with child wellbeing and to examine possible determinants of bedtime routines.

Methods

A total of 50 families with children between 3 and 5 years old took part in the study. Data on bedtime routines, parenting styles, school readiness, children’s dental health, and executive function were collected.

Results

Children in families with optimal bedtime routines showed better performance in terms of executive function, specifically working memory (t (44)= − 8.51, p ≤ .001), inhibition and attention (t (48)= − 9.70, p ≤ .001) and cognitive flexibility (t (48)= − 13.1, p ≤ .001). Also, children in households with optimal bedtime routines scored higher in their readiness for school (t (48)= 6.92, p ≤ .001) and had better dental health (U = 85.5, p = .011). Parents in households with suboptimal bedtime routines showed worse performance on all measures of executive function including working memory (t (48)= − 10.47, p ≤ .001), inhibition-attention (t (48)= − 10.50, p ≤ .001) and cognitive flexibility (t (48)= − 13.6, p ≤ .001). Finally, parents with optimal bedtime routines for their children deployed a more positive parenting style in general (i.e. authoritative parenting) compared to those with suboptimal bedtime routines (t (48)= − 6.45, p ≤ .001).

Conclusion

The results of the present study highlight the potentially important role of bedtime routines in a variety of areas associated with child wellbeing and the need for further research.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-5290-3) contains supplementary material, which is available to authorized users.