R E S E A R C H
Background. As a result of the introduc-
The relationship
between healthful
eating practices and
dental caries in
children aged 2-5
years in the United
States, 1988-1994
BRUCE A. DYE, D.D.S., M.P.H.; JONATHAN D.
SHENKIN, D.D.S., M.P.H.; CYNTHIA L. OGDEN,
M.R.P., Ph.D.; TERESA A. MARSHALL, Ph.D.;
STEVE M. LEVY, D.D.S., M.P.H.;
MICHAEL J. KANELLIS, D.D.S., M.S.
he relationship between diet and tooth decay
T in the reduced caries environment of the
United States has not been well-studied.
Dietary patterns among children and adoles-
cents have shifted dramatically during the
last few decades in the United States
1,2
Dental health and worldwide. Milk consumption has
decreased, while consumption of soft
education
drinks and noncitrus juices and drinks
should has increased.
encourage Although the American Academy of
parents, Pediatrics recommends that fruit juice
primary intake among 1- to 6-year-olds be lim-
3 inform parents and caregivers regarding
caregivers and ited to 4 to 6 ounces per day, more than
10 percent of preschoolers in the United
policy-makers
States consume at least 12 fluid oz of
to promote fruit juice per day.4 Overall carbohy-
healthful eating drate intake has increased from 46.3
practices for percent of total energy intake in 1965 to
young children. 54.2 percent of total energy intake in
1996.2 On a positive note, breast-feeding
rates have risen since the middle
1970s.5 From the 1970s through the 1990s, dental decay
among U.S. children and adolescents has seen a marked
Copyright ©2004 American Dental Association. All rights reserved.
ABSTRACT
tion of multiple fluoride vehicles and other
preventive agents, caries prevalence rates in
young children have been declining over the
past two decades in the United States. How-
ever, changing dietary patterns in young
children may offset some of the oral health
benefits of fluoridation. The objective of this
study was to examine the relationship
between caries in primary teeth and
healthful eating practices in young children.
Methods. The authors used data from
the third National Health and Nutrition
Examination Survey to investigate the rela-
tionship between healthful eating practices
(such as breast-feeding, eating breakfast
and consuming five servings of fruits and
vegetables a day) and dental caries
(untreated tooth decay and overall caries
experience) in the primary dentition among
children aged 2 through 5 years.
Results. The odds of experiencing caries
in primary teeth were significantly greater
in nonpoor children who did not eat break-
fast daily or ate fewer than five servings of
fruit and vegetables per day (odds ratio, or
OR = 3.77; 95 percent confidence interval,
or CI, 1.80 to 7.89 and OR = 3.21; 95 per-
cent CI, 1.74 to 5.95, respectively). No asso-
ciation was found between breast-feeding
and caries in primary teeth.
Conclusion. Young children with poor
eating habits are more likely to experience
caries. Overall, the findings support the
notion that dental health education should
encourage parents, primary caregivers and
policy-makers to promote healthful eating
practices, such as eating breakfast daily, for
young children.
Practice Implications. Dental
professionals are well-positioned to
age-appropriate healthful eating practices
for young children entrusted in their care.
decrease in prevalence, due largely to the
effectiveness of fluoridating drinking water
and dentifrices.6
The role of refined carbohydrates in the
caries process is well-accepted in the dental
community.1,7-9 The most important dietary
JADA, Vol. 135, January 2004 55
R E S E A R C H

etiological factor in the promotion of dental caries
is sugar consumption, particularly sucrose.
Aggregate observations from a review of studies
indicate that when sugar intake exceeds 15 to 20
kilograms per person per year, such intake is
directly associated with increasing caries preva-
10
lence. Earlier research, such as the landmark
Vipeholm study of the 1950s,7 was conducted
when caries prevalence was much higher. Conclu-
sions generally have supported the idea that
sugar consumption increases caries prevalence,
and the risk of caries increases when sugar is con-
sumed between meals. Indeed, current dental
health education for the control of dental caries is
based on this earlier research and supports the
promotion of dietary restriction of sugars to pre-
vent caries.11
Although the United States is in
an era of relatively low caries preva-
lence, 60 percent of children still Sixty percent of
have one or more decayed or
children have one or
restored teeth by age 5 years, with
20 percent of children experiencing more decayed or
approximately 80 percent of the restored teeth by
total dental caries burden.12 This age 5 years.
raises the following question: what
are the effects of our changing
eating habits on caries in primary
teeth in an environment of reduced caries preva-
lence in the United States?
Some meals, such as breakfast, often are
skipped altogether. Teenagers who miss breakfast
are more likely to snack during the day13 and
snacks have the highest sugar content of any type
of meal (that is, breakfast, lunch, dinner or
snacks).14 Consumption of whole grains and dairy
products has been shown to decrease an indi-
vidual’s appetite,15-18 while diets high in sugar
cause people to feel hungry and seek more calo-
ries.19,20 Missing meals could have a direct influ-
ence on consumption of refined carbohydrates,
and skipping meals such as breakfast could lead
to increased sugar consumption.
The last national report on diet and dental
health in the United States concluded, “There was
a direct, strong, and statistically significant rela-
tionship between DMF [decayed-missing-filled]
experience and the frequency of intake of sugary
snacks between meals.”21 However, this report,
which was released two decades ago, was limited
to school-aged children and permanent teeth.
Public health advocates widely believe that
poor infant feeding practices, particularly feeding
with juice in a bottle at bedtime, are associated
with the development of caries in primary teeth.
Douglass and colleagues22 have suggested that
dietary factors other than bottle feeding may pro-
mote caries in primary teeth among young chil-
dren. Al-Dashti and colleagues23 reported that
breast-fed children are more likely to be caries-
free compared with children who are bottle-fed.
However, researchers generally believe that
breast-feeding is associated with dental caries
only if it is prolonged.23
Although human milk is potentially more cari-
ogenic than cow’s milk because of its higher lac-
tose and lower calcium and phosphate levels,24
breast-feeding might mitigate consumption of
refined carbohydrates by promoting reduced con-
sumption of juices and drinks high in sugar. Con-
sequently, if breast-feeding preva-
lence increases, pediatric caries
experience should decline.
Our study poses two main ques-
tions. First, it attempts to deter-
mine if the regular consumption of
breakfast or five servings per day
of fruits or vegetables is associated
with less caries in young children,
based on the hypothesis that chil-
dren who eat five fruits or vegeta-
bles, breakfast or both on a regular basis consume
fewer snacks and, therefore, are exposed to fewer
carbohydrates. Second, this study investigates
the relationship between a history of breast-
feeding and caries in primary teeth. We hypothe-
size that breast-feeding could delay an infant’s
exposure to high-sugar-content fruit juices, thus
promoting a lower prevalence of pediatric caries.
METHODS
Study population. We used data from 4,236
children who participated in the third National
Health and Nutrition Examination Survey, or
NHANES III, from 1988 to 1994.25 The NHANES
III was conducted by the National Center for
Health Statistics, or NCHS, of the Centers for
Disease Control and Prevention, or CDC. It used
a complex, stratified, multistage probability
design capable of producing a nationally repre-
sentative sample for the noninstitutionalized
civilian population of the United States. Details of
the sample design and methods used to obtain
informed consent from study participants have
been described elsewhere.26
The NHANES III oversampled people who

56 JADA, Vol. 135, January 2004

Copyright ©2004 American Dental Association. All rights reserved.
 R E S E A R C H

were either younger than 6 years or older than 60 molars). Caries experience was based on the
years, Mexican-Americans and non-Hispanic number of decayed or filled primary dental sur-
blacks. Information regarding sociodemographic faces, or dfs, as derived from the coronal caries
characteristics, growth and social development, examination. For our analysis, we defined caries
and oral health was collected through the house- experience as at least one primary tooth surface
hold interview questionnaire and physical exami- with a dental filling or untreated decay, which
nation. Dietary information was obtained via was dichotomized as “yes” or “no.” We derived the
adult proxy from one 24-hour dietary recall untreated decay status variable from the number
administered in the mobile examination center, or of primary surfaces with caries, or ds, and catego-
MEC, on the day of the examination, and has rized it into four levels: no untreated decay, one
been described in detail elsewhere.26 We produced or two surfaces with untreated decay, three
additional information about healthful eating through five surfaces with untreated decay and
using the Healthy Eating Index, or HEI, Data six or more surfaces with untreated decay.
File, which was created by CDC and NCHS using Covariate selection. For these analyses, we
NHANES III dietary intake data and the U.S. included sociodemographic indicators that have
Department of Agriculture guidelines.27 been reported to be associated with oral health.
For our study, we obtained data Race/ethnicity was categorized as
from questionnaire information (the Mexican-American, non-Hispanic
Youth File), dietary information Caries experience black, non-Hispanic white and
(the HEI File) and a standardized other. Children who were identified
was based on the
oral health examination (Exam as “other” were included in the
File). Three trained dentists in number of decayed total population estimates, but not
NHANES III conducted the or filled primary in the regression analyses. We cat-
majority of the dental examinations, dental surfaces as egorized educational attainment
all of which were performed in derived from for the identified adult responsible
MECs. Dental examiners were cali- the coronal caries for the child as “some or no high
brated periodically by the survey’s school experience,” “completed high
examination.
expert dental examiner, and inter- school” and “at least some college
rater reliability between the survey experience.” Poverty status was
examiners and the reference exam- dichotomized as either equal to or
iner was considered to be very good (κ statistics below 200 percent of the federal poverty level or
ranged from 0.96 to 1.00).28 Detailed descriptions greater than 200 percent, and was calculated by
about the NHANES III oral health component dividing total family income by the adjusted fed-
protocol, quality control and measurement issues eral poverty income threshold. We categorized
have been described elsewhere.26,29 dental history as either having had a dental visit
We identified a total of 13,944 participants who within the previous 12 months or not. Sex also
had a record in the NHANES III Youth File as was included in the analyses.
potentially eligible for this analysis. We excluded We assessed past and current healthful eating
824 people who had no recorded examination practices using the history of breast-feeding,
value for age. We then excluded 8,567 people who breakfast eating frequency, and eating five serv-
were not within the targeted age range (2 through ings of fruits and vegetables a day. A child’s his-
5 years) for this analysis. From the remaining tory of breast-feeding or receiving breast milk
group, we excluded 317 people who did not was categorized as “positive” or “negative.” We
receive a completed dental examination. This assigned a “positive” score if the respondent
yielded an analytical sample of 4,236 participants reported that the child had ever been breast-fed
for our study. or received breast milk, regardless of periodicity.
Outcome variables. Caries experience and A child’s frequency of eating breakfast was
existing untreated decay in primary teeth were dichotomized as either “every day” or “not every
the two dependent variables used in our analysis. day.” The “not every day” value was obtained by
Coronal dental assessments in NHANES III were aggregating the following possible responses from
made according to visual/tactile examinations, the reporting adult: never, some days, rarely or
without radiographs at the surface level for both weekends only. Using fruit and vegetable serving
primary and permanent teeth (excluding third information from the HEI file, we categorized a

JADA, Vol. 135, January 2004 57

Copyright ©2004 American Dental Association. All rights reserved.
R E S E A R C H

“5-a-Day” variable as either currently eating modeling to assess the relationships between the
fewer than five servings of fruits and vegetables a covariates. Parsimonious models were determined
day or eating five or more servings a day. by covariate exclusion, with criteria for inclusion
Overweight and short stature among children set for a Satterthwaite-adjusted F statistic of
were defined on the basis of the sex-specific 2000 P < .05. Potential two-way interactions were
CDC growth charts for the United States.30 Over- explored throughout the modeling process. We
weight was defined as the 95th percentile or considered P < .05 to be statistically significant.
higher of body mass index, or BMI, in kilograms
per square meter for age, and at risk of being RESULTS
overweight was defined as the 85th percentile or Table 1 shows the sociodemographic, nutrition,
higher but less than the 95th percentile of BMI body measure and oral health characteristics.25
for age. The Committee on Clinical Guidelines for Table 2 shows the prevalence of dental caries
Overweight in Adolescent Preventive Services31 experience (dfs) (a measure of the history of car-
recommended use of the 95th percentile of BMI to ious activity) and untreated decay (ds) according
classify adolescents as being overweight. Short to characteristics of interest.25 Caries experience
stature was defined as less than the fifth per- increased with age (to 40.2 percent for 5-year-olds)
centile of stature for age. We used a database and and was greater for Mexican-American children
statistics program (Epi Info 2000) (39.7 percent) than it was for non-
to make the calculations using the Hispanic black and non-Hispanic
2000 CDC growth charts.32 Caries experience white children (28.6 percent and
Data analysis. We performed all increased with age 18.1 percent, respectively). Children
statistical analyses using SUDAAN, and was greater for with the greatest number of tooth
a software package that is specifi- surfaces affected by untreated decay
Mexican-American
cally designed to accommodate com- (≥ six surfaces) were more likely to
plex sample surveys.33 Sample children than it was be Mexican-American (15.7 per-
weights were used to account for the for non-Hispanic black cent), to live in households with an
unequal probability of selection and and non-Hispanic adult who had not completed high
nonresponse of the study partici- white children. school (12.6 percent) and to be at or
pants to produce prevalence esti- below 200 percent of the federal
mates, relative odds and related poverty line (11.0 percent).
standard errors. We conducted bivariate analyses Unadjusted regression models showed that
of the sociodemographic, healthful eating and caries experience in children aged 2 through 5
anthropometric characteristics with dental caries. years was significantly associated (P < .05) with
We used pairwise t-tests to assess for significant lower educational achievement, poverty, being
differences between groups. non-Hispanic black or non-Hispanic white, not
Using the LOGISTIC and MULTILOG func- receiving breast milk, not eating breakfast every
tions within SUDAAN, respectively, we used stan- day, eating fewer than five servings of fruits and
dard and cumulative logistic regression models to vegetables a day, and not having had a dental
compute adjusted odds ratios, or OR, and 95 per- visit within the past 12 months (data not shown).
cent confidence intervals, or CI. The cumulative During the modeling process, the addition of
logistic function uses an ordinal categorical out- “5-a-Day” fruit and vegetable information miti-
come variable of two or more categories, compared gated any significant effects by educational
with the standard logistic function, which uses a achievement of the referenced adult. Moreover,
dichotomous outcome variable. The MULTILOG additional modeling revealed a significant inter-
function produces estimates using a proportional action between race/ethnicity and poverty.
odds model with a cumulative link. This statistical The unadjusted regression models also showed
methodology has been reported to be the most fre- that more untreated decayed surfaces (that is, ds)
quently used model for ordinal logistic regression in children aged 2 through 5 years were signifi-
applications.34 These estimates indicate the odds cantly associated (P < .05) with lower educational
of a categorical increase in the number of surfaces achievement, poverty, being Mexican-American or
affected by untreated decay for the indicators non-Hispanic black, not receiving breast milk,
included in the model. eating fewer than five servings of fruits and veg-
We used nonautomated stepwise regression etables a day, and not eating breakfast every day

58 JADA, Vol. 135, January 2004

Copyright ©2004 American Dental Association. All rights reserved.
 R E S E A R C H

TABLE 1

SELECTED CHARACTERISTICS FOR CHILDREN AGED 2 THROUGH

5 YEARS: UNITED STATES, 1988-1994.*
VARIABLE SAMPLE SIZE (N = 4,236†) WEIGHTED DISTRIBUTION (SE‡)

Age at Examination (Years)

2 1,081 23.4 (0.61)

3 1,054 25.3 (0.84)
4 1,056 24.7 (1.04)

5 1,045 26.6 (0.95)

Sex
Boys 2,081 50.8 (0.92)
Girls 2,155 49.2 (0.92)

Race/Ethnicity
Mexican-American 1,489 9.93 (0.88)

Non-Hispanic black 1,346 16.4 (1.23)

Non-Hispanic white 1,190 62.8 (1.63)

Other 211 10.8 (1.55)

Educational Attainment (Reference Adult)

Some high school or less 1,609 24.8 (1.12)

Completed high school 1,342 33.5 (1.34)

Some college 1,207 41.7 (1.82)

Poverty Status
≤ 200% federal poverty line 2,712 53.7 (1.52)
> 200% federal poverty line 1,182 46.3 (1.52)

Breast-feeding
Yes 1,891 53.4 (1.66)
No 2,337 46.7 (1.66)

Breakfast Status
Eats breakfast every day 3,821 89.9 (0.80)
Not every day 412 10.1 (0.80)

Fruits or Vegetables

< Five servings a day 2,711 69.6 (1.67)

≥ Five servings a day 1,140 30.4 (1.67)

Short Stature for Age

Yes 146 3.4 (0.55)

No 4,043 96.6 (0.55)

Overweight (BMI § for Age)

≥ 95% 370 7.0 (0.72)

≥ 85% and < 95% 484 10.8 (0.59)

< 85% 3,313 82.2 (0.87)

Dental Visit Within Past 12 Months

Yes 2,626 56.9 (1.39)
No 1,564 43.1 (1.39)
Some Caries Experience ¶
Yes 1,265 23.7 (1.37)
No 2,971 76.3 (1.37)
Untreated Decay Status **
≥ Six surfaces 428 7.2 (0.85)
Three to five surfaces 242 4.5 (0.64)

One to two surfaces 409 7.4 (0.58)

No untreated decay 3,157 80.9 (1.20)

* Source: National Center for Health Statistics.25

† For some variables, the numbers do not total 4,236 because of missing data.
‡ SE: Standard error.
§ BMI: Body mass index.
¶ Decayed and/or filled tooth surfaces, or dfs, in the primary dentition.
** Decayed tooth surfaces, or ds, in the primary dentition.

Copyright ©2004 American Dental Association. All rights reserved.

R E S E A R C H

TABLE 2

CARIES EXPERIENCE AND UNTREATED DECAY AMONG CHILDREN

AGED 2 THROUGH 5 YEARS BY SELECTED CHARACTERISTICS:
UNITED STATES, 1988-1994.*
VARIABLE SOME CARIES EXPERIENCE † UNTREATED DECAY§
% PREVALENCE (SE‡) % PREVALENCE (SE)
>
– 6 3-5 1-2 No
Surfaces Surfaces Surfaces Surfaces

Age at Examination (Years)

2 (reference) 7.7 (0.96) 3.4 (0.63) —¶ 3.2 (0.65) 92.0 (0.98)
3 15.5 (1.87)** 5.8 (1.09) —¶ 4.9 (0.81) 85.5 (1.76)**
4 29.6 (2.30)** 9.5 (1.37)** 4.2 (0.86) 10.5 (1.28)** 75.8 (2.08)**
5 40.2 (2.69)** 9.9 (1.86)** 8.0 (1.43) 10.6 (1.26)** 71.6 (2.60)**
Sex
Boys (reference) 23.0 (1.44) 7.1 (1.01) 4.3 (0.62) 7.9 (0.71) 80.7 (1.33)
Girls 24.5 (1.68) 7.3 (0.93) 4.7 (0.84) 6.9 (0.77) 81.2 (1.49)
Race/Ethnicity
Mexican-American 39.7 (1.81)** 15.7 (1.11)** 6.1 (0.85)** 13.0 (1.32)** 65.3 (1.70)**
Non-Hispanic 28.6 (2.07)** 8.5 (1.17)** 6.1 (0.46)** 10.1 (1.10)** 75.3 (1.94)**
black

Non-Hispanic white 18.1 (1.86) 4.1 (0.84) 3.5 (0.82) 6.2 (0.80) 86.2 (1.57)
(reference)
Educational Attainment
(Reference Adult)
Some high school or less 34.4 (2.90)** 12.6 (1.60)** 7.3 (1.46)** 9.1 (1.01)** 71.0 (2.84)**
Completed high school 23.7 (2.10)** 9.0 (1.82)** 3.5 (0.68) 8.5 (1.05)** 79.0 (2.16)**

Some college (reference) 17.2 (1.56) 2.4 (0.53) 3.5 (0.88) 5.5 (0.69) 88.6 (1.25)
Poverty Status
≤ 200% federal poverty 31.5 (1.91)** 11.0 (1.35)** 6.8 (0.95)** 9.3 (0.96)** 73.0 (1.89)**
line
> 200% federal poverty 14.1 (1.31) 2.4 (0.51) —¶ 5.4 (0.64) 90.4 (0.98)
line (reference)
Breast-feeding
Yes (reference) 21.2 (1.78) 5.4 (0.74) 3.9 (0.96) 6.8 (0.99) 83.9 (1.36)

No 26.7 (1.63)** 9.3 (1.21)** 5.2 (0.54) 8.1 (0.87) 77.4 (1.58)**

Breakfast Status
Eats breakfast every day 22.6 (1.28) 6.9 (0.77) 4.4 (0.62) 6.9 (0.63) 81.8 (1.10)
(reference)
Not every day 33.6 (4.24)** 10.6 (2.68) 5.3 (1.71) 11.5 (2.10)** 72.6 (3.60)**

Fruits or Vegetables
< Five servings a day 25.5 (1.81)** 7.7 (1.29) 5.0 (0.81)** 7.4 (0.62) 79.8 (1.49)**

≥ Five servings a day 17.8 (1.56) 5.9 (0.98) 2.9 (0.59) 6.5 (1.27) 84.8 (1.44)
(reference)
Short Stature for Age
Yes 21.3 (4.42) 9.5 (2.43) —¶ —¶ 84.4 (3.25)

No (reference) 23.8 (1.39) 7.1 (0.89) 4.6 (0.66) 7.6 (0.58) 80.8 (1.22)

Overweight (BMI †† for Age)

≥ 95% 23.0 (3.56) 7.2 (1.44) —¶ 7.6 (1.57) 81.6 (2.73)
≥ 85% and < 95% 26.4 (3.00) 5.7 (1.06) 6.4 (1.58) 7.6 (1.48) 80.3 (2.54)
< 85% (reference) 23.5 (1.40) 7.4 (0.97) 4.4 (0.65) 7.6 (1.48) 80.9 (1.21)
Dental Visit Within Past 12
Months
Yes (reference) 19.2 (1.34) 7.6 (1.19) 5.0 (0.93) 6.5 (0.64) 80.9 (1.33)
No 29.7 (2.13)** 6.9 (1.00) 3.7 (0.79) 8.6 (1.08) 80.9 (1.85)

TOTAL 23.7 (1.37) 7.2 (0.85) 4.5 (0.64) 7.4 (0.58) 80.9 (1.20)

* Source: National Center for Health Statistics.25

† Decayed and/or filled tooth surfaces, or dfs, in the primary dentition.
‡ SE: Standard error.
§ Decayed tooth surfaces, or ds, in the primary dentition.
¶ Estimates do not meet standards for reporting.
** P < .05 when compared with the reference group.
†† BMI: Body mass index.

Copyright ©2004 American Dental Association. All rights reserved.

 R E S E A R C H

(data not shown). During the modeling process, eating practices were associated with caries in
we also found an interaction between poverty and primary teeth among those not living in poverty.
educational attainment. Specifically, not eating breakfast every day was
Because of the interactions between poverty found to be associated with overall caries experi-
and education and race/ethnicity, we performed ence and untreated decay in the primary denti-
additional regression analyses that were strati- tion in children aged 2 through 5 years. The
fied by poverty status (Table 325). For children finding that caries was associated with
living at or below 200 percent of the federal unhealthful eating practices (that is, not eating
poverty level, caries experience was only signifi- breakfast or five fruits and vegetables per day)
cantly associated (P < .05) with being Mexican- and that these relationships were not homoge-
American or not having had a dental visit within nous across the poverty strata (that is, the effect
the past 12 months. For children not living in is not the same at different levels of household
poverty (> 200 percent of the federal poverty line), income) are important to consider in health pro-
race/ethnicity, not eating breakfast daily, not motion and policy deliberations. Moreover, these
eating five fruits and vegetables a day, and not findings reinforce the notion that good dietary
having had a dental visit within the past 12 habits promote oral health; thus, reinforcing good
months were significantly associated with caries eating practices such as daily breakfast consump-
experience (P < .05). Among this group of chil- tion could be an important adjunct to fluoridation
dren, the likelihood of experiencing to further reduce caries experience
caries was greater for those who did in children.
not eat breakfast daily (OR = 3.77; Daily breakfast consumption.
Not eating breakfast
95 percent CI, 1.80 to 7.89) and who We used daily breakfast consump-
did not eat five servings of fruits every day was found tion as an indicator of consistent
and vegetables a day (OR = 3.21; 95 to be associated with good nutrition. This is based on
percent CI, 1.74 to 5.95). overall caries several studies that have associ-
For children living at or below experience and ated a lack of breakfast consump-
200 percent of the federal poverty untreated decay in tion with higher rates of caloric
line, being Mexican-American or intake, poor nutrient intake and
the primary dentition
not having had a dental visit within obesity.35,36 Although breakfast con-
the past 12 months continued to be in children aged 2 sumption among many young chil-
strong indicators of having an through 5 years. dren is limited to presweetened
increasing amount of untreated cereals, many studies have indi-
decay (OR = 2.12; 95 percent CI, cated that these cereals are nutri-
1.40 to 3.22 and OR = 1.46; 95 percent CI, 1.06 to tionally beneficial.37 However,
2.02, respectively) (Table 3). many people view presweetened packaged cereals
Among children aged 2 through 5 years not consumed by children as being potentially
living in poverty, the odds of having increasing cariogenic.
levels of untreated decay associated with not Gibson38 examined this perception using data
eating breakfast every day (OR = 2.76; 95 percent from the 1995 United Kingdom National Diet and
CI, 1.21 to 6.26) were similar to the independent Nutrition Survey of preschool-aged children, and
effects of race/ethnicity (OR = 2.63 and 2.64 for found caries experience to be unrelated to eating
being Mexican-American and non-Hispanic black, presweetened cereals. Furthermore, Gibson
respectively). Furthermore, not eating five fruits reported that children who consumed breakfast
and vegetables a day was significantly associated cereals were more likely to reduce consumption of
with having more untreated decay, but not sugary snacks or soda compared with children
having had a dental visit within the past 12 who skipped breakfast. Dairy products also have
months was not significantly associated with the been shown to have some anticariogenic
amount of untreated decay (P > .05). effects.39,40 Thus, it is possible that the relation-
ship between sugars in breakfast cereals and
DISCUSSION caries could be mitigated when children consume
presweetened cereals with milk.
Poor eating practices. In this analysis of more Breast-feeding. We used any history of
than 4,000 preschoolers, we found that poor breast-feeding, regardless of frequency, as

JADA, Vol. 135, January 2004 61

Copyright ©2004 American Dental Association. All rights reserved.
R E S E A R C H

TABLE 3

CARIES EXPERIENCE AND UNTREATED DECAY AMONG CHILDREN AGED

2 THROUGH 5 YEARS STRATIFIED BY POVERTY STATUS FOR ALL OTHER
INDEPENDENT INDICATORS: UNITED STATES, 1988-1994.*
VARIABLE SOME CARIES EXPERIENCE†‡ UNTREATED DECAY§¶

<– 200% Federal > 200% Federal <– 200% Federal > 200% Federal
Poverty Line Poverty Line Poverty Line Poverty Line
Odds Ratio (CI**) Odds Ratio (CI**) Odds Ratio (CI**) Odds Ratio (CI**)

Race/Ethnicity
Mexican-American 2.59 (1.75-3.84) 2.67 (1.29-5.51) 2.12 (1.40-3.22) 2.63 (1.17-5.94)
Non-Hispanic 1.43 (0.96-2.13) 2.05 (1.19-3.53) 1.33 (0.91-1.93) 2.64 (1.51-4.64)
black
Non-Hispanic white 1.00 1.00 1.00 1.00
Educational
Attainment
(Reference Adult)
Some high school or †† †† 1.39 (0.88-2.18) 2.29 (0.77-6.81)
less
Completed high †† †† 1.11 (0.70-1.76) 2.63 (1.17-5.94)
school
Some college †† †† 1.00 1.00
Breakfast Status
Not every day 1.50 (0.92-2.46) 3.77 (1.80-7.89) 1.39 (0.91-2.12) 2.76 (1.21-6.26)
Eats breakfast 1.00 1.00 1.00 1.00
every day
Fruits or Vegetables
< Five servings a day 1.12 (0.78-1.61) 3.21 (1.74-5.95) 1.00 (0.71-1.41) 2.24 (1.17-4.30)
≥ Five servings a day 1.00 1.00 1.00 1.00
Dental Visit Within
Past 12 Months
No 2.45 (1.84-3.26) 2.85 (1.77-4.59) 1.46 (1.06-2.02) 1.66 (0.94-2.92)
Yes 1.00 1.00 1.00 1.00

* Source: National Center for Health Statistics.25

† Decayed and/or filled tooth surfaces, or dfs, in the primary dentition.
‡ Models produced by logistic regression.
§ Decayed tooth surfaces, or ds, in the primary dentition.
¶ Models produced by cumulative logistic regression.
** CI: Confidence interval.
†† Nonsignificant covariate not included in the models.

another indicator of good nutritional practices. breast-feeding beyond age 2 years.42-44

We proposed that breast-feeding would likely
delay or reduce the consumption of juices and
drinks that contain high levels of sugar. Dini and
colleagues41 reported that children aged 3 through
4 years who were never breast-fed were likely to
have more caries compared with children who
were breast-fed, regardless of duration, within
the first 24 months of life.
Currently, differing recommendations exist for
promoting prolonged breast-feeding. The Ameri-
can Academy of Pediatric Dentistry has endorsed
the recommendation by the American Academy of
Pediatrics to promote breast-feeding during the
first 12 months of childhood; however, the World
Health Organization advocates unrestricted
Although Dini and colleagues41 reported that
children who were breast-fed beyond 24 months of
age were more likely to have caries compared
with children who were breast-fed only up to 24
months of age, Weerheijm and colleagues45
reported that prolonged breast-feeding “does not
lead to a higher caries prevalence.” Roberts and
colleagues46 reported that infant feeding methods
are not related to the prevalence of caries in pri-
mary teeth, but when caries is present, the mag-
nitude of caries is related to feeding methods.
Furthermore, a systematic review by Valaitis and
colleagues,47 which examined the relationship
between early childhood caries and breast-
feeding, yielded inconclusive findings. Our find-

62 JADA, Vol. 135, January 2004

Copyright ©2004 American Dental Association. All rights reserved.
 R E S E A R C H

ings indicate that there is no relationship use and dental care visits were better indicators
between caries and a history of ever of primary caries experience. In addition,
breast-feeding. McMahon and colleagues59 reported that there
BMI. For our study, we used anthropometrics was no relationship between carbohydrate intake
measures, such as BMI, to control for potential and caries in the primary dentition among young
confounding effects. Published research exam- children who lived in areas with optimal commu-
ining the relationships between body measures nity water fluoridation. However, their study did
and tooth decay has been sparse and inconclusive, report that young children being treated with
with most studies failing to control for the poten- medication mixed with sweetened syrups were
tial confounding effects of diet on tooth decay. more likely to develop caries, and that socioeco-
Studies have reported an association between nomic status was an independent indicator of pri-
BMI and decay in the permanent dentition,48,49 mary caries prevalence.
but no findings of association between BMI and The data from our study produced mixed find-
decay in the primary dentition have ings with regard to previous anal-
been reported.50 Our findings show yses of the impact of socioeconomic
that after adjusting for the more The data from this status on oral health status. It is
important known indicators of well-known that minority children
study produced mixed
caries in primary teeth (such as or children identified within lower
race/ethnicity and dental visit fre- findings with regard socioeconomic groups, assessed by
quency), healthful eating practices to previous analyses either the level of the primary care-
are more significant in the preva- of the impact of taker’s education or household
lence of caries than are BMI socioeconomic status income, are more likely to experi-
measures. on oral health status. ence caries compared with nonmi-
Changes in dietary habits also nority children or children in higher
have been linked to increased levels socioeconomic groups.57,60-63 How-
of obesity in the United States and ever, our findings suggest that the
other nations. Fragmented meals and meals away effect of the primary caretaker’s education on a
from home both are contributors to overconsump- preschooler’s caries experience is not significant
tion of foods.51 Decreased stature and failure to when the effects of healthful eating practices,
thrive have been reported with excessive fruit such as eating breakfast or five fruits and vegeta-
juice intake in some children, while in others, bles every day, are accounted for.
excessive comsumption of juice drinks has been Our findings also suggest that poverty status is
found to be related to excessive caloric intake and a significant effect modifier in the relationship
obesity.4 Skinner and Carruth52 reported that con- between healthful eating practices and primary
sumption of 100 percent juice was not associated tooth decay. For children who are at or below the
with either obesity or short stature, but as juice 200 percent federal poverty level, being Mexican-
consumption decreases, soda and juice drink American or not having had a dental visit within
intake increases. Consumption of high-carbohy- the past 12 months were the only independent
drate liquids may be a risk factor for excessive factors that were significantly related to caries
caloric intake,53 and may have harmful added experience or more untreated tooth decay in the
effects for people with poor oral hygiene.54 primary dentition.
Scandinavian studies have reported that Conversely, for children above the 200 percent
preschool-aged children were more likely to expe- federal poverty line, being non-Hispanic black or
rience caries in primary teeth when they had poor Mexican-American, not having had a dental visit
oral hygiene independent of poor dietary within the past 12 months, and not eating break-
habits,55,56 and that poor dietary practices at 12 fast or five fruits and vegetables per day all were
months of age are related to caries incidence at 3 significantly related to caries experience. The
years of age.57 Other studies have suggested that results were similar for having more untreated
there is no relationship between nutrient intake decay, except that not having had a dental visit
and caries in the primary dentition. within the past 12 months was not a significant
Marques and Messer58 reported that sugar con- indicator.
sumption was not associated with primary caries Caries prevalence. In the United States,
and that increasing age and history of fluoride caries prevalence in primary teeth among 5- to 9-

JADA, Vol. 135, January 2004 63

Copyright ©2004 American Dental Association. All rights reserved.
R E S E A R C H

Dr. Dye is the dental At the time this study
epidemiology officer, was conducted, Dr.
Analysis Branch, Divi- Shenkin was a resident
in pediatric dentistry,
sion of Health and
Nutrition Examination University of Iowa, Iowa
Survey, National Center City. He currently is an
for Health Statistics, assistant clinical pro-
Centers for Disease fessor of Health Policy,
Control and Prevention, Health Services
3311 Toledo Road, Research and Pediatric
Room 4416, Hyattsville, Dentistry at the
Md. 20782, e-mail Goldman School of
Dental Medicine, Boston
“bfd1@cdc.gov”.
Address reprint University. He also is in
requests to Dr. Dye. full-time private prac-
tice in Bangor, Maine.
year-olds has
gradually declined from a mean dfs of 5.3 in the
early 1980s64 to 3.9 in the mid-1990s (B. Dye,
unpublished data, 2003). Although the prevalence
of caries in primary teeth has been decreasing
during the past two decades in older children,
Brown and colleagues6 reported that the preva-
lence has remained unchanged among 2- to 5-
year-olds since the 1970s. Recent studies have
reported that caries prevalence and unmet dental
needs continue to be an important public health
issue, especially among high-caries-risk preschool-
aged children.65,66
At first glance, our findings that unhealthful
eating practices, such as not having breakfast or
five fruits and vegetables every day, are signifi-
cant risk factors for caries in primary teeth only
among nonpoor preschool-aged children may
seem to be counterintuitive. However, many high-
caries-risk children attend Head Start and
related programs, where they receive free or sub-
sidized meals, particularly breakfast. Poverty
may be the more important cofactor in indicating
caries risk, but healthful eating practices are an
important factor in the overall, complex process
that leads to caries experience in young children.
Our findings support the notion that even if the
effects of poverty could be mitigated, healthful
eating practices among preschoolers would con-
tribute to a further reduction in caries.
The results of our study suggest that dietary
habits of children are still a component of the
caries process in the primary dentition, and there
appears to be a “protective effect” from engaging
in healthful eating practices in early childhood,
especially among the nonpoor. Unfortunately, the
frequency of con-
sumption of
breakfast among
children has
decreased by
more than 10
Dr. Ogden is a nutri- Dr. Levy is a professor,
tional epidemiologist, Department of Preven-
Dr. Kanellis is an percent during
associate professor and
Analysis Branch, Divi- tive and Community head, Department of the last 30
sion of Health and
Nutrition Examination
Dentistry, College of
Dentistry, and Depart-
Pediatric Dentistry, years36 and the
College of Dentistry,
Survey, National Center ment of Epidemiology, University of Iowa, Iowa consumption of
for Health Statistics, School of Public Health,
Centers for Disease University of Iowa,
City. dairy products
Control and Prevention, Iowa City. has decreased
Hyattsville, Md.
by 30 percent, while consumption
of sugar-containing soft drinks has doubled
during this period.2 As dietary habits continue to
progress along a similar trend within the United
States, unhealthful eating practices may become
a significant barrier to efforts to help children
reach a caries-free status in adulthood.
Study limitations. Limitations of our study
are related to the use of a cross-sectional design
to examine indicators of untreated tooth decay
and caries experience. We were unable to accu-
rately determine weekly caloric intake or dietary
composition based on self-reported frequency of
breakfast consumption. In addition, we were
unable to ascertain the level of parental bias in
responding to self-reported nutritional questions.
Although survey protocols for caries assessment
in NHANES III were more conservative compared
with clinical standards, and radiographs were not
obtained, the direction of the bias produced from
underreporting disease during the dental exami-
nation may have underestimated the magnitude
of the association between caries and healthful
eating practices. The strength of our study is its
use of a large, nationally representative sample of
preschool-aged children to explore and control for
multiple risk factors.
CONCLUSION
To our knowledge, this is the first epidemiologic
study to examine the relationship between
dietary habits and tooth decay among preschool-
aged children through the use of a nationally rep-
resentative sample. Overall, our findings suggest
that young, nonpoor children with poor dietary
habits are more likely to experience caries in pri-
mary teeth compared with poor children.
Although we did not find an association between
caries and breast-feeding, relationships with
other surrogates for healthful eating practices
during early childhood—such as eating five fruits

64 JADA, Vol. 135, January 2004

Copyright ©2004 American Dental Association. All rights reserved.

and vegetables per day and, in particular, eating
breakfast every day—are important findings.
The data suggest that improved access to well-
balanced meals and to breakfast programs for
children may be an important oral health promo-
tion activity. Given the results of our study,
future research opportunities include more
detailed cross-sectional and longitudinal studies.
More in-depth dietary information with longer
periods of data collection could assist in defining
nutritional risk factors for caries development.
The impact of increasing carbohydrate exposure,
including consumption of sodas and juice drinks,
on the rate of dental caries also should be further
investigated. ■
Dr. Marshall is a clinical assistant professor, Department of Preven-
tive and Community Dentistry, College of Dentistry, University of
Iowa, Iowa City.
The authors thank Cheryl D. Fryar, M.S.P.H., for statistical pro-
gramming support and review.
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