caries in adolescence – influence from early childhood

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Risk factors and indicators are often discussed in the

literature, and a recent systematic review by the

Swedish Council on Technology Assessment in

Health Care (1) stated that past caries experience is

the single best predictor of future caries develop-ment among preschool children, schoolchildren and

adolescents. In addition, it has been known for

several decades that the high and frequent con-

sumption of sugar is an aetiological factor in caries

(2). A recent prospective Finnish study examined

children from infancy to the age of 10 years. It

concluded that a persistently high sucrose intake

increases the risk of dental caries in children (3).

However, a systematic review has shown that,

today, with frequent fluoride exposure, the rela-

tionship between sugar consumption and caries

experience is not consistent (4). This is in line with

the findings reported by Zero (5), who pointed out

that, in subgroups without the same fluoride pro-

tection, sugar still acts as a potential risk. Previously,the caries-risk factors that attracted most interest

were factors associated with the local caries process

itself. According to Burt (6), these factors should be

extended. He stated that ‘we should broaden our

view of risk to include social determinants of health

and population health’. Furthermore, a systematic

review of the literature on risk factors for dental

caries in young children (7) concludes that ‘there is a

shortage of high quality studies using the optimum

study design, i.e. a longitudinal study’.

Community Dent Oral Epidemiol 2012; 40: 125–133 All rights reserved

2011 John Wiley & Sons A/S

Caries in adolescence – influencefrom early childhoodAlm A, Wendt LK, Koch G, Birkhed D, Nilsson M. Caries in adolescence – influence from

early childhood. Community Dent Oral Epidemiol 2012; 40: 125–133. 2011 John Wiley &

Sons A ⁄ S

Abstract – Objective: To analyse the relationship between caries determinantsin early childhood and caries prevalence in proximal surfaces in adolescents atthe age of 15 years. Methods: The present longitudinal study is part of a seriesof surveys of oral health in 671 children followed from 1 to 15 years of age. Datawere selected from examinations, interviews and questionnaires at 1, 3 and6 years and bitewing radiographs at 15 years of age. Uni- and multivariablelogistic regression analyses were performed to identify caries-relateddeterminants. The outcome variable was carious lesions and fillings (DFa) inapproximal tooth surfaces at 15 years of age. Statistical comparisons were made

between caries-free teenagers, DFa = 0 and teenagers with DFa > 0, DFa ‡ 4and DFa ‡ 8, respectively. Results: In the final logistic regression analyses,caries experience at 6 years and mother’s self-estimation of her oral health careas being less good to poor remained statistically significant and were related tocaries in all three caries groups (i.e. DF > 0, ‡4 and ‡8) at 15 years of age. Theconsumption of sweets at 1 year remained statistically significant, with a cariesexperience of DF ‡ 4 and ‡ 8. The variables ‘parents born abroad’ and femalegender were statistically significantly associated with DFa ‡ 4 and DFa ‡ 8,respectively. Furthermore, infrequent toothbrushing habits at 3 years of age andfailure to attend the examination at 1 year were statistically significantlyassociated with caries at 15 years in the univariable analyses. Conclusion: Early

caries experience, consumption of sweets at an early age and mother’s self-estimation of her oral health care as being less good to poor are associated withapproximal caries in adolescents. The study indicates that caries determinantsidentified during early childhood have a strong impact on approximal caries inadolescence.

A. Alm1 , L. K. Wendt2 , G. Koch3 ,

D. Birkhed4 and M. Nilsson5

1

Department of Paediatric Dentistry,Karnsjukhuset, Skovde, 2Centre of OralHealth, School of Health Sciences, JonkopingUniversity, Jonkoping, 3Department of Paediatric Dentistry, The Institute forPostgraduate Dental Education, Jonkoping,4Department of Cariology, SahlgrenskaAcademy at Gothenburg University,Goteborg, 5Futurum – The Academy of Healthcare, County Hospital, Jonkoping,Sweden

Key words: adolescents; approximal caries;early childhood; oral hygiene; sweets

Anita Alm, Specialistklinken for pedodonti,

Karnsjukhuset, SE-54185 Skovde, SwedenTel.: +46 500432900Fax: +46 500432913e-mail: [email protected]

Submitted 8 October 2010;accepted 14 September 2011

doi: 10.1111/j.1600-0528.2011.00647.x 125



Longitudinal studies of oral health in children

followed from 1 to 15 years of age have been

performed in Jonkoping, Sweden (8–13). These

studies have discussed the influence of caries

determinants recorded in early childhood, such as

caries experience, oral hygiene, snacking habits

and parent-related variables, in relation to approx-

imal caries at 15 years of age (8–10). However,combined analyses of these studies to elucidate the

strength of caries determinants have never been

made. The aim of the present longitudinal study

was therefore statistically to analyse the relation-

ship between caries determinants in early

childhood and proximal caries prevalence in

adolescence.

Material and methods

This study, which was designed as a prospectivelongitudinal study, is part of a series of surveys of

oral health in children followed from 1 to 15 years

of age and living in the Municipality of Jonkoping,

Sweden. All 671 children who were 1 year of age in

1988 and living within four of the thirteen child

welfare centres in the Municipality of Jonkoping

were invited to participate. The four districts

included the town, suburbs and rural areas and

were chosen to reflect the socio-economic levels of

the population living in this part of Sweden (8–13).

The Ethics Committee at the University of Linko-ping, Sweden, approved the study.

Data relating to explanatory variables in the

present study were selected from examinations,

interviews and questionnaires at 1, 3 and 6 years of

age. The examinations at 1, 3 and 6 years were

conducted by one of the authors (L-KW) and have

been described in detail elsewhere (11–13). The

outcome variable in the present study was approx-

imal carious lesions and fillings at 15 years of age.

Information on approximal caries was obtained

from bitewing radiographs, which were analysed

by one of the authors (AA). The number of dropouts between 1 and 15 years of age totalled

103 and, as a result, 568 of the 15-year-olds (85% of

the original 671 children invited at 1 year of age)

were finally included in the study. In all, 539

children (80%) were examined at 1 and 15 years of

age, 555 (83%) at 3 and 15 years of age, and 517

(77%) at 6 and 15 years of age. The 20 children who

failed to attend the examination at 1 year of age

(but were examined at 15 years) were analysed

separately. There was a statistically significant

difference in mean caries prevalence between

children who failed to attend the examination at

1 year of age compared with those who were

examined at both 1 and 15 years (7.0 versus 3.1:

P < 0.01).

Both parents answered a structured question-

naire on parent-related variables in connection

with the examination at 1 year of age. The responserate for the 539 children who were examined at 1

and 15 years of age was 81% (based on whether the

mother, father or both parents had answered the

questionnaire). When it came to dropouts from the

questionnaire at 1 year of age, there was no

statistically significant difference in caries experi-

ence among adolescents whose parents answered

the questionnaire compared with those who did

not answer (3.0 versus 3.6). A chi-square analysis of

behavioural determinants was conducted on the

group of children who dropped out from the

questionnaire on parent-related variables at 1 yearof age. Children who dropped out had a statisti-

cally significantly higher consumption of sweets

and caries-risk products at 1 year of age, while this

difference was not seen at 3 years of age. More

details on the study population and analyses of

caries experience at 15 years of age have been

given previously (9).

Outcome variable Approximal caries experience at 15 years. Information

on approximal carious lesions and fillings at15 years of age was obtained from bitewing radio-

graphs, which were analysed by one of the authors

(AA). To calculate intra-examiner reproducibility,

10% of the radiographs were analysed twice, with

an interval of 2 months. The intra-examiner agree-

ment produced Cohen’s kappa values of 0.95. The

radiographic procedures have been described in

detail elsewhere (9). The approximal surfaces from

the distal surface of the first premolar to the mesial

surface of the second molar (a total of 24 surfaces)

were evaluated in terms of carious lesions and

fillings. Caries was registered as initial or manifestcaries as follows. Initial caries was defined as a

carious lesion in the enamel that had not reached

the dentino–enamel junction or a lesion that

reached or penetrated the dentino–enamel junction

but did not appear to extend into the dentine.

Manifest caries was defined as a carious lesion that

clearly extended into the dentine. The mean total

for total approximal caries experience (including

initial caries) and fillings was grouped and used in

the analyses as a dependent (outcome) variable and

126

Alm et al.



will subsequently be called DFa. According to the

caries experience at 15 years of age, the children

were grouped as follows: DFa = 0 (n = 187; 33%),

DFa > 0 (n = 381; 67%), DFa ‡ 4 (n = 189; 33%) and

DFa ‡ 8 (n = 79; 14%). It should be noted that all

the individuals in the DFa ‡ 8 group are also

included in the DFa ‡ 4 group and that DFa ‡ 4

and DFa ‡

8 are included in the DFa > 0 group.More detailed data relating to the 15-year-olds

have previously been presented (8–10).

Explanatory variablesCaries experience at 3 and 6 years. Caries was regis-

tered clinically by visual examination and probing

and radiographically if proximal contacts in pri-

mary molars made clinical examination impossible.

Clinically, initial caries was defined as a deminer-

alized surface without cavitation, while manifest

caries was defined as a carious lesion with cavita-

tion (that extended into the dentine). Radiograph-ically, initial proximal caries was defined as a

radiolucency in the enamel that had not passed the

dentino–enamel junction, whereas manifest caries

was defined as a radiolucency passing into the

dentine. Decayed, extracted and filled surfaces

(defs), including initial carious lesions, were regis-

tered (12). The children were stratified according to

caries experience at 3 and 6 years as follows:

• defs (including initial caries): 0, 1–2 or >2;

• manifest caries experience: no or yes.

These classifications were used as explanatoryvariables in the analysis. When it came to caries

experience at three and 6 years of age, the degree of

agreement was 0.3 (Spearman’s rank correlation).

Both these variables were therefore included in the

analysis. For the number of children in the different

groups, see Table 1.

Snacking habits at 1 and 3 years. Data relating to the

consumption of caries-risk products in early child-

hood were extracted from interviews conducted

with the parents at the dental examinations when

the children were 1 and 3 years of age (14). Using a

semi-structured form, the accompanying parentwas asked questions about the children’s dietary

habits at 1 and 3 years of age. Questions regarding

the consumption of caries-risk products, such as

soft drinks, fruit soup, sweets (candy, confection-

ery), ice cream or biscuits, were grouped as

follows: (i) no consumption, (ii) 1–7 times ⁄ week,

(iii) 8–14 times ⁄ week, (iv) 15–21 times ⁄ week and

(v) > 21 times ⁄ week. The consumption of sweets

was grouped as follows: (i) no consumption, (ii)

once a week or less and (iii) sweets more than once

a week. These classifications were used as explan-

atory variables in the analysis. When it came to

snacking habits at three and 6 years of age, the

degree of agreement was 0.2 (Spearman’s rank

correlation). Both these variables were therefore

included in the analysis. For the number of children in the different groups, see Table 1.

Toothbrushing habits at 3 years. The frequency of

toothbrushing habits at 3 years of age was grouped

as follows: (i) sometimes ⁄ never (n = 17), (ii) once a

day (n = 96) and (iii) twice daily or more (n = 376).

In the present study, 95% of the children utilized

fluoride toothpaste.

Dental avoidance behaviour at 1 year. Children were

grouped according to dental avoidance behaviour

at 1 year of age as follows: (i) children who failed to

Table 1. Distribution of variables recorded in earlychildhood included in the uni- and multivariable logisticregression analyses

VariablesAll 15-year-oldsn (%)

defs (including initial caries) at 3 years (n = 555)0 408 (74)1–2 56 (10)

>2 91 (16)Manifest caries experience at 3 years (n = 555)

No 474 (84)Yes 81 (16)

defs (including initial caries) at 6 years (n = 517)0 239 (46)1–2 80 (16)>2 198 (38)

Manifest caries experience at 6 years (n = 517)No 301 (58)Yes 216 (42)

Consumption of caries-risk products at 1 year(times ⁄ week; n = 538)

No consumption 53 (10)

1–7 227 (42)8–14 144 (27)15–21 63 (12)>21 51 (10)

Consumption of sweets at 1 year (times ⁄ week; n = 537)No consumption 368 (69)Once a week 123 (23)More than once a week 46 (9)

Consumption of caries-risk products at 3 years(times ⁄ week; n = 492)

No consumption 3 (1)1–7 22 (5)8–14 102 (21)15–21 150 (31)

>21 215 (44)Consumption of sweets at 3 years (times ⁄ week; n = 491)No consumption 28 (6)Once a week 279 (57)More than once a week 184 (38)

127

Caries in adolescence



attend the examination at 1 year of age but were

examined at 15 years (n = 20) and (ii) children

examined at both 1 and 15 years of age ( n = 539).

Previously performed analyses of oral hygiene and

parent-related variables. In a previous paper, uni-

and multivariable analyses of the explanatory

variables of oral hygiene at 1 and 3 years of age

and parent-related variables at 1 year of age were

performed (10). Parent-related variables were

extracted from a questionnaire that was completed

when the children were 1-year old; the questionscovered several topics, such as socio-economic

status and behavioural and attitudinal factors.

Statistically significant variables in the univariable

analyses are presented in Table 2.

Statistical analysesThe data analysis was generated using SAS ⁄ STAT

software (version 9 of the SAS System for Win-

dows Copyright 2002; SAS Institute Inc., Cary,

NC, USA), STATISTICA (data analysis software

system), version 8.0, StatSoft, Inc. (2007) and SPSS

15.0, SPSS Inc. (2006). The statistical analysesincluded a t-test for continuous data and logistic

regression to estimate odds ratios. In the logistic

regression, the outcome variable was approximal

caries and fillings at 15 years of age. Explanatory

variables were collected from clinical examinations

and interviews at 1 and 3 years of age and from

questionnaires at 1 year of age.

Uni- and multivariable logistic regression was

used to calculate the odds ratio (OR) and 95%

confidence intervals (95% CI). Explanatory vari-

ables that were statistically significant in the

univariable analyses were included in the multi-

variable analyses (including corrections for gen-

der). All the statistical comparisons were made

between caries-free teenagers (DFa = 0) and teen-

agers with DFa > 0, DFa ‡ 4 and DFa ‡ 8, respec-

tively. Univariable logistic regression was used for

the explanatory variables described in ‘Material

and Methods’. Variables relating to snacking habits

and caries experience at 3 and 6 years of age are

presented in Table 1. Variables associated with oralhygiene, gender and parent-related factors, which

remained statistically significant in previously

performed univariable analyses in one or more of

the groups with different caries experience at

15 years of age, are presented in Table 2. Standard

deviation (SD) in this paper is given as ±SD.

P-values below 0.05 were considered statistically

significant. NS is an abbreviation for nonsignifi-

cant.

Results

Caries status at 15 years of ageThe mean number of DFa was 3.2 (±4.0). The mean

DFa was 3.5 (±4.1) for the girls and 3.0 (±3.9) for the

boys (NS).

Univariable analysesCaries experience at 3 and 6 years. In the univariable

analyses, defs 1–2 and defs > 2 (including initial

carious lesions) and manifest caries experience at 3

Table 2. Child- and parent-related variables that remained statistically significant in the univariable analyses in aprevious paper (10) and were thus included in the final multivariable logistic regression analyses

Variables statistically significant in the univariable analysesAll 15-year-oldsna (%) Significant for DFa

Child relatedPlaque on maxillary incisors at 1 year 38 ⁄ 538 (7) >0, ‡4, ‡8Intermediate oral hygiene at 3 years 189 ⁄ 492 (38) ‡4, ‡8Poor oral hygiene at 3 years 95 ⁄ 492 (19) >0, ‡4, ‡8

Female gender 286 ⁄ 568 (50) ‡4, ‡8Parent related

Mother single 20 ⁄ 434 (5) >0, ‡4, ‡8Father less satisfied to dissatisfied with his social situation 166 ⁄ 382 (43) ‡4,‡8Mother has responsibility for the child on her own 109 ⁄ 425 (26) ‡8Mother’s self-estimation of her own oral health care less good to poor 225 ⁄ 433 (52) >0, ‡4, ‡8Father’s self-estimation of his own oral health care less good to poor 267 ⁄ 402 (66) ‡4Mother born in Sweden, father abroad 19 ⁄ 536 (4) >0, ‡4, ‡8Father born in Sweden, mother abroad 19 ⁄ 536 (4) >0, ‡4, ‡8Both parents born abroad 49 ⁄ 536 (9) >0, ‡4, ‡8

Comparisons were made between caries-free teenagers (DFa = 0) and teenagers with DFa > 0, DFa ‡ 4 and DFa ‡ 8respectively.aNumber of children ⁄ total number of children.

128

Alm et al.



and 6 years of age were statistically significantly

associated with caries experience of DFa > 0,

DFa ‡ 4 and DFa ‡ 8 at 15 years of age (Table 3).

Snacking habits. The consumption of sweets at 1 and

3 years of age and the consumption of caries-risk

products at 1 year of age were statistically signif-

icantly associated with caries experience of

DFa > 0, DFa ‡

4 and DFa ‡

8. The consumptionof caries-risk products at 3 years of age was not

statistically significantly associated with caries

experience at 15 years (Table 4).

Toothbrushing habits at 3 years. Toothbrushing some-

times ⁄ never versus twice daily or more at 3 years

of age was statistically significantly associated with

caries experience of DFa ‡ 4 and DFa ‡ 8 at

15 years of age (OR = 3.0 and 8.5; CI; 1.3–7.0 and

3.0–24.4, respectively), as was toothbrushing once a

day versus twice daily or more (OR = 1.7 and 2.9;

CI: 1.1–2.6 and 1.7–4.9, respectively).

Dental avoidance behaviour at 1 year. In the univari-able analysis, failure to attend the examination at

1 year of age was statistically significantly associ-

ated with caries experience of DFa ‡ 4 and DFa ‡ 8

(OR = 3.8 and 5.5; CI: 1.3–13.8 and 1.6–22.4, respec-

tively).

Unfavourable behaviour. Children who consumed

snacking products more than 14 times ⁄ week and

also had infrequent toothbrushing habits (i.e. once

a day or less) at 3 years of age were analysed

separately (n = 100; here called unfavourable

behaviour). In the univariable analysis, the variable

‘unfavourable behaviour’ at 3 years of age was

statistically significantly associated with caries

experience of DFa > 0, DFa ‡ 4 and DFa ‡ 8

(OR = 2.4, 2.9 and 5.7; CI: 1.4–4.2, 1.6–5.5 and 2.8–

11.8, respectively). The variable ‘unfavourable

behaviour’ has not been included in the multivar-

iable analysis, as it is a mixture of two of theexplanatory variables used in the analysis.

Multivariable analyses, final logistic regressionIn the final logistic regression analyses, caries

experience at 6 years and mother’s self-estimation

of her own oral health care as being less good

remained statistically significant and were associ-

ated with caries experience in all three groups with

different caries experience, i.e. DFa > 0, DFa ‡ 4

and DFa ‡ 8 at 15 years of age. The consumption of

sweets at 1 year of age was statistically signifi-

cantly associated with caries experience of DFa ‡ 4and DFa ‡ 8. The variables ‘parents born abroad’

and female gender were statistically significantly

associated with DFa ‡ 4 and DFa ‡ 8, respectively

(Table 5). If the two most extreme cases are

compared, the interpretation of the final model is

as follows: a 15-year-old girl consuming sweets

more than once a week at 1 year manifest caries at

6 years and with a mother who estimated her oral

health as less good ⁄ poor compared with a 15-year-

old boy with no manifest caries at 6 years, no

Table 3. Univariable logistic regression analyses of the association between caries experience at 3 and 6 years and cariesexperience at 15 years of age

Variables at 3and 6 years

Caries experience at 15 years

DFa > 0 DFa ‡ 4 DFa ‡ 8

n OR 95% CI P-value n OR 95% CI P-value n OR 95% CI P-value

defs (including initial caries) at 3 years0 408 1.0 0.0003 258 1.0 <0.0001 187 1.0 <0.00011–2 56 1.7 1.3–2.2 44 2.2 1.6–2.9 31 2.8 2.0–4.1>2 91 2.7 1.6–4.8 64 4.6 2.6–8.6 42 8.0 4.0–16.6

Manifest caries experience at 3 yearsNo 474 1.0 0.001 303 1.0 <0.0001 218 1.0 <0.0001Yes 81 2.7 1.5–5.1 63 4.5 2.5–8.9 42 7.3 3.6–15.3

defs (including initial caries) at 6 years0 239 1.0 <0.0001 155 1.0 <0.0001 122 1.0 <0.00011–2 80 1.8 1.5–2.2 50 2.3 1.8–3.0 31 3.1 2.2–4.5>2 198 3.2 2.1–5.0 132 5.3 3.2–8.8 86 9.4 4.7–19.8

Manifest caries experience at 6 yearsNo 301 1.0 <0.0001 186 1.0 <0.0001 142 1.0 <0.0001Yes 216 2.5 1.7–3.8 151 4.5 2.9–7.2 97 8.0 4.3–15.9

OR, odds ratio; CI, confidence interval.

Comparisons were made between caries-free teenagers (DFa = 0) and teenagers with DFa > 0, DFa ‡ 4 and DFa ‡ 8,respectively.

129




consumption of sweets at 1 year and a mother who

estimated her oral health as good; the odds for the

girl being in the DFa ‡ 8 group are 21 compared

with the boy.

Discussion

The study indicates that caries determinants during

early childhood still have an impact on approximal

caries in adolescence. A strong relationship was

found between caries during preschool years and

caries development in the permanent posterior

teeth up to mid-teenage. It therefore appears that

the foundations of adolescents’ oral health are laid

during the preschool years. Even if similar resultshave previously been presented (15–19), the follow-

up periods in these earlier studies were between 2

and 8 years, compared with 14 years in the present

study. Caries experience at 6 years of age remained

statistically significant in the final multivariable

logistic regression in all groups with different

caries experience at 15 years of age. Furthermore,

in a previous part of this study (9), it has been

shown that the mean value for caries experience at

15 years of age was significantly higher for chil-

dren who already had manifest caries at 3 years of

age than for children who were caries free at

3 years but had manifest caries at 6 years (5.7 ± 5.2

versus 3.8 ± 4.0). Manifest caries at 3 years there-fore has high ‘clinical significance’. Based on these

findings, it seems reasonable to conclude that

individualized prevention at an early age could

play an important role in paediatric dentistry.

The frequent consumption of caries-risk prod-

ucts at 1 year of age and the consumption of sweets

at 1 and 3 years of age were associated with

approximal caries at 15 years of age. This is in

agreement with a previous long-term Finnish study

by Mattila et al. (20). They reported that the daily

intake of sweets at the age of 3 years was associ-

ated with a caries increment between 7 and10 years. Ruottinen et al. (21) followed children’s

sucrose intake from infancy to 10 years of age and

found that, once a high sucrose intake is adopted,

changes later in life are unlikely. Snacking habits

established during early childhood therefore

appear to be maintained throughout adolescence.

These facts highlight the importance of the early

establishment of good dietary habits.

In modern society, sugar-containing products

and beverages are easily accessible, and consump-

Table 4. Univariable logistic regression analyses of the association between the consumption of caries-risk products andsweets at 1 and 3 years of age and caries experience at 15 years of age

Variables at1 and 3 years

Caries experience at 15 years

DFa > 0 DFa ‡ 4 DFa ‡ 8

n OR 95% CI P-value n OR 95% CI P-value n OR 95% CI P-value

Consumption of caries-risk products at 1 year (times ⁄ week)No consumption 53 1.0 0.03 33 1.0 0.002 26 1.0 0.0041–7 227 1.2 1.0–1.4 145 1.4 1.1–1.7 103 1.5 1.1–8.98–14 144 1.5 1.0–2.1 97 1.9 1.3–2.8 70 2.1 1.3–3.615–21 63 1.8 1.1–3.0 42 2.6 1.4–4.7 31 3.1 1.5–6.8>21 51 2.1 1.1–4.2 36 3.5 1.6–7.7 20 4.5 1.6–12.7

Consumption of sweets at 1 year (times ⁄ week)No consumption 368 1.0 0.02 229 1.0 <0.0001 171 1.0 0.002Once a week 123 1.4 1.1–1.9 89 2.0 1.4–2.7 62 2.0 1.3–3.0More than once a week 46 2.1 1.1–3.8 34 3.8 1.9–7.5 17 3.9 1.6–9.2

Consumption of caries-risk products at 3 years (times ⁄ week)No consumption 3 1.0 NS 2 1.0 NS 2 1.0 NS1–7 22 1.2 1.0–1.4 13 1.1 0.9–1.4 8 1.3 0.9–1.88–14 102 1.4 0.9–2.0 73 1.3 0.8–2.1 52 1.6 0.8–3.215–21 150 1.6 0.9–2.9 99 1.5 0.7–3.0 73 2.0 0.7–5.8>21 215 1.8 0.8–4.0 132 1.6 0.6–4.3 93 2.5 0.7–10.4

Consumption of sweets at 3 years (times ⁄ week)No consumption 28 1.0 0.03 17 0.0108 13 1.0 0.01Once a week 279 1.4 1.0–2.0 183 1.7 1.1–2.5 133 2.1 1.2–3.7More than once a week 184 2.0 1.1-3.9 118 2.8 1.3–6.2 81 4.4 1.5–13.4

OR, odds ratio; CI, confidence interval.Comparisons were made between caries-free teenagers (DFa = 0) and teenagers with DFa > 0, DFa ‡ 4 and DFa ‡ 8,respectively.

130

Alm et al.



tion is extensive in many groups of children and

adolescents (22). Even if the frequent consumption

of fermentable carbohydrates in the aetiology of

dental caries is well established (2), some studies

have failed to demonstrate this relationship (23).

Duggal et al. (24) discussed this and stated that

‘one reason for the difficulty involved in showing a

strong association is probably the frequent use of

fluoride, which has changed the role of sugars’.

This assumption is confirmed in the present study,

as the consumption of caries-risk products at

3 years was not associated with approximal caries

at 15 years of age, whereas unfavourable behaviour

at 3 years (i.e. the frequent consumption of snack-

ing products and infrequent toothbrushing habits)

was statistically significantly associated with caries

experience at 15 years of age. This could be a goodillustration of the compensatory factor of frequent

toothbrushing with fluoride toothpaste in some

children who frequently consume caries-risk prod-

ucts.

Toothbrushing with fluoride toothpaste (twice a

day or more) is important for the prevention of

caries. This study reveals that teenagers with high

caries experience (DFa ‡ 4 and DFa ‡ 8) brushed

their teeth infrequently at 3 years of age and, in

addition, teenagers who were caries free at 15 years

of age were more likely to brush their teeth twice a

day at 3 years of age. This is in accordance withother studies showing that toothbrushing behav-

iour that is established during infancy is often

maintained during early childhood (25, 26) and

even throughout adolescence and into adulthood

(27).

It has been demonstrated that social, economic

and environmental factors have a fundamental

impact on oral health (28, 29). Moreover, Newton

and Bower (30) have discussed the complexity of

life social processes and the causal networks

between social structure and dental disease. Theinteraction between these factors could presumably

explain why children who failed to attend the

1-year examination had significantly more filled

and decayed surfaces at 15 years of age than those

who attended. This is in agreement with Wang and

Aspelund (31), who report that children with a

history of broken appointments had a higher caries

experience and higher caries activity compared

with the rest of the group. This indicates that extra

attention should be paid to children and families

who fail to attend health examinations and

appointments.The variable ‘mother’s self-estimation of her own

oral health care as being less good to poor’

remained statistically significant in the final multi-

ple logistic regression and was strongly associated

with a high caries prevalence in the children at

15 years of age. These findings indicate that oral

hygiene habits are transferred from parent (espe-

cially the mother) to child and that parents consti-

tute an important social model for their children.

This is in agreement with a study by A strøm and

Table 5. The final multivariable logistic regression anal-yses in teenagers with different caries experience at15 years of age as outcome variables and statisticallysignificant explanatory variables

Variables OR 95% CI P-value

Children with DFa > 0 (final model)defs (including initial caries) at 6 years

0 1.0 0.0003

1–2 1.6 1.2–2.0>2 2.5 1.5–4.0

Mother’s self-estimation of her oral health careVery good 1.0 0.02Less good to poor 1.6 1.1–2.5

Children with DFa ‡ 4 (final model)defs (including initial caries) at 6 years

0 1.0 <0.00011–2 2.0 1.4–2.7>2 3.9 2.1–7.1

Consumption of sweets at 1 year (times ⁄ week)No consumption 1.0 0.004Once a week 2.0 1.2–3.2More than once a week 4.0 1.6–10.2


Parents’ country of birthBoth parents born in Sweden 1.0 0.04Mother born in Sweden,

father abroad1.5 1.0–2.3

Father born in Sweden,mother abroad

2.4 1.0–5.5

Both parents born abroad 3.7 1.1–12.8Children with DFa ‡ 8 (final model)

GenderMale 1.0 0.01Female 3.1 1.3–7.3

Manifest caries experience at 6 yearsNo 1.0 <0.0001Yes 9.7 4.0–23.6

Consumption of sweets at 1 year (times ⁄ week)No consumption 1.0 0.001Once a week 3.3 1.6–6.7More than once a week 10.9 2.6–45.4


OR, odds ratio; CI, confidence interval.Comparisons were made between caries-free teenagers(DFa = 0) and teenagers with DFa > 0, DFa ‡ 4 andDFa ‡ 8 respectively.

131




Jakobsen (32), which revealed that the toothbrush-

ing habits of parents and their adolescent offspring

are statistically significantly associated.

In the present study, having parents with an

immigrant background, especially when both par-

ents were born abroad, was associated with a

higher caries experience at 15 years of age. Even

though these teenagers were born and had lived inSweden from early childhood and received the

same dental health education and treatment as

those with Swedish-born parents, the cultural

background still appears to have an effect on caries

prevalence. The question of whether parental

attitudes towards children’s oral health are im-

pacted by cultural and ethnic diversity has been

discussed in several studies (10, 13, 33, 34). Poor

knowledge of the aetiology of the caries disease

could be one explanation of why dental care,

especially at preschool age, is not always given

priority. Risk-oriented public health programmesshould be developed for children with an immi-

grant background.

It is possible to argue about whether exposure to

a factor in early childhood is a causal relationship

in the development of caries at 15 years of age. A

caries determinant is a characteristic or an expo-

sure that coexists with an increased probability of

developing a disease or may lead to a measurable

change in health status. Furthermore, caries deter-

minants can be helpful in identifying groups at

risk. However, for an individual, the circumstancescan change over time.

Outcome variables, cut-off points and external

validity (generalization to other groups) can always

be discussed. In this study, the DFa ‡ 4 group

corresponds to 33% of the population and is thus in

line with the SIC index presented by Bratthall (35).

In Scandinavia, the 10–15% of the population with

the highest caries scores are usually regarded as a

‘risk group’. This corresponds to DFa ‡ 8 in the

present study and represents 14% of the popula-

tion. We therefore used four cut-off points for the

statistical analysis, i.e. DFa = 0, DFa > 0, DFa ‡ 4,corresponding to the SIC index, and DFa ‡ 8,

corresponding to the ‘risk index value’ that is

generally used in Scandinavia. In this way, the

conclusions in our study can be generalized to

other groups of children and adolescents.

Statistical methods can also be discussed. As we

have repeated measurements of individuals, it is

possible to argue that a statistical method that

accounts for this should be used in the multivariate

analysis. In this study, the outcome variable, as

well as the explanatory variables, is not repeated.

For this reason, repeated measurement analysis has

not been utilized in this study.

In conclusion, we found that the establishment of

good dental habits during the formative preschool

years creates a foundation for low caries prevalence

in adolescence. Dental health from early childhood

up to mid-teenage reflects the conditions in whichthe child has lived. This underlines the importance

of a longitudinal study design when investigating

chronic diseases such as dental caries. Further, we

emphasize the fact that preventive programmes

should start at an early age and should also include

the mother during pregnancy to attain optimal

dental health later in life.

Acknowledgements

This project received support from the SkaraborgResearch and Development Council and the SwedishDental Association.

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