PEDIATRIC DENTAL JOURNAL 22(2): 117124, 2012

Influences of diet on caries activities and caries-risk grouping

in children, and changes in parenting behavior
Michiko Nishimura1,*, Omar M.M. Rodis2, Seishi Matsumura2 and Michiyo Matsumoto-Nakano2
Pediatric Dentistry, Okayama University Hospital of Medicine and Dentistry
2-5-1 Shikata-cho, Kita-ku, Okayama 700-8525, JAPAN
2
Department of Pediatric Dentistry,
Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
2-5-1 Shikata-cho, Kita-ku, Okayama 700-8525, JAPAN
1

Abstract BACKGROUND: Dental caries incidence in early childhood is

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

Introduction
Koch1) emphasized the importance of early prediction
and determination of caries-risk and the problems of
* Correspondence to: Michiko Nishimura
E-mail: naruto10@md.okayama-u.ac.jp

Received on December 6, 2011; Accepted on July 25, 2012

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

early prediction of caries-risk have been discussed

without giving too scientific or practical details2,3).
The American Academy of Pediatric Dentistry
(AAPD) reported that caries-risk assessment is an
essential element of contemporary clinical care for
infants and children4). Furthermore, strategies for
managing dental caries have increasingly emphasized
117

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

The subjects who were

born between Oct. 2000
and Sep. 2001

Oral examination by the

dentists of Kurashiki City
Dental Society

Oral examination by the

two pediatric dentists of
Okayama University

Questionnaires

Questionnaires

Oral hygiene instruction

Oral hygiene instruction

Cariostat testing

Cariostat testing

18-month-old health examination

from Apr. 2002 to Mar. 2003

24-month-old oral examination

from Oct. 2002 to Sep. 2003

42-month-old health
from Apr. 2004 to
Mar. 2005

Fig. 1 Time schedule of the investigation

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

the concept of risk assessment5). In our previous

study6),we performed caries-risk assessment for very
young children using Cariostat, a caries activity test
(Dentsply-Sankin Co., Tokyo) and established 6
caries-risk groups. We speculated the parent compliance with oral health instructions was associated
with caries-risk grouping of their children. Dental
caries is a multifactorial, chronic, and lifestylerelated disease. Hunter7) considered diet, such as
sucrose intake, frequency of sucrose-containing
foods intake and total exposed time to such foods,
oral hygiene, and micro flora, to be as lifestyle
related factors while Reich et al.8) added child
behavior to that list. However, the lifestyles and
habits of children are primarily controlled by their
parents. Therefore, parent education, understanding
of nutrition, socioeconomic status and behavior are
all related to prevention of dental caries in their
children911).
The objectives of this longitudinal study were
to identify the influence of diet on 18- and 24month-old children in regard to caries activities, and
investigate the effects of dietary changes following
oral health instructions to their parents according to
caries-risk grouping.

Subjects and Methods

Subjects
The initial group of subjects was composed of 1,208
children born between Oct. 2000 and Sep. 2001,
who received the 18-, 24-, and 42-month-old health
examinations at Kurashiki City Public Health Center
in Japan. The subjects exclusion criteria were as
follow, 1) Any medication taken during either of

2 Cariostat sampling periods. 2) No Cariostat test

undertaken at 18 months of age. As result, 1,206
subjects were enlisted as participants in this study.
This study was performed through Kurashiki City
Public Health Center ethical committees approval
and local city health officers completely sealed each
subjects private information and released the data
to us in coded form.
Methods
Oral Examination System of Kurashiki City
Oral examinations of 18- and 42-month-old children
are routinely performed in Japan as part of government sanctioned national dental check-up activities.
In addition, a 24-month-old oral examination is conducted by Kurashiki Citys part of the community
general health program. Monthly programs for those
ages began in 1975, 1961, and 1980, respectively.
In the present study, 2 pediatric dentists of Okayama
University performed Cariostat testing of 18 and
24 months of age, while dentists of Kurashiki City
Dental Society performed oral examinations during
the 18 and 42 months of age. Oral examinations of
subjects at 24 months of age were performed by
the same pediatric dentists of Okayama University.
Caries-risk assessment was done based on Cariostat
test results in using cross-sectional and longitudinal
analysis. Calibration of the examinations was not
possible because of the different programs. However,
these have been performed regularly by the same
dentists including one of the authors (M.N.) and were
done in accordance with the criteria of the Health
Policy Bureau, Ministry of Labor and Welfare, of
Japan12). Figure 1 shows the time schedule of this
study.

Child Dietary Influenceand Changesin Behaviors

119

42-month-old predicted cutoff based

on 18-month-old Cariostat scores

42-month-old predicted cutoff based

on 24-month-old Cariostat scores
24-mo
18-mo

0
0.5
1.0
1.5
2.0
2.5
3.0

0.5

1.0

1.5

2.0

2.5

3.0

Low caries-risk
(LR)
n=538

Progressive
border caries-risk
(PB)
n=145

Moderately high
caries-risk
(MHR)
n=60

Moderate caries-risk
(MR)
n=261

Improved
border caries-risk
(IB) n=124

High caries-risk
(HR)
n=78

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

Local city health officers completely sealed

subjects private information and released the data
to us in coded form.
Six caries-risk groups
The 42-month-old predicted cutoff points based
on the 18- and 24-month-old Cariostat test results
were 1.5 and 2.0, respectively6). The 6 caries-risk
groups used in the present study were as follows:
(1) Low risk (LR): children who had a Cariostat
score at or lower than the 18-month-old cutoff point,
and a score lower than the 24-month-old cutoff
point. (2) Moderate risk (MR): children who had a
Cariostat score higher than the 18-month-old cutoff
point but had scores lower than the 24-month-old
cutoff point. (3) Progressive border (PB): children
who had a Cariostat score at or lower than the 18month-old cutoff point but reaching the 24-monthold cutoff point. (4) Improved border (IB): children
who had a Cariostat score higher than the 18-monthold cutoff point and reaching the 24-month-old
cutoff point. (5) Moderately high (MHR): children
who had a Cariostat score at or lower than the
18-month-old cutoff point but higher than the 24month-old cutoff point. (6) High (HR): children who
had a higher Cariostat score than the cutoff points
for both ages (Fig. 2).
Questionnaire
A questionnaire was given to the parents, which
evaluated which dietary factors were associated with
high caries-risk in their children and the data were
released by the Kurashiki City Public Health Center.
The questions were as follows: 1) Do you check

and brush your childs teeth? 2) How many times

a day does your child ingest sucrose-containing
foods? 3) Do you determine the total time of your
childs sucrose-containing foods intake? 4) Does
your child continue to breast feed or drink a liquids
other than water through a bottle? These questionnaires were sent to individual subjects by mail along
with a notification of their examination date. The
parents completed and brought it to Kurashiki City
Public Health Center on the day of their childs
scheduled examination.
Oral health instructions
The same Kurashiki City public dental hygienists
provided the parents with instructions for caries
prevention. The results of the oral examinations
and the Cariostat tests as well as completed questionnaires were computerized and provided to us as
coded data. These results identified whether or not
the patient was at high-risk for caries prevalence.
Oral hygiene instructions were tailored to the risk
level of each parent. Oral hygiene instructions for
caries prevention included the following: 1) cessation
of bottle feeding before 18 months of age, 2) parentassisted daily tooth brushing, and 3) instructions
to decrease the frequency of consuming sucrosecontaining foods during the day.
Statistical methods
The authors analyzed the coded data released by
the Kurashiki City Public Health Center using SPSS
Ver.12.5. A Chi-square test was used to assess the
significant differences in the distribution of answers
between the 2 groups. A Mann-Whitney U test was

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

Table 1Significant lifestyles changes at 18 months of age

LR

MR

LR

Q.3*

PB

IB
Q.3**

MR

MHR

HR
Q.4***

Q.3*

IB

LR

MR

PB

IB

MHR

HR

LR

Q.4**

MR

Q.4*

Q.4***

PB

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

Q.4*

IB

Q.4*** Q.4*

PB

Table 2Significant lifestyles changes at 24 months of age

MHR

MHR

HR

HR

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

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

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

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

Q.2 How many times a day does your child ingest sucrose-containing foods? (Less than 2 times or more than 3 times)

LR

n=538

MR

n=261

PB

n=145

IB

n=124

MHR

n=60

HR

n=78
0
Less than 2 times
at both ages

100%
*: P<0.05, **: P<0.01, ***: P<0.001
From more than 3 times to
less than 2 times

From less than 2 times to

more than 3 times

More than 3 times at both

ages

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

used to investigate changes in behavior from 18 to

24 months of age. A P-value of 0.05 was considered
to be significant.

Results
Dietary factors found to influence caries-risk
Table 1 shows the influence of diet on Cariostat test

results of the 18-month-old children. Sugar-intake

total time was related to the 24-month-old cutoff
point, as children belonging to the MR, PB, and IB
groups had caries activities below the 42-month-old
predictive cutoff point based on the 18-month-old
cutoff point (Cariostat test result of 1.5). Breastfeeding or liquid intake other than water significantly
increased the risk for caries at 18 months old.

Child Dietary Influenceand Changesin Behaviors

121

Q.3 Do you determine the total time of your childs sucrose-containing foods intake? (Yes or No)

LR

n=538

MR

n=261

PB

n=145

IB

n=124

MHR
n=60

HR

n=78
0

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

Yes at both ages

From no to yes

From yes to no

No at both ages

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

Table 2 shows the influence of lifestyle on Cariostat

test results of the 24-month-old children. Again
breast-feeding or liquid intake other than water had
a significant relationship with increased risk for
caries, at 24 months old.
Changes in parent behavior from 18- to
24-month examination
1) Do you check and brush your childs teeth?
There were no data released from the Kurashiki City
Public Health Center.
2) How many times a day does your child ingest
sucrose-containing foods?
Changes in the behavior of children in the HR group
were significantly worse as compared to those in the
LR, MR, PB, and IB groups from 18 to 24 months
old (Fig. 3).
3) Do you determine the total time of your childs
sucrose-containing foods intake?
Changes in the behavior of children in IB group
were significantly worse as compared to those in the
children belonging to LR and PB groups from 18 to
24 months old. Changes in the behavior of children
belonging to the MR group were significantly worse
than that of those in LR group and significantly
better as compared to those in the PB group from
18 to 24 months old (Fig. 4).

4) Does your child continue to breast feed or drink

liquids other than water through a bottle?
Changes in the behavior of children in HR group
were significantly worse as compared to those in
LR, MR, and PB groups from 18 to 24 months old.
Changes in behavior of children belonging to the IB
and MR groups were significantly worse as compared
to LR group from 18 to 24 months old. Changes in
childrens behavior belonging to moderate cariesrisk group were significantly worse than children
belonging to low-caries-risk group (Fig. 5).

Discussion
Caries is a multi-factorial disease7,8) and the most
important dietary component contributing to cariesrisk without any doubt is ingestion of fermentable
carbohydrates, particularly sugar. The frequency of
sucrose-containing food intake per day and total time
of sucrose-containing foods intake have been shown
to be related to susceptibility to caries in children13).
Prolonged breast-feeding and liquid intake other
than water through a bottle in early childhood is a
factor related to increased caries-risk1416). Some
researchers reported that when sucrose-containing
food was eaten frequently, newly erupted teeth are
at risk at a time when the immune response of

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

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

LR

n=538

MR

n=261

PB

n=145

***

IB

n=124

MHR

***

n=60

HR

n=78
0
No at both ages

100%
*: P<0.05, **: P<0.01, ***: P<0.001
From yes to no

From no to yes

Yes at both ages

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

c hildren is still immature7,17,18). Furthermore, the

mothers parenting behavior toward the child influenced the childs caries status1921). In our previous
study13), we reported that the 18-month-old caries
activity influenced the childs future oral conditions
compared to caries activity at more than 24 months
of age. This result supported Newbruns conclusion17).
Newbrun concluded as follows In the clinical
situation, the accurate prediction of caries is not
as important as the assessment of the individual
caries risk and risk factors. Even with routinely
available clinical and sociodemographic information
at clinical examination, a dentist can identify high
caries risk subjects with good accuracy.
In the present study, Cariostat test results of
children belonging to the LR and PB groups were
at or the cutoff levels for 18- and 24-month-old
children. Thus it is reasonable that were no significant differences in the lifestyles of the children in
those groups, as shown in Figs. 2 and 3. The reason
for the increased risk of caries in 18-month-old
children is due to increased total time of sucrosecontaining food intake. Thus, the lifestyle factor of
18-month-old children that had the greatest effect to
make them susceptible to caries was feeding method.
There were no data released by the Public Health
Center of Kurashiki City regarding parent-assisted

brushing with their 24-month-old children.

In contrast, there were no significant differences
in dietary habits among the LR, MR, PB, and HR
groups, which showed the importance of dietary
habits in 18-month-old children to prevent caries
initiation. Children in the HR group did not significantly change their dietary habits after the parent
received oral care instructions, such as the frequency
of sucrose-containing food intake. On the other hand,
there were significant differences for the total time
of sucrose-containing food intake among children
belonging to LR, MR, PB, and IB groups whose
Cariostat scores were below or at the predicted
cutoff point at age of 24 months. Furthermore, there
were significant differences for change in dietary
habits between the LR and IB groups, the MR and
PB groups, and the PB and IB groups. Those results
indicated that children belonging to these 4 cariesrisk groups and whose Cariostat scores were above
the predicted cutoff point at 18 months old, did
not significantly change their diet. Children whose
Cariostat scores became worse from 18 to 24 months
did not significantly change their behavior regarding
feeding method. An understanding of the most
problematic dietary factors is a prerequisite before
effective instructions for prevention of caries initiation can be given. We consider that appropriate oral

Child Dietary Influenceand Changesin Behaviors

health instructions for parent, especially those with

very young children, are effective tools for caries
prevention. However, compliance by the parents to
oral health instructions varies, so it is also useful
to understand the rate of compliance in accordance
to caries-risk grouping of their children in order to
provide effective instructions. The limitation of the
study was that we did not have full access of the
data and that what we analyzed was just the data
released by Kurashiki City. As a result, we could
not analyze the data associated with the effects on
mothers regarding brushing their childrens teeth.
Therefore, we instructed the parents to regularly
check their childrens oral health to assess intake
of foods and drinks containing sucrose and at the
same time to brush their childrens teeth before
sleeping at the night. Furthermore, we researched
mothers parenting stress in each caries-risk group.
The mother having a high-risk child significantly felt
less anxiety than mothers having other caries-risks
children (data not shown). The mothers character
might be strongly associated with the effectiveness
of oral care instruction.
We began research regarding caries-risk assessment in 2001, with sampling for Cariostat tests,
calculation of current and predicted screening
indexes, determination of cutoff points19), cariesrisk assessment6), and analyses of changes in child
behaviors from 18 to 24 months performed until
2005. When the children, born in 2000, became
42 months old, their caries prevalence was 32.4%
from 2003 to 2004. After completing caries-risk
assessment in 2005, we managed and instructed
parents with children in the low and moderate
caries-risk groups, as shown in our previous study6).
As a result, caries prevalence in our subjects at 42
months old (2007) was 24.7%. The children in these
studies were very young and could not determine
their own dietary habit
Based on our findings, we consider that parents
of children with a higher risk of caries are more
likely to neglect oral health instructions.

Conclusion
Appropriate assessment of problematic lifestyle
habits in children is very important to understand
their relationship with caries-risk. Furthermore,
identification of parenting behaviors is important for
providing effective caries prevention instructions.

123

References
1) Koch, G.: Importance of early determination of
caries risk. Int Dent J 38: 203210, 1988.
2) Federation Dentaire International (FDI) Technical
Report No.31: Review of methods of identification
of high caries risk groups and individuals. Int Dent
J 38: 177189, 1988.
3) Krasse, B.: Biological factors as indicators of future
caries. Int Dent J 38: 219225.
4) AAPD.: Policy on use of a caries-risk assessment
tool (CAT) for infants, children, and adolescents.
Pediatr Dent 27(7 Suppl): 2527, 20052006.
5) AAPD.: Guideline on periodicity of examination,
preventive dental service, anticipatory guidance and
oral treatment for children. Pediatr Dent 27(7 Suppl):
8486, 20052006.
6) Nishimura, M., Rodis, O.M.M., Kariya, N. and
Matsumura, S.: Caries-risk assessment in early childhood using a caries activity test. Ped Dent J 21:
116122, 2011.
7) Hunter, P.B.: Risk factors in dental caries. Int Dent
J 38: 211217, 1988.
8) Reich, E., Lussi, A., Newbrun, E. and FDI Commission:
Caries-risk assessment. Int Dent J 49: 1526, 1999.
9) Febres, C., Echeverri, E.A. and Keene, H.J.: Parental
awareness, habits, and social factors and relationship
to baby bottle tooth decay. Pediatr Dent 19: 2227,
1997.
10) Huntington, N.L., Kim, I.J. and Hughes, C.V.: Cariesrisk factors for Hispanic children affected by early
childhood caries. Pediatr Dent 24: 536542, 2002.
11) Davies, G.N.: Early childhood caries: A synopsis.
Community Dent Oral Epidemiol 26(suppl 1): 106
116, 1998.
12) Report on the survey of dental diseases by Health
Policy Bureau, Ministry of Labor and Welfare Japan.
Oral Health Assoc Japan, Tokyo, 1999, pp.3353.
13) Nishimura, M., Oda, T., Kariya, N., Matsumura, S.
and Shimono, T.: Using caries activity test Cariostat,
to predict early childhood caries-risk. J Am Dent
Assoc 139: 6371, 2008.
14) Johnson, C.D., Gersternmaier, J.H., Schwartz, E.,
Michal, B.C. and Parrish, S.: Background comparisons of pre-3 1/2-year-old children with nursing caries
in four practice settings. Pediatr Dent 6: 5054, 1984.
15) Tinanoff, N. and Osullivan, D.M.: Early childhood
caries: overview and recent findings. Pediatr Dent
19: 1216, 1997.
16) Nishimura, M., Rodivick, O.D., Matsumura, S. and
Shimono, T.: The effect of feeding methods on caries
activity evaluated by Cariostat. Report of two cases.
Ped Dent J 4(1): 2327, 1994.
17) Newbrun, E.: Sucrose in the dynamic of the carious
process. Int Dent J 32: 1323, 1982.
18) Sheiham, A.: Dietary effects on dental diseases.
Public Health Nutrition 4(2B): 569591, 2001.
19) Kurokawa, I. and Shimooka, S.: The caries activity
test in primary dentition period for estimation of
progression on the same subjects. Jpn J Ped Dent

124

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

29: 791813, 1991. (in Japanese)

20) Clark, P., Fraser-Lee, N.J. and Shimono, T.: Identifying risk factors for predicting caries in school-aged
children using dental health information collected at
preschool age. J Dent Child 68: 373378, 2001.

21) Quin, M., Li, J., Zang, S. and Ma, W.: Risk factors
for severe early childhood caries in children younger
than 4 years old in Beijing China. Pediatr Dent 30:
122128, 2008.