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Preventive Measures

Dietary pattern of Finnish children with low and high caries experience EijA KLEEMOLA-KUJALA'

AND LEENA RASANEN"

^Department of Pcdodotttics and Orthodotitics, Institute of Dentistry, University of Helsinki, and ^Department of Nutrition, University of Helsinki, Helsinki, Finland

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Kleemola-Kujala, E. & Rasanen, L.: Dietary pattern of Finnish children with low and high caries experience. Community Dent. Oral Epidemiol. 1979: 7: 199-205.

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Abstract - The correlations between dietary patterns and caries were studied in a series consisting of 534, 5-, 9- and 13-year-old Finnish rural children from low-fluoride areas (0.10-0.46 parts/lO"). The food consumption of tbe children was assessed by the 24-hour recall method. The consumption of sweets was estimated by the dietary history niethod. Caries was diagnosed by clinical inspection. Children with a low and children with a high caries experience were compared with regard to food and nutrient intakes per 1000 kcal. The intakes of most foods and nutrients were similar in the low-caries and in the higlicaries groups. However, the diet of the high-caries groups of 5- and 13-ycar-olds contained less iron, thiamine and ascorbic acid than the diet of the low-caries groups, l h e intake of sugar and sugar-containing products per unit of energy \vas higher in the high-caries groups. This was true for soft drinks in particular. Among the 9-year-olds the proportion of sugar consumed as such was greater in the high-caries than in the low-caries children. With regard to the total monthly consumption of sweets no significant differences were observed between the high- and low-caries groups. Analysis of the energy-standardized consumption of food and nutrients thus showed that the relative proportion of sugar and sugar-coiitaming products was somewhat greater in the diet of the high-caries children than in the diet of the low-caries children, but not as high as could be expected. These products replaced foods with a higher nutritive value with the result that the diet of the high-canes groups was on the whole more refined than the diet of the low-caries groups. Key words: dental caries; diet; epidemiology, oral. Eija Kleemola-Kujala, Institute of Dentistry, Fabianinkatu 24, SF-00100 Helsinki 10, Finland. Accepted for publication 21 January 1979.

Gurrent knowledge about the important role played by food and dietary habits in the etiology of caries is based on extensive theoretical and clinical research. A correlation between an increase in caries and a high sucrose consumption as well as frequent intake of sucrose-containing products has been demonstrated in studies of populations, clinical trials and animal experiments (2,9,12,19,26). Glinical trials and animal experiments have shown that other carbohydrates and other kinds of sugar are less cariogenic than sucrose (4,18,25,34). Moreover, some experimental evidence exists that fine-grained, adherent foods or foods that do not

require vigorous chewing may contribute to the development of caries (3,24). The decisive factor in this context is considered to be the retention of sugar on the tooth surfaces due the stickiness of the food and the consequent maintenance of a high sugar concentration in the oral cavity (6). The results of animal and in vitro experiments corroborate the assumption that unrefined foods may contain components which reduce the solubility of the tooth enamel and thus protect against caries (14). Investigations from the 1970s have shown that Finnish children have a high prevalence of canes.

0301-566I/79/040199-07$02.50/0 © 1979 Munksgaard, Copenhagen

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KLEEMOLA-KUJALA AND RASANEN

The proportion of entirely caries-free children of different ages in the series studied was low, and the caries experience measured by indices was higher than in many other Scandinavian series (15, 16). Although it is clear that the diet is of essential importance, the relationships between dietary patterns and caries have not been analyzed in any series of Finnish children. Information on this point would be of practical value, since it could be used as a guide in the prevention of caries. In connection with a survey of child nutrition in Finland (29), the dental health of the children was also recorded. The present investigation was undertaken in order to find out whether rural children with low and with high caries experience differed significantly from each other with regard to dietary patterns and intake of nutrients.

MATERIAL AND METHODS The basic material was collected from seven rural municipalities representing different provinces in South Finland and comprised 806 children. The children invited to the examinations were selected by systematic sampling from lists on the basis of card registers of the child health centers in the respective district. The children were evenly distributed over three age groups, 5-, 9- and 13-year-olds. Material, its background data, caries prevalence and treatment status of the children as well as methods of examinations have been presented and discussed in detail in previous papers (15,28,29). Complete data on dietary pattern and caries experience was obtained for 767 of the children. Of these children, 233 were lifelong residents in two high-fluoride (0.50-1.73 parts/lO") municipalities. The significance of fluoride as a background factor was considered so great that these children ought to have been separately analyzed. On the other hand, division of this population according to age and caries experience would have given subgroups too small for a reliable evaluation of the dietary data. For this reason the ehildren from the high-fluoride municipalities were excluded, and the final sample thus consisted of 534 children from five low-fluoride (0.10-0.46 parts/IO") municipalities in South Finland. The teeth of the children were examined clinically in good artificial illumination using mirror, probe and a manually operated air syringe. In tbe diagnosis of caries, MOIXER'S criteria (23) were used and lesions of types 2, 3 and 4 were recorded. Carious lesions and fillings were recorded by surfaces. For eacb child the dmfs/DMFS value was determined; a tooth removed for caries (m/M) was considered carious on four surfaces (15). The food consumption of the children attending the investigation was assessed by the 24-hour recall method, by which detailed information was obtained on the kind

and amount of food consumed by the child during the 24 h preceding tbe day of the interview. Energy and nutrient intakes were calculated from this information, using Finnish and foreign food composition tables as well as analytical data obtained from the manufacturers (28). The variables selected to depict the composition of the diet and the intake of nutrients were as follows: Total daily intakes of the following food groups: milk; sour milk; cheese; other milk products; butter, margarine and oils; eggs; beef; pork; other meats; internal organs and blood; sausages and other meat products; rye; wbeat; other cereal products; potatoes; roots; legumes and nuts; other vegetables; fruits and berries: sugar and candy; beverages. In addition, the mean daily intake of sugar, consumed as such, or used in food preparation and baking at home was calculated. Tbe daily intakes of energy and of the following nutrients were calculated: protein, fat, carbohydrate, calcium, iron, vitamin A, retinol equivalents, thiamine, riboflavin, niacin and ascorbic acid. In the nutrition interviews using the dietary bistor)method it was further asked what kind of sweets the child was given, bow frequently the different kinds were eaten and how much the child ate at a time (27). The monthly consumption of sweets measured in grams was calculated on the basis of the interview data. The daily eating frequency was defined as the number^ of meals and snacks during the preceding 24 h. The children were arbitrarily divided into tertiles, the 5-year-olds by dmfs values, the 9- and 13-year-olds by DMFS values (tbe 33rd and 67th percentile points of dmfs/DMFS). The division into tertiles in the 9-year-olds was carried out on the basis of caries prevalence for the permanent teeth only, because of the often poor condition of remaining primary teeth and great number of missing primary canines and molars, of which it could not be established wbether they were lost by normal shedding or extraction (15). The division was carried out for girls and boys separately in eacb age group. Those children who had the lowest dmfs/DMFS scores (the first tertile)5 were considered as a low-caries group (L-C), wbile tbose who had the highest dmfs/DMFS scores (the third tertile) were considered as a high-caries group (H-C) (Table 1). The significance of the differences between the mean values for tbe dietary variables in the L-C and H-C groups was determined by Student's t-test. The significance of the differences between the mean values was expressed as follows: 0.01 < P < 0 . 0 5 + ,, , . ^ 0.001 < P < 0 . 0 1 -¥+ . ' ''

RESULTS A significant difference in mean daily intake oi energy was only observed between the 5-year-old children in the L-C and H-C groups (P

Dietary pattern of Finnish children with low high caries experience.

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