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Impact of Fluoride on Associations Between Free Sugar Intake and Dental Caries in US Children
abstract
This abstract is available on the publisher's site.
Access this abstract nowOBJECTIVE
Dental caries is the most prevalent chronic disease in US children, with the highest burden among Black and Hispanic youth. Sugars are a primary risk factor, but few studies have specifically measured intakes of free sugars and related this to dental caries or explored the extent to which water fluoride mitigates the cariogenicity of free sugars. Furthermore, the cariogenicity of certain free sugars sources, such as extruded fruit and vegetable products, is unclear.
METHODS
Using cross-sectional data on 4,906 children aged 2 to 19 y in the US National Health and Nutrition Examination Survey 2013-2016, we examined associations of free sugars intake with counts of decayed or filled primary tooth surfaces (dfs) and decayed, missing, or filled permanent surfaces (DMFS) in negative binomial regressions. Stratified models examined these associations in children with home water fluoride above or below the Centers for Disease Control and Prevention (CDC)-recommended level of 0.7 ppm.
RESULTS
Free sugars accounted for 16.4% of energy, primarily contributed by added sugars. In adjusted models, a doubling in the percentage of energy from free sugars was associated with 22% (95% confidence interval [CI], 1%-47%) greater dfs among children aged 2 to 8. A doubling in energy from added sugars was associated with 20% (95% CI, 1%-42%) greater dfs and 10% (95% CI, 2%-20%) greater DMFS in children aged 6 to 19 y. Beverages were the most important source of added sugars associated with increased caries. Other free sugars were not associated with dfs or DMFS. Associations between free sugars and caries were diminished among children with home water fluoride of 0.7 ppm or greater.
CONCLUSIONS
Free sugars intake, especially in the form of added sugars and specifically in sweetened beverages, was associated with higher dental caries. Water fluoride exposures modify these associations, reducing caries risk in the primary dentition of children whose home water meets recommended fluoride levels.
KNOWLEDGE TRANSFER STATEMENT
Intake of free sugars, especially in the form of added sugars and specifically in beverages, was associated with higher dental caries in US children in this study. Water fluoride exposure at CDC-recommended levels protected against caries, especially in the primary dentition. These findings suggest that household water fluoridation at CDC-recommended levels protects against the cariogenic potential of free and added sugars during childhood.
Additional Info
Disclosure statements are available on the authors' profiles:
Impact of Fluoride on Associations between Free Sugars Intake and Dental Caries in US Children
JDR Clin Trans Res 2022 Apr 21;[EPub Ahead of Print], MM Melough, S Sathyanarayana, FV Zohoori, HC Gustafsson, EL Sullivan, DL Chi, SM Levy, CM McKinneyFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
Dental caries remains the most prevalent chronic disease in childhood. The etiology of dental caries involves a combination of factors that include diet, bacteria capable of fermenting carbohydrates, fluoride exposure, and a susceptible host. The term “free sugars,” used in the title of this paper, was introduced by the World Health Organization in 2015 and is defined as mono- and/or disaccharides added to foods and drinks plus naturally present in honey, syrups, fruit juices, and concentrates. However, studies in the US have focused on the roles of added sugars or sugar-sweetened beverages (SSBs), finding compelling evidence of their cariogenicity. The difference between “free sugars” and “added sugars” is that the “free sugar” category also includes 100% fruit juices and fruit concentrates. The 2020 to 2025 Dietary Guidelines for Americans do not provide specific recommendations regarding the types of sugars; however, they recommend limiting added sugars to no more than 10% of energy intake to prevent dental caries.
The stated purposes of this report were to examine the association of free sugars with dental caries and evaluate the extent to which fluoridated water may lessen the cariogenic potential of free sugars. This study went to great lengths to identify the types of sugars from a 24-hour dietary survey using cross-sectional data from the US National Health and Nutrition Examination Survey 2013–2016 and examine the association of free sugar intake with decayed or filled surfaces in primary tooth surfaces (dfs) and decayed, missing, or filled surfaces in permanent teeth (DMFS). Furthermore, this study examined the associations in children with home water fluoride above or below the CDC’s recommended level of 0.7 ppm.
This study found that free sugars accounted for 16.4% of energy from food, primarily contributed by added sugars. A doubling in energy from added sugars was associated with 20% greater dfs and 10% greater DMFS. SSBs were found to be the most important source of added sugars associated with increased caries; however, other “free sugars,” such as 100% fruit juices, were not associated with dfs or DMFS. The study also found that the association between sugars and caries diminished (27%) in primary teeth of children whose home water source contained ≥0.7 ppm of fluoride.
Perhaps, this study also can be used to comment on the confusing terminology that has crept into the dental dietary literature. Currently, we find terms such as dietary sugars (sugar added to foods or naturally occurring), added sugar (mono- and disaccharides added to foods), intrinsic sugars (sugar within the structure of grains, fruits, vegetables, and milk products), fermentable carbohydrates (sugars and refined starches that can be metabolized by acid-producing bacteria), SSBs (primarily from high fructose corn syrup), and, more recently, “free sugars” (sugars added to foods or naturally present in honey, syrups, fruit juices, and concentrates). This current study by Melough et al builds on other studies that implicate SSBs as an important risk factor for dental caries but not 100% fruit juices. Thus, it is unclear how the terminology “free sugars” helps with our understanding of dietary caries risk factors.