Intake of sweet drinks and sweet treats versus reported and observed caries experience.
Abstract: Aim: This was to study the intakes of sweet drinks and sweet treats of children and their caries risk using the Paediatric Risk Assessment Tool (PRAT, 2003) and Caries-risk Assessment Tool (CAT, 2007-8). STUDY DESIGN: Parents of 266 healthy primary school children completed the PRAT questionnaire during their child's dental appointment at the Royal Dental Hospital of Melbourne, Australia, describing their fluid and sweet treat intakes in the past 24 hours, oral hygiene practices and past caries. A subgroup (n = 100) was examined clinically (CAT) for caries requiring restoration, visible plaque, gingivitis, orthodontic appliances, enamel defects, and use of dental care. RESULTS: The estimated mean daily fluid intake was 1.5 [+ or -] 0.5L; fluids were consumed 3-5/ day by 57% of children and 78% usually had evening/night drinks. Fluids consumed were: tap water by 90%, milk by 74%, juice by 50%, regular soft drink by 30%; sweet treats were consumed by 62% and confectionery by 25%. Most children (69%) brushed their teeth >2/day; 5% flossed daily. Parentally-reported caries was associated significantly with increasing treats frequency (p = 0.006). In the subgroup, 81% were at high caries risk; 47% had irregular dental care; 21% had sweet drinks/foods frequently between meals; 49% had visible plaque/gingivitis, and 34% had enamel demineralisation. Caries observed in the past 12 months was associated significantly with evening sweet drinks (p = 0.004), and suboptimal fluoride exposure (p = 0.009). Caries observed in the past 24 months was associated significantly with treats frequency (p = 0.006), intake of sweet drinks plus treats (p = 0.000), enamel demineralisation (p = 0.000) and irregular dental care (p = 0.000). CONCLUSIONS: The PRAT and CAT are valuable tools in assessing children's caries risk. The risk of caries from frequent intake of sweet drinks, either alone or in addition to sweet treats, must be emphasised to parents. All parents, and particularly those of children assessed at high risk from intakes of sweet drinks and sweet treats, suboptimal fluoride exposure, or enamel demineralisation, must be encouraged to obtain regular dental care for their children.

Key words: Sweet drinks, sweet treats, reported caries, observed caries
Article Type: Report
Subject: Children (Health aspects)
Dental caries (Risk factors)
Dental caries (Research)
Dental caries (Care and treatment)
Carbonated beverages (Health aspects)
Carbonated beverages (Research)
Authors: Lee, J.G.
Messer, L.B.
Pub Date: 02/01/2010
Publication: Name: European Archives of Paediatric Dentistry Publisher: European Academy of Paediatric Dentistry Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2010 European Academy of Paediatric Dentistry ISSN: 1818-6300
Issue: Date: Feb, 2010 Source Volume: 11 Source Issue: 1
Topic: Event Code: 310 Science & research
Product: Product Code: E121920 Children; 2086000 Canned & Bottled Soft Drinks NAICS Code: 312111 Soft Drink Manufacturing SIC Code: 2086 Bottled and canned soft drinks
Geographic: Geographic Scope: Australia Geographic Code: 8AUST Australia
Accession Number: 277106712
Full Text: Introduction

An increase in dental caries in young children in Australia was reported recently by the School Dental Service (SDS). Since SDS data collection commenced in 1977, decreasing dmft/DMFT scores and improved dental health of Australian children had been attributed to the introduction of community water fluoridation [AIHW, 1998]. However, increasing caries experience of 6 yr-old and 12 yr-old children has been reported from the mid to late 1990's by the SDS [Armfield and Spencer, 2008]. In the most recent Australian child dental health survey conducted in 2002 and reported in 2007, 47.4% of 6 yr-olds had experienced caries in the primary dentition; the mean dmft was 1.96 (SD: 3.01), and the 10% of children with the greatest caries experience had more than nine cariously-affected teeth [Armfield et al., 2007]. For 12 yr-olds, over 40% had experienced caries in their permanent teeth; the mean DMFT was 1.02 (SD: 1.73) and the 10% of children with the greatest caries experience had nearly five cariously-affected teeth, exceeding the national average by almost five and a half-fold [Armfield et al., 2007]. Children living in low-fluoride areas had poorer dental health than those living in optimally-fluoridated areas, regardless of socioeconomic disadvantage [Armfield et al., 2007].

Speculation on the caries increase has focussed on fluid intakes, noting that societal changes such as expanding urbanisation and ready access to sweet drinks and fast and processed foods, have altered children's diets in Australia and elsewhere [Sivaneswaran and Barnard, 1993; Ismail et al., 1997; Shenkin et al., 2003]. International reports indicate a common trend of increasing consumption of soft drinks by children. In 2000, the most frequently-reported form of added sugars in the USA diet was regular soft drink, accounting for one third of dietary sugar intake [Touger-Decker and van Louveren, 2003]. In the UK, soft drink intake in 11-12 yr-old children increased in the last 20 years [Tahmassebi et al., 2006; Rugg-Gunn et al., 2007]. A similar shift in fluid consumption towards sweet drinks may be occurring in Australia [NHMRC, 2008], and concerns over increasing childhood obesity in Australian children has led to the restriction of sales of sweet drinks in public schools [Sanigorski et al., 2006; Tam et al., 2006].

The intake of dairy products by Australian children appears to be decreasing. In 1998, the National Nutrition Survey (conducted in 1995) reported a low intake of dairy products in children, with about 30% of 2-18 yr-olds consuming less than one serving of dairy product daily, and a mean milk intake for 4-7 yr-olds of 0.38L and 0.39L for 8-11 yr-olds [ABS, 1999]. The Australian dietary guidelines recommend 2-3 servings/day of dairy products including milk for 4-11 yr-olds, and 3-5 serves/day for adolescents [NHMRC, 2008]. Due to the low milk intake, studies reporting increased intake of sweet drinks, without displacing milk, may reflect displacement of other fluids such as water, rather than the small volume of milk currently consumed.

A high consumption of non-milk extrinsic sugars is a risk for caries development [Sheiham, 2001]. A cross-sectional survey of 1,681 primary school-aged children in Victoria, Australia, reported one third were drinking water and another third were consuming juice or cordial while at school [Sanigorski et al., 2005]. The high consumption of sweet drinks and low intake of dairy products amongst Australian children may be contributing to the recent caries increases.

Responding to apparent increases in soft drink intake and decreases in dairy consumption by USA children, a Paediatric Risk Assessment Tool (PRAT) was devised [Shenkin et al., 2003]. The PRAT questionnaire is completed by carers, recording fluid intake in the past 24 hours and the number of drinks per day, especially after the evening meal and during the night. Meal-time foods are not examined, but carbohydrate intake between meals (confectionery, baked starches), fluoride exposure, oral hygiene practices and past caries experience are noted. The PRAT does not include a clinical examination.

Caries risk assessment is the standard of care in modern paediatric dentistry [Fontana and Zero, 2006; Trueblood et al., 2008], defining a child's risk for developing caries at a given time; it should be reconsidered periodically throughout life [Selwitz et al., 2007]. Recently, a Caries-risk Assessment Tool (CAT) was developed by the American Academy of Paediatric Dentistry [AAPD, 2007-08]. The CAT records a child's use of dental care, past caries, orthodontic appliances, diet cariogenicity, fluoride exposure, oral hygiene habits and the carer's socio-economic status. A clinical examination records visible plaque, gingivitis, and enamel defects (demineralisation, hypoplasia, molar-incisor hypomineralisation). Allowing utilisation of the CAT by other professionals, dental equipment and diagnostic tools (e.g., periodontal probe, radiographs, salivary or microbial tests) are not used, but dentists can add these in as a supplemental assessment. Caries risk is classified as high, moderate or low.

Using the PRAT and the CAT, this study examined intake of fluids and sweet treats, oral hygiene habits, reported caries and observed caries of as a convenience sample of primary school-aged children attending a public dental hospital in Melbourne, Australia.

Materials and Methods

Ethics Approval and Selection of Subjects. The study was approved by the Human Research Ethics Committees of The University of Melbourne and the Department of Human Services Victoria, Australia. Children were selected from those attending the Paediatric Dentistry Clinic, Royal Dental Hospital of Melbourne (RDHM), for preventive and restorative treatment between April 2007 and June 2008. All parents gave written informed consent for their child's participation. Individuals receiving care at the RDHM hold a means-tested health care card or pension card. The two inclusion criteria were: (a) healthy child (ASA I or II), (b) living in and attending school in metropolitan Melbourne.

A convenience sample (253 parents of 290 children) was invited to participate; 24 parents declined (due to lack of time or uncertainty of their child's diet); the remaining 229 parents (of 266 children) completed usable PRAT questionnaires free of uncertain responses. Clinical examinations (CAT) were conducted also for 100 of these children.

The PRAT Questionnaire. A preliminary questionnaire was trailed with 5 parents of 7-12 yr-old children during their child's appointment (these children were not included in the study). Their comments were included in the final questionnaire1 which was completed for each child by their parent during their appointment. One author (JL) answered queries and ensured completion of all questionnaire fields. Fluid and sweet treat intakes between meals were recorded for the previous 24 hours; parents indicated if these were typical. Questionnaires and consents were stored separately to preserve anonymity.

The CAT Examination. Subjects were categorised for 11 caries risk factors as follows:

* Use of a 'dental home': Low risk: regular attendance in an established 'dental home'; moderate risk: irregular attendance; high risk: no usual source of care.

* Time elapsed since the last diagnosis or treatment of caries: Low risk: greater than 24 months; moderate risk: between 12-24 months ago and caries free in past 12 months; high risk: within the past 12 months.

* Current orthodontic appliance: Low risk: none worn; high risk: appliance worn.

* Daily between-meal exposures to simple sugars or foods strongly associated with caries initiation: Low risk: consumption primarily at meal times; moderate risk: occasional (1-2/day) exposures; high risk: frequent (3 or more/ day) exposures.

* Fluoride exposure: Low risk: age-appropriate fluoride toothpaste used at least twice daily and fluoridated water consumed (i.e., optimal topical and systemic fluoride exposure); moderate risk: age-appropriate fluoride toothpaste used at least twice daily and fluoridated water not usually consumed (i.e., optimal topical but suboptimal systemic fluoride exposure); high risk: fluoride toothpaste of inadequate strength for chronologic age and fluoridated water not usually consumed (i.e., suboptimal topical and systemic fluoride exposure).

* Times per day teeth are brushed: Low risk: brushes twice or more; moderate risk: brushes once; high risk: brushes less than once.

* Visible plaque on anterior teeth: Low risk: none; high risk: present.

* Gingivitis on anterior teeth: Low risk: none; high risk: present.

* Enamel demineralisation: Low risk: none; moderate risk: one demineralised area present; high risk: more than one demineralised area present.

* Enamel hypoplasia: Low risk: none; high risk; present.

* Molar-incisor hypomineralisation: Low risk: none; high risk: present.

Use of Dental Care. Dental care use was determined from patient records. The RDHM recall guidelines are between 6 and 24 months, depending on the child's history, and are typically 12 months. Attendance at the child's recommended intervals was denoted 'regular use of dental care in an established dental home'; attendance at greater intervals was denoted 'irregular use of dental care'; sporadic attendance was noted as 'no usual source of dental care'.

Caries Histories. Patient records were reviewed for caries histories and available radiographs were examined for caries requiring restoration (radiographs were not taken for the purpose of this study). Fissure sealants were assumed to have been placed on non-carious pits and fissures. Past caries was diagnosed by noting restorations and treatment dates, categorising the child as follows:

* 'Carious teeth in past 12 months': Caries present at this examination, or caries diagnosed/restored within the past 12 months.

* 'Carious teeth in past 12-24 months': Caries diagnosed/ restored between 12 and 24 months ago, but caries-free for the past 12 months.

* 'No carious teeth in past 24 months': No caries diagnosed/ restored in the past 24 months and caries-free at this examination.

Available bitewing radiographs (n = 26 subjects) were read blindly by the examiner (JL) on two occasions to determine intra-examiner reliability for caries diagnosis.

A mirror and explorer examination was conducted by one author (JL) using a dental light and triplex syringe. Carious teeth requiring restoration were diagnosed by WHO criteria [WHO, 1997], using an explorer instead of a CPI probe if diagnosis needed light tactile sensation. Caries was diagnosed if visible dentinal cavitation was present or radiographs showed dentinal caries, and recorded as 'carious teeth in past 12 months'. No further classification of individual teeth or tooth surfaces was undertaken.

Cariogenic Exposures. The child's intake of cariogenic drinks and foods in the past 24 hours was assessed from the PRAT responses. The number of cariogenic exposures was estimated; each glass of sweet drink was counted as one exposure and this number was added to the number of reported occasions of confectionery, cakes, biscuits and sugar-containing gum. Subjects were classified as follows:

* Consumption of simple sugars or foods strongly associated with caries initiation primarily at mealtimes: Subjects with 0-2 total exposures.

* Occasional between-meal exposures to simple sugars or foods strongly associated with caries: Subjects with 3-4 total exposures.

* Frequent between meal exposures to simple sugars or foods strongly associated with caries: Subjects with 5 or more total exposures.

Fluoride Exposure. The child's fluoride exposure was assessed from PRAT questions on use of fluoride toothpaste and fluoridated water. Current Australian guidelines deem use of non- or low-fluoride toothpaste in fluoridated areas by children aged over 6 years as suboptimal [ARCPOH, 2006]. The guidelines recommend 'for people aged 6 years or more, the teeth should be cleaned twice a day or more with standard fluoride toothpaste (1mgF/g)'; subjects brushing less than twice daily or using toothpaste without an age-appropriate fluoride concentration were recorded as 'suboptimal topical fluoride exposure', regardless of their intake of fluoridated water. The guidelines for optimum fluoride use in children aged 6 years and above include consumption of fluoridated water. Subjects meeting both criteria were recorded as receiving 'optimal systemic and topical fluoride exposure'. Subjects under 6 years of age consuming fluoridated water and brushing twice daily with 400-500 ppmF toothpaste were recorded as receiving 'optimal systemic and topical fluoride exposure'.

Oral Hygiene and Gingival Health. Visible plaque and gingivitis on anterior teeth were assessed by the Modified Plaque (MPI) and Gingival Inflammation (GII) Indices [Loe and Silness, 1963; Silness and Loe, 1964]. An MPI score of 2 or 3 was denoted 'visible plaque'; bleeding on probing was not recorded. For subjects with an MPI of 0 or 1, the GII was also used. A GII score of 1, 2 or 3 was recorded as 'gingivitis present'. An MPI of 0 or 1 and GII of 0 were recorded as 'no visible plaque or gingivitis'.

Enamel Demineralisation and Developmental Defects of Enamel. Air-dried teeth were inspected visually for enamel demineralisation using ICDAS II codes [Ismail et al., 2007], recording chalky opaque, white-brown lesions diagnosed in clinically-appropriate locations (ICDAS II codes 1, 2 or 3). Enamel hypoplasia was noted for non-carious enamel defects of reduced enamel thickness such as pitting [Winter and Brook, 1975]. For molar-incisor hypomineralisation (MIH), permanent first molars and incisors were examined for white-brown opaque demarcated opacities, post-eruptive breakdown, and atypical restorations in the cuspal/incisal coronal one third [Weerheijm et al., 2003].

Caries Risk. Caries risk was determined from the 11 risk factors, assessing risk based on the highest category assigned to any factor. One factor scored as high risk constituted high caries risk', regardless of status of other factors [AAPD, 2007-08]. For example, a child scored high risk for visible plaque, but low risk for all other factors, was classified as 'high caries risk' based solely on this risk factor. Subjects at 'moderate caries risk' had one or more factors scored as moderate with the remainder at low risk and none at high risk. A child scored at low risk for all factors was classified as 'low caries risk'.

Data Management and Statistical Analysis. Observed caries categories were collapsed and compared as follows: 'no carious teeth in past 12 months' (subjects with no observed caries in the past 12-24 months + those with no observed caries in past 24 months) were compared with 'carious teeth in past 12 months' (subjects with caries observed currently or within the past 12 months); 'no carious teeth in past 24 months' (subjects with no observed caries in the past 12 months + those with no observed caries in the past 12-24 months) were compared with 'carious teeth in past 24 months' (subjects with observed current caries + those with observed caries in the past 12 months + those with observed caries in the past 12-24 months).

Data were entered into Excel spreadsheets (Microsoft Corp., Seattle, WA, USA) and analysed using the SPSS Graduate Pack 16.0 for Windows[R] (SPSS Inc., Chicago, IL, USA). The intra-examiner reliability (weighted Cohen Kappa coefficient) was 1.0. Descriptive statistics were prepared for independent and dependent variables; categorical data were examined using Pearson Chi-squared tests. Noting the potential for inflating Type II errors (possibility of accepting a null hypothesis when the alternative hypothesis was true) in clinical data, Bonferroni adjustment of the p value for multiple comparisons was not applied [Perneger, 1998] and alpha was set conservatively at 0.01. A multiple risk factor model was constructed using odds ratios for caries risk factors (binary logistic regression), and backward logistical regression using Chi-squared tests (p = 0.1). Multi-variable modelling of independent variables (caries risk factors) was performed (backward elimination) until remaining variables were significant at p = 0.05.

Results

Distribution of Sample and Parental Report of Past Caries. The sample of 266 children (136 males, 130 females) completing the PRAT were aged 56-152 months (mean: 110[+ or -]23 months; Table 1). The subgroup (50 males, 50 females) also examined clinically (CAT) were aged 56-152 months (109[+ or -]25). Most children (91%) were aged 72-143 months (6-12 years). Caries in the past 12 months was reported for 37.2% of the sample (subgroup: 36.0%); 29.7% (subgroup: 34%) reported no caries experience. A few parents (sample: 5.6%; subgroup: 6.0%) were unsure of their child's past caries. The subgroup appeared representative of the sample for age, gender and past caries.

Oral Hygiene Habits. In the sample, 30.8% (82/266) of subjects (subgroup: 18.0%), brushed less than twice daily (Table 1). Most subjects (80.8%; subgroup: 82.9%) did not floss; daily flossing was rare (5.3%; 5.9%). All subjects used toothpaste, citing Colgate[TM] (Colgate Palmolive Pty Ltd., Sydney, Australia) products most frequently (sample: 88.3%; subgroup: 92%), in either child (400-500 ppmF) or adult strengths (1,000 ppmF). Some children used toothpastes of inappropriate fluoride concentration; among 4-7 yr-olds, adult strength (1,00 0ppmF) toothpaste was used inappropriately by 16.5%, and 13.2% of 8-12 yr-olds used child strength (400-500 ppmF) toothpaste (not tabulated).

Fluid Consumption. Most children reported drinking 3-5 times/day, and over one third reported [greater than or equal to] 6 occasions (Table 2). Most children (78.6%; 209/266) reported drinking fluids in the evening and/or night and for 86.1% (subgroup: 88.7%) these drinks included water. Of note, 35.9% (75/209) of children (subgroup: 35.2%, 25/71) reported drinking juices, cordials or soft drinks in the evening/night. Drinks without added sugars were consumed in the evening/night by 64.1% (subgroup: 64.8%). Of drinks consumed in the past 24 hours, tap water was the most popular, consumed by 90.2% (subgroup: 92%; Table 2). Few children (8.6%) reported drinking bottled, rain or mineral water. While 55.6% of the sample (subgroup: 52.0%) drank plain milk, 26.0% (subgroup: 25%) had not drunk milk in the past 24 hours. Almost half the sample (subgroup: 48.0%) drank juice, and 19.0% had drunk cordial. The intake of diet soft drink was lower than for regular soft drink (sample: 5.6% vs 30.5%).

Parental estimates of fluid consumed (number of glasses) in the past 24 hours are not tabulated. Milk consumption was low: less than one glass was consumed by 30.1% of the sample (subgroup: 28%), and two or more glasses were consumed by 31.1% (subgroup: 37%). Over half a glass of juice was consumed by 37.6% (subgroup: 43%). The intake of cordial was less frequent than juice: 18% had consumed over half a glass and 80% had not drunk cordial. More than half a glass of regular soft drink was consumed by 23.7% (subgroup: 17%), and a similar volume of diet soft drink was consumed by 4.9% (subgroup: 7%). Sports drinks or tea were rarely consumed.

Fluid volumes drunk in the past 24 hours were calculated from parental estimates of the number of 250mL glasses consumed (Table 3). The total fluid intake range was 0.25-3.25L (mean: 1.50 [+ or -] 0.50L) for the sample (subgroup: 0.50-3.00L; 1.50 [+ or -] 0.40L). The intake range for waters was 0-2.5L (0.82 [+ or -] 0.42L), and 0-1.25L (0.30 [+ or -] 0.24L) for milks.

The reported intakes of waters, milks and sweet drinks by 40, 4-7 yr-olds and 226, 8-12 yr-olds were estimated as proportions of their total fluid intakes (Table 4). Among 4-7 yr-olds, waters were 51-100% of fluid intake for 60% of the sample (subgroup: 58.8%); milks were 26-75% of fluid intake for 42.5% (subgroup: 53%), and sweet drinks were 26-75% of fluid intake for 40% (subgroup: 47.1%). Among 8-12 yr-olds, waters were 51-100% of fluid intake for 54.9% of the sample (subgroup: 57.8%); milks were 26-75% of fluid intake for 28.3% (subgroup: 31.3%), and sweet drinks were 51-100% of fluid intake for 13.3% (subgroup: 13.2%). Parents of 87.0% of the sample (subgroup: 88%) reported that the responses for fluid consumption in the last 24 hours were typical of their child's usual intake. The subgroup appeared representative of the sample for fluid intake.

24-hour Recall of Intakes of Confectionery, Baked Starches and Chewing Gum. The range in the number of treat occasions (excluding sugar-free gum) in the past 24 hours was 0-9 (1.1 [+ or -] 1.3) for the sample (subgroup: 0-4; 0.8 [+ or -] 0.9; Table 5). No treats were consumed by 38.3% (subgroup: 49%). One or two confectionery treats were consumed by 35% (subgroup: 34%), and one or two baked treats were eaten by 36.1% (subgroup: 27%). Very few children chewed either sugared (5.6%) or sugar-free gum (11.3%). Parents of 72.9% of the sample (subgroup: 83%) considered the reported treat intake for the past 24 hours was typical of their child's usual intake.

Caries Risk Factors and Categories. About half the subgroup examined clinically had regular dental care; 47% accessed dental care irregularly (Table 6). No child was without a usual source of dental care. Patient records and clinical examinations showed 47.0% of subjects had experienced caries in the past 12 months, and 44.0% were caries-free in the past 24 months. The consumption of simple sugars or foods primarily associated with caries initiation was typically at mealtimes for 40.0% of children; occasional between-meal exposures were noted for 39.0% and frequent between-meal exposures for 21.0%. While most subjects had optimal topical and systemic fluoride exposure, for 23.0% the topical fluoride exposure was suboptimal. Visible plaque on anterior teeth was seen in 35.0% of subjects and 49% had gingivitis. Areas of enamel demineralisation were present in 34% of subjects, enamel hypoplasia in 3%, and MIH in 5%. Except for fluoride exposure, risk factors were distributed similarly for both genders.

Parental report of past caries and the observed caries for their child were compared (not tabulated) and parental underestimates were noted: no carious teeth in the past 24 months: 53% subjects reported vs. 49% observed; carious teeth in the past 12-24 months: 5% vs. 9%; carious teeth in the past 24 months: 36% vs. 47%.

Children were categorized by caries risk (Table 7). In decreasing order, factors most likely to place a child at high risk were: gingivitis (affecting 42%), time since last caries diagnosis/restoration (35%), visible plaque (29%), and enamel demineralisation (23%). The age groups were distributed similarly for caries risk: 4-7 yr-olds: 82% high, 6% moderate, 12% low; 8-12 yr-olds: 81% high, 10% moderate, 10% low. Collapsing age groups, 81% were at high risk, 9% moderate, and 10% at low risk.

Reported Past Caries, Fluid Intakes and Treats. Associations between intakes of fluids and treats in the past 24 hours and reported caries of 251 children (15 subjects were excluded due to parental uncertainty of past caries) were examined. No significant associations were seen between reported caries in the past 12 mths, or reported past caries at any time, and the variables: drinking frequency, fluids (water, milk, sweet drinks) in the evening/night, number of glasses of fluids in the past 24 hrs, fluid intakes as proportion of total fluid intake, and frequency of daily tooth brushing. The association between treats (confectionery, baked starches, sugared chewing gum) in the past 24 hrs and reported past caries at any time was statistically significant (p = 0.006), but not with caries in the past 12 mths (p = 0.244) (Table 8).)

Observed Caries, Fluid Intakes, Treats and Caries Risk Factors. Associations between intakes of fluids and treats in the past 24 hours, caries risk factors, and observed caries were examined for the subgroup. No significant associations were seen between observed caries in the past 12 months and 24 months and the following variables: drinking frequency, fluids (waters, milks, sweet drinks) in the evening/ night, number of glasses of fluids consumed in the past 24 hours, fluid intakes as proportion of total fluid intake, daily tooth brushing frequency, flossing, visible plaque/gingivitis, enamel defects, and MIH.

Statistically significant associations (Table 8) were seen between the following: sweet drinks in the evening/night and observed caries in the past 12 months (p = 0.004); treats in the past 24 hours and observed caries in both the past 12 months and 24 months (p = 0.002; p = 0.006); daily between-meal exposure to sweet drinks/foods and observed caries in the past 12 months and 24 months (p = 0.001; p = 0.000); suboptimal fluoride exposure and observed caries in the past 12 months (p = 0.009); enamel demineralisation and observed caries in the past 12 months and 24 months (p = 0.000; p = 0.000); irregular dental care and observed caries in past 12 months and 24 months (p = 0.000; p = 0.000).

Multiple logistic regression and odds ratios of observed caries in the past 12 and 24 months and independent variables. The final model for observed caries in the past 12 and 24 months showed statistically significant associations with these independent variables: in the past 12 months: increasing frequency of treats consumption in the previous day, suboptimal fluoride exposure, presence of enamel demineralisation; in the past 24 months: presence of enamel demineralisation, irregular dental visitation (Table 9).

Discussion

This study examining dental caries experience and intakes of fluids and sweet treats was conducted on a convenience sample of 266 primary school children aged 4-12 years. It is acknowledged that the sample size was small but it was within the range of similar clinical studies [Blum et al., 2005; Tam et al., 2006]. Parental recall of caries experience and of dietary intakes in the past 24 hours was intrinsic to the study. This method is commonly used in epidemiological studies, to provide an indication of overall fluid and treat intakes. Assessing response reliability, parents indicated the information given was typical of their child's usual intake of fluids (for 87.0%) and treats (for 72.9%). However, a child's diet may have changed since past diagnosis/restoration of caries, and the responding parent may have been unaware of their child's caries history or diet.

The subgroup of 100 children examined clinically appeared similar to the sample population in many aspects, allowing generalizations to be made to the sample population. The subgroup appeared to be a representative subset of the sample with respect to age and gender distribution; frequency and pattern of fluid intake; types, volumes and distributions of fluids consumed; distribution and frequency of treats consumed; oral hygiene practices, and distribution of parentally-reported past caries.

The original PRAT questionnaire [Shenkin et al., 2003] was modified for the present study, expanding questions on fluid intake and omitting a scoring system for caries risk which was replaced with the CAT [AAPD, 2007-08]. The CAT includes socio-economic status (SES) as a risk factor; this factor was omitted as the sample population was limited to children of low SES parents holding health-care cards allowing care at a public dental hospital. Using the other CAT risk factors, the final caries risk status was similar for subjects aged 4-7 years and those aged 8-12 years: overall, 81% were categorized as high caries risk, 9% were moderate caries risk and 10% were low risk. However, if SES were included as a risk factor, all children in the study would be considered high caries risk.

In the last 24 hours, most children had consumed tap water and milk; a few drank bottled water; half drank fruit juice; and less than one third consumed soft drink. The mean fluid intake of 1.50 [+ or -] 0.50L was approximately 500mL higher than reported in other studies of similarly-aged children in Australia by the 1995 NNS survey [ABS, 1999] and others [Bell et al., 2005], and in the USA [Forshee and Storey, 2003]. This may reflect parental overestimation of volumes or fluid exposures, or differing approaches to estimations by researchers. Accurate measurement of fluid intake in such studies is only possible with direct observation, potentially altering intake patterns resulting in atypical observations.

The study was conducted in the fluoridated city of Melbourne. Water was the most popular drink consumed, with 90.2% of the sample drinking at least one glass of tap water in the past 24 hours. Information was not obtained on whether families filtered the reticulated water, potentially removing fluoride. The mean volume of water consumed (0.82 [+ or -] 0.42L) was higher than that reported in the 1995 NNS survey (0.54L for 4-7 yr-olds and 0.69L for 8-11 yr-olds) [ABS, 1999]. Although both studies obtained information by 24-hour recall, the difference may be due to parental misinterpretation of volumes or number of drinks. The low intake of bottled water in the past 24 hours (by 8.6% in the sample, 12% in the subgroup) suggests that these primary school children were not consuming bottled water preferentially to fluoridated tap water.

The low mean milk intake for the sample (0.30 [+ or -] 0.24L) was similar to that reported in the 1995 NNS survey (0.28L for 4-7 yr-olds and 0.28L for 8-11 yr-olds) [ABS, 1999]. The Australian Dietary Guidelines recommend consuming two to three serves of dairy product per day, where one serving is equivalent to 0.25L of milk [NHMRC, 2008]. These findings of low milk intake over the past decade support reports of declining dairy consumption in children elsewhere [Rampersaud et al., 2003; Friedman et al., 2007]. In the present study 26.0% of the sample had not drunk milk in the past 24 hours, but sweet drinks did not appear to be displacing milk intake as children who did or did not drink milk differed little in their proportional consumption of other fluids, agreeing with other reports of children in Australia [Tam et al., 2006] and the USA [Story et al., 2004].

Fruit juice was consumed in the previous 24 hours by almost half the sample population, with almost 90% drinking less than one glass. The mean juice intake of 0.13L was less than that reported by the 1995 NNS survey (0.31L for 4-7 yr-olds and 0.29L for 8-11 yr-olds) [ABS, 1999]. Juice intake per se was not associated significantly with either parentally-reported or observed caries, agreeing with the findings of a 1971-1974 USA national survey [Ismail, 1986]. Regular soft drink was consumed by 30.5% of the sample in the last 24 hours, approximating the proportion (29.7%) reported in a larger survey of children conducted in the same Australian state [Sanigorski et al., 2006]. In the present study, 76.3% of the sample had consumed less than half a glass of soft drink, with a mean intake of 0.12L. This was less than the mean intake of 0.17L calculated in the 1995 NNS survey for 7-11 yr-olds [ABS, 1999], but similar to the frequency of soft drink intake reported from a mail-in questionnaire survey of USA children [Grimm et al., 2004].

The significant association between observed caries in the past 12 months and the intake of sweet drinks at night corroborates an earlier report from a much larger study in the USA on the cariogenicity of sweet drinks in children [Ismail et al., 1984]. The latter study showed significant associations between the frequencies of intakes of sweet drinks between meals and with meals, and high DMFT scores [Ismail et al., 1984]. Parents may well be unaware of the cariogenic risk to the teeth of sweet fluids consumed overnight.

The number of treat occasions in the past 24 hours and parentally-reported past caries at any time were associated significantly. This was confirmed in the subgroup, where statistically significant associations were seen between the frequency of treat occasions in the past 24 hours and observed past caries, and between the frequency of intake of sweet drinks plus treats and observed caries. These findings support those of others [Ismail et al., 1984; Marshall et al., 2003]. Of note, these significant findings were obtained from parental recall of past caries and 24 hour dietary recall, rather than direct observation, and with caries data recorded as either parental report or as simple binary data (i.e., clinical observation of caries/restorations present or absent). These findings suggest that the two tools used, the Paediatric Risk Assessment Tool and the Caries-risk Assessment Tool, can be valuable adjuncts in both clinical practice for dentists and as survey tools.

For the purposes of the CAT, caries was defined as a lesion requiring restoration, i.e., the end stage of the lesion. Enamel demineralisation and observed caries in the past 12 months and 24 months were associated significantly, as expected, since enamel demineralisation is the earliest visible sign of caries. In comparison with caries observed in the CAT examination, parents of children in the subgroup underestimated their caries history. This is of note, as no significant associations were found between parentally-reported caries in the sample and either fluid intake or oral hygiene habits. Given the close representation of the sample by the subgroup, it is likely that parentally-reported caries was also underestimated in the sample population.

Clinical examination showed 47.0% of the subgroup had experienced caries in the past 12 months, 9.0% had experienced caries in the past 12-24 months, and 44.0% had no caries in the past 24 months. Strong associations between irregular dental care and increasing caries experience within the last 12 months and 24 months were found. These observations highlight the importance of regular dental visits to identify early disease, review caries risk and educate parents in their role in caries prevention. Similar associations between caries and lack of dental visits in the last 12 months for young children in the USA were noted by others [Dye et al., 2004].

No significant associations were seen between oral hygiene habits and parentally-reported caries, in agreement with a USA study of low income children [Kolker et al., 2007]. However, in the present study, observed caries in the subgroup in the past 12 months was associated significantly with suboptimal fluoride exposure. In the sample, 13.9% were using a lower fluoride concentration toothpaste than recommended by age, thereby receiving suboptimal fluoride exposure, and 16.7% used a higher fluoride concentration toothpaste than recommended in the Australian guidelines [ARCPOH, 2006]. Since it is not known for how long the children had been using these toothpastes, no conclusions can be drawn as to the level of caries protection afforded. The use of fluoride toothpaste of the appropriate concentration for age and caries risk should be addressed by dentists and dental auxiliaries in clinical practice to ensure children are receiving the full benefits of fluoride. Dental professionals should also consider each child's exposure to other fluoride modalities such as fluoridated water when recommending the appropriate fluoride toothpaste, in accordance with current guidelines.

Conclusions

This retrospective study of the intakes of fluids and sweet treats of 266 primary school children aged 4-12 years, 81% of whom were deemed to be at high caries risk, draws three conclusions:

* The PRAT and CAT are valuable tools in assessing children's caries risk.

* Noting that observed caries was associated significantly with suboptimal fluoride exposure, evening sweet drinks, frequency of treats, and frequency of sweet drinks plus sweet treats in the last 24 hours, the cariogenic risk of these intakes must be emphasised to parents.

* All parents, and particularly those of children assessed at high risk from intakes of sweet drinks and sweet treats, suboptimal fluoride exposure, or enamel demineralisation, must be encouraged to obtain regular dental care for their children.

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J.G. Lee, L.B. Messer Dept. Paediatric Dentistry, Melbourne Dental School, University of Melbourne, Victoria, Australia

Postal address: Emeritus Prof. L. B. Messer, Melbourne Dental School, The University of Melbourne, 720 Swanston Street, Victoria 3010 Australia.

Email: ljbm@uniinelb.edu.au

(1) A copy of the questionnaire is available from the corresponding author.
Table 1: Distribution of primary school-aged Australian children in
the sample population (N = 266) and the subgroup (N = 100) by age,
gender, parentally-reported past caries experience and oral hygiene
habits.

                                              Distribution of children
Age, past caries experience
and oral hygiene habits                        sample       subgroup
                                              (N = 266)    (N = 100)
                                                n (%)        n (%)

Age (months)       56-95 Males                    40           15
                           Females                39           16
                           Subtotal           79 (29.7)     31 (31)
                   96-131 Males                   69           25
                           Females                64           22
                           Subtotal           133 (49.9)    47 (47)
                   132-152 Males                  27           10
                           Females                27           12
                           Subtotal           54 (20.4)     22 (22)
                           Total males         136 (50)     50 (50)
                           Total females       130 (50)     50 (50)

parentally-        None                       79 (29.7)     34 (34)
reported past      Over 2 years ago           66 (24.8)     19 (19)
caries             Between 12-24 months ago    7 (2.6)       5 (5)
experience         Within past 12 months      99 (37.2)     36 (36)
                   Unsure                      15 (5.6)      6 (6)

Frequency of       Never/rarely                7 (2.6)      1 (1.0)
tooth brushing     Less than once per day      6 (2.3)      4 (4.0)
                   Once per day               69 (25.9)    13 (13.0)
                   Twice per day              176 (66.2)   77 (77.0)
                   More than twice per day     8 (3.0)      5 (5.0)

Frequency of       Never/rarely               215 (80.8)   82 (82.9)
flossing           Once per week              37 (13.9)    13 (13.9)
                   Once per day                14 (5.3)     5 (5.9)

Type of            Child strength fluoride    68 (25.6)    26 (26.0)
toothpaste used    Adult strength fluoride    196 (73.7)   73 (73.0)
                   Fluoride-free               2 (0.8)      1 (1.0)

Table 2: Distribution of daily drinking frequency, pattern and
drinks consumed in the evening/night and past 24 hours by the sample
(W = 266) population and a subgroup (N=100) of Australian children.

                                                           Distribution
 Daily drinking                                            of children
   frequency,
   pattern and                                                Sample
 drinks consumed                                            (N = 266)
 in the evening/                                              n (%)
      night

No. of drink        1-2                                      15 (5.6)
occasions           3-5                                     152 (57.1)
per day             6-9                                     82 (30.8)
                    10 or more                               17 (6.4)

Drinking pattern    No drinks consumed                      57 (21.4)
in evening/night    Drinks in evening only                  162 (60.9)
                    Drinks in night only                     5 (1.9)
                    Drinks in evening and night             42 (15.8)

Drinks (a)          Water (tap, rain, bottled, mineral)     180 (86.1)
consumed            Milk (plain, flavoured, soy)            98 (46.9)
(evening/night)     Juice, cordial                          47 (22.5)
                    Soft drink (regular, diet)              24 (11.5)

Drinks (a) +/-      Water, milk (b), unsugared tea          204 (97.6)
added sugars        Non-milk drinks, sugars added (c)       58 (27.8)
consumed            Drinks with added sugars (d)            75 (35.9)
(evening/night)     Drinks without added sugars (e)         134 (64.1)

Drinks (a)          Tap water                               240 (90.2)
consumed (in        Bottled water                            23 (8.6)
past 24 hours)      Rain water                               7 (2.6)
                    Mineral water                            3 (1.1)

                    Milk (plain)                            148 (55.6)
                    Milk (flavoured)                        64 (24.1)
                    Milk (soy)                               3 (1.1)
                    No milks                                70 (26.0)

                    Fruit juice                             115 (43.2)
                    Cordial                                 50 (18.8)
                    Soft drink (regular)                    81 (30.5)
                    Soft drink (diet)                        15 (5.6)
                    Sports drink                             3 (1.1)

                                                           Distribution
 Daily drinking                                            of children
   frequency,
   pattern and                                               Subgroup
 drinks consumed                                            (N = 100)
 in the evening/                                              n (%)
      night

No. of drink        1-2                                      3 (3.0)
occasions           3-5                                     61 (61.0)
per day             6-9                                     32 (32.0)
                    10 or more                               4 (4.0)

Drinking pattern    No drinks consumed                      29 (29.0)
in evening/night    Drinks in evening only                  58 (58.0)
                    Drinks in night only                    13 (13.9)
                    Drinks in evening and night                 0

Drinks (a)          Water (tap, rain, bottled, mineral)     63 (88.7)
consumed            Milk (plain, flavoured, soy)            33 (46.5)
(evening/night)     Juice, cordial                          18 (25.4)
                    Soft drink (regular, diet)               8 (11.3)

Drinks (a) +/-      Water, milk (b), unsugared tea          71 (100.0)
added sugars        Non-milk drinks, sugars added (c)       21 (29.6)
consumed            Drinks with added sugars (d)            25 (35.2)
(evening/night)     Drinks without added sugars (e)         46 (64.8)

Drinks (a)          Tap water                               92 (92.0)
consumed (in        Bottled water                           12 (12.0)
past 24 hours)      Rain water                               1 (1.0)
                    Mineral water                            2 (2.0)

                    Milk (plain)                            52 (52.0)
                    Milk (flavoured)                        32 (32.0)
                    Milk (soy)                                  0
                    No milks                                25 (25.0)

                    Fruit juice                             48 (48.0)
                    Cordial                                 19 (19.0)
                    Soft drink (regular)                    22 (22.0)
                    Soft drink (diet)                        7 (7.0)
                    Sports drink                             3 (3.0)

(a) Multiple responses permitted; (b) One or more of the following:
Water (tap, rain, bottled, mineral), milk (plain, flavoured, soy),
unsugared tea; (c) One or more of the following: Juice, cordial,
soft drink (regular, diet), sports drink, sugared tea; (d) One or
more of the following: Juice, cordial, soft drink (regular, diet),
sports drink, sugared tea, flavoured milk; (e) One or more of the
following: Water (tap, rain, bottled, mineral), milk (plain, soy),
unsugared tea.

Table 3: Distribution of fluids consumed as recalled for past 24
hours by sample population (W = 266) and subgroup (W = 100) of
Australian children.

Fluids consumed in past 24 hours                Volume of fluid
                                               consumed (Litres)

                                                Sample (N = 266)
                                            Range (Mean [+ or -] SD)

Waters (a)                                0-2.50 (0.82 [+ or -] 0.42)
Milks (b)                                 0-1.25 (0.30 [+ or -] 0.24)
Sweet drinks (excl. flavoured milk) (c)    0-1.5 (0.35 [+ or -] 0.32)
Sweet drinks (incl. flavoured milk) (d)   0-1.75 (0.42 [+ or -] 0.35)
Total fluid intake                       0.25-3.25 (1.50 [+ or -] 0.50)

Fluids consumed in past 24 hours                Volume of fluid
                                               consumed (Litres)

                                               Subgroup (N = 100)
                                            Range (Mean [+ or -] SD)

Waters (a)                                0-2.50 (0.84 [+ or -] 0.43)
Milks (b)                                 0-1.25 (0.29 [+ or -] 0.24)
Sweet drinks (excl. flavoured milk) (c)   0-1.25 (0.32 [+ or -] 0.27)
Sweet drinks (incl. flavoured milk) (d)   0-1.25 (0.42 [+ or -] 0.31)
Total fluid intake                       0.50-3.00 (1.50 [+ or -] 0.40)

(a) Waters: tap, rain, bottled, mineral, unsugared tea; (b) Milks:
plain, soy; (c) Sweet drinks: Juice, cordial, soft drink (regular,
diet) sports drink, sugared tea; (d) Sweet drinks: Juice, cordial,
soft drink (regular, diet), sugared tea, flavoured milk.

Table 4: Distribution of fluids consumed as a proportion of total
fluid intake recalled for past 24 hours by sample population (N = 266
children) and subgroup (N = 100 children).

                             Distribution of fluids consumed
Proportion of total
fluid intake                    By 4 to 7-year-olds n (%)
(24 hour recall)
                          Waters (a)   Milks (b)      Sweet
                                                    drinks (c)

Sample       0                0        14 (35.0)    14 (35.0)
(N = 266)    1-25%         1 (2.5)      9 (22.5)    10 (25.0)
             26-50%       15 (37.5)    15 (37.5)    13 (32.5)
             51-75%       15 (37.5)     2 (5.0)      3 (7.5)
             76-100%       9 (22.5)        0            0
             Subtotal         40           40           40

Subgroup     0                0         3 (17.6)     5 (29.4)
(N = 100)    1-25%            0         5 (29.4)     4 (23.5)
             26-50%        7 (41.2)     8 (47.1)     6 (35.3)
             51-75%        7(41.2)      1 (5.9)      2 (11.8)
             76-100%       3 (17.6)        0            0
             Subtotal         17           17           17

                             Distribution of fluids consumed
Proportion of total
fluid intake                   By 8 to 12-year-olds n (%)
(24 hour recall)
                          Waters (a)   Milks (b)      Sweet
                                                    drinks (c)

Sample       0             12 (5.3)    59 (26.1)    42 (18.6)
(N = 266)    1-25%         9 (3.9)     103 (45.6)   64 (28.3)
             26-50%        81 (35.8    62 (27.4)    90 (39.8)
             51-75%       91 (40.3)     2 (0.9)      18 (8.0)
             76-100%      33 (14.6)        0         12 (5.3)
             Subtotal        226          226          226

Subgroup     0             3 (3.6)     22 (37.3)    11 (13.3)
(N = 100)    1-25%         3 (3.6)     35 (42.2)    28 (33.7)
             26-50%       29 (34.9)    25 (30.1)    33 (39.8)
             51-75%       39 (47.0)     1 (1.2)      8 (9.6)
             76-100%       9 (10.8)        0         3 (3.6)
             Subtotal         83           83           83

(a) Waters: Tap, rain, bottled, mineral, unsugared tea; (b) Milks:
Plain, soy; (c) Sweet drinks: Juice, cordial, soft drink (regular,
diet), sports drink, sugared tea, flavoured milk.

Table 5: Distribution of occasions when treats were used in the
previous 24 hours for sample population (W = 266) and subgroup of
(N = 1000) Australian children.

   Number of treat occasions         Distribution of children
     in previous 24 hours
                                       Sample        Subgroup
                                     (N = 266)      (N = 100)
                                       n (%)          n (%)

Total treat occasions        None    102 (38.3)     49 (49.0)
(excl. sugar-free chewing    1       87 (32.7)      31 (31.0)
gum)                         2       47 (17.7)      16 (16.0)
                             3-5     27 (10.2)       4 (4.0)
                             6-9      3 (1.1)           0

Occasions for sweets         None    166 (62.4)     66 (66.0)
and/or chocolate             1       66 (24.8)      26 (26.0)
                             2       27 (10.2)       8 (8.0)
                             3-5      7 (2.7)           0

Occasions for biscuits       None    166 (62.4)     73 (73.0)
and/or cake                  1       69 (25.9)      22 (22.0)
                             2       27 (10.2)       5 (5.0)
                             3-4      4 (1.6)           0

Occasions for sugared        None    251 (94.4)     98 (98.0)
chewing gum                  1        12 (4.5)       2 (2.0)
                             2        3 (1.1)           0

Occasions for sugar-free     None    236 (88.7)     87 (87.0)
gum                          1        20 (7.5)      10 (10.0)
                             2-3      10 (3.8)       3 (3.0)

Table 6: Distribution of caries risk factors in subgroup of 100
Australian children.

                                          Distribution of children

Caries risk factors in                Male       Female       Total
Caries-risk Assessment Tool         (N = 50)     (N = 50)   children
                                                            (N = 100)
                                                              n (%)

Regular use of dental care,            27          26        53 (53)
established 'dental home'

Irregular use of dental care           23          24        47 (47)

No usual source of dental care          0           0           0

No carious teeth in the past 24        22          22        44 (44)
months

Carious teeth in the past 12-24         4           5         9 (9)
months

Carious teeth in the past 12           24          23        47 (47)
months

No orthodontic appliance worn          50          49        99 (99)

Orthodontic appliance worn              0           1         1 (1)

Consumption of simple sugars or        22          18        40 (40)
foods strongly associated with
caries initiation primarily at
mealtimes

Occasional between-meal exposures      20          19        39 (39)
to simple sugars or foods
strongly associated with caries

Frequent between-meal exposures         8          13        21 (21)
to simple sugars or foods
strongly associated with caries

Tooth brushing 2 or more times/        42          40        82 (82)
day

Tooth brushing once/day                 5           8        13 (13)

Tooth brushing less than once/          3           2         5 (5)
day

Optimal systemic and topical           33          39        72 (72)
fluoride exposure

Optimal topical but suboptimal          1           4         5 (5)
systemic fluoride exposure

Suboptimal topical fluoride            16           7        23 (23)
exposure

No visible plaque or gingivitis        24          27        51 (51)

Gingivitis, and no visible plaque      10           4        14 (14)

Visible plaque on anterior teeth       16          19        35 (35)
and gingivitis

No enamel demineralisation             32          34        66 (66)

One area of enamel                      2           1         3 (3)
demineralisation

More than one area of enamel           16          15        31 (31)
demineralisation

No enamel hypoplasia present           48          49        97 (97)

Enamel hypoplasia present               2           1         3 (3)

No molar-incisor                       41          41        82 (82)
hypomineralisation

Molar hypomineralisation present        7           6        13 (13)

Molar and incisor                       2           3         5 (5)
hypomineralisation present

Table 7: Distribution of caries risk factors and categories of
caries risk for subgroup (N = 100) of Australian children.

Caries risk factors in caries-          Distribution of children by
risk Assessment Tool (CAT)                caries risk categories

                                         Age 4 to 7 years (N = 17)

                                      Low        Moderate       High
                                      risk         risk         risk
                                     n (%)        n (%)        n (%)

Use of 'dental home'                 7 (7)       10 (10)         0

Time since last caries               5 (5)          0         12 (12)
diagnosis/restoration

Currently wears orthodontic/        17 (17)       na (a)         0
oral appliance/s

Daily between-meal exposures to      5 (5)        9 (9)        3 (3)
cariogenic foods and drinks

Fluoride exposure                    9 (9)          0          8 (8)

Times per day child's teeth         12 (12)       5 (5)          0
brushed

Visible plaque                      11 (11)         na         6 (6)

Gingivitis                          10 (10)         na         7 (7)

Areas of enamel                      9 (9)          0          8 (8)
demineralisation

Enamel hypoplasia                    17(17)         na           0

Molar-incisor                       14 (14)         na         3 (3)
hypomineralisation

Distribution of 4-7 yr-olds by       2 (12)       1 (6)       14 (82)
caries risk category (n = 17)

Distribution of 8-12 yr-olds by        --           --           --
caries risk category (n = 83)

Caries risk factors in caries-          Distribution of children by
risk Assessment Tool (CAT)                caries risk categories

                                        Age 8 to 12 years (N = 83)

                                      Low        Moderate       High
                                      risk         risk         risk
                                     n (%)        n (%)        n (%)

Use of 'dental home'                46 (46)      37 (37)         0

Time since last caries              39 (39)       9 (9)       35 (35)
diagnosis/restoration

Currently wears orthodontic/        82 (82)         na         1 (1)
oral appliance/s

Daily between-meal exposures to     35 (35)      30 (30)      18 (18)
cariogenic foods and drinks

Fluoride exposure                   63 (63)       5 (5)       15 (15)

Times per day child's teeth         70 (70)       8 (8)        5 (5)
brushed

Visible plaque                      54 (54)         na        29 (29)

Gingivitis                          41 (41)         na        42 (42)

Areas of enamel                     57 (57)       3 (3)       23 (23)
demineralisation

Enamel hypoplasia                   80 (80)         na         3 (3)

Molar-incisor                        68 (8)         na        15 (15)
hypomineralisation

Distribution of 4-7 yr-olds by         --           --           --
caries risk category (n = 17)

Distribution of 8-12 yr-olds by      8 (10)       8 (10)      67 (81)
caries risk category (n = 83)

(a) na: No moderate category designated in the
Caries-risk Assessment Tool

Table 8: Significant associations between fluid intake and treat
occasions in past 24 hours and caries experience.

                                             Distribution of children

                                             Caries in        Caries
                    Reported intake of        past 12        free in
                 fluids and sweet treats       months        past 12
                                                              months

Sample (a)       No. treat occasions in
N = 251          past 24 hours:
                 0                               32             65
                 1-2                             55             70
                 3 or more                       12             17

Subgroup (b)     sweet drinks (swD)
N = 100          consumed in eve/night
                 (c)
                 None                            29             46
                 SwD consumed                    18             7

                 No. treat occasions in
                 past 24 hours:
                 0                               16             33
                 1                               15             16
                 2 or more                       16             4

                 Daily between-meal
                 cariogenic foods &
                 drinks:
                 Mainly at meals                 10             30
                 Occasionally                    23             16
                 Frequently                      14             7

                 Fluoride exposure:
                 Optimal                         28             44
                 Suboptimal                      19             9

                 Enamel demineralisation:
                 None                            20             46
                 Present                         27             7

                 Dental visits:
                 Regular                         41             12
                 Irregular                       12             35

                                             Distribution of children

                                               Total          signif
                    Reported intake of                     [chi square]
                 fluids and sweet treats                       (df)

Sample (a)       No. treat occasions in
N = 251          past 24 hours:
                 0                               97         2.824 (2)
                 1-2                            125          p = 0.244
                 3 or more                       29

Subgroup (b)     sweet drinks (swD)
N = 100          consumed in eve/night
                 (c)
                 None                            75         8.363 (1)
                 SwD consumed                    25         p = 0.004 *

                 No. treat occasions in
                 past 24 hours:
                 0                               49         12.816 (2)
                 1                               31         p = 0.002 *
                 2 or more                       20

                 Daily between-meal
                 cariogenic foods &
                 drinks:
                 Mainly at meals                 40         13.278 (2)
                 Occasionally                    39         p = 0.001 *
                 Frequently                      21

                 Fluoride exposure:
                 Optimal                         72         6.791 (1)
                 Suboptimal                      28         p = 0.009 *

                 Enamel demineralisation:
                 None                            66         21.725 (1)
                 Present                         34         p = 0.000 *

                 Dental visits:
                 Regular                         53         28.860 (1)
                 Irregular                       47         p = 0.000 *

                                             Distribution of children

                                                past         No past
                    Reported intake of         caries         caries
                 fluids and sweet treats     experience     experience
                                             or in past     or caries
                                             24 months     free in past
                                                            24 months

Sample (a)       No. treat occasions in
N=251            past 24 hours:
                 0                               55             42
                 1-2                             95             30
                 3 or more                       22             7

Subgroup (b)     sweet drinks (swD)
N=100            consumed in eve/night
                 (c)
                 None                            37             38
                 SwD consumed                    19             6

                 No. treat occasions in
                 past 24 hours:
                 0                               21             28
                 1                               18             13
                 2 or more                       17             3

                 Daily between-meal
                 cariogenic foods &
                 drinks:
                 Mainly at meals                 13             27
                 Occasionally                    27             12
                 Frequently                      16             5

                 Fluoride exposure:
                 Optimal                         37             35
                 Suboptimal                      19             9

                 Enamel demineralisation:
                 None                            28             38
                 Present                         28             6

                 Dental visits:
                 Regular                         17             36
                 Irregular                       39             8

                                             Distribution of children

                                               Total         signif.
                    Reported intake of                     [chi square]
                 fluids and sweet treats                       (df)

Sample (a)       No. treat occasions in
N = 251          past 24 hours:
                 0                               97         10.250 (2)
                 1-2                            125         p=0.006 *
                 3 or more                       29

Subgroup (b)     sweet drinks (swD)
N = 100          consumed in eve/night
                 (c)
                 None                            75         5.411 (1)
                 SwD consumed                    25          p = 0.020

                 No. treat occasions in
                 past 24 hours:
                 0                               49         10.315 (2)
                 1                               31         p = 0.006 *
                 2 or more                       20

                 Daily between-meal
                 cariogenic foods &
                 drinks:
                 Mainly at meals                 40         15.210 (2)
                 Occasionally                    39         p = 0.000 *
                 Frequently                      21

                 Fluoride exposure:
                 Optimal                         72         2.219 (1)
                 Suboptimal                      28          p = 0.136

                 Enamel demineralisation:
                 None                            66         14.520 (1)
                 Present                         34         p = 0.000 *

                 Dental visits:
                 Regular                         53         26.195 (1)
                 Irregular                       47         p = 0.000 *

(a) PRAT questionnaire group; (b) PRAT questionnaire and CAT
examination subgroup; (c) Sweet drinks: Juice, cordial, soft drink
(regular, diet), sports drink, sugared tea, flavoured milk; * p<0.01

Table 9: Logistic regression model for the occurrence of observed
caries in subgroup (N = 100 children) and association with independent
variables.

Observed caries      Independent             Reference       Com-
                     variable               independent    parative
                                             variable     independent
                                                           variable

In past 12 months    Reported treat              0             1
                     occasions in past
                     24 hours                    1        [less than
                                                           or equal
                                                             to] 2

                                                 0        [less than
                                                           or equal
                                                             to] 2

                     Reported fluoride        Optimal     Suboptimal
                     exposure

                     Enamel                    None         Present
                     demineralisation

In past 24 months    Enamel                    None         Present
                     demineralisation

                     Dental visitation        Regular      Irregular
                     pattern

Observed caries      Independent                 OR (95% CI)
                     variable

In past 12 months    Reported treat           3.50 (1.42, 8.62)
                     occasions in past
                     24 hours                4.41 (1.25, 15.63)

                                             5.88 (1.34, 25.64)

                     Reported fluoride        3.02 (1.01, 9.07)
                     exposure

                     Enamel                  8.42 (2.90, 24.47)
                     demineralisation

In past 24 months    Enamel                  4.17 (1.37, 12.66)
                     demineralisation

                     Dental visitation       8.00 (2.97, 21.74)
                     pattern

Observed caries      Independent              p value       Overall
                     variable                               p value

In past 12 months    Reported treat            0.328        0.007 *
                     occasions in past
                     24 hours                 0.019 *

                                              0.002 *

                     Reported fluoride        0.049 *       0.049 *
                     exposure

                     Enamel                   0.000 *       0.000 *
                     demineralisation

In past 24 months    Enamel                   0.000 *       0.000 *
                     demineralisation

                     Dental visitation        0.012 *       0.012 *
                     pattern

* significant p<0.05
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