Abstract
Objective
This retrospective chart review evaluated the relationship between specific dietary questions used in caries risk assessment and planned restorative treatment among patients attending a dental school's clinic.
Methods
Records for 6,218 adult patients attending the University of Iowa College of Dentistry who completed caries risk assessments and comprehensive oral examinations during 2018–2019 were included. The number of planned caries restorative treatments were compared between groups based on responses to specific dietary questions on the caries risk assessment. Analyses included chi‐square and Wilcoxon rank‐sum tests and logistic regression for factors associated with caries treatments.
Results
About 20% of subjects needed caries treatment, and regression analyses found that younger age, having unstructured meals, drinking sugared beverages daily, and drinking them for more than 30 min were significantly (p < 0.01) associated with having caries.
Conclusions
Specific and focused questions on dietary practices are strongly associated with caries, and may be useful in improving caries risk assessments.
Keywords: caries risk assessment, dental caries, diet, general health, oral health
INTRODUCTION
Dental caries is one of the most prevalent diseases in the world, affecting billions of people worldwide, including 90% of the U.S. adult population age 20–64 years [1]. The most recent data from the National Health and Nutrition Examination Survey (NHANES) indcated that while caries experience increased with age during adulthood, prevalence of caries among the youngest adults aged 20–34 years was high—82%. Moreover, these same NHANES data demonstrated that 26% of the U.S. adult population had untreated dental caries, with profound disparities based on race and ethnicity, poverty status and education levels. The level of untreated decay in adults was much higher (26%) than that reported for children (5%) or adolescents (17%) in the same survey [1].
Although the prevalence of dental caries in adults remains high, studies of caries risk in adult populations is relatively uncommon. Similarly, development of caries risk assessment (CRA) tools has mostly focused on caries in children, with few tools adapted specifically for adults [2]. Of particular concern, while it is well‐accepted that diet, specifically sugar consumption, is a key causative factor for dental caries [3], current CRA tools include no more than one or two items concerning sugar consumption, and questions regarding sugar‐sweetened beverage consumption are especially lacking. For example, the Cariogram system includes two items on diet related to “fermentable carbohydrates”—content and frequency—and groups data into four broad categories, but relies on clinicians to use more detailed means (such as food frequency or 24‐h recall) to collect these data [4]. On the other hand, the American Dental Association's caries risk assessment form for those older than 6 years includes one item on “sugary foods or drinks” and only distinguishes whether they are consumed at mealtime or between meals [5]. Similarly, the caries management by risk assessment (CAMBRA) system includes a single item on “frequent snacking” (more than 3 times/day) [6, 7]. The Previser system utilizes a single item, “snacks or beverages containing sugar consumed between meals or 4 or more times per day” [8].
Numerous studies have found sugar‐sweetened beverages to be important caries risk factors in children [9, 10, 11]. While there are fewer such studies in adult populations, there are clear links between sugar consumption levels and caries in adults [12, 13, 14]. Despite this evidence, questions about sugary beverage consumption are conspicuously absent from current CRA tools for children and adults [4, 5, 6, 7, 8]. Thus, little is known about how useful specific questions about sugar‐sweetened beverage consumption may be in assessing caries risk, or in how practical it is to use such questions in CRAs.
The purpose of this retrospective chart review was to evaluate the relationship between specific dietary questions used in CRA and caries diagnosis among adult patients attending a dental school's clinic. The study's hypothesis was that in a clinical setting, select dietary questions as part of a CRA would be associated with caries.
METHODS
This study was a retrospective chart review of adult patients attending the student dental clinics at the University of Iowa during 2018–2019. All adult patients who completed CRA and who had treatment plans developed within 6 months (before or after) of the CRA were eligible and included in the study. It should be noted that CRAs are not completed in certain specialty clinics (e.g., oral surgery, endodontics) or in the Geriatric & Special Needs Dentistry Clinic. CRAs were conducted by students at all levels (D1–D4), and while all received instruction in completing the assessment, no attempt was made to formally calibrate the students in completing the form.
The CRA tool used at the University of Iowa is based on several other tools—both published [4, 5, 15] and unpublished—but is unique in that it emphasizes dietary contributors to caries risk. Specifically, the CRA tool includes questions pertaining to the number of meals and snacks per day, structured vs. unstructured meals/snacks, sugared beverage consumption and whether such consumption is of more than 20 ounces/day and whether consumption occurs over 30 min or more, and sugared candy consumption. In addition, the tool includes assessments of fluoride exposure, general health conditions including tobacco use, and clinical conditions including xerostomia, previous caries experience, plaque level, and an assessment of current oral hygiene practices. (See Appendix A).
To obtain data for the study, the informational technology (IT) staff at the UI College of Dentistry identified all patients, 18 years and older, who had completed their initial CRAs during 2018–19. Data on caries diagnoses (in the absence of diagnostic codes) were obtained by specifying treatment codes that encompassed procedures that were considered as most likely related to caries, and included composite resin restorations (D2330, D2331, D2332, D2335, D2391, D2392, D2393, D2394), glass ionomer restorations(D2330.1, D2331.1 D2332.1, D2335.1, D2391.1, D2392.1, D2393.1, 2394.1), and amalgam restorations (D2140, D2150, D2160, D2161). Certain demographic data were also obtained from the electronic records, including age, and sex, as well as insurance status (public insurance, private insurance, no insurance/self‐pay). As the data were obtained from health records retrospectively, data on other factors such as race/ethnicity and income level were not available. The IT staff assembled these data, de‐identified them, and shared the resulting dataset with the study team. The study was approved by the UI Institutional Review Board (IRB).
The analysis compared the proportion of subjects with any planned restorative treatments (from the list of CRT codes) and number of these planned treatments for those who answered “yes” and “no” for each of the dietary questions in the CRA. Initial analyses included chi‐square tests and Wilcoxon rank sum tests. Logistic regression analyses which controlled for age, sex, and insurance status was conducted to identify factors associated with having planned caries treatments. The multivariable models utilized a backward stepwise variable selection approach based on Akaike's Information Criterion (AIC). Data were initially assembled into an Excel database but were converted into SAS and R formats for analyses. The alpha level was set at p < 0.05 for all statistical tests and analyses.
RESULTS
A total of 6,218 unique individuals met the study's inclusion criteria. The mean age of the subjects was 50.9 years, and 54% were female. Thirty‐five percent had public insurance (Medicaid), 30% had private insurance and 35% were self‐pay (had no insurance).
Overall, 20% (n = 1,246) of subjects had caries requiring treatment as determined by having one or more of the CRT codes included in their “planned treatment” at the time of the CRA. Only a small minority (9%) reported eating more than three meals per day or eating more than three snacks per day (20%); two‐thirds (66%) reported having structured meals, as opposed to “grazing” throughout the day. Thirty‐nine percent reported drinking sugared beverages (juice, soft drinks, or energy drinks) on a daily basis, while a smaller portion (15%) reported eating sugared candy on a daily basis.
As presented in Table 1, bivariate chi‐square analyses found that all of the dietary variables were positively and significantly (p < 0.05) associated with having planned caries treatment—that is those who drank sugared beverages, ate sugared candies, had more than three meals or snacks per day and had unstructured meals, were more likely to have caries than were those who did not drink sugared beverages or eat candy, had three or fewer meals/snacks per day and had structured meals, respectively. Those who drank more than 20 ounces of sugared beverages or drank them over a span of more than 30 min were also more likely to have planned caries treatments. Comparisons of the number of caries treatments between those who answered “yes” and “no” to each of the dietary questions was assessed utilizing Wilcoxon rank sum tests, and those with daily sugared beverage consumption, daily sugared candy consumption, more than three meals or snacks per day, and those with unstructured meal patterns had significantly more planned restorative treatments on average than did those with healthier dietary characteristics (data not shown).
TABLE 1.
Bivariate analysis of dietary questions and planned caries treatment.
| Caries risk assessment question | Planned caries treatment | p‐value* | |
|---|---|---|---|
| No (%) | Yes (%) | ||
| Eats more than 3 meals per day | – | – | 0.037 |
| No | 3680 (92%) | 1036 (90%) | – |
| Yes | 325 (8.1%) | 116 (10%) | – |
| Eats more than 3 snacks per day | – | – | <0.001 |
| No | 3241 (81%) | 868 (76%) | – |
| Yes | 768 (19%) | 281 (24%) | – |
| Meals are NOT structured (on and off‐grazing) | – | – | <0.001 |
| No | 2724 (68%) | 657 (57%) | – |
| Yes | 1279 (32%) | 491 (43%) | – |
| Drinks sugared beverages (juice, soda, energy drinks) daily | – | – | <0.001 |
| No | 2593 (65%) | 548 (48%) | – |
| Yes | 1414 (35%) | 603 (52%) | – |
| Drinks more than 20 ounces of sugared beverages/day | – | – | <0.001 |
| No | 3055 (76%) | 718 (62%) | – |
| Yes | 800 (20%) | 354 (31%) | – |
| Drinks sugared beverages for more than 30 min | – | – | <0.001 |
| No | 3055 (76%) | 718 (62%) | – |
| Yes | 953 (24%) | 432 (38%) | – |
| Eats sugared candy or medicated lozenges daily | – | – | 0.017 |
| No | 3422 (85%) | 946 (83%) | – |
| Yes | 581 (15%) | 199 (17%) | – |
p‐value based on chi‐squared test.
Multivariable logistic regression analyses were conducted and due to missing data for some of the explanatory variables, sample size was reduced to 5,046. The initial regression models included all dietary and demographic variables, but through backward selection based on the AIC, the model was reduced to a more parsimonious one which included four variables, as presented in Table 2. The final model shows that younger age, having unstructured meals, drinking sugared beverages daily and drinking them for more than 30 min were significantly associated with having caries as determined by having planned caries treatments.
TABLE 2.
Final logistic regression model of factors related to having planned caries treatment.
| Caries risk assessment question | OR | 95% CI | p‐value |
|---|---|---|---|
| Age | 0.98 | 0.98, 0.99 | <0.001 |
| Meals are NOT structured (on and off‐grazing) | – | – | <0.001 |
| No | ref | – | – |
| Yes | 1.31 | 1.14, 1.51 | – |
| Drinks sugared beverages (juice, soda, energy drinks) daily | – | – | <0.001 |
| No | ref | – | – |
| Yes | 1.56 | 1.33, 1.84 | – |
| Drinks sugared beverages for more than 30 min | – | – | 0.002 |
| No | ref | – | – |
| Yes | 1.32 | 1.11, 1.57 | – |
DISCUSSION
The results of the study support the hypothesis that select dietary questions as part of a CRA are associated with caries in adults. The study demonstrated consistent associations between dietary sugar consumption and planned restorative treatments, specifically about sugared beverage consumption. The study also found that unstructured meals were also associated with restorative treatment. The results provide evidence for including specific dietary questions in CRA tools.
The study findings are consistent with extensive evidence linking sugar consumption to dental caries [3], and studies linking unhealthy eating patterns to caries [16]. However, since commonly used CRA tools include only minimal dietary assessments, these findings are unique in demonstrating that a few select and specific dietary questions included in a CRA tool are associated with caries in adults, and thus, may be useful in improving CRA. The data used in this study were obtained during routine dental visits utilizing a CRA scheme that included seven dietary questions, which suggests that such information could be readily obtained for nearly all dental patients [16]. Limiting questions to the three items identified in multivariable analyses—drinking sugared beverages, drinking them for 30 min or more and having unstructured meals—would further reduce the time required to identify those at high risk for dental caries.
While the study had several strengths including a large sample size that focused on adults, there were limitations. First, planned restorative treatments were used as a proxy measure of caries, as no diagnostic codes were available. Thus, procedure codes for planned restorative treatments were used to identify procedures often used to treat caries, but clearly, some of these restorations were planned for reasons other than caries, such as lost restorations, abrasion or for esthetics. In addition, some caries may have been planned for procedures not included in the list of codes extracted from the electronic health records. Additionally, the CRA was administered by a variety of student practitioners who were not calibrated, so that there was likely variation in how the questions were asked and responses recorded, with the possibility of misclassification of dietary question responses. The study was conducted at one dental school, during a defined period, and the findings may not be applicable to other dental schools, practice settings or to data obtained from a more recent time. Lastly, the CRA and caries diagnosis data were obtained at approximately the same time, so that only associations, and not causality, could be established. It should be noted that the original study design was to assess the CRA question responses' association with future caries treatment over a subsequent two‐year period; however, this study yielded muddled results, as only a portion of patients appeared for restorative appointments and completed any caries treatment.
Many previous studies have found dietary factors associated with caries, but these studies have often assessed sugar consumption via extensive food diaries or diet questionnaires, which are not practical in assessing caries risk in‐office [9, 10, 11]. This study demonstrated that a small number of dietary factors—notably sugar‐sweetened beverage consumption—are associated with caries. The results of the study suggest that specific dietary questions may be useful additions to new or existing CRA tools and may help to focus patient counseling and behavior change strategies [16]. However, more study is necessary to determine whether inclusion of dietary questions improves caries prediction of CRA tools when a variety of other factors are also considered. In addition, future studies should be conducted in different settings and with different populations should be conducted to confirm these findings. Finally, future studies may wish to investigate the impact of other dietary factors—both pathogenic and protective—that may be related to caries risk.
In conclusion, study results suggest that certain specific and focused questions on dietary practices posed as part of a CRA are strongly associated with caries. Thus, as CRAs evolve, specific questions on sugared beverage consumption, meal structure, and length of eating/drinking events should be included.
CONFLICT OF INTEREST STATEMENT
The authors declare no conflicts of interest.
APPENDIX A.
Caries Risk Assessment Tool.
Float Anchor Appendix A
| Contributing conditions | |||
|---|---|---|---|
| Fluoride Exposure (drinking water, tooth brushing frequency/toothpaste use, rinse, gel) | No | Yes | |
| Dental Home – established patient of record, receiving regular dental care | No | Yes | |
| General Health Conditions (from health history on AxiUm and today's update) | |||
| Special Health Care Needs | No | Yes | |
| Chemotherapy/Radiation Therapy | No | Yes | |
| Eating Disorders | No | Yes | |
| Drug/Alcohol Abuse | No | Yes | |
| Smokeless Tobacco Use or Vaping | No | Yes | |
| Xerostomic Medications | No | Yes | |
| Dietary Factors | |||
| How many meals do you usually eat per day? | 3 or less | > 3 | |
| How many snacks? | 3 or less | > 3 | |
| Are your meals/snacks: Structured (same time each day) Not Structured (on and off – grazing) | |||
| Do you drink sugared beverages (juice, carbonated or non‐carbonated soft drinks, energy drinks) daily? | No | Yes | |
| If yes, > 20 ounces per day? | No | Yes | |
| If yes, do you drink beverages for more than 30 minutes? | No | Yes | |
| Do you eat sugared candy or medicated lozenges each day? | No | Yes | |
| Clinical Conditions | |||
| Active cavitated or Incipient Caries or Restorations (past 36 months): Low (none) Moderate (1, 2) High (3+) | |||
| Teeth Missing Due to Caries in past 36 months | No | Yes | |
| Plaque Index ≥1.0 | No | Yes | |
| Severe Dry Mouth | No | Yes | |
| Exposed Root Surfaces Present | No | Yes | |
| Interproximal Restorations | No | Yes | |
| Dental/Orthodontic Appliances | No | Yes | |
| Restorations with Overhangs, Open Margins or Open Contacts | No | Yes | |
Delaney C, Warren J, Rysavy OA, Marshall T. Dietary questions in caries risk assessment and their relationship to caries. J Public Health Dent. 2025;85(2):197–202. 10.1111/jphd.12647
REFERENCES
- 1. Centers for Disease Control and Prevention . Oral Health Surveillance Report: Trends in Dental Caries and Sealants, Tooth Retention, and Edentulism, United States, 1999–2004 to 2011–2016. Atlanta, GA: centers for disease control and prevention, US Dept of Health and Human Services 2019.
- 2. Cagetti MG, Bonta G, Cocco F, Lingstrom P, Strohmenger L, Campus G. Are standardized caries risk assessment models effective in assessing actual caries status and future caries increment? A systematic review. BMC Oral Health. 2018;18:1–10. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3. Sheiham A, James WPT. Diet and dental caries: the pivotal role of free sugars reemphasized. J Dent Res. 2015;94(10):1341–1347. [DOI] [PubMed] [Google Scholar]
- 4. Bratthall D, Hansel‐Petersson G, Stjernsward JR. Cariogram Manual—Internet Version 2.01. 2004. Accessed June 27, 2024. Available from: https://mau.app.box.com/s/pzbw506n8ll7gftp9l2yjb1nhpftzask
- 5. American Dental Association . ADA Caries Risk Assessment Form Completion Instructions. 2011. Accessed June 27, 2024. Available from: https://www.ada.org/‐/media/project/ada‐organization/ada/ada‐org/files/resources/public‐programs/give‐kids‐a‐smile/gkas_caries_risk_assessment_forms.pdf
- 6. Featherstone JDB, Crysal YO, Chaffee BW, Zhan L, Ramos‐Gomez FJ. An updated CAMBRA caries risk assessment tool for ages 0 to 5 years. J Cal Dent Assoc. 2019;47:37–47. [Google Scholar]
- 7. Featherstone JDB, Crystal YO, Alston P, Chaffee BW, Doméjean S, Rechmann P, et al. Evidence‐based caries management for all ages—practical guidelines. Front Oral Health. 2021;2:657518. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8. Previser—Oral Health Information User Guide. 2024. Accessed June 27, 2024. Available from: https://www.previser.com/wp-content/uploads/2020/09/ClinicalSuite-v4-User-Documentation.pdf
- 9. Marshall TA, Levy SM, Broffitt B, Warren JJ, Eichenberger‐Gilmore JM, Burns TL, et al. Dental caries and beverage consumption in young children. Pediatrics. 2003;112(3):e184–e191. [DOI] [PubMed] [Google Scholar]
- 10. Karjalainen S, Söderling E, Sewón L, Lapinleimu H, Simell O. A prospective study on sucrose consumption, visible plaque and caries in children from 3 to 6 years of age. Community Dent Oral Epidemiol. 2001;29:136–142. [DOI] [PubMed] [Google Scholar]
- 11. Warren JJ, Weber‐Gasparoni K, Marshall TA, Drake DR, Dehkordi‐Vakil F, Dawson DV, et al. A longitudinal study of dental caries risk among very young low SES children. Community Dent Oral Epidemiol. 2008;37:116–122. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12. Heller KE, Burt BA, Eklund SA. Sugar soda consumption and dental caries in the United States. J Dent Res. 2001;80(10):1949–1953. [DOI] [PubMed] [Google Scholar]
- 13. Bernabé E, Vehkalahti MM, Sheiham A, Aromaa A, Souminen AL. Sugar‐sweetened beverages and dental caries in adults: a 4‐year prospective study. J Dent. 2014;42(8):952–958. [DOI] [PubMed] [Google Scholar]
- 14. Barrington G, Khan S, Kent K, Brennan DS, Crocombe LA, Bettiol S. Obesity, dietary sugar and dental caries in Australian adults. Int Dent J. 2019;69(5):383–391. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15. American Academy of Pediatric Dentistry . Guideline on Caries‐risk Assessment and Management for Infants, Children and Adolescents. 2023. Accessed July 6, 2023. Available from: https://www.aapd.org/globalassets/assets/1/7/use_of_cat-charts.pdf
- 16. Marshall TA. Dietary implications for dental caries—a practical approach on dietary counseling. Dent Clin N Am. 2019;63:595–605. [DOI] [PubMed] [Google Scholar]