Abstract
BACKGROUND/OBJECTIVES
Adolescence is a critical period for developing healthy oral habits and preserving permanent teeth, which largely determine oral health throughout life. This study investigated the association between water intake and oral disease-related symptoms among Korean adolescents based on sugar-sweetened beverages (SSB) consumption.
SUBJECTS/METHODS
The Korea Youth Risk Behavior Web-based Survey (18th to 20th) was used, and 159,383 adolescents were analyzed in this study. Daily water intake was categorized as ≤ 2, 3–4, or ≥ 5 cups/day whereas SSB consumption was categorized as 0, 1–2, 3–4, or ≥ 5 times/week. Oral disease-related symptoms include tooth fractures, tooth pain during drinking or eating, aching or throbbing toothache, and gingival bleeding. Stratified analyses, adjusted for sociodemographic, health behavior, and dietary behavior variables, were performed to estimate adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for oral disease-related symptoms according to their daily water intake within each SSB consumption category, using the ≥ 5 cups/day group as a reference.
RESULTS
Compared with adolescents with the highest water intake, those with the lowest water intake had higher odds of at least one oral disease-related symptom when they consumed SSB 1–2 times/week (aOR, 1.134; 95% CI, 1.065–1.207; P < 0.001) or 3–4 times/week (aOR, 1.107; 95% CI, 1.044–1.174; P = 0.002). However, no significant differences were observed among those who consumed SSB 0 times/week and ≥ 5 times/week.
CONCLUSION
Low water intake was associated with a higher prevalence of at least one oral disease-related symptom among Korean adolescents consuming SSB 1–4 times per week. Further research using objective oral health outcomes (e.g., actual caries treatment) is needed to better clarify the association between water intake, SSB consumption and oral health.
Keywords: Water, oral health, adolescent, sugar-sweetened beverages, Republic of Korea
INTRODUCTION
Adolescence is characterized by rapid physical, emotional, and social changes [1]. Health behaviors established during this period substantially influence overall health and quality of life across the lifespan [2]. Oral health constitutes an integral component of general health and is associated with chronic diseases in adulthood [3,4]. Tooth loss in adulthood and later life commonly results from dental caries and periodontal disease that originate during adolescence [3,5]. Establishing appropriate oral health behaviors at this stage is therefore critical. However, the Korean Children’s Oral Health Survey (2024) reported a 60.3% prevalence of permanent tooth decay among middle school-aged children [6]. Additionally, the 2021 Korea Youth Risk Behavior Survey indicated that 48.8% of Korean adolescents experienced at least one oral disease symptom [7].
The oral health symptoms of adolescents are largely influenced by dietary behaviors, such as skipping breakfast, consuming fruits, and frequent consumption of sweet drinks and fast food [8,9]. In particular, sugar-sweetened beverages (SSB) have been extensively recognized as important risk factors for dental caries because they promote acid production that demineralizes the dental enamel [10,11,12,13]. Considering that processed foods, especially beverages, are the major sources of sugar intake among adolescents aged 12–18 yrs, according to the Korea National Health and Nutrition Examination Survey [14], strategies to alleviate oral symptoms or improve oral health associated with SSB consumption are warranted. Furthermore, because SSB consumption often replaces water intake, both beverage consumption behaviors should be considered together when evaluating their associations with oral health [15].
Water comprises a substantial proportion of the human body and is essential for maintaining physiological homeostasis [16]. Because the body cannot store water, routine daily losses must be replenished to sustain normal biological function [17,18]. Insufficient water intake may lead to dehydration, resulting in xerostomia, oral discomfort, and reduced salivary secretion. Decreased saliva weakens its protective functions, increasing susceptibility to oral diseases [19,20]. Saliva plays a central role in buffering acids, stabilizing oral pH, and protecting oral soft tissues; reduced secretion compromises these defenses and facilitates the development of dental caries [21,22]. Conversely, adequate water intake enhances salivary lubrication and supports oral self-cleansing thereby lowering exposure to cariogenic substrates [23,24].
The associations between oral health and SSB consumption [13], dental caries or erosion due to frequent SSB consumption [10], oral health outcomes and water intake [25] have been previously reported. Although adolescence is a critical period for developing healthy oral habits and preserving permanent teeth, which largely determine oral health throughout life, few studies have investigated the association between water intake and oral health in adolescents according to their level of SSB consumption. Considering the beneficial effects of water on dental health, preventive strategies that incorporate nutritional education on SSB consumption and adequate water intake may help improve oral health. Therefore, this study investigated the association between water intake and oral health in Korean adolescents based on SSB consumption.
SUBJECTS AND METHODS
Data source and study population
This study used data from the 18th to 20th Korea Youth Risk Behavior Web-based Survey (KYRBS; 2022–2024), a nationally representative cross-sectional survey of Korean adolescents conducted annually since 2005 by the Ministry of Education, the Ministry of Health and Welfare, and the Korea Disease Control and Prevention Agency. The KYRBS uses a stratified cluster sampling design to obtain a representative sample, selecting 400 middle and 400 high schools annually. Health information is collected through an anonymous, self-administered online questionnaire. Participation rates were 92.2% (51,850) in 2022, 92.9% (52,880) in 2023, and 94.9% (54,653) in 2024, yielding a total of 159,383 adolescents included in the analysis. The KYRBS is a government-approved national survey (approval No. 117058) and has been exempt from Institutional Review Board review since 2015 under the Enforcement Rule of the Bioethics and Safety Act. This study conducted a secondary analysis of data obtained under the approved protocol.
Water intake assessment
Water intake was assessed using the question: “In the past 7 days, how often did you drink water, including bottled water, carbonated water, or barley tea, per day?” One cup was defined as 200 mL. According to the 2020 Dietary Reference Intakes for Koreans [26], the recommended daily intake of plain water for adolescents aged 12–18 yrs is 610–920 mL. To examine differences in oral health according to water intake, participants were categorized into three groups: ≤ 2 cups/day (≤ 400 mL/day; low intake), 3–4 cups/day (600–800 mL/day; moderate intake), and ≥ 5 cups/day (≥ 1,000 mL/day; high intake).
Oral health characteristics
Oral health was assessed using four questions asking whether participants had experienced the following in the past 12 mon: 1) a cracked or broken tooth, 2) tooth pain when consuming hot or cold foods or beverages, 3) a sore, throbbing, or painful tooth, and 4) sore or bleeding gums. These were defined as oral disease-related symptoms: 1) tooth fracture, 2) tooth pain during drinking or eating, 3) aching or throbbing toothache, and 4) gingival bleeding. Participants who answered “yes” to a specific item were considered to have that symptom. Those who responded “yes” to at least one of the four items were classified as having oral disease-related symptom.
Dietary behavior characteristics
Dietary behaviors were assessed using four questions on the frequency of the following behaviors during the past seven days: 1) eating breakfast (excluding only milk or juice), 2) eating fruit (excluding fruit juice), 3) drinking SSB, and 4) eating fast food. Breakfast consumption was categorized as 0, 1–2, 3–4, or 5–7 days/week. Fruit intake, SSB consumption, and fast food intake were categorized as 0, 1–2, 3–4, or ≥ 5 times/week.
Other variables
Sociodemographic variables included sex (male or female), school level (middle or high school), residential area (rural area, city, or metropolis), subjective academic achievement (high, middle, or low), subjective household economic status (high, middle, or low), family type (living with family or living with others), and parental education. Paternal and maternal education were assessed separately and categorized as college or above, high school, middle school or less, do not know, or no parents. Health behavior variables included subjective health status, physical activity, body mass index (BMI), weight control effort, current drinking, current smoking, drug use, experience of violence, daily tooth brushing frequency, and tooth brushing after lunch. Subjective health status was categorized as good, normal, or poor. Physical activity was classified as ≤ 4 days/week (no) or ≥ 5 days/week (yes). BMI was classified according to the 2017 Korean National Growth Charts using age- and sex-specific BMI percentile thresholds [27]. Participants were categorized as underweight (< 5th percentile), normal (≥ 5th to < 85th percentile), overweight (≥ 85th to < 95th percentile), or obesity (≥ 95th percentile). Weight control effort was classified as no effort or effort to control weight (including attempts to lose, gain, or maintain weight). Current drinking, current smoking, drug use, and experience of violence were classified as yes or no. Daily toothbrushing frequency was categorized as ≤ 1 time/day, 2 times/day, or ≥ 3 times/day. Toothbrushing after lunch was categorized as always, usually, sometimes, or never.
Statistical analyses
All analyses incorporated sampling weights and complex survey design variables. The Rao–Scott χ2 test assessed differences in covariates across levels of daily water intake. Logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for the association between daily water intake and oral disease-related symptoms, using the ≥ 5 cups/day group as the reference. Following KYRBS guidelines, models were sequentially adjusted for sociodemographic, health behavior, and dietary behavior variables. Covariates including age, sex, school level, city size, subjective academic achievement, subjective household economic status, paternal education, maternal education, subjective health status, physical activity, BMI, frequency of tooth brushing (daily), frequency of tooth brushing (after lunch), breakfast, fruit, and fast food were selected based on a previous study [28]. Family type was also included as a covariate because family structure influences adolescents’ eating habits and beverage choices, as well as oral health behaviors and outcomes, indicating its potential role as a confounding factor in the association between water intake and oral health outcomes [29,30]. SSB consumption was further adjusted for in the overall analysis but was excluded from the stratified models because it was used as the stratification variable. All analyses were performed using IBM SPSS Statistics for Mac (version 30.0; IBM Corp., Armonk, NY, USA). Statistical significance was defined as a 2-sided P-value < 0.05.
RESULTS
Sociodemographic characteristics of participants according to water intake groups
Table 1 summarizes sociodemographic characteristics of the participants according to their daily water intake. Among the 159,383 adolescents included, 22.2% consumed ≤ 2 cups/day, 40.3% consumed 3–4 cups/day, and 37.5% consumed ≥ 5 cups/day. The mean age of the participants was 15.1 yrs. Of the participants, 51.5% were male, and 48.5% were female, with 51.0% in middle school and 49.0% in high school. The highest proportion of adolescents reporting high subjective academic achievement was observed in the 3–4 cups/day group (39.7%), followed by the ≥ 5 cups/day group (38.8%). Low academic achievement was most prevalent in the ≤ 2 cups/day group (35.3%). Similarly, high subjective household economic status was most common in the ≥ 5 cups/day group (46.1%), whereas low economic status was most frequent in the ≤ 2 cups/day group (12.6%). Living with family was reported most often in the 3–4 cups/day group (96.2%), followed by the ≥ 5 cups/day group (96.1%), and least often in the ≤ 2 cups/day group (94.5%).
Table 1. Sociodemographic characteristics of participants based on the daily water intake.
| Variables | Total (n = 159,383) | Daily water intake | P-value1) | |||
|---|---|---|---|---|---|---|
| ≤ 2 cups (n = 35,620) | 3–4 cups (n = 63,903) | ≥ 5 cups (n = 59,860) | ||||
| Weighted % | 100 | 22.2 (0.2) | 40.3 (0.1) | 37.5 (0.2) | ||
| Age (yrs) | 15.1 (0.0) | 15.3 (0.0) | 15.1 (0.0) | 15.0 (0.0) | < 0.001 | |
| Sex | < 0.001 | |||||
| Male | 51.5 (0.6) | 32.5 (0.6) | 49.9 (0.7) | 64.6 (0.6) | ||
| Female | 48.5 (0.6) | 67.5 (0.6) | 50.1 (0.7) | 35.4 (0.6) | ||
| School level | < 0.001 | |||||
| Middle school | 51.0 (0.4) | 46.2 (0.5) | 51.4 (0.5) | 53.5 (0.5) | ||
| High school | 49.0 (0.4) | 53.8 (0.5) | 48.6 (0.5) | 46.5 (0.5) | ||
| City size | < 0.001 | |||||
| Rural area | 5.6 (0.3) | 6.1 (0.3) | 5.6 (0.3) | 5.3 (0.3) | ||
| Cities | 53.1 (0.5) | 53.8 (0.6) | 53.1 (0.5) | 52.7 (0.5) | ||
| Metropolis | 41.3 (0.4) | 40.0 (0.5) | 41.3 (0.5) | 42.1 (0.5) | ||
| Subjective academic achievement | < 0.001 | |||||
| High | 38.4 (0.2) | 35.3 (0.3) | 39.7 (0.2) | 38.8 (0.3) | ||
| Middle | 29.5 (0.1) | 29.4 (0.2) | 29.9 (0.2) | 29.0 (0.2) | ||
| Low | 32.2 (0.2) | 35.3 (0.3) | 30.4 (0.2) | 32.2 (0.2) | ||
| Subjective household economic status | < 0.001 | |||||
| High | 43.3 (0.2) | 39.2 (0.3) | 43.0 (0.3) | 46.1 (0.3) | ||
| Middle | 45.7 (0.2) | 48.2 (0.3) | 46.6 (0.3) | 43.1 (0.3) | ||
| Low | 11.0 (0.1) | 12.6 (0.2) | 10.4 (0.1) | 10.8 (0.1) | ||
| Family type | < 0.001 | |||||
| Living with family | 95.8 (0.1) | 94.5 (0.2) | 96.2 (0.2) | 96.1 (0.1) | ||
| Living with others | 4.2 (0.1) | 5.5 (0.2) | 3.8 (0.2) | 3.9 (0.1) | ||
| Paternal education | < 0.001 | |||||
| College or above | 60.0 (0.3) | 59.3 (0.4) | 60.8 (0.4) | 59.6 (0.4) | ||
| High school | 18.0 (0.2) | 17.6 (0.3) | 17.7 (0.2) | 18.6 (0.2) | ||
| Middle school or less | 1.0 (0.0) | 1.2 (0.1) | 1.0 (0.0) | 1.0 (0.0) | ||
| Do not know | 16.9 (0.2) | 17.3 (0.2) | 16.7 (0.2) | 16.8 (0.2) | ||
| No father | 4.0 (0.1) | 4.6 (0.1) | 3.8 (0.1) | 3.9 (0.1) | ||
| Maternal education | < 0.001 | |||||
| College or above | 60.0 (0.3) | 59.1 (0.4) | 60.8 (0.3) | 59.7 (0.4) | ||
| High school | 20.3 (0.2) | 20.7 (0.3) | 19.9 (0.2) | 20.5 (0.2) | ||
| Middle school or less | 0.9 (0.0) | 1.1 (0.1) | 0.8 (0.0) | 0.8 (0.0) | ||
| Do not know | 16.0 (0.2) | 16.0 (0.2) | 15.9 (0.2) | 16.2 (0.2) | ||
| No mother | 2.8 (0.1) | 3.1 (0.1) | 2.6 (0.1) | 2.8 (0.1) | ||
Values are presented as weighted means ± SE or weighted percentages (SE). All estimates were derived using complex sample analysis with integrated sample weights to ensure representativeness of the Korean population.
1)P-values were calculated using survey-weighted analysis of variance for continuous variables and the Rao–Scott χ2 test for categorical variables.
Health behavior characteristics of participants according to water intake groups
Table 2 indicates that all health behavior variables differed significantly across water intake groups. Good subjective health status was most frequently reported in the ≥ 5 cups/day group (69.1%), whereas poor health was most common in the ≤ 2 cups/day group (12.1%). Physical activity was lowest in the ≤ 2 cups/day group (7.9%) and highest in the ≥ 5 cups/day group (26.2%). Underweight was most prevalent in the ≤ 2 cups/day group (12.8%), whereas obesity was most common in the ≥ 5 cups/day group (17.1%). Attempts at weight control were least common in the ≤ 2 cups/day group (45.4%) and most common in the ≥ 5 cups/day group (58.4%). Alcohol consumption (12.4%) and smoking (4.9%) were highest in the ≥ 5 cups/day group, whereas drug use was most prevalent in the ≤ 2 cups/day group (1.7%). Oral hygiene behaviors also varied by water intake. Brushing once or less per day was most common in the ≤ 2 cups/day group (12.8%), whereas brushing three or more times per day was most frequent in the ≥ 5 cups/day group (43.4%). The proportion of those who never brushed after lunch was highest in the ≤ 2 cups/day group (16.4%). In contrast, always brushing after lunch was most common in the 3–4 cups/day group (58.0%), followed by the ≥ 5 cups/day group (57.7%).
Table 2. Health behaviors of participants based on the daily water intake.
| Variables | Total | Daily water intake | P-value1) | |||
|---|---|---|---|---|---|---|
| ≤ 2 cups | 3–4 cups | ≥ 5 cups | ||||
| Subjective health status | < 0.001 | |||||
| Good | 65.0 (0.2) | 57.8 (0.3) | 65.2 (0.2) | 69.1 (0.2) | ||
| Normal | 25.3 (0.1) | 30.1 (0.3) | 25.6 (0.2) | 22.3 (0.2) | ||
| Poor | 9.7 (0.1) | 12.1 (0.2) | 9.3 (0.1) | 8.6 (0.1) | ||
| Physical activity | < 0.001 | |||||
| No | 83.1 (0.1) | 92.1 (0.2) | 86.7 (0.2) | 73.8 (0.2) | ||
| Yes | 16.9 (0.1) | 7.9 (0.2) | 13.3 (0.2) | 26.2 (0.2) | ||
| Body mass index | < 0.001 | |||||
| Underweight | 8.3 (0.1) | 12.8 (0.2) | 8.5 (0.1) | 5.5 (0.1) | ||
| Normal | 70.2 (0.1) | 74.1 (0.2) | 71.9 (0.2) | 66.1 (0.2) | ||
| Overweight | 9.2 (0.1) | 6.4 (0.1) | 8.9 (0.1) | 11.3 (0.1) | ||
| Obesity | 12.2 (0.1) | 6.7 (0.1) | 10.7 (0.1) | 17.1 (0.2) | ||
| Weight control effort | < 0.001 | |||||
| No | 47.2 (0.1) | 54.6 (0.3) | 48.3 (0.2) | 41.6 (0.2) | ||
| Yes | 52.8 (0.1) | 45.4 (0.3) | 51.7 (0.2) | 58.4 (0.2) | ||
| Current drinking | < 0.001 | |||||
| No | 88.9 (0.1) | 89.7 (0.2) | 89.7 (0.2) | 87.6 (0.2) | ||
| Yes | 11.1 (0.1) | 10.3 (0.2) | 10.3 (0.2) | 12.4 (0.2) | ||
| Current smoking | < 0.001 | |||||
| No | 96.0 (0.1) | 96.6 (0.1) | 96.6 (0.1) | 95.1 (0.1) | ||
| Yes | 4.0 (0.1) | 3.4 (0.1) | 3.4 (0.1) | 4.9 (0.1) | ||
| Drug use | < 0.001 | |||||
| No | 98.6 (0.0) | 98.3 (0.1) | 98.7 (0.0) | 98.6 (0.1) | ||
| Yes | 1.4 (0.0) | 1.7 (0.1) | 1.3 (0.0) | 1.4 (0.1) | ||
| Experience of violence | 0.002 | |||||
| No | 97.7 (0.0) | 97.6 (0.1) | 97.8 (0.1) | 97.6 (0.1) | ||
| Yes | 2.3 (0.0) | 2.4 (0.1) | 2.2 (0.1) | 2.4 (0.1) | ||
| Frequency of tooth brushing (daily) | < 0.001 | |||||
| ≤ 1 time | 10.2 (0.1) | 12.8 (0.2) | 10.0 (0.1) | 8.8 (0.1) | ||
| 2 times | 50.4 (0.2) | 52.5 (0.3) | 51.5 (0.2) | 47.8 (0.2) | ||
| ≥ 3 times | 39.4 (0.2) | 34.6 (0.3) | 38.5 (0.3) | 43.4 (0.3) | ||
| Frequency of tooth brushing (after lunch) | < 0.001 | |||||
| Never | 15.1 (0.2) | 16.4 (0.3) | 14.7 (0.3) | 14.7 (0.2) | ||
| Sometimes | 10.3 (0.1) | 10.6 (0.2) | 10.2 (0.2) | 10.2 (0.1) | ||
| Usually | 17.1 (0.1) | 16.4 (0.2) | 17.1 (0.2) | 17.4 (0.2) | ||
| Always | 57.6 (0.3) | 56.6 (0.4) | 58.0 (0.4) | 57.7 (0.3) | ||
Values are presented as weighted means ± SE or weighted percentages (SE). All estimates were derived using complex sample analysis with integrated sample weights to ensure representativeness of the Korean population.
1)P-values were calculated using the Rao–Scott χ2 test for categorical variables.
Dietary behavior characteristics of participants according to water intake groups
As shown in Table 3, all dietary behaviors differed significantly across water intake groups. Adolescents in the ≤ 2 cups/day group exhibited the highest proportions reporting no breakfast consumption (27.3%) and no fruit intake (12.9%). This group also had the highest proportions consuming SSB (37.0%) and fast food (6.5%) five or more times per week. In contrast, adolescents in the ≥ 5 cups/day group had the highest proportions consuming breakfast (47.2%) and fruit (29.5%) five or more times per week. This group also had the highest proportions reporting no consumption of SSB (7.7%) and fast food (16.7%).
Table 3. Dietary behaviors of participants based on the daily water intake.
| Variables | Total | Daily water intake | P-value1) | |||
|---|---|---|---|---|---|---|
| ≤ 2 cups | 3–4 cups | ≥ 5 cups | ||||
| Breakfast (weekly) | < 0.001 | |||||
| No | 24.0 (0.1) | 27.3 (0.3) | 22.9 (0.2) | 23.3 (0.2) | ||
| 1–2 times | 16.8 (0.1) | 18.3 (0.2) | 16.9 (0.1) | 15.8 (0.2) | ||
| 3–4 times | 14.2 (0.1) | 14.4 (0.2) | 14.5 (0.1) | 13.7 (0.1) | ||
| ≥ 5 times | 45.0 (0.2) | 40.0 (0.3) | 45.7 (0.2) | 47.2 (0.3) | ||
| Fruit (weekly) | < 0.001 | |||||
| No | 11.5 (0.1) | 12.9 (0.2) | 10.5 (0.1) | 11.6 (0.1) | ||
| 1–2 times | 32.6 (0.1) | 34.9 (0.3) | 32.7 (0.2) | 31.1 (0.2) | ||
| 3–4 times | 28.0 (0.1) | 26.0 (0.2) | 29.3 (0.2) | 27.8 (0.2) | ||
| ≥ 5 times | 27.9 (0.2) | 26.2 (0.3) | 27.5 (0.2) | 29.5 (0.2) | ||
| Sugar-sweetened beverages (weekly) | < 0.001 | |||||
| No | 6.3 (0.1) | 5.0 (0.1) | 5.6 (0.1) | 7.7 (0.1) | ||
| 1–2 times | 29.5 (0.1) | 26.0 (0.3) | 30.0 (0.2) | 31.0 (0.2) | ||
| 3–4 times | 33.3 (0.1) | 32.1 (0.3) | 34.8 (0.2) | 32.5 (0.2) | ||
| ≥ 5 times | 30.9 (0.1) | 37.0 (0.3) | 29.6 (0.2) | 28.8 (0.2) | ||
| Fast food (weekly) | < 0.001 | |||||
| No | 15.8 (0.1) | 16.4 (0.2) | 14.7 (0.1) | 16.7 (0.2) | ||
| 1–2 times | 56.4 (0.1) | 55.3 (0.3) | 57.5 (0.2) | 56.0 (0.2) | ||
| 3–4 times | 21.9 (0.1) | 21.8 (0.2) | 22.4 (0.2) | 21.4 (0.2) | ||
| ≥ 5 times | 5.8 (0.1) | 6.5 (0.1) | 5.3 (0.1) | 5.9 (0.1) | ||
Values are presented as weighted means ± SE or weighted percentages (SE). All estimates were derived using complex sample analysis with integrated sample weights to ensure representativeness of the Korean population.
1)P-values were calculated using the Rao–Scott χ2 test for categorical variables.
Oral disease-related symptoms of participants according to water intake groups
Table 4 shows significant differences in all oral disease-related symptoms across water intake groups. Tooth fracture was lowest in the 3–4 cups/day group (9.7%), and highest in both the ≤ 2 cups/day and ≥ 5 cups/day groups (10.6%). For tooth pain during drinking or eating, aching or throbbing toothache, and gingival bleeding, the ≤ 2 cups/day group consistently had the highest prevalence (36.8%, 25.9%, and 21.8%, respectively), whereas the ≥ 5 cups/day group had the lowest (31.8%, 20.1%, and 18.3%, respectively). A similar pattern was observed for having at least one oral disease-related symptom, with prevalence highest in the ≤ 2 cups/day group (52.3%) and lowest in the ≥ 5 cups/day group (45.3%).
Table 4. Association between the presence of symptoms of poor oral health and the frequency of daily water intake.
| Variables | Total | Daily water intake | P-value1) | |||
|---|---|---|---|---|---|---|
| ≤ 2 cups | 3–4 cups | ≥ 5 cups | ||||
| Tooth fracture | < 0.001 | |||||
| No | 89.8 (0.1) | 89.4 (0.2) | 90.3 (0.1) | 89.4 (0.1) | ||
| Yes | 10.2 (0.1) | 10.6 (0.2) | 9.7 (0.1) | 10.6 (0.1) | ||
| Tooth pain during drinking or eating | < 0.001 | |||||
| No | 66.2 (0.1) | 63.2 (0.3) | 66.0 (0.2) | 68.2 (0.2) | ||
| Yes | 33.8 (0.1) | 36.8 (0.3) | 34.0 (0.2) | 31.8 (0.2) | ||
| Aching or throbbing toothache | < 0.001 | |||||
| No | 77.8 (0.1) | 74.1 (0.2) | 77.8 (0.2) | 79.9 (0.2) | ||
| Yes | 22.2 (0.1) | 25.9 (0.2) | 22.2 (0.2) | 20.1 (0.2) | ||
| Gingival bleeding | < 0.001 | |||||
| No | 80.4 (0.1) | 78.2 (0.2) | 80.4 (0.2) | 81.7 (0.2) | ||
| Yes | 19.6 (0.1) | 21.8 (0.2) | 19.6 (0.2) | 18.3 (0.2) | ||
| Oral disease-related symptom ≥ 1 | < 0.001 | |||||
| No | 51.8 (0.2) | 47.7 (0.3) | 51.2 (0.2) | 54.7 (0.2) | ||
| Yes | 48.2 (0.2) | 52.3 (0.3) | 48.8 (0.2) | 45.3 (0.2) | ||
Values are presented as weighted means ± SE or weighted percentages (SE). All estimates were derived using complex sample analysis with integrated sample weights to ensure representativeness of the Korean population.
1)P-values were calculated using the Rao–Scott χ2 test for categorical variables.
ORs for oral health outcomes depending on water intake and SSB consumption
Table 5 presents the ORs and 95% CIs for oral disease-related symptoms by water intake, with ≥ 5 cups/day serving as the reference group. In the fully adjusted model, the 3–4 cups/day group had lower odds of tooth fracture (adjusted OR [aOR], 0.955; 95% CI, 0.913–0.999), whereas the ≤ 2 cups/day group did not differ significantly (aOR, 1.008; 95% CI, 0.956–1.063). For tooth pain during drinking or eating and aching or throbbing toothache, aORs increased as water intake decreased, with statistically significant associations observed in both the 3–4 cups/day group (aOR, 1.033; 95% CI, 1.004–1.064 and aOR, 1.036; 95% CI, 1.003–1.070, respectively) and the ≤ 2 cups/day group (aOR, 1.079; 95% CI, 1.042–1.117 and aOR, 1.102; 95% CI, 1.061–1.145, respectively). For gingival bleeding, no statistically significant association with water intake was observed after full adjustment (3–4 cups/day: aOR, 1.020; 95% CI, 0.987–1.054; ≤ 2 cups/day: aOR, 1.038; 95% CI, 0.998–1.079). For having at least one oral disease-related symptom, aORs increased as water intake decreased (3–4 cups/day: aOR, 1.045; 95% CI, 1.017–1.074; ≤ 2 cups/day: aOR, 1.083; 95% CI, 1.048–1.120).
Table 5. ORs for oral disease symptoms by daily water intake in Korean adolescents.
| Model | Daily water intake | Oral disease-related symptoms | ||||
|---|---|---|---|---|---|---|
| Tooth fracture | Tooth pain during drinking or eating | Aching or throbbing toothache | Gingival bleeding | Oral disease-related symptom ≥ 1 | ||
| Unadjusted | ≥ 5 cups | 1 | 1 | 1 | 1 | 1 |
| 3–4 cups | 0.910 (0.876–0.944) | 1.108 (1.081–1.136) | 1.132 (1.102–1.164) | 1.092 (1.062–1.123) | 1.151 (1.125–1.177) | |
| ≤ 2 cups | 1.006 (0.964–1.050) | 1.251 (1.216–1.288) | 1.394 (1.351–1.438) | 1.248 (1.209–1.289) | 1.325 (1.289–1.362) | |
| P-value | < 0.001 | < 0.001 | < 0.001 | < 0.001 | < 0.001 | |
| Partially adjusted | ≥ 5 cups | 1 | 1 | 1 | 1 | 1 |
| 3–4 cups | 0.968 (0.926–1.013) | 1.071 (1.041–1.102) | 1.074 (1.040–1.108) | 1.043 (1.009–1.078) | 1.087 (1.057–1.116) | |
| ≤ 2 cups | 1.050 (0.996–1.107) | 1.171 (1.132–1.212) | 1.197 (1.153–1.243) | 1.096 (1.054–1.139) | 1.180 (1.142–1.220) | |
| P-value | 0.005 | < 0.001 | < 0.001 | < 0.001 | < 0.001 | |
| Fully adjusted | ≥ 5 cups | 1 | 1 | 1 | 1 | 1 |
| 3–4 cups | 0.955 (0.913–0.999) | 1.033 (1.004–1.064) | 1.036 (1.003–1.070) | 1.020 (0.987–1.054) | 1.045 (1.017–1.074) | |
| ≤ 2 cups | 1.008 (0.956–1.063) | 1.079 (1.042–1.117) | 1.102 (1.061–1.145) | 1.038 (0.998–1.079) | 1.083 (1.048–1.120) | |
| P-value | 0.044 | < 0.001 | < 0.001 | 0.171 | < 0.001 | |
Partially adjusted for age, sex, city size, school level, subjective academic achievement, subjective household economic status, family type, paternal education, maternal education, subjective health status, physical activity, and body mass index. Fully adjusted for the partially adjusted model plus the frequency of tooth brushing (daily), the frequency of tooth brushing (after lunch), breakfast, fruit, sugar-sweetened beverages, and fast food. Values are presented as odds ratio (95% confidence interval).
Stratified analyses were performed according to SSB consumption (Table 6). Among adolescents who did not consume SSB, water intake was not significantly associated with at least one oral disease-related symptom (P = 0.718). In contrast, among those consuming SSBs 1–2 times/week, lower water intake was associated with progressively higher odds of at least one oral disease-related symptom (3–4 cups/day: aOR, 1.070; 95% CI, 1.020–1.122; ≤ 2 cups/day: aOR, 1.134; 95% CI, 1.065–1.207) (P < 0.001). A similar pattern was observed among those consuming SSBs 3–4 times/week, with higher odds of at least one oral disease-related symptom (3–4 cups/day: aOR, 1.060; 95% CI, 1.011–1.112; ≤ 2 cups/day: aOR, 1.107; 95% CI, 1.044–1.174) (P = 0.002). However, among the heaviest SSB consumers (≥ 5 times/week), the association was attenuated and was no longer statistically significant (P = 0.657). The association was most consistent for tooth pain during drinking or eating, whereas no significant association was observed for tooth fracture and gingival bleeding. Regardless of SSB consumption, the lowest water intake (≤ 2 cups/day) was associated with higher odds of aching or throbbing toothache compared with the ≥ 5 cups/day serving as the reference group (0 times/week: aOR, 1.191; 95% CI, 1.002–1.417; P = 0.036; 1–2 times/week: aOR, 1.135; 95% CI, 1.053–1.222; P = 0.003; 3–4 times/week: aOR, 1.096; 95% CI, 1.024–1.173; P = 0.029; ≥ 5 times/week: aOR, 1.074; 95% CI, 1.006–1.146; P = 0.037).
Table 6. Fully adjusted ORs for oral health outcomes and water intake according to sugar-sweetened beverages consumption.
| Sugar-sweetened beverages consumption (weekly) | Daily water intake | Oral disease-related symptoms | ||||
|---|---|---|---|---|---|---|
| Tooth fracture | Tooth pain during drinking or eating | Aching or throbbing toothache | Gingival bleeding | Oral disease-related symptom ≥ 1 | ||
| 0 times | ≥ 5 cups | 1 | 1 | 1 | 1 | 1 |
| 3–4 cups | 1.119 (0.920–1.360) | 0.914 (0.810–1.031) | 0.961 (0.835–1.106) | 0.912 (0.788–1.057) | 0.964 (0.856–1.084) | |
| ≤ 2 cups | 1.054 (0.828–1.340) | 0.991 (0.858–1.145) | 1.191 (1.002–1.417) | 1.017 (0.851–1.216) | 1.015 (0.886–1.163) | |
| P-value | 0.530 | 0.313 | 0.036 | 0.361 | 0.718 | |
| 1–2 times | ≥ 5 cups | 1 | 1 | 1 | 1 | 1 |
| 3–4 cups | 0.963 (0.885–1.047) | 1.052 (0.999–1.108) | 1.078 (1.014–1.146) | 1.008 (0.947–1.074) | 1.070 (1.020–1.122) | |
| ≤ 2 cups | 1.014 (0.915–1.123) | 1.116 (1.045–1.192) | 1.135 (1.053–1.222) | 1.060 (0.982–1.144) | 1.134 (1.065–1.207) | |
| P-value | 0.508 | 0.004 | 0.003 | 0.286 | < 0.001 | |
| 3–4 times | ≥ 5 cups | 1 | 1 | 1 | 1 | 1 |
| 3–4 cups | 0.935 (0.867–1.009) | 1.055 (1.004–1.109) | 1.048 (0.993–1.107) | 1.055 (0.995–1.119) | 1.060 (1.011–1.112) | |
| ≤ 2 cups | 0.976 (0.890–1.070) | 1.104 (1.039–1.173) | 1.096 (1.024–1.173) | 1.089 (1.014–1.170) | 1.107 (1.044–1.174) | |
| P-value | 0.211 | 0.005 | 0.029 | 0.055 | 0.002 | |
| ≥ 5 times | ≥ 5 cups | 1 | 1 | 1 | 1 | 1 |
| 3–4 cups | 0.948 (0.877–1.024) | 1.012 (0.962–1.064) | 0.999 (0.943–1.058) | 0.990 (0.925–1.059) | 1.018 (0.968–1.070) | |
| ≤ 2 cups | 1.024 (0.938–1.118) | 1.039 (0.980–1.102) | 1.074 (1.006–1.146) | 1.011 (0.952–1.074) | 1.027 (0.969–1.088) | |
| P-value | 0.135 | 0.421 | 0.037 | 0.788 | 0.657 | |
Fully adjusted for age, sex, city size, school level, subjective academic achievement, subjective household economic status, family type, paternal education, maternal education, subjective health status, physical activity, body mass index, the frequency of tooth brushing (daily), the frequency of tooth brushing (after lunch), breakfast, fruit, and fast food. Values are presented as odds ratio (95% confidence interval).
DISCUSSION
This study demonstrated that adolescents with the lowest water intake exhibited consistently higher ORs for tooth pain during drinking or eating, even after adjustment for sociodemographic, health behavioral, and dietary factors. In contrast, tooth fracture and gingival bleeding showed different patterns. Tooth fracture is primarily related to external mechanical forces and trauma [31], whereas gingival bleeding is mainly associated with plaque accumulation and gingival inflammation [32]. Accordingly, these outcomes warrant separate consideration.
Regarding tooth fracture, when the ≥ 5 cups/day group was used as the reference, the 3–4 cups/day group had lower odds of tooth fracture in the fully adjusted model (P = 0.044). However, this finding should be interpreted with caution because statistical significance in a large sample size can arise even for very small effect sizes and clinical meaningfulness is negligible. Further stratified analyses depending on SSB consumption showed no consistent association in the ORs for tooth fracture and water intake levels. Tooth fracture is primarily related to traumatic events, such as falls and collisions [33] and is therefore less responsive to dietary exposure. Nevertheless, tooth fracture was included as an oral health outcome to provide a contrast with pain and sensitivity outcomes, which are plausibly associated with acid exposure and enamel demineralization, which may be mitigated by the buffering and rinsing effects of water.
Adolescents with lower water intake had higher aORs for tooth pain. This finding aligns with those of previous research linking inadequate hydration to an increased prevalence of tooth pain, a common symptom of dental caries [28,34]. Dental caries are driven by pathogenic bacteria, particularly Streptococcus mutans [35,36], and lower water intake has been associated with higher detection rates of S. mutans [37]. Water contributes to oral homeostasis by enhancing salivary secretion, improving natural tooth cleansing, and inhibiting cariogenic bacterial growth [16,21,36]. Reduced water intake may decrease salivary flow and increase oral dryness, weakening saliva’s buffering and antimicrobial functions and promoting the proliferation of pathogenic microorganisms [22]. Lower water intake was also associated with higher consumption of SSB, consistent with prior studies [15,38]. High sucrose intake promotes acidogenic conditions in the oral cavity, accelerating dental caries development [39].
Notably, stratified analyses in this study demonstrated that low water intake was associated with higher odds of tooth pain during drinking or eating among adolescents consuming SSB 1–2 and 3–4 times/week, whereas no such association was observed among those consuming no SSB and SSB ≥ 5 times/week, indicating that this association was SSB-dependent. In contrast, an association between low water intake and higher odds of aching or throbbing toothache was observed regardless of SSB consumption level. Tooth pain during drinking or eating is a stimulus-evoked pain triggered by an external stimulus such as cold, hot, or sweet foods, or by chewing pressure. It usually disappears once the stimulus is removed, indicating an earlier stage of the disease [40]. In contrast, an aching or throbbing toothache is a persistent pain that occurs without an external trigger and lasts over time, indicating a more advanced stage of the disease [41].
Frequent consumption of SSB may increase repetitive acidogenic challenges, leading to tooth pain during the early stages of dental caries. Adequate water intake may attenuate this association by facilitating natural tooth cleansing and suppressing the growth of cariogenic bacteria, although its protective effect may no longer be sufficient when the cariogenic burden exceeds a certain threshold. In contrast, aching or throbbing toothache was significant even among non-SSB consumers and the heaviest consumers, indicating that adequate water intake may reduce toothache in the advanced stage of disease regardless of SSB exposure. A clinical study found that higher body hydration levels were associated with less pain during endodontic therapy, possibly because hydration supports efficient hemodynamic function and the circulatory system, thereby contributing to pain relief [42]. In particular, because adequate water intake may reduce tooth pain associated with the early stages of dental disease among adolescents with low-to-moderate SSB consumption, school-based education incorporating both water intake and SSB consumption is required to improve oral health.
No significant association was observed between water intake and gingival bleeding after full adjustment, consistent with previous findings [28]. However, other studies have suggested a potential association between lower water intake and higher prevalence of periodontal disease [34,43]. Dental plaque accumulation and poor oral hygiene are major risk factors for periodontal disease [32]. Inadequate oral hygiene promotes plaque accumulation, bacterial proliferation, and persistent biofilm formation [32,44]. The present study was limited in assessing detailed plaque-related factors and oral hygiene practices—such as plaque and calculus accumulation and interdental cleaning behaviors—that are closely associated with gingival bleeding [45,46]. The attenuated association after adjustment may therefore reflect residual confounding by unmeasured plaque- and hygiene-related factors. Further studies incorporating detailed clinical indicators of oral hygiene are needed to clarify the relationship between water intake and periodontal health among adolescents.
This study has several limitations. First, the validity of the water intake assessment in reflecting adolescents’ actual water consumption could not be fully established because intake was assessed using a cup-based measure (200 mL per cup), although the cup volume was based on the Korean Dietary Reference Intakes. Second, clinically assessed data, including the presence and number of dental caries, were unavailable because the KYRBS relies on self-reported symptoms. Moreover, the self-reported survey may have limited the validity and reliability of the oral health measures; for example, adolescents may have had difficulty differentiating between tooth pain during drinking or eating and aching or throbbing toothaches. Third, the water intake variable included not only plain water but also other beverages such as carbonated water and barley tea. Considering that carbonated water has a lower pH than plain water, which may cause dental erosion, the observed associations may reflect a combination of beneficial and adverse effects. Fourth, as this study used cross-sectional data, causal relationships cannot be established, and reverse causality is possible, as adolescents with oral pain or discomfort may reduce their water intake. Finally, although several associations were significant, the effect sizes were relatively small. Given the large sample size in this study, even modest differences may have reached statistical significance. Therefore, these findings, particularly regarding their clinical significance, should be interpreted with caution. Nevertheless, because the analyses were based on a large nationally representative sample of Korean adolescents, the findings may have important public health implications by identifying population-level associations that could inform oral health promotion strategies.
In conclusion, the association between low water intake and a higher prevalence of at least one oral disease-related symptom was observed among adolescents consuming SSB 1–4 times/week, whereas no such association was found among those consuming no SSB or SSB ≥ 5 times/week. These findings suggest that promoting water intake among adolescents with low-to-moderate SSB consumption may be important for improving oral health and highlight the need for school-based oral health promotion strategies incorporating both water intake and SSB consumption.
Footnotes
Conflict of Interest: The authors declare no potential conflicts of interests.
- Conceptualization: Hwang H, Lee JW.
- Formal analysis: Hwang H.
- Investigation: Hwang H.
- Methodology: Hwang H, Lee JW.
- Supervision: Koh J, Lee JW.
- Validation: Koh J, Lee JW.
- Writing - original draft: Hwang H.
- Writing - review & editing: Koh J, Lee JW.
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