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INTRODUCTION
Dental caries is an infectious-contagious disease, of a multifactorial nature resulting from the interaction of physical-chemical, biologic (saliva and teeth), behavioral (dietary habits, oral hygiene, lifestyle) and modulating factors (general health, socio-economic and educational levels)1-2.
Caries lesions have accompanied the human being since prehistoric times, an epoch in which the disease was characterized as being of low population impact in quantitative terms and severity2. Concomitant with the process of "civilization", an increase could be observed in the prevalence of the disease as a result of reduction in the consumption of complex carbohydrates and fibers and the introduction of a diet richer in fats, sugars and refined foods3. Thus, up to today, dental caries has been considered a serious public health problem2.
A balanced diet capable of providing an adequate nutritional status has certainly contributed to a desirable oral condition in an individual. Therefore, some dietary restrictions, or even the excess ingestion of some specific dietary components, may influence the processes of odontogenesis (dental formation), eruption and the development of caries disease4.
Dental caries is one of the diseases with the highest incidence in childhood and the hosts diet may be seen as a primary factor in determining susceptibility to the disease5. A study of the nutritional status of the Brazilian population indicates that children belonging to the rural stratum present a more unfavorable nutritional situation than those in the urban stratum, as a result of poorer living conditions6. Cross sectional studies conducted in various countries in the world have demonstrated that residing in rural areas is a predictive factor for the development of dental caries in childhood7-9.
The consumption of sweetened foods is influenced by a variety of biological, psychological, social and environmental factors. It has been suggested that there is a preference for sweets in populations with worse socioeconomic conditions10. Knowing the cariogenic power of fermentable carbohydrates, especially sugar, it makes it necessary to know the dietary habits of the population, in order to develop public policies, adopt efficient preventive methods, in addition to encouraging changes towards developing healthier habits11. Therefore, the aim of this study was to evaluate the preference for sugar and its association with the prevalence of caries in schoolchildren from 05 to 12 years of age at a municipal school in Sumaré (SP).
METHODS
Ethical aspects
This study was conducted in accordance with the precepts determined by resolution 196/96 of 10/10/96 of the National Health Council of the Ministry of Health, and approved by the Research Ethics Committee of the São Leopold Mandic School of Dentistry, Protocol Number 2010/0324.
Study population
The population of this study was 128 schoolchildren from 5 to 12 years of age, of both genders, enrolled at "Escola Municipal de Ensino Fundamental Rural Maria Aparecida de Jesus Segura" of the rural settlement II in the municipality of Sumaré-SP. The participants in this study were 96 schoolchildren of both genders (n=96), who presented the Term of Free and Informed Consent (TFIC) signed by the persons legally responsible for them. Volunteers who used fixed orthodontic appliances, presented difficulty in opening the mouth at the time of the exam, and reported a restriction on sugar consumption were excluded from the study. A pilot study was conducted with the researchers involved in the survey, to evaluate the degree of the children's discernment as regards the flavor of grape juice solutions with different concentrations of sugar.
Calibration
The calibration process began with a theoretical stage of four hours duration, which consisted of presentation of the criteria of the DMFS and dmf (decayed, missing, filled surfaces in permanent and primary dentition)12. Each type of criterion was presented by means of slides for the purposes of learning and discussion. After this, the chart that was used was presented, and the clinical exam routine was explained. Later a practical stage was conducted, with a clinical exam performed in 12 volunteers. The diagnostic reproducibility of the examiners was evaluated by Kappa Statistics, and in cases in which an agreement lower than 85% was observed, further training was implemented. To verify the oral health conditions, the DMFS and dmft indices were used, which evaluate the total number of decayed, missing and filled teeth for permanent and primary dentition, respectively, in accordance with the methodology recommended by the World Health Organization13. The data were collected and noted on the clinical chart prepared by the researchers themselves.
Test of preference for sugar
The test of preference for sugar was prepared in accordance with a modified version of the "Sweet Preference Inventory". For this test, sweetened grape juice products always of the same commercial brand were used, respecting the proportion determined by the manufacturer (1 portion of concentrated juice to 2 portions of water). The following five sucrose concentrations were used: Without the addition of sugar - 0 M (-g/liter); 0.15 M (10g/liter); 0.29 M (20g/liter); 0.44 M (30g/liter) and 0.59 M (40g/liter). To perform the test, after going through the clinical evaluation (survey of DMFS and dmft indices), each child received the juice in small disposable cups (containing 10 ml), at ambient temperature, in sequence by letters A, B, C, D, E, with cup marked with letter A being without the addition of sugar and the one with letter E that with the highest concentration of sugar. To "neutralize" the palate before all the tasting tests, the children ate a piece of "cream cracker" type of biscuit. Between one tasting test and the other, the child was asked which solution he/she preferred, and at the end of the test, the child pointed out the solution of his/her choice, which was noted on the child's chart. The sample was dichotomized as low preference for sugar (Solutions A, B, C, D) and high preference (Solution E). The participants who present urgent treatment needs were duly referred for dental treatment at the São Leopoldo Mandic School of Dentistry clinic, Campinas (SP).
The data were analyzed by the Chi-Square and Fisher Exact tests with the use of the BioEstat software program.
RESULTS
After data collection, it was observed that the solution with the highest sugar concentration (E) was the one preferred by the majority of the volunteers both of the male (n=36) and female (n=29) gender, however there was no association between gender and preference for sugar in the grape juice solutions, according to Table 1.
Table 1 Distribution of sample according to gender and grape juice solutions.
Note: Exact Fischer Test: p = 0.2150.
When associating gender and caries history, there was no statistically significant association, according to Table 2.
Table 2 Distribution of sample according to gender and caries history.
| Caries history | ||||
|---|---|---|---|---|
| Absent DMFS and dmf = 0) |
Present DMFS or dmf ≥ 1) |
|||
| Gender | n | % | n | % |
| Male | 13 | 59.1 | 34 | 46.0 |
| Female | 9 | 40.9 | 40 | 54.0 |
| Total | 22 | 100.0 | 74 | 100.0 |
Note: Chi-square Test: p = 0.2789.
Figure 1 illustrates the analysis between the association with low preference for sugar (A, B, C, D) and high preference (E) in the sample dichotomized for presence or absence of caries. For both caries history situations, the preference of the majority of the children was for high sugar concentration (history of absence of caries (n=21) and history of caries presence (n=64), without statistically significant association between the variables.
DISCUSSION
According to the International Sugar Organization14, the quantity of sucrose consumed in the Brazilian diet is 55 kg/person/year. The use of sugar in the Brazilian diet increased significantly over the last few decades. The mean consumption of this carbohydrate in the 1930s was 15 kilos/inhabitant/year, and rose to kilos/inhabitant/year in 1950, 40 kilos/inhabitant/year in 1950 and 50 kilos/inhabitant/year in 1990. At world level, Brazil consumes less only than India and the countries of the European Union15. According to the Family Budget Survey 2008-2009, the mean daily intake of total sugars underwent great variation between the age ranges, being higher in the group of adolescents of both sexes, ranging from 105.4 g to 113.1 g among boys and 106.8 g to 110.7 g among girls. In individuals of 60 years or older presented the lowest mean total sugar consumption. The mean daily total sugar consumption among adolescents was around 30% higher than it was among the elderly, being 15% to 18% higher among adults16.
In this study, the solution with the highest concentration of sugar (E) was the one preferred by the majority of the volunteers, irrespective of gender, a result differing from the findings of Honkala et al.17 and Nilsson & Holm18.
The taste pattern of preference for sweeter solutions, and consequently, higher sugar consumption has been related in the literature to higher levels of caries10,19. However, in this study, this association could not be observed.
In addition, no statistically significant differences were observed with regard to the caries index in relation to gender, in agreement with the findings of Amaral et al.20 and Barbosa et al.21.
The relationship between sugar consumption and dental caries is difficult to quantify, due to inherent limitations, such as the duration of exposure of the teeth to sugars affected by the variability of the patterns of consumption, prevalence of caries, influenced by diverse factors that are difficult to control, including the mineral content in the diet (fluoride, calcium, phosphorous), health care, oral hygiene habits and educational level22.
Although the majority of volunteers in this study opted for the sweeter juice (Juice E), no statistically significant association was observed between caries history and preference for sweeter substances, in agreement with the study of Brandão et al.23. In disagreement, however, with Neumann et al.24, who found a positive correlation. Nevertheless, a further investigation is suggested with regard to the consumption of fermentable carbohydrates and caries experience in this population, in order to seek new data related to behavioral and biologic factors involved in the process of dental caries disease formation.
The literature has shown a moderate relationship between sucrose intake and the increase in caries prevalence in the population7,25. According to Hoffmann et al.26, in 2002 in the city of Campinas (SP), the DMFS was 1.34 and the dmft = 1.68. In this study, the dental caries prevalence found in primary dentition was 3.16 and the DMFS 0.60.
Understanding dental caries as a multifactorial disease, the biologic, social and behavioral factors appear to be frequently associated with dental caries, and have shown to be easier to understand when the risk factors for this disease are studied27.
The relationship between sugar consumption and caries is much weaker in the modern era, due to the exposure to fluoride, than it used to be in pervious epochs. Controlling sugar consumption continues to be an important part in caries prevention, however, it is not the most relevant aspect28.
