Association of dental caries with social and nutritional factors in Brazilian schoolchildren

Associação da cárie dentária com fatores sociais e nutricionais em escolares brasileiros

Abstract

Background:  Dental caries is the oral disease that most affects children and is one of the most important diseases worldwide.

Objectives:  The aim of this study was to verify the association between dental caries, consumption of processed/ultra-processed foods, quantity and place of daily feeding, body mass index, and sociodemographic data in schoolchildren.

Method:  This cross-sectional study evaluated 358 students aged between 12 and 14 from public schools in a south Brazilian city. All students were clinically evaluated in order to verify the frequency and mean of dental caries, using the index score for decayed, missing, and filled teeth (DMFT). Weight and height were measured and classified using anthropometric indicators, according to the diagnosis of nutritional status. We applied a questionnaire including sociodemographic questions and others related to the food frequency of the diet, using the Food Frequency Questionnaire. Data were analyzed through descriptive, bivariate, and multiple analyses; crude and adjusted odds ratios and 95% confidence intervals were estimated in a binary logistic regression model (p<0.05).

Results:  The higher the quantity of processed and/or ultra-processed foods consumed per day (OR=1.09; 95%CI 1.03–1.14), the larger the consumption of meals daily (OR=1.26; 95%CI 1.01–1.58), the lower the monthly family income (OR=2.31; 95%CI 1.03–5.13), and the greater the chances of having dental caries.

Conclusions:  There was a positive association between experience of dental caries and higher consumption of processed and ultra-processed foods and a higher frequency of daily meals.

Keywords:
dental caries; food; diet; nutrition science; industrialized foods; eating; nutritional status; body mass index

Resumo

Introdução:  A cárie dentária é a doença bucal que mais afeta as crianças e é uma das doenças mais importantes a nível mundial.

Objetivos:  O objetivo deste estudo foi verificar a associação entre cáries dentárias, consumo de alimentos processados/ultraprocessados, quantidade e local de alimentação diária, índice de massa corporal e dados sociodemográficos em crianças em idade escolar.

Método:  Este estudo transversal avaliou 358 alunos com idades entre 12 e 14 anos de escolas públicas de uma cidade do sul do Brasil. Todos os alunos foram avaliados clinicamente para verificar a frequência e a média de cáries dentárias, utilizando o índice de dentes cariados, perdidos e obturados (CPOD). O peso e a altura foram medidos e classificados usando indicadores antropométricos, conforme o diagnóstico do estado nutricional. Foi aplicado um questionário incluindo perguntas sociodemográficas e outras relacionadas à frequência alimentar da dieta, utilizando o Questionário de Frequência Alimentar. Os dados foram analisados por meio de análises descritivas, bivariadas e múltiplas; razões de chances brutas e ajustadas e intervalos de confiança de 95% foram estimados em um modelo de regressão logística binária (p<0,05).

Resultados:  Quanto maior a quantidade de alimentos processados e/ou ultraprocessados consumidos por dia (OR=1,09; IC95% 1,03–1,14), maior o consumo de refeições diárias (OR=1,26; IC95% 1,01–1,58), menor a renda familiar mensal (OR=2,31; IC95% 1,03–5,13), e maiores as chances de ter cáries dentárias.

Conclusões:  Houve uma associação positiva entre a experiência de cáries dentárias e o maior consumo de alimentos processados e ultraprocessados, além da maior frequência de refeições diárias.

Palavras-chave:
cárie dentária; alimentos; dieta; ciências da nutrição; alimentos industrializados; ingestão de alimentos; estado nutricional; índice de massa corporal

INTRODUCTION

Despite the global decline in recent decades, dental caries remains a significant public health challenge in most countries. It is a multifactorial condition influenced by factors such as biofilm accumulation, exposure to sugars and fluorides, and biological and social factors¹. Dental caries is an oral disease, which primarily affects children and is among the top 10 most prevalent diseases worldwide². A recent systematic review reported that 9% of children globally have untreated caries, highlighting its significance as an international public health issue³.

Assessing an individual's nutritional status during childhood and adolescence is crucial for their growth and development⁴. Factors such as diet diversity, dietary habits, quality of information, age, body image, respondent's memory, beliefs, behavior, culture, and socioeconomic level, as well as exposure factors can complicate the evaluation of food intake⁵. The growth process of children and adolescents considers their hormonal, nutritional, and psychosocial factors and genetics. Deviation from this regular growth pattern may be the first manifestation of a wide variety of diseases, both endocrine and non-endocrine⁶. Therefore, carrying out a growth evaluation on a regular basis is of great value; after all, there are major changes in dietary habits that may be directly manifested in children's body composition⁷. Eating habits can also manifest as changes in the oral cavity of children, influencing the appearance of the most prevalent oral disease, dental caries. In the world, dental caries is the oral disease that most affects children and is one of the most important diseases. In the year 2016, dental caries was one of the ten causes with the highest prevalence among adults worldwide³.

Fruits and vegetables are important components for reducing the occurrence of non-communicable chronic diseases, such as cardiovascular diseases, diabetes, obesity, dental caries, periodontal diseases, and others, and the risk of mortality. They also prevent micronutrient deficiencies⁸. However, dietary habits based on fibers and nutrients have been exchanged for industrialized products with high fat and carbohydrate content, which facilitate the installation of these diseases⁸. They also have negative effects on immunity, growth, development, aging, and oral health. A classification of food consumption items was developed based on the extent and purpose of food processing, dividing consumption items into four groups: in natura or minimally processed foods; processed culinary ingredients; processed food products; and ultra-processed foods and drinks, according to Monteiro et al.⁹ Ultra-processed products are mainly industry formulations, which have been mostly or entirely made from ingredients with little or no whole-grain food, while processed products are whole foods preserved in salt, sugar, or oil⁹-¹¹.

The selection of an instrument to measure nutritional information should be based on several principles: study purpose, characteristic of the population to be studied, food and nutrients of interest, available resources, and study methodological design¹². It is based on the principle that the average intake analysis over a longer period (consumption of weeks, months, or years) conceptually responds to a more important exposure than the consumption of some specific days¹³. The Food Frequency Questionnaire (FFQ) is highly valued as a reference in validity studies, mainly because it relies less on the participant's memory¹⁴.

Dental caries in childhood and regular body weight deviation are two conditions that may be influenced by several predisposing factors, such as diet, socioeconomic condition, and lifestyle¹⁵, but it has not been fully defined yet.

The importance of this study is in food investigation, according to a classification that involves ultra-processed foods and their relation with dental caries. Such classification has been little evaluated in the association with oral diseases. In addition, some research on the association between dental caries, consumption of industrialized foods, and body mass index (BMI) also shows many contradictory results¹⁶.

Thus, this study aimed to verify the association between dental caries, consumption of processed and ultra-processed foods, the quantity and location of daily meals, BMI, and sociodemographic data in students from the city of Passo Fundo, Rio Grande do Sul, Brazil.

MATERIALS AND METHODS

The Research Ethics Committee of Faculty xxx, xxx under protocol 3,078,320 and CAEE 98405418.7.0000.5319 approved this study on December 12, 2018, following the standards of Resolution 466/12. All the research participants signed the free and informed consent form (ICF) and/or minor consent form. Informed consent was provided by the parent and/or legal guardian of students.

Study location

The research was carried out in xxx, a Brazilian municipality located at northwest of Rio Grande do Sul State in Brazil. It has 3,973 residents¹⁷. The field of education in this city develops educational and pedagogical actions, through the two Public Schools of Education, where the research was conducted.

Study design and population

The research consisted of a cross-sectional study with a quantitative approach. The population was non-probabilistic, based on the census, considering all students from 12 to 14 years old in two public schools in the city during the data collection period—February and March 2020. The number of students enrolled in the schools was 392 (total number of students). However, there was a loss of 8.6% (n=34) for refusing to participate in the research. This resulted in a sample of 358 students.

Inclusion and exclusion criteria

Inclusion criteria were male and female children and adolescents, aged between 12 and 14 years, from municipal and state schools in xxx. Children and adolescents who reported (by them or their guardians) neurological and genetic diseases, allergies, or food intolerances and students who were using orthodontic braces at the time of data collection were excluded from the survey; however, there were no such cases.

Instruments and procedures for data collection

Questionnaire application

The interview was made from a questionnaire conducted in the two city schools. Before any intervention in the students, the school principals were invited to clarify the procedures that would be performed, and then they both approved the research.

The students were invited to take part in the study through direct contact in the classrooms, and they received information about study objectives, voluntary and free character of participation, location, interview content, and duration. Subsequently, an ICF was sent to their guardians. Students received instructions on how to fill out the questionnaires, prior to their application.

Data collection included a questionnaire regarding demographic data and characterized the socioeconomic profile (gender, mother's educational level, and family income) and food diet.

Questions on food diet—FFQ—were designed to obtain qualitative, semiquantitative, or quantitative information on the food pattern and ingestion of specific foods or nutrients. It basically has two components: a list of foods and a field, in which the individual replies to the frequency of each food consumption¹⁸.

For this study, based on data from the classification of groups formed in the FFQ, which were answered by research participants, the authors regrouped foods and divided them into two new groups, following the classification of Monteiro et al.⁹. However, foods were united in two large groups. The first one consisted of all in natura and/or minimally processed foods and processed culinary ingredients: roots and tubers (rice, manioc, sweet potato, potato); greens and vegetables (lettuce, cabbage, cress/arugula, cauliflower, beet, carrot, kale, cucumber, tomato, pumpkin, chayote); fruits (avocado, pineapple, banana, orange, apple, papaya, melon, watermelon, mango, guava); dairy (whole milk); legumes (beans); meat and eggs (beef, chicken, fresh fish, pork, eggs). The second group consisted of all processed foods and ultra-processed foods and drinks: breads and cereals (pasta, cookies with and without stuffing, roll, cake, popcorn); dairy (yogurt, cheese and cream curd cheese, canned meat and fish, and sausages); oils and fats (mayonnaise, butter, oils); sugars and sweets (sugar, candies, sweets, chocolate); and miscellaneous (coffee, soda, juices, finger food, ice cream, soups, toasted manioc flour). Groups were named: in natura and minimally processed products; and processed and ultra-processed products.

Examiner calibration

A single examiner and a commenter performed oral clinical examinations. The examiner, who is a dentist, took specific training on dental caries (DMFT) for 12 h, based on a theoretical class, using the Calibration Guide for Examiners of SB2000 Project¹⁹. Then, 20 images were presented on slides that exhibited several conditions to be observed in the examinations (decayed teeth, filled teeth without and with caries, lost teeth, crown fractures, and unerupted teeth).

After the training session, the calibration itself was performed in 20 students aged 12 years, whose data were used for the evaluator's intra-examiner calibration, resulting in 90% weighted Kappa. For the anthropometric evaluation, measurements were performed by a nurse who is also trained on these measures. In the weighted Kappa test for intra-examiner concordance, the result was K=99%.

Oral clinical examinations

Clinical diagnosis was performed in the dental office that each school presents in its dependencies, with a reflective light and dental instruments for intraoral examination.

To measure and compare dental caries in populations, its value was expressed by the mean of decayed, lost, and filled teeth in a group of individuals, using the DMFT index score for permanent teeth (decayed, missing, and filled teeth), following the diagnostic criteria defined by the World Health Organization²⁰.

Index and body mass examination

To measure body weight, children and adolescents were weighed barefoot on a digital scale, with a sensitivity of 0.001 kg. Height was measured by means of an inelastic tape measure. The BMI number was calculated using the standard formula for adults (Equation 1):

(1) $$\text{current weight}(\text{kg})\text{/ height}{(\text{m})}^2$$

After the percentile outcome, children and adolescents are classified using anthropometric indicators and according to the diagnosis of their nutritional status: obesity—≥percentile 97, overweight—≥percentile 85 and <percentile 97, adequate or eutrophic—≥percentile 3 and <percentile 85, low weight—<percentile 3). The weight condition categories of BMI for age and percentiles were based on recommendations of the expert committee. The data set used in this outline of the national BMI reference curve originated from the Brazilian Survey of Health and Nutrition (PNSN, acronym in Portuguese)²¹.

Variables

Teeth that had dental caries experience were considered to analyze dental caries, which were then classified as: 0 (zero)—without experience of caries; 1 (one)—with some experience of dental caries.

Processed foods were evaluated using the sum of all processed and/or ultra-processed foods that students consumed daily (at least once a day) as a continuous variable. Likewise, the quantities of meals performed daily by the students were also added. Places where they performed daily meals were: home; home and/or school.

The descriptive evaluation of students’ weight and height data used the nutritional diagnosis (categorical variable): low weight, regular weight, overweight, and obesity, according to the World Health Organization. The BMI of each individual was also assessed as a continuous variable. The sociodemographic issues (age, gender, mother's educational level, and monthly family income) were also assessed.

Data analysis

Descriptive, univariate, and bivariate analyses were used (according to the frequencies of variables) to analyze the data, as well as the multiple analyses. Summary measures (absolute and relative frequencies) were calculated for univariate analyses. In the multivariate analysis, odds ratios (OR) and their respective 95% confidence intervals (95%CI), crude and adjusted by the exposure variables (p<0.05), were estimated. In order to verify associations between the outcome variable, gross analyses were performed between the exposure variables and the outcome (dental caries), but only variables with p<0.10 were included in the final model. Variables that remained associated with p<0.05 were statistically significant. All assumptions were met for using the model: normality (adjusted residue analysis), linearity, and homoscedasticity (graphs), in addition to the evaluation of collinearity through the variance inflation factor (VIF).

Thus, the variables’ age, BMI, monthly family income, quantity of meals performed daily, place of meals, and quantity of processed and ultra-processed food consumed per day were included in the logistic regression model. It used the Enter method, applying the reference categories determined by the researcher a priori. Data were analyzed using the statistical program SPSS^® software (Statistical Package for the Social Sciences), version 20.0 (IBM, Armonk, New York, USA).

RESULTS

In this study, we analyzed 358 students from two public schools aged between 12 and 14 years old, representing 94.4% of the total of students initially included (47.8% females and 52.2% males). To characterize this population, sociodemographic data were evaluated, and most families had a monthly family income of around two to five minimum wages (54.2%). Regarding mothers, being illiterate, knowing how to read and write, and having an elementary school degree correspond to 36.9% of the sample (Table 1).

Table 1
Distribution of frequencies on sociodemographic and nutrition data of students in a city of the Rio Grande do Sul, Brazil, 2020 (n=358)

		N	%
Sex
	Male	187	52.2
	Female	171	47.8
Monthly household income
	Less than 1 to 1 minimum wage	107	29.9
	2 to 5 minimum wages	194	54.2
	6 or more minimum wages	57	15.9
Mother's educational level
Illiterate, can read and write, elementary school		132	36.9
High school		139	38.8
Higher and graduate education		87	24.3
Place of daily meals
	At home	101	28.2
	At home and/or at school	257	71.8
Nutritional diagnosis
	Low and regular weight	169	47.2
	Overweight and obesity	189	52.8
Amount of daily meals
	2 to 4 times/day	198	55.3
	5 to 7 times/day	160	44.7
Caries experience
	No	259	72.3
	Yes	99	27.7

Frequencies of the clinical data evidenced that the experience of dental caries occurred in 27.3% of the students, considering the decayed components, restored but decayed components, restored and lost due to decay through the DMFT index. Regarding the nutritional diagnosis, 47.2% of the students had low and regular weight, 52.8% were overweight and obese, 55.3% of the students reported two to four meals a day, and 44.7% performed five to seven meals per day (Table 1).

Table 2 shows the students’ descriptive results. The mean age was 13 years old (SD=1.32), and the mean BMI was 15.79 (SD=0.86). The mean DMFT was 2.78 (SD=3.87). The amount of in natura and minimally processed foods consumed per day was from 0 to 18 foods (mean of 2.78, SD=3.05), on average of 6.80 (SD=4.53) per week. The amount of processed and ultra-processed foods consumed per day was from 0 to 29 foods (mean of 6.46, SD=4.70), with a mean of 12.92 (SD=5.49) per week, as shown in Table 2.

Table 2
Descriptive statistics (minimum, maximum, mean, and standard deviation values) of variables including continuous data of school students from the city of Rio Grande do Sul, Brazil, 2020 (n=358)

	Minimum	Maximum	Mean	Standard deviation
Age	12	14	13	1.32
BMI	14	17	15.79	0.86
DMFT	0	24	2.78	3.87
In natura and minimally processed food/day	0	18	2.78	3.05
Processed and ultra-processed food/day	0	29	6.46	4.70
In natura and minimally processed food/week	0	21	6.80	4.53
Processed and ultra-processed food/week	0	30	12.92	5.49

To verify the associations between the outcome variables, first, crude analyses were performed between each one and the outcome (dental caries). However, only variables with p<0.10 were included in the final multiple model. The variables "mothers’ educational level" and "genders" were not added to the multivariate model (p>0.25). Thus, the variables that had a statistically significant association were: age (p<0.001), monthly family income (p=0.067), quantity of processed and/or ultra-processed foods consumed per day (p<0.001), place where meals are consumed (0.020), quantity of daily meals (p=0.016), and BMI (p=0.002). However, those that remained associated in the adjusted final model were: age (p<0.001), quantity of processed and/or ultra-processed foods consumed per day (p=0.002), quantity of daily meals (p=0.038), and monthly family income (p=0.042), as seen in Table 3.

Table 3
Crude and adjusted odds ratio (OR) and respective 95% confidence intervals (95%CI) for experience of dental caries in school students, Rio Grande do Sul, Brazil, 2020

		Crude model			Adjusted model
		OR	95%CI	p-value*	OR	95%CI	p-value*
Age		1.74	1.05–1.28	0.001	1.73	1.04–1.26	0.001
Sex
	Female	1.0	-	-	-	-	-
	Male	1.23	0.77–1.95	0.380	-	-	-
Monthly family income
	6 or more minimum wages/month	1.0	-	-	1.0	-	-
	1 to 5 minimum wages/month	1.97	0.95–4.07	0.067	2.31	1.03–5.13	0.042
Mother's educational level
	Higher and graduation school	1.0	-	-	-	-	-
	High school	0.97	0.52–1.78	0.929	-	-	-
	Illiterate and elementary school	1.21	0.66–2.21	0.537	-	-	-
BMI		0.90	0.85–0.96	0.002	1.01	0.94–1.08	0.694
Amount of daily meals
	2 to 4 times/day	1.0	-	-	1.0	-	-
	5 to 7 times/day	1.26	1.05–1.53	0.012	1.26	1.01–1.58	0.038
Daily place of meals
	At home	1.0	-	-	1.0	-	-
	At home and/or at school	1.95	1.10–3.43	0.020	1.24	0.65–2.37	0.506
Consumption of processed food per day		1.10	1.04–1.15	0.001	1.08	1.03–1.14	0.002

• ^*
  Wald's test (p<0.05): statistically significant; OR: odds ratio; 95%CI: 95% confidence interval; Adjusted by the variables: age, frequency of processed and ultra-processed foods consumption per week, amount of meals performed daily, monthly family income, and BMI (p<0.10).

Table 3 presents the gross, adjusted values, and 95%CI of the binary logistic regression result. The variables educational level and gender were not included in the multivariate model. The higher age (years) of students was considered a higher chance of having dental caries (OR=1.73; 95%CI 1.04–1.26). The higher the quantity of processed and/or ultra-processed foods consumed per day (units/day), the greater the chance of having dental caries (OR=1.09; 95%CI 1.03–1.14). In addition, the higher the number of daily meals (OR=1.26; 95%CI 1.01–1.58), the lower the monthly family income (OR=2.31; 95%CI 1.03–5.13). The variables "BMI" and "place where meals are consumed" were not still associated.

Thus, the adjusted model was statistically significant: X² (6)=78.79; p<0.01; R²Negelkerke=0.285.

DISCUSSION

This study evaluated the consumption of processed and ultra-processed foods, quantity and place of daily feeding, nutritional status, and sociodemographic data and their association with dental caries in students from a city. Results show the need for strategies appropriate to the analyzed students’ profile because the greater chance of having dental caries was associated with the consumption of these foods and the number of meals, besides age and family income. The school period is a phase of development and rapid growth, characterized by great transformations in body composition. Considering that it is closely related to the nutritional and health status, its evaluation assumes greater importance in this period of life.

In general, oral health has not improved in recent decades in many countries, and oral conditions are still a major public health challenge around the world. Due to demographic changes, including population growth and aging, the cumulative load of oral conditions increased dramatically between 1990 and 2015. The number of people with untreated oral conditions increased considerably in this period²². Therefore, it has a great association with demographic and socioeconomic factors, especially for populations with lower financial conditions, and this association may influence the access and use of health services²³,²⁴.

In this study, there was a high amount of data regarding the nutritional diagnosis of students. Overweight and obesity corresponded to 52.8% of students with an average BMI of 15.79. These findings are higher than in a study, in which the overweight and obesity prevalence was 34.5%, with no statistically significant difference between genders²⁵. In Rio Grande do Sul, in four cities, we found 37.7, 30, 28.6, and 40.4%, respectively²⁶. Studies have shown that the nutritional pattern alteration is a concern, especially when it occurs early in children and adolescents²⁵,²⁶. However, the present study, compared to other studies, had a higher prevalence. In addition to the consumption of ultra-processed foods, currently, the offer is very high, despite the knowledge that these foods are causes of countless diseases.

In the present study, dental caries was associated with monthly family income, and students with lower incomes had a greater chance of having dental caries (OR=2.31). This is similar to another research, in which the burden of oral diseases is particularly higher in population groups with lower socioeconomic conditions, both in developed and developing countries²². This factor may be associated with the importance given to health, the way life is taken, the degree of training, as well as access to information on health care²⁷.

In Brazil, poor oral health conditions are related to poverty and lower financial conditions²⁸,²⁹. This was also evidenced in another study, in which most of the participants in need of restorative treatment had lower economic conditions. It may influence the prevalence and their associations³⁰. A survey conducted in a probabilistic sample resulted in greater demand and use of dental services by the female gender, besides association with the highest economic level, higher educational level, and previous orientation on prevention³¹. Health is a consequence of individuals’ interaction with their family, culture, and social condition. Thus, health promotion actions aimed at early childhood should prioritize the education of parents or guardians, by providing aid to create healthy habits that will decrease the occurrence of diseases in children and adolescents³².

Regarding age in this study, older age was considered a higher chance of having dental caries (OR=1.73). This is similar to other studies, in which the higher risk of acquiring new caries lesions increases with the years of life because the young person is progressively more exposed to determinant factors of dental caries³³. In very young children, the presence of dental caries may acquire devastating characteristics, with the following consequences: pain and infection. These, in turn, may indicate an inadequate dietary pattern, resulting in damage to the child's physical development³⁴,³⁵. In one study, the authors observed, during a follow-up period, a high incidence of caries, and caries’ average had its initial value tripled at the end of one year³⁶.

Another variable that had a statistically significant association in the present study was the greater amount of daily meals and the presence of dental caries (OR=1.26). Results of a study conducted with students found that infants who consumed two to three daily school meals had a higher intake of fresh and minimally processed foods when compared to children who did not consume school meals³⁷. In a systematic review study, the authors found that the greatest amount of daily meals influences dental caries in adolescents and young people³⁸.

In an attempt to explain that the feeding frequency is more important than the amount of food, there are authors who point out that sugar is not a causal factor in the etiopathogenic process of dental caries, but a risk³⁹. Adhesiveness and retention of food in hard and soft tissues depend on the type of ingested food. Food fat reduces retention time in the mouth, and liquids are eliminated much faster than solid foods⁴⁰. The parameters for food retention and acid formation are important in the appearance of dental caries, but they do not constitute a good epidemiological indicator of dental caries. Therefore, it is difficult to associate food cariogenicity with an individual physical property, such as buffer capacity or acid production.

Another determinant factor evaluated in this study that was associated with dental caries was the higher consumption of ultra-processed and/or processed foods by the students (OR=1.08). The chances of developing dental caries are higher when the amount of these foods consumed during the day is high. However, some studies, both in developed and developing countries, have shown an increase in the size of portions of consumed food, especially regarding sugary drinks⁴¹,⁴². In two studies conducted by the Pesquisa Nacional de Saúde do Escolar (PENSE), in students of the ninth grade from elementary school in Brazil in 2012 and 2015, students presented the problem of consuming a lot of unhealthy feeding markers⁴³. Authors evaluated the PENSE survey data in order to verify the influence of school meals after consuming ultra-processed foods in Brazilian adolescents, showing that the offer of school meals through the National School Feeding Program (PNAE) was associated with lower consumption of ultra-processed foods, while the presence of a school cafeteria was related to higher consumption of these foods⁴⁴.

The dietary pattern has been altered over the years, both among children and adults. Short-time meals have been the choice of food type, by consuming pre-prepared foods, canned and/or frozen, or even meals outside the home. This reflects the easy access and low cost of this type of food, which results in it being the choice not only of families with low socioeconomic conditions but also of all families regardless of their social condition. Another factor that significantly implies a higher risk of dental caries development is the high frequency of sweets and sweetened drinks⁴⁵.

Despite the results of this study in relation to processed and ultra-processed foods and the number of daily meals, we have to emphasize that the frequency and quality of students’ oral hygiene were not evaluated. It has been proven that it is an effective habit to remove bacterial plaque (disorganization of cariogenic bacteria, avoiding future enamel demineralization), besides preservation of periodontal integrity, that is, they are the key to reversing and preventing oral diseases⁴⁶.

This study's limitations include aspects related to the FFQ, which are due to the restrictions imposed by the population's long-term memory, discernment of the portion size, and interpretation of questions. Thus, we cannot affirm that these data fully reflect the food intake of children and adolescents, since the information was self-reported. A reference method could be the Food Registry, because it is a method that does not depend on memory and the foods consumed are directly recorded. Therefore, errors of perception and interpretation would decrease. Another limitation is the study design (cross-sectional), which does not allow us to know the action of factors in the past and to establish a cause–effect relationship. It is noteworthy, however, that for oral clinical evaluation, longitudinal studies are scarce, especially on the incidence of dental caries and risk factors in students.

However, the present study has great relevance because it contributed to the initial diagnosis of oral and nutritional health of students from a city in the interior of Brazil, which will serve to promote the planning of future interventions through the dental caries indicator.

We also expect this study to contribute to the reorientation of food and nutritional education actions in city schools. Therefore, the importance of using epidemiology for planning should be highlighted, considering the data reveal the need for more information about caries disease, especially for those with lower family income. In addition, the importance of oral health should be emphasized, as should the importance of consuming more healthy foods and decreasing the consumption of unhealthy foods, which were named processed and ultra-processed foods in this study.

CONCLUSION

There has been an association between the presence of dental caries and the higher consumption of processed and ultra-processed foods and the higher frequency of daily meals. From these findings, we suggest establishing urgent guidance to parents and young people on reducing the frequency of exposure to these industrialized foods and replacing them with healthier foods and beverages.

Higher age and lower family income were factors associated with dental caries among the students investigated in the city, which reinforces the need for a greater focus on prevention, reducing the impact of caries as early as possible.

Primary prevention aims to prevent caries before it occurs; therefore, modifying unhealthy behaviors by increasing resistance to disease is more efficient than investing in treatments.

• Funding:
  none.

REFERENCES

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• ³ Kassebaum NJ, Bernabe E, Dahiya M, Bhandari B, Murray CJ, Marcenes W. Global burden of untreated caries: a systematic review and metaregressio. J Dent Res. 2015;94(5):650-8. https://doi.org/10.1177/0022034515573272
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Publication Dates

• Publication in this collection
  13 Dec 2024
• Date of issue
  2024

History

• Received
  02 Feb 2021
• Accepted
  12 Mar 2022