Sugar Consumption and Changes in Dental Caries from Childhood to Adolescence

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DOI: 10.1177/0022034515625907
Abstract
There are no prospective studies investigating the effects of sugar-related feeding practices on changes in dental caries from early childhood to young adulthood. The aim of this study was to assess whether sugar-related feeding practices affect dental caries between the ages of 6 and 18 y. This birth cohort study was initiated in 1993 in Pelotas, Brazil. There were 3 dental clinical assessments; at ages 6 y (n = 359), 12 y (n = 339), and 18 y (n = 307). Sugar-related feeding practices were assessed at ages 4, 15, and 18 y. Covariates included sex and life course variables, such as family income, breast-feeding, mother's education, regularity of dental visit, and child's toothbrushing habits. Group-based trajectory analysis was performed to characterize trajectories of time-varying independent variables that had at least 3 time points. We fitted a generalized linear mixed model assuming negative binomial distribution with log link function on 3-time repeated dental caries assessments. One in 5 participants was classified as "high" sugar consumers, and nearly 40% were "upward consumers." "Low consumers" accounted for >40% of the sample. High and upward sugar consumers had higher dental caries prevalence and mean DMFT in all cohort waves when compared with low sugar consumers. Caries occurred at a relatively constant rate over the period of study, but in all sugar consumption groups, the increment of dental caries was slightly higher between ages 6 and 12 y than between 12 and 18 y. Adjusted analysis showed that dental caries increment ratio between ages 6 and 18 y was 20% and 66% higher in upward and high sugar consumer groups as compared with low consumers. The higher the sugar consumption along the life course, the higher the dental caries increment. Even the low level of sugar consumption was related to dental caries, despite the use of fluoride.
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Research Reports: Clinical
Introduction
There is a consensus that sugars are implicated in several non-
communicable diseases, including dental caries (World Health
Organization [WHO] 2003; Sheiham and James 2014; WHO
2015). Moreover, sugars are a “sufficient” cause of dental car-
ies (Rothman and Greenland 1999); sugars determine whether
or not caries develops. Despite the wide-scale decrease in den-
tal caries in children, caries remains a major international pub-
lic health problem. Untreated caries in permanent affected 36%
of the world’s population (Marcenes et al. 2013).
The most reliable design to demonstrate the association
between sugar intake and caries increment is prospective
cohort studies. Surprisingly, although sugars are a well-known
causal factor to dental caries, there are very few cohort studies
that investigate prospectively the effect of sugar-related feed-
ing practices on dental caries increment (Moynihan and Kelly
2014). Furthermore, there is no prospective cohort study from
early childhood to young adulthood looking at this important
public health problem. The lack of well-designed studies
investigating the relationship between sugar intake and dental
caries was the reason why the WHO (2015) graded the evi-
dence of such an association as being of moderate quality
(Moynihan and Kelly 2014; WHO 2015).
Patterns of sugar consumption change along the life course.
There is a change in behavior from early childhood to adoles-
cence, with adolescents being more independent in selecting
their foods and drinks. That could increase the risk for caries
development (Sheehy et al. 2008; Ogden et al. 2011).
As there is a dearth of well-conducted longitudinal studies
of the relation between feeding practices and caries experience,
a study was carried out with the aim of assessing whether
625907JDR
XXX10.1177/0022034515625907Journal of Dental ResearchSugar Consumption and Changes in Dental Caries
research-article2016
1
Australian Research Centre for Population Oral Health, School of
Dentistry, The University of Adelaide, Adelaide, Australia
2
Department of Epidemiology and Public Health, The University College
London, London, UK
3
Postgraduate Program in Dentistry, Federal University of Pelotas,
Pelotas, Brazil
4
Postgraduate Program in Epidemiology, Federal University of Pelotas,
Pelotas, Brazil
A supplemental appendix to this article is published electronically only at
http://jdr.sagepub.com/supplemental.
Corresponding Author:
M.A. Peres, Australian Research Centre for Population Oral Health,
School of Dentistry, Faculty of Health Sciences, University of Adelaide,
Adelaide, 5000 Australia.
Email: marco.peres@adelaide.edu.au
Sugar Consumption and Changes in
Dental Caries from Childhood to
Adolescence
M.A. Peres
1
, A. Sheiham
2
, P. Liu
1
, F.F. Demarco
3,4
, A.E.R. Silva
3
, M.C. Assunção
4
,
A.M. Menezes
4
, F.C. Barros
4
, and K.G. Peres
1
Abstract
There are no prospective studies investigating the effects of sugar-related feeding practices on changes in dental caries from early
childhood to young adulthood. The aim of this study was to assess whether sugar-related feeding practices affect dental caries between
the ages of 6 and 18 y. This birth cohort study was initiated in 1993 in Pelotas, Brazil. There were 3 dental clinical assessments; at
ages 6 y (n = 359), 12 y (n = 339), and 18 y (n = 307). Sugar-related feeding practices were assessed at ages 4, 15, and 18 y. Covariates
included sex and life course variables, such as family income, breast-feeding, mother’s education, regularity of dental visit, and child’s
toothbrushing habits. Group-based trajectory analysis was performed to characterize trajectories of time-varying independent variables
that had at least 3 time points. We fitted a generalized linear mixed model assuming negative binomial distribution with log link function
on 3-time repeated dental caries assessments. One in 5 participants was classified as “high” sugar consumers, and nearly 40% were
“upward consumers.” “Low consumers” accounted for >40% of the sample. High and upward sugar consumers had higher dental caries
prevalence and mean DMFT in all cohort waves when compared with low sugar consumers. Caries occurred at a relatively constant rate
over the period of study, but in all sugar consumption groups, the increment of dental caries was slightly higher between ages 6 and 12 y
than between 12 and 18 y. Adjusted analysis showed that dental caries increment ratio between ages 6 and 18 y was 20% and 66% higher
in upward and high sugar consumer groups as compared with low consumers. The higher the sugar consumption along the life course,
the higher the dental caries increment. Even the low level of sugar consumption was related to dental caries, despite the use of fluoride.
Keywords: epidemiology, cohort study, children, adolescents, incidence, risk factor
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sugar-related feeding practices affect dental caries between the
ages of 6 and 18 y.
Methods
This study is reported according to STROBE (Strengthening
the Reporting of Observational Studies in Epidemiology)
guidelines.
Participants and Study Design
This is a prospective population-based birth cohort initiated in
1993 in Pelotas, Brazil (n = 5,249). The first cohort’s assess-
ment was undertaken at birth, and a random subsample of the
cohort infants was subsequently selected and visited at their
homes at ages 1 mo (n = 649), 3 mo (n = 644), 6 mo (n =
1,414), and 12 (n = 1,383) mo. In 1997, all low birth weight
children were sampled, plus 20% of the remaining—including
those visited at 1 and 3 mo. Among the 1,460 eligible children,
87% (1,270 children) were located. For the oral health studies
nested in the cohort, a random subsample of 400 children was
drawn at age 6 y from the 1997 cohort assessment, and 359
children were dentally assessed (Peres et al. 2005). Further
assessments of all participants were at ages 6, 11, 15, and 18 y.
Detailed methodological aspects of the cohort have been pub-
lished elsewhere (Victora et al. 2008; Gonçalves et al. 2014).
All children who participated in oral health studies were
assessed at 1, 3, 6, and 12 mo and at ages 4, 6, 11, 15, and 18 y.
Among the 359 children who participated in the study at 6 y of
age, 339 (94.4%) were investigated at 12 y, and 307 (90.6%) of
those dentally examined and interviewed at age 12 y were
investigated at age 18 y.
Dental Caries Assessments at Ages 6, 12, and 18 y
All dental assessments followed WHO (1997) dental caries
diagnostic criteria. Assessments included a dental examination
for dental caries in the primary and permanent dentitions at
aged 6 y, while at ages 12 and 18 y, only permanent dentition
was assessed.
Eight, 6, and 1 examiners were involved in the fieldwork at
ages 6, 12, and 18 y, respectively. Examiner calibration was
performed on a tooth-by-tooth basis in all dental assessments
(Peres et al. 2001). Interexaminer reliability was measured
with the weighted kappa statistic. The lowest kappa value for
dental caries was 0.6, which is considered good or substantial
(Szklo and Javier Nieto 2007). As the oral health study at age
18 y was performed by only 1 trained dentist, the calibration
was performed as compared with another dentist who did not
participate in the fieldwork. For this reason, it was possible to
assess inter- and intraexaminer agreement. All examinations
were conducted at participants’ homes in the 6- and 12-y-old
assessments and at a clinic for those aged 18 y. All dental
examinations were carried out under artificial light (a head-
lamp), with dental mirrors, and using Community Periodontal
Index probes, observing proper safety and biohazard measures.
Assessments of Sugar-related Feeding Practices
The sugar-related feeding practices variable was constructed
with data from the cohort waves at ages 4, 15, and 18 y. At age
4 y, mothers were questioned in relation to the foods and drinks
that their children consumed and the frequency of consump-
tion. The questions related to 6 foods: chips, soda, chocolate,
candies, bubble gum, and lollypop. If the mothers response
was affirmative, then the interviewer asked how many times
the child consumed that food daily, weekly, or less than once a
week. From all of these foods and drinks, the daily intake was
determined. Scores ranged from 0 to 6 foods/drinks ingested
(Chafee et al. 2015).
For the ages 15 and 18 y, the adolescents answered a Food
Frequency Questionnaire. They were questioned in relation to
the consumption of 81 foods and 88 drinks in the last year. At
age 15 y, teenagers reported whether the food was ingested and
the number of times per day, week, month, or year. At age 18 y,
the options of response were closed: never or <1 per month; 1
to 3 per month; 1 per week; 2 to 4 per week; 5 to 6 per week; 1
per day; 2 to 4 per day; 5 per day. To create a variable of daily
consumption, 11 foods with cariogenic potential were selected
at ages 15 and 18 y: cake, chips/snacks, cookies, ice cream or
popsicle, sugar, candies, chocolate in powder or chocolate
bars, pudding, nondiet soda, natural fruit juice, and processed
fruit juice. A daily consumption diary was created at ages 15
and 18 y, with scores varying from 0 to 11 foods consumed.
The methodology proposed by Chafee et al. (2015), by using
scores, was used to construct the sugar-related variable that we
used. The Food Frequency Questionnaire used at 18 y old was
transformed into annual consumption as shown in Table 1. At
15-y-old assessment of food collection allowed us to estimate
the daily consumption (regardless of daily frequency). After all
annual frequencies were computed, these were divided by
365.25 to obtain the daily consumption, and a score was
subsequently created (0 to 11 consumed foods). The formulas
Table 1. FFQ Data Transformation into Annual Consumption.
Responses to FFQ Never or <1/mo 1 to 3/mo 1/wk 2 to 4/wk 5 to 6/wk 1/d 2 to 4/d 5/d
Estimated yearly frequency 0 1 × 12 1 × 52 2 × 52 5 × 52 1 × 365.25 2 × 365.25 5 × 365.25
Calculation 0 12 52 104 260 365.25 730.5 1,826.25
The definition of low-, intermediate-, and high-level sugar-related feeding practices was based on approximate tertile distribution.
FFQ, Food Frequency Questionnaire.
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Sugar Consumption and Changes in Dental Caries 3
used to calculate the annual consumption are displayed in
Table 1.
Covariates
Based on the literature, some potential confounders of the
association between sugar-related feeding practices and dental
caries were selected: sex, family income, breast-feeding, moth-
ers level of education, regularity of dental visit, toothbrushing
habits. Family income was collected at birth and at ages 4, 11,
15, and 18 y. Family income was a sum of all forms of income
(salary, wages, pensions, cash transfer program, rental income,
and investments). It was collected in reais (Brazilian currency)
and transformed in tertiles for each assessment. Information on
breast-feeding was collected immediately after birth and at 3,
6, 12, and 24 mo at 4 y of age according to the following ques-
tions: “Is your child being breastfed? If ‘No,’ when did she/he
stop being breastfed?” Breast-feeding was categorized as fol-
lows: 9+ mo, 4.0 to 8.9 mo, 1.0 to 3.9 mo, and <1 mo (Peres
et al. 2007). Mothers level of education was collected 3 times
(at child’s birth and at child’s 15- and 18-y assessments)
according to year of study and then categorized as <4, 5 to 8, 9
to 11, and 12+ y. Dental visits (yes/no) in the last 12 mo were
assessed at ages 6, 12, and 15 y. Daily toothbrushing frequency
(<2 times a day / 2 times a day) was measured at aged 6, 12,
15, and 18 y. All behavior-related covariates were reported by
the participants’ parents (usually the mother) in the first wave
(6 y old) and by the participants in the subsequent assessments.
Family income was reported by the participants’ parents.
Statistical Analyses
Caries experience was the main dependent variable. Its descrip-
tive statistics were presented with caries prevalence (propor-
tion of people with DMFT >0) and caries experience (means
and standard errors, DMFT). As in the follow-up study, the
proportion of low birth weight children was 29.7%, while in
the original cohort, it was 9.7%; therefore, it was necessary to
calculate a weighted factor to perform statistical analysis. For
the oral health study, a weight factor of 0.33 was used for chil-
dren born with low birth weight, and 1.28 was applied for those
born with adequate birth weight. Household incomes and other
covariates were all descripted in cross-tables with their regrouped
categories.
Group-based trajectory analysis was performed with PROC
TRAJ in SAS 9.3 (Jones et al. 2001) to characterize trajectories
of time-varying independent variables that have at least 3 time
points. The parameters for the trajectory model were deter-
mined on a maximum-likelihood basis by a general quasi-
Newton method (Dennis et al. 1981; Jones and Nagin 2007).
The model selection procedure involved estimating the num-
ber of latent classes and the order of the polynomial for each
latent trajectory. The final number of trajectories was estab-
lished when sequential comparisons of the Bayesian informa-
tion criterion (BIC) and adjusted BIC between the model with
k and k + 1 trajectories yielded no further substantial difference
in the BIC score than the k + 1 model. We fitted each group
with trajectory of quadratics and started with the null model
with 1 group. BIC analysis supports a 3-group model. The like-
lihood of each case belonging to each trajectory (posterior
probabilities) was used to classify individual group member-
ship. To validate the group model, we listed all the group mem-
bers and tried to interpret their latent pattern. Low, intermediate,
and high levels of sugar-related feeding practices were used to
establish the latent 3 classes.
Ultimately, a 3-group sugar consumption trajectory was
selected:
Low: 2 of ages 4, 15, and 18 y have been measured low
(40.4%).
Upward: early life was measured low, and at least 1 of ages
15 and 18 y has been measured not low (38.7%).
High: early life was measured high or not low, and 2 of
ages 4, 15, and 18 y have been measured not low (20.9%;
see Appendix Table).
In the interests of parsimony, a 4-group trajectory analysis
model was defined for family incomes and 3 groups for moth-
ers education. Selection of that number balanced the interests
of parsimony with the objective of reporting the distinctive
developmental pattern in the data (Broadbent et al. 2008).
To identify the association with the main exploratory vari-
able—sugar-related feeding practice groups—we fitted a gen-
eralized linear mixed model with SAS PROC GLIMMIX by
assuming negative binomial distribution with log link function
(negative binomial [NB] model) on 3-time repeated dental car-
ies assessments. The primary assumption underlying the analy-
ses performed by PROC GLIMMIX on the data is that it
contains random effects in dealing with repeated measures on
each individual. As our main focus is on the group differences,
we only applied random effect to the intercept. The choice of
NB model is due to the positive skewness and overdispersion
of the DMFT index. Type 3 likelihood statistics were used for
testing the overall effect of the variables, and Wald chi-square
statistics tested the effect of category of variable as compared
with the reference group in the model. All variables with type
3 likelihood statistics with P < 0.20 were kept in the models.
Sex was kept in the models regardless of its P value. All mod-
els were adjusted for birth weight. The model allowed estima-
tion of dental caries incidence rate ratio and respective 95%
confidence intervals. Least square means were estimated
through the models. The estimated expected counts of dental
caries were obtained by applying the inverse link function to
the least squares means. The outcome variable of the general-
ized linear mixed model is DMFT that was repeated measured at
ages 6, 12, and 18 y. This model was used to assess the change
in DMFT over time and the difference among different groups
in sugar-related feeding practices. As this is an individual
growth model, it must have a time variable—in our case, age.
Ethical Issues
Consent for interviews and examinations was obtained and
approved by the Pelotas Federal University Ethics Committee.
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Participants who had dental treatment needs were referred to
the Dental Clinic of the Postgraduate Program in Dentistry
of Pelotas Federal University. All assessments for those in
the cohorts were also approved by the Human Research
Ethics Committee of the Federal University of Pelotas
(Brazil).
Results
Data from 302 participants who had completed data on dental
caries, sugar-related feedings practices, and covariates from
birth to 18 y were analyzed. Prevalence of dental caries in pri-
mary dentition at age 6 y was 64.4%; mean dmft was 3.46 (SD,
3.9). Prevalence of dental caries in permanent dentition ranged
from 2.8% at age 6 y to 48.0% when participants were 18 y old.
Mean DMFT varied from almost zero at age 6 y to 1.2 at age
12 y. It almost doubled at age 18 (2.1; Table 2). Core character-
istics of the participants of oral health assessments are similar
to those from the original cohort. For example, the proportion
of participants’ mothers with >8 y of schooling was 74.2% for
the general cohort and 76.0%, 77.8%, and 70.2% for partici-
pants at ages of 6, 12, and 18 y, respectively.
Trajectories of sugar consumption along the life course and
dental caries prevalence and experience are presented in Table
3. One in 5 participants was classified as a “high” sugar con-
sumer, and nearly 40% were “upward consumers.” “Low con-
sumers” accounted for >40% of the sample. High and upward
sugar consumers had statistically significant higher dental car-
ies prevalence and higher mean DMFT at the age 12- and 18-y
waves when compared with low sugar consumers (Appendix
Table, Table 3). Caries occurred at a relatively constant rate
over the period of study, but in all sugar consumption groups,
the increment of dental caries was slightly higher between ages
6 and 12 y than between 12 and 18 y. Table 4 displays negative
binomial models of the association of dental caries increment
from age 6 to 18 y according to sugar-feeding practice trajecto-
ries. After adjustment for potential confounders, the dental car-
ies increment ratios between ages 6 and 18 y were 20% and
Table 2. Sample Characteristics Studied in Each Wave.
Age, y
Variables/Categories 0 4 6 11 12 15 18
Sex
Male 158 (53.3)
Female 144 (46.7)
Caries prevalence, n (%)
dmft > 0 199 (64.4)
DMFT > 0 9 (3.2) 157 (50.3) 217 (70.8)
Caries experience, mean (SD)
dmft 3.39 (3.8)
DMFT 0.07 (0.4) 1.20 (1.6) 2.10 (2.4)
Sugar-related feeding
practices, n (%)
Low 210 (69.4) 180 (58.9) 199 (65.7)
Intermediate 74 (24.5) 99 (33.9) 87 (29.7)
High 18 (6.1) 23 (7.1) 16 (4.6)
Family income, n (%)
Lower tertile
a
134 (44.3) 98 (29.4) 91 (28.3) 87 (28.3) 88 (29.1)
Intermediate tertile 63 (20.2) 87 (29.1) 101 (33.4) 106 (32.8) 102 (33.8)
Higher tertile 103 (35.5) 117 (41.5) 110 (36.4) 109 (38.9) 112 (37.1)
Breast-feeding, mo; n (%)
9.0 64 (22.9)
4.0 to 8.9 68 (24.6)
1.0 to 3.9 108 (36.0)
<1.0 60 (16.5)
Mother’s schooling, y; n (%)
0 to 4 83 (25.0) 81 (25.7 ) 63 (20.3)
5 to 8 145 (48.9) 131 (42.9) 131 (45.8)
9 to 11 55 (20.3) 80 (28.5) 80 (30.4)
12+ 15 (5.9 ) 9 (2.9) 10 (3.5 )
Dental visits
Yes 110 (36.6) 140(64.5) 156 (53.5)
No 189 (63.4) 77(35.5) 145 (46.6)
Toothbrushing, n (%)
<2/d 40 (11.0) 67 (22.2) 11 (2.5) 64 (19.3)
2/d 262 (89.0) 235 (77.8) 291 (97.5) 238 (80.7)
Birth weight, g; mean (SD) 3,194.37 (549.5)
The mean and percentage were adjusted by the oversampling on low birth weight children.
a
Tertile was derived from the original cohort.
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Sugar Consumption and Changes in Dental Caries 5
66% higher in upward and high sugar consumer groups as
compared with low consumers. However, statistically signifi-
cant differences were found only for high when compared with
low consumers and not for upward versus low or high versus
upward. The predicted values of DMFT from model 1 (Table
4) are shown in the Figure.
The aim of this study was to assess the progression and
dynamic growth of dental caries in the permanent dentition
from 6 to 18 y of age. However, we included dmft as a covari-
ate given that dental caries in deciduous teeth is a strong pre-
dictor of dental caries in permanent dentition. We sum up
dmft-DMFT at age 6 y in Table 4 (Appendix Table).
Table 3. Caries Prevalence and Experience from Age 6 to 18 y and Group Trajectories of Sugar-related Feeding Practices.
Caries Prevalence, n (%) Caries Experience–DMFT, Mean (SD)
Sugar Group n (%) Age 6 Age 12 Age 18 Age 6 Age 12 Age 18
High 63 (20.86) 3 (6.14) 41 (65.63) 48 (78.43) 0.12 (0.52) 1.92 (2.12) 3.28 (3.34)
Upward 117 (38.74) 3 (1.64) 61 (49.05) 91 (75.10) 0.03 (0.24) 1.09 (1.46) 1.97 (2.25)
Low 122 (40.40) 3 (3.20) 55 (43.60) 78 (62.59) 0.09 (0.52) 0.92 (1.33) 1.50 (1.62)
Total 302 (100.00) 9 (3.20) 157 (50.34) 217 (71.80) 0.07 (0.43) 1.20 (1.61) 2.10 (2.40)
The mean and percentage were adjusted by the oversampling on low birth weight children.
Table 4. Negative Binomial Models on the Association between Increases in Dental Caries from Ages 6 to 18 y and Sugar-related Feeding Practice
Groups.
Model 1 Model 2 Model 3
IRR 95% CI
a
IRR 95% CI IRR 95% CI
Age/6 1,378.15 362.97 to 5,232.64 1,378.15 362.97 to 5,232.64 1,378.15 362.97 to 5,232.64
(Age/6)
2
0.26 0.20 to 0.34 0.26 0.20 to 0.34 0.26 0.20 to 0.34
Sugar group
b
High 1.88 1.37 to 2.57 1.68 1.23 to 2.28 1.67 1.23 to 2.25
Upward 1.33 1.01 to 1.75 1.20 0.92 to 1.57 1.22 0.94 to 1.59
Low 1 1 1
Birth weight 0.09 0.71 to 1.03 0.11 0.72 to 1.04 0.84 0.70 to 1.00
Sex
Male 0.97 0.78 to 1.26 0.996 0.79 to 1.26
Female 1 1
dmft at age 6 y 1.10 1.07 to 1.13 1.10 1.07 to 1.14
Breast-feeding, mo
9.0 1.08 0.75 to 1.57
4.0 to 8.9 1.17 0.81 to 1.68
1.0 to 3.9 1.14 0.82 to 1.58
<1.0 1
Dental visit at age 6 y
Yes 0.83 0.64 to 1.06 0.89 0.71 to 1.13
No 1 1
Family income
Stable low 1.22 0.88 to 1.70
Downward 1.16 0.72 to 1.85
Upward 1.05 0.71 to 1.56
Stable high 1
Mother’s education
Low 1.22 0.87 to 1.71
Intermediate 1.24 0.93 to 1.65
High 1
Toothbrushing
Inconsistent 0.97 0.72 to 1.31
Consistent 1
Statistically significant differences were found only for high vs. low and not for upward vs. low or high vs. upward.
CI, confidence interval; IRR, incident rate ratio.
a
Wald test.
b
P < 0.01 in the type 3 likelihood ratio statistics, which test the overall effect of sugar specified in the MODEL statement (null hypothesis: sugar in the
model does not explain a significant proportion of the variance, given the other variables are in the model), while the Wald statistic tests the effect of
sugar groups as compared with the reference group (null hypothesis: there is no difference for the outcome variable between the other categories of
sugar and reference).
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Discussion
Dental caries increment from 6- to 18-y-olds was consistently
and positively associated with high patterns of sugar consump-
tion along the life course even after adjustment for potential
well-known confounders. As identified in the Dunedin cohort
study (Broadbent et al. 2008), caries occurred at a relatively
constant rate throughout the study period in the sample as a
whole, but the pattern dental caries varied across sugar con-
sumption trajectory groups. Caries prevalence and experience
in the highest sugar consumer group were higher than for low
and upward sugar consumers.
As water fluoridation was implemented in the study area in
1962 and covers almost all of the population (Lima et al. 2004)
and as toothbrushing with fluoride toothpaste is ubiquitous in
Pelotas (e.g., at 18 y of age, only 3% of participants brushed
teeth once a day and 99.8% used fluoride toothpaste) and was
controlled for, the role of different sources of fluoride cannot
explain our findings. Caries increased even among low sugar
consumers, suggesting that caries occurs even in low sugar
consumers using multiple sources for fluoride. Moreover, in
those where sugar consumption goes upward, the disease will
eventually be as high as in the high consumption group, indi-
cating that low sugar consumption in a specific period of life is
unlikely to prevent dental caries later on in life.
This study has several strengths. It is a long-term population-
based birth cohort study with 3 dental assessments at ages 6, 12,
and 18 y performed by the same research team. Examiner reli-
ability and participation rates were high, contributing to the
strength and internal validity of the study. In addition, the statis-
tical approach used allowed us to analyze time-varying vari-
ables and impute missed cases. When the food frequencies were
collected, the traditional practice is using factor analysis to
reduce the variable to a few factors. That is variable centered. In
our analysis, food consumption was first conducted to person-
centered categories. Furthermore, as there were 3 categories in
each of the 3 assessments, there was a total of 27 possible
permutations for the sugar-related feeding practices. Based on
the group trajectory method, sugar intake was modeled to cate-
gories of sugar-related feeding practice latent groups (low,
upward, and high). Another strength of this study was the use of
group trajectory analysis. It is common practice to use multiple
imputing to deal with data missing in a longitudinal study.
Group trajectory analysis provided another statistical approach
that allowed us to analyze time-varying variables that permit
inclusion of individuals not accessed at all time points.
Most research on dental caries has been based on cross-
sectional data collection, or, even when the data were collected
longitudinally, the final caries outcomes or caries increments
over time were not considered in the analyses. It is not clear
about caries changes over time in the general population or a
given sample and what variables are associated with the over-
all trend and the differences within person and between person.
Growth mixed model was used to examine the unique trajecto-
ries of individuals and groups in repeated measured data. A
time-varying variable representing different status of outcome
is needed in the model. This method overcomes some of the
limitations of traditional repeated measuring techniques and
offers additional benefits and information.
However, this study has some limitations. It is a relatively
small sample, which may have precluded the identification of
some differences. The lack of the assessment of the amount of
added sugars may have underestimated the magnitude of the
effect of sugar-related feeding practices on dental caries incre-
ment. In addition, the use of different instruments to collect
dietary data is another limitation of the current study. However,
we used the same approach adopted in a similar population
(Chaffee et al. 2015).
The findings of this study should be generalized to popula-
tions with similar socioeconomic characteristics and similar
patterns of sugar-related feeding practices. Our findings have
clear public health policy implications. As sugar-related feed-
ing practices in childhood and adolescence are risk factors for
dental caries, diabetes, obesity, and early surrogate markers of
Figure. Actual mean DMFT (left) and estimated expected counts of DMFT from model 1 (right) with sugar-related feeding practices.
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Sugar Consumption and Changes in Dental Caries 7
cardiovascular diseases, the common risk factor approach
(Sheiham and Watt 2000) should be adopted as the most effec-
tive way to prevent these diseases. Caries has serious impacts
on individuals and populations. It causes pain, discomfort, and
social and functional limitations, which ultimately can impair
oral health–related quality of life. Also, the economic impact
of caries is considerable. The WHO estimates that oral diseases
are the fourth-most expensive disease to treat in industrialized
countries (Petersen et al. 2005).
In conclusion, the higher the life course sugar consumption,
the higher the dental caries increment. Low levels of sugar
consumption caries occurred even in low sugar consumers
using multiple sources for fluoride.
Author Contributions
M.A. Peres contributed to conception, design, data acquisition,
analysis, and interpretation, drafted and critically revised the manu-
script; A. Sheiham contributed to conception and data interpreta-
tion, drafted and critically revised the manuscript; P. Liu contributed
to conception, data analysis, and interpretation, drafted and criti-
cally revised the manuscript; F.F. Demarco, A.E.R. Silva, M.C.
Assunção, and A.M. Menezes contributed to conception, data
acquisition, and interpretation, drafted and critically revised the
manuscript; F.C. Barros contributed to design, data acquisition,
drafted and critically revised the manuscript; K.G. Peres contributed
to conception, design, data acquisition, analysis, and interpretation,
drafted and critically revised the manuscript. All authors gave final
approval and agree to be accountable for all aspects of the work.
Acknowledgments
This article is based on data from the study “Pelotas Birth Cohort,
1993” conducted by the Postgraduate Program in Epidemiology at
Universidade Federal de Pelotas. The 1993 birth cohort study is
currently supported by the Welcome Trust through the program
entitled Major Awards for Latin America on Health Consequences
of Population Change. The European Union, the National Support
Program for the Centers of Excellence, the Brazilian National
Research Council, and the Brazilian Ministry of Health supported
previous phases of the study. Oral health assessment at age 12 y
was sponsored by the Brazilian National Council for Scientific
and Technological Development (grant 403362/2004-0). We
thank Professor Cesar Victora for his support. The authors declare
no potential conflicts of interest with respect to the authorship and/
or publication of this article.
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  • ... In this scenario of transformations, adolescents may become more vulnerable to behaviors that weaken health. Where oral health is concerned, eating habits and neglect of oral hygiene are preponderant factors for the establishment of oral diseases [7,8]. ...
    Article
    Full-text available
    Background Adolescents are vulnerable to behaviors that weaken health, by adopting habits that interfere with adherence to treatment. The aims of the present study were to investigate adolescents’ adherence to dental treatment and the relations between this behavior and socioeconomic factors and consumption of licit and illicit chemical substances. Methods A longitudinal study was conducted with 474 adolescents from Piracicaba/SP/Brazil, who initially underwent a dental examination to verify the adherence for dental treatment. After 18 months, 325 adolescents were reassessed. Valid questions about socioeconomic conditions and use of alcohol and drugs were applied to participants. The chi-square test and Fisher’s exact test were used. The prevalence ratios were estimated with the respective 95% confidence intervals, using generalized linear models with Poisson distribution. Results Eighteen (18) months after the first consultation, 325 adolescents were reassessed: 161 (49%) did not adhere to the treatment, and 164 (51%) adhered to it and answered the socioeconomic and alcohol and illicit drug questionnaires. Their mean age was 15 ± 1 years; of them, 189 (58%) were female. The prevalence of adherence to treatment decreased in patients without their own home (p = 0.034). In the individual analysis of the variables, drinking alcohol alone, experimenting with drugs, and proximity of friends who consumed illicit substances were associated with the outcome (p < 0.05). However, in the joint analysis, only proximity of friends who consumed drugs was the factor related to low adherence to dental treatment among the adolescents (p = 0.035). Conclusion Adolescents who consumed alcohol and socialized with friends who used illicit drugs had greater difficulty in adhering to dental treatment.
  • ... The number of life years with sugar consumption beyond the recommended threshold multiply the risk for caries. [3] The need for a tool to measure the amounts of sugars consumed and to relate the same to the effect on oral health was emphasized. Datasets with this aspect are missing. ...
    ... Datasets with this aspect are missing. [3] It was suggested that a re-focus on obtaining more valid data on the trends in sugar consumption is the needed to underpin intervention efforts. [4][5][6] Food labeling and the role of regulatory bodies Nutrition labeling, a significant aspect in educating the public on a mass level, was discussed by the experts. ...
  • ... That time was determined, because, besides the evidences lack high quality in interval favor of six month or in any other frequency, in the routine odontological exams accomplishment, patient of risk could have subclinical discoveries with the evolution and, consistently significantly shaken severity in this period, the prevention of the biggest damages being made viable by the accompaniment [8]. It is recognized that oral illnesses, of singular way the dental caries, represent the main reason for teenagers' consultation, in the public network of services in Brazil's Health [9]. It is worth stressing, however, that in the consultations sector did not occur the odontological attention, but the control of the prenatal in formed team by doctors, male nurses, psychologists and social workers. ...
  • ... The relationship between dietary practices and dental caries has been suggested and reinforced since classic studies conducted in the 1950s [10][11][12]. In the last 10 years, evidence has demonstrated that dietary practices, particularly the con- sumption of free sugars,* are of critical importance to the development of dental caries, constituting the necessary cause of its occurrence, and modulate other fac- tors, such as dental biofilm [5,13,14]. ...
    ... A birth cohort study conducted in Pelotas, Brazil, performed the first investiga- tion of the effects of sugar-related feeding practices on changes in dental caries from early childhood to young adulthood [14]. Feeding practices were assessed at 4, 15 and 18 years of age. ...
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    Full-text available
    This chapter aims to address the aspects involved in the relationship between dietary practices and dental caries, such as early introduction of sucrose, frequency and quantity of free sugars consumed. These concepts will be illustrated by previous community experiences in promoting healthy eating practices that have been proposed to prevent dental caries. Additionally, this chapter will address the role of oral hygiene in biofilm control with special emphasis to oral hygiene counselling as a strategy with potential to contribute to the prevention and control of carious lesions. Guidelines for promoting healthy eating practices and oral hygiene will be discussed according to each stage of child growth and development, always recognising the role of the family and the environment throughout the process. In this way, we intend to contribute to the understanding of the aetiology of dental caries as well as in the elaboration and implementation of strategies for prevention and control of the disease.
  • ... Viscous e-liquids made from propylene glycol and glycerin, along with sweet flavors facilitate attachment and provide additional food source which patho- genic oral bacteria such as S. mutans prefer. Youth and young adults are a uniquely vulnerable population to dental caries due to their high-sucrose diet and poor to minimal oral hygiene practice [87][88][89][90]. This study suggests that flavored e-cigarette products negatively affect teeth and pose potential oral health risk. ...
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    Background Most electronic-cigarette liquids contain propylene glycol, glycerin, nicotine and a wide variety of flavors of which many are sweet. Sweet flavors are classified as saccharides, esters, acids or aldehydes. This study investigates changes in cariogenic potential when tooth surfaces are exposed to e-cigarette aerosols generated from well-characterized reference e-liquids with sweet flavors. Methods Reference e-liquids were prepared by combining 20/80 propylene glycol/glycerin (by volume fraction), 10 mg/mL nicotine, and flavors. Aerosols were generated by a Universal Electronic-Cigarette Testing Device (49.2 W, 0.2 Ω). Streptococcus mutans (UA159) were exposed to aerosols on tooth enamel and the biological and physiochemical parameters were measured. Results E-cigarette aerosols produced four-fold increase in microbial adhesion to enamel. Exposure to flavored aerosols led to two-fold increase in biofilm formation and up to a 27% decrease in enamel hardness compared to unflavored controls. Esters (ethyl butyrate, hexyl acetate, and triacetin) in e-liquids were associated with consistent bacteria-initiated enamel demineralization, whereas sugar alcohol (ethyl maltol) inhibited S. mutans growth and adhesion. The viscosity of the e-liquid allowed S. mutans to adhere to pits and fissures. Aerosols contained five metals (mean ± standard deviation): calcium (0.409 ± 0.002) mg/L, copper (0.011 ± 0.001) mg/L, iron (0.0051 ± 0.0003) mg/L, magnesium (0.017 ± 0.002) mg/L, and silicon (0.166 ± 0.005) mg/L. Conclusions This study systematically evaluated e-cigarette aerosols and found that the aerosols have similar physio-chemical properties as high-sucrose, gelatinous candies and acidic drinks. Our data suggest that the combination of the viscosity of e-liquids and some classes of chemicals in sweet flavors may increase the risk of cariogenic potential. Clinical investigation is warranted to confirm the data shown here.
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    Aim To investigate the presence of early childhood caries (ECC) in relation to plaque index, colony-forming units of Streptococcus mutans (S. mutans) and Lactobacillus spp., pH and salivary buffer capacity in day-care pre-schooler’s aged 3–4 years old in Cali, Colombia, 2016. Methods Caries prevalence was determined in 124 children using the International Caries Detection and Assessment System and plaque index. In addition, a non-stimulated saliva sample was obtained to determine its pH, and buffer capacity. Results 55.65% of the children had ECC. The mean decayed-missing-filled teeth index was 2.94 ± 4.26. The absence or presence of ECC, compared to the median plaque index showed statistically significant differences (p < 0.05). There was not an association between ECC and S. mutans, Lactobacillus spp. colonies, pH and buffer capacity of saliva. Conclusions This study reported association between ECC and the increasing amount of bacterial plaque. Other important biological risk factors were not associated with ECC. Regular tooth cleaning can be the most important public health measure to control ECC in day-care children.
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    Prior studies suggest dental caries traits in children and adolescents are partially heritable, but there has been no large-scale consortium genome-wide association study (GWAS) to date. We therefore performed GWAS for caries in participants aged 2.5-18.0 years from 9 contributing centres. Phenotype definitions were created for the presence or absence of treated or untreated caries, stratified by primary and permanent dentition. All studies tested for association between caries and genotype dosage and results were combined using fixed-effects meta-analysis. Analysis included up to 19,003 individuals (7,530 affected) for primary teeth and 13,353 individuals (5,875 affected) for permanent teeth. Evidence for association with caries status was observed at rs1594318-C for primary teeth (intronic within ALLC, Odds Ratio (OR) 0.85, Effect Allele Frequency (EAF) 0.60, p 4.13e-8) and rs7738851-A (intronic within NEDD9, OR 1.28, EAF 0.85, p 1.63e-8) for permanent teeth. Consortium-wide estimated heritability of caries was low (h2 of 1% [95% CI: 0%:7%] and 6% [95% CI 0%:13%] for primary and permanent dentitions, respectively) compared to corresponding within-study estimates (h2 of 28%, [95% CI: 9%:48%] and 17% [95% CI:2%:31%]) or previously published estimates. This study was designed to identify common genetic variants with modest effects which are consistent across different populations. We found few single variants associated with caries status under these assumptions. Phenotypic heterogeneity between cohorts and limited statistical power will have contributed; these findings could also reflect complexity not captured by our study design, such as genetic effects which are conditional on environmental exposure.
  • Thesis
    Objectif : l’objectif principal de cette étude est de mesurer l’impact de l’alimentation et du grignotage sur l’apparition des lésions carieuses et de l’érosion dentaire à l’aide d’une analyse critique de la littérature. Méthode : La recherche documentaire s’est faite de manière électronique à l’aide du site Pubmed ainsi que de la Cochrane Library. Deux équations de recherche distinctes ont été utilisées. Les critères d’inclusion et d’exclusion, ainsi que l’utilisation d’une grille de lecture ont permis in fine de sélectionner 12 articles pour la partie carie, et 14 articles pour la partie érosion. Résultats : sur les 12 études sélectionnées sur la carie, 5 démontrent une relation significative avec la consommation de soda et 3 études associent la consommation de snacks aux caries. L’importance du brossage et l’effet protecteur des produits laitiers sont également mis en évidence. Concernant l’érosion, 8 études sur les 14 sélectionnées montrent que les dents les plus souvent touchées par l’érosion sont globalement les incisives maxillaires et les premières molaires maxillaires. Neuf études trouvent une association significative avec le soda. Enfin, la consommation d’agrumes, de jus de fruits et de bonbons acides est pointée du doigt. L’effet protecteur du lait est à nouveau mis en évidence. Conclusion : Les schémas alimentaires actuels sont responsables de pathologies tant au plan général qu’au plan bucco-dentaire. L’un des objectifs essentiels du métier de chirurgien-dentiste reste donc la prévention, que ce soit en matière d’hygiène bucco-dentaire ou de diététique.
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    Full-text available
    Purpose: To describe total fluid intake (TFI) and types of fluid consumed in urban China by age, gender, regions and city socioeconomic status relative to the adequate intakes (AI) set by the Chinese Nutrition Society. Methods: In 2016, participants aged 4-9, 10-17 and 18-55 years were recruited via a door-to-door approach in 27 cities in China. In total, 2233 participants were included. The volumes and sources of TFI were collected using the Liq.In 7 record, assisted by a photographic booklet of standard fluid containers. Results: The mean daily TFI among children, adolescents and adults were 966, 1177 and 1387 mL, respectively. In each age group, TFI was significantly higher in male vs female (981 vs 949, 1240 vs 1113, 1442 vs 1332; mL). Approximately 45, 36 and 28% of children, adolescents and adults reached the AI. Although plain water was the highest contributor to TFI, the contribution of sugar sweetened beverages (SSB) was ranked in the top three together with water and milk and derivatives. Approximately 27, 48 and 47% of children, adolescents and adults consumed more than one serving of SSB per day, respectively. Conclusions: A relatively large proportion of participants did not drink enough to meet the AI in urban China. Many children, adolescents and adults consumed more than one serving of SSB per day. A majority of children, adolescents and adults in the study population do not meet both quantitative and qualitative fluid intake requirements, and signal socioeconomic disparities.
  • ... Most studies found in the literature on eating habits and dental caries in children relate the consumption of foods and/or beverages that contain sucrose to caries and this association has been well established (Johansson, Lif Holgerson, Kressin, Nunn, & Tanner, 2010;Karjalainen, Sara, Soderling Eva, Sewon Liisi, Lapinleimu Helena, 2001;Marshall et al., 2003;Moynihan & Kelly, 2014;Palmer et al., 2010;Peres et al., 2015;Sheiham & James, 2015;Warren et al., 2009;Watanabe et al., 2014). In the present investigation, the association between the frequency of the consumption of cariogenic foods and the prevalence of dental caries among preschool children was also found, as a greater daily consumption of foods and beverages with sucrose translated to a greater prevalence rate of caries in the population studied. ...
    Article
    OBJECTIVE: Evaluate the association of the consumption of healthy and cariogenic foods with the prevalence of untreated dental caries among preschool children. MATERIALS AND METHODS: A cross-sectional study was conducted with 427 five-year-old preschoolers. Caries was evaluated through a clinical exam (dmft). Parents/guardians answered a questionnaire addressing socioeconomic status, eating frequency and oral hygiene habits. RESULTS: The prevalence of untreated caries was 51%. The multiple models demonstrated a seven percent increase in the prevalence of untreated caries with each additional daily contact with cariogenic foods, whereas a four percent reduction in this prevalence rate was found for each additional contact with healthy foods. When the number of daily contacts with cariogenic and healthy foods were incorporated into the same model, the former reached only borderline statistical significance (p=0.05), whereas the latter maintained an association with lower caries rates (p=0.01). CONCLUSION: A dietary assessment based solely on the frequency of the consumption of cariogenic foods may not be sufficient to understand the occurrence of dental caries in preschool children. It is necessary a more comprehensive evaluation of the dietary pattern, once a healthy diet can present an association with lower prevalence of caries even among preschool children who consume cariogenic foods. This article is protected by copyright. All rights reserved.
  • Early-life feeding behaviors foretell later dietary habits and health outcomes. Few studies have examined infant dietary patterns and caries occurrence prospectively. Assess whether patterns in food and drink consumption before age 12 months are associated with caries incidence by preschool age. We collected early-life feeding data within a birth cohort from low-income families in Porto Alegre, Brazil. Three dietary indexes were defined, based on refined sugar content and/or previously reported caries associations: a count of sweet foods or drinks introduced <6-months (e.g., candy, cookies, soft drinks), a count of other, nonsweet items introduced <6-months (e.g., beans, meat), and a count of sweet items consumed at 12 months. Incidence of severe early childhood caries (S-ECC) at age 38 months (N = 458) was compared by score tertile on each index, adjusted for family, maternal, and child characteristics using regression modeling. Introduction to a greater number of presumably cariogenic items in infancy was positively associated with future caries. S-ECC incidence was highest in the uppermost tertile of the ‘6-month sweet index’ (adjusted cumulative incidence ratio, RR, versus lowest tertile: 1.46; 95% CI: 0.97, 2.04) and the uppermost tertile of the ‘12-month sweet index’ (RR: 1.55; 95% CI: 1.17, 2.23). The association was specific for sweet items: caries incidence did not differ by tertile of the ‘6-month nonsweet index’ (RR: 1.00; 95% CI: 0.70, 1.40). Additionally, each one-unit increase on the 6-month and the 12-month sweet indexes, but not the 6-month nonsweet index, was statistically significantly associated with greater S-ECC incidence and associated with more decayed, missing, or restored teeth. Results were robust to minor changes in the items constituting each index and persisted if liquid items were excluded. Dietary factors observed before age 12-months were associated with S-ECC at preschool age, highlighting a need for timely, multilevel intervention.
  • Article
    Objective: To examine the quantitative relationship between sugar intake and the progressive development of dental caries. Design: A critical in-depth review of international studies was conducted. Methods included reassessing relevant studies from the most recent systematic review on the relationship between levels of sugars and dental caries. Reanalysis of dose-response relationships between dietary sugars and caries incidence in teeth with different levels of caries susceptibility in children was done using data from Japanese studies conducted by Takeuchi and co-workers. Setting: Global, with emphasis on marked differences in both national sugar intake and fluoride use and preferably where one factor such as sugar intake changed progressively without changes in other factors over a decade or more. Subjects: Children aged 6 years or more and adults. Results: Caries occurred in both resistant and susceptible teeth of children when sugar intakes were only 2-3 % of energy intake, provided that the teeth had been exposed to sugars for > 3 years. Despite increased enamel resistance after tooth eruption, there was a progressive linear increase in caries throughout life, explaining the higher rates of caries in adults than in children. Fluoride affects progression of caries development but there still is a pandemic prevalence of caries in populations worldwide. Conclusions: Previous analyses based on children have misled public health analyses on sugars. The recommendation that sugar intakes should be <= 10 % of energy intake is no longer acceptable. The much greater adult burden of dental caries highlights the need for very low sugar intakes throughout life, e. g. 2-3% of energy intake, whether or not fluoride intake is optimum.
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  • Article
    A systematic review of studies in humans was conducted to update evidence on the association between the amount of sugars intake and dental caries and on the effect of restricting sugars intake to < 10% and < 5% energy (E) on caries to inform the updating of World Health Organization guidelines on sugars consumption. Data sources included MEDLINE, EMBASE, Cochrane Database, Cochrane Central Register of Controlled Trials, Latin American and Caribbean Health Sciences, China National Knowledge Infrastructure, Wanfang, and South African Department of Health. Eligible studies reported the absolute amount of sugars and dental caries, measured as prevalence, incidence, or severity. The review was conducted and reported in accordance with the PRISMA statement, and the evidence was assessed according to GRADE Working Group guidelines. From 5,990 papers identified, 55 studies were eligible - 3 intervention, 8 cohort, 20 population, and 24 cross-sectional. Data variability limited meta-analysis. Of the studies, 42 out of 50 of those in children and 5 out of 5 in adults reported at least one positive association between sugars and caries. There is evidence of moderate quality showing that caries is lower when free-sugars intake is < 10% E. With the < 5% E cut-off, a significant relationship was observed, but the evidence was judged to be of very low quality. The findings are relevant to minimizing caries risk throughout the life course.
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    This article is a follow-up to Jones, Nagin, and Roeder (2001), which described an SAS procedure for estimating group-based trajectory models. Group-based trajectory is a specialized application of finite mixture modeling and is designed to identify clusters of individuals following similar progressions of some behavior or outcome over age or time. This article has two purposes. One is to summarize extensions of the methodology and of the SAS procedure that have been developed since Jones et al. The other is to illustrate how group-based trajectory modeling lends itself to presentation of findings in the form of easily understood graphical and tabular data summaries.
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    This article introduces a new SAS procedure written by the authors that analyzes longitudinal data (developmental trajectories) by fitting a mixture model. The TRAJ procedure fits semiparametric (discrete) mixtures of censored normal, Poisson, zero-inflated Poisson, and Bernoulli distributions to longitudinal data. Applications to psychometric scale data, offense counts, and a dichotomous prevalence measure in violence research are illustrated. In addition, the use of the Bayesian information criterion to address the problem of model selection, including the estimation of the number of components in the mixture, is demonstrated.
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    The Global Burden of Disease (GBD) 2010 Study produced comparable estimates of the burden of 291 diseases and injuries in 1990, 2005, and 2010. This article reports on the global burden of untreated caries, severe periodontitis, and severe tooth loss in 2010 and compares those figures with new estimates for 1990. We used disability-adjusted life-years (DALYs) and years lived with disability (YLDs) metrics to quantify burden. Oral conditions affected 3.9 billion people, and untreated caries in permanent teeth was the most prevalent condition evaluated for the entire GBD 2010 Study (global prevalence of 35% for all ages combined). Oral conditions combined accounted for 15 million DALYs globally (1.9% of all YLDs; 0.6% of all DALYs), implying an average health loss of 224 years per 100,000 population. DALYs due to oral conditions increased 20.8% between 1990 and 2010, mainly due to population growth and aging. While DALYs due to severe periodontitis and untreated caries increased, those due to severe tooth loss decreased. DALYs differed by age groups and regions, but not by genders. The findings highlight the challenge in responding to the diversity of urgent oral health needs worldwide, particularly in developing communities.