Abstract Dental caries, commonly known as tooth decay, is a significant health concern among children globally. It is one of the most prevalent chronic diseases in pediatric populations, affecting millions of children each year. The role of nutrition in the development and prevention of dental caries is critical, yet complex, involving various dietary factors and habits. The aim of this study to explore and analyze the relationship between nutrition and dental caries in children. This case-control study was conducted at the pediatric clinic in the College of Dentistry, Uruk University, Iraq, between April 2023 to June 2023. The study involved 100 children aged 4 to 14 years, categorized into four groups: underweight, overweight, at-risk weight, and healthy weight, with 25 children in each group. BMI was calculated, and dental caries were assessed using the decayed, missing, and filled surfaces (dmfs/DMFS) index according to WHO criteria. The study revealed that there were no variations in tooth decay occurrences across the four weight categories. Nevertheless, noticeable disparities in body mass index (BMI) were evident among the groups (P = 0.000). In the healthy weight group, a negative relationship between BMI and, dmfs was identified, while a positive connection was observed between BMI and DMFS in the underweight group. The results suggest that factors other than weight, such as eating habits, dental care routines, and social and economic circumstances, can have a significant impact on children's dental health. Efforts to enhance nutrition and oral hygiene should consider a broader set of elements rather than focusing solely on weight.

Keywords: Dental caries, Nutrition, Pediatric oral health, Body Mass Index (BMI), DMFS, dmfs.

Citation: Basim, Y. and Al-Dahan, Z.A.A. 2025. Nutritional analysis in relation to dental caries among children. Natural and Life Sciences Communications. 24(2): e2025033.

INTRODUCTION

Tooth decay, also known as dental caries, is a serious health concern affecting children worldwide. It is a long-term issue, impacting young individuals every year. Early onset of cavities can lead to pain, infections, and potentially impact a child's overall health and happiness (Earls and Carlson, 2001; Ozdemir, 2013).

Maintaining health relies heavily on proper nutrition, which plays a vital role in preventing dental cavities. A balanced diet is not only important for overall well-being but also critical for keeping teeth and gums in top shape. Unhealthy eating patterns in kids can negatively impact their health and contribute to the formation of tooth decay (Moynihan and Petersen, 2004; Jevtic et al., 2015; Talib and Taha, 2024).

The development of tooth decay involves an interaction between eating habits, hygiene, and the presence of cavity-causing bacteria. Consuming sugary foods and carbohydrates plays a crucial role in causing tooth decay. When these carbohydrates are metabolized by bacteria in the mouth, they produce acids that can weaken tooth enamel and lead to cavities (Ozdemir, 2013; Feldens et al., 2019).

Beyond sugars, other aspects of diet—such as how you eat and the types of foods and drinks you consume—are also important. Conversely, certain nutrients such as fluoride, calcium, and phosphates assist in remineralization and help protect against cavities (Tinanoff and Palmer, 2000; Zohoori, 2020).

Research has explored the connection between nutrition and dental cavities, but there are still some unknowns that require further investigation. For example, while the harmful effects of sugar on dental health are widely recognized, the influence of eating habits and specific nutrients is not as well understood. Additionally, there is a need for in-depth studies that consider the various factors contributing to cavities, such as socioeconomic conditions, access to dental services, and overall dietary practices (Tinanoff and Palmer, 2000; Zohoori, 2020; Dimopoulou et al., 2023; Ali and Taha, 2024). The main goal of this research is to investigate and understand the connection between children's nutrition and tooth decay.

MATERIALS AND METHODS

This case-control study was conducted at a pediatric clinic in the College of Dentistry of Uruk University, Iraq, between April 2023 to June 2023. The study involved 100 children aged between 4 and 14 years, divided into four groups: 25 children underweight, 25 children overweight, 25 children at-risk weight, and 25 healthy children.

Sample size

The sample size calculation was performed using G*Power version 3.1.9.7 for a one-way ANOVA with four groups, targeting 85% power, and a 5% significance level. Based on a medium effect size, the total sample size required was 100 participants, 25 participants per group.

Ethical approval

Ethical approval was obtained from the scientific committee at the College of Dentistry of Uruk University (Project No. 233006). Furthermore, the necessary permissions were obtained from the Ministry of Health and the Ministry of Education to carry out clinical examinations and laboratory biochemical tests. In addition, each participant was given a written consent form and a patient information leaflet to request approval from the child's parents or carers.

Inclusion criteria

Selection of cases based on the followings

1.  They were already diagnosed with dental caries.

2.  Cooperative child.

3.  Age range 4 to 14 years

Exclusion criteria

1.  Children known by their medical history that they suffering from any systemic disease which could influence the severity of dental caries or the occurrence of periodontal diseases, such as periodentitits and gingivitis.

2.  Un cooperative child.

3.  Children who their parents refuse their participation in the study.

The weight was recorded via an electronic digital scale and rounded to the closest 1 kg. The BMI was calculated by dividing the weight in kilogrammes by the square of the height in meters. The Body Mass Index (BMI) was classified into four categories: underweight (BMI < 18.5), normal weight (BMI 18.5–24.9), overweight (BMI 25–30), and at-risk weight (BMI > 30) (de Onis, 2007).

Oral examination

The clinical examination and evaluation of the oral health of each participant was performed under standardized condition described in the oral health survey of the WHO (2013). During examination, a suitable comfortable chair was used with noticing that it supports the head of the child. Dental caries experience was recorded according to the decayed, missing, filled index (dmfs/ DMFS) according to the criteria of WHO (2013) using a CPI probe.

Statistical analysis

The data analysis was conducted using SPSS Ver. 26.0 and Excel 2019. The data from the current study underwent thorough testing for normality to determine whether it followed a parametric or non-parametric distribution. Consequently, Chi-Square tests and LSD (Least Significant Difference) One-Way ANOVA post hoc analyses were conducted.

RESULTS

The age distribution of children in four weight categories: healthy, underweight, overweight, and at-risk weight shown in Table 1. The mean ages are 9.44, 8.36, 9.20, and 8.68 years, respectively, with standard deviations indicating moderate variability within each group. The overall age range is 4 to 14 years. Statistical analysis, with a p-value of 0.298, shows no significant differences in mean ages across the groups.

The proportions of females (27.6%, 24.1%, 22.4%, 25.9%) and males (21.4%, 26.2%, 28.6%, 23.8%) are similar in each group, with a total count of 58 females and 42 males. With a statistical analysis, there was a non-significant difference
(P =0.844) in gender distribution among the groups. As demonstrated in Table 2.

Table 1. Demographic data of age.

Table 2. Demographic data of gender.

Table 3 illustrates the caries experience in primary teeth among four weight groups: healthy, underweight, overweight, and at-risk weight. The mean decayed, missing, and filled surfaces (dmfs) scores are 6.72, 12.04, 8.04, and 6.28, respectively.

The statistical analysis shows no significant differences in caries experience across the groups, with F-values of 2.290 (P = 0.083) for decayed surfaces, 0.099 (P = 0.961) for missing surfaces, 0.670 (P = 0.573) for filled surfaces, 1.915 (P = 0.132) for dmfs, and 2.422 (P = 0.071) for decayed, missing, and filled teeth (dmft).

Table 3.  Descriptive and statistical test of caries experience of primary teeth among groups.

Regarding caries experience in permanent teeth across four weight groups: healthy, underweight, overweight, and at-risk weight observed in Table 4.

The mean decayed, missing, and filled surfaces (DMFS) scores are 4.32, 3.96, 4.48, and 2.68, respectively, with standard deviations reflecting variability within each group. Statistical analysis shows no significant differences in caries experience among the groups, with F-values of 1.122 (P = 0.344) for decayed surfaces, 0.724 (P = 0.540) for missing surfaces, 0.453 (P = 0.715) for filled surfaces, 0.607 (P = 0.612) for DMFS, and 1.156 (P = 0.331) for decayed, missing, and filled teeth (DMFT).

Table 4. Descriptive and statistical test of caries experience of permanent teeth among groups.

The Body Mass Index (BMI) data in groups. The mean BMI values are 16.98, 16.02, 22.11, and 24.68, respectively. Statistical analysis reveals significant differences in BMI among the groups (P= 0.000). As illustrated in Table 5.

Table 5. Descriptive and statistical test of BMI among groups.

Table 6 shows multiple comparisons of BMI between the four weight groups: healthy, underweight, overweight, and at-risk weight. Significant differences are found between several pairs: healthy vs. overweight (-5.12480, P = 0.024), healthy vs. at-risk (-7.70040, P = 0.001), underweight vs. overweight (-6.08920, P = 0.007), and underweight vs. at-risk (-8.66480, P = 0.000).

No significant differences are found between healthy vs. underweight, overweight vs. at-risk, and at-risk vs. overweight (P >0.05).

Table 6. Multiple comparisons between groups among BMI.

Note: *. The mean difference is significant at the 0.05 level.

Table 7 shows the correlation between BMI and caries experience in primary teeth among four weight groups: healthy, underweight, overweight, and at-risk weight. For the healthy group, BMI negatively correlates with decayed surfaces (ds) (r = -0.555, P = 0.004) and dmfs (r = -0.432, P = 0.031). The underweight group shows no significant correlations. In the overweight group, BMI negatively correlates with dmfs (r = -0.142, P = 0.500), but it is not significant. The at-risk weight group shows no significant correlations.

Table 7. Correlation between BMI and caries experience of primary teeth.

The correlation between BMI and caries experience in permanent teeth across four weight groups: healthy, underweight, overweight, and at-risk weight observed in Table 8. In the healthy group, BMI shows a significant positive correlation with decayed surfaces (DS) (r = 0.434, P = 0.030), DMFS (r = 0.476, P = 0.016), and DMFT (r = 0.471, P = 0.018). In the underweight group, BMI also positively correlates with DS (r = 0.430, P = 0.032) and DMFS (r = 0.426, P = 0.034). In contrast, the overweight and at-risk weight groups show no significant correlations between BMI and any caries experience metrics.

Table 8. Correlation between BMI and caries experience of permanent teeth.

DISCUSSION

Childhood obesity is a fast escalating and significant global public health issue (Consultation, 2000; Lobstein and Frelut, 2003; Berghöfer et al., 2008). The likelihood of obesity continuing into adulthood is greater in cases of more severe overweight and obesity. Therefore, the most alarming rise in childhood obesity occurs among those at the highest end of the BMI range (Ekelund et al., 2004; Freedman, Khan, et al., 2005; Freedman, Ogden, et al., 2005; Yngve et al., 2007). While there has been a significant rise in childhood overweight and obesity in recent decades, the prevalence of dental caries, a chronic illness, has shown a notable decline in most Western nations over the last 20 years (Petersen, 2003). The correlation between dental caries and childhood or adolescent overweight/obesity has garnered increasing attention. However, the findings of earlier research have not provided solid evidence (Sánchez-Pérez et al., 2010; D’MELLO et al., 2011). Childhood and teenage overweight/obesity and caries are both complex disorders that occur together in many communities (Kantovitz et al., 2006). The correlation between dental caries and obesity is not a causative relationship, but rather a coexistence that may occur in a community due to the clustering of shared contributing variables. These factors include genetics, socioeconomic status, cultural influences, sugar consumption, environmental factors, and lifestyle choices (Davison and Birch, 2001; Must et al., 2012). The difficulty in examining the connection is in quantifying any confounding factors or variables that may modify the impact (Hong et al., 2008).

The current study provides the result of the caries experience in primary teeth and permanent teeth across different weight categories: healthy, underweight, overweight, and at-risk weight. The findings suggest that although there are differences in the mean dmfs and DMFS scores among the weight groups, these differences are not statistically significant. The underweight group had an average dmfs score of 12.04, while the at-risk weight group showed an average DMFS score of 2.68. This finding might be surprising, as one might assume that the overweight or at-risk weight groups would have more cavities due to dietary patterns commonly linked to these groups. However, the absence of variations suggests that body weight alone might not play a significant role in the occurrence of cavities in both baby and adult teeth. Moreover, the connection between weight and tooth decay is intricate and could involve both biological and behavioral mechanisms. Factors such as diet quality, oral hygiene habits, and socioeconomic status can impact both body weight and oral health. In agreement with Naidoo, (2013), Underweight children may have dietary restrictions that could increase sugar intake from certain foods, resulting in higher caries experience. Conversely, overweight children might have access to higher quantities of sugary snacks, but their overall diet could be more balanced, mitigating the risk of caries (Naidoo, 2013). The link between Obesity and dental caries in this study aligns with other clinical studies conducted by Willershausen et al. (2007), Alm et al. (2008), Gerdin et al. (2008), and Modéer et al. (2010), although conflicting results are presented by (Tuomi, 1989; Kantovitz et al., 2006; Flink et al., 2008). 

In contrast, Marshall et al. (2007) caries and obesity coexists in children of low socioeconomic status (Marshall et al., 2007). One potential reason for varying findings on the link between dental caries and obesity is that researchers sometimes fail to account for factors that may influence the results, such as sociodemographic variables. Furthermore, the correlation between obesity and dental caries is likely to be weak and might fluctuate over time and across various locations owing to variations in preventative fluoride programs targeted at children (Gerdin et al., 2008).

The findings indicate significant differences in BMI between several pairs of weight groups.

The nutritional intake of individuals within each weight group is likely to differ significantly. Healthy individuals may consume a balanced diet rich in fruits, vegetables, and whole grains, while overweight and at-risk individuals may have higher caloric intake from processed foods and sugary beverages (Touger-Decker and van Loveren, 2003; Moynihan et al., 2018). Additionally, physical activity is a critical determinant of BMI. Healthy and underweight individuals may engage in more regular physical activity, whereas overweight and at-risk individuals may lead more sedentary lifestyles, contributing to higher BMI values (Achmad et al., 2021).

Also, individual metabolic rates can also play a role in determining BMI. Genetic predispositions, hormonal balances, and other metabolic factors can influence how the body stores fat and utilizes energy, leading to differences in BMI across weight groups.

An inherent limitation of this research is the inability to analyse the extent of preventative treatment provided to patients. The variables "not daily tooth-brushing in the evening or morning" did not introduce any additional factors that might have influenced the association between obesity and dental caries.  The usage of fluoride in toothpaste during the tooth-brushing technique is crucial because to its notable anticaries impact. Nevertheless, it is important to consider the possibility that there may be variations in preventive treatment across the groups, which might potentially impact the magnitude of the association between obesity and dental caries. This research did not find any correlation between caries experience, measured in terms of dmft and DMFT, and weight groups. According to our data, it is more suitable to utilise decaying surface as the outcome variable. The length of obesity in the participants was not recorded, which may potentially be significant when considering the relationship between obesity and dental caries, in addition to the degree of obesity.

CONCLUSIONS

This study underscores the multifactorial nature of dental caries, suggesting that factors beyond weight, such as dietary habits, oral hygiene practices, and socio-economic conditions, may significantly influence children's oral health. The lack of significant differences in caries experience across weight categories suggests that interventions to improve nutrition and dental health should address a broader range of factors beyond weight status. Future research should aim to clarify these relationships and explore effective strategies for preventing dental caries in children.

ACKNOWLEDGEMENTS

The authors thank the College of Dentistry, Uruk University for providing instruments.

AUTHOR CONTRIBUTIONS

Yasir basim: contributed to conceptualizing, validation, writing original draft, supervision, and project administration, also contributed to the methodology, formal analysis, resources, original draft, review, editing, and visualization.

Zainab Al-Dahan: contributed to the methodology, formal analysis, resources, original draft, review, editing, and visualization.

CONFLICT OF INTEREST

The authors declare that they hold no competing interests.

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