Journal of Dental Research

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Carbonated Soft Drinks and Dental Caries in the Primary Dentition

W. Sohn, B.A. Burt and M.R. Sowers
J DENT RES 2006 85: 262
DOI: 10.1177/154405910608500311

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 RESEARCH REPORTS
Clinical
W. Sohn1*, B.A. Burt2, and M.R. Sowers2
1 Department
of Cariology, Restorative Sciences, and
Endodontics, School of Dentistry, University of Michigan,
1101 N. University, Ann Arbor, MI 48109-1078, USA; and
2Department of Epidemiology, School of Public Health,
University of Michigan; *corresponding author,
woosung@umich.edu
J Dent Res 85(3):262-266, 2006
ABSTRACT
We analyzed fluid intake data among children
aged 2-10 years from a 24-hour dietary recall
interview in the NHANES III (1988-94) to
investigate the effect of high consumption of
carbonated soft drinks on caries in the primary
dentition. We used cluster analysis to determine
fluid consumption patterns. Four distinct fluid
consumption patterns were identified: high
carbonated soft drinks, high juice, high milk, and
high water. About 13% of children had a high
carbonated soft drink consumption pattern; they
also had a significantly higher dental caries
experience in the primary dentition than did
children with other fluid consumption patterns. A
fluid intake pattern comprised mainly of milk,
water, or juice was less likely to be associated
with dental caries. Findings of this study suggest
that high consumption of carbonated soft drinks
by young children is a risk indicator for dental
caries in the primary dentition and should be
discouraged.
KEY WORDS: fluid consumption pattern,
carbonated, soft drinks, NHANES III, cluster
analysis, dental caries, primary dentition.
Received August 12, 2004; Last revision August 26, 2005;
Accepted October 27, 2005
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International and American Associations for Dental Research
Carbonated Soft Drinks
and Dental Caries
in the Primary Dentition
INTRODUCTION
Pconditions
atterns of fluid consumption by children are of public health interest,
since they may be related to both oral health and general health
such as obesity and diabetes (Marshall, 2003). It has been
reported that contemporary fluid consumption patterns of children are now
more diverse than in past years, since carbonated soft drinks and fruit juices
have replaced much of the previous consumption of water and milk among
children (Harnack et al., 1999; Heller et al., 1999). The implications of
these changes in fluid consumption have not been well-studied, especially
the association between carbonated soft drink consumption and dental
caries. While the association between the consumption of sugars (all mono-
and disaccharides) and dental caries experience in permanent teeth has been
well-documented (Ismail et al., 1984; Rugg-Gunn, 1996; Jones et al., 1999),
the association between carbonated soft drink consumption and dental caries
in the primary dentition is less clear. Some studies have reported significant
associations (Grindefjord et al., 1995; Moynihan and Holt, 1996; Levy et
al., 2003), while others did not (Heller et al., 2001; Sayegh et al., 2002).
These inconsistencies may arise because fluid consumption patterns are
complex and methodologically challenging to ascertain. For example, like
other diet and nutrition data, fluid consumption sources are highly
correlated, which precludes testing the association between fluid intake from
a single source and a disease outcome without considering the effect of fluid
intake from other sources (Wirfalt and Jeffery, 1997). To develop a more
simple measure of complex patterns, some investigators have used cluster
analysis (Aldenderfer and Blashfield, 1984) to aggregate dietary patterns
and then associate the patterns with disease outcomes (Akin et al., 1986;
Tucker et al., 1992; Wirfalt and Jeffery, 1997).
The aims of this analysis were: (1) to identify, by cluster analysis,
distinct fluid consumption patterns, with a focus on high consumption of
carbonated soft drinks, among children aged 2 to 10 yrs; and (2) to assess
the association between high consumption of carbonated soft drinks and
dental caries in the primary dentition among children in the United States.
MATERIALS & METHODS
The NHANES III Survey
Data for Fluid Consumption
This analysis used fluid intake data from a 24-hour dietary recall interview in the
Third National Health and Nutrition Examination Survey (NHANES III, 1988-
94) in the United States (National Center for Health Statistics, 1994). Detailed
descriptions of the data preparation and variables used in this analysis can be
found elsewhere (Sohn et al., 2001). We defined major fluid sources as milk (and
milk drinks), juice (fruit and vegetable juices and other non-carbonated drinks),
carbonated soft drinks (sugared and non-sugared), plain water (tap and spring
water), and coffee and tea. Fluid intake from sources other than these major
J Dent Res 85(3) 2006 Carbonated Soft Drink Consumption and Dental Caries 263

sourcessuch as soup, homemade beverages, and water used for
cookingwas all grouped into 'other foods and beverages'. This
definition is consistent with previous studies from other researchers
(Ershow and Cantor, 1989; Heller et al., 1999). In this analysis,
sugared and non-sugared carbonated soft drinks were not separated;
natural juice and fruit-based juice drinks were also not separated.
Dental Caries Data
Dental caries data were obtained in the form of decayed and filled
tooth surfaces (dfs) in the primary dentition through dental
examinations conducted at the Mobile Examination Centers
(MECs) during the NHANES III. Details of dental caries
examinations and diagnostic criteria have been described (Kaste et
al., 1996). The sample for this analysis consisted of the 5985
children aged 2-10 yrs who completed both a 24-hour dietary
interview and dental examination during the NHANES III. Due to
a skewed distribution of dental caries among children, a
dichotomized dental caries outcome was used in the analysis, i.e.,
children with at least one decayed or filled primary tooth surface
vs. those with no decayed or filled primary tooth surface.
Sociodemographic Information
Race and ethnicity classifications were non-Hispanic whites, non-
Hispanic Blacks (African-Americans), Mexican-Americans, and
Others. The 'Others' category included all Hispanics, regardless of
race, who were not Mexican-American and also all non-Hispanics
from racial groups other than whites or African-Americans. Socio-
economic status (SES) was categorized on the basis of the poverty
income ratio (PIR), which is a ratio of reported annual family
income to the Federal poverty threshold. The categories of SES in
this analysis were: low SES (0.000-1.300 PIR), middle SES
(1.301-3.500 PIR), and high SES (3.501 and above PIR).
Statistical Analysis
We used cluster analysis to group children based on similarity of
fluid consumption patterns. The FASTCLUS procedure in the
Statistical Analysis System Software (version 9.1, SAS Institute,
Inc., Cary, NC, USA) was used for this cluster analysis.
FASTCLUS performs a disjoint cluster analysis on the basis of
Euclidean distances computed from one or more quantitative
variables. The observations are divided into clusters such that
every observation belongs to a unique cluster (SAS Institute Inc.,
1989-1996). The dataset is first scanned for initial cluster 'seeds'.
The procedure then makes repeated comparisons between the
variable means of initial clusters with subsequent updates of
cluster groupings and means. Subjects are moved between clusters
and new means are computed until the distances between
observations within a cluster are smaller than the distances
between cluster means.
We conducted the cluster analysis based on the proportions of
total fluid intake represented by each of the four primary sources
defined above, rather than the absolute amount of fluid intake.
With the FASTCLUS procedure, the number of clusters as an
outcome must be pre-determined. We did this by evaluating
various cluster numbers (2 to 10) by comparing the approximate R-
squared values and the within-cluster standard deviations. The R-
squared value increased with more clusters, but the within-cluster
standard deviations no longer decreased after four clusters, which
was the criterion for determining the number of clusters to be used
in our analyses.
Drinking habits and amounts varied substantially by children's
age in our preliminary analysis. Hence, the cluster analysis
procedures were applied to data that were stratified by children's
age groups: 2-year-olds (toddlers), 3- to 5-year-olds (pre-school
children), and 6- to 10-year-olds (school-aged children).
The crude associations between dental caries and fluid
consumption groups, as well as with other sociodemographic
characteristics, were analyzed with the chi-square test.
Subsequently, a multivariate logistic regression model was
constructed to predict dental caries in the primary dentition with
fluid consumption patterns and sociodemographic factors.
All analyses incorporated sampling weights to adjust for
unequal sampling probabilities and non-response bias (National
Center for Health Statistics, 1994). We used SUDAAN (Release
9.0.0 SAS Callable, Research Triangle Institute, Research Triangle
Park, NC, USA) to estimate variances adjusted for the design
effect from the complex, multi-stage cluster sample design of
NHANES III (Shah et al., 1997).
RESULTS
Fluid Consumption Patterns
Carbonated soft drinks comprised 8.5% of total fluid
consumption among children aged 2-10 yrs. Milk and juice
each comprised less than 20%, whereas plain water constituted
about 32% of total fluid consumption (Table 1).
Cluster analysis identified the four groupings with distinct

Table 1. Fluid Consumption Clusters and Fluid Consumption Profile among Children Aged 2-10 Years Old: NHANES III (1988-1994)

Fluid Consumption Pattern (cluster)

High Carbonated High Juice High Milk High Plain
Fluid Source Total Soft Drink (HS) (HJ) (HM) Water (HW)

(n = 5985) (n = 619) (n = 1201) (n = 1387) (n=2778)

mL/day % mL/day % mL/day % mL/day % mL/day %

Coffee/tea 30.8 1.9 29.9 2.1 27.5 2.0 35.2 2.3 30.1 1.6
Carbonated soft drinks 145.0 8.5 510.1* 31.8 66.5 4.4 76.5 5.0 113.9 5.5
Juice 226.6 13.7 106.8 7.0 524.3 34.5 131.7 8.7 168.3 8.2
Milk 323.6 19.4 228.9 14.2 196.5 12.9 569.8 38.2 272.0 13.2
Plain water 637.4 31.6 332.0 19.1 305.6 18.9 296.6 18.5 1098.5 49.5
Other/food 423.2 24.7 403.4 25.7 404.9 26.9 413.5 27.1 444.1 21.9
Total fluid 1789.9 100.0 1611.9 100.0 1533.2 100.0 1526.8 100.0 2128.6 100.0

* Numbers in bold indicate amount and percentage from a major fluid source of each cluster.
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International and American Associations for Dental Research

264 Sohn et al. J Dent Res 85(3) 2006

fluid consumption profiles (Table 1). There was a clear pattern surface in the primary dentition; the mean number of decayed
in each fluid consumption grouping, based on the proportion of and filled primary tooth surfaces (dfs) was 2.94. Only 52% of
major fluid sources. For example, the first (left-most column) children with high carbonated soft drink consumption were
grouping constituted, on average, 31.8% of the total fluid caries-free, which was from 10% to 15% lower than children in
intake from carbonated soft drinks, and was labeled as the high the other groups (Table 2). In a logistic regression model, these
carbonated soft drink consumption cluster. The other groupings children were about 1.8 times more likely to experience dental
were similarly named, according to their largest contributing caries in the primary dentition than those in the 'high milk' and
fluid sources: high juice consumption cluster, high milk 'high water' clusters, after adjustment for age, race/ethnicity,
consumption cluster, and high plain water consumption cluster, sex, and SES (Table 3). Children in the 'high carbonated soft
respectively. Overall, 619 children (12.7%) were grouped in the drink consumption' cluster also showed a significantly higher
'high carbonated soft drink consumption' cluster. Similarly, tendency toward caries experience than those in the 'high juice'
21.1% were grouped in the 'high juice' cluster, 24.5% in the clusters. While children of the 'high juice' cluster showed a
'high milk' cluster, and 41.7% in the 'high plain water' cluster higher tendency toward caries experience than those children in
(Table 1). the 'high milk' and 'high water' clusters, the differences were
There were significant associations between the fluid not statistically significant. Children with a high milk
consumption pattern and sociodemographic factors (Table 2). consumption pattern had a tendency toward lowest caries
High carbonated soft drink consumption and high water intake experience. The model explained about 15% of variability of
appeared to be more characteristic of older children (aged 6-10 dental caries prevalence among children.
yrs). Boys showed slightly higher carbonated soft drink
consumption than girls. African-American children showed
DISCUSSION
higher water consumption and lower milk consumption than
children from other race/ethnic groups. White children showed Using the cluster analysis method, we analyzed children's fluid
a higher tendency toward high carbonated soft drink consumption patterns. To our knowledge, this is the first cluster
consumption than children from other race/ethnic groups. analysis of fluid consumption patterns among children in the
There was a positive association between SES and high United States. We identified four distinct fluid consumption
carbonated soft drink and high juice consumption, and an patterns. Because different clustering methods can generate
inverse relationship between SES and the 'high water different solutions in the same dataset, several trials with higher
consumption' pattern. numbers of groupings (5 to 10 clusters) were evaluated to
provide more detailed fluid consumption patterns (i.e., high-
Carbonated Soft Drink Consumption milk-high-juice; high-juice-high-water; and so on). However,
and Dental Caries in the Primary Dentition more complicated patterns were not necessarily always clearly
About 38% of children had at least one decayed or filled tooth discernible, or useful in subsequent analyses.
Children with high
Table 2. Socio-demographic Characteristics, Dental Caries Status, and Fluid Consumption Clusters among Children carbonated soft drink
Aged 2-10 Years Old: NHANES III (1988-1994) consumption had a
significantly higher
Proportion of Fluid Consumption Pattern (cluster) (% SE)a prevalence of dental
High Carbonated High p-value caries in the primary
N (%)b Soft Drink High Juice High Milk Plain Water (chi2) dentition than did
children with any other
Age Group < 0.001 fluid consumption pat-
2 yrs 964 ( 10.6) 9.5 1.3 24.6 2.0 28.3 2.3 37.6 2.1 tern. We did not sep-
3-5 yrs 2689 ( 33.4) 8.9 1.0 23.6 1.4 28.3 1.1 39.1 1.9 arately analyze sugared
6-10 yrs 2332 ( 56.0) 15.5 2.0 18.9 1.3 21.5 1.3 44.0 2.4 and non-sugared carbon-
Sex 0.046 ated soft drinks, due to a
M 3000 ( 51.8) 14.1 1.3 19.4 1.4 25.6 1.9 40.9 2.1 small number of children
F 2985 ( 48.2) 11.1 1.4 23.0 1.6 23.4 1.4 42.5 2.0 (only 6.7%) who re-
Race/Ethnicity < 0.001 ported consuming non-
White 1694 ( 66.1) 14.9 1.6 21.7 1.4 25.3 1.8 38.1 2.2 sugared carbonated soft
African-Am. 1891 ( 15.4) 8.6 0.9 21.3 1.2 13.5 1.2 56.5 1.8 drinks. A preliminary
Mexican-Am. 2135 ( 9.3) 9.8 1.0 16.7 1.2 28.9 2.5 44.6 2.6 analysis showed that
Other 265 ( 9.2) 6.8 2.8 21.0 3.2 32.7 3.7 39.8 4.0 cluster analysis with
SES < 0.001 non-sugared carbonated
Low 2820 ( 33.9) 10.9 1.4 17.2 1.5 22.0 1.8 49.9 2.2 soft drinks as a separate
Middle 2116 ( 46.6) 13.1 1.3 21.2 1.4 26.3 1.8 39.4 2.2 entity yielded results that
High 570 ( 19.5) 15.7 3.0 28.0 2.9 23.4 2.7 32.9 3.1 did not differ from those
Caries-free Children (%)b 0.0136 in the combined cat-
5985 (100) 51.7 3.1 64.1 2.3 66.4 2.2 62.3 1.5 egory. Children with a
Total 5985 (100) 12.7 1.1 21.1 1.1 24.5 1.2 41.7 1.7 high carbonated soft
drink consumption pat-
a Weighted (row) percentage. tern showed signif-
b Weighted (column) percentage. icantly higher caries
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J Dent Res 85(3) 2006 Carbonated Soft Drink Consumption and Dental Caries 265

experience, even compared with those children with a high Table 3. Logistic Regression Model of Dental Cariesa in the Primary
juice consumption pattern. Dentition by Fluid Consumption Pattern and Socio-demographic Factors
The findings of this analysis agree with the results from
some previous studies (Grindefjord et al., 1995; Moynihan and Adjusted Odds Ratio
Holt, 1996; Marshall et al., 2003). In contrast, a previous OR 95% CI
analysis of the NHANES III data reported no significant
association between sugared soda consumption and dental Fluid consumption pattern (cluster)
caries in the primary dentition (Heller et al., 2001). The High-carbonated soft drinks 1.79b 1.27- 2.52
disparity between these results could be explained, in part, by High-juice 1.22 0.94- 1.59
differences in data analytic methods, for the previous analysis High-milk 0.98 0.76- 1.27
(Heller et al., 2001) used individual fluids rather than clusters. High-water 1
Cluster analysis has the advantage of dealing with a greater Age
complexity of fluid consumption patterns when compared with 2 yrs 1
single-fluid-source approaches; it examines all fluid sources, 3-5 yrs 4.55 3.03- 6.82
especially those that are consumed in high quantities (Akin et 6-10 yrs 13.43 10.36-17.41
al., 1986). Gender
Children who consumed high amounts of carbonated soft M 1
drinks may also have undesirable eating patterns and eat high F 1.06 0.84- 1.34
amounts of sugars from other dietary sources. If so, the high Race/ethnicity
carbonated soft drink consumption pattern might serve more as White 1
a marker for unhealthy diet patterns, such as high consumption African-Am. 1.08 0.87- 1.35
of sugars. The complexity of the modern diet makes the Mexican-Am. 1.80 1.47- 2.20
analysis of diet patterns and fluid consumption patterns Other 1.74 1.25- 2.42
challenging. Nevertheless, further analysis, such as cluster SES
analysis including both solid food and fluid sources, should Low 3.79 2.65- 5.41
investigate more detailed relationships between diet and fluid Middle 2.17 1.50- 3.12
intake patterns, and their implications for health and disease High 1
outcomes such as dental caries and obesity.
Fluid consumption patterns of children varied significantly n 5506
by sociodemographic factors. This finding showed some R-square 0.15
consistency with results from previous reports (Ershow and -2 LL (intercept) 7285.4
Cantor, 1989; Harnack et al., 1999; Sohn et al., 2001). In our -2 LL (full model) 6396.8
results, white children showed a higher tendency toward a high Chi-square 888.7
carbonated soft drink consumption pattern, and African- Degrees of freedom 11
American children showed a tendency toward higher plain
a Odds of having 1 or more decayed or filled tooth surfaces.
water and lower milk consumption patterns than did children
b Numbers in bold indicate statistically significant OR (odds ratio) at
from other race/ethnic groups. Unfortunately, the implication of
5% error level.
various fluid consumption patterns among different population
groups in relation to their health outcomes has received only
limited attention. Conducting a large-scale study on fluid
consumption and dental caries may not be practical; however, In summary, we found that a high consumption of
small-scale studies of beverage and diet intake, focusing on carbonated soft drinks in early childhood was significantly
specific population groups, could widen our understanding of associated with an increased risk of dental caries in the primary
the mechanism behind these interactions. dentition after adjustment for age, sex, race/ethnicity, and SES,
A few limitations of this analysis should be noted. The as well as consumption of fluid from other sources. Findings
NHANES III used a cross-sectional design. Therefore, the from this study suggest that the high consumption of carbonated
results from this analysis should not be interpreted as a cause- soft drinks by young children is a risk indicator for dental caries
effect relationship between and among variables. A fluid in the primary dentition, and should be discouraged.
consumption pattern from a 24-hour recall interview may not
be representative of an individual's general fluid consumption ACKNOWLEDGMENTS
pattern over time. Although the 24-hour recall interview has
This research was funded independently by the lead author
been reported to provide reliable group mean estimations
while a student at the University of Michigan School of Public
(Persson and Carlgren, 1984), it was also reported to be prone
Health.
to reporting of extreme values, non-reporting, and under-
reporting (Yetley et al., 1992). In the NHANES III dietary
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