Free sugars intake and dental caries status among preschool children in Sri Lanka: investigating the relative balance between free sugars and fluoride toothpaste

Abstract

Abstract Background: In order to implement WHO sugar guidelines into policy in Sri Lanka, it is necessary to consider its context as a developing country with high levels of dental caries at all ages, where fluoridated toothpaste is widely available as the only mode of fluoride administration. Therefore, this study aims to identify a level of free sugars intake associated with a minimum caries risk in deciduous dentition, balancing the effect of fluoride toothpaste by investigating the relationship between the amount and frequency of free sugars intake and dental caries status quantitatively among preschool children in Sri Lanka. Methods: Using probability proportionate to size technique and cluster sampling, 813 children aged 04-05 years were selected from preschools in the Colombo district, Sri Lanka. A 67-item quantitative food frequency questionnaire was developed and validated to evaluate free sugars intake. Dental caries was assessed using decayed, missing and filled teeth index. For the selection of cut-off values for free sugars intake levels, Receiver Operating Characteristic curves were used. Results: The median (IQR) amount of free sugars intake was 57.9 (33.2 -95.8) g/day or21.1% (12.5%-35.9%) of total energy requirement, with a frequency of 4.0 (2.7-6.1) times/day. Dental caries prevalence was 42.9% (n=349). Among other possible risk and protective factors, free sugars intake as a percentage of total energy requirement (p<0.001) and frequency of free sugars intake (p<0.001) were significantly associated with dental caries. Whether or not twice daily toothbrushing with fluoride toothpaste was undertaken had low sensitivity in predicting caries after sugar intake was taken into account. The percentage of free sugars that discriminates against a maximum number of children with dental caries (99%) was determined as 4%, of the total energy requirement of a child, which is approximately 12g/day (3 level teaspoons/day). One time per day should be the maximum frequency. Conclusion: Sri Lankan preschool children had high levels of dental caries, associated with free sugars intake that exceeded current recommended thresholds.