Community Dent Oral Epidemiol 2012; 40: 125133 All rights reserved

2011 John Wiley & Sons A/S

Caries in adolescence inuence from early childhood

Alm A, Wendt LK, Koch G, Birkhed D, Nilsson M. Caries in adolescence inuence from early childhood. Community Dent Oral Epidemiol 2012; 40: 125133. 2011 John Wiley & Sons A S

A. Alm1, L. K. Wendt2, G. Koch3, D. Birkhed4 and M. Nilsson5

Department of Paediatric Dentistry, Ka rnsjukhuset, Sko vde, 2Centre of Oral Health, School of Health Sciences, Jo nko ping University, Jo nko ping, 3Department of Paediatric Dentistry, The Institute for Postgraduate Dental Education, Jo nko ping, 4 Department of Cariology, Sahlgrenska Academy at Gothenburg University, Go teborg, 5Futurum The Academy of Healthcare, County Hospital, Jo nko ping, Sweden
1

Abstract Objective: To analyse the relationship between caries determinants in early childhood and caries prevalence in proximal surfaces in adolescents at the age of 15 years. Methods: The present longitudinal study is part of a series of surveys of oral health in 671 children followed from 1 to 15 years of age. Data were selected from examinations, interviews and questionnaires at 1, 3 and 6 years and bitewing radiographs at 15 years of age. Uni- and multivariable logistic regression analyses were performed to identify caries-related determinants. The outcome variable was carious lesions and llings (DFa) in approximal tooth surfaces at 15 years of age. Statistical comparisons were made between caries-free teenagers, DFa = 0 and teenagers with DFa > 0, DFa 4 and DFa 8, respectively. Results: In the nal logistic regression analyses, caries experience at 6 years and mothers self-estimation of her oral health care as being less good to poor remained statistically signicant and were related to caries in all three caries groups (i.e. DF > 0, 4 and 8) at 15 years of age. The consumption of sweets at 1 year remained statistically signicant, with a caries experience of DF 4 and 8. The variables parents born abroad and female gender were statistically signicantly associated with DFa 4 and DFa 8, respectively. Furthermore, infrequent toothbrushing habits at 3 years of age and failure to attend the examination at 1 year were statistically signicantly associated with caries at 15 years in the univariable analyses. Conclusion: Early caries experience, consumption of sweets at an early age and mothers selfestimation of her oral health care as being less good to poor are associated with approximal caries in adolescents. The study indicates that caries determinants identied during early childhood have a strong impact on approximal caries in adolescence.

Key words: adolescents; approximal caries; early childhood; oral hygiene; sweets Anita Alm, Specialistklinken fo r pedodonti, Ka rnsjukhuset, SE-54185 Sko vde, Sweden Tel.: +46 500432900 Fax: +46 500432913 e-mail: anita.alm@vgregion.se Submitted 8 October 2010; accepted 14 September 2011

Risk factors and indicators are often discussed in the literature, and a recent systematic review by the Swedish Council on Technology Assessment in Health Care (1) stated that past caries experience is the single best predictor of future caries development among preschool children, schoolchildren and adolescents. In addition, it has been known for several decades that the high and frequent consumption of sugar is an aetiological factor in caries (2). A recent prospective Finnish study examined children from infancy to the age of 10 years. It concluded that a persistently high sucrose intake increases the risk of dental caries in children (3). However, a systematic review has shown that, today, with frequent uoride exposure, the reladoi: 10.1111/j.1600-0528.2011.00647.x

tionship between sugar consumption and caries experience is not consistent (4). This is in line with the ndings reported by Zero (5), who pointed out that, in subgroups without the same uoride protection, sugar still acts as a potential risk. Previously, the caries-risk factors that attracted most interest were factors associated with the local caries process itself. According to Burt (6), these factors should be extended. He stated that we should broaden our view of risk to include social determinants of health and population health. Furthermore, a systematic review of the literature on risk factors for dental caries in young children (7) concludes that there is a shortage of high quality studies using the optimum study design, i.e. a longitudinal study.

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Longitudinal studies of oral health in children followed from 1 to 15 years of age have been performed in Jo nko ping, Sweden (813). These studies have discussed the inuence of caries determinants recorded in early childhood, such as caries experience, oral hygiene, snacking habits and parent-related variables, in relation to approximal caries at 15 years of age (810). However, combined analyses of these studies to elucidate the strength of caries determinants have never been made. The aim of the present longitudinal study was therefore statistically to analyse the relationship between caries determinants in early childhood and proximal caries prevalence in adolescence.

Material and methods

This study, which was designed as a prospective longitudinal study, is part of a series of surveys of oral health in children followed from 1 to 15 years of age and living in the Municipality of Jo nko ping, Sweden. All 671 children who were 1 year of age in 1988 and living within four of the thirteen child welfare centres in the Municipality of Jo nko ping were invited to participate. The four districts included the town, suburbs and rural areas and were chosen to reect the socio-economic levels of the population living in this part of Sweden (813). The Ethics Committee at the University of Linko ping, Sweden, approved the study. Data relating to explanatory variables in the present study were selected from examinations, interviews and questionnaires at 1, 3 and 6 years of age. The examinations at 1, 3 and 6 years were conducted by one of the authors (L-KW) and have been described in detail elsewhere (1113). The outcome variable in the present study was approximal carious lesions and llings at 15 years of age. Information on approximal caries was obtained from bitewing radiographs, which were analysed by one of the authors (AA). The number of dropouts between 1 and 15 years of age totalled 103 and, as a result, 568 of the 15-year-olds (85% of the original 671 children invited at 1 year of age) were nally included in the study. In all, 539 children (80%) were examined at 1 and 15 years of age, 555 (83%) at 3 and 15 years of age, and 517 (77%) at 6 and 15 years of age. The 20 children who failed to attend the examination at 1 year of age (but were examined at 15 years) were analysed separately. There was a statistically signicant

difference in mean caries prevalence between children who failed to attend the examination at 1 year of age compared with those who were examined at both 1 and 15 years (7.0 versus 3.1: P < 0.01). Both parents answered a structured questionnaire on parent-related variables in connection with the examination at 1 year of age. The response rate for the 539 children who were examined at 1 and 15 years of age was 81% (based on whether the mother, father or both parents had answered the questionnaire). When it came to dropouts from the questionnaire at 1 year of age, there was no statistically signicant difference in caries experience among adolescents whose parents answered the questionnaire compared with those who did not answer (3.0 versus 3.6). A chi-square analysis of behavioural determinants was conducted on the group of children who dropped out from the questionnaire on parent-related variables at 1 year of age. Children who dropped out had a statistically signicantly higher consumption of sweets and caries-risk products at 1 year of age, while this difference was not seen at 3 years of age. More details on the study population and analyses of caries experience at 15 years of age have been given previously (9).

Outcome variable
Approximal caries experience at 15 years. Information on approximal carious lesions and llings at 15 years of age was obtained from bitewing radiographs, which were analysed by one of the authors (AA). To calculate intra-examiner reproducibility, 10% of the radiographs were analysed twice, with an interval of 2 months. The intra-examiner agreement produced Cohens kappa values of 0.95. The radiographic procedures have been described in detail elsewhere (9). The approximal surfaces from the distal surface of the rst premolar to the mesial surface of the second molar (a total of 24 surfaces) were evaluated in terms of carious lesions and llings. Caries was registered as initial or manifest caries as follows. Initial caries was dened as a carious lesion in the enamel that had not reached the dentinoenamel junction or a lesion that reached or penetrated the dentinoenamel junction but did not appear to extend into the dentine. Manifest caries was dened as a carious lesion that clearly extended into the dentine. The mean total for total approximal caries experience (including initial caries) and llings was grouped and used in the analyses as a dependent (outcome) variable and

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will subsequently be called DFa. According to the caries experience at 15 years of age, the children were grouped as follows: DFa = 0 (n = 187; 33%), DFa > 0 (n = 381; 67%), DFa 4 (n = 189; 33%) and DFa 8 (n = 79; 14%). It should be noted that all the individuals in the DFa 8 group are also included in the DFa 4 group and that DFa 4 and DFa 8 are included in the DFa > 0 group. More detailed data relating to the 15-year-olds have previously been presented (810).

Table 1. Distribution of variables recorded in early childhood included in the uni- and multivariable logistic regression analyses Variables All 15-year-olds n (%)

Explanatory variables
Caries experience at 3 and 6 years. Caries was registered clinically by visual examination and probing and radiographically if proximal contacts in primary molars made clinical examination impossible. Clinically, initial caries was dened as a demineralized surface without cavitation, while manifest caries was dened as a carious lesion with cavitation (that extended into the dentine). Radiographically, initial proximal caries was dened as a radiolucency in the enamel that had not passed the dentinoenamel junction, whereas manifest caries was dened as a radiolucency passing into the dentine. Decayed, extracted and lled surfaces (defs), including initial carious lesions, were registered (12). The children were stratied according to caries experience at 3 and 6 years as follows: defs (including initial caries): 0, 12 or >2; manifest caries experience: no or yes. These classications were used as explanatory variables in the analysis. When it came to caries experience at three and 6 years of age, the degree of agreement was 0.3 (Spearmans rank correlation). Both these variables were therefore included in the analysis. For the number of children in the different groups, see Table 1. Snacking habits at 1 and 3 years. Data relating to the consumption of caries-risk products in early childhood were extracted from interviews conducted with the parents at the dental examinations when the children were 1 and 3 years of age (14). Using a semi-structured form, the accompanying parent was asked questions about the childrens dietary habits at 1 and 3 years of age. Questions regarding the consumption of caries-risk products, such as soft drinks, fruit soup, sweets (candy, confectionery), ice cream or biscuits, were grouped as follows: (i) no consumption, (ii) 17 times week, (iii) 814 times week, (iv) 1521 times week and (v) > 21 times week. The consumption of sweets was grouped as follows: (i) no consumption, (ii) once a week or less and (iii) sweets more than once

defs (including initial caries) at 3 years (n = 555) 0 408 (74) 12 56 (10) >2 91 (16) Manifest caries experience at 3 years (n = 555) No 474 (84) Yes 81 (16) defs (including initial caries) at 6 years (n = 517) 0 239 (46) 12 80 (16) >2 198 (38) Manifest caries experience at 6 years (n = 517) No 301 (58) Yes 216 (42) Consumption of caries-risk products at 1 year (times week; n = 538) No consumption 53 (10) 17 227 (42) 814 144 (27) 1521 63 (12) >21 51 (10) Consumption of sweets at 1 year (times week; n = 537) No consumption 368 (69) Once a week 123 (23) More than once a week 46 (9) Consumption of caries-risk products at 3 years (times week; n = 492) No consumption 3 (1) 17 22 (5) 814 102 (21) 1521 150 (31) >21 215 (44) Consumption of sweets at 3 years (times week; n = 491) No consumption 28 (6) Once a week 279 (57) More than once a week 184 (38)

a week. These classications were used as explanatory variables in the analysis. When it came to snacking habits at three and 6 years of age, the degree of agreement was 0.2 (Spearmans rank correlation). Both these variables were therefore included in the analysis. For the number of children in the different groups, see Table 1. Toothbrushing habits at 3 years. The frequency of toothbrushing habits at 3 years of age was grouped as follows: (i) sometimes never (n = 17), (ii) once a day (n = 96) and (iii) twice daily or more (n = 376). In the present study, 95% of the children utilized uoride toothpaste. Dental avoidance behaviour at 1 year. Children were grouped according to dental avoidance behaviour at 1 year of age as follows: (i) children who failed to

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Alm et al. Table 2. Child- and parent-related variables that remained statistically signicant in the univariable analyses in a previous paper (10) and were thus included in the nal multivariable logistic regression analyses Variables statistically signicant in the univariable analyses Child related Plaque on maxillary incisors at 1 year Intermediate oral hygiene at 3 years Poor oral hygiene at 3 years Female gender Parent related Mother single Father less satised to dissatised with his social situation Mother has responsibility for the child on her own Mothers self-estimation of her own oral health care less good to poor Fathers self-estimation of his own oral health care less good to poor Mother born in Sweden, father abroad Father born in Sweden, mother abroad Both parents born abroad All 15-year-olds na (%) 38 538 (7) 189 492 (38) 95 492 (19) 286 568 (50) 20 434 (5) 166 382 (43) 109 425 (26) 225 433 (52) 267 402 (66) 19 536 (4) 19 536 (4) 49 536 (9) Signicant for DFa >0, 4, 4, >0, 4, 4, 8 8 8 8

>0, 4, 8 4,8 8 >0, 4, 8 4 >0, 4, 8 >0, 4, 8 >0, 4, 8

Comparisons were made between caries-free teenagers (DFa = 0) and teenagers with DFa > 0, DFa 4 and DFa 8 respectively. a Number of children total number of children.

attend the examination at 1 year of age but were examined at 15 years (n = 20) and (ii) children examined at both 1 and 15 years of age (n = 539). Previously performed analyses of oral hygiene and parent-related variables. In a previous paper, uniand multivariable analyses of the explanatory variables of oral hygiene at 1 and 3 years of age and parent-related variables at 1 year of age were performed (10). Parent-related variables were extracted from a questionnaire that was completed when the children were 1-year old; the questions covered several topics, such as socio-economic status and behavioural and attitudinal factors. Statistically signicant variables in the univariable analyses are presented in Table 2.

Statistical analyses
The data analysis was generated using SAS STAT software (version 9 of the SAS System for Windows Copyright 2002; SAS Institute Inc., Cary, NC, USA), STATISTICA (data analysis software system), version 8.0, StatSoft, Inc. (2007) and SPSS 15.0, SPSS Inc. (2006). The statistical analyses included a t-test for continuous data and logistic regression to estimate odds ratios. In the logistic regression, the outcome variable was approximal caries and llings at 15 years of age. Explanatory variables were collected from clinical examinations and interviews at 1 and 3 years of age and from questionnaires at 1 year of age. Uni- and multivariable logistic regression was used to calculate the odds ratio (OR) and 95% condence intervals (95% CI). Explanatory vari-

ables that were statistically signicant in the univariable analyses were included in the multivariable analyses (including corrections for gender). All the statistical comparisons were made between caries-free teenagers (DFa = 0) and teenagers with DFa > 0, DFa 4 and DFa 8, respectively. Univariable logistic regression was used for the explanatory variables described in Material and Methods. Variables relating to snacking habits and caries experience at 3 and 6 years of age are presented in Table 1. Variables associated with oral hygiene, gender and parent-related factors, which remained statistically signicant in previously performed univariable analyses in one or more of the groups with different caries experience at 15 years of age, are presented in Table 2. Standard deviation (SD) in this paper is given as SD. P-values below 0.05 were considered statistically signicant. NS is an abbreviation for nonsignicant.

Results
Caries status at 15 years of age
The mean number of DFa was 3.2 (4.0). The mean DFa was 3.5 (4.1) for the girls and 3.0 (3.9) for the boys (NS).

Univariable analyses
Caries experience at 3 and 6 years. In the univariable analyses, defs 12 and defs > 2 (including initial carious lesions) and manifest caries experience at 3

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Caries in adolescence Table 3. Univariable logistic regression analyses of the association between caries experience at 3 and 6 years and caries experience at 15 years of age Caries experience at 15 years Variables at 3 and 6 years defs (including 0 12 >2 Manifest caries No Yes defs (including 0 12 >2 Manifest caries No Yes DFa > 0 n OR 95% CI P-value DFa 4 n 258 44 64 303 63 155 50 132 186 151 OR 1.0 2.2 4.6 1.0 4.5 1.0 2.3 5.3 1.0 4.5 95% CI P-value <0.0001 1.62.9 2.68.6 <0.0001 2.58.9 <0.0001 1.83.0 3.28.8 <0.0001 2.97.2 DFa 8 n 187 31 42 218 42 122 31 86 142 97 OR 1.0 2.8 8.0 1.0 7.3 1.0 3.1 9.4 1.0 8.0 95% CI P-value <0.0001 2.04.1 4.016.6 <0.0001 3.615.3 <0.0001 2.24.5 4.719.8 <0.0001 4.315.9

initial caries) at 3 years 408 1.0 0.0003 56 1.7 1.32.2 91 2.7 1.64.8 experience at 3 years 474 1.0 0.001 81 2.7 1.55.1 initial caries) at 6 years 239 1.0 <0.0001 80 1.8 1.52.2 198 3.2 2.15.0 experience at 6 years 301 1.0 <0.0001 216 2.5 1.73.8

OR, odds ratio; CI, condence interval. Comparisons were made between caries-free teenagers (DFa = 0) and teenagers with DFa > 0, DFa 4 and DFa 8, respectively.

and 6 years of age were statistically signicantly associated with caries experience of DFa > 0, DFa 4 and DFa 8 at 15 years of age (Table 3). Snacking habits. The consumption of sweets at 1 and 3 years of age and the consumption of caries-risk products at 1 year of age were statistically significantly associated with caries experience of DFa > 0, DFa 4 and DFa 8. The consumption of caries-risk products at 3 years of age was not statistically signicantly associated with caries experience at 15 years (Table 4). Toothbrushing habits at 3 years. Toothbrushing sometimes never versus twice daily or more at 3 years of age was statistically signicantly associated with caries experience of DFa 4 and DFa 8 at 15 years of age (OR = 3.0 and 8.5; CI; 1.37.0 and 3.024.4, respectively), as was toothbrushing once a day versus twice daily or more (OR = 1.7 and 2.9; CI: 1.12.6 and 1.74.9, respectively). Dental avoidance behaviour at 1 year. In the univariable analysis, failure to attend the examination at 1 year of age was statistically signicantly associated with caries experience of DFa 4 and DFa 8 (OR = 3.8 and 5.5; CI: 1.313.8 and 1.622.4, respectively). Unfavourable behaviour. Children who consumed snacking products more than 14 times week and also had infrequent toothbrushing habits (i.e. once a day or less) at 3 years of age were analysed separately (n = 100; here called unfavourable

behaviour). In the univariable analysis, the variable unfavourable behaviour at 3 years of age was statistically signicantly associated with caries experience of DFa > 0, DFa 4 and DFa 8 (OR = 2.4, 2.9 and 5.7; CI: 1.44.2, 1.65.5 and 2.8 11.8, respectively). The variable unfavourable behaviour has not been included in the multivariable analysis, as it is a mixture of two of the explanatory variables used in the analysis.

Multivariable analyses, nal logistic regression

In the nal logistic regression analyses, caries experience at 6 years and mothers self-estimation of her own oral health care as being less good remained statistically signicant and were associated with caries experience in all three groups with different caries experience, i.e. DFa > 0, DFa 4 and DFa 8 at 15 years of age. The consumption of sweets at 1 year of age was statistically signicantly associated with caries experience of DFa 4 and DFa 8. The variables parents born abroad and female gender were statistically signicantly associated with DFa 4 and DFa 8, respectively (Table 5). If the two most extreme cases are compared, the interpretation of the nal model is as follows: a 15-year-old girl consuming sweets more than once a week at 1 year manifest caries at 6 years and with a mother who estimated her oral health as less good poor compared with a 15-yearold boy with no manifest caries at 6 years, no

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Alm et al. Table 4. Univariable logistic regression analyses of the association between the consumption of caries-risk products and sweets at 1 and 3 years of age and caries experience at 15 years of age Caries experience at 15 years Variables at 1 and 3 years DFa > 0 n OR 95% CI P-value DFa 4 n OR 1.0 1.4 1.9 2.6 3.5 1.0 2.0 3.8 1.0 1.1 1.3 1.5 1.6 1.7 2.8 95% CI P-value 0.002 1.11.7 1.32.8 1.44.7 1.67.7 <0.0001 1.42.7 1.97.5 NS 0.91.4 0.82.1 0.73.0 0.64.3 0.0108 1.12.5 1.36.2 DFa 8 n 26 103 70 31 20 171 62 17 2 8 52 73 93 13 133 81 OR 1.0 1.5 2.1 3.1 4.5 1.0 2.0 3.9 1.0 1.3 1.6 2.0 2.5 1.0 2.1 4.4 95% CI P-value 0.004 1.18.9 1.33.6 1.56.8 1.612.7 0.002 1.33.0 1.69.2 NS 0.91.8 0.83.2 0.75.8 0.710.4 0.01 1.23.7 1.513.4

Consumption of caries-risk products at 1 year (times week) No consumption 53 1.0 0.03 33 17 227 1.2 1.01.4 145 814 144 1.5 1.02.1 97 1521 63 1.8 1.13.0 42 >21 51 2.1 1.14.2 36 Consumption of sweets at 1 year (times week) No consumption 368 1.0 0.02 229 Once a week 123 1.4 1.11.9 89 More than once a week 46 2.1 1.13.8 34 Consumption of caries-risk products at 3 years (times week) No consumption 3 1.0 NS 2 17 22 1.2 1.01.4 13 814 102 1.4 0.92.0 73 1521 150 1.6 0.92.9 99 >21 215 1.8 0.84.0 132 Consumption of sweets at 3 years (times week) No consumption 28 1.0 0.03 17 Once a week 279 1.4 1.02.0 183 More than once a week 184 2.0 1.1-3.9 118

OR, odds ratio; CI, condence interval. Comparisons were made between caries-free teenagers (DFa = 0) and teenagers with DFa > 0, DFa 4 and DFa 8, respectively.

consumption of sweets at 1 year and a mother who estimated her oral health as good; the odds for the girl being in the DFa 8 group are 21 compared with the boy.

Discussion
The study indicates that caries determinants during early childhood still have an impact on approximal caries in adolescence. A strong relationship was found between caries during preschool years and caries development in the permanent posterior teeth up to mid-teenage. It therefore appears that the foundations of adolescents oral health are laid during the preschool years. Even if similar results have previously been presented (1519), the followup periods in these earlier studies were between 2 and 8 years, compared with 14 years in the present study. Caries experience at 6 years of age remained statistically signicant in the nal multivariable logistic regression in all groups with different caries experience at 15 years of age. Furthermore, in a previous part of this study (9), it has been shown that the mean value for caries experience at 15 years of age was signicantly higher for chil-

dren who already had manifest caries at 3 years of age than for children who were caries free at 3 years but had manifest caries at 6 years (5.7 5.2 versus 3.8 4.0). Manifest caries at 3 years therefore has high clinical signicance. Based on these ndings, it seems reasonable to conclude that individualized prevention at an early age could play an important role in paediatric dentistry. The frequent consumption of caries-risk products at 1 year of age and the consumption of sweets at 1 and 3 years of age were associated with approximal caries at 15 years of age. This is in agreement with a previous long-term Finnish study by Mattila et al. (20). They reported that the daily intake of sweets at the age of 3 years was associated with a caries increment between 7 and 10 years. Ruottinen et al. (21) followed childrens sucrose intake from infancy to 10 years of age and found that, once a high sucrose intake is adopted, changes later in life are unlikely. Snacking habits established during early childhood therefore appear to be maintained throughout adolescence. These facts highlight the importance of the early establishment of good dietary habits. In modern society, sugar-containing products and beverages are easily accessible, and consump-

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Caries in adolescence Table 5. The nal multivariable logistic regression analyses in teenagers with different caries experience at 15 years of age as outcome variables and statistically signicant explanatory variables Variables OR 95% CI P-value

Children with DFa > 0 (nal model) defs (including initial caries) at 6 years 0 1.0 0.0003 12 1.6 1.22.0 >2 2.5 1.54.0 Mothers self-estimation of her oral health care Very good 1.0 0.02 Less good to poor 1.6 1.12.5 Children with DFa 4 (nal model) defs (including initial caries) at 6 years 0 1.0 <0.0001 12 2.0 1.42.7 >2 3.9 2.17.1 Consumption of sweets at 1 year (times week) No consumption 1.0 0.004 Once a week 2.0 1.23.2 More than once a week 4.0 1.610.2 Mothers self-estimation of her oral health care Very good 1.0 0.001 Less good to poor 2.5 1.44.3 Parents country of birth Both parents born in Sweden 1.0 0.04 Mother born in Sweden, 1.5 1.02.3 father abroad Father born in Sweden, 2.4 1.05.5 mother abroad Both parents born abroad 3.7 1.112.8 Children with DFa 8 (nal model) Gender Male 1.0 0.01 Female 3.1 1.37.3 Manifest caries experience at 6 years No 1.0 <0.0001 Yes 9.7 4.023.6 Consumption of sweets at 1 year (times week) No consumption 1.0 0.001 Once a week 3.3 1.66.7 More than once a week 10.9 2.645.4 Mothers self-estimation of her oral health care Very good 1.0 0.0002 Less good to poor 5.5 2.213.5 OR, odds ratio; CI, condence interval. Comparisons were made between caries-free teenagers (DFa = 0) and teenagers with DFa > 0, DFa 4 and DFa 8 respectively.

tion is extensive in many groups of children and adolescents (22). Even if the frequent consumption of fermentable carbohydrates in the aetiology of dental caries is well established (2), some studies have failed to demonstrate this relationship (23). Duggal et al. (24) discussed this and stated that one reason for the difculty involved in showing a strong association is probably the frequent use of uoride, which has changed the role of sugars.

This assumption is conrmed in the present study, as the consumption of caries-risk products at 3 years was not associated with approximal caries at 15 years of age, whereas unfavourable behaviour at 3 years (i.e. the frequent consumption of snacking products and infrequent toothbrushing habits) was statistically signicantly associated with caries experience at 15 years of age. This could be a good illustration of the compensatory factor of frequent toothbrushing with uoride toothpaste in some children who frequently consume caries-risk products. Toothbrushing with uoride toothpaste (twice a day or more) is important for the prevention of caries. This study reveals that teenagers with high caries experience (DFa 4 and DFa 8) brushed their teeth infrequently at 3 years of age and, in addition, teenagers who were caries free at 15 years of age were more likely to brush their teeth twice a day at 3 years of age. This is in accordance with other studies showing that toothbrushing behaviour that is established during infancy is often maintained during early childhood (25, 26) and even throughout adolescence and into adulthood (27). It has been demonstrated that social, economic and environmental factors have a fundamental impact on oral health (28, 29). Moreover, Newton and Bower (30) have discussed the complexity of life social processes and the causal networks between social structure and dental disease. The interaction between these factors could presumably explain why children who failed to attend the 1-year examination had signicantly more lled and decayed surfaces at 15 years of age than those who attended. This is in agreement with Wang and Aspelund (31), who report that children with a history of broken appointments had a higher caries experience and higher caries activity compared with the rest of the group. This indicates that extra attention should be paid to children and families who fail to attend health examinations and appointments. The variable mothers self-estimation of her own oral health care as being less good to poor remained statistically signicant in the nal multiple logistic regression and was strongly associated with a high caries prevalence in the children at 15 years of age. These ndings indicate that oral hygiene habits are transferred from parent (especially the mother) to child and that parents constitute an important social model for their children. strm and This is in agreement with a study by A

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Jakobsen (32), which revealed that the toothbrushing habits of parents and their adolescent offspring are statistically signicantly associated. In the present study, having parents with an immigrant background, especially when both parents were born abroad, was associated with a higher caries experience at 15 years of age. Even though these teenagers were born and had lived in Sweden from early childhood and received the same dental health education and treatment as those with Swedish-born parents, the cultural background still appears to have an effect on caries prevalence. The question of whether parental attitudes towards childrens oral health are impacted by cultural and ethnic diversity has been discussed in several studies (10, 13, 33, 34). Poor knowledge of the aetiology of the caries disease could be one explanation of why dental care, especially at preschool age, is not always given priority. Risk-oriented public health programmes should be developed for children with an immigrant background. It is possible to argue about whether exposure to a factor in early childhood is a causal relationship in the development of caries at 15 years of age. A caries determinant is a characteristic or an exposure that coexists with an increased probability of developing a disease or may lead to a measurable change in health status. Furthermore, caries determinants can be helpful in identifying groups at risk. However, for an individual, the circumstances can change over time. Outcome variables, cut-off points and external validity (generalization to other groups) can always be discussed. In this study, the DFa 4 group corresponds to 33% of the population and is thus in line with the SIC index presented by Bratthall (35). In Scandinavia, the 1015% of the population with the highest caries scores are usually regarded as a risk group. This corresponds to DFa 8 in the present study and represents 14% of the population. We therefore used four cut-off points for the statistical analysis, i.e. DFa = 0, DFa > 0, DFa 4, corresponding to the SIC index, and DFa 8, corresponding to the risk index value that is generally used in Scandinavia. In this way, the conclusions in our study can be generalized to other groups of children and adolescents. Statistical methods can also be discussed. As we have repeated measurements of individuals, it is possible to argue that a statistical method that accounts for this should be used in the multivariate analysis. In this study, the outcome variable, as

well as the explanatory variables, is not repeated. For this reason, repeated measurement analysis has not been utilized in this study. In conclusion, we found that the establishment of good dental habits during the formative preschool years creates a foundation for low caries prevalence in adolescence. Dental health from early childhood up to mid-teenage reects the conditions in which the child has lived. This underlines the importance of a longitudinal study design when investigating chronic diseases such as dental caries. Further, we emphasize the fact that preventive programmes should start at an early age and should also include the mother during pregnancy to attain optimal dental health later in life.

Acknowledgements
This project received support from the Skaraborg Research and Development Council and the Swedish Dental Association.

References
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