摘要：Objectives. We examined demographic and socioeconomic differences in the consumption of sugar-sweetened beverages (SSBs), its association with dental caries in children, and whether exposure to water fluoridation modifies this association. Methods. In a cross-sectional study, we used a stratified, clustered sampling design to obtain information on 16 508 children aged 5 to 16 years enrolled in Australian school dental services in 2002 to 2005. Dental staff assessed dental caries, and parents completed a questionnaire about their child’s residential history, sources of drinking water, toothbrushing frequency, socioeconomic status (SES), and SSB consumption. Results. Children who brushed their teeth less often and were older, male, of low SES, from rural or remote areas consumed significantly more SSBs. Caries was significantly associated with greater SSB consumption after controlling for potential confounders. Finally, greater exposure to fluoridated water significantly reduced the association between children’s SSB consumption and dental caries. Conclusions. Consumption of SSBs should be considered a major risk factor for dental caries. However, increased exposure to fluoridated public water helped ameliorate the association between SSB consumption and dental decay. These results reconfirm the benefits of community water fluoridation for oral health. Sugar-sweetened beverages (SSBs), including soft drinks (soda or pop), mineral waters (sweetened but noncarbonated beverages), cordials (sweet concentrates to which water is added), and sports (electrolyte) drinks, are commonly consumed in many countries, and consumption patterns have demonstrated an increase over time. In the United States, for example, soft drink consumption increased by approximately 500% between 1947 and 1999. 1 Increases in consumption occurred for both children and adults. In the 25-year period between 1977 and 2002, consumption of soft drinks as a percentage of total beverage intake by children aged 6 to 11 years increased from 15% to 33%. 2 In Australia, consumption of carbonated beverages increased by 240% between 1969 and 1999. 3 Because of SSBs’ often high sugar content, their excessive consumption has been linked to several deleterious heath effects, most notably overweight and obesity. One US study found that for each additional serving per day of a sugar-sweetened drink, the risk for obesity increased 60% after adjustment for anthropometric, demographic, dietary, and lifestyle variables. 4 In Australia, children consuming 3 or more soft drinks per day have 2.2 times the odds of being obese or overweight than children who do not consume soft drinks. 5 Excessive soft drink consumption has also been linked to diabetes, metabolic dysfunction, osteoporosis, high blood pressure, and liver disease. 6 In terms of oral diseases, the association between SSB consumption and both dental erosion and caries has been investigated. Consistent evidence has shown, for example, that the high acidity of many sweetened drinks, particularly soft drinks and sports drinks, can be a causal factor in dental erosion. 7 However, and despite studies going as far back as the 1950s implicating the role of soft drink consumption in dental decay, 8 relatively few studies have examined the cariogenicity of SSBs. One reason is that SSB consumption is often subsumed within a broader research perspective investigating the role of dietary sugars generally in the process of dental caries. Although the etiological role of sugars and other fermentable carbohydrates in caries activity has been well established, 9,10 the causal role of specific foods in the overall diet can be harder to determine. 11 Only a handful of studies have shown associations between SSB consumption and dental caries. For example, Ismail et al. 12 found a significant positive association between the frequency of at- and between-meal consumption of soft drinks and dental caries. More recently, children aged 2 to 10 years with a predominantly high soft drink diet were found to be 1.8 times more likely to experience dental caries in the primary dentition than children with a predominantly high water consumption pattern. 13 Similarly, young children with caries have significantly greater intake of soft drinks than children without caries. 14 In the United Kingdom, caries prevalence in the primary dentition was found to be substantially higher among children with a higher than average frequency of SSB consumption, but little difference was found in the permanent dentition of older children. 15 In Australia, higher soft drink consumption among children aged 12 years and younger was found to be positively associated with more primary tooth extractions. 16 However, other studies investigating soft drink consumption and dental caries have yielded contradictory evidence. 11,17 Indeed, a recent review and meta-analysis of the literature, which included only 4 studies, indicated only a small positive ( r = .03) association between soft drink consumption and caries. 6 One question that has received little attention is whether other risk or protective factors might modify any association between soft drink consumption and dental caries. The effect of soft drink consumption on caries might be weaker for children who come from higher income families, who brush their teeth with fluoride toothpaste more often, or who have greater exposure to fluoridated water. In particular, an overwhelming amount of research has demonstrated, and continues to demonstrate, that drinking fluoridated water offers a considerable caries preventive benefit. 18–20 The US Surgeon General has declared that water fluoridation is not only efficient and cost effective but is also the single most effective means of preventing tooth decay over a person’s lifetime. 21 However, surprisingly little research has been conducted into whether water fluoridation also confers benefits by reducing the impact of risk factors for dental caries. Any effect of soft drink consumption on dental caries may be mitigated to some extent when children are also receiving the benefits of consuming fluoridated water. We investigated this possible association between sweetened drink consumption and caries in both deciduous and permanent teeth in a large and representative group of Australian schoolchildren. In addition, we aimed to describe demographic and socioeconomic status (SES) differences in SSB consumption. Finally, we examined whether other protective factors for dental disease, such as higher SES, more frequent toothbrushing, and residing in an area with fluoridated water, modified any association between the consumption of sugared beverages and dental caries.
