Impactul obiceiurilor alimentare asupra sănătății orale a copiilor din județul Maramureş

Introduction

Oral health represents an essential component of a child’s health, well-being and quality of life. A healthy oral cavity promotes functions such as effective mastication and digestion, clear articulation of speech, restful sleep, and contributes significantly to the development of a positive self-image. From early development, the maintenance and monitoring of oral health are imperative and require the integration of proper nutritional habits, rigorous oral hygiene practices, and regular dental examinations. Diet develops as a principal determinant influencing the oral health status of children. Dietary sugars represent a primary etiological factor in the development of dental caries⁽¹⁾. Upon the ingestion of sugar-rich foods and drinks, cariogenic bacteria within the dental biofilm metabolize these carbohydrates to produce organic acids, which, as a result, induce demineralization of the tooth enamel. The frequency of sugar consumption is critical; recurrent exposure to fermentable carbohydrates does not allow sufficient time for enamel remineralization, thereby facilitating caries progression. Saliva plays a protective role by buffering acids and promoting the repair of demineralized enamel, emphasizing that both the quantity and timing of sugar consumption are essential⁽²⁾. Frequent snacking, particularly between meals or before sleep, substantially elevates caries risk.

The cariogenic potential of sugar varies according to its chemical nature. Sucrose exhibits the highest cariogenicity, followed by glucose and fructose, whereas lactose, predominant in milk, demonstrates comparatively lower cariogenic effects, especially when consumed in natural dairy products. Additionally, sugar substitutes such as xylitol and sorbitol show minimal cariogenicity and may have a protective role by stimulating salivary flow and inhibiting pathogenic bacterial proliferation⁽³⁾.

Beverage consumption critically impacts children’s oral health. Acidic and sugar-sweetened drinks, including soft drinks, sweetened fruit juices and energy drinks, contribute not only to caries but also to dental erosion (a pathological condition characterized by the direct chemical demineralization of enamel by acids, independent of bacterial association)^(4-6). Unlike caries, dental erosion typically affects extensive tooth surface areas and may result in hypersensitivity and substantial tooth structure loss. The risk of erosion increases with frequent, voluminous or prolonged consumption of acidic drinks, particularly when ingested before sleep, during which salivary flow – and, consequently, natural dental protection – is reduced^(7-9).

Oral hygiene practices are indispensable in preventing dental diseases. From early infancy, parents should encourage proper toothbrushing techniques. Before tooth eruption, cleaning the oral mucosa with a soft, damp cloth is recommended, progressing to the use of an age-appropriate toothbrush and fluoride toothpaste once teeth erupt. Supervised brushing remains essential until children demonstrate adequate dexterity, typically by age six to eight. Plaque control is vital for preventing both caries and periodontal disease. The introduction of flossing should coincide with the eruption of adjacent teeth to ensure interdental cleanliness inaccessible to toothbrush bristles⁽⁹⁾.

Socioeconomic determinants influence pediatric oral health outcomes. Children from socioeconomically disadvantaged backgrounds often experience reduced access to professional dental care, nutritious foods, and oral hygiene supplies. Furthermore, insufficient oral health literacy among parents and children contributes to increased disease prevalence in these populations. Unhealthy dietary patterns, including frequent consumption of sugary snacks and drinks, are disproportionately observed in low-income environments⁽¹⁰⁾.

Genetic predisposition may modulate individual susceptibility to dental caries and related pathologies; however, the majority of oral health issues are preventable through appropriate lifestyle modifications and preventive interventions. Focus should be placed on promoting diets rich in calcium, phosphorus, and essential vitamins – found abundantly in dairy products, leafy greens, and fruits – which support optimal tooth development and maintenance. Substituting cariogenic snacks and drinks with healthier alternatives, such as fresh fruit, nuts, yogurt and water, is strongly recommended⁽¹¹⁾.

Breastfeeding has been associated with a reduced incidence of dental caries relative to bottle-feeding, particularly when artificial feeding involves exposure to sugary liquids. However, long-term or nocturnal breastfeeding without subsequent oral hygiene can increase caries risk. The practice of allowing children to sleep with bottles containing milk, sweetened tea or juice predisposes to early childhood caries, often referred to as “baby bottle tooth decay”⁽¹²⁾. 

Water remains the preferred beverage for children, as it is devoid of cariogenic potential and instrumental in cleansing the oral cavity and neutralizing acids. Fluoridated water supplies confer additional anticaries benefits by improving enamel resistance to acid demineralization. Fluoride, a key mineral in caries prevention, is widely incorporated in dental care products such as toothpaste and mouth rinses⁽¹³⁾.

Topical fluoride application through twice-daily brushing with fluoride toothpaste is a simple yet highly effective caries preventive measure. Pediatric oral care regimens should employ fluoride concentrations appropriate for age. Professional fluoride treatments may be warranted in high-risk individuals to augment protection⁽¹⁴⁾.

Parental education and involvement are critical to encouraging effective oral hygiene behaviors in children. Parents should serve as role models and verify consistent daily oral care routines. Additionally, oral health education programs within schools and early education settings can substantially improve knowledge and behaviors relating to oral hygiene and nutrition^(15,16).

Materials and method

For this cross-sectional study, a questionnaire including 20 questions was developed in 2024, to evaluate the impact of diet on children’s oral health. The questionnaire was distributed online via the Google Forms platform, targeting educational institutions such as kindergartens and primary schools from both urban and rural areas in Maramureş county. The children’s parents completed it, and the collected data were electronically processed and analyzed using Microsoft Excel software. Participation was voluntary, and all responses were anonymous and based on their consent. The first four questions collected basic information about the child (including age, gender, area of residence, and parents’ educational level), questions 5 to 9 focused on the child’s and family’s dietary habits (the frequency of consumption of sweets, acidic drinks, fresh fruits, and snacks), and questions 10 to 17 addressed the child’s oral hygiene practices (tooth brushing, use of fluoride toothpaste, dental floss, mouthwash, frequency of dental visits, presence of dental caries, and any general health disorders that could potentially affect oral health). The final three questions explored parents’ perceptions regarding the importance of prevention, their views on the risks associated with children’s dietary habits, the need for educational campaigns on dental disease prevention and the evaluation of their child’s oral health status.

Results

The study included 165 children, with an age distribution covering from early childhood (12 years old), from Maramureş county, in the northern part of Romania (Figure 1). The educational level of parents varied (71.51% had graduated from university).

The dietary habits revealed a frequent consumption of sweets among children, with 37.57% reporting daily and 46.66% reporting multiple times per week consumption. Similarly, carbonated or sweetened drink consumption was common, with 20.6% of children consuming these drinks weekly, the preferred types of drinks being sweetened juices and sodas. Fresh fruit consumption was moderate in quantity and daily in frequency for 60% of them. Frequent snacking between meals, often involving biscuits and chips, was reported in 74.54% of the sample at least once per week.

Oral hygiene practices varied considerably. Tooth brushing frequency showed that, while 33.33% of children brushed their teeth at least once daily, 58.78% adhered to the recommended twice-daily brushing. A concerning finding was the consumption of food or sugar-sweetened drinks after brushing, particularly before bedtime, which was reported by a substantial number of participants (27.87%). The use of fluoride toothpaste was common but not universal, indicating the need for improvement in preventive care. Additionally, auxiliary oral hygiene methods such as flossing and mouthwash usage were less commonly practiced, with only 13.93% daily.

Dental care access and oral health status indicators highlighted that regular dental visits were not consistent among all participants, with some children visiting the dentist only when issues appeared. The prevalence of dental caries remained significant (76.96%) within the study population, underscoring the need for enhanced preventive strategies.

Parental attitudes towards oral health were generally positive. Most parents expressed satisfac­tion with the dental services their children received (95.75%). Awareness regarding the negative impact of carbonated drinks on oral health was high, with the majority recognizing the importance of limiting these drinks (92.72%). Similarly, the value of educational campaigns aimed at preventing dental diseases was widely acknowledged. Finally, parents tended to assess their children’s oral health as good to very good, though this self-assessment may not always align with clinical findings (Figure 2).

Discussion

Dental caries represents a major public health concern in many industrialized countries, affecting between 60% and 90% of school-aged children. In the United States of America, an estimated 42% of children aged 2 to 11 have had cavities in their primary teeth, and 59% of adolescents aged 12 to 19 have experienced cavities in permanent teeth. Studies in South America, Asia and Europe show that caries incidence varies widely, from 20% to 100% of the population. In some developing countries, especially where community oral prevention programs are lacking, caries rates are rising⁽¹³⁾.

Reducing sugar consumption is a crucial preventive measure to lower the risk of dental caries. According to the World Health Organization (WHO) guidelines, added sugar consumption from foods and sugary drinks should be less than 10% of daily energy consumption, ideally below 5%. This recommendation offers dentistry an important opportunity to promote the benefits of reduced sugar consumption. Sugar reduction can be achieved by lowering sugar content in products or limiting the frequency of sugary food and drink consumption⁽¹⁷⁾. Early introduction of sugar in a child’s diet is associated with a higher prevalence of dental caries. The earlier sugar is introduced, the greater the risk of developing carious lesions. Longitudinal studies in various communities have demonstrated this connection.

A study in Scotland found that sugary drinks consumed during the first year of life lead to a high incidence of dental caries in children. Similarly, in Brazil, a higher consumption of cariogenic foods before 6 months of age correlated with severe caries lesions at a young age. Given the negative impact of sugar in childhood, delaying sugar introduction is important. One possible strategy is taxing sugary products, which is effective in reducing chronic diseases, including dental caries. Studies show that taxes on sugary drinks significantly reduce sugar consumption. In Hungary, following a tax on sugar-added foods, the consumption of such products fell by 4%, helping to reduce caries incidence and other dental diseases⁽¹⁸⁾. A study in India examined the role of teachers in reducing sugar consumption among school children through training modules. Data revealed that oral health education programs for children and parents help encourage proper dental hygiene. The results showed a significant increase in knowledge after completing the training module. Educating teachers and children about the adverse effects of sugar can prevent dental caries in early childhood⁽¹⁹⁾.

In Saudi Arabia, a study with 300 children, aged 3 to 6, revealed a 76% caries incidence, with higher rates in rural areas, suggesting geographic and dental care access influences. Social and economic factors, such as poor oral hygiene, dietary habits and parents’ education and profession, also contributed⁽²⁰⁾. Research in Scotland highlighted that, while frequent consumption of sweets or chocolate increases caries risk, this risk was significantly lower among children who brushed their teeth regularly (once or twice a day) compared to those who brushed less often. This shows that tooth brushing is an important factor moderating the relationship between sugar consumption and caries incidence. Inadequate oral hygiene practices, especially after night-time sugary snacks, and insufficient parental supervision were associated with higher caries risk⁽⁸⁾.

A cross-sectional study in Kisarawe, Tanzania, assessed early childhood caries prevalence, risk factors, and connection with nutrition and demographics in children aged 3-5. The results showed a high early caries frequency (44.8%), higher than in other Tanzanian regions and developed countries. Rural children had higher caries incidence due to limited information and oral hygiene practices. The statistical analysis confirmed a direct association between caries, dental plaque, and sugar consumption frequency. The study emphasized integrating oral health into pediatric nutrition programs and health education in rural communities⁽²¹⁾. A study across five Sub-Saharan African countries examined unhealthy eating habits in young children, finding a combined frequency of 62.4%, lower than in high-income countries like the USA (84.4%), Argentina (90.8%) and Brazil (94%). This difference is associated to greater economic capacity, availability and marketing of unhealthy foods. Sugar-sweetened drink consumption was 15.3%, lower than in urban studies. Children from wealthier families were 23% more likely to have unhealthy diets, influenced by financial means, nutrition perceptions and marketing exposure. Unhealthy eating habits result from a complex mix of economic, cultural and educational factors⁽²²⁾.

A study in 16 European Union countries analyzed energy drink consumption among adults, adolescents and children, focusing on active substances like caffeine and taurine. Adolescents were the most frequent consumers – 68% reported drinking these products in the past year, with boys (74%) consuming more than girls (63%). The consumption increased with age. Czech Republic, Hungary and Poland had the highest adolescent rates. Also, 18% of children aged 3-10 reported consuming energy drinks, especially in Czechia, Spain and the UK. Energy drinks are popular among adolescents for physical or intellectual effort and social activities, but they can cause significant health risks due to high caffeine and sugar⁽²³⁾.

In Rome, a study surveyed Italian parents about children’s oral hygiene habits via online questionnaire (291 parents, children mostly 9-12 years old). The results showed low parental knowledge about caries; only 45% recognized caries as pathological, and most thought it wasn’t contagious. However, 47% of children had caries, many treated by dentists. Regarding hygiene habits, the results were better: each family member had their own toothbrush, and sharing cutlery was rare. About 53% of parents started brushing their children’s teeth between the ages of 2 and 3, using age-appropriate toothpaste. Only 40% knew about dental sealants, and most hadn’t received fluoride in their early years, showing a lack of oral health information⁽²⁴⁾.

Globally, caries incidence is rising, especially in low- and middle-income countries, affecting up to 70% of the population, compared to 1-12% in developed countries. WHO reports that only advanced economies like the USA and Western Europe have significantly reduced caries in recent decades. Countries like Gambia, Croatia, Saudi Arabia and the Republic of Moldova have seen increases. Children from low socioeconomic backgrounds show the highest caries prevalence, being 52% more likely to develop caries than others. Medium socioeconomic groups have a similar prevalence but a 20% lower risk, while high socioeconomic groups have the lowest prevalence (24%). Developed countries focus on prevention programs; poorer countries emphasize emergency treatments and pain relief⁽²⁵⁾.

A cross-sectional study in Uruguay analyzed food additives in processed and ultra-processed products for children. Among 7343 products in 18 categories, 573 (7.8%) were for children, often promoted with attractive designs and cartoon characters. The most common were candies and biscuits (19.4% and 18.3%). Other common products included sweetened cocoa powder, chewing gum, breakfast cereals, dairy desserts, flavored milk, water-based ice cream, baby purees, and growing-up milk. These snacks promote unhealthy eating habits due to high sugar, salt and fat. Common additives were artificial flavors and colors. Nearly half the products were packaged in Uruguay, with Brazil (25.1%) and Argentina (22%) also major sources⁽²⁶⁾.

In Türkiye, a study on 270 parents examined the factors affecting children’s access to dental treatment during the COVID-19 pandemic. The most participants were mothers, and children averaged 8 years old. About 60% of parents had at least a high school education; 52% of mothers were homemakers, and 40% of fathers had fixed jobs. Access to dental care was easier for children whose parents had higher education or stable jobs. Family income was also significant, with wealthier families’ children more likely to get treatment. Requests to university hospitals and private clinics succeeded more often than public dental units. Having a stable job increased the chances of dental care by 3.3 times. The results emphasize the impact of socioeconomic factors on children’s dental care access during crises⁽²⁷⁾. In Brazil, over 50% of children develop caries by the age of 5 years old, with 80% untreated.

Sugar consumption is very high, with over 80% exposed to sugary foods before 6 months old. To prevent caries, authorities have expanded water fluoridation, improved monitoring, provided free healthcare for mothers and children, promoted fluoride oral hygiene products, and reduced sugar consumption. Nutritional guidelines recommend avoiding highly processed foods and sugary products for children under the age of 2. Long-term success requires addressing social inequalities, as socioeconomic factors strongly influence the children’s oral health⁽²⁸⁾.

Conclusions

Frequent consumption of sugar-rich foods is a major factor in the development of dental caries in children, influenced by their daily and weekly eating habits. Although the consumption of sugar-sweetened drinks is moderate, regular consumption of carbonated drinks lowers oral pH and promotes the formation of caries and dental erosion. On a positive note, most children in our area primarily hydrate with water and consume fresh fruits daily, indicating a trend toward healthier eating. However, frequent consumption of unhealthy snacks and eating after brushing teeth can negatively affect oral hygiene.

While many children brush their teeth regularly, the use of auxiliary oral hygiene methods remains low. Preventive dental visits are underutilized, with most children only visiting the dentist in emergencies.

Educational campaigns are well-received by parents, but greater parental involvement is needed to support healthy oral care habits. Therefore, promoting a balanced diet, early oral health education, and active participation from parents and healthcare providers are essential for preventing dental diseases and main­taining long-term oral health.   

Autor corespondent: Esztella-Éva Kis E-mail: esztella.kis@umfst.ro

CONFLICT DE INTERESE: niciunul declarat.

SUPORT FINANCIAR: niciunul declarat.

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