Skip to main content

Free sugars and early childhood caries development: a prospective cohort study

Freie Zucker und frühkindliche Kariesentwicklung: eine prospektive Kohortenstudie


Purpose : To investigate the impact of giving children younger than 2 years foods and beverages with free sugars on the prevalence of early childhood caries at 5 years.

Materials and methods: The study group consisted of 208 children (105 boys and 103 girls) with a complete set of data on nursing, diet and caries from birth to 5 years. We collected feeding habits and dietary data through structured questionnaires at 6, 12, 18 and 24 months and the presence of decayed (d), missed (m) and filled (f) teeth was scored according to the WHO criteria at 5 years of age. We processed data with chi-square tests and expressed as relative risk (RR) with 95 % confidence intervals.

Results: At the age of 5 years, 22% of the children had caries. Intake of fruit juice with meals (RR 2.3) and cookies or biscuits at 24 months of age (RR 2.4), as well as fast food consumption at least once every week (RR 2.9), more than doubled the risk for early childhood caries (p < 0.05).

Conclusions: Within the limitations of the present study, we found a relationship between consumption of free sugars early in life and dental caries prevalence at 5 years. It therefore seems important to embrace and emphasise the current sugar recommendations in primary and dental care to educate caregivers to avoid serving free sugars to their children before the age of 2 years.


Zweck: Es wurde untersucht, welche Auswirkungen die Gabe von Lebensmitteln und Getränken mit freien Zuckern an Kinder unter 2 Jahren auf die Prävalenz der frühkindlichen Karies im Alter von 5 Jahren hat.

Material und Methoden: Die Studiengruppe bestand aus 208 Kindern (105 Jungen und 103 Mädchen) mit einem vollständigen Datensatz zu Stillen, Ernährung und Karies von der Geburt bis zum Alter von 5 Jahren. Die Daten zu den Fütterungsgewohnheiten und zur Ernährung wurden mit strukturierten Fragebögen im Alter von 6, 12, 18 und 24 Monaten erhoben, und das Vorhandensein von kariösen, fehlenden und gefüllten Zähnen wurde im Alter von 5 Jahren nach den WHO-Kriterien bewertet. Die Daten wurden mittels Chi-Quadrat-Test verarbeitet und als relatives Risiko (RR) mit 95 %-Konfidenzintervall angegeben.

Ergebnisse: Im Alter von 5 Jahren hatten 22 % der Kinder Karies. Die Gabe von Fruchtsaft zu den Mahlzeiten (RR 2,3) und von Keksen oder Gebäck im Alter von 24 Monaten (RR 2,4) sowie die Gabe von Fast Food mindestens einmal pro Woche (RR 2,9) haben das Risiko für frühkindliche Karies mehr als verdoppelt (p < 0,05).

Schlussfolgerung: Innerhalb der Limitationen der vorliegenden Studie konnte ein Zusammenhang zwischen der Gabe von freien Zuckern im frühen Kindesalter und der Karies-prävalenz im Alter von 5 Jahren festgestellt werden. Daher erscheint es wichtig, die aktuellen Zuckerempfehlungen in der Primär- und Zahnpflege zu berücksichtigen und hervorzuheben, um Betreuungspersonen dahingehend zu schulen, die Gabe von freien Zuckern an Kinder unter 2 Jahren zu vermeiden.

This is a preview of subscription content, access via your institution.

Figure 1 Abbildung 1


  1. Bernabé E, Ballantyne H, Longbottom C, Pitts NB. (2020) Early introduction of sugar-sweetened beverages and caries trajectories from age 12 to 48 months. J Dent Res 99:898-906

  2. Boustedt K, Dahlgren J, Twetman S, Roswall J (2020a) Tooth brushing habits and prevalence of early childhood caries: a prospective cohort study. Eur Arch Paediatr Dent 21:155-9

  3. Boustedt K, Roswall J, Kjellberg E, Twetman S, Dahlgren J (2020b) A prospective study of perinatal and metabolic risk factors for early childhood caries. Acta Paediatr 109:2356-61

  4. Boustedt K, Roswall J, Twetman S, Dahlgren J (2018) Influence of mode of delivery, family and nursing determinants on early childhood caries development: a prospective cohort study. Acta Odontol Scand 76:595-9

  5. Diani L, Forchielli ML (2021) Sugar intake: are all children made of sugar? Life (basel) 11:444.

  6. Echeverria MS, Schuch HS, Cenci MS, Motta JVS, Bertoldi AD, Hallal PC, Demarco FF (2022) Trajectories of sugar consumption and dental caries in early childhood. J Dent Res 101:724-30

  7. Ha DH, Spencer AJ, Moynihan P, Thomson WM, Do LG (2021) Excess risk of dental caries from higher free sugars intake combined with low exposure to water fluoridation. J Dent Res 100:1243-50

  8. Keller MK, Kressirer CA, Belstrøm D, Twetman S, Tanner ACR (2017) Oral microbial profiles of individuals with different levels of sugar intake. J Oral Microbiol 9(1):1355207.

  9. Kitsaras G, Goodwin M, Kelly MP, Pretty IA (2021) Bedtime oral hygiene behaviours, dietary habits and children's dental health. Children (basel) 8(5):416.

  10. Mahboobi Z, Pakdaman A, Yazdani R, Azadbakht L, Montazeri A (2021) Dietary free sugar and dental caries in children: a systematic review on longitudinal studies. Health Promot Perspect 11:271-80

  11. Melough MM, Sathyanarayana S, Zohoori FV, Gustafsson HC, Sullivan EL, Chi DL, Levy SM, McKinney CM (2022) Impact of fluoride on associations between free sugars intake and dental caries in US children. JDR Clin Trans Res

  12. Pitts NB, Baez RJ, Diaz-Guillory C, Donly KJ, Feldens CA, McGrath C, Phantumvanit P, Seow WK, Sharkov N, Songpaisan Y, Tinanoff N, Twetman S (2019) Early childhood caries: IAPD Bangkok declaration. Int J Paediatr Dent 29:384-6

  13. Pitts NB, Twetman S, Fisher J, Marsh PD (2021) Understanding dental caries as a non-communicable disease. Br Dent J 231:749-53

  14. Riggs E, Kilpatrick N, Slack-Smith L, Chadwick B, Yelland J, Muthu MS, Gomersall JC (2019) Interventions with pregnant women, new mothers and other primary caregivers for preventing early childhood caries. Cochrane Database Syst Rev 2019(11):CD012155

  15. Robinson SL, Sundaram R, Lin TC, Putnick DL, Gleason JL, Ghassabian A, Stevens DR, Bell EM, Yeung EH (2022) Age of juice introduction and child anthropometry at 2-3 and 7-9 years. J Pediatr S0022-3476(22):00140-8.

  16. Robinson SL, Sundaram R, Putnick DL, Gleason JL, Ghassabian A, Lin TC, Bell EM, Yeung EH (2021) Predictors of age at juice introduction and associations with subsequent beverage intake in early and middle childhood. J Nutr 151:3516-23

  17. Ruxton CHS, Myers M (2021) Fruit juices: are they helpful or harmful? an evidence review. Nutrients 13(6):1815.

  18. Thornley S, Bach K, Bird A, Farrar R, Bronte S, Turton B, Atatoa Carr P, Fa'alili-Fidow J, Morton S, Grant C (2021) What factors are associated with early childhood dental caries? A longitudinal study of the growing up in New Zealand cohort. Int J Paediatr Dent 31:351-60

  19. Tinanoff N, Baez RJ, Diaz Guillory C, Donly KJ, Feldens CA, McGrath C, Phantumvanit P, Pitts NB, Seow WK, Sharkov N, Songpaisan Y, Twetman S (2019) Early childhood caries epidemiology, aetiology, risk assessment, societal burden, management, education, and policy: Global perspective. Int J Paediatr Dent 29:238-48

  20. U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary guidelines for Americans. 9th Edn. December 2020. Available at (2020-2025). Accessed May 15 2022

  21. WHO (2015) Sugars intake for adults and children. Geneva: WHO. Available online: Accessed May 15 2022

  22. World Health Organization (2013) Oral health surveys: basic methods. 5th ed. Geneva: World Health Organization

  23. Zaror C, Matamala-Santander A, Ferrer M, Rivera-Mendoza F, Espinoza-Espinoza G, Martínez-Zapata MJ (2022) Impact of early childhood caries on oral health-related quality of life: a systematic review and meta-analysis. Int J Dent Hyg 20:120-35

  24. Ziesmann A, Kiflen R, Rubeis V, Smith BT, Birken CS, Anderson LN, Maguire on behalf of the TARGet kids collaboration JL (2019) The association between early childhood and later childhood sugar-containing beverage intake: a prospective cohort study. Nutrients 11(10):2338.

Download references


We thank all parents and children for their kind willingness to invest time and take part in the present project and Dr. Jovanna Dahlgren for data access.


The project was funded by grants from Region Halland, Sweden and the author's institutions.

Author information

Authors and Affiliations


Corresponding author

Correspondence to Svante Twetman.

Ethics declarations

The authors report no conflicts of interest.

Rights and permissions

Reprints and Permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Boustedt, K., Roswall, J. & Twetman, S. Free sugars and early childhood caries development: a prospective cohort study. Oralprophylaxe Kinderzahnheilkd 45, 88–93 (2023).

Download citation

  • Published:

  • Issue Date:

  • DOI: