Controlling sugar consumption still has a role to play in the prevention of dental caries

Selection Criteria: A systematic literature search was conducted in the databases MEDLINE and EMBASE for articles published between January 1980 and July 2000 using the keywords populations, sugar, sucrose, fructose, glucose, disaccharides, monosaccharides, high-fructose corn syrup, HFCS, corn syrup, diet history, diet interview, diet questionnaire, dietary interview, dietary questionnaire, sweets, confectionery, honey, candy, candies, and sports drinks. The initial search included articles written in English that used cohort, case-control, or crosssectional research designs with human subjects. Relevant titles and abstracts were searched. Final full review for inclusion was performed based on a set of defined exclusion criteria and scored according to the quality of the individual article. The exclusion criteria included the following: studies in countries with no widespread fluoride exposure; studies with no measure of individual sugar intake, or caries experience; sugar consumption given, but not statistically related to caries experience; studies with caries experience but no diagnostic criteria listed; studies of secondary analysis of previously analyzed data; studies of the effect of a single food; clinical trials of chewing gums that contain sugar substitutes; and studies on early childhood caries in infancy. Key Study Factor: Sugar intake (eg, total amount consumed, frequency of sugar intake). The authors established a series of categories and a scoring method to assess the quality of each article reviewed. The highest score was given to studies that used a structured interview for a 24-hour recall, a food frequency questionnaire, or a 3-day food diary to determine sugar intake. A lower score was given to studies that indicated an interview was conducted, but the authors failed to provide further details. Studies of self-reports that were not validated, and in which the method for quantifying sugar intake was either not described or not clear were also given low scores. Each article reviewed was scored, with a range from 12 to 79. The authors based their conclusions only on those articles that scored 55 or higher. Main Outcome Measure: Any caries development (any visual dental caries history, radiographic caries, etc.). Main Results: A meta-analysis of the key findings was not conducted because of heterogeneity of the reviewed studies. The evaluations were made based on 2 main measurements: (1) the risk of sugar-associated caries according to the risk ratio (odds ratio [OR], relative risk [RR]); and (2) the correlation coefficient for relating sugar intake to caries experience. The authors decided that an OR or RR of 2.5 or higher would be counted as a strong association; ORs/RRs of 1.5 to 2.4 would be scored as moderate; and ORs/RRs of 1.4 or lower would be scored as weak or no association. A correlation coefficient less than 0.4 would constitute a weak relationship. The initial search identified 809 articles, and from these, 134 articles were selected for full review; only 69 satisfied the inclusion criteria. The authors finally selected 36 articles that scored 55 or higher for inclusion in the review. There were only 2 studies that reported a strong relationship between sugar intake and caries development, whereas 16 found a moderate relationship, and another 18 showed the relationship was weak to none. Conclusions: The authors concluded that the relationship between sugar consumption and caries is much weaker in the modern age of fluoride exposure than it used to be. However, controlling the consumption of sugar remains a justifiable part of caries prevention, if not always the most important aspect. 5