Ma et al. BMC Pediatrics(2024) 24:506
https://doi.org/10.1186/s12887-024-04984-9

BMC Pediatrics

RESEARCH

Open Access

Relationship of dietary nutrients with earlychildhood caries and caries activity amongchildren aged 3–5 years—a cross-sectional
study
Siting Ma1, Zhe Ma2, Xinfeng Wang3, Min Lei4, Yanning Zhang5, Xiuyan Lin1 and Hong Shi1*
Abstract
Background Early childhood caries (ECC) is a challenge for pediatric dentists all over the world, and dietary factor
is an important factor affecting the occurrence of ECC. Currently, there is limited research on the impact of dietarynutrient intake from Chinese diets on ECC. The purpose of this study is to explore the correlation of dietary nutrients
intake with ECC and caries activity (CA) among children aged 3–5 years, and to provide dietary guidance to slow
down the occurrence and development of ECC.
Methods A cross-sectional study was conducted in 2022. A total of 155 children were divided into three groups:
caries-free group, ECC group and Severe early childhood caries (SECC) group according to the caries statues. And
according to the caries activity test (CAT) value, they were also divided into three group: low CA group (L-CA), middle
CA group (M-CA) and high CA group (H-CA). The 24-hour dietary intake information was collected by mobile phone
application (APP). The intake of children’s daily dietary nutrients were calculated referring to “China Food Composition
Tables”.
Results In this study, 17, 39,and 99 children were diagnosed with caries-free, ECC, and SECC. There were 33,
36, and 86 children diagnosed with L-CA, M-CA, and H-CA. The risk of ECC was increased with the intake ofcholesterol(OR = 1.005) and magnesium (OR = 1.026) and decreased with the intake of iron (OR = 0.770). The risk of
SECC was increased with the intake of cholesterol (OR = 1.003). The risk of high CA was increased with the intake
of cholesterol (OR = 1.002). The combined application of dietary total calories, carbohydrate, cholesterol, sodium,magnesium and selenium in the diagnosis of ECC had an area under ROC curve of 0.741.
Conclusions The increased dietary cholesterol intake may be a common risk factor for ECC and high CA in children
aged 3–5. The combined application of dietary intake of total calories, carbohydrate, cholesterol, sodium, magnesium
and selenium has a higher predictive value for the occurrence of ECC.
Keywords Early childhood caries, Caries activity, The decayed, missing and filled teeth, Dietary nutrients, Diagnostic
model*Correspondence:
Hong Shishihong@hebmu.edu.cn
Full list of author information is available at the end of the article© The Author(s) 2024. Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0
International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you
give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified thelicensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images orother third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to thematerial. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation
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Ma et al. BMC Pediatrics(2024) 24:506

Background
Early Childhood Caries (ECC) is one of the most common chronic non-communicable diseases in children.
In 1999, the American Academy of Pediatric Dentistry(AAPD) officially named and defined ECC as “any primary tooth caries in children under or equal to 71
months, including one or more decayed (with or without cavity caries), missing (due to caries), or filled tooth
surfaces.“ [1] In 2016, the global disease burden research
reported: about 486 million children worldwide sufferedfrom primary tooth caries [2], while in 2022, the World
Health Organization (WHO) reported: about 514 million children worldwide suffered from primary tooth caries [3]. The global oral disease burden is obviously rising.
A meta-study in 2021 showed that the incidence of ECC
in Africa, America, Europe, Oceania and Asia was 30%,
48%, 43%, 82% and 52% respectively, and the incidence of
ECC in Asia was significantly higher than the global average [4]. The results of the fourth oral health epidemiological survey in China in 2018 showed that the caries rates
of primary teeth of children aged 3, 4 and 5 were 50.8%,
63.6% and 71.9% respectively, while the proportions ofteeth treated with fillings were only 1.5%, 2.9% and 4.1%
[5]. Compared with ten years ago, the caries rate of primary teeth of five-year-old children in China increased
by 5.8%, but the treatment rate only increased by 1.3%
[6]. This shows that the task of the prevention and treatment of ECC is arduous in China, and how to accurately
predict and prevent ECC at an early stage is the focus ofattention of Chinese pediatric dentists.
The occurrence and development of ECC are related tomany factors, including enamel hypoplasia, oral colonization with elevated levels of cariogenic bacteria (especially
Mutans streptococci [MS]), diet (substrate of bacterial
metabolism) and time, among which diet is an importantrisk factor for ECC [7]. Studies have shown that a healthy
diet can provide six nutrients to maintain human reproduction, growth and survival, including carbohydrates,
fat, protein, inorganic salts, vitamins and water (dietaryfiber is called “the seventh nutrient”), while an unhealthy
diet not only causes premature death [8], but also affects
children’s oral health.Wang X et al. [9] evaluated the
dietary quality of 150 children aged 2–5 in Hebei Province and found that ECC was related to excessive dietaryintake and dietary imbalance, high cereal intake and low
food diversity. Zhang M et al. [10] included 1301 children aged 3–5 in Shandong province for epidemiologicalinvestigation and found that exclusive breastfeeding in
the first six months after birth and high-frequency-sweet
eating before sleep were the high-risk influencing factorsof ECC in the 3-year-old group and the 5-year-old grouprespectively. The previous researches between ECC anddiet mostly focus on the influence of different food types,
eating frequency and food diversity on children’s caries

Page 2 of 16[9, 10], while the research on the correlation between
ECC and inorganic salts or vitamins focuses on the correlation between ECC and inorganic salt ions or vitamins
in saliva or blood. Shen H et al. [11] found that the serum
potassium level in biochemical indexes of blood test ofchildren with high caries risk was higher than that ofchildren without caries. Chen Z et al. [12] detected theserum of 1510 children aged 24–72 months in Hangzhou
and found that there was a significant difference in vitamin D levels between ECC children and caries-free children. Compared with children with sufficient vitamin D,
the prevalence of ECC in children with vitamin D deficiency increased significantly. At present, there are few
studies on the correlation between the intake of nutrientsand ECC, and they always focus on individual nutrients,
but there is no report on the correlation between total
nutrients and ECC.
Caries activity test(CAT) is one of the key indicators
in caries risk prediction [13]. Before the formation ofdental caries, the microenvironment in the oral cavity
has changed, such as the increase in the number of cariogenic bacteria, the decrease in the diversity of microbial communities in dental plaque, the increase in acidic
products in dental plaque, the decrease in the PH of dental plaque and saliva, and the decrease in saliva buffering
capacity, etc. CAT can find the limit of dental caries fromthe above changes as a test index to detect the sensitivity of individuals or groups to dental caries. According to
the results people can take different preventive measures,
thus improving the prevention and treatment efficiency[14, 15].
Cariostat is one of the most commonly used methods
to detect caries activity(CA) in clinic. Nishimura M etal. [13] showed that the CAT value of preschool children
was positively correlated with the number of decayedteeth (dt). Wang XY [16] also found that there was a positive correlation between the CAT and dmft in children
aged 3–5 years, and the sensitivity, specificity, false negative rate, false positive rate and accuracy of Cariostat in
the diagnosis of dental caries were 57.8%, 80.7%, 42.2%,
19.3% and 63.9%, respectively. The above results showthat there is a correlation between children’s CAT anddecayed, missing and filled teeth (dmft), so CAT was areliable index to predict the occurrence and developmentof ECC. Many studies have shown that children’s CA
may be related to their daily diet [16–18]. Wang XF et al.
[19] found that the CAT value of children aged 2–5 wassignificantly increased with the dietary deficiency anddietary imbalance and significantly decreased with fooddiversity, but they didn’t find that the scores of different food types had statistical significance on CA. It suggests that whether the influence of dietary factors on CA
comes from the insufficient or excessive intake of somedietary nutrients caused by unbalanced diet. However,Ma et al. BMC Pediatrics(2024) 24:506

at present, there is no report on the influence of dietarynutrients intake on CA in preschool children.
The accurate evaluation of food weight is very important to calculate children’s dietary nutrients intake. At
present, the commonly used dietary survey methods athome and abroad include 24-hour dietary review, chemical analysis and food frequency questionnaire (FFQ),
but these traditional methods have some limitations
such as more manpower costs, more material costs andrecall bias which affect the accuracy of dietary records[20]. Recently, with the pursuit of more reasonable andbalanced dietary intake and the development of smart
devices, various mobile phone applications (APP) related
to food estimation comes into being. In this study, children’s meals were photographed and recorded by mobile
phone APP, which not only shortened the operating time(e.g., food weighing and recording), but also reduced
the recall bias. And then more accurate 24-hour dietaryintake of children can be obtained.
At present, the research on dietary nutrition abroad
mostly refers to the nutrient composition tables or
national food databases of various countries, but there
are obvious differences in eating habits between China
and the West. Chinese diet structure is dominated byplant foods, such as grains, beans, vegetables and fruits,
supplemented by a small amount of animal foods. While
the western diet is dominated by animal foods, such asmeat, eggs and milk, supplemented by fruits and vegetables. Therefore western dietary nutrition data may not beapplicable to China. “China Food Composition Tables”isa data table of Chinese food nutrition composition established by the Institute of Nutrition and Health of China
Center for Disease Control and Prevention with reference to several databases at home and abroad. It is a collection of existing animal and plant food data in China.
It absorbs the development and progress of nutrition,
analytical chemistry and food science in recent years andstrives to keep pace with the professional development infood classification and data expression, which makes it
more widely used in nutrition research, diet investigationand the research of the relationship between diet and disease in China [21]. Compared with the previous researchmethods, it can provide more comprehensive and reliable
data, which is more in line with Chinese food nutrients
content standards. In this study, the dietary nutrients
intakes of children aged 3–5 with different caries status
were evaluated and analyzed with reference to “China
Food Composition Tables”, and the influences of dietarynutrients intakes on their caries status and CA were discussed, so as to provide scientific basis for preventing andslowing down the occurrence and development of ECC
in Chinese children’s dietary nutrition.

Page 3 of 16

Methods
Study population

A cross-sectional study design was carried out in 2022.
In this study 155 healthy children aged 3–5 were selectedfrom the Department of Pediatric Stomatology of Hebei
Medical University and four kindergartens in Shijiazhuang, Hebei Province by sample sampling method.
The recruitment of participants is based on the inclusion and exclusion criteria preseted in this study. Inclusion criteria: (1) Healthy children living with theirparents/legal guardians; (2) Only primary dentition;(3) Children who obtain the informed consent of parents/legal guardians; Exclusion criteria: (1) Children
with permanent dentition or mixed dentition; (2) Children or their parents/legal guardians uncooperative; (3)Children with any systemic diseases that may affect thehealth of teeth and the intake of dietary nutrients; (4)Children who took antibiotics 2 weeks before the study;(5) Children who take other drugs that may affect theiroral health or dietary intake for a long time; (6) Children
undergoing orthodontic treatment.
Sample size estimation

According to the results of the fourth oral health epidemiological survey in China released in 2018, the caries
rate of deciduous teeth of children aged 3–5 years old
was 62.5%, the allowable error was 15% of the total rate,
and the test level was 5%. Calculated by PASS(Version15), the sample size was about 120 cases. Taking 10% of
the lost-visit rate, and finally 155 children were included.
Ethical considerations

This study was approved by the Medical Ethics Committee of Stomatological Hospital of Hebei Medical University (No. [2018] 028) and conducted with reference tothe Declaration of Helsinki issued in 1964 and its revised
ethical principles. Before the start of the study, the parents/legal guardians of the children who participated in
the study were informed in detail of the purpose of thestudy, research methods, possible risks or adverse reactions to the children who participated in the study, andthen the written informed consent of the parents/legal
guardians of the recruited children was obtained. The
data in this study were confidential and only used for scientific research. In addition, we would also give some scientific dietary guidance to the participating children andtheir parents/legal guardians.
Dental examinations

The examiners were trained and calibrated the clinicalexamination method, evaluation method and recording
method before the research to control the examiner bias.
The dental examination were completed by two pediatric dentists with rich clinical experience, and the Kappa

Ma et al. BMC Pediatrics(2024) 24:506

value between the two examiners was greater than 80%.
The WHO dental caries inspection standard was adopted
to evaluate the caries status of children. After cleaning
the dental surfaces and using cotton rolls to isolate moisture, the decayed (without filled), missing (due to caries),and filled surface (dmfs) and the dmft of children were
examined and recorded by using sterile stomatoscope
and CPI probe under sufficient illumination. According
to the diagnostic criteria of oral health defined by AAPD,
the samples were divided into three groups: caries-freegroup, ECC group and Severe Early Childhood Caries(SECC) group. At present, the international diagnostic
standard of SECC is that one or more dmfs on any maxillary anterior teeth, or 3 years old (dmfs ≥ 4), 4 years old(dmfs ≥ 5) and 5 years old (dmfs ≥ 6).
Caries activity tests

The caries activity test was conducted by a strictlytrained pediatric dentist from 9: 00 am to 11: 00 am andfrom 3: 00 pm to 4: 00 pm. Before sampling, children
were required to rinse their mouths with clear waterand spat or swallowed saliva in their mouths to avoid alarge number of food residues or saliva affecting the test
results. According to the instructions of the Cariostat kit(GangDa Medical Technology Co. LTD., Beijing, China),
examiners wore disposable medical rubber gloves andused special sterile cotton swabs to repeatedly wipe thebuccal surfaces of maxillary molars and labial surfacesof mandibular incisors for 3–5 times to collect dental
plaque, and then immediately put the cotton swabs into
2.5 ml Cariostat reagent bottle. The reagent bottle wassealed and the label was attached to the bottle where it
did not block the liquid in the bottle, so as not to affectthe observation of the inspection results. The reagent
bottle was cultured in a constant temperature incubator
at 37 °C for 48 ± 4 h, and the CAT results were read andrecorded in comparison with the standard colorimetric card under natural light. CAT results can be divided
into seven grades, including 0, 0.5, 1.0, 1.5, 2.0, 2.5 and3.0. According to the results, children were divided into
three group: 0–1.0 for low CA group (L-CA group), 1.5
for middle CA group (M-CA group) and 2.0–3.0 for highCA group (H-CA group).
Intake of dietary nutrients in 24 h

The 24-hour diets of the examined children wererecorded by the WeChat APP (Beijing Sihai Huachen
Technology Co., Ltd.) to avoid the recall bias. Before
the survey, Parents/legal guardians were instructed andtrained by professionals to use the APP. And then 25 parents/legal guardians were randomly selected to test theircorrect use of the APP to determine whether to further
explain the operation method of the software.

Page 4 of 16

The parents/legal guardians were asked to upload
photos of all foods (including meals, drinks, snacks andsupplements) eaten by children on a certain day of weekend to the APP. The examined children were asked to eat
normally (excluding special circumstances such as eatingout or parties). Each food in the photos is photographed
separately and a one-yuan coin is used as a reference.
Before uploading the records, parents/legal guardians
could make some necessary supplements or explanations
for the information that was difficult to confirm onlyby photos. The next day, the researchers re-verified thefood intake calculated by APP according to the uploaded
records, and further confirmed the relevant information.
If mistakes or omissions were found, parents should be
asked to upload photos again to obtain reliable information on children’s dietary intake. After confirmation, theresearchers would further sort out all the informationand calculate the types and intake of children’s daily common dietary nutrients referring to the “China Food Composition Tables”.
Statistical analysis

Statistical analysis was carried out by SPSS 26, andthe test level was P = 0.05. There is no missing data. In
descriptive statistics, the counting data was expressed bypercentage (%), and the measuring data was expressedby median and quartile interval because of skew
distribution.
The univariate analysis was conducted to evaluate
demographic data (Mann-Whitney U test, Kruskal-Wallis H test, Chi-Squared test).
The Kruskal-Wallis H test was used to evaluate the difference of nutrient intake among caries-free group, ECC
group and SECC group and the variables with P < 0.1
were included in the multinomial logistic regression analysis. The Kruskal-Wallis H test was also used to evaluate
the difference of nutrient intake among L-CA, M-CA and
H-CA and the variables with P < 0.1 were included in theordinal logistic regression analysis. The OR and 95% confidence interval were calculated.
The Spearman correlation analysis was conducted toevaluate the associations between CAT value and dmft,
the nutrient intake and CAT value, and the nutrient anddmft.
The receiver operating characteristic curve (ROC) wasused to evaluate the diagnostic value of related nutrient
intake levels for ECC, and the area under curve(AUC),
sensitivity, specificity and Youden index were calculated.

Results
General information

A total of 170 children aged 3–5 participated in the study,
15 of whom failed to upload photos as required. And
finally 155 children were included.(shown in Fig. 1) The

Ma et al. BMC Pediatrics(2024) 24:506

Page 5 of 16

Fig. 1 Flow diagram for study subject inclusion

Table 1 Caries status of different ages and sexes
Variables
GenderMale
FemaleAge3(years)4(years)5(years)
total
a, b

number(%)

Caries prevalence(%)

P-valuedmft
median(IQR)

0.649
74(47.7)81(52.3)

87.8
90.1

41(26.5)72(46.5)42(27.1)
155

73.2a
94.4b
95.2b
89

P-valueP-value

Caries groupcaries-free[n(%)]

ECC[n(%)]

SECC[n(%)]

9(52.9)8(47.1)18(46.2)
21(53.8)

47(47.5)
52(52.5)

11(64.7)4(23.5)2(11.8)17(11.0)8(20.5)20(51.3)
11(28.2)
39(25.2)

22(22.2)
48(48.5)29(29.3)
99(63.9)

0.380
8(2.75,12.25)
6(4,10.5)

0.002*

0.893

0.001*
5(0,8)a7(4,11)b9.5(4,13.25)b7(3, 12)0.006*

Different letters indicate statistical differences. *Significantly different at P < 0.05

Table 2 CA of different ages and sexes
Variables
GenderMale
FemaleAge3(years)4(years)5(years)total

P-value

Caries group
L-CA[n(%)]

M-CA[n(%)]

H-CA[n(%)]

13(39.4)
20(60.6)

20(55.6)
16(44.4)

41(47.7)45(52.3)

10(30.3)
15(45.5)8(24.2)33(21.3)

10(27.8)
19(52.8)
7(19.4)36(23.2)

21(24.4)
38(44.2)
27(31.4)
86(55.5)

0.406

0.482

*Significantly different at P < 0.05

total caries prevalence rate was 89%, that of males was
87.8%, and that of females was 90.1%. There was no statistical difference between males and females (P = 0.649).
The caries prevalence rate of 3-year-old children was significantly lower than that of 4-year-old children and thatof 5-year-old children (P = 0.002). In this study, 17 children (11.0%) in caries-free group, 39 children (25.2%) in
ECC group and 99 children (63.9%) in SECC group were
included. There was no significant difference in gender

distribution among the three groups (P = 0.893), but there
was a significant difference in age distribution(P = 0.006).
According to their CAT values, the population in thisstudy was divided into three groups: 86 children for
H-CA group, 36 children for M-CA group and 33 children for L-CA group. There was no significant differencein age distribution and gender distribution among thethree groups (P = 0.482 and P = 0.406). (shown in Tables 1
and 2 )

Ma et al. BMC Pediatrics(2024) 24:506

Univariate analysis of caries and intake of different
nutrients in children aged 3–5 years

The intakes of total calories (P = 0.020), carbohydrate(P = 0.023), cholesterol (P = 0.010), sodium (P = 0.040),
magnesium (P = 0.041), iron (P = 0.027) and selenium(P = 0.025) were significantly different among caries-freegroup, ECC group and SECC group. The intakes of total
calories, carbohydrate, sodium and selenium in SECC
group were significantly higher than that in caries-freegroup. The intake of Cholesterol in caries-free group was
significantly lower than that in ECC group and SECC
group. The intake of iron in SECC group was significantly
higher than that in ECC group (shown in Table 3).
Multivariate analysis of caries and intake of different
nutrients in children aged 3–5 years

The model passed the test (P = 0.010). The intake of Cholesterol (OR = 1.005, 95%CI = 1.002–1.009, P = 0.002)
and magnesium (OR = 1.026, 95%CI = 1.002–1.051,
P = 0.033) were the independent risk factors of ECC.
The intake of iron was an independent protective factor of ECC (OR = 0.770, 95%CI = 0.626–0.946, P = 0.013).
The increase of cholesterol intake was an independentrisk factor for SECC (OR = 1.003, 95%CI = 1.000-1.006,
P = 0.030). (shown in Table 4)
The establishment of diagnostic model of ECC for children
aged 3–5 years based on dietary nutrient intakes

The predictive evaluation value of indicators with statistical differences in the results of univariate analysis for
ECC is as follows: (1) The diagnostic analysis model of
ROC curve established by the single application of eachindex showed that the intake of total calories, carbohydrate, cholesterol, sodium, magnesium and selenium had
certain evaluation value. The AUC of total calories, carbohydrate, cholesterol, sodium, magnesium and selenium
were 0.684, 0.668, 0.713, 0.681, 0.659, and 0.695, respectively, but the intake of iron had no evaluation value(P = 0.284). (2) Comprehensive regression was performedon the above-mentioned single application indexes withevaluation value. The prediction and evaluation efficiency
of ECC by the combined application of each indicators
was higher than that of each individual indicator and the
AUC was 0.741. (shown in Table 5; Fig. 2)
Univariate analysis of CA and intake of different nutrientsin children aged 3–5 years

The intake of cholesterol (P = 0.036), phosphorus(P = 0.035) and selenium (P = 0.039) were significantly different. The intake of cholesterol, phosphorus and selenium in L-CA group was significantly lower than that in
H-CA group (shown in Table 6).
Multivariate analysis of CA and intake of different
nutrients in children aged 3–5 years.

Page 6 of 16

The model passed the test (P = 0.021). Only the intake
of cholesterol was associated with CA (P = 0.022). The
CAT value increased with the intake of cholesterol(OR = 1.002, 95% CI: 1.000-1.003). (shown in Table 7)
Analysis of related factors of CAT value and dmft inchildren aged 3–5 years.
There was a positive correlation between the CAT value
and the dmft of children aged 3–5 (r = 0.570, P < 0.01).
The CAT value was positively correlated with theintake of total calories (r = 0.200, P = 0.013), cholesterol(r = 0.186, P = 0.021), fat (r = 0.185, P = 0.021), phosphorus(r = 0.184, P = 0.022) , sodium (r = 0.210, P = 0.009), iron(r = 0.162, P = 0.045) and selenium (r = 0.202, P = 0.012).
The dmft was positively correlated with the intake of total
calories (r = 0.244, P = 0.002), protein (r = 0.203, P = 0.011),
carbohydrate (r = 0.218, P = 0.006), calcium (r = 0.162,
P = 0.043), phosphorus (r = 0.249, P = 0.002), potassium(r = 0.230, P = 0.004) , sodium (r = 0.186, P = 0.02). magnesium (r = 0.221, P = 0.006), iron (r = 0.176, P = 0.029), selenium (r = 0.187, P = 0.02), copper (r = 0.160, P = 0.047) andmanganese (r = 0.180, P = 0.025). Total calories, phosphorus, sodium, iron and selenium are the common related
factors of CA and dmft (shown in Table 8).

Discussion
To date, this study is the first time to explore the relationship of different dietary nutrients intake with ECC and
CA of children aged 3–5 in Hebei Province and evaluate the common dietary nutrients affecting the dmft andCAT value in preschool children. The results showed thatthe occurrence and development of ECC in preschool
children might be related to the intake of total calories,
carbohydrate, cholesterol, sodium, magnesium, iron andselenium. The CA of preschool children might be related
to the intake of cholesterol, phosphorus and selenium.
It was found that cholesterol was a common risk factor
for ECC and CA, and total calories, phosphorus, sodium,iron and selenium were the common risk factors for
CAT value and dmft in this study. It suggests that we can
improve children’s oral health by controlling the intake ofcholesterol, total calories, phosphorus, sodium, iron andselenium in the future. Also it provide new methods forpreventing and slowing down the occurrence and development of ECC.
ECC is a disease that is affected by many factors,
especially daily diet. Hebei Province is located in North
China, with complex and diverse landforms, such as plateaus, mountains, hills, basins and plains. And it is richin animal resources and plant resources. In this way
compared with other regions, Hebei Province has morediverse ingredients and it is a typical representative ofChina’s northern diet [22]. Through the univariate analysis, it was found that there were significant differencesin dietary carbohydrate intake among caries-free group,Ma et al. BMC Pediatrics(2024) 24:506

Page 7 of 16

Table 3 Univariate analysis of caries and intake of different nutritional elements in children aged 3-5 years
Variable
Total calories kJ

Protein g

Fat g

Carbohydrate g

Dietary fiber g

Cholesterol mg

Vitamin A ugRAE

Thiamin mg

Riboflavin mg

Niacin mg

Vitamin C mg

Vitamin E mg

Calcium mg

Phosphorus mg

Potassium mg

Sodium mg

Magnesium mg

Group
Caries-free
ECC
SECC
Caries-free
ECC
SECC
Caries-free
ECC
SECC
Caries-free
ECC
SECC
Caries-free
ECC
SECC
Caries-free
ECC
SECC
Caries-free
ECC
SECC
Caries-free
ECC
SECC
Caries-free
ECC
SECC
Caries-free
ECC
SECC
Caries-free
ECC
SECC
Caries-free
ECC
SECC
Caries-free
ECC
SECC
Caries-free
ECC
SECC
Caries-free
ECC
SECC
Caries-free
ECC
SECC
Caries-free
ECC
SECC

N
17
39
99
17
39
99
17
39
99
17
39
99
17
39
99
17
39
99
17
39
99
17
39
99
17
39
99
17
39
99
17
39
99
17
39
99
17
39
99
17
39
99
17
39
99
17
39
99
17
39
99

Mean Rank
52.65a73.08a, b
84.29b
55.06
77.56
82.11
57.35
77.64
81.69
54.76a71.44a, b
84.58b
61.65
79.95
80.04
48.56a87.65b79.25b
73.82
73.69
80.41
74.65
74.05
80.13
79.35
70.46
80.74
73.00
77.31
79.13
88.59
73.55
77.93
77.29
75.79
78.99
73.94
68.31
82.52
59.71
70.41
84.13
63.41
68.79
84.13
53.00a76.74a, b
82.79b56.12a72.38a83.97aKruskal-Wallis H
7.838

P0.020*

5.274

0.072

4.267

0.118

7.513

0.023*

2.534

0.282

9.194

0.010*

0.793

0.673

0.620

0.734

1.484

0.476

0.283

0.868

1.329

0.515

0.146

0.929

2.959

0.228

5.785

0.055

5.282

0.071

6.430

0.040*

6.401

0.041*

Ma et al. BMC Pediatrics(2024) 24:506

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Table 3 (continued)
Variable
Iron mg

Zinc mg

Selenium ug

Copper mg

Manganese mg

a, b

Group
Caries-free
ECC
SECC
Caries-free
ECC
SECC
Caries-free
ECC
SECC
Caries-free
ECC
SECC
Caries-free
ECC
SECC

N
17
39
99
17
39
99
17
39
99
17
39
99
17
39
99

Mean Rank
67.00a, b
64.31a85.28b
72.29
69.97
82.14
51.12a76.74a, b
83.11b
55.12
76.51
82.52
53.35
79.10
81.80

Kruskal-Wallis H
7.255

P0.027*

2.364

0.307

7.411

0.025*

5.462

0.065

5.857

0.053

Different letters indicate statistical differences. *Significantly different at P < 0.05

Table 4 Multivariate analysis of caries and intake of different nutrients in children aged 3–5 years
Group

Variable

B

S.E.

Wald

P

Exp(B)

ECC

Total calories kJ
Protein g
Carbohydrate g
Cholesterol mg
Phosphorus mg
Sodium mg
Magnesium mg
Iron mg
Selenium ug
Copper mg
Manganese mg
Potassium mg
Total calories kJ
Protein g
Carbohydrate g
Cholesterol mg
Phosphorus mg
Sodium mg
Magnesium mg
Iron mg
Selenium ug
Copper mg
Manganese mg
Potassium mg

0.000
0.013
0.006
0.005
-0.0040.001
0.026-0.262-0.011-0.4740.251-0.0020.000-0.0070.010
0.003-0.003
0.000
0.009
0.006
0.011
-1.251
0.269
0.000

0.001
0.041
0.013
0.002
0.003
0.001
0.012
0.105
0.046
1.217
0.573
0.001
0.001
0.036
0.012
0.002
0.002
0.001
0.011
0.053
0.038
1.074
0.496
0.001

0.012
0.104
0.228
9.306
1.983
0.871
4.551
6.183
0.056
0.152
0.191
2.296
0.228
0.044
0.721
4.696
2.269
0.035
0.767
0.011
0.090
1.358
0.295
0.002

0.913
0.747
0.633
0.002*
0.159
0.351
0.033*
0.013*
0.814
0.697
0.662
0.130
0.633
0.835
0.396
0.030*
0.132
0.852
0.381
0.918
0.764
0.244
0.587
0.962

1.000
1.013
1.006
1.005
0.996
1.001
1.026
0.770
0.989
0.623
1.285
0.998
1.000
0.993
1.010
1.003
0.997
1.000
1.009
1.006
1.011
0.286
1.309
1.000

SECC

95%CI for Exp(B)Lower Bound
0.999
0.935
0.980
1.002
0.992
0.999
1.002
0.626
0.903
0.057
0.418
0.996
0.999
0.925
0.987
1.000
0.992
0.999
0.989
0.906
0.939
0.035
0.495
0.998

Upper Bound
1.001
1.098
1.033
1.009
1.001
1.002
1.051
0.946
1.083
6.767
3.950
1.001
1.001
1.065
1.035
1.006
1.001
1.002
1.030
1.117
1.090
2.348
3.461
1.002

*Significantly different at P < 0.05. B: Regression coefficient; S.E.: Standard error; Wald: Chi-square value; Exp(B): Odds ratio (OR). CI: Confidence interval

ECC group and SECC group, but through multinomial
logistic regression analysis the intake of carbohydrate
was not the independent risk factor of ECC and SECC in
this study. This result was similar to that of Laine MA etal. [23] and Cantoral A et al. [24]. They also found no correlation between carbohydrate intake and children’s caries status. However, Allam GG et al. [25] conducted dietrecords and oral examination on 120 Egyptian children,and found that their caries status was positively correlated with carbohydrate intake between meals. The different results of our study may be due to the fact that ourstudy only pays attention to the correlation between total
carbohydrate intake and caries status, but it does not
focus on the types of carbohydrate and eating frequency,Ma et al. BMC Pediatrics(2024) 24:506

Page 9 of 16

Table 5 Predictive value of nutrients intake on ECC
Index
Total calories kJ
Carbohydrate g
Cholesterol mg
Sodium mg
Magnesium mg
Selenium ug
combined application

AUC
0.684
0.668
0.713
0.681
0.659
0.695
0.741

P
0.014
0.024
0.004
0.015
0.033
0.009
0.001

95%CI
Low
0.512
0.495
0.590
0.538
0.484
0.549
0.595

High
0.855
0.841
0.837
0.824
0.833
0.841
0.886

Sensitivity

Specificity

Youden Index

86.2%
79.7%
78.3%
79.7%
87.7%
85.5%
93.5%

64.7%
64.7%
70.6%
58.8%
52.9%
52.9%
58.8%

50.9%
44.4%
48.9%
38.5%
40.6%
38.4%
52.3%

AUC: Area under curve. CI: Confidence interval

which also affect children’s caries status. Some studies have found that monosaccharides and disaccharides
with smaller molecular weights such as sucrose, lactose,
fructose and glucose have higher cariogenic property,
while macromolecular polysaccharides have lower cariogenic property, and refined sugar has higher cariogenic property than coarse sugar [26, 27]. Nakai Y et al.
[28] included 118 Japanese children aged 1–4 and examined their teeth. It was found that the frequent intake ofsugar between meals was related to a higher incidenceof ECC. With the increase of the frequency of sugar
intake between meals, the proportion of ECC children
increased. The frequent intake of carbohydrates keeps
teeth in acidic environment for a long time, which leads
to the demineralization and caries.
This study found that the intake of cholesterol in cariesfree group was lower than that in ECC group and SECC
group, and the difference was statistically significant. This
study also concluded that excessive cholesterol intake isan independent risk factor for CA. This result was similar to that of Subramaniam P et al. [29] and Sharma A
et al. [30]. They found that the saliva cholesterol level ofchildren was positively correlated with their caries status, and the saliva cholesterol level of ECC children wasslightly higher than that of caries-free children. The reason may be that the high cholesterol level can reduce thesaliva flow rate [30], thus affecting the buffering capacityof saliva and the clearance rate of food, and finally leading
to the occurrence and development of dental caries.
The results of this study showed that dietary magnesium intake was an independent risk factor of ECC, andthe magnesium intake of children in ECC group is higher
than that of children without caries. And it was similar
to the research results of Babu NV et al. [31], who foundthat the DMFT/dmft scores and the content of magnesium ions in saliva of autistic children were higher thanthose of normal children. Interestingly, most studies
believed that magnesium ions could inhibit dental caries,
which could inhibit the growth of cariogenic bacteria andhinder the development of dental caries [32, 33]. The different conclusions of this study may be due to the excessive intake of magnesium in ECC group, which leads tothe imbalance of calcium ions and magnesium ions in
the local oral microenvironment. In this way, it further
produces competitive inhibition and promotes the dissolution of hydroxyapatite and the release of calcium ions[34].
It was found that the iron intake of ECC group was
lower than that of caries-free group, and iron was anindependent protective factor of ECC in this study.
As an essential trace element of human, iron plays animportant role in various life activities. Previous studies have found that iron ions can inhibit the growth ofStreptococcus mutans [35], and at the same time, iron
ions can also inhibit the dissolution of enamel [36, 37].
Mohamed WE et al. [38] detected the serum of 80 children aged 24–71 months in Egypt and found that there
was a positive correlation between the occurrence of irondeficiency anemia and the occurrence of ECC. Jha A etal. [39] also found that the ferritin level of ECC children
decreased by nearly 2 times compared with caries-freechildren through serum testing of 266 children in 2021.
The incidence of iron deficiency anemia in ECC children
is 6 times higher than that in caries-free children. However, this study also found that the iron intake of children
with SECC was higher than that of children with ECC,
and there was no statistical difference between SECC
children and caries-free children, which was contrary to
the conclusions of Zhu S et al. [40] and Atri Y et al. [41].
This may be due to the excessive defects or loss of teeth
leading to the decline of children’s chewing ability, which
affects the digestion and absorption of iron.
Consistent with the previous results [17], this study
also found this the CAT value was positively correlatedwith the dmft. This may be due to the stronger acidproducing ability of oral cariogenic bacteria in high CA
children, which in turn leads to more serious caries. The
result further proves that Cariostat method can be used
to evaluate the risk of caries in preschool children, thus
providing a method for realizing the “early detection,
early diagnosis and early treatment” of ECC.
This research revealed that CAT value was positively
correlated with the intake of total calories, cholesterol,fat, phosphorus, sodium, iron and selenium. The dmft

Ma et al. BMC Pediatrics(2024) 24:506

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Fig. 2 a ROC curve of single index (Total calories, Carbohydrate, Cholesterol, Sodium, Magnesium, Selenium). b ROC curve of combined application ofeach single index

was positively correlated with the intake of total calories,
protein, carbohydrate, calcium, phosphorus, potassium,
sodium, magnesium, iron, selenium, copper and manganese. Total calories, phosphorus, sodium, iron and selenium were the common related factors of CA and dmft,
which suggested that they might be more reliable andworthy indicators for predicting the caries status of preschool children.

Dietary calorie mainly comes from carbohydrates, fat
and protein in food. Adequate calorie intake can provide
necessary support for human life. While insufficient orexcessive calorie intake will lead to underweight, emaciation and obesity, which will further affect children’s
oral health [42–45]. This study found that the value ofdmft and CAT in children increased with the total calories intake. This may be because with the improvementof living conditions, children consume more and more

Ma et al. BMC Pediatrics(2024) 24:506

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Table 6 Univariate analysis of CA and intake of different nutrient elements in children aged 3–5 years
Variable
Total calories kJ

Protein g

Fat g

Carbohydrate g

Dietary fiber g

Cholesterol mg

Vitamin A ugRAE

Thiamin mg

Riboflavin mg

Niacin mg

Vitamin C mg

Vitamin E mg

Calcium mg

Phosphorus mg

Potassium mg

Sodium mg

Magnesium mg

Group
L-CA
M-CA
H-CA
L-CA
M-CA
H-CA
L-CA
M-CA
H-CA
L-CA
M-CA
H-CA
L-CA
M-CA
H-CA
L-CA
M-CA
H-CA
L-CA
M-CA
H-CA
L-CA
M-CA
H-CA
L-CA
M-CA
H-CA
L-CA
M-CA
H-CA
L-CA
M-CA
H-CA
L-CA
M-CA
H-CA
L-CA
M-CA
H-CA
L-CA
M-CA
H-CA
L-CA
M-CA
H-CA
L-CA
M-CA
H-CA
L-CA
M-CA
H-CA

N
33
36
86
33
36
86
33
36
86
33
36
86
33
36
86
33
36
86
33
36
86
33
36
86
33
36
86
33
36
86
33
36
86
33
36
86
33
36
86
33
36
86
33
36
86
33
36
86
33
36
86

Mean Rank
66.21
73.47
84.42
67.67
74.94
83.24
67.79
71.67
84.57
72.27
74.47
81.67
71.00
79.31
80.14
62.48a74.14a, b
85.57b
65.30
80.88
80.41
75.64
77.58
79.08
75.36
72.58
81.28
77.33
80.39
77.26
75.44
83.69
76.60
71.15
81.22
79.28
74.15
73.75
81.26
63.94a71.64a, b
86.06b
64.55
76.83
83.65
64.67
77.67
83.26
65.39
75.97
83.69

Kruskal-Wallis H
4.400

P
0.111

3.089

0.213

4.267

0.118

1.336

0.513

1.028

0.598

6.654

0.036*

3.398

0.183

0.145

0.930

1.097

0.578

0.133

0.936

0.771

0.680

1.023

0.599

1.018

0.601

6.732

0.035*

4.352

0.113

4.092

0.129

4.056

0.132

Ma et al. BMC Pediatrics(2024) 24:506

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Table 6 (continued)
Variable
Iron mg

Group
L-CA
M-CA
H-CA
L-CA
M-CA
H-CA
L-CA
M-CA
H-CA
L-CA
M-CA
H-CA
L-CA
M-CA
H-CA

Zinc mg

Selenium ug

Copper mg

Manganese mg

a, b

N
33
36
86
33
36
86
33
36
86
33
36
86
33
36
86

Mean Rank
66.45
72.50
84.73
68.12
72.11
84.26
61.09a78.03a, b
84.48b
72.91
76.50
80.58
70.33
74.58
82.37

Kruskal-Wallis H
4.658

P
0.097

3.888

0.143

6.473

0.039*

0.749

0.688

1.987

0.370

95%CI for Exp(B)
Low
High
1.000
1.003
0.999
1.003
0.978
1.161
0.932
1.006

Different letters indicate statistical differences. *Significantly different at P < 0.05

Table 7 Multivariate analysis of CA and intake of different nutrients in children aged 3–5 years
Variable

B

S.E.

Wald

P

Exp(B)

Cholesterol mg
Phosphorus mg
Iron mg
Selenium ug

0.002
0.001
0.064
-0.0320.00070.00080.04370.0194

5.270
1.603
2.133
2.789

0.022*
0.205
0.144
0.095

1.002
1.001
1.066
0.968

*Significantly different at P < 0.05. B: Regression coefficient; S.E.: Standard error; Wald: Chi-square value; Exp(B): Odds ratio (OR); CI: Confidence interval

processed foods rich in sugar and fat. More and more frequent intake of sugar and fat provides a large amount ofacid for cariogenic bacteria, causing enamel demineralization, which in turn leads to dental caries.
Phosphorus is one of the main components of teeth,
which plays an important role in the development ofteeth. It is found that the decrease of blood phosphorus
content will affect the mineralization of teeth, thus reducing the anti-caries ability of teeth. And phosphate ions insaliva and dental plaque also play an important role inanti-caries [46]. Madali B et al. [47] found that DMFT/DMFS was negatively correlated with dietary phosphorus
intake through dietary analysis of 70 children aged 2–9.
On the contrary, this study found that dietary phosphorus intake was positively correlated with CAT value anddmft. This may be due to the fact that children’s dental
caries is not only affected by phosphorus intake, but also
by calcium intake. Some experiments have proved thatthe optimum intake ratio of calcium and phosphorus indiet is 0.55, Whenever the intake ratio of calcium andphosphorus is higher or lower than 0.55, the incidence
of dental caries increases [48]. In this study, children’s
intake ratio of calcium and phosphorus was poor, whichmight have an impact on the results.
In this study, the intake of sodium was positively correlated with CAT value and dmft, which was consistent

with the results of Priyadarshini P et al. [49]. This may
be owing to the excessive intake of sodium from the processed food, which leads to the competition between
excessive sodium ions and calcium ions in the process of reabsorption. As a result, the loss of calcium ion
increases [50, 51], which further affects the occurrence ofdental caries.
Selenium is one of the 15 essential trace elements forhuman. Excessive or insufficient intake will affect health.
In the past, many epidemiological studies and animal
experiments have found that selenium had a certain cariogenic effect [52–55]. The result also showed that dietary
selenium intake of children aged 3–5 was positively correlated with dmft and CAT value in our study. This may
be because excessive selenium will affect the mineralization of enamel, making enamel more sensitive to acidic
environment [56]. However, Krasniqi S et al. [57]. and Si
B et al. [58]. found that a certain concentration of selenium could not only inhibit the growth and reproductionof Streptococcus mutans, but also affect the expression ofgenes responsible for biofilm formation of Streptococcus
mutans. Tran P et al. [59] and Alshahrani SS et al. [60]also found that adding selenium to sealing agent could
reduce the biofilm formation of cariogenic bacteria suchas Streptococcus salivarius and Streptococcus sanguis.
The difference of selenium concentration may be theMa et al. BMC Pediatrics(2024) 24:506

Page 13 of 16

Table 8 Analysis of related factors of CAT value and dmft in children aged 3–5 years
CATdmft
Total calories kJ
Cholesterol mg
Protein g
Fat g
Carbohydrate g
Dietary fiber g
Vitamin A ugRAE
Thiamin mg
Riboflavin mg
Niacin mg
Vitamin C mg
Vitamin E mg
Calcium mg
phosphorus mg
Potassium mg
Sodium mg
Magnesium mg
Iron mg
Zinc mg
Selenium ug
Copper mg
Manganese mg

r
P
r
P
r
P
r
P
r
P
r
P
r
P
r
P
r
P
r
P
r
P
r
P
r
P
r
P
r
P
r
P
r
P
r
P
r
P
r
P
r
P
r
P
r
P
r
P

*Significantly different at P < 0.05.**Significantly different at P < 0.01

CAT
1
.
0.570
<0.01**
0.200
0.013*
0.186
0.021*
0.139
0.085
0.185
0.021*
0.15
0.063
0.073
0.366
0.046
0.573
0.04
0.623
0.034
0.673
-0.0060.937-0.059
0.462
0.019
0.815
0.059
0.465
0.184
0.022*
0.128
0.111
0.210
0.009**
0.151
0.061
0.162
0.045*
0.131
0.104
0.202
0.012*
0.074
0.363
0.155
0.055

dmft
0.570
<0.01**
1.
0.244
0.002**
0.071
0.378
0.203
0.011*
0.151
0.06
0.218
0.006**
0.023
0.777
0.033
0.687
0.111
0.169
0.105
0.192
0.083
0.306
-0.047
0.562
0.007
0.932
0.162
0.043*
0.249
0.002**
0.230
0.004**
0.186
0.02*
0.221
0.006**
0.176
0.029*
0.147
0.068
0.187
0.02*
0.160
0.047*
0.180
0.025*

Ma et al. BMC Pediatrics(2024) 24:506

Page 14 of 16

reason for the difference of these research conclusions[55]. At present, the research on the effect of selenium
intake on ECC and CA in the world is rare and the appropriate dose of selenium to prevent ECC have not been
discovered, which needs further study.
Through the analysis of ROC curve, it was found thatthe intake of total calories, carbohydrate, cholesterol,
sodium, magnesium and selenium in diet had certain predictive value for the occurrence of ECC in children aged
3–5, and the combined application of multiple factors
was more effective in the diagnosis of ECC. Which has acertain application value in slowing down the occurrence
and development of ECC in children by modifying theirdietary intake.
The purpose of this study is to provide dietary guidance
to prevent ECC and reduce the risk of ECC by analyzing
the correlation of different dietary nutrients intake withcaries status and CA of preschool children and establishing a comprehensive diagnosis model based on dietarynutrition. Although this study has achieved the above
meaningful results, this study still has some limitations.
First of all, as a cross-sectional study, this study can notestablish the causal relationship of nutrient intake with
ECC and CA, and more experimental researches areneeded to prove our observed conclusions in the future.
Secondly, this study only focuses on the types of foodintake, however it does not pay attention to the cooking
methods. Different cooking methods may have an impact
on the specific utilization rate of food, and then affectthe conclusion. Finally, the sample included in this study
is limited, and it is expected to carry out larger-scale
researches involving more regions in the future.

methods for establishing a model based on dietary nutrition to predict and slow down the occurrence and development of ECC.

Conclusion

Declarations

1. The occurrence and development of ECC in children
aged 3–5 years may be related to the intake of
total calories, carbohydrates, cholesterol, sodium,magnesium, iron and selenium in diet, among whichcholesterol is an independent risk factor for ECC.
2. The CA of children aged 3–5 years may be affectedby the intake of cholesterol, phosphorus andselenium in diet, among which cholesterol is anindependent risk factor for high CA.
3. The high intake of total calories, phosphorus,
sodium, iron and selenium in diet may be thecommon risk factors affecting CAT value and dmft.
4. The combined application of dietary intake of
total calories, carbohydrate, cholesterol, sodium,magnesium and selenium has higher predictive value
for the occurrence of ECC.
The above findings can provide dietary guidance forthe prevention of ECC, and provide scientific basis andAbbreviations
ECC	Early Childhood Caries
CA	Caries activity
dmfs	Decayed, missing and filled surface
dmft	Decayed, missing and filled teeth
SECC	Severe Early Childhood Caries
ROC	Receiver operating characteristic curve
AAPD	American academy of pediatric dentistryCAT	Caries activity test
FFQ	Food frequency questionnaire
APP	ApplicationWHO	World Health Organization
AUC	Area under curve
DMFT	Decayed, Missing and Filled Teeth
DMFS	Decayed, Missing and Filled Surface
dt	Decayed teeth
MS	Mutans streptococci
Acknowledgements
Not applicable.
Author contributions
H.S. conceived and designed the study, Z.M., X.W., M.L., Y.Z., and S.M.
conducted research. S.M., X.W., and X.L. analyzed and reconciled the data. S.M.
and Z.M. wrote the paper. H.S. had primary responsibility for final content.
Funding
This study was funded by the Hebei Provincial Department of Finance:
Government-funded project leader for training outstanding clinical medical
talents(Grant No: MXZB01610), the Project funded by the Hebei Provincial
Department of Finance: Study on the Correlation of Caries Activity and Dietary
Nutrition among Younger Children (Grant No: 361029).The funder had norole in the design, data collection, data analysis, and reporting of this study
and the supporting source had no such involvement or restrictions regarding
publication.
Data availability
Data is provided within the manuscript or supplementary information files.

Ethics approval and consent to participate
This study was approved by the Medical Ethics Committee of Stomatological
Hospital of Hebei Medical University (No. [2018] 028). Also, the written
informed consent was obtained from the parents/legal guardians of therecruited children to start the research.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Author details
1
Department of Pediatric Dentistry, Hospital of Stomatology and Hebei
Provincial Key Laboratory of Stomatology, Hebei Medical University,
Shijiazhuang, China
2
Department of Preventive Dentistry, Hospital of Stomatology and Hebei
Provincial Key Laboratory of Stomatology, Hebei Medical University,
Shijiazhuang, China
3
Department of Pediatric Dentistry, Qingdao Stomatological Hospital,
Qingdao University, Qingdao, China
4
Department of Nutrition, Third Hospital of Hebei Medical University,
Shijiazhuang, China

Ma et al. BMC Pediatrics(2024) 24:506

5

Department of Oral pathology, Hospital of Stomatology and Hebei
Provincial Key Laboratory of Stomatology, Hebei Medical University,
Shijiazhuang, China
Received: 13 March 2024 / Accepted: 30 July 2024

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