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Original Research/Pediatric Dentistry • Braz. oral. res. 40 • 2026 • https://doi.org/10.1590/1807-3107bor-2026.vol40.042 linkcopy

Open-access Association between incidence of dental caries and body mass index among preschool children: a longitudinal study

AuthorshipSCIMAGO INSTITUTIONS RANKINGS

Abstract:

Body mass index (BMI) disorders and dental caries are common and interrelated conditions in children, sharing risk factors such as inadequate diet and socioeconomic factors. This longitudinal study was designed to improve understanding of the determinants of children's health and, consequently, to promote health from childhood. The research was conducted between August 2017 and November 2018 in Diamantina, Brazil, and investigated the association between the incidence of dental caries and BMI in preschool children. The final sample included 122 children aged three to four years and 11 months, who were evaluated at two points over a one-year interval. The analysis showed that reduced family income (RR = 3.94; 95%CI: 1.26–12.39) and the incidence of caries (RR = 1.86; 95%CI: 1.01–3.42) were significant risk factors for low weight. Although maternal education initially appeared relevant (RR = 4.67; 95%CI: 1.48–14.73), its influence diminished when family income was considered. In conclusion, this study found an association between incidence of dental caries and low BMI (underweight) in preschoolers after one year of follow-up. The incidence of caries and the reduction or maintenance of low monthly family income were identified as risk factors for low weight in preschoolers during one year of follow-up.

Descriptors:
Body Mass Index; Dental Caries; Child; Preschool; Longitudinal Studies

Introduction

Obesity and underweight, often assessed using Body Mass Index (BMI), are public health issues that pose risks to human health.1 These conditions have a multifactorial and complex etiology,2 similar to dental caries. Dental caries is the most prevalent oral disease worldwide, affecting an estimated 621 million children.3 A recent systematic analysis for the Global Burden of Disease Study 2021 showed that global trends in the prevalence of untreated caries in deciduous teeth remained unchanged between 1990 and 2021.4 A diet rich in fermentable carbohydrates, processed foods, and low nutritional value is a common risk factor associated with BMI variations and dental caries in childhood.5,6 Consequently, studies have investigated whether there is an association between BMI variations and dental caries, but the findings remain conflicting.

Some studies have identified a potential association between dental caries and obesity.7,8 This link is often attributed to high sucrose intake, which can contribute to both obesity and dental caries.9,10 Conversely, other studies have reported an inverse relationship, with higher BMI associated with a lower prevalence of caries.11-13 Additional research has found a connection between dental caries and low BMI.14,15 Socioeconomic status may serve as a common risk factor linking these conditions.16,17 However, it is also possible that dental caries precede the onset of low weight, as the association between these conditions might be explained by masticatory difficulties resulting from severe caries lesions.18,19 Some studies have found no association between these conditions.20-22

Systematic reviews23,24 have not reached a consensus on the associations between dental caries and BMI in children. However, Chen et al.24 identified an association between dental caries and obesity in high-income countries. Investigating this topic is crucial, as the findings can help professionals address health issues in an interdisciplinary manner. Furthermore, dental caries affects almost 47.0% of Brazilian children aged five years,26 and childhood obesity has increased in prevalence in recent years in that country.27 Thus, studying this topic with more robust study designs is also significant for developing public health strategies to improve the population's quality of life. This study aims to evaluate the association between the incidence of dental caries and changes in BMI among preschool children over one year of follow-up. Additionally, it assessed the influence of socioeconomic factors as potential confounders.

Methods

The preparation of this study followed the STROBE guidelines for cohort studies. This study is part of a larger project aimed at evaluating the masticatory performance of preschool children before and after dental treatment. The project was approved by the Human Research Ethics Committee of the Federal University of Vales do Jequitinhonha e Mucuri, Brazil (Protocol number CAAE 830023018.0.0000.5108). Data were collected from August 2017 to November 2018. All guardians of the participating children were fully informed about the study's objectives and signed a written informed consent form.

Sample and study design

Data collection took place at the Pediatric Dentistry clinics of the Federal University of Vales do Jequitinhonha e Mucuri (UFVJM) with children aged 3 to 4 years and 11 months. The participants were selected from public and private preschools and daycare centers in Diamantina, MG, Brazil.

This project was a prospective longitudinal study. The study population included children aged 3 to 4 years and 11 months at baseline, of both sexes, enrolled in public and private daycare centers and preschools in Diamantina, Minas Gerais. At the end of the observation period, the population was divided into two groups: one consisting of children who developed dental caries and the other of those who did not. The allocation of children into each group was determined through prior examination and assessment. This assessment, which evaluated the presence of dental caries, was conducted at daycare centers and preschools in the city after obtaining parental consent.

This study was part of a broader investigation aimed at evaluating masticatory performance before and after dental caries treatment in preschool children. Considering the variables involved, a sample size calculation was conducted, and the statistical power for the previously defined sample size was determined.

Masticatory performance parameters before and after dental caries treatment were obtained from a pilot study involving 20 children: 10 children with cavitated carious lesions were matched by sex and age with 10 children without cavitated lesions. The masticatory performance of the group without carious lesions was assessed during the same period as their matched pairs with carious lesions. Using a standard deviation of 0.32 - corresponding to the mean standard deviation of the median particle size across group evaluations - a detectable difference of 0.2, a statistical power of 90%, and a standard error of 5%, the minimum required sample size was calculated as 54 children per group. To account for potential losses, 12 additional children were included in each group, resulting in a total study population of 136 children. The sample size calculation was performed using the OpenEpi platform, version 3.0119 (Figure). Only 12 children were included to minimize the occurrence of losses because these children were selected from a database of a previous study28 with 285 children, of whom 136 met the eligibility criteria for the present investigation.

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Figure 1
Flowchart of the study

The study included children in the primary dentition phase, aged 3 to 4 years and 11 months, regardless of sex, enrolled in public and private daycare centers and preschools in Diamantina, MG. Exclusion criteria applied to children who: had systemic conditions (e.g., syndromes or neurological disorders) as reported by parents/caregivers; had erupting first molars; were using orthodontic appliances; or showed any signs or symptoms of pulp involvement, such as spontaneous pain during the initial examination, abscesses, or fistulas.

A trained team conducted the research, consisting of a dentist who performed all oral clinical examinations and an assistant. The team underwent a training and calibration process that included both theoretical and practical components. This process involved training on dental caries and malocclusion examinations, including review of diagnostic criteria and analysis of photographs. Fifteen children were first examined by an experienced professional and then by the dentist responsible for the study to establish inter-examiner calibration (Kappa = 0.77 for dental caries and 0.89 for malocclusion). One week later, the same dentist re-examined the same group of children to evaluate intra-examiner reliability (Kappa = 0.81 for dental caries and 0.92 for malocclusion). The children involved in this training were not included in the main study.

Data collection

All assessment instruments were applied at two time points for the study sample. Evaluations through clinical examination and anthropometric measurements were carried out both at the beginning of the follow-up period (M1) and at the end (M2). Additionally, two forms were used for data collection: one to record the oral clinical examination and another to document sociodemographic and economic factors, such as maternal education and household income.

Clinical examination

Clinical examinations were performed under artificial light from a reflector, using personal protective equipment (PPE), in accordance with the biosafety standards in place at the time of data collection. The procedures used a clinical mirror, a millimeter-marked periodontal probe, and a WHO probe. The clinical examination was conducted after the examiner brushed the teeth with fluoride toothpaste, followed by drying the teeth with sterile gauze.

Dental caries was assessed using the International Caries Detection and Assessment System (ICDAS).29 The ICDAS is a tool designed to identify caries lesions and their severity, classifying lesions based on the progression of cavitation.29 Using this system, the number of teeth affected by caries in each child in the sample was determined, specifying the extent of each lesion. Both cavitated and non-cavitated caries lesions, as well as active and inactive lesions, were considered to determine the incidence of caries.

The classification for occlusal problems in primary dentition was defined according to the criteria proposed by Foster and Hamilton in 1969.30 In this study, anterior open bite, posterior crossbite, anterior crossbite, and excessive overjet were evaluated. All assessments were conducted with the teeth in occlusion.

Anthropometric assessment

Each child's weight was measured using a G-Tech Glass G4FB digital scale (Accumed Produtos Médico Hospitalares Ltda, Rio de Janeiro, Brazil), calibrated to an accuracy of 100 grams (g). A deduction of 200 g was made from each child's weight to account for clothing. Height was measured using a portable stadiometer with a vertical adjustable rod (WCS, Cardiomed, Curitiba, Brazil). Children were positioned with their backs against the stadiometer, ensuring the Frankfurt Plane was parallel to the ground. The movable part of the stadiometer was placed at the highest point of the head. For both weight and height assessments, children were barefoot, with their feet together and shoulders straight.

BMI was calculated using the recommended formula, dividing weight (kg) by height (m) squared (BMI = weight/height2). The resulting BMI values were plotted on a WHO-recommended growth curve, which accounts for the child's age and sex. This process determined the Z-scores for each child. Children with Z-scores above +1 are considered at risk of overweight; those with Z-scores above +2 and +3 are classified as overweight and obese, respectively. Children with Z-scores below -2 are considered underweight, and those with Z-scores below -3 are considered malnourished. Children with Z-scores from -2 to +1 are considered to have normal weight.31

Statistical analysis

Data analysis was performed using the Statistical Package for the Social Sciences (SPSS), version 24.0, and included descriptions of variable frequencies at baseline and follow-up. Unadjusted and adjusted Poisson regression with robust variance was used to assess the association between caries incidence and BMI changes, as well as to control for confounding factors. The unadjusted analysis was used to exclude variables with a p-value ≥ 0.20. However, variables with a p-value ≥ 0.20 that were considered by the team to be important confounding factors for the outcome were included. Only explanatory variables with a p-value < 0.05 after adjustment were selected for the final model. Relative risk (RR) and 95% confidence intervals (95%CI) were calculated.

Results

The final sample consisted of 122 children who had a normal BMI or were underweight at follow-up (89.70%) (Figure). Fourteen children did not return for follow-up. Table 1 presents the descriptive analysis of the variables at baseline and/or follow-up according to BMI at follow-up.

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Table 1
Descriptive analysis of variables at baseline and/or follow-up according to BMI at follow-up.

Table 2 shows both unadjusted and adjusted analyses of the factors associated with underweight BMI at follow-up. The unadjusted analysis revealed that lower maternal education (RR = 4.67; 95%CI: 1.48–14.73), a reduction in monthly household income (RR = 4.23; 95%CI: 1.33–13.50), low income at both baseline and follow-up (RR = 3.67; 95%CI: 1.31–10.25), and the incidence of dental caries (RR = 2.40; 95%CI: 1.19–4.87) were risk factors for underweight at follow-up (Table 2).

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Table 2
Unadjusted and adjusted analysis of factors associated with underweight BMI at follow-up.

In the final Poisson regression model, a reduction in monthly household income (RR = 3.94; 95%CI: 1.25–12.38), low income at both baseline and follow-up (RR = 3.40; 95%CI: 1.22–9.44), and the incidence of dental caries (RR = 1.86; 95%CI: 1.01–3.42) remained risk factors for underweight at follow-up.

This analysis was only possible by considering the change in BMI to the underweight category, since only one child presented with both dental caries and overweight/obesity during the follow-up period, which limited analyses involving higher BMI categories.

Discussion

This study demonstrated that the risk factors for low BMI (underweight) at follow-up were a reduction in family income, persistent low income, and the occurrence of dental caries. These results highlight the relationship between dental caries and BMI, which is often attributed to shared risk factors. However, the findings of this study suggest a different perspective for explaining this association.

A reduction in family income is a determining factor that can significantly affect children's nutritional health, leading to underweight. This is due to several reasons, including food insecurity.32 Studies indicate that low income increases the prevalence of food insecurity within families, as households with reduced income face difficulties in purchasing sufficient and nutritious food, resulting in inadequate intake of calories and essential nutrients needed for children's healthy growth and development.32,33 Moreover, low-income families often consume ultraprocessed foods that are rich in sugars and fats but low in micronutrients essential for healthy growth.34 Another important factor is the cost of foods necessary for a balanced diet, which often exceeds the financial capacity of families with reduced income. The cost of basic food in various Brazilian capitals consumes, on average, 54.0% of the salary of a worker earning the minimum wage.35 Due to this financial imbalance, families are forced to buy cheaper foods that are less nutritious, increasing the risk of underweight and other health problems associated with malnutrition.36

Although maternal education is a crucial factor for knowledge and health practices, this variable lost its significance when associated with low income in the same statistical model. Gundersen and Ziliak33 demonstrate that when controlling for income, the significance of maternal education in statistical analyses of child health often decreases, suggesting that income is a more immediate and direct determinant of living conditions that affect children's health. This occurs because there is a direct proportional relationship between education and income. In other words, individuals with higher education levels tend to secure better job opportunities and, consequently, higher income.38 Thus, since these variables were included together in the model of the present investigation, family income was more important for the outcome analyzed.

The lack of association between a child's weight at baseline and after one year suggests that children's weight can vary significantly over short periods, reflecting the dynamic nature of growth during childhood. In the early years of life, children can rapidly gain weight and height, leading to significant BMI changes in brief periods.1 Additionally, studies show that lifestyle interventions, such as changes in socioeconomic conditions, the home environment, and participation in physical activity, can result in significant BMI changes within a few months, highlighting the influence of these factors on children's growth.38,39

Studies have shown an association between the incidence of dental caries and both high and low BMI in children.9,13 Acs et al.40 and Ayhan et al.41 found that children with severe caries had significantly lower weight than children without caries. This result was also observed in the present study, as the incidence of caries remained a risk factor for low weight in children. Research indicates that children with dental caries consume fewer fruits and vegetables and more processed and sugary foods, negatively impacting their nutritional status, as these foods are poor in essential nutrients and can lead to malnutrition and low weight.42,43 Moreover, children with cavitated caries lesions may reduce their eating frequency due to pain, resulting in weight loss. A study conducted by Losso et al.44 demonstrated that pain and infection associated with caries can alter eating habits, affecting the growth pattern of children, and influencing low BMI.

Considering the common causal relationship between dental caries and overweight or obesity, cross-sectional studies may identify an association between these conditions. However, in longitudinal studies, it is reasonable to assume that children with dental caries, especially when the dentin is exposed, may reduce their sugar intake due to pain caused by exposed microscopic tubules. Consequently, these children may experience weight loss over time. Furthermore, diets predominantly rich in fatty foods, which are also considered obesogenic, are not direct risk factors for the development of dental caries. This may partially explain the heterogeneity observed in the association between obesity and caries among the studies.

Efforts were made to contact all the children who participated in the baseline study; 14 could not be found. Three children moved to another city and 11 changed their phone numbers and addresses, making it impossible to locate them. All of these children had normal BMI, and only one had dental caries at baseline. Thus, it is possible that the data from these children do not have a relevant impact on the results.

This study has some limitations that should be considered when interpreting the results. The sample size was relatively small, and the lack of representativeness may limit the generalization of the findings to the broader population. Additionally, the outcome analyzed focused exclusively on low weight, without considering other possible nutritional or health variables that could provide a more comprehensive view of the child's nutritional status. Another important limitation is the absence of information regarding the children's physical activity levels, which may act as a confounding factor, since physical activity directly influences energy balance, growth patterns, and nutritional status. The short follow-up period of just one year may not be sufficient to capture all the variations and trends in the development and nutritional status of these children. Therefore, future studies with larger sample sizes, multiple outcomes, and longer follow-up periods are recommended to validate and expand the conclusions presented here.

Despite its limitations, this study broadens understanding of the relationship between BMI and dental caries in childhood and reinforces the importance of developing integrated preventive strategies, with an emphasis on promoting healthy eating habits.

Conclusion

This study found an association between the incidence of dental caries and low BMI (underweight) in preschoolers after one year of follow-up. The incidence of caries and a reduction or maintenance of low monthly family income were identified as risk factors for low weight in preschoolers during one year of follow-up. The child's weight at baseline and follow-up was not associated with low weight. Further studies should be conducted with a larger sample size, a longer follow-up period, and multiple outcomes to more accurately assess this association.

  • Financial support:
    Fundação de Amparo à Pesquisa do Estado de Minas Gerais (Minas Gerais State Agency for Research and Development - Fapemig); Coordination for the Improvement of Higher Education Personnel (Capes), National Council for Scientific and Technological Development (CNPq), Brazil.

Data availability:

The authors declare that all data generated or analyzed during this study are included in this published article.

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Edited by

  • Editor-in-Chief:
    Lucianne Maia
  • Associate Editor:
    Martinho Campolina Rebello Horta

Publication Dates

  • Publication in this collection
    24 July 2026
  • Date of issue
    2026

History

  • Received
    08 May 2025
  • Reviewed
    21 Mar 2026
  • Accepted
    22 Apr 2026
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This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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