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The role of sugar, xylitol,

toothbrushing frequency, and use of
fluoride toothpaste in maintenance of
adults’ de...
Hannu Hausen, Battsetseg Tseveenjav

European Journal of Oral Sciences

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Sugars and Dent al Caries

Merja Laine
Eur J Oral Sci 2011; 119: 40–47  2011 Eur J Oral Sci
DOI: 10.1111/j.1600-0722.2010.00804.x European Journal of
Printed in Singapore. All rights reserved
Oral Sciences

Battsetseg Tseveenjav1,2, Anna

The role of sugar, xylitol, toothbrushing L. Suominen3,4, Hannu Hausen5,
Miira M. Vehkalahti1
frequency, and use of fluoride 1
Department of Oral Public Health, Institute of
Dentistry, University of Helsinki, Helsinki;
2

toothpaste in maintenance of adultsÕ Dental Health Care Department, City of

Helsinki Health Centre, Helsinki; 3Department
of Health, Functional Capacity and Welfare/

dental health: findings from the Finnish Department of Environmental Health, National
Institute for Health and Welfare, Helsinki;
4
Department of Public Health Dentistry,

National Health 2000 Survey Institute of Dentistry, University of Turku,

Turku; 5Finnish Dental Association, Helsinki,
Finland

Tseveenjav B, Suominen AL, Hausen H, Vehkalahti MM. The role of sugar, xylitol,
toothbrushing frequency, and use of fluoride toothpaste in maintenance of adultsÕ dental
health: findings from the Finnish National Health 2000 Survey.
Eur J Oral Sci 2011; 119: 40–47.  2011 Eur J Oral Sci

We assessed the effect of certain oral health-related behaviours on adultsÕ dental

health. As part of the Finnish nationwide Health 2000 Survey, dentate subjects,
30–64 yr of age, reported their frequency of consumption of eight sugar- and xylitol-
containing products, together with toothbrushing frequency and use of fluoride
toothpaste, and underwent clinical oral examination (n = 4,361). The mean number
of teeth present (NoT) was 24.2 and the mean numbers of sound teeth (ST), filled teeth
(FT), and decayed teeth (DT) were 10.8, 12.1, and 1.1 for men and 9.6, 13.8, and 0.5
for women, respectively. Consumption of sugar-sweetened beverages was more
frequent than that of other sugar-containing products, and greater in men than in
women. Daily use of xylitol chewing gum was reported by 13% of the men and by
22% of the women. Toothbrushing at least twice daily was reported by 47% of the Battsetseg Tseveenjav, Institute of Dentistry,
men and by 79% of the women; 86% and 96%, respectively, reported daily use of University of Helsinki, PO Box 41, FI-00014
fluoride toothpaste. The frequency of consumption of sugar- and xylitol-containing Helsinki, Finland
products and of toothbrushing, as well as use of fluoride toothpaste, play a role in the
Telefax: +358–9–19127346
dental health of dentate adults, with the impact being weak on NoT, ST, and FT, but E-mail: battsetseg.tseveenjav@helsinki.fi
stronger on DT, especially concerning toothbrushing frequency (relative risk = 1.5)
and use of fluoride toothpaste (relative risk = 1.8). Understanding the impact of Key words: dental health; epidemiology;
national survey; sugar; toothbrushing; xylitol
certain oral health-related behaviours on dental health in adults would facilitate better
targeting of oral self-care messages. Accepted for publication December 2010

Despite a substantial decrease in caries prevalence in many
western countries, caries still remains a public health
problem (1) and, despite being preventable, is mainly
treated by restorative actions (2). Nowadays, an increas-
ing number of dental health-protective aids, but also of
harmful products (such as sugary snacks and drinks), are
widely available. However, little is known about their joint
impacts on the dental health of adults. Recommendations
for the maintenance of dental health over a lifetime in-
clude adequate home care for controlling caries, such as
the restriction of sugar use and regular removal of dental
plaque by means of toothbrushing twice daily with fluo-
ride toothpaste (3–6). In addition, daily use of xylitol has
been recommended for children and adolescents (7–9).
As early as the 1950s, a 5-yr Swedish trial showed that
frequent sugar use is harmful for adultsÕ dental health
(10); more recent studies have shown that a frequency of
sugar intake beyond four times a day is detrimental to
dental health (11, 12). On the other hand, numerous
studies carried out during recent decades have reported
that when people are exposed to fluoride (e.g. in water, in
toothpaste or as supplements), the role of sugar as the
most important determinant of caries incidence seems to
weaken (13–15). A review of longitudinal studies,
however, indicates that the correlation between caries
incidence and sugar consumption still exists (16). In
populations where fluoride use and a preventive
approach to oral healthcare are limited, abundant use of
sugar seems to have a significant detrimental impact on
dental health (17, 18).
In the presence of poor oral hygiene, the use of sugary
products is extremely harmful for dental health, as
shown among young adults in Sweden (19). In Finland,
the nationwide survey in 1980 showed analogous findings
among adults: the combination of frequent toothbrush-
ing and limited use of sugar was associated with a lower
occurrence of caries (20, 21), which may partly result
from the beneficial topical effect of fluoride toothpaste.
The daily use of fluoride toothpaste is therefore strongly
recommended to maintain dental health (22, 23).

The use of xylitol-containing products has also been
strongly recommended because the habitual use of xylitol
is associated with a significant reduction in caries inci-
dence and with lesion remineralization in young children,
schoolchildren, and mothers, and in children via their
mothers; these effects are caused by the substitution of
fermentable sugar and the stimulation of saliva (24–29).
The recommended daily dose is 5 g of xylitol, dispensed
in chewing gum, lozenges, candies, toothpaste or mouth
rinse, divided into three to five occasions a day, imme-
diately after every meal or snack (7–9).
Toothbrushing twice daily is adopted best among
those with a high socioeconomic status and worst among
those with a low socioeconomic status (20, 30, 31). A
nationwide survey in 1980 among adults in Finland
revealed better dental health for those who brush their
teeth twice daily, but also verified these findings within
each educational level in the age groups 30–44 and 45–
64 yr, separately for men and for women (20).
Dental health outcomes in adults have traditionally
been described as numbers of teeth present and as pres-
ence of untreated caries lesions, but could also be mea-
sured as numbers of sound teeth (ST), particularly
among adults. One of the few studies showing data on
ST is the series of the nationwide surveys from the UK.
From 1978 to 1998 in the UK, the percentages of adults
with 18 or more ST increased among men, from 28% to
44%, and among women, from 22% to 39%; the
increase was also seen in subgroups according to socio-
economic status and age (30). Unfortunately, the report
did not provide results for associations between oral
health-related behaviours and the presence of ST.
In order to assess the role of oral health-related
behaviours on adultsÕ dental health, the present study
investigated the association of the frequency of con-
sumption of sugar- and xylitol-containing products and
of toothbrushing, as well as the use of fluoride tooth-
paste, with adultsÕ dental health indicators. Our working
hypotheses were that less frequent consumption of sugar-
containing products or more frequent use of xylitol-
containing products, combined with toothbrushing at
least twice daily using fluoride toothpaste, are associated
with higher numbers of teeth present (NoT), filled teeth
(FT), and ST, as well as with lower numbers of decayed
teeth (DT).
Material and methods
The present study is part of the nationwide Health 2000
Comprehensive Health Examination Survey in Finland,
which used a stratified two-stage cluster sample of a total of
8,028 citizens, ‡ 30 yr of age (31–33). The sampling frame
was regionally stratified according to the five university
hospital regions, each comprising approximately one million
inhabitants. From each regional stratum, 16 healthcentre
districts were sampled as clusters. The ultimate sampling
units were persons selected by systematic random sampling
from these 80 healthcentre districts.
Data collection was carried out using structured health
interviews, self-administered questionnaires, and compre-
hensive clinical health examinations. Subjects were first
Sugar, xylitol, brushing, and dental health 41
interviewed at home by Statistics Finland professional
interviewers. On completion of the interview, a question-
naire was handed to each interviewee to be filled in at home
and returned at the clinical examination, which took place,
on average, 1 month later. The interviews and question-
naires were in both of FinlandÕs official languages (Finnish
and Swedish). The original forms and their English trans-
lations are available on the Internet pages of the survey
(http://www.terveys2000.fi/forms.html).
Permission for the study was given by the Ethics Com-
mittees of the University Hospital Region of Helsinki and
Surroundings and the National Public Health Institute.
Informed consent was obtained from each survey partici-
pant.
Information on the frequency of toothbrushing and use of
fluoride toothpaste was obtained in the structured health
interview. Five responses (more than twice daily, twice
daily, once daily, less than once daily, and never) were
offered for the question ÔHow often do you usually brush
your teeth?Õ, which were later dichotomized as at least twice
daily and less than twice daily. Four responses (daily,
weekly, less often, and never) were offered for the question
ÔWhen cleaning your teeth, how often do you use fluoride
toothpaste?Õ. For the analyses, these were dichotomized as
daily or not daily.
Frequency of consumption of sugar- or xylitol-containing
products was assessed in the self-administered questionnaire
by asking ÔHow often do you usually consume the following
products?Õ The eight product groups were: sugary coffee or
tea; other sugary drinks, such as sugared juices, fizzy drinks
or cocoa; toffee, liquorices or dried fruits; xylitol lozenges or
candies; non-xylitol lozenges or candies; chocolate or filled
biscuits; non-xylitol chewing gum; and xylitol chewing gum.
For each product group, the following five alternatives for
consumption frequencies were given: three times a day or
more often; once or twice a day; two to five times a week;
more seldom; and never. For descriptive analysis, the
frequencies were subgrouped into daily, weekly, and less
often or never. For subjects with one (n = 143; 3.3%) or
two (n = 16; 0.4%) missing answers out of the eight
product groups, the values were replaced by the mean of the
variable in question.
The oral health examination was part of the compre-
hensive health examination and was carried out by five
calibrated dentists with the assistance of a dental nurse or an
oral hygienist. The equipment consisted of a dental chair, a
portable dental unit (Dentronic Mini-Dent; Planmeca,
Helsinki, Finland), a high-powered suction motor, and a
fibre optic head lamp (Tekmala, Vantaa, Finland); the
routine instruments were a dental mirror, a fibre optic light,
and a periodontal probe recommended by WHO (31).
Identification of a tooth and determination of its status were
based on the methodology of the Mini-Finland Survey (20)
as well as on the WHO guidelines (34). The presence of teeth
was recorded tooth by tooth, and included all teeth and
tooth remnants that were visible and tactile in the mouth.
The teeth were blown dry before the status of all tooth
surfaces was examined, and observations were recorded for
each tooth as follows: sound; decayed (either primary or
secondary caries cavities extending into dentine, separately
for coronal or root surfaces or both); filled (no caries
lesion); fractured; and residual root, with or without caries.
The percentage agreement between examiners and the
reference examiner for dental status of each tooth, assessed
for 269 subjects in real-field circumstances, was 93%
(kappa = 0.87) (31). A subjectÕs dental health was
described as NoT, ST, FT, and DT.
42 Tseveenjav et al.

Age, gender, and educational level served as background dentate with complete data on dental health status
information. The subjects were grouped, according to age, (n = 4,585). When further restricted to those subjects
into four groups: 30–34, 35–44, 45–54, and 55–64 yr. The 35– with no more than two missing answers to the eight
44 yr age-group has been defined by the WHO as an index age questions on consumption frequency of sugary products,
group for the global data bank. The subjectsÕ level of educa- who answered the question on their toothbrushing
tion combined information about their basic and vocational
education. The question about basic education instructed the
frequency, and who participated in the clinical oral
respondent to select, from the eight options offered, the examination, a total of 4,361 subjects were included in
highest level of education attained, ranging from Ôless than this study (Fig. 1).
elementary schoolÕ to Ômatriculation examinationÕ. The Subjects had an average of 24.2 teeth present, of which
question about vocational education instructed the respon- 10.2 were sound, 13.0 were filled, and 0.8 were decayed.
dent to select, from the 11 options, the highest education The mean numbers of ST, FT, and DT were 10.8
completed, ranging from Ôno vocational educationÕ to Ôdoc- (SE = 0.2), 12.1 (SE = 0.1), and 1.1 (SE = 0.1) for the
toral degreeÕ. For the analyses, the subjectsÕ educational level men and 9.6 (SE = 0.1), 13.8 (SE = 0.1), and 0.5
included the three categories: basic, intermediate, and higher. (SE = 0.003) for the women (Table 1). Of all subjects,
63% reported brushing their teeth twice or more daily,
Statistical analysis and 91% reported daily use of fluoride toothpaste. Of
the eight sugary products, sugary coffee or tea and other
We used spss 16.0 (IBM Corp., New York, NY, USA) and sugary drinks were most commonly reported as being
sas callable sudaan (Research Triangle Institute,
Research Triangle Park, NC, USA) software and weights
consumed on a daily basis, with smaller frequencies for
for handling correlated data with unequal sampling proba- women than for men. Daily use of xylitol gum was
bilities and for correcting for the effects of non-response. reported by 17% of the subjects; a minority, 7%,
Non-response was accounted for by calibrating the original reported use of xylitol gum at least three times daily.
design weights using post-stratification (33). The weights Consumption of the other products was rare. For a
were based on post-stratification with gender, age, and detailed description of the study subjects, see Table 1.
geographical region. The purpose of sampling weights is to Table 2 shows the associations between the dental
adjust the observed data to correspond to the distribution of health indicators and the behaviours after adjusting for
the target population. Sampling weights can therefore be adultsÕ age, gender, and educational level. The impacts of
used to adjust for sampling variability and errors caused by the oral health-related behaviours on dental health
non-response. Because of the skewed distributions of the
dental health indicators, relative risk (RR) values according
indicators were weak when the outcomes NoT, ST, and
to behavioural aspects were estimated by Poisson regression FT (RR = 1.0–1.1) were considered, but stronger when
models for NoT, ST, and FT and by negative binominal DT was the outcome variable. Hence, the RR estimate
regression models for DT because of its overdispersed for toothbrushing less than twice daily was 1.5, and the
distribution. The covariates were adultsÕ age, gender, and
educational level. Number of teeth present served as the
offset variable for ST, FT, and DT analyses. Interactions
between background and explanatory variables were tested,
and because of the interactions detected with gender, the
regression models were performed also by gender.
In order to combine consumption frequencies of the eight
sugary products into possible underlying patterns, factor
analysis was applied. Factor analysis formed five distinct
patterns of consumption of sugar-containing products. In
factor F1, strong loadings indicated consumption of sugary
coffee or tea and of sugary juices, fizzy drinks or cocoa. In
factor F2, strong loadings indicated consumption of
lozenges and candies regardless of whether or not they
contained xylitol, and in factor F3, strong loadings indi-
cated the consumption of toffee, liquorice or dried fruits,
and chocolate or filled biscuits. In factor F4, strong loadings
indicated the consumption of xylitol chewing gum and in
factor F5, strong loadings indicated the consumption of
non-xylitol chewing gum. Based on these loadings, the fac-
tors were further labelled as follows: F1 as sugar-sweetened
beverages; F2 as lozenges; F3 as sticky sweets; F4 as xylitol
chewing gum; and F5 as non-xylitol chewing gum. Further
analyses included only factors F1 and F4, as a result of the
greatest use of sugary products loaded in these patterns.

Results
The present study covered 30–64-yr-old subjects (sample Fig. 1. Inclusion and exclusion criteria used to establish the
n = 5,871; participation rate 83%) and included those study population.
 Sugar, xylitol, brushing, and dental health 43

Table 1
Description of study subjects (n = 4,361) according to background information, dental findings, and dental health-related behaviours

Background information, Gender Age

dental findings, dental
health-related behaviours, Men Women 30–34 yr 35–44 yr 45–54 yr 55–64 yr
and use of sugary products (n = 2,078) (n = 2,283) (n = 666) (n = 1,370) (n = 1,448) (n = 877)

Age (yr) 45.7 (0.2) 46.1 (0.2)

Educational level
Higher 28 42 48 39 32 24
Intermediate 44 31 42 44 35 29
Basic 28 27 10 17 33 47
No. of teeth 24.3 (0.2) 24.2 (0.2) 28.4 (0.1) 27.2 (0.1) 22.8 (0.2) 19.1 (0.3)
< 21 19 18 <1 4 25 44
‡ 21 81 82 100 96 75 56
No. of sound teeth 10.8 (0.2) 9.6 (0.1) 16.9 (0.2) 11.4 (0.2) 8.2 (0.2) 6.9 (0.2)
<5 22 25 2 16 30 42
6–11 36 40 16 37 47 43
12–17 26 22 36 30 18 12
‡ 18 16 13 46 17 5 3
No. of filled teeth 12.1 (0.1) 13.8 (0.1) 10.7 (0.2) 14.9 (0.2) 13.4 (0.2) 11.2 (0.2)
< 12 45 35 58 28 37 49
12–18 38 39 35 44 39 33
19–32 17 26 7 28 24 18
No. of decayed teeth 1.1 (0.1) 0.5 (0.0) 0.7 (0.1) 0.7 (0.1) 0.9 (0.1) 0.8 (0.1)
No teeth with untreated caries 63 78 74 73 69 67
1–2 teeth with untreated caries 24 17 19 20 20 24
3–32 teeth with untreated caries 13 5 7 7 11 9
Frequency of toothbrushing
At least twice daily 47 79 65 64 62 46
Less than twice daily 53 21 35 36 38 46
Use of fluoride toothpaste
On a daily basis 86 96 95 93 91 86
Less frequently 14 4 5 7 9 14
Sugary coffee or tea
On a daily basis 53 31 43 42 40 43
Weekly 6 5 6 5 6 5
Less often or never 41 64 51 53 54 52
Other sugary drinks
On a daily basis 23 13 26 20 15 16
Weekly 31 25 33 32 25 23
Less often or never 46 62 41 48 60 61
Xylitol lozenges or candies
On a daily basis 7 7 7 8 7 6
Weekly 21 20 24 24 17 17
Less often or never 72 73 69 68 76 77
Non-xylitol lozenges or candies
On a daily basis 3 3 2 3 3 2
Weekly 14 11 18 15 10 9
Less often or never 83 86 80 82 87 89
Toffee or liquorice or dried fruit
On daily basis 2 1 1 1 2 1
Weekly 12 11 14 14 10 9
Less often or never 86 88 85 85 88 90
Chocolate or filled biscuits
On daily basis 3 3 4 3 3 2
Weekly 27 35 44 39 26 19
Less often or never 70 62 52 58 71 79
Non-xylitol chewing gum
On a daily basis <1 <1 1 1 1 <1
Weekly 2 2 3 2 1 1
Less often or never 98 98 97 97 98 99
Xylitol chewing gum
On a daily basis 12 21 22 21 16 9
Weekly 19 26 30 28 18 15
Less often or never 69 53 48 51 66 76

Values are given as mean (standard error) or as %; missing values for the use of fluoride toothpaste: n=39.
44 Tseveenjav et al.

Table 2 behaviours, daily use of fluoride toothpaste had the

Association of dental health indicators (numbers of teeth present, strongest impact on DT among men (RR = 2.0),
sound teeth, filled teeth, and decayed teeth) with dental health- whereas twice or more daily toothbrushing impacted on
related behavioural covariates [frequency of consumption of DT in both genders (RR = 1.5).
sugar-sweetened beverages (SSB) and of xylitol chewing gum
(XCG), toothbrushing frequency (TBF), and use of fluoride
toothpaste (FTP)] among 30–64-yr-old subjects (n = 4,361) in
Finland Discussion
All subjects This study aimed to assess the impact of oral health-
related behaviours, such as frequency of consumption of
b SE P-value RR (95% CI)
sugar- and xylitol-containing products, toothbrushing,
No. of teeth present and use of fluoride toothpaste, on dental health in adults.
SSB )0.022 0.004 < 0.0001 1.0 (1.0–1.0) Our results revealed that the behaviours considered had
XCG 0.031 0.004 < 0.0001 1.0 (1.0–1.0) the greatest impact on subjectsÕ DT, particularly daily
TBF use of fluoride toothpaste in men (RR = 2.2) and twice
‡ 2 daily 0.004 0.009 0.624 1.0 (1.0–1.0)
<2 daily 1
or more daily toothbrushing in both genders
FTP (RR = 1.5). For the other dental health indicators, the
Daily use 0.032 0.017 0.057 1.0 (1.0–1.1) impacts were weak (RR = 0.9–1.1).
< daily 1 The less frequent consumption of sugar-sweetened
beverages was weakly associated with greater NoT. This
Sound teeth
association partly supports earlier studies that reported a
SSB )0.015 0.008 0.074 1.0 (1.0–1.0)
XCG )0.015 0.009 0.086 1.0 (1.0–1.0) weak correlation between caries incidence and sugar
TBF consumption in populations where the use of fluoride
‡ 2 daily )0.035 0.018 0.055 1.0 (0.9–1.0) toothpaste is widespread (13–15).
<2 daily 1 The frequent use of xylitol chewing gum was associated
FTP with higher NoT and FT, in line with recent reviews (7, 8)
Daily use 0.007 0.032 0.825 1.0 (1.0–1.1) indicating that xylitol enhances dental health. However,
< daily 1
the impact remained weak. Of the adults in this study, a
Filled teeth minority (17%) used xylitol chewing gum on a daily basis,
SSB 0.003 0.007 0.618 1.0 (1.0–1.0) and the daily frequency was far below the recommended
XCG 0.021 0.007 0.002 1.0 (1.0–1.0) frequency of three to five times a day (7, 8). The current
TBF recommendations for the use of xylitol-containing pro-
‡ 2 daily 0.058 0.015 0.0001 1.1 (1.0–1.1)
ducts are mostly based on, and directed towards, young
<2 daily 1
FTP children, schoolchildren, and mothers, because most
Daily use 0.075 0.032 0.020 1.1 (1.0–1.2) studies on xylitol and caries incidence deal with these
< daily 1 population groups. However, according to our findings,
messages aimed at oral health promotion should place
Decayed teeth more emphasis on the role of xylitol-containing products,
SSB 0.172 0.040 < 0.001 1.2 (1.1–1.3)
XCG )0.153 0.040 0.001 0.9 (0.8–0.9)
such as xylitol chewing gum, as a beneficial supplement
TBF for dental health also among adults.
‡ 2 daily 1 Toothbrushing frequency and the use of fluoride
<2 daily 0.413 0.077 < 0.001 1.5 (1.3–1.8) toothpaste showed no strong impact on the numbers of
FTP NoT, ST, and FT. However, both of these behavioural
Daily use 1 aspects had stronger impacts on adultsÕ DT (RR = 1.4–
< daily 0.606 0.112 < 0.001 1.8 (1.5–2.3)
2.0), emphasizing the importance of frequent tooth-
95% CI, 95% confidence interval; SE, standard error. brushing using fluoride toothpaste in the maintenance of
The relative risk (RR) values were estimated by Poisson dental health (3–6). The benefit of mechanical plaque
regression models for no. of teeth present, sound teeth, and removal and of the topical use of fluoride as a primary
filled teeth, and by negative binominal regression for decayed preventive measure for oral health is well established (35,
teeth.
Number of teeth present served as the offset variable for sound 36), and this message should be better addressed in
teeth, filled teeth, and decayed teeth, and the results are activities aimed at oral health promotion. Use of fluoride
expressed as b–estimates. toothpaste seemed to be the strongest behavioural indi-
The models were adjusted for age (treated as continuous), cator, out of those included in this study, for numbers of
gender, and educational level (categorical). untreated caries lesions among men (RR = 2.0). This
aspect should be taken into account for oral health-
education activities.
RR estimate for not using fluoride toothpaste on a daily In our study group, the greatest consumption among
basis was 1.8. The stratified analyses by gender (Table 3) the eight sugary product groups was of sugary coffee or
showed that the impacts of the oral health-related tea or other sugary drinks, such as sugared juices, fizzy
behaviours on NoT, ST, and FT remained weak in both drinks or cocoa. This indicates that data on adultsÕ oral
genders (RR = 0.9–1.1). Of all the oral health-related health behaviour should always include these products.
 Sugar, xylitol, brushing, and dental health 45

Table 3
Association of dental health indicators (number of teeth present, sound teeth, filled teeth, and decayed teeth) with dental health-related
behavioural covariates [frequency of consumption of sugar-sweetened beverages (SSB) and of xylitol chewing gum (XCG), tooth-
brushing frequency (TBF) and use of fluoride toothpaste (FTP)] among 30–64-yr-old subjects in Finland, separately for men
(n = 2,078) and for women (n = 2,283)

Men Women
b SE P-value RR (95% CI) b SE P-value RR (95% CI)

No. of teeth present

SSB )0.029 0.006 < 0.0001 1.0 (1.0–1.0) )0.013 0.005 0.013 1.0 (1.0–1.0)
XCG 0.025 0.006 0.0001 1.0 (1.0–1.0) 0.037 0.005 < 0.0001 1.0 (1.0–1.1)
TBF
‡ 2 daily )0.013 0.011 0.233 1.0 (1.0–1.1) 0.027 0.012 0.030 1.0 (1.0–1.1)
<2 daily 1 1
FTP
Daily use 0.340 0.020 0.091 1.0 (1.0–1.1) 0.046 0.035 0.194 1.1 (1.0–1.1)
< daily 1 1
Sound teeth
SSB )0.017 0.011 0.114 1.0 (1.0–1.0) )0.010 0.011 0.392 1.0 (1.0–1.0)
XCG )0.015 0.012 0.206 1.0 (1.0–1.0) )0.018 0.011 0.105 1.0 (1.0–1.0)
TBF
‡ 2 daily )0.034 0.022 0.119 1.0 (0.9–1.1) )0.025 0.028 0.370 1.0 (0.9–1.0)
<2 daily 1 1
FTP
Daily use 0.040 0.034 0.234 1.0 (1.0–1.1) )0.094 0.073 0.196 0.9 (0.8–1.1)
< daily 1 1
Filled teeth
SSB 0.009 0.011 0.407 1.0 (1.0–1.0) )0.002 0.008 0.774 1.0 (1.0–1.0)
XCG 0.025 0.010 0.018 1.0 (1.0–1.1) 0.020 0.008 0.007 1.0 (1.0–1.0)
TBF
‡ 2 daily 0.063 0.020 0.002 1.1 (1.0–1.1) 0.043 0.021 0.036 1.0 (1.0–1.1)
<2 daily 1 1
FTP
Daily use 0.062 0.037 0.094 1.1 (1.0–1.1) 0.088 0.046 0.054 1.1 (1.0–1.2)
< daily 1 1
Decayed teeth
SSB 0.131 0.056 0.020 1.1 (1.0–1.3) 0.220 0.053 < 0.0001 1.3 (1.1–1.4)
XCG )0.107 0.056 0.055 0.9 (0.8–1.0) )0.189 0.056 0.0007 0.8 (0.7–0.9)
TBF
‡ 2 daily 1 1
<2 daily 0.419 0.104 < 0.0001 1.5 (1.2–1.9) 0.370 0.119 0.002 1.5 (1.2–1.8)
FTP
Daily use 1 1
< daily 0.692 0.125 < 0.0001 2.0 (1.6–2.6) 0.306 0.242 0.242 1.4 (0.9–2.2)

95% CI, 95% confidence interval; SE, standard error.

The relative risk (RR) values were estimated by Poisson regressions for no. of teeth present, sound teeth and filled teeth, and by
negative binominal regression for decayed teeth.
Number of teeth present served as the offset variable for sound teeth, filled teeth, and decayed teeth, and the results are expressed as
b-estimates.
The models were adjusted for age (treated as continuous) and educational level (categorical).

Furthermore, in all age groups, consumption of sugar-
sweetened beverages was lower for women than for
men, which is in agreement with the Finnish National
FINDIET 2007 Study (37), which reported that men
more frequently add sugar to food or drink. The most
commonly used products (sugary coffee or tea and
other sugary drinks) were loaded into one factor and
xylitol chewing gum was loaded into another, separate,
factor. Because of the common use of these products
among the adults in this study, these two patterns were
used for further analyses, also representing a health-
detrimental habit and a health-enhancing habit of
individuals.
The present study is part of the nationwide Health
2000 Health Examination Survey in Finland, which used
a two-stage stratified cluster sample (32). The study
subjects are representative of the adult population in
Finland, and the results can be generalized nationwide
because of the study design and the high response rate. In
addition, sampling weights were used in order to gener-
alize the results to the target population and to adjust
sampling variability and errors caused by non-response.
The dental status of each individual was clinically
assessed by one of five calibrated dentists who reached a
high level of reliability for the recordings in real-field
circumstances (31), thus ensuring the precision of the
46 Tseveenjav et al.
data. Data regarding the frequency of sugar consump-
tion and of toothbrushing were collected using ques-
tionnaires and interviews, where a tendency towards
giving positive and socially accepted answers is always a
concern (38). Such a tendency, however, may exert lim-
ited influence because the structured health interviews
were carried out primarily in the subjectÕs home by
trained interviewers, not at a dental surgery or other
healthcare location, and these questions were less inti-
mate than many other questions asked in the Health
2000 interviews.
Participation rates were high at all stages of the Health
2000 survey (33). Almost 85% attended the health
examination, which included the oral health examination
and during which the questionnaire was delivered.
Therefore, selection bias is minimized. Participation in
the health examination did not vary by gender, and the
most active participants among women were those who
were 40–69 yr of age, and among men were those who
were 50–79 yr of age. Variation by socioeconomic status
was rather insignificant.
In conclusion, oral health-related behaviours, such as
frequent consumption of sugar- and xylitol-containing
products and of toothbrushing, as well as use of fluoride
toothpaste, play a role in the dental health among dentate
adults. The impact of these behaviours seem to be weak
on adultsÕ NoT, ST, and FT, but strong on DT, especially
concerning daily use of fluoride toothpaste in men and
twice or more daily toothbrushing in both genders.
Understanding the behavioural aspects of dental health,
as aimed in this study, would facilitate better targeting of
oral self-care messages among dentate adults.
Acknowledgements – The Health 2000 Health Examination
Survey in Finland was organized by the National Institute for
Health and Welfare (former National Public Health Institute)
of Finland (http://www.ktl.fi/health2000) and was partly sup-
ported by the Finnish Dental Society Apollonia and the Finnish
Dental Association. A personal grant to B.T. by the Finnish
Dental Society Apollonia is gratefully acknowledged.
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