Genetic and Early-Life Environmental

Influences on Dental Caries Risk: A

Twin Study
Mihiri J. Silva, DCD,a,b,c Nicky M. Kilpatrick, PhD,a,c Jeffrey M. Craig, PhD,d,e David J. Manton, PhD,f Pamela Leong, PhD,c,d
David P. Burgner, PhD,b,c,g,h Katrina J. Scurrah, PhDa,i

To explore the relative contributions of genetic and environmental influences on

OBJECTIVES: abstract
dental caries risk and to investigate fetal and developmental risk factors for dental caries.
METHODS:We recruited children from 250 twin pregnancies midgestation and collected
demographic, health, and phenotypic data at recruitment, 24 and 36 weeks’ gestational age,
birth and 18 months, and 6 years of age. 25-hydroxyvitamin D was quantified in mothers at 28
weeks’ gestation and in infants at birth. Dental caries and enamel defects were measured at
six years of age. We compared concordance for the presence of any caries and advanced caries
in monozygotic and dizygotic twin pairs. To investigate environmental risk factors for caries,
we fitted multiple logistic regression models using generalized estimating equations to adjust
for twin correlation.
RESULTS: A total of 345 twins underwent dental assessment, with 111 (32.2%) showing signs of
any caries and 83 (24.1%) having advanced caries. There was no evidence of higher
concordance in monozygotic twins compared with dizygotic twins, with a difference of 0.05
(95% confidence interval 20.14 to 0.25; P = .30) and 0.00 (95% confidence interval 20.26 to
0.26; P = .50) for any caries and advanced caries, respectively, suggesting that environmental
factors, rather than genetics, are the predominant determinant of caries risk. After adjusting
for potential confounders, lack of community water fluoridation, hypomineralized second
primary molars, dichorionic placenta, and maternal obesity were associated with caries.
Environmental rather than genetic factors drive dental caries risk and arise as
CONCLUSIONS:
early as prenatal life.

a
Facial Sciences, bInflammatory Origins, and dMolecular Epidemiology, Murdoch Children’s Research Institute, WHAT’S KNOWN ON THIS SUBJECT: Understanding of
Melbourne, Australia; cDepartment of Paediatrics, Melbourne Medical School, fMelbourne Dental School, and early-life risk factors for dental caries is limited by
i
School of Population and Global Health, University of Melbourne, Melbourne, Australia; eCentre for Molecular and lack of prospective studies that adequately control for
Medical Research, School of Medicine, Deakin University, Geelong, Australia; gDepartment of Paediatrics, Monash
confounding. Caries is believed to be highly heritable,
University, Melbourne, Australia; and hInfectious Diseases, Royal Children’s Hospital, Melbourne, Australia
but genetic studies to date have failed to identify
Dr Silva conceptualized and designed the study, collected data, conducted the analyses, drafted the strong associations.
initial manuscript, and reviewed and revised the manuscript; Drs Kilpatrick and Craig
conceptualized and designed the study, collected and interpreted the data, and critically reviewed WHAT THIS STUDY ADDS: Robust exposure data and
the manuscript; Dr Manton conceptualized and designed the study, interpreted the data, and comprehensive statistical methods were used to
critically reviewed the manuscript; Dr Leong conceptualized and designed the study, designed the identify potentially modifiable environmental risk
data collection instruments, collected data, and reviewed and revised the manuscript; Dr Burgner factors from the prenatal period onward. Environment
conceptualized and designed the study, interpreted the data, contributed to data analysis, and exposures may be more important than genetics in
critically reviewed and revised the manuscript; Dr Scurrah conceptualized and designed the study, determining dental caries risk in children.
conducted data analysis and interpretation, and reviewed and revised the manuscript; and all
authors approved the final manuscript as submitted and agree to be accountable for all aspects of
To cite: Silva MJ, Kilpatrick NM, Craig JM, et al. Genetic
the work.
and Early-Life Environmental Influences on Dental Caries
Risk: A Twin Study. Pediatrics. 2019;143(5):e20183499

Downloaded from www.aappublications.org/news at Indonesia:AAP Sponsored on February 27, 2021

PEDIATRICS Volume 143, number 5, May 2019:e20183499 ARTICLE 167
Oral health is an integral part of
general health. In addition to
impacting the ability to eat, speak,
smile, grow, and learn, oral diseases
have been linked with
noncommunicable diseases (NCDs)
such as cardiovascular disease and
diabetes.1 Despite advances in
prevention and management, 60% to
90% of schoolchildren worldwide
experience dental caries, potentially
resulting in pain, infection, and
hospitalization.2 Toothache may
result in school absence, poor
nutrition, compromised growth and
development, and impaired quality of
life for the child and their caregivers.1
Furthermore, childhood dental caries
is the strongest indicator of future
poor oral health, and therefore caries
prevention in children is important
for oral health outcomes in
adulthood.3
Dental caries is a dynamic process
that occurs when demineralization of
dental hard tissues, triggered by
a sugar-driven dysbiosis of the dental
plaque microbiome, overwhelms
remineralization by protective factors
in the mouth.4 Initial
demineralization of tooth enamel is
often subclinical but can lead to the
development of carious lesions, which
range from incipient areas of
increased enamel opacity and
porosity to frank cavitation.
Genetic factors are linked to dental
caries,5 but the implications of these
associations for caries risk, both at
individual and population levels, have
not been widely considered. Studying
familial (including twin) aggregation
of complex conditions, such as dental
caries, is a valuable tool for further
optimizing prevention when both
genetic and environmental factors are
likely to be important.6 Monozygotic
twins share all genetic variation,
whereas dizygotic twins, like siblings,
share 50% on average. Comparison of
concordance in monozygotic and
dizygotic pairs can help determine
the influence of shared, nonshared,
Downloaded from www.aappublications.org/news at Indonesia:AAP Sponsored on February 27, 2021
168
and genetic factors to the variation in
risk of dental caries.7
Consistent with the developmental
origins of health and disease
paradigm, early-life exposures may
increase caries risk through biological
early-life programming.8 Reframing
prevention of dental caries in terms
of developmental origins of health
and disease may provide novel
targets for prevention before disease
onset but are hampered by a lack of
prospective studies.
In this prospective longitudinal twin
cohort, we aimed to investigate fetal
and developmental risk factors for
dental caries and the relative
contributions of environmental and
genetic influences on dental
caries risk.
METHODS
Peri/Postnatal Epigenetic Twins
Study
The Peri/postnatal Epigenetic Twins
Study (PETS) is a longitudinal birth
cohort of 250 mothers and their twin
children established in 2007.9
Women, pregnant with twins, were
recruited midgestation.
Questionnaires regarding maternal
prepregnancy weight, illness
(including infection), medication use,
stress, alcohol intake, and smoking
were collected at 3 time points during
pregnancy (Supplemental Fig 2). We
determined the socioeconomic status
(SES) of participants at birth by
linking to the Index of Relative Socio-
Economic Disadvantage, one of the
Socio-Economic Indexes For Areas
(SEIFA) developed by the Australian
Bureau of Statistics on the basis of
census data, via postal codes.10 The
children were reviewed (and hospital
records accessed) in the immediate
postnatal period to obtain obstetric,
birth anthropometric, and neonatal
data. Chorionicity (ie, whether twins
had separate [dichorionic] or shared
[monochorionic] placentas) was
determined from ultrasound scans
and placental examination at delivery.
All different-sex twins were assumed
to be dizygotic. We determined
zygosity for all same-sex twins using
12-marker microsatellite polymerase
chain reaction with DNA from
umbilical cord and/or buccal samples
when available.11
A total of 244 twin pairs were
reviewed at age 18 months, and data
on breastfeeding duration, illnesses
(including infection, infantile eczema,
asthma, and food allergy),
hospitalization, and medication use
were obtained from parents. At age
6 years, dental examinations were
performed, and data were collected
on dietary sugar intake (Dietary
Sugar Intake section of the
Supplemental Information) and oral
hygiene. Access to community water
fluoridation was determined by using
residential postal codes.
We determined 25-hydroxyvitamin D
levels from serum collected from
mothers at 28 weeks’ gestation and
from twin offspring at birth from
serum or plasma from cord blood. For
all samples, 25-hydroxyvitamin D
levels were determined by using the
LIAISON 25 OH Vitamin D TOTAL kit
(DiaSorin; Saluggia, Vercelli, Italy). A
subset of newborn serum samples
were analyzed in 2011, and the
remaining available serum and
plasma samples were analyzed in
2017, with appropriate adjustment
for batching effects between (1)
different samples type and (2)
measurements at different time
points (Vitamin D Levels at Birth
section of the Supplemental
Information).
Ethics approval was obtained from
the Royal Children’s Hospital Human
Research Ethics Committee (33174
A), and informed consent was
obtained from a parent or guardian.
Dental Examinations
Dental examinations were performed
on-site at the research facility or, for
participants unable to travel, at home
by 2 trained and calibrated oral
SILVA et al
health professionals (M.J.S. and P.L.)
(Dental Examinations section of the
Supplemental Information,
Supplemental Tables 6 and 7). We
recorded dental caries using the
International Caries Detection and
Assessment System (ICDAS), which
allows for quantification of carious
lesions, from early to large cavitated
lesions with significant destruction of
tooth structure. The common
developmental defect of enamel,
hypomineralized second primary
molars (HSPMs), was recorded by
using standardized criteria.12
Data Analysis
We collected and managed the study
data using Research Electronic Data
Capture tools13 and analyzed data
using Stata 15 (Stata Statistical
Software: Release 15; Stata Corp,
College Station, TX). Two binary
outcome variables, the presence or
absence of (1) any caries (including
noncavitated lesions and/or past
treatment) and (2) advanced caries,
(established carious lesions with
ICDAS codes 4–6 and/or past
treatment) were derived from the
ICDAS index (Methods section of the
Supplemental Information). For each
outcome variable, we classified twin
pairs as concordant (both children
affected) or discordant (1 twin
affected). To explore the role of
genetic and unmeasured
environmental factors, we estimated
and compared casewise concordances
with 95% confidence intervals (CIs)
for monozygotic and dizygotic twins.
To estimate similarities for
monozygotic and dizygotic twins after
adjusting for known risk factors, we
fitted a multiple logistic regression
model using generalized estimating
equations (GEEs) (Data Analysis
section of the Supplemental
Information). To investigate
associations between environmental
risk factors and presence of any or
advanced caries, we fitted logistic
regression models using GEEs to
adjust for twin correlation. The
Downloaded from www.aappublications.org/news at Indonesia:AAP Sponsored on February 27, 2021
PEDIATRICS Volume 143, number 5, May 2019
FIGURE 1
Study retention from recruitment to dental examinations at 6 years of age.
associations were reported as odds
ratios (ORs) with 95% CI.
We selected biologically plausible
exposure variables from data
collected during pregnancy, at birth,
and at 18 months of age on the basis
of previous evidence of association
with dental caries. Exposure variables
with P , .1 in simple regression
models were included in the final
multiple regression models to adjust
for confounding. As an exploratory
study, we adopted an inclusive
approach to model building, aiming to
identify potential factors rather than
exclude factors.
Within-pair analyses (to explore the
role of categorical nonshared risk
factors, such as early-life
hospitalization and antibiotic use, in
caries for discordant twin pairs)
could not be performed because there
were too few twin pairs discordant
for both outcome and exposure. To
determine if observed associations
with nonshared continuous variables
were likely to be causal or due to
unmeasured shared or unshared
factors, we fitted within- and
between-pair models using GEEs.14
RESULTS
A total of 345 twin children (69% of
the original cohort) participated in
the dental examinations (Fig 1). One
child was uncooperative with the
caries assessment, resulting in 172
complete twin pairs (101 dizygotic
and 71 monozygotic pairs). Most
children (n = 277; 80.3%) were aged
6 or 7 years (range: 6–9 years), and
185 (53.6%) were girls. The mean
SEIFA for the cohort was 1014.3 (SD
57.9), indicating that the sample had
a higher SES and less variation than
the Australian average.15
A total of 111 (32.2%) children had
any caries, with a mean of 3.0 teeth
(median = 2) affected. Thirty-nine
twin pairs were concordant and 33
pairs were discordant for the
presence of any caries. A total of 83
(24.1%) children had advanced
caries, with those affected having
a mean of 2.8 teeth (median = 2) with
advanced caries. Twenty-six twin
pairs were concordant and 31 twin
pairs were discordant for advanced
caries, with the twin who was
unaffected having either no caries or
only early caries (ICDAS caries
codes 1–3).
Dental Caries Concordance
The overall concordance for any
caries was 0.70 (95% CI 0.61 to 0.80).
There was no evidence of higher
unadjusted concordance in
monozygotic twins (0.74; 95% CI
169
0.58 to 0.89) compared with dizygotic
twins (0.69; 95% CI 0.56 to 0.81),
with a difference of 0.05 (95% CI
20.14 to 0.25; P = .30). The overall
concordance for advanced caries was
0.63 (95% CI 0.51 to 0.75; Suppleme
ntal Fig 3). There was no evidence of
higher unadjusted concordance in
monozygotic twins (0.63; 95% CI
0.43 to 0.82) compared with dizygotic
twins (0.63; 95% CI 0.47 to 0.78),
with a difference of 0.00 (95% CI
20.26 to 0.26; P = .50). A logistic
regression GEE model adjusted for
known risk factors revealed no
differences in concordance between
monozygotic and dizygotic twins
(Results section of the Supplemental
Information).
Risk Factors
Maternal stress during pregnancy,
cord attachment, smoking beyond the
first trimester of pregnancy, age at
examination, home visit for
examination, nonfluoridated town
water, and the presence of HSPMs
were all associated (P , .1) with any
caries in unadjusted regression
models (Table 1). The evidence for an
association between covariates
HSPMs (OR 2.15; 95% CI 1.04 to 4.47;
P = .04), nonfluoridated town water
(OR 5.98; 95% CI 1.59 to 22.55;
P = .01), and monochorionicity (OR
0.37; 95% CI 0.17 to 0.78; P = .01)
and the outcome (any caries) did not
attenuate after adjusting for
confounding (Table 2, Supplemental
Table 11).
Maternal and newborn vitamin D
levels, chorionicity, maternal obesity,
smoking beyond the first trimester of
pregnancy, age at examination, sex,
nonfluoridated town water, and the
presence of HSPMs were all
associated (P , .1) with advanced
caries in the unadjusted regression
models (Table 1). Because maternal
and newborn vitamin D levels were
highly correlated, only maternal
vitamin D was included in the
multiple regression model.
Nonfluoridated town water (OR 6.26;
Downloaded from www.aappublications.org/news at Indonesia:AAP Sponsored on February 27, 2021
170
95% CI 1.74 to 22.54; P = .01),
maternal obesity (OR 2.68; 95% CI
1.19 to 6.08; P = .02), and HSPMs (OR
2.43; 95% CI 1.11 to 5.36; P = .03)
were strongly associated with
advanced lesions after adjusting for
confounding (Table 2, Supplemental
Table 12).
A within-pair analysis of birth weight
(BW), a continuous variable, and both
caries outcome variables failed to
reveal any association, with a mean
within-pair difference between twins
who were affected and unaffected of
258.9 g (95% CI 2163.6 to 45.8;
P = .62) and 236.1 g (95% CI 2152.5
to 80.3; P = .53) in the 33 and 31
pairs discordant for any and
advanced caries, respectively.
From the subset of children with
vitamin D levels measured at birth,
the mean within-pair difference
between twins who were affected and
unaffected was 0.52 nmol/L (95% CI
24.97 to 6.01; P = .84) in the 21 pairs
discordant for any caries and 1.62
nmol/L (95% CI 25.46 to 8.70;
P = .63) in the 16 pairs discordant for
advanced caries. Within- and
between-pair analyses were only
applied for advanced caries given the
weak association identified in the
unadjusted regression model
(Table 1). Although there was no
evidence of an association between
advanced caries and within-pair
differences in birth vitamin D levels
(OR 0.95; 95% CI 0.38 to 2.36;
P = .91), there was strong evidence
for an association for between-pair
differences (OR 1.91; 95% CI 1.18 to
3.08; P = .01) after adjusting for the
effect of HSPMs, maternal obesity,
nonfluoridated town water, and
chorionicity. Results were robust to
the exclusion of outlying and
influential observations (Data
Analysis section of the Supplemental
Information).
DISCUSSION
This study revealed no difference in
concordance between monozygotic
and dizygotic twins, indicating that
shared and nonshared environmental
factors predominate over genetic
factors in determining variation in
caries risk in children. Dental caries is
likely to be a genetically complex
phenotype, with small contributions
from many loci. These genetic factors
may include variants in loci for
enamel formation, saliva, immunity,
and taste.16,17 Our findings reveal
that despite the biological plausibility,
genetic factors are relatively less
important determinants of caries risk
than shared environmental factors.
This finding has important clinical
implications because the perceived
genetic nature of dental caries may
lead to a sense of determinism that
impedes rather than motivates
behavioral change.18 If replicated,
findings from our study will help
clinicians motivate such change by
revealing that caries risk is
modifiable.
Previous twin studies of dental caries
have been retrospective and have
not fully capitalized on the
advantages of analyzing twin data,
being focused only on the genetic
contribution or heritability. Bretz
et al19 reported a heritability of 70%
for the prevalence rate of surface-
based caries in 388 pairs aged 1 to
8 years in a low SES community
with nonfluoridated water. Authors
of a follow-up study also reported
that lesion progression was modestly
heritable, with estimates of 30%
to 51%, and that heritability of
sweet taste and caries was unrelated
to early childhood caries.20,21
However, using heritability
estimates as low as 30% and as high
as 70% to support genetic etiology is
potentially misleading. Rather, the
great potential of the classic twin
model is determining the overall
genetic influence on caries risk,
compared with environmental
factors. Therefore, in our study,
associations with genetic factors,
although plausible in dental caries,
are less relevant caries risk at an
SILVA et al
TABLE 1 Simple (Unadjusted) Logistic Regression for Risk Factors for Any and Advanced Caries
Factor Any Caries Advanced Caries
OR (95% CI) P OR (95% CI) P
Age
Q1 (n = 70) 6.00–6.28 Reference .01 Reference .035
Q2 (n = 69) 6.28–6.43 0.58 (0.22 to 1.50) — 0.46 (0.17 to 1.25) —
Q3 (n = 68) 6.43–6.66 1.75 (0.72 to 4.24) — 1.39 (0.56 to 3.49) —
Q4 (n = 70) 6.68–7.00 0.74 (0.30 to 1.81) — 0.58 (0.21 to 1.62) —
Q5 (n = 68) 7.02–9.05 2.50 (0.99 to 6.30) — 1.81 (0.72 to 4.55) —
Dizygotic twin (n = 203) 1.53 (0.85 to 2.77) .16 1.14 (0.62 to 2.14) .66
Female sex (n = 185) 0.73 (0.47 to 1.15) .17 0.6 (0.37 to 0.97) .04
SEIFA (per 100 U) (n = 343) 1.19 (0.69 to 2.03) .53 1.05 (0.58 to 1.91) .87
Maternal obesity (n = 44) 1.56 (0.70 to 3.46) .27 2.02 (0.90 to 4.58) .09
Maternal stress score
Q1 (n = 72) 3–16 Reference .04 Reference .18
Q2 (n = 66) 17–21 0.65 (0.26 to 1.65) — 0.70 (0.27 to 1.80) —
Q3 (n = 62) 22–24 0.41 (0.15 to 1.10) — 0.39 (0.13 to 1.14) —
Q4 (n = 80) 25–30 0.76 (0.33 to 1.77) — 0.65 (0.27 to 1.59) —
Q5 (n = 49) 31–45 1.92 (0.78 to 4.73) — 1.49 (0.56 to 3.92) —
Maternal infection during pregnancy (n = 205) 1.00 (0.56 to 1.78) .996 1.11 (0.60 to 2.07) .73
Maternal antibiotic use during pregnancy (n = 66) 1.74 (0.87 to 3.52) .12 1.49 (0.71 to 3.14) .29
Maternal vitamin D at 28 wk (20 nmol/L) n = 329 1.07 (0.79 to 1.44) .68 1.36 (0.97 to 1.91) .08
Maternal smoking in second or third trimester 2.17 (1.00 to 4.69) .05 2.07 (1.00 to 4.31) .05
(n = 46)
Maternal alcohol intake during pregnancy (n = 199) 0.80 (0.45 to 1.42) .45 1.15 (0.62 to 2.12) .67
Gestational age (n = 345), wk 0.93 (0.82 to 1.05) .23 0.97 (0.86 to 1.09) .61
Vaginal delivery (n = 119) 0.95 (0.52 to 1.72) .86 0.78 (0.41 to 1.47) .44
Chorionicity
Monochorionic (n = 96) 0.36 (0.17 to 0.74) .01 0.47 (0.21 to 1.03) .06
Dichorionic (n = 217) Reference — Reference —
Cord attachment
Central cord (n = 141) Reference .05 Reference .19
Peripheral cord (n = 122) 1.49 (0.90 to 2.47) — 1.40 (0.81 to 2.40) —
Velamentous cord (n = 37) 0.68 (0.35 to 1.30) — 0.64 (0.25 to 1.66) —
BW (standardized, per unit) (n = 345) 1.10 (0.89 to 1.37) .38 1.08 (0.83 to 1.40) .57
NICU or SCN (n = 146) 1.48 (0.87 to 2.51) .14 1.21 (0.67 to 2.19) .52
Birth vitamin D (20 nmol/L) (n = 241) 1.19 (0.87 to 1.63) .28 1.50 (1.04 to 2.15) .03
Breastfeeding (any) (n = 301) 0.54 (0.21 to 1.35) .19 0.89 (0.31 to 2.59) .83
Formula feeding (any) (n = 302) 1.07 (0.47 to 2.48) .86 1.39 (0.40 to 4.85) .60
Hospitalization in first 18 mo (n = 67) 1.10 (0.60 to 2.03) .76 1.14 (0.56 to 2.30) .72
Infection in first 18 mo (n = 171) 1.19 (0.70 to 2.00) .52 0.90 (0.50 to 1.61) .71
Antibiotics in first 18 mo (n = 75)a 0.92 (0.54 to 1.57) .75 0.80 (0.41 to 1.57) .52
Sugar intake
Low (n = 83) Reference — Reference —
Medium (n = 214) 1.36 (0.71 to 2.57) .35 1.77 (0.83 to 3.76) .14
High (n = 38) 1.36 (0.57 to 3.29) .49 2.00 (0.74 to 5.37) .17
Brushing frequency
Twice daily (n = 204) Reference — Reference —
Once a day (n = 106) 1.24 (0.64 to 2.41) .52 1.09 (0.56 to 2.13) .79
Once every 2–4 d (n = 21) 0.50 (0.13 to 1.89) .31 0.32 (0.08 to 1.33) .12
No water fluoridation (n = 26) 5.56 (1.83 to 16.93) .003 7.27 (2.31 to 22.85) .001
Home visit (n = 62) 1.99 (0.96 to 4.14) .07 1.83 (0.86 to 3.90) .12
HSPM (n = 68) 2.67 (1.47 to 4.86) .001 2.85 (1.43 to 5.67) .003
Q, quintile; SCN, special care nursery; —, not applicable.
a Medications consumed in hospital were not included because these data were not collected.

individual level compared with
environmental factors and, indeed,
may distract from addressing
modifiable environmental factors.6
Nevertheless, genetic studies may be
used to additionally inform
mechanistic understanding because
environmental exposures operate in
a genetic context. In addition, with
our study, we can only comment on
the relative influence of genetic and
environmental factors for the
conditions of this study, in
particular, for the age range of
participants, which was 6 years.
Genetic and environmental
influences are likely to vary
with age.

Downloaded from www.aappublications.org/news at Indonesia:AAP Sponsored on February 27, 2021

PEDIATRICS Volume 143, number 5, May 2019 171
TABLE 2 The ORs, 95% CIs, and P Values for Factors Found to Be Associated With Any Caries and Advanced Caries After Adjusting for Confounding by
Covariates Identified in the Unadjusted Logistic Regression
Factor
Adjusted OR (95% CI)
HSPM
Nonfluoridated water
Placenta (monochorionic)
Maternal obesity
—, not applicable.
With our study, we emphasize
the parallels between dental caries,
one of the most ubiquitous chronic
diseases of childhood, and other
NCDs, in particular, the role of early-
life environmental factors on
disease risk. Our findings reveal
that for dental caries, an
evolutionary mismatch between
human development and
environmental change may be
relevant, as suggested for other NCDs
(such as allergy and psychiatric
disorders).22 An analysis of historical
skeletons, from before farming
(Mesolithic) to medieval periods,
reveals that dental caries is one of
the first signs of this mismatch, with
the change from hunting and
gathering to farming and, later, the
industrial revolution leading to
a shift to a disease-associated
microbiome with reduced diversity.23
Given the significant morbidity
and mortality from NCDs,24 including
dental caries, a cohesive global
strategy to address environmental
risk factors is pertinent.
We used statistical models fitted to
data from twins to identify a number
of modifiable environmental risk
factors, including those in the
prenatal period. These modifiable
factors should be considered when
determining the caries risk of
individuals as well as when designing
public health initiatives. Community
water fluoridation is widely
recognized for its socially equitable
reduction in caries experience, and
the strong associations between lack
of community water fluoridation and
both caries outcomes clearly support
Downloaded from www.aappublications.org/news at Indonesia:AAP Sponsored on February 27, 2021
172
Any Caries Experience (n = 268)
P Adjusted OR (95% CI)
2.16 (1.04 to 4.47) .04
5.98 (1.59 to 22.55) .01
0.37 (0.17 to 0.78) .01
— —
its effectiveness as a population
health measure.25
We identified maternal obesity in
pregnancy as a modifiable risk
factor for childhood caries, in keeping
with previous cohort studies.26 The
relationship between maternal
and child obesity and dental caries
is complex because it is difficult
to delineate whether the increased
caries risk is due to biological
influences on the child or developing
fetus, transfer of dietary and/or
lifestyle habits, or confounding
by social and other unknown
factors. Aspects of the intrauterine
environment, such as maternal
obesity, may lead to epigenetic
changes that result in fetal
programming, which, in turn, may
increase future susceptibility to
dental caries.27
Authors of several studies have
reported that HSPMs and their
related condition in the permanent
teeth, molar incisor
hypomineralization (MIH), are
risk factors for caries.28 HSPMs
are clinically detectable immediately
after tooth eruption at 2 to 3 years,
so early dental examinations are
important to identify children at
risk. Developmental defects of
enamel, such as HSPMs, are due to
early (prenatal) exposures during
tooth enamel formation.29 As such,
the association between caries
and HSPMs strengthens the case
for early programming of caries
risk. The concordance for caries is
low, suggesting that the nonshared
environment is relatively important
for caries risk. Nonshared factors
Advanced Caries (n = 265)
P
2.43 (1.11 to 5.36) .03
6.26 (1.74 to 22.54) .01
— —
2.68 (1.19 to 6.08) .02
account for phenotypic differences
between twins and may arise
as early as the prenatal period,
for example, because of differential
cord attachment affecting nutritional
supply to the embryo.30 Although
HSPMs are the only nonshared
risk factor identified here, further
studies exploring these nonshared
early-life factors are warranted.
Our study has some limitations.
Although a high retention rate
was maintained, the sample size
limited power and precision of
some findings. Although the exposure
data were obtained prospectively,
the outcome variables (any and
advanced caries) are based on
measurements at a single time
point and do not capture lifetime
caries experience. Community water
fluoridation does not necessarily
correspond to consumption of
fluoridated water, which is influenced
by amount of water consumption,
source of drinking water, and
level of fluoride in drinking water.
Dental examinations did not
include radiographs, and therefore
some carious lesions and
restorations, particularly on
approximal surfaces, may have not
been detected. A longitudinal
measurement of caries development
from tooth eruption onward
would allow for analysis of the
period of maximal influence of risk
factors in early life. Despite efforts
to minimize batch effects, we
cannot discount imprecision in the
vitamin D measurements. Only
1 area-level measure of SES was used,
and including household and
SILVA et al
personal SES in future studies may Interventions in which these early-
be more informative regarding life factors are targeted may
ABBREVIATIONS
possible social gradients in caries help address the persistently BW: birth weight
risk. Finally, replication of our high caries rates worldwide. CI: confidence interval
findings in singleton studies and These findings can help GEE: generalized estimating
other populations would be pediatricians and other health equation
informative. professionals involved in the care HSPM: hypomineralized second
of children instigate preventive primary molar
modalities early in life, before the ICDAS: International Caries
CONCLUSIONS
onset of clinical disease and Detection and Assessment
In this twin study, we report damage to dental tissues. System
that shared and, to a lesser degree, MIH: molar incisor
nonshared environmental factors hypomineralization
appear to be the most important NCD: noncommunicable disease
determinants of caries risk, ACKNOWLEDGMENTS
OR: odds ratio
with a likely modest contribution We thank all twins and their families PETS: Peri/postnatal Epigenetic
from genetic factors. Water and Richard Saffery, Tina Vaiano, Twins Study
fluoridation, maternal obesity, and Jane Loke, Anna Czajko, Chrissie SEIFA: Socio-Economic Indexes
HSPMs may be important and Robinson, Hillary Ho, and Supriya For Areas
modifiable risk factors for dental Raj for their expertise and SES: socioeconomic status
caries in young children. assistance.

DOI: https://doi.org/10.1542/peds.2018-3499
Accepted for publication Feb 25, 2019
Address correspondence to Mihiri J. Silva, DCD, Inflammatory Origins, Murdoch Children’s Research Institute, Royal Children’s Hospital, 70 Flemington Rd, Parkville,
VIC 3052, Australia. E-mail: mihiri.silva@mcri.edu.au
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2019 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: Supported by the National Institute of Dental and Craniofacial Research of the National Institutes of Health (award R01DE019665). The Peri/postnatal
Epigenetic Twins Study was supported by grants from the Australian National Health and Medical Research Council (grants 437015 and 607358), the Bonnie Babes
Foundation (grant BBF20704), the Financial Markets Foundation for Children (grant 032-2007), the Victorian government’s Operational Infrastructure Support
Program, the Australian and New Zealand Society for Paediatric Dentistry (Victorian branch), and the University of Melbourne Paediatric Dentistry Fund. Dr Silva is
supported by a National Health and Medical Research Council Postgraduate Health Research Scholarship. Dr Scurrah is supported by a Centre of Research
Excellence grant in twin research and a National Health and Medical Research Council project grant (1084197). Funded by the National Institutes of Health (NIH).
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

REFERENCES
1. Finucane D. Rationale for restoration of
carious primary teeth: a review. Eur
Arch Paediatr Dent. 2012;13(6):281–292
2. Petersen PE. The World Oral Health
Report 2003: continuous improvement
of oral health in the 21st century–the
approach of the WHO Global Oral Health
Programme. Community Dent Oral
Epidemiol. 2003;31(suppl 1):3–23
3. Poulton R, Caspi A, Milne BJ, et al.
Association between children’s
experience of socioeconomic
disadvantage and adult health: a life-
course study. Lancet. 2002;360(9346):
1640–1645
4. Selwitz RH, Ismail AI, Pitts NB. Dental
caries. Lancet. 2007;369(9555):51–59
5. Vieira AR, Modesto A, Marazita ML.
Caries: review of human genetics
research. Caries Res. 2014;48(5):
491–506
6. Hopper JL, Dite GS, Byrnes GB. Risks to
relatives. Encyclopedia of Life Sciences.
Chichester, UK: John Wiley & Sons;
2008:1–6
7. Neale MC, Eaves LJ, Kendler KS. The
power of the classical twin study to
resolve variation in threshold traits.
Behav Genet. 1994;24(3):239–258
8. Gluckman PD, Hanson MA, Buklijas T. A
conceptual framework for the
developmental origins of health and
disease. J Dev Orig Health Dis. 2010;
1(1):6–18
9. Saffery R, Morley R, Carlin JB, et al.
Cohort profile: the peri/post-natal
epigenetic twins study. Int J Epidemiol.
2012;41(1):55–61

Downloaded from www.aappublications.org/news at Indonesia:AAP Sponsored on February 27, 2021

PEDIATRICS Volume 143, number 5, May 2019 173
 10. Australian Bureau of Statistics. Socio-
Economic Indexes for Areas (SEIFA),
data cube only, 2006: Table 3. Postal
area (POA) index of relative socio-
economic disadvantage, 2006. Available
at: www.abs.gov.au/AUSSTATS/abs@.
nsf/DetailsPage/2033.0.55.0012006?
OpenDocument. Accessed August 2,
2016
11. Becker A, Busjahn A, Faulhaber HD,
et al. Twin zygosity. Automated
determination with microsatellites.
J Reprod Med. 1997;42(5):260–266
12. Ghanim A, Elfrink M, Weerheijm K,
Mariño R, Manton D. A practical method
for use in epidemiological studies on
enamel hypomineralisation. Eur Arch
Paediatr Dent. 2015;16(3):235–246
13. Harris PA, Taylor R, Thielke R, Payne J,
Gonzalez N, Conde JG. Research
electronic data capture (REDCap)–a
metadata-driven methodology and
workflow process for providing
translational research informatics
support. J Biomed Inform. 2009;42(2):
377–381
14. Carlin JB, Gurrin LC, Sterne JA, Morley
R, Dwyer T. Regression models for twin
studies: a critical review. Int
J Epidemiol. 2005;34(5):1089–1099
15. Australian Bureau of Statistics. 2039.0 -
Information Paper: An Introduction to
Socio-Economic Indexes for Areas
(SEIFA). Available at: http://www.abs.
gov.au/ausstats/abs@.nsf/mf/2039.0.
Accessed March 25, 2019
Downloaded from www.aappublications.org/news at Indonesia:AAP Sponsored on February 27, 2021
174
16. Shaffer JR, Wang X, Feingold E, et al.
Genome-wide association scan for
childhood caries implicates novel
genes. J Dent Res. 2011;90(12):
1457–1462
17. Werneck RI, Mira MT, Trevilatto PC. A
critical review: an overview of genetic
influence on dental caries. Oral Dis.
2010;16(7):613–623
18. Marteau TM, Lerman C. Genetic risk and
behavioural change. BMJ. 2001;
322(7293):1056–1059
19. Bretz WA, Corby PM, Hart TC, et al.
Dental caries and microbial acid
production in twins. Caries Res. 2005;
39(3):168–172
20. Bretz WA, Corby PM, Melo MR, et al.
Heritability estimates for dental caries
and sucrose sweetness preference.
Arch Oral Biol. 2006;51(12):1156–1160
21. Bretz WA, Corby PM, Schork NJ, et al.
Longitudinal analysis of heritability for
dental caries traits. J Dent Res. 2005;
84(11):1047–1051
22. Barouki R, Gluckman PD, Grandjean P,
Hanson M, Heindel JJ. Developmental
origins of non-communicable disease:
implications for research and public
health. Environ Health. 2012;11:42
23. Adler CJ, Dobney K, Weyrich LS, et al.
Sequencing ancient calcified dental
plaque shows changes in oral
microbiota with dietary shifts of the
Neolithic and Industrial revolutions. Nat
Genet. 2013;45(4):450–455, 455e1
24. World Health Organization. Global
Action Plan for the Prevention and
Control of Noncommunicable Diseases
2013-2020. Geneva, Switzerland: World
Health Organization; 2013
25. Burt BA. Fluoridation and social equity.
J Public Health Dent. 2002;62(4):
195–200
26. Wigen TI, Wang NJ. Maternal health and
lifestyle, and caries experience in
preschool children. A longitudinal study
from pregnancy to age 5 yr. Eur J Oral
Sci. 2011;119(6):463–468
27. Wu Q, Suzuki M. Parental obesity and
overweight affect the body-fat
accumulation in the offspring: the
possible effect of a high-fat diet
through epigenetic inheritance. Obes
Rev. 2006;7(2):201–208
28. Americano GC, Jacobsen PE, Soviero
VM, Haubek D. A systematic review on
the association between molar incisor
hypomineralization and dental caries.
Int J Paediatr Dent. 2017;27(1):11–21
29. Silva MJ, Scurrah KJ, Craig JM, Manton
DJ, Kilpatrick N. Etiology of molar
incisor hypomineralization -
a systematic review. Community Dent
Oral Epidemiol. 2016;44(4):342–353
30. Plomin R, Daniels D. Why are children in
the same family so different from one
another? Behav Brain Sci. 1987;10(1):
1–16
SILVA et al
Genetic and Early-Life Environmental Influences on Dental Caries Risk: A Twin
Study
Mihiri J. Silva, Nicky M. Kilpatrick, Jeffrey M. Craig, David J. Manton, Pamela
Leong, David P. Burgner and Katrina J. Scurrah
Pediatrics 2019;143;
DOI: 10.1542/peds.2018-3499 originally published online April 26, 2019;

Updated Information & including high resolution figures, can be found at:
Services http://pediatrics.aappublications.org/content/143/5/e20183499
References This article cites 26 articles, 1 of which you can access for free at:
http://pediatrics.aappublications.org/content/143/5/e20183499#BIBL
Subspecialty Collections This article, along with others on similar topics, appears in the
following collection(s):
Dentistry/Oral Health
http://www.aappublications.org/cgi/collection/dentistry:oral_health_
sub
Permissions & Licensing Information about reproducing this article in parts (figures, tables) or
in its entirety can be found online at:
http://www.aappublications.org/site/misc/Permissions.xhtml
Reprints Information about ordering reprints can be found online:
http://www.aappublications.org/site/misc/reprints.xhtml

Downloaded from www.aappublications.org/news at Indonesia:AAP Sponsored on February 27, 2021

Genetic and Early-Life Environmental Influences on Dental Caries Risk: A Twin
Study
Mihiri J. Silva, Nicky M. Kilpatrick, Jeffrey M. Craig, David J. Manton, Pamela
Leong, David P. Burgner and Katrina J. Scurrah
Pediatrics 2019;143;
DOI: 10.1542/peds.2018-3499 originally published online April 26, 2019;

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/143/5/e20183499

Data Supplement at:

http://pediatrics.aappublications.org/content/suppl/2019/04/19/peds.2018-3499.DCSupplemental

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since 1948. Pediatrics is owned, published, and trademarked by
the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2019
by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

Downloaded from www.aappublications.org/news at Indonesia:AAP Sponsored on February 27, 2021