Research Article|Articles in Press

Changes in Dental Outcomes After Implementation of the Philadelphia Beverage Tax

Published:February 28, 2023DOI:


      Beverage taxes are associated with declines in sugar-sweetened beverage sales and consumption, but few studies have evaluated the associations of these taxes with health outcomes. This study analyzed changes in dental decay after the implementation of the Philadelphia sweetened beverage tax.


      Electronic dental record data were obtained on 83,260 patients living in Philadelphia and control areas from 2014 to 2019. Difference-in-differences analyses compared the number of new Decayed, Missing, and Filled Teeth with that of new Decayed, Missing, and Filled Surfaces before (January 2014–December 2016) and after (January 2019–December 2019) tax implementation in Philadelphia and control patients. Analyses were conducted in older children/adults (aged ≥15 years) and younger children (aged <15 years). Subgroup analyses stratified by Medicaid status. Analyses were conducted in 2022.


      The number of new Decayed, Missing, and Filled Teeth did not change after tax implementation in Philadelphia in panel analyses of older children/adults (difference-in-differences= –0.02, 95% CI= –0.08, 0.03) or younger children (difference-in-differences=0.07, 95% CI= –0.08, 0.23). There were similarly no post-tax changes in the number of new Decayed, Missing, and Filled Surfaces. However, in cross-sectional samples of patients on Medicaid, the number of new Decayed, Missing, and Filled Teeth was lower after tax implementation in older children/adults (difference-in-differences= –0.18, 95% CI= –0.34, –0.03; –22% decline) and younger children (difference-in-differences= –0.22, 95% CI= –0.46, 0.01; –30% decline), with similar results for number of new Decayed, Missing, and Filled Surfaces.


      The Philadelphia beverage tax was not associated with reduced tooth decay in the general population, but it was associated with reduced tooth decay in adults and children on Medicaid, suggesting potential health benefits for low-income populations.
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        • Malik VS
        • Hu FB.
        The role of sugar-sweetened beverages in the global epidemics of obesity and chronic diseases.
        Nat Rev Endocrinol. 2022; 18: 205-218
        • Te Morenga L
        • Mallard S
        • Mann J
        Dietary sugars and body weight: systematic review and meta-analyses of randomised controlled trials and cohort studies.
        BMJ. 2012; 346: e7492
        • Chi DL
        • Scott JM.
        Added sugar and dental caries in children: a scientific update and future steps.
        Dent Clin North Am. 2019; 63: 17-33
        • Andreyeva T
        • Marple K
        • Marinello S
        • Moore TE
        • Powell LM.
        Outcomes following taxation of sugar-sweetened beverages: a systematic review and meta-analysis.
        JAMA Netw Open. 2022; 5e2215276
        • Edmondson EK
        • Roberto CA
        • Gregory EF
        • Mitra N
        • Virudachalam S.
        Association of a sweetened beverage tax with soda consumption in high school students.
        JAMA Pediatr. 2021; 175: 1261-1268
      1. Rosinger A, Herrick K, Gahche J, Park S. Sugar-sweetened beverage consumption among U.S. adults, 2011-2014, NCHS Data Brief, (270), 2017, 1–8. Accessed February 22, 2023.

      2. Rosinger A, Herrick K, Gahche J, Park S. Sugar-sweetened beverage consumption among U.S. youth, 2011-2014, NCHS Data Brief, (271), 2017, 1–8. Accessed February 22, 2023.

      3. Get the facts: sugar-sweetened beverages and consumption, Centers for Disease Control and Prevention, 2022. Updated April 11, 2022. Accessed August 11, 2022.

        • Vercammen KA
        • Moran AJ
        • Soto MJ
        • Kennedy-Shaffer L
        • Bleich SN
        Decreasing trends in heavy sugar-sweetened beverage consumption in the United States, 2003 to 2016.
        J Acad Nutr Diet. 2020; 120 (1974–1985.e5)
      4. Fleming E, Afful J. Prevalence of total and untreated dental caries among youth: United States, 2015–2016, NCHS Data Brief, (307), 2018, 1–8. Accessed February 22, 2023.

      5. Dye BA, Thornton-Evans G, Li X, Iafolla TJ. Dental caries and tooth loss in adults in the United States, 2011–2012, NCHS Data Brief, (197), 2015, 197. Accessed February 22, 2023.

        • Williams S
        • Wei L
        • Griffin SO
        • Thornton-Evans G.
        Untreated caries among U.S. working-aged adults and association with reporting need for oral health care.
        J Am Dent Assoc. 2021; 152: 55-64
        • Seirawan H
        • Faust S
        • Mulligan R.
        The impact of oral health on the academic performance of disadvantaged children.
        Am J Public Health. 2012; 102: 1729-1734
        • Jackson SL
        • Vann WF
        • Kotch JB
        • Pahel BT
        • Lee JY.
        Impact of poor oral health on children's school attendance and performance.
        Am J Public Health. 2011; 101: 1900-1906
        • Heilmann A
        • Tsakos G
        • Watt RG.
        Oral Health over the life course.
        in: Burton-Jeangros C Cullati S Sacker A Blane D A Life Course Perspective on Health Trajectories and Transitions. Springer, Cham, Switzerland2015: 39-59
        • Cheng F
        • Zhang M
        • Wang Q
        • et al.
        Tooth loss and risk of cardiovascular disease and stroke: A dose-response meta analysis of prospective cohort studies.
        PLoS One. 2018; 13e0194563
        • Xu K
        • Yu W
        • Li Y
        • et al.
        Association between tooth loss and hypertension: a systematic review and meta-analysis.
        J Dent. 2022; 123104178
        • Schwendicke F
        • Thomson WM
        • Broadbent JM
        • Stolpe M.
        Effects of taxing sugar-sweetened beverages on caries and treatment costs.
        J Dent Res. 2016; 95: 1327-1332
      6. Jevdjevic M, Trescher AL, Rovers M, Listl S. The caries-related cost and effects of a tax on sugar-sweetened beverages. Public Health. 2019;169:125–132.

        • Sowa PM
        • Birch S.
        The effects of a sugar-sweetened beverage tax: moving beyond dental health outcomes and service utilisation.
        Health Econ Policy Law. 2022; (In press. Online August 2)
        • Hernández-F M
        • Cantoral A
        • Colchero MA
        Taxes to unhealthy food and beverages and Oral Health in Mexico: an observational study.
        Caries Res. 2021; 55: 183-192
      7. The Philadelphia Code: Chapter 19-4100, Sugar-Sweetened Beverage Tax. Bill No. 160176, 2016, American Legal Publishing; Cincinnati, OH. Published June 2016. Accessed February 22, 2023.

        • Petimar J
        • Gibson LA
        • Yan J
        • et al.
        Sustained impact of the Philadelphia Beverage tax on beverage prices and sales over 2 years.
        Am J Prev Med. 2022; 62: 921-929
        • Seiler S
        • Tuchman A
        • Yao S.
        The impact of soda taxes: pass-through, tax avoidance, and nutritional effects.
        J Mark Res. 2021; 58: 22-49
      8. Medicaid adult dental benefits: an overview. Center for Health Care Strategies, Inc. Updated September 2019. Accessed 18 January 2023.

        • Shulman JD
        • Cappelli DP.
        Epidemiology of dental caries.
        in: Cappelli DP Mobley CC Prevention in Clinical Oral Health Care. Mosby Elsevier, St. Louis, MO2008: 2-13
        • Butler DC
        • Petterson S
        • Phillips RL
        • Bazemore AW.
        Measures of social deprivation that predict health care access and need within a rational area of primary care service delivery.
        Health Serv Res. 2013; 48: 539-559
      9. Social deprivation index (SDI). Robert Graham Center. Updated July 22, 2021. Accessed June 24, 2022.

      10. Medicaid/CHIP eligibility limits. Kaiser Family Foundation. Accessed July 5, 2022.

        • Wing C
        • Simon K
        • Bello-Gomez RA.
        Designing difference in difference studies: best practices for public health policy research.
        Annu Rev Public Health. 2018; 39: 453-469
        • Austin PC
        • Stuart EA.
        Moving towards best practice when using inverse probability of treatment weighting (IPTW) using the propensity score to estimate causal treatment effects in observational studies.
        Stat Med. 2015; 34: 3661-3679
        • Gracner T
        • Marquez-Padilla F
        • Hernandez-Cortes D.
        Changes in weight-related outcomes among adolescents following consumer price increases of taxed sugar-sweetened beverages.
        JAMA Pediatr. 2022; 176: 150-158
      11. City of Philadelphia Department of Public Health. Staying healthy: access to primary care in Philadelphia. Philadelphia, PA: City of Philadelphia Department of Public Health. Published 2018. Accessed July 5, 2021.

        • Gupta N
        • Vujicic M
        • Yarbrough C
        • Harrison B.
        Disparities in untreated caries among children and adults in the U.S., 2011–2014.
        BMC Oral Health. 2018; 18: 30
        • Moss ME
        • Luo H
        • Rosinger AY
        • Jacobs MM
        • Kaur R.
        High sugar intake from sugar-sweetened beverages is associated with prevalence of untreated decay in U.S. adults: NHANES 2013–2016.
        Comm Dent Oral Epidemiol. 2022; 50: 579-588
        • Batis C
        • Rivera JA
        • Popkin BM
        • Taillie LS.
        First-year evaluation of Mexico's tax on nonessential energy-dense foods: an observational study.
        PLoS Med. 2016; 13e1002057
        • Bleich SN
        • Dunn CG
        • Soto MJ
        • et al.
        Association of a sweetened beverage tax with purchases of beverages and high-sugar foods at independent stores in Philadelphia.
        JAMA Netw Open. 2021; 4e2113527
        • Colchero MA
        • Rivera-Dommarco J
        • Popkin BM
        • Ng SW.
        In Mexico, evidence of sustained consumer response two years after implementing a sugar-sweetened beverage tax.
        Health Aff (Millwood). 2017; 36: 564-571
        • Colchero MA
        • Molina M
        • Guerrero-López CM.
        After Mexico implemented a tax, purchases of sugar-sweetened beverages decreased and water increased: difference by place of residence, household composition, and income level.
        J Nutr. 2017; 147: 1552-1557
        • Cawley J
        • Frisvold D
        • Hill A
        • Jones D.
        The impact of the Philadelphia beverage tax on purchases and consumption by adults and children.
        J Health Econ. 2019; 67102225
        • Kenney EL
        • Barrett JL
        • Bleich SN
        • Ward ZJ
        • Cradock AL
        • Gortmaker SL.
        Impact of the Healthy, Hunger-Free Kids Act on obesity trends.
        Health Aff (Millwood). 2020; 39: 1122-1129
        • Richardson AS
        • Weden MM
        • Cabreros I
        • Datar A.
        Association of the Healthy, Hunger-Free Kids Act of 2010 with body mass trajectories of children in low-income families.
        JAMA Netw Open. 2022; 5e2210480
        • Pulvera R
        • Altman E
        • Avina L
        • Thompson H
        • Schillinger D
        • Madsen K.
        Pandemic-related financial hardship and disparities in sugar-sweetened beverage consumption and purchasing among San Francisco Bay Area residents during COVID-19.
        Prev Med Rep. 2022; 26101759
        • Lyu W
        • Wehby GL.
        Effects of the COVID-19 pandemic on children's oral health and oral health care use.
        J Am Dent Assoc. 2022; 153 (787–796.e2)
        • Matsuyama Y
        • Isumi A
        • Doi S
        • Fujiwara T.
        Impacts of the COVID-19 pandemic exposure on child dental caries: difference-in-differences analysis.
        Caries Res. 2022; 56: 546-554