|Year : 2019 | Volume
| Issue : 2 | Page : 65-71
Prevalence of early childhood caries and associated risk factors in 2–6-year-old children of North East Delhi attending anganwadis: A cross-sectional study
Gaurav Panwar, Namita Kalra, Rishi Tyagi, Amit Khatri, Kopal Garg
Department of Paedodontics and Preventive Dentistry, University College of Medical Sciences, Delhi University, Dilshad Garden, Delhi, India
|Date of Web Publication||9-Jul-2019|
Dr. Rishi Tyagi
Department of Paedodontics and Preventive Dentistry, University College of Medical Sciences, Delhi University, Dilshad Garden, Delhi - 110 095
Aims: This study was conducted to find out: (a) the prevalence of early childhood caries (ECC) in 2–6-year-old children of North East Delhi attending Anganwadis. (b) The association, if any, between known risk factors and ECC. Settings and Design: A cross-sectional study was conducted in 4012 to 6-year-old children of North East Delhi attending Anganwadis. Materials and Methods: A total of 401 children were clinically examined and their dental caries status was measured by the decayed, missing, filled surface (dmfs) index for deciduous teeth given by the WHO, Oral Health Surveys, Basic Method (2013). Structured questionnaires for the mother/caretaker of the children were used to gather information regarding their age, birth weight, feeding habits, oral hygiene practices, etc. Statistical Analysis: Statistical analysis involved the Chi-square test and multivariable logistic regression analysis. Results: The prevalence of ECC and severe ECC was 38.4% and 22.9%, respectively. The mean dmfs was 2.89 ± 5.89. The prevalence of ECC was statistically high in children involved in maternal sharing of utensils (odds ratio = 6.41; 95% confidence interval = 3.61–11.38). Age, increased frequency of between meal snacking, increased frequency of eating sweets and chocolates, low birthweight, and fell asleep with the nipple of milk bottle in the mouth also emerged out as risk indicators for ECC in logistic regression analysis. Conclusions: The prevalence of ECC in Anganwadi children was high and all the dmfs was due to untreated caries. This suggests the paucity of awareness among the studied population. Treatment along with the extensive preventive program in these young children is immensely required.
Keywords: Early childhood caries, prevalence, risk factors
|How to cite this article:|
Panwar G, Kalra N, Tyagi R, Khatri A, Garg K. Prevalence of early childhood caries and associated risk factors in 2–6-year-old children of North East Delhi attending anganwadis: A cross-sectional study. SRM J Res Dent Sci 2019;10:65-71
|How to cite this URL:|
Panwar G, Kalra N, Tyagi R, Khatri A, Garg K. Prevalence of early childhood caries and associated risk factors in 2–6-year-old children of North East Delhi attending anganwadis: A cross-sectional study. SRM J Res Dent Sci [serial online] 2019 [cited 2020 Jun 7];10:65-71. Available from: http://www.srmjrds.in/text.asp?2019/10/2/65/262379
| Introduction|| |
Oral health is an essential component of total health and well-being. It affects numerous aspects of a person's health status, quality of life, including self-esteem, learning, employment, ability to masticate, and speak and other levels of routine activities. Among oral diseases, dental caries is the most common chronic disease of humankind., It affects people regardless of their sex, socioeconomic strata, and race and age.
The most common chronic disease of childhood is early childhood caries (ECC). It is a frustrating condition that is difficult to treat, retards the child's growth, is infectious, and results in impairment of nutrition and esthetics with accompanying psychological problems.
In infants and young children, there are numerous unique risk factors of ECC. One of these factors is their feeding practices and it plays a major role in the development of ECC because teeth are more vulnerable to caries immediately after eruption. Oral biology may be modified by several factors unique to young children such as the immaturity of the host defense system, the behavioral patterns associated with feeding, and oral hygiene in early childhood. The scope and severity of the problems appear to vary with cultural, genetic, and socioeconomic differences within a community.
In some developed countries having advanced programs for oral health protection, the prevalence of ECC is around 5%. However, developing countries have been reported with higher prevalence rates. Indian studies also reflect significantly high prevalence of ECC among children under 5 years of age. For instance one study conducted in Anganwadis of Wardha reported a prevalence of 31.81%, another study in Nagpur revealed a prevalence of 63.58%.
In general, marginal farmers, laborers, agricultural laborers, and those living below poverty line send their children to Anganwadis. These children predominantly belong to lower level of socioeconomic status, along with poor feeding conditions and dietary patterns. The parents of these children lack health awareness and have limited utilization of health facilities.
Since Anganwadi is a part of Indian Public Health Care system and an Anganwadi worker forms the first point of contact between the masses and the health system, they can help in propagating the importance of oral health. In addition, it is particularly essential to educate this underprivileged population about oral health issues and risk factors of dental caries. Hence, this study was conducted because knowledge on prevalence and associated factors of ECC is necessary to develop targeted interventions for the prevention of subsequent tooth decay, and decrease the number of children that require emergency treatment.
| Materials and Methods|| |
The present study was carried out from November 2014 to April 2016 at various Anganwadis of North East Delhi. Ethical clearance was taken from the Institutional Ethical Committee. The study was cross sectional in nature. Official permission through the proper channel was obtained from the Chief District Medical Officer of North East Delhi before visiting any Anganwadi. Written informed consent was obtained from the parents/caretakers of all the children before enrolling them in the study.
Based on the previous Indian studies, the prevalence of ECC varies from 20% to 50%.,, Considering a 32% expected prevalence and by taking ±5% error margin with 95% of confidence level a sample size of 332 children was calculated. Thus, it was decided to recruit 400 children as the sample size of the study.
Children between 2 and 6 years of age, attending various Anganwadis of North East Delhi area were included in the study.
Children with any major debilitating illness, physically challenged children were excluded from the study.
A multistage sampling technique was adopted to select the study population. In the first stage, 10 of 17 towns of North East Delhi were selected randomly. Subsequently, from the list of Anganwadis of each selected town, 2 Anganwadis were randomly identified. From the list of children present on the day of examination, first 20 children were selected from each of the selected Anganwadi.
Recording early childhood caries and data collection
Children suffering from ECC and severe ECC (S-ECC) were recognized according to the definition of ECC given by the American Academy of Pediatric Dentistry – The presence of one or more decayed (noncavitated or cavitated), missing (due to caries), or filled tooth surfaces in any primary tooth in a child up to 71 months of age or younger. The academy also specifies that, in children younger than 3 years of age, any sign of smooth surface caries is indicative of S-ECC. From ages 3 through 5, 1 or more cavitated, missing (due to caries) or filled smooth surfaces in primary maxillary anterior teeth or decayed, missing, or filled score of ≥4 (age 3), or ≥5 (age 4), or ≥6 (age 5) surfaces constitutes S-ECC.
Clinical examination of the children was carried out by a single examiner within the Anganwadi premises with the help of mouth mirror and Community periodontal index (CPI) probe. Calibration between both guide and investigator was conducted before the study. Intra- and inter-examiner reproducibility was assessed with the help of kappa statistics and the κ = 0.95 for intra-examiner reproducibility and 0.87 for inter-examiner reproducibility were found.
Examination was carried out under broad daylight or artificial light if required. Sterile gauze pads were used to clean and dry teeth surfaces before examination.
Caries status was measured by decayed, missing, filled surface (dmfs) index for deciduous teeth given by the WHO, Oral Health Surveys, Basic Method (2013).
Information regarding age, birth weight, maternal sharing of utensils, feeding habits, and oral hygiene practices of the child was obtained through personal interviews of mother/care taker of the children by the use of structured questionnaires.
Low birth weight: According to the WHO criteria, the weight of <2500 g at birth.
Data were analyzed using the Statistical Package for the Social Sciences software version 16 (IBM, India); Chi-square test was performed to compare qualitative data and to find the statistical significance. The strength of association between the risk factors and the outcome was calculated by the Chi-square test. The level of statistical significance was set at P < 0.05 and for finding the independent association with outcome multivariable logistic regression was used.
Variables that showed only significant associations were included in multivariable logistic regression models that were constructed to assess the independent effect of these covariates on the prevalence of ECC. For the logistic regression analysis, Statistics and data software version 9 (Stata Corp., Chicago, USA) was used.
| Results|| |
A total number of children included in the study from various Anganwadis of North East Delhi were 401 including 223 (55.61%) males and 178 (44.38%) females. In the age group, 2–3 years, 3–4 years, 4–5 years, and 5–6 years number of children examined were 139 (34.7%), 99 (24.7%), 82 (20.4%), and 81 (20.2%), respectively.
The prevalence of ECC and S-ECC was 38.4% and 22.9%, respectively. The mean dmfs was 2.89 ± 5.89. The prevalence was 40.4% in males and 36% in females. The age-wise prevalence of ECC is given in [Table 1].
The mean dmfs of children affected with ECC was 7.52 ± 7.47. Maximum dmfs score was found to be 42. The most affected tooth was primary maxillary left central incisor, while the least affected was primary mandibular right central incisor.
[Table 2] shows that children having birth weight <2.5 kg were significantly more affected with ECC in comparison to children with birth weight ≥2.5 kg (53.3% vs. 34%; P = 0.001). This table also describes the occurrence of ECC in relation to maternal sharing of utensils. The effect of different feeding practices of children included in the study on the occurrence of ECC was analyzed [Table 3]. [Table 4] shows ECC in relation to oral hygiene practices among the studied group. [Table 5] shows the results from the multivariable logistic regression models. The logistic regression analysis revealed six risk indicators for ECC: Age, birth weight, maternal sharing of utensils, fell asleep with the nipple of milk bottle in mouth, frequency of between meal snacking, frequency of eating sweets, and chocolates.
|Table 2: Association of early childhood caries to the birth weight of children and maternal sharing of utensils among children included in the study|
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|Table 3: Early childhood caries in relation to feeding practices of children included in the study|
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|Table 4: Early childhood caries in relation to oral hygiene practices among children included in the study|
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|Table 5: Multivariable logistic regression analysis for finding the independent association of variables with the early childhood caries|
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Results showed highly significant increment in the prevalence of ECC with the increase in age of child (odds ratio [OR] = 1.89; 95% confidence interval [CI] = 1.36–2.62). The children involved in maternal sharing of utensils had 6.41 times more chances of having ECC in comparison to those who were not involved in this practice (OR = 6.41; 95% CI = 3.61–11.38).
The increase in the prevalence of ECC is highly significant with increase in the frequency of between meal snacking (OR = 2.62; 95% CI = 1.46–4.67) and frequency of eating sweets and chocolates (OR = 1.78; 95% CI = 1.46–2.18). Furthermore, the children with birth weight <2.5 kg were found to be more affected with ECC than those with birth weight ≥2.5 kg, and this difference was statistically significant (OR = 1.97; 95% CI = 0.99–3.89).
ECC was recorded more in those children who fell asleep with the nipple of milk bottle in the mouth in comparison to those who were not involved in this type of feeding practice, and the difference is statistically significant (OR = 3.66; 95% CI = 1.32–10.17).
| Discussion|| |
The present study was undertaken in Anganwadis of North East Delhi with the aim to find out the prevalence of ECC and its associated risk factors in 2–6-year-old children.
The caries prevalence was 38.4% in the present study. This finding was similar to the study done by Priyadarshini et al. (37.3%) in various Anganwadis of Bangalore. Caries prevalence was higher in this population in comparison to the studies conducted by Virdi. and Tyagi in Davangere who reported a prevalence of 17.2% and 19.2%, respectively. These variations in prevalence could be due to the differences in case definitions, criteria's, and geographical location.
In the present study, the prevalence of S-ECC was 22.9%. A similar finding was reported by Mazhari et al. (25%) in Quchan, Iran. In contrast, very low prevalence of S-ECC was documented in the study done by Nobile et al. in Southern Italy (2.7%).
An important finding of this study was that about 59.74% of children with ECC showed S-ECC and all the carious lesions observed and recorded in the study were untreated. There was not a single filled tooth, and all the children required treatment. It could be because most of the children attending Anganwadis were of lower socioeconomic status with lack of awareness, accessibility, and affordability for oral health care.
The present study illustrated that caries prevalence increased significantly with age. This finding was reaffirmed by the logistic regression model, and a similar finding was suggested by various earlier studies., This increase in prevalence with age was most likely because as the age increases, the cariogenic challenge also increases and there is a change in the dietary habits and hygiene practices.
In the present study, caries prevalence was found to be statistically high in children with birth weight <2.5 kg in comparison to those with birth weight of ≥2.5 kg. Other similar studies also found a significant association between low birthweight and ECC., The reason for this could be that low birthweight and preterm births, predisposes to high levels of streptococcal colonization, in addition to favoring the development of enamel hypoplasia and salivary disorders. Some studies did not report any association between ECC and birth weight.,
The association of maternal sharing of utensils with ECC was highly significant and this variable emerged as an important risk factor for ECC in logistic regression analysis also. The same finding was also reported by the Retnakumari and Cyriac in their study. The simple explanation for this may be the transfer of Streptococcus mutans hers to children during the sharing of utensils while having food.
Children who were exclusively breast fed had significantly lower ECC when compared with children who were exclusively bottle-fed or fed by both breast and bottle. Contrary results were given by some previous studies., According to them, children who were exclusively breastfed had slightly higher caries prevalence.
When bottle feeding was taken into consideration, it was observed that the association of duration of bottle feeding and ECC was statistically significant. The relation of the history of bottle feeding at night and falling asleep with the nipple of milk bottle in the mouth with the prevalence of ECC was statistically highly significant in this study. Hallet and O'Rourke found that sleeping with milk bottle was the key determinant of S-ECC. Studies that described bottle feeding in detail concluded that bottle feeding at night is the most important risk factor for the development of ECC in comparison to bottle feeding itself. These findings can be easily explained by the decreased salivary flow and swallow reflex during sleep which allows liquid carbohydrate to remain in the mouth and pool around the teeth. This decreased rate at which carbohydrates are cleared from the oral cavity is a determinant in caries initiation. Some studies did not find any significant association between duration of bottle feeding with the prevalence of ECC.,
In this study, children who took in between meal snacks more than three times had significantly higher caries prevalence. Many studies found an association between the frequency of snacking and dental caries.,
The present study shows the highly significant role of sweets and chocolates in the greater prevalence of ECC. The prevalence of ECC was recorded to be much higher in children who eat sweets and chocolates on demand. This corroborates with the findings of former studies.,
There was a significant association between teeth cleaning and ECC. The prevalence of caries was significantly high in those children who cleaned their teeth themselves without any guidance. Similar finding was reported by Prakash et al. in their study. Teeth cleaning by parents or caregivers have the more potential of removing dental plaque, optimally saturating the oral environment with fluoride, thereby decreasing the risk of caries among their children.
In the current study, a significant association was found between the prevalence of ECC and age at which teeth cleaning were initiated. The children in whom teeth cleaning were initiated before 2 years of age were less affected with ECC in comparison to those in whom teeth cleaning was initiated after 2 years. This corroborates with the findings of various other studies.,,
Our study had some limitations. One of them was the possible underestimation of caries prevalence. This was because caries was identified using the WHO criteria which led to the neglect of incipient carious lesions (noncavitated lesions) as these lesions are not identified as caries in the former.
Furthermore, the cross-sectional nature of this study does not tell about the cause–effect relationship, since data on “associated factors” and “outcomes” were assessed at the same time.
As our study is based on a self-administered questionnaire, we have received information from the memory of parents which may have its inherent inaccuracies leading to some bias. Li et al. noted that the reliability and validity of the mother's recall on breastfeeding data were high only for the first 36 months. The reliability and validity of the mother's recall ability on other feeding practice were also low.
The present study showed the prevalence of ECC and its associated risk factors. One of the strengths of the study is that data was collected through a survey in various Anganwadis across North East Delhi which means that the results of the study were generalizable to the study population. Another strength is the inclusion of a number of variables that have some effect on the outcome (ECC) and the inclusion of the various potential risk factors in the multivariable logistic regression model predicting ECC for the study population which differs from those studies that had simply conducted a univariate analysis.
| Conclusions|| |
The present study concludes that identifying the burden of ECC in this socioeconomically low and underprivileged population is very important. In this study, all of the dmfs was due to untreated caries. It indicates lack of awareness among this population. An effort should be made to mitigate the suffering of these children from socially deprived homes with marginalized income. Treatment along with extensive preventive programs for the entire population of young children is a basic right of this age group.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Retnakumari N, Cyriac G. Childhood caries as influenced by maternal and child characteristics in pre-school children of Kerala – An epideomological study. Contemp Clin Dent 2012;3:2-8.
] [Full text]
Preethi BP, Reshma D, Anand P. Evaluation of flow rate, pH, buffering capacity, calcium, total proteins and total antioxidant capacity levels of saliva in caries free and caries active children: Anin vivo
study. Indian J Clin Biochem 2010;25:425-8.
Prabhakar AR, Dodawad R, Raju OS. Evaluation of flow rate, pH, buffering capacity, calcium, total proteins and total antioxidant capacity levels of saliva in caries free and caries active children: Anin vivo
study. Int J ClinPediatr Dent 2009;2:9-12.
Animireddy D, Reddy Bekkem VT, Vallala P, Kotha SB, Ankireddy S, Mohammad N. Evaluation of pH, buffering capacity, viscosity and flow rate levels of saliva in caries-free, minimal caries and nursing caries children: Anin vivo
study. Contemp Clin Dent 2014;5:324-8.
] [Full text]
Tyagi R. The prevalence of nursing caries in Davangere preschool children and its relationship with feeding practices and socioeconomic status of the family. J Indian Soc Pedod Prev Dent 2008;26:153-7.
] [Full text]
Perera PJ, Fernando MP, Warnakulasooriya TD, Ranathunga N. Effect of feeding practices on dental caries among preschool children: A hospital based analytical cross sectional study. Asia Pac J Clin Nutr 2014;23:272-7.
Subramaniam P, Prashanth P. Prevalence of early childhood caries in 8 – 48 month old preschool children of Bangalore city, South India. Contemp Clin Dent 2012;3:15-21.
] [Full text]
Begzati A, Berisha M, Meqa K. Early childhood caries in preschool children of Kosovo – A serious public health problem. BMC Public Health 2010;10:788.
Gaidhane AM, Patil M, Khatib N, Zodpey S, Zahiruddin QS. Prevalence and determinant of early childhood caries among the children attending the anganwadis of Wardha district, India. Indian J Dent Res 2013;24:199-205.
] [Full text]
Bhayade SS, Mittal R, Chandak S, Bhondey A. Assessment of social, demographic determinants and oral hygiene practices in relation to dental caries among the children attending anganwadis of Hingna, Nagpur. J Indian Soc Pedod Prev Dent 2016;34:124-7.
] [Full text]
Shashidhara R, Maiya AS, Ramakrishna BV. India's integrated child development scheme and its implementation: Performance of anganwadi and analysis. OIDA Int J Sustain Dev 2012;5:29-38.
Gangwar C, Kumar M, Nagesh L. KAP toward oral health, oral hygiene and dental caries status among anganwadi workers in Bareilly city, Uttar Pradesh: A cross-sectional survey. J Dent Sci Oral Rehabil 2014;5:53-7.
Prakash P, Subramaniam P, Durgesh BH, Konde S. Prevalence of early childhood caries and associated risk factors in preschool children of urban Bangalore, India: A cross-sectional study. Eur J Dent 2012;6:141-52.
Priyadarshini HR, Hiremath SS, Puranik M, Rudresh SM, Nagaratnamma T. Prevalence of early childhood caries among preschool children of low socioeconomic status in Bangalore city, India. J Int Soc Prev Community Dent 2011;1:27-30.
Dawani N, Nisar N, Khan N, Syed S, Tanweer N. Prevalence and factors related to dental caries among pre-school children of Saddar town, Karachi, Pakistan: A cross-sectional study. BMC Oral Health 2012;12:59.
American Academy of Pediatric Dentistry Reference Manual 2002–03. Policies on early childhood caries; unique challenges and treatment options. Pediatr Dent 2003;23:24-5.
World Health Oraganization. Oral Health Surveys, Basic Method. 5th
ed. Geneva: World Health Oraganization; 2013.
Puffer RR, Serrano C. Patterns of Birth Weight. (Scientific Publication, 504). Washington DC: PAHO; 1987.
Virdi M. Prevalence of severe early childhood caries in preschool children in Bahadurgarh, Haryana, India. Internet J Epidemiol 2009;8:2.
Mazhari F, Talebi M, Zoghi M. Prevalence of early childhood caries and its risk factors in 6-60 months old children in Quchan. Dent Res J 2007;4:96-101.
Nobile CG, Fortunato L, Bianco A, Pileggi C, Pavia M. Pattern and severity of early childhood caries in Southern Italy: A preschool-based cross-sectional study. BMC Public Health 2014;14:206.
Hallett KB, O'Rourke PK. Social and behavioural determinants of early childhood caries. Aust Dent J 2003;48:27-33.
Lai PY, Seow WK, Tudehope DI, Rogers Y. Enamel hypoplasia and dental caries in very-low birthweight children: A case-controlled, longitudinal study. Pediatr Dent 1997;19:42-9.
Fearne JM, Bryan EM, Elliman AM, Brook AH, Williams DM. Enamel defects in the primary dentition of children born weighing less than 2000 g. Br Dent J 1990;168:433-7.
Seow WK. Biological mechanisms of early childhood caries. Community Dent Oral Epidemiol 1998;26:8-27.
Shulman JD. Is there an association between low birth weight and caries in the primary dentition? Caries Res 2005;39:161-7.
Dini EL, Holt RD, Bedi R. Caries and its association with infant feeding and oral health-related behaviours in 3-4-year-old Brazilian children. Community Dent Oral Epidemiol 2000;28:241-8.
Hallett KB, O'Rourke PK. Pattern and severity of early childhood caries. Community Dent Oral Epidemiol 2006;34:25-35.
Schwartz SS, Rosivack RG, Michelotti P. A child's sleeping habit as a cause of nursing caries. ASDC J Dent Child 1993;60:22-5.
Corrêa-Faria P, Martins-Júnior PA, Vieira-Andrade RG, Marques LS, Ramos-Jorge ML. Factors associated with the development of early childhood caries among Brazilian preschoolers. Braz Oral Res 2013;27:356-62.
Paunio P, Rautava P, Helenius H, Alanen P, Sillanpää M. The Finnish family competence study: The relationship between caries, dental health habits and general health in 3-year-old Finnish children. Caries Res 1993;27:154-60.
Reisine S, Douglass JM. Psychosocial and behavioral issues in early childhood caries. Community Dent Oral Epidemiol 1998;26:32-44.
Jose B, King NM. Early childhood caries lesions in preschool children in Kerala, India. Pediatr Dent 2003;25:594-600.
Rosenblatt A, Zarzar P. Breast-feeding and early childhood caries: An assessment among Brazilian infants. Int J Paediatr Dent 2004;14:439-45.
Li R, Scanlon KS, Serdula MK. The validity and reliability of maternal recall of breastfeeding practice. Nutr Rev 2005;63:103-10.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]