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Dental caries and oral hygiene practices of children and caregivers in Kerala, India

Jose, Babu

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2001

http://hdl.handle.net/10722/40688

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Dental caries and oral hygiene practices of children and caregivers in Kerala, India

A thesis submitted to the University of Hong Kong in partial fulfilment of the requirements for the degree of

Master of Dental Surgery By

Babu Jose 2001

Paediatric Dentistry and Orthodontics Faculty of Dentistry University of Hong Kong Hong Kong Special Administrative Region Thesis supervisor: Professor N. M. King

TOE UNIVERSITY OF HONG KONG LIBRARIES

Thesis Collection Deposited by the Author

Abstract

Abstract

Abstract

No published data are available on the prevalence of caries and feeding habits of children aged below 4 years of age, and the dental knowledge and attitudes of their caregivers in Kerala, south-western India. Therefore, this study was conducted to gather data on caries prevalence, feeding habits and oral hygiene practices of preschool children plus the oral health related knowledge and attitudes of their caregivers, which were then used to determine any associations between caries, and feeding habits and oral health care practices. Data from a sample of 530 children, aged from 8 to 48 months (mean age = 2.53 ± 0.96 years), were collected from thirteen Day Care Centers by interviewing their caregivers using a structured questionnaire.

The children were clinically examined for caries using a disposable mouth mirror, tongue spatula and a torch. The dmft of the 252 girls and 278 boys, was 1.84 ± 2.87 with 56.1% (288/513) being caries free. Fifty-nine (11.5%) were considered to have early childhood caries (ECC) based on the criteria that all four maxillary incisor teeth exhibited caries. Breast-feeding was practiced by 99.1% (525/530) of these children, and 4.7% (25) did so exclusively, and was generally, on demand. Of the breast-fed children, 171 were still being breast-fed, while the mean age of weaning was 9.22 + 5.00 months.

Milk was taken from a feeding bottle by 109 children, and 75.2% (82/109) received milk to which sugar had been routinely added. Sleeping with the feeding bottle was

Abstract

practiced by 40.4% (44/109) of the children who used a feeding bottle, and 26,6% (29/109) of the children still used a bottle.

Snacking habits were reported in 88.5% (454/513) of the 513 dentate children. Oral cleansing habits were practiced by 90.2% (478/530). Only 1.1% (6/530) of the caregivers started to clean their child's mouth soon after birth. Tooth-brushing was reported for 58.1% (298/513) of the children of which 38.9% brushed by themselves. Toothpaste was reportedly used by 39.3% (117/298) of the children. Primary teeth were considered to be important by 63.6% (337/530) of the caregivers. Remarkably, 95.9% (508/530), wished to have received more oral health related information. Statistically significant correlations were found between caries and the child's dental condition, as perceived by the caregiver (p< 0.0001), the caregiver's dental status (p=0.0417), consumption of snacks (p=0.0177), giving of sweets as a reward (p< 0.0001), cleaning of the child's mouth (p< 0.0001), the child's oral hygiene status (p< 0.0001) and low socio-economic status (p< 0.0001).

111

Table of Contents

Table of Contents

VI

Table of Contents

Abstract

i

Acknowledgements

Iv

Table of Contents

vi

List of Tables

x

List of Figures

xii

Chapter 1

Statement of the Problem and Objectives

1

1-0

Statement of the Problem

2

1-1

Aims

6

1-2

Objectives

6

1-3

Null hypothesis

7

Review of the literature

8

2.0

Introduction

9

2.1

Dental Caries

10

2.2

Caries prevalence in preschool children

12

2.3

Saliva

13

2.4

Dental Plaque

14

2.5

Bacteria

15

2.6

Teeth

17

2-7

Substrates

18

2.8

Nursing habits

22

2.9

Socio-economic status

22

2.10

Oral hygiene habits

23

Chapter 2

VII

Table of Contents

2.11

Prevention

23

2.12

Fluorides

24

2.13

Nutrition, tooth development, and dental caries

25

2.14

Growth

25

2.15

Risk factors in early childhood caries

26

2.16

Surveys in Kerala

27

2.17

Summary

28

Materials and Methods

29

3.1

Target Population

30

3.2

Sampling

30

3.2.1 Sample size determination

30

3.2.2 Sampling method and recruitment

31

Components of the investigation

31

3.3.1 Questionnaire

31

33.2 Clinical examination

31

3.4-

Examiner calibration

32

3.5

Data processing and analysis

32

Chapter 4

Results

33

Chapter 5

Paper I

35

Chapter 6

Paper H

57

Chapter 7

Discussion

86

Chapter 3

3.3

VIU

Table of Contents

7.0 Introduction

87

7.1 Questionnaire

8?

7.2 Clinical examination

88

73 Sample

88

7A Questionnaire responses

90

Chapter 8

Conclusions

91

Chapter 9

List of References

94

Appendix I Documents A

Consent form

B

Survey Questionnaire

C

Clinical Assessment Record Form Appendix II Raw Data Printout Appendix JXL Statistical Result Printout Appendix IV Poster Presentation 54th Annual Session Of The American Academy of Pediatric Dentistry, Atlanta, USA (24* to 28th May, Pediat 2001)

IX

List of Tables

List of Tables

List of Tables

Chapter

No.

Title of the table

Page_

Chapter 2

1

The prevalence of dental caries in cohorts of children aged 12-24 months and 24-36 months from different countries around the world over the past 37 years

13

Chapter 5

1

The age distribution of 530 children from Kerala, south-western India

45

2

Major food type for the 530 children at the time of the investigation

45

3

Breast-feeding habit in the group of 530 children Kerala.

46

1

The caries status of the 513 dentate children out of the group of 530 children from Kerala who had a snacking habit

69

2

The caries status of the 513 dentate children Kerala who received sweets as a reward

69

3

The caries status of the 298 children who had a toothbrushing habit out of the group of 513 dentate children from Kerala

70

4

The caries status and the use of toothpaste by the 298 Kerala children who brushed their teeth out of the group of 513 dentate children

70

5

The caries status and the toothpaste usage of the 117 children who brush their own teeth

71

6

The caries status of the 530 children from Kerala according to the education status of the father

71

7

The caries status of the 530 children from Kerala according to the education status of the mother

72

8

The caries experience of the child who had a caregiver with an above average dental condition in the group of 530 children from Kerala

72

Chapter 6

from

from

XI

List of Figures

List of Figures

Xll

List of Figures

Chapter Chapter 6

No.

Title of the figure

Page

1

The distribution by age of the 225 children with dental caries

68

2

Caries distribution among 530 children aged between 8 and 48 months

68

Xlll

Statement of the Problem and Objectives

Chapter 1

Statement of the Problem aod Objectives

Statement of the Problem and Objectives

LO Statement of the problem Southeast Asia, as, defined by the World Health Organization (WHO), consists of ten countries: India, Bhutan, Nepal, Bangladesh, Burma, Sri Lanka, Maldives, Thailand, Indonesia and Mongolia. All these are developing Third World countries, still grappling with major health problems such as tuberculosis and malnutrition, and have high mortality rates. As a result, oral health is not yet regarded as a high priority in these countries. Data on dental caries are not available from most of these countries at the national level.

India is the largest democracy in the world with the population crossing the one billion barrier in 2000. Geographically the country is divided into 27 states and 4 union territories. The diversity in the different cultures is unique in India since the life style; socioeconomic conditions and food habits in the various states are markedly different. Kerala is a southwestern state of India.

The public water supply is not fluoridated in Kerala. The public is not aware of the beneficial effects of fluoride preventing dental caries. The major sources of potable water are the public water supply and wells. Moreover, in traditional Indian medicine, Ayurveda, which has a tradition dating back thousands of years, fluoride is considered harmful for human consumption.

A number of caries prevalence studies for children aged five to six years have been conducted in different parts of India including Kerala, by individual investigators, using different diagnostic criteria and a variety of analytical and

Statement of the Problem and Objectives

reporting techniques. Hence, making comparisons between these studies is invalid. However, a National Epidemiological Study was planned and conducted in 1985-1986 by Tewari and her co-workers from the Post Graduate Institute for Medical Education and Research, Chandigarh, covering the majority of twentyseven Indian states including Kerala, for children aged between five to six years. This study used standardized recording methods and the WHO deft index. According to this study, in the age group of five to six years in Kerala, the average dmft was 1.9 in the urban population and 1.6 in the rural population (Gupta 1987). This was the lowest caries experience observed among the southern Indian states of Andhra Pradesh, Tamilnadu, Karnataka and Kerala.

No published studies have focused on the age group below four years. Diet and oral hygiene habits learned during these years become engrained in an individual's life during these initial formative years. The primary caregivers are the persons who instill the above habits in pre-school children.

The term early childhood caries (ECC), as used to describe dental caries in infants and young children, was suggested at a workshop in 1994 sponsored by the Centers for Disease Control and Prevention (Kaste and Gift 1995).

Early childhood caries is a form of severe dental caries that affects the primary teeth

of infants

and toddlers.

The

disease

has

several

distinguishing

characteristics: the pattern of caries development may be distinctive and many teeth may be affected; caries develops rapidly, often soon after tooth erupt; and it

Statement of the Problem and Objectives

develops in tooth surfaces that usually are at low risk of dental caries, such as the labial surfaces of maxillary incisors and the lingual and buccal surfaces of the maxillary and mandibular molars (Ripa 1988).

A universally accepted definition for ECC does not exist (Milnes 1996), and criteria for the condition have varied among epidemiological surveys, making comparative data difficult to interpret (Ripa 1988). The pattern of caries development is characteristic of the disease and is affected by the sequence of eruption of the primary teeth, the duration of the causative behavior and perhaps patterns of tongue movement and oral muscular action (Duperon 1995). Early childhood caries usually begins with the maxillary primary incisors initially developing a dull white demineralized band along the gingival margins. As the condition progresses, cavitation occurs which involves the cervical region of the teeth.

In the advanced stages, the crowns of all the maxillary incisors may become completely destroyed, leaving only the root stumps. Mandibular primary molars often become affected from the repeated pooling or stagnation of cariogenic liquids. Other primary tooth surfaces may become carious, depending on the duration and frequency of a harmful feeding habit (Dilley et al 1980). The basic reasons for tooth demineralization in children are extensive exposure to a cariogenic diet and early infection with cariogenic bacteria while the main source of Mutans streptococci is the mother (Caufield and Li 1995).

Statement of the Problem and Objectives

As the primary caregivers, the parents are the individuals who control the oral health care of their children. The early diet of an individual is a determinant of the later dietary habits, and the dietary habits of mothers are associated with those of their off spring, at least, during the first years of life (Ismail 1993). Moreover, research has shown that socioeconomic and demographic factors influence the caries experience of the children. High parental educational attainment and income are related to lower caries experience (Al-Hosani and Rugg-Gunn 1998). Research clearly shows that children who have dental caries in their primary dentition are more likely to have dental caries in their permanent dentition (Kaste et all 992).

The Government of India initiated the Integral Child Development Services (ICDS) for pre-school children aged below six years in 1975. The objectives of ICDS are to improve the nutritional and health status of children below the age of six years, lay the foundation for the proper psychological, physical and social development of the child, reduce the incidence of mortality, morbidity, malnutrition and school dropouts, achieve effective coordination of policy and implementation among various departments to promote child development, and enhance the capability of the mother to look after the normal health and nutritional needs of the child, through proper health and nutrition education. The health services provided by the ICDS are immunizations, health check-ups and referral services. It also undertakes supplementary feeding, growth monitoring and promotion, Nutrition and Health Education (NHED) and treatment of minor illnesses. ICDS provides early childhood care and pre-school education to

Statement of the Problem and Objectives

children in the age group of three to six years and have other support services such as providing safe drinking water, environmental sanitation, women's empowerment programs, non-formal education and adult literacy. Pre-school children in Kerala attend both the government sponsored and privately run Day Care Centers. No information is known about the feeding habits and oral health of pre-school children along with the oral health knowledge, attitudes and behavior of their caregivers in Kerala.

Hence it was decided to conduct a survey to gather baseline data on the feeding habits, caries prevalence of pre-school children along with the oral health knowledge, attitudes and behavior of their caregivers in Kerala. The survey could identify " high risk" groups and preventive measures could then be formulated.

1.1 Aims To determine the oral health status of pre-school children in Kerala, India and to identify possible risk indicators for dental caries. 1.2 Objectives The objectives of this study were:

i)

to gather baseline data on the oral health status of infants in Kerala including dental caries status and oral cleanliness,

ii)

to gather data on infant feeding habits in Kerala,

Statement of the Problem and Objectives

iii)

to gather data on the oral hygiene habits of pre-school children, and to identify the oral health related perceptions, knowledge, attitudes and dental behavior of the caregivers of pre-school children.

1.3 Null hypothesis The data gathered was intended to test the null hypothesis that the high caries prevalence of pre-school children in Kerala is not associated with poor feeding habits and that the oral health knowledge of the caregivers of pre-school children in Kerala is low.

Review of the Literature

Chapter 2

Review of the Literature

Review of the Literature

2.0 I0troductioo A review of the published literature on the prevalence of dental caries in infants, with an emphasis on Early Childhood Caries (ECC) is proposed along with the attitudes, knowledge, and influence of caregivers on dental caries in their children.

The existence of rampant caries in infants and young children was recognized as early as the latter part of the nineteenth century (Jacobi 1862). This pattern of early caries in young children was described as "black teeth of the very young" (Beltraini 1952). The term "nursing bottle mouth" was coined by Dr. Elias Pass in 1962. In his classic paper he described the caries pattern as affecting all the primary anterior teeth, upper and lower primary first molars and the lower primary canine teeth, and he observed that the lower four anterior teeth were unaffected or very slightly carious and also the fact that the children was put to bed, either for a nap or at night with a nursing bottle of milk to help them fall asleep.

The term "nursing bottle mouth" was succeeded by the terms "nursing caries" and "baby bottle tooth decay". The term ccEarly Childhood Caries" (ECC) was agreed upon at a conference in 1994 at the Centers for Disease Control and Prevention, Atlanta, USA. The attendees also found no absolute link between bottle-feeding habits and dental caries.

Support for the term ECC is, at least in part, based on the finding that sleeping with a feeding bottle containing milk or other sweetened beverages does not always cause caries (Kaste and Gift 1995). Data from developing countries suggest that

Review of the Literature

high caries prevalence in infants and toddlers cannot, in many cases, be attributed to inappropriate bottle-feeding (Songpaisan and Davies 1989, Matee et al 1994, Douglass et al 1994). The high caries incidence in the subjects in the above studies was due to caries in the primary maxillary incisors, a pattern generally assumed to be due to bottle-feeding practices (Songpaisan and Davies 1989, Matee et al 1994, Douglass et al 1994). A study in the United States in children aged 4 and 5 years old; also noted caries in the maxillary anterior teeth, at an age by which bottle use has ordinarily been discontinued (Tinanoff and O5 Sullivan 1997). Moreover, the term ECC did not rule out the reasons for tooth demineralization in very young children; for example extensive exposure to a cariogenic diet and early infection with cariogenic bacteria.

Early childhood caries is caused by Mutans streptococci, which ferment dietary carbohydrates leading to acid attacks on susceptible teeth over a period of time. The etiology of early childhood caries is similar to other types of coronal and smooth surface caries, but the predisposing factors are unclear. Implantation of cariogenic bacteria, immaturities of the host defense systems and the behavioral patterns associated with feeding and oral hygiene in early childhood possibly modifies the biology of early childhood caries (Seow 1998). Moreover the tooth surfaces that are affected are newly erupted and hence the enamel is not fully mature and may exhibit hypoplastic defects.

2.1 Dental caries Dental caries is an infectious and transmissible disease, which is strongly modified

10

Review of the Literature

by diet (Krasse 1965). The various etiological factors involved in dental caries are cariogenic micro-organisms, fermentable carbohydrates, susceptible teeth and the host (Tanzer 1989). These three etiological components should be simultaneously present before caries can occur (Keyes and Jordan 1963).

The current understanding of dental caries centers on the fermentation of carbohydrates by cariogenic plaque bacteria producing organic acids which act on the susceptible tooth (Keyes and Jordan 1963). The carious lesion develops over a period of time, and is the result of dynamic, complex interactions of cariogenic bacteria and host defense mechanisms. The major group of cariogenic bacteria is Mutans streptococci, which possess many virulent cariogenic characteristics (Loesche 1986, Tanzer 1989).

The source of carbohydrates in ECC may be sugars in the drinks and solid foods consumed by the infant (Rossow et al 1990, Milnes 1996). After the ingestion of carbohydrate, the acids produced by fermentation cause a drop in plaque pH (Koulourides et al 1976), which may lead to demineralization of enamel (Johnson etal!980).

The caries process is dynamic, and demineralization by acid may well be followed by a process of remineralization (Fejerskov and Clarkson 1996). The actual process of remineralization or demineralization of the enamel depends on whether the concentrations of calcium and phosphate in the plaque fluid are saturated with respect to the minerals present in tooth enamel, as well as the pH of the

11

Review of the Literature

environment (Rolla and Ekstrand 1996). The presence of fluoride will catalyze the transformation of calcium phosphates to hydroxyapatite during remineralization phase, as well as aiding the deposition of fluoridated hydroxyapatite and fluorapatite; both of which are less soluble than hydroxyapatite (Fejerskov and Clarkson 1996, Rolla and Ekstrand 1996).

2.2 Caries prevalence in preschool children Dental caries in infants and toddlers is influenced by the sequence of tooth eruption that may determine both the age of initial caries plus the teeth and teeth surfaces that are affected. Characteristic lesions develop rapidly in many teeth on surfaces normally considered to be at low risk to decay. The maxillary primary incisors are the most severely affected; they are also the first teeth to be affected, initially developing broad areas of enamel demineralization or white spot lesions at the gingival margin. The next most susceptible teeth are the primary maxillary first molars, which erupt at around 12-18 months of age. The primary canines and primary second molars, because they erupt at a later time when many children have been weaned from the bottle or breast, are often spared or are only minimally affected. The primary mandibular incisors are usually unaffected by the cariogenic challenge because, during sucking, the tongue is extended over the lower incisor teeth, thereby affording physical protection from the liquids that bathe other teeth. The caries prevalence in 12-36 months old children from dental health surveys in various countries around the world in the past four decades is shown in Table 1.

12

Review of the Literature

Caries prevalence Year of study J

Investigator &

Countiy J

,0 „ expressed as % 12-23 months 24-36 months

1964 Tank and Storvik USA 1 1969 Hennon et al USA 8 1971 Winter et al England 2 1974 Infante and Russel USA 2 1978 Cleaton- Jones et al 37 South Africa 1981 7 Weddell and Klein USA 1988 1 Holt et al England 1991 Japan 3 Fujiwara et al 1991 Sweden 0.5 Wendt et al 1993 Janson and Fakhouri Jordan 5 1994 1 O' Sullivan et al USA 1995 4 Hinds and Gregory England 1995 38 Tsbouchi et al USA Table 1. The prevalence of dental caries in cohorts of children aged 12-24 months and 24-36 months from different countries around the world over the past 37 years. Early childhood caries appears in the teeth in the order of their eruption. It is characterized by first affecting the primary maxillary incisors, followed by the first molars, canines, and finally the second molars (Ripa 1988). Some studies report that only 12-24 months old children have caries on the maxillary anterior teeth. Caries of the molars, without there being any caries of the maxillary teeth reportedly is found only in children older than 30 months of age (Johnsen and Schechner 1987, Greenwall et al 1990).

2.3 Saliva Saliva serves as a reservoir of calcium and phosphate minerals that are essential for the remineralization of enamel (Dawes 1984), Saliva is the major mechanism for the clearance of foods (Lagerlof and Oliveby 1994) as well as oral bacteria (Mandel and Ellison 1981) in the oral cavity as well as providing the main buffering systems

13

5 35 18 15 53 28 15 32 8 25 44 14 56

Review of the Literature

to neutralize acids (Lagerlof and Oliveby 1994). The host defense systems in the caries process are mainly found in the saliva - the salivary buffers (Dawes 1984) and to a lesser extent in the gingival crevicular fluid (Tenovuo et al 1987, Lagerlof and Oliveby 1994).

2.4 Dental plaque There are relatively few studies on the formation and development of plaque in young children. The first stage in plaque formation is the deposition of an acquired pellicle on the tooth surface leading to microbial colonization and the dental caries (Scannapieco 1994).

In human in vivo studies, the early colonizers are mainly streptococci, namely Streptococcus sanguis, Streptococcus oralis, Streptococcus mitis biovar 1 (Nyvad and Kilian 1987, Macpherson et al 1991). These three streptococcal species account for more than 96% of the streptococci, and 56% of the initial microbial flora (Nyvad and Fejerskov 1996).

The metabolic and basic end products of bacteria in plaque depend on the diet of the host (Nyvad and Fejerskov 1996). Lactate is produced mainly when fermentable carbohydrates are present, resulting in a pH drop in the plaque (Geddes 1975). The pH of the plaque may drop from a resting level of 6.5 to below 5.5 when a sucrose rinse is given (Scheie et al 1992, Fejerskov et al 1992). Mutans streptococci have a virulent characteristic ability to tolerate high levels of acid in the environment (Tanzer 1989). This ability is mediated by ATPases

14

Review* of the Literature

enzymes, which are highly sensitive to fluoride (Marquis 1995), Bacteria and their alkaline products raise the plaque pH (Marquis 1993) and many researchers believe that the base generating metabolism of plaque bacteria is a significant determinant of cariogenicity of plaque (Wijeyeweera and Kleinberg 1989).

2.5 Bacteria The basic reasons for tooth demineralization in children are extensive exposure to a cariogenic diet and early infection with cariogenic bacteria. Children who consume beverages containing sucrose in their baby bottle had levels of Mutans streptococci four times the level of those who consumed milk from a baby bottle (Mohan et al 1998). It is possible to differentiate the strains of Mutans streptococci by membrane fatty acid spectra (MFAS) and peroxidase reaction (PR) after aerobic incubation (Rupfetal2001).

The main source of the Mutans streptococci is the mother (Newbrun 1992, Caufield and Li 1995). Transmission can occur through direct, saliva, or indirect contacts (Newbrun 1992). Indirect contact can occur through fomites, such as spoons (Kohler and Bratthall 1978), cups, toys, or toothbrushes (Newbrun 1992).

Frequent transfer of maternal saliva to the mouth of the baby before tooth eruption is negatively associated with oral infection by Mutans streptococci and to caries in the primary dentition, possibly due to protective immune mechanisms (Aaltonen and Tenovuo 1994). Children who have had frequent maternal close-contacts in their first year have significantly more IgG antibodies against Mutans streptococci

15

Review of the Literature

than children with rare close-contacts (Aaltonen et al 1985).

Studies suggest that breast-feeding, especially prolonged breast-feeding, may correlate with the fidelity of transmission of Mutans streptococci and that prolonged breast-feeding may contribute to a higher caries rate (Li et al 2000). Children who are breast-fed for more than nine months are likely to harbor strains of Mutans streptococci common to their mothers and experience more dental caries at three years of age compared with children who are breast-fed for less than nine months (Li et al 2000).

The age at which Mutans streptococci is first acquired is thought to influence the susceptibility of an individual to future caries; the earlier the colonization with Mutans streptococci, the higher the caries risk (Grindefjord et al 1996).

Habitual xylitol consumption by mothers is associated with a significant reduction in the probability of mother-child transmission of Mutans streptococci assessed at two years of age. Xylitol-associated reduction in the probability of mother-child transmission of Mutans streptococci has been found in the children's Mutans streptococci counts at the ages of three and six years (Soderling et al 2001).

Specific immune defense against cariogenic Mutans streptococci is provided largely by salivary secretory IgA antibodies, which are generated by the common mucosal immune system. This system is functional in newborn infants, who develop salivary IgA antibodies as they become colonized by oral microorganisms.

16

Review of the Literature

Strategies of mucosal immunization against Mutans streptococci, which are under development, include the use of surface adhesins and glucosyl transferase as key antigens, which are being incorporated into novel mucosal vaccine delivery systems and adjuvants. The oral application of preformed, genetically engineered antibodies to Mutans streptococcal antigens also offers new prospects for passive immunization against dental caries (Russell et al 1999).

2.6 Teeth There is scientific evidence associating prolonged or night-time breast-feeding and caries of the maxillary anterior teeth (Gardner et al 1977, Kotlow 1977, Curzon and Drummond 1987), High caries rates in the primary maxillary incisors have been observed in developing countries like China, Thailand and Tanzania where feeding of babies with bottles is rare. This high caries prevalence of the primary maxillary incisors cannot therefore be solely attributed to inappropriate bottle-feeding (Songpaisan and Davies 1989, Douglass et al 1994, Matee et al 1994).

The maxillary incisors are the most seriously affected teeth (Derkson et al 1982). Generally, the caries pattern is usually assumed to be due to bottle-feeding practices. In the United States of America, children who are between four and five years old, an age by which bottle use ordinarily has been discontinued, have been noted to develop caries in the primary maxillary anterior teeth (Tinanoff and O* Sullivan 1998).

Epidemiological studies suggest that the periods immediately after eruption and

17

Review of the Literature

prior to final maturation of the enamel are the periods of greatest susceptibility to dental caries (Carlos and Gittelsohn 1965). This may be because of the need for post-eruptive maturation of the immature enamel (Fejerskov and Clarkson 1966).

In addition to the lack of completion of maturation of enamel, the presence of structural defects in enamel may increase the caries risk (Li et al 1996). Developmental defects of enamel maybe manifested as quantitative defects like enamel hypoplasia or as qualitative defects like enamel opacity (FDI1992).

Hereditary diseases, acquired developmental disturbances involving the prenatal, perinatal and postnatal life of the child like premature birth, low birth-weight, infections, and malnutrition can lead to generalized enamel defects in the primary dentition (Seow 1991). Local trauma and infections can also be responsible for localized enamel defects in the developing tooth (Seow 1984).

In severe cases of enamel hypoplasia there can be a total loss of enamel exposing the dentin, which provides little resistance to acid attack. Structural defects such as enamel hypoplasia retain plaque (Svanberg and Loesche 1977); thus, causing increased colonization of streptococci (Li et al 1994) and then possibly caries.

2.7 Substrates Bovine milk is the commonest fluid placed in the feeding bottle of infants and it is said to be non-cariogenic (Bowen and Pearson 1993). Milk decreases the solubility

18

Review of the Literature

of enamel, a fact that is supported by numerous in vitro studies (Jenkins and Ferguson 1966, Weiss and Bibby 1966).

Milk exerts a protective effect by decreasing demineralization and increasing remineralization of enamel (McDougall 1977, Reynolds 1987), probably by increasing the calcium and phosphate concentrations in plaque, as well as by increasing the acid buffering capacity of plaque through catabolism of the peptides by plaque bacteria (Reynolds et al 1995).

The main components of milk involved in reducing demineralization and increasing remineralization is the various forms of casein, namely alpha casein, sodium caseinate, and trypsin-treated casein (Reynolds et al 1995). The milk protein known as alpha-1 casein may be concentrated in the acquired pellicle and act as an inhibitor of Mutans streptococci

adherence to

saliva-coated

hydroxyapatite (Vacca-Smith et al 1994, Schupbach et al 1996).

The current literature suggests that milk is non-cariogenic (Stephan 1966, Bowen et al 1990). Milk given in combination with relatively high concentrations of sucrose seems to exert a protective effort, even though the addition of sucrose appears to increase the cariogenicity of milk (Bowen et al 1990, Bowen and Pearson 1993).

When compared to bovine milk, human breast milk has according to Darke (1976) a lower mineral content, a higher concentration of lactose (7% vs. 3%), and less protein (1.2g vs. 3.3g per 100ml). Epidemiological studies have suggested that

19

Review of the Literature

frequent breast-feeding is associated with a caries prevalence of approximately 5% (Duperon 1995) to 10% (Mattee et al 1992, Roberts 1994). The relationship between breast-feeding and dental caries, which is complex, is confounded by many variables such as streptococcal infection (Mattee et al 1992), enamel hypoplasia (Seow 1991), the intake of sugars (Rossow et al 1990), as well as social variables such as parental education and socioeconomic status (Roberts 1994).

Bowen and his co-workers reported in 1997 that all of the milk formulas that they tested caused less caries compared with sucrose, the most cariogenic one induced about one-third of the carious lesions caused by sucrose. Acids present in fruit juices and soft drinks decrease the oral pH (Grenby 1990), and the excessive intake or consumption of fruit drinks causes the loss of enamel (Frostell 1970, Bowen 1997). If sugars are also present in these drinks, this fall of pH is likely to enhance that which results from bacterial fermentation of carbohydrates; thus causing a more profound degree of enamel demineralization.

Sucrose, glucose and fructose, which are present in fruit juices and vitamin C drinks (Newbrun 1982, Grenby et al 1990), as well as in solids, are probably the main sugars associated with ECC (King 1978, Persson et al 1985, Moynihan and Holt 1996). Sucrose, being the most widely used sugar, is considered to be the most important one in dental caries (Gustafsson et al 1954, Newbrun 1989) because it is the only substrate used by bacteria in the production of plaque dextrans which aid in bacterial adherence (Mikkelsen 1996) and thus facilitates the implantation of cariogenic bacteria in the oral cavity (Gibbons et al 1966).

20

Review of the Literature

Other sugars of significance in early childhood caries are glucose and fructose, which are present in fruit and honey respectively (Grenby et al 1990, Moynihan and Holt 1996). The findings of in vitro studies suggest that glucose and fructose are as cariogenic as sucrose due to their abilities to drop the pH intraorally (NefF 1967) and to demineralize enamel (Koulourides et al 1976).

Children with ECC generally have a high frequency of sugar consumption., not only of fluids given in the nursing bottle (Winter 1980, Holt et al 1982, Wendt et al 1991, Weinstein et al 1992), but also of sweetened solid foods (Gordon and Reddy 1985, Tsubouchi et al 1995). This dietary characteristic is likely to be one of the most significant caries risk factors in ECC. This association is indicated by the results of clinical studies (Gustaffsson et al 1954).

The increased frequency of eating sucrose raises the acidity of plaque, and enhances the establishment and dominance of the aciduric Mutans streptococci (van Houte 1994). Loesche (1986) reported that, the total time sugar is in the mouth increases the potential for enamel demineralization; when there is inadequate time for remineralization by saliva, the result is that demineralization becomes the predominant mechanism.

The consumption of sugar by infants with ECC is common characteristic. The low salivary flow during sleep decreases the oral clearance of the sugars and increases the length of time that plaque and substrates are in contact with the teeth; thus,

21

Review of the Literature

significantly increasing the cariogenicity of the substrate (Firestone 1982). Intraoral site differences in the rates of oral clearance are probably related to the velocity of the saliva in different regions of the mouth (Dawes 1989).

The labial surfaces of the maxillary incisors and the buccal surfaces of the primary mandibular molars have the slowest clearance of glucose in the mouth (Hanaki et al 1993). These site differences in oral clearance may explain, at least in part, the distribution of carious lesions in ECC, which are characteristically localized to the maxillary primary incisors and the first molars (Ripa 1988, Milnes 1996).

2.8 Nursing habits Several studies have associated prolonged or night-time breast-feeding and caries of the maxillary anterior teeth (Gardner et al 1977, Kotlow 1977, Dilley et al 1980, Curzon and Drummond 1987). On the contrary one study reported that breastfeeding of the child for more than 40 days may act preventively and inhibits the development of nursing caries in children and that the nursing habit of bottle-feeding is not the only factor determining the development of nursing caries (Constantine et al 1999). Human breast milk is not cariogenic (Pamela Erickson and Elham Mazhari 1999). Falling asleep with the bottle seems to be the most determinant factor associated with the development of nursing caries (Constantine et all 999).

2.9 Socio-economic status Apart from age, the parents' level of education and income has been found to be

22

Review of the Literature

statistically significantly related to the caries experience of their child. High parental educational attainment was found to be related to lower caries experience; conversely, high parental income was related to higher caries experience (Al-Hosani and Rugg-Gunn 1998).

Temperament alone is not a predictor of the duration of a feeding habit but together, shyness and the duration of feeding habit have been shown to be associated with early childhood caries (Quinonez et al 2001).

2.10 Oral hygiene habits Most children commence tooth-brushing by the age of 18 to 24 months (Dowell 1981, Simard et al 1991, Levy et al 1992). Regular brushing (twice a day) with fluoridated toothpaste may have a greater impact on dental caries in young children than restricting sugary foods (Gibson and Williams 1999).

2.11 Prevention The American Academy of Pediatrics recommends the age of three years as being appropriate for the initial dental referral (American Academy of Pediatrics 1996). The American Academy of Pediatric Dentistry recommends that the initial visit, for an oral evaluation, should occur within 6 months of the eruption of the first tooth and not later than the age of one year (American Academy of Pediatric Dentistry 1994).

23

Review of the Literature

Despite increased preventive measures being implemented for children who have experienced early childhood caries and have had treatment under general anesthesia, they are still highly predisposed to greater caries incidence in later years. These findings strongly suggest that more aggressive preventive therapies may be required to prevent the future development of carious lesions in children who have experienced early childhood caries (Almeida et al 2000),

It is sad to note that the cariogenic challenge and harmful habits of certain children may be so extreme that they can over-whelm even extraordinary preventive efforts (Tinanoffetall999). 2.12 Fluorides The benefits of water fluoridation and postnatal fluoride supplementation in the primary dentition have been extensively written about and are well known (Ismail 1994); however, there is minimal information on the cariostatic effects of topical fluorides in the early primary dentition which is disappointing because Fluoride appears to be one of the most effective methods of caries prevention available for children with ECC (Weinstein et al 1994).

The cariostatic effects of fluoride are probably due to topical effects, rather than, as originally thought, decreasing enamel solubility through the incorporation of fluoride into the developing enamel from systemic sources (Fejerskov and Clarkson 1996). The topical effects include changes in the mineral phases (Fejerskov and Clarkson 1996), as well as the modulation of metabolic effects on Mutans streptococci and other bacteria in dental plaque (Hamilton and Bowden 1996). Low

24

Review of the Literature

concentrations of fluoride can affect the demineralization process in a carious lesion by decreasing the rate of subsurface dissolution and enhancing the deposition of fluoroxyapatite in the surface zone (Larsen and Bruun 1994). Fluoride inhibits early white spot lesions (Larsen 1989) and "healed" lesions are more resistant to subsequent demineralization (Silverstone et al 1981).

Fluoride has been shown to act as a direct inhibitor of enzymes, which affects the metabolic activity of Mutans streptococci in dental plaque (Marquis 1995). It also reduces the acid tolerance of Mutans streptococci (Sturr and Marquis 1990). In the acidic conditions of cariogenic plaque, complete arrest of glycolysis by intact cells of Mutans streptococci may occur at fluoride at levels as low as 0.1 mmol (Marquis 1995).

2.13 Nutrition, tooth development, and dental caries Cross-sectional studies have shown that in malnourished children the pattern of dental caries development as a function of age is significantly altered as a result of a delayed eruption and exfoliation of the primary teeth. Alvarez (1995) reported that one mild to moderate malnutrition episode occurring during the first year of life is associated with increased caries activity in both the primary and permanent teeth many years later.

2.14 Growth It has been established that comprehensive dental rehabilitation results in a catch-up growth, such that the children with a history of nursing caries no longer

25

Review of the Literature

differ in the percentile weights from their peers (Acs et al 1999), Severe caries not only affects the weight of children but also the quality of life of the affected individuals (Low et al 1999).

2.15 Risk factors in early childhood caries In ECC, risk factors that are unique to the children in the susceptible age group may also exist. These include early colonization with Mutans streptococci, frequent nursing, and the eating of snacks, and other factors that create an environment that encourages the growth and dominance of Mutans streptococci in dental plaque.

A high percentage of children with early childhood caries have a history of medical conditions in infancy (van Everdingen et al 1996). Chronically sick children have an increased risk of developing dental caries which is likely to be related to the predisposition of these children to enamel hypoplasia (Seow 1991, Pascoe and Seow 1994). There is also the possibility that many chronically sick infants are comforted with bottles containing sweetened fluids., or have frequent ingestions of sucrose sweetened medications (Feigal and Jensen 1982, Hallett et al 1992), The sucrose may well make the medication more acceptable to the child but the primary function is to preserve the medication. Children on long-term medications such as antihistamines (Ryberg et al 1991, Lawrence et al 1995), which inherably have a xerostomic side effect, may be further predisposed to caries; however, the contribution of this risk factor to ECC remains unclear.

Chronic malnutrition has been associated with increased caries rates (Alvarez et al

26

Review of the Literature

1991, Johansson et al 1992), but the mechanisms involved have not been extensively evaluated. The effects may be mediated through alterations of salivary composition and volume (Johnson 1993). Malnutrition may also increase caries susceptibility by decreasing tooth resistance through the formation of enamel defects, such as linear enamel hypoplasia (Jelliffe and Jelliffe 1971, Seow et al 1996, Seow 1997), or perhaps by increasing enamel solubility (Aponte-Merced and Navia 1980). Further research may well clarify the situation. Maternal smoking is a significant factor to be considered as an additional risk indicator beyond social class when predicting caries risk in young children. Recently, the prevalence of maternal, rather than paternal, smoking was stated to be significantly related to caries and substantially attenuated social class differences (Williams et al 2000).

2.16 Surveys in Kerala Caries prevalence studies for children aged five to six years have been conducted in Kerala, by individual investigators, using different diagnostic criteria and a variety of analytical and reporting techniques. Comparison between these studies, hence, is invalid. A National Epidemiological Study was conducted by Tewari and co-workers (Gupta 1987) from the Post Graduate Institute for Medical Education and Research, Chandigarh, in Kerala, for children aged between five to six years. This study used standardized recording methods and the WHO deft index. According to this study, in the age group of five to six years in Kerala, the average dmft was 1.9 in the urban population and 1.6 in the rural population (Gupta 1987).

27

Review of the Literature

This was the lowest caries experience observed among the southern Indian states of Andhra Pradesh, Tamilnadu, Karnataka and Kerala, No published studies have focused on the age group below four years.

2.17 Summary Early childhood caries has a complex etiology and the predisposing factors are unclear. Cariogenic micro-organisms, fermentable carbohydrates, susceptible teeth and the host are the various etiological factors involved. Mutans streptococci are transmitted from the primary caregiver to the child. ECC appears in the teeth in the order of their eruption, characterized by first affecting the primary maxillary teeth, then the incisors, followed by the first molars, canines, and finally the second molars. Children who experience ECC have a greater chance of developing carious lesions in the future. Therefore, aggressive preventive strategies should aim at education of the primary caregivers about the etiology of the condition and concerted efforts should be made to stress the importance of primary preventive measures to combat ECC.

28

Materials and Methods

Chapter 3

Materials and Methods

29

Materials and Methods

3A Target Population The pre-school children aged below four years In Kerala attend both government sponsored and privately run Day Care Centres. These Day Care Centres serve as a preparatory stage for children before they enter into primary school, which begins at the age of five years. These centres were chosen to be the sources for data collection because the target population for this study was below the age of four years and the majority of preschool children attend these Day Care Centres.

3.2 Sampling The Day Care Centres in Kerala are divided into district, block and panchayat levels. The state divisional office was requested to select Day Care Centres representing the various districts in Kerala. As a result, thirteen Day Care Centres were identified. Regular attendees below the age of four years who attended the selected Day Care Centres were invited to participate in the study.

3.2.1 Sample size determination The minimum sample size was predicted based on an error of tolerance equating to a confidence interval of 95%. The sample size was dependant upon the disease prevalence and the statistical prevalence and the statistical power required. The formula used was SE =

/P (1-P)/N where SE is the standard deviation, P is the

disease prevalence and N is the sample size needed. The predicted sample size was thus 369 children.

30

Materials and Methods

3.2.2 Sampling method and recruitment The personnel in charge of the selected Day Care Centres were notified of the survey and they in turn informed the parents and arranged for the children aged less than four years of age to join the survey. Informed written consent (Appendix LA) was obtained from the parent or caregiver before the clinical examination.

3.3 Components of the investigation 3.3.1 Questionnaire A specially structured questionnaire (Appendix IB) was completed by interviewing the parent or caregiver. The questionnaire collected data on the oral hygiene practices of the children and their caregivers, feeding patterns, sugar consumption, dental visit pattern, attitude and oral health knowledge of the caregivers along with details of their educational and socio-economic backgrounds. Since the study was conducted in Kerala, the questionnaire was translated to the local Malayalam language and then back translated into English to test the accuracy of the translation. The interviewers were pre-trained to interview the caregivers as a means of completing the questionnaire.

3.3.2 Clinical Examination A sole examiner performed the clinical examination of the child that followed the interview with the caregiver. Procedure The clinical examination was carried out with the infants having their heads placed on the examiner's lap. A seated position was preferred for the older

31

Materials and Methods

armamentarium for examination included a disposable mirror, tongue spatula and a torch. Only visually observed cavitations were counted as carious. The caries diagnosis was thus based on a modified version of WHO criteria (1997). Stained and doubtful fissures were recorded as sound. A modified version of the Simplified Oral Hygiene Index (Appendix 1C) was used to record plaque, the criteria being visible plaque on the labial surfaces of two or more maxillary primary incisor teeth,

3.4 Examiner calibration The intra-exarniner reliability was tested using Cohen's Kappa coefficients (Fleiss et al 1979), by, the administrative assistant, randomly selecting ten percent of the sample for re-examination. The Kappa coefficient scores were 0.96 and 1.00 for caries and plaque accumulation.

3.5 Data processing and analysis The data collected through the structured questionnaires were entered into a computer database in the program Microsoft Access. The GraphPad Instat version 3.00 for Windows 95, GraphPad software, San Diego, California, U.S.A., was used for statistical analysis. The Fisher's exact test and the Chi-square test were used when appropriate with the probability level of 0.05 set to be highly statistically significant. Two-sided P value was calculated for each statistical test along with the relative risk and the 95% confidence interval using the approximation of Katz.

32

Results

Chapter 4

Results

33

Results

4.1 Results The findings of this investigation are presented and discussed in Paper I and Paper II, which are in Chapter 5 and Chapter 6 respectively. All of the raw data and the statistical printout are displayed in Appendices II and III.

34

Paper I

Chapter 5

Paper I Infant feeding and oral care practices of pre-school children and their caregivers' dental knowledge and attitudes in Kerala, south-western India

35

Paper I

Infant feeding and oral care practices of pre-school children and their caregivers' dental knowledge and attitudes in Kerala, southwestern India Jose B, King NM

Paediatric Dentistry and Orthodontics, Faculty of Dentistry, The University of Hong Kong, Hong Kong S AR

To be submitted to The Journal of Clinical Pediatric Dentistry

Correspond to:

Professor Nigel King, Paediatric Dentistry and Orthodontics, 2/F, Prince Philip Dental Hospital, 34 Hospital Road, Sai Ying Pun, Hong Kong SAR.

36

Paper I

Abstract The literature does not contain any data on the feeding habits of children aged below 4 years of age and the dental knowledge and attitudes of their caregivers in Kerala, India. Therefore, this study was carried out to gather information on the feeding habits and oral hygiene practices of preschool children along with oral health related knowledge and attitudes of their caregivers. Data from a random sample of 530 children (mean age = 2.53 ± 0.96 years), 278 boys and 252 girls were collected from thirteen Day Care Centers by interviewing their caregivers so as to complete a structured questionnaire. The children who were breast-fed were 99.1% (525/530); of whom 171 were still being breast-fed. The mean age of weaning was 9.22 ± 5.00 months.

Milk was taken from a feeding bottle by 109 children; of these children 75.2% (82/109) received milk to which sugar was frequently added. Forty percent (44/109) of the children went to sleep with the feeding bottle prior to sleep. A feeding bottle was still being used by 26.6% (29/109) of the children. Nonnutritive sucking habits were practiced by 8.1% (43/530) of the children.

Snacking habits were reported in 83% (426/513) of the dentate children. Oral cleansing habits were practiced by 90.2% (478/530) and only 1.1% (6/530) of caregivers started to clean their child's mouth immediately after birth. Toothbrushing was reported for 58.1% (298/513) of the dentate children of which 38.9% brushed their teeth themselves. Toothpaste use was reported used by 39.3% (117/298) of the children. Primary teeth were considered to be important by

37

Paper I

63.6% (337/530) of the caregivers. Almost all of the caregivers 95.9% (508/530) would have liked to have received more oral health related information.

38

Paper I

Introduction As there are no data available on the oral health and feeding practices of preschool children and their caregivers' oral health related knowledge and oral hygiene practices in Kerala, southwest India, there was a need for an investigation to gather information on the feeding habits and oral hygiene practices of these children. Dietary habits are formulated early in life, and a mother's choice of foods is a strong determinant of her offspring's dietary habits (Arbeit et al 1988). Furthermore, dietary patterns seem to be established early in life (Rossow et al 1990). The early diet of an individual is a determinant of the later dietary habits. In addition, during the first years of life, the dietary habits of mothers are associated with those of their offspring. (Ismail 1998).

Sugar consumption is of particular importance to dental caries, and early consumption of sugary foods contributes to a higher consumption of sugar containing items later in life (Ismail 1998). Mothers in some developing countries have a tendency to provide, early in life, sugary products to their children and to use sugar as a reward (Stacey and Wright 1991). Children, who have caries in their primary teeth in infancy, or as toddlers, tend to develop additional carious lesions in their primary teeth (Hallonsten et al 1995, O'Sullivan and TinanofF 1996) and are more likely to develop caries in their permanent teeth (Kaste et al 1992). An understanding of the oral health related behavior and feeding habits of caregivers would be beneficial for the development of preventive strategies to benefit preschool children especially in Kerala.

39

Paper I

The state of Kerala in south-western India, with a population of 31 million, is noted for its social development such as high adult literacy rate, high life expectancy, low infant mortality rate, and low birth rate, when compared to other states in India (Ramachandran 1997). The majority of preschool children attend either a private or a government managed Day Care Center. Therefore, it was decided to conduct a survey of preschool children aged below 4 years of age who attended private or government managed Day Care Centers.

Materials and Methods Thirteen Day Care Centers were randomly selected on the investigator's behalf The survey was scheduled to last for a six-week period and the preschool children attending these centers were invited to participate in the survey. Prior to the investigation commencing, the parents were notified about the nature of the interview and examination with the help of pamphlets and notices. Written consent was obtained from all of the caregivers who agreed to participate in the investigation. A structured questionnaire to gather data on infant feeding and oral hygiene habits together with the responses from the caregivers on their oral health related knowledge and oral hygiene practices, was completed by a trained nurse who performed the interviews with the caregivers. The structured questionnaire was pre-coded and the use of interviewer ensured standard interpretation of the questions.

An oral examination followed the interview, which was performed by a sole examiner using a torch, wooden spatula and a disposable mouth mirror. Modified

40

Paper I

WHO criteria (1997) for dental caries was used to diagnose dentinal caries. GraphPad InStat version 3.00 for Windows 95, GraphPad software, San Diego, California (www.graphpad.com) was used to perform the statistical analysis of the data.

Results Sample A total of 530 children constituted the sample of which 278 were boys and 252, girls. The mean age was 2.53 ± 0.96 years (Table 1).

Feeding habits Although the major food consumed by the children at the time of the investigation was normal adult food (Table 2), the majority of the children 99.1% (525/530) were, or had been breast-fed (Table 3). By the age of 24 months, 55.2% (290/525) of the children had stopped breast-feeding. Children who were still being breastfed were 32.6% (171/525). Exclusive breast-feeding had been practiced by 4.8% (25/525) of the children, while breast-feeding on demand accounted for 517 children (98.5%).

Feeding bottle usage (Table 3) to take milk was practiced by 20.6% (109/530) of the children; of these 109 children, 75.2% (82/109) had sugar added to their bottle every time they fed. Non-milk products were taken from a bottle by 13.8% (15/109) of the infants. These drinks were taken more than six times a day by 20% (3/15) of the infants. A milk bottle was given, at naptime, to 44% (48/109) of the

41

Paper I

infants. For these children, milk was the major ingredient in the bottle for 72.9% (35/48) of them. The milk bottle was used at bedtime by 40.4% (44/109) of the children, and 61.4% (27/44) of the children had milk inside the bottle. The bedtime bottle was taken away after the child had fallen asleep in 52.3% (23/44) of the cases. The milk bottle was still being used by 26.6% (29/109) of the infants.

Weaning The mean age of weaning of the children who had been weaned was 9.22 ± 5.00 months. Non-dairy products, as two daily major meals, were given to 84.9% (450/530) of the children.

Non-nutritive sucking habits Digit sucking habits were prevalent in 8.1% (43/530) of the children and 16 of the children still had a digit sucking habit; that means that 37.2% (16/43), while the remaining 62.8% (27/43) stopped the habit by themselves.

Oral hygiene habits Oral cleansing habits were practiced by 90.2% (478/530) of the children; and only 1.3% (6/478) had reportedly started the practice soon after birth.

Tooth-brushing habits Tooth-brushing was practiced by 58.1% (298/513) of the dentate children. Adults brushed the teeth of 61.1% (182/298) of the children. Children performed the tooth-brushing exclusively in 38.9% (116/298) of the sample, while adults

42

Paper I

supervised the tooth-brushing for 65.5% (76/116) of the children who brushed their teeth themselves. A twice a day tooth-brushing habit was reported for 42.6% (127/298) of the children. By the age of two years 68% (203/298) of the children had begun tooth-brushing and toothpaste was used by 49.2% (117/298) of the children.

Confectionery consumption Snacking habits were prevalent in 83% (426/513) of the dentate children. Sweets were given as rewards to 83.8% (430/513) of the children.

Attitudes, knowledge, and beliefs of parents/caregivers The mothers/caregivers of 3.4% of the children (18/530) were unable to reply to the question about the age at which their child's first tooth erupted. However, it was encouraging that 78.5% (416/530) of the caregivers had some knowledge of the etiological factors responsible for dental caries, with the majority replying that sugar consumption is the main cause of dental caries. However, 10.5% (79/751) of the responders were "not sure" when asked the question on ways to prevent dental caries.

The mothers/caregivers of 20% (106/530) of the children thought that the oral cavity of an infant should be cleaned from birth. Primary teeth were considered to be unimportant by 28.1% (149/530) of the respondents and 18% (129/716) of the respondent's responses indicated that they were unsure of the function of the primary teeth. Only 21.9% (116/530) of the caregivers felt that the primary teeth

43

Paper I

should be restored when they are carious. The age of the child at the time of the first dental visit should be around the age of one year according to only 18.7% (99/530) of the caregivers.

The mothers/caregivers who never visited a dentist were 47% (249/530). It was reported by 24.7% (131/513) of the mothers/caregivers that they did not know the dental condition of their children. The mothers/caregivers who reported that their own oral and dental conditions were above average were 44% (230/530).

Of the 464 mothers that were interviewed, 79.8% and 81.1% reportedly had not received any oral health messages during the antenatal and postnatal period respectively. The majority of the caregivers (95.6%) expressed a wish to receive more information about oral health.

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Paper I

Table 1. The age distribution of 530 children from Kerala, south-western India. Age in months

Frequency n

0-11

41

7.74

12-23

116

21.89

24-35

143

26.98

36-48

230

43.39

Table 2. Major food type for the 530 children at the time of the investigation. Food source Baby food

Infant food

Adult food

n

%

n

%

n

%

77

14.53

52

9.81

401

75.66

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Paper I

Table 3, Breast-feeding habit In the group of 530 children from Kerala, Infant-feeding techniques Breast-feeding

Milk bottle use

n

%

n

%

525

99.05

109

20.57

46

Paper I

Discussion Infant feeding Breast-feeding is widely practiced by the mothers in Kerala; the majority being breast-fed on demand. Interestingly 97.8% (220/225) of the children with dental caries were breast-fed on demand. The mean age for weaning was 9.22±5 months, which was slightly later than the stated ideal range, which is approximately 6 months (Eronat and Eden 1992). The WHO/UNICEF (2000) published a joint statement entitled "Ten Steps to Successful Breast-feeding", in which they recommend that every facility providing maternity services and care for newborn infants should have a written breast-feeding policy that is routinely communicated to all health care staff to ensure commitment and consistency. The statement also provided information for dissemination to all pregnant women on the benefits of breast-feeding their children. In addition, it provided guidelines to support mothers during the postnatal period on how to initiate and maintain breast-feeding. Although this study showed that 99.1% (525/530) of the mothers practiced breast-feeding, this may well be out of necessity rather than being based on the mother's knowledge of the benefits of this practice.

Of the breast-fed dentate children, 42.9% (220/513) had dental caries. The breast-feeding was on demand for 98.4% (517/525) of the children. Prolonged breast-feeding, it is said, can have an adverse effect on dental health (Eronat and Eden 1992). However, the relationship between breast-feeding and dental caries is complex and compounded by many variables such as streptococcal infection (Mattee et al 1992), enamel hypoplasia (Seow 1991), the intake of sugars

47

Paper I

(Rossow et al 1990), as well as social variables such as parental education and socioeconomic status (Roberts 1994). An investigation of the role of human breast milk in caries development (Erickson and Mazhari 1999) concluded that human breast milk has non-cariogenic properties. The present findings and the published data seems to suggest that it is not the breast milk that is responsible for the dental caries but one or several of the associated environmental factors or habits.

Children breast-fed beyond the age of two years have been shown to have a higher prevalence of caries affecting the molars as well as the incisors (Dini et al 2000). Another study reported that children who are breast-fed for more than 9 months are likely to harbor strains of Mutans streptococci common to their mothers and so they experience more dental caries at three years of age compared with children who are breast-fed for less than 9 months (Li et al 2000). In this study, 140 of the children, who were three years and older, and had been breast-fed for more than 9 months, had dental caries. Breast-feeding beyond the age of three years was practiced by 2.1% of the infants. This habit was probably due to the insistence of the children and the ignorance of the mothers. The factors related to breast-feeding are numerous and because of the apparent association between the length of time a mother breast-feeds and extent of dental caries need to be carefully considered when formulating infant feeding policies and health promotion initiatives so as not to produce misleading, ambiguous or confusing statements.

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Paper I

During the last two decades, nursing mothers, who are spending increasing amounts of time at work have elected to consider bottle-feeding. The child is then taken care of by a maid, grandparent, or a close relative. Formula milk is thus a simple option adopted by many mothers rather than expressing their own breast milk. Mothers were the major caregivers of 70% of the children. Formula milk was taken, from the bottle, by 109 of the children; sadly, 82 children had sugar added to the bottle every time they used the bottle. This is probably based on the misguided belief that this practice is beneficial and necessary. Mothers, in some developing countries, have a tendency to provide sugary products as snacks later in their child's life and to use sugar as a reward (Stacey and Wright 1991). Night-time use of the bottle was reported for 40.4% (44/109) of the infants; of these 52.3% (23/44) had the bottle taken away after falling asleep. Falling asleep with the bottle, in the mouth, is said to be a determining factor in the development of dental caries (Oulis et al 1999). In this study, only 4 children retained the bottle until the next morning.

Non-milk products such as boiled water and congee water (rice water) were commonly consumed from a feeding bottle by the children in this study, and of the 44 children who drank these non-milk products, 11.4% drank fruit juice. Snacking habits were common amongst the dentate children (83.1%) with the preferred foods being biscuits or cakes (69.4%), since they are readily available, easy to obtain and convenient. Early diet is a determinant of later dietary habits; in addition, the dietary habits of mothers are associated with those of their offspring, at least during the first years of life (Ismail 1998). So patterns of sugar

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Paper I

consumption are of particular importance in the development of dental caries because consumption of sugary foods, early in life, contributes to a higher consumption of sugary items later in life (Ismail 1998).

Non-nutritive sucking is regarded to be a normal part of growth and development; and one study found that 70% of children had some history of a non-nutritive sucking habit (Ravn 1974). By contrast only 8.11% of the children in this study had non-nutritive sucking habits. This low prevalence may, at least in part, be due to the fact that the data were gathered retrospectively. Consistent with an earlier study in Hong Kong (Chan 1999), the non-nutritive sucking habits of the Indian children were found to be discontinued by the age of 3 years.

Oral hygiene Ninety percent of the caregivers cleansed their children's mouths, but only 1.3% of them had started the cleansing soon after birth. Studies on the age of initiation of tooth-brushing have demonstrated few associations with the caries status of the children being studied (Serwint et al 1993). In this study, tooth-brushing was practiced by 56.2% of the children, 68.1% of which started to brush their teeth before the age of two years. Several studies have shown that increased toothbrushing frequency and parental involvement decrease carious lesions on the smooth surfaces of the teeth (Wendt et al 1994). In this study, tooth-brushing with a frequency of twice a day was reported for 42.6% of the children and 38.9% of these children cleaned their teeth by themselves. This may be due to the notion of the caregivers that the children had the ability to brush effectively.

SO

Paper I

In this study, out of the cohort of 225 children who had caries, 170 of the children had a tooth-brushing habit; 43 brushed by themselves whilst an adult aided the other 127. The reason for the adult assistance may simply be due to the fact that all of the primary teeth had erupted or an awareness that their child had carious teeth. Toothpaste was used by 39.3% of the children, who reportedly had a tooth-brushing habit. Sixty percent of these children used the same fluoridated toothpaste that was being used by the adults in the family.

Knowledge, attitudes, and beliefs

qfmothers/caregivers

The knowledge of a mother, about her own dental status, self-care practices, about the use of the dental care system, and about the proper care of her child are all important behavioral concerns. Feeding practices after a baby is bom are generally the product of cultural and family influences (Murphy 1984). In Kerala, it is mainly private dentists who provide the dental care services because government run facilities are few in number. The mothers acknowledged that the majority of hospitals did not provide any antenatal and/or postnatal oral health related information. Encouragingly, almost all of the mothers agreed that they would liked to have received more information about infant oral health, even if this had only been stimulated by their participation in this investigation.

The caregivers* oral health care knowledge was illustrated by most of the respondents (85%) indicating that they did know how to prevent dental caries; while more than half (58.5%) of the caregivers stated that there was no reason to restore carious primary teeth. Remarkably, only five children in the study had

51

Paper I

attended a dentist for restoration of their carious teeth. Only 19% of the caregivers indicated that the first dental visit should be around the age of one year. Disappointingly, the majority of the caregivers (76%) indicated that a dental visit is necessary only if their child is suffering from dental pain. In this study, 43.9% of the children who were found to have caries tallied well with the responses of their mothers/caregivers who indicated that their children had poor oral status. Of the 131 caregivers who had indicated a poor oral condition in their children, the main caregiver for 89.3% was the mother while 52% of the caregivers had visited a dentist.

Medical professionals have a greater opportunity to interact with expectant mothers; consequently, if educated, they can be an important source of oral health care information for the mothers to be. Since, currently there is no formal delivery of dental health messages on infant oral health for pregnant and nursing mothers in Kerala; it would be beneficial if a policy could be developed to target expectant mothers to make them aware of the importance of infant oral health, ensuring that this information is simple and easy for them to understand.

52

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References 1. Arbeit ML, Nicklas TA, Frank GC, Webber LS, Miner MH, Berenson GS. Caffeine intakes of children from a biracial population: The Bogalusa Heart Study. JAm DietAssoc 88: 466-471, 1988.

2. Chan CLS. Caries prevalence and feeding habits of toddlers in Hong Kong. MDS Thesis, Faculty of Dentistry, University of Hong Kong, 1999.

3. Dini EL, Holt RD, Bedi R. Caries and its association with infant feeding and oral health related behaviors in 3-4 year-old Brazilian children. Comm Dent Oral Epidemiol 28: 241-248, 2000.

4. Erickson PR, Mazhari E. Investigation of the role of human breast milk in caries development. Pediatr Dent 21: 86-90, 1999.

5. Eronat S, Eden E. A comparative study of some influencing factors of rampant or nursing caries in pre-school children. JClin Pediatr Dent 16: 275-279, 1992.

6. Hallonsten AL, Wendt LK, Majare I, Birkhed D, Hakansson C, Lindwall AM et al. Dental caries and prolonged breast-feeding in 18 months old Swedish children. IntJPaediatr Dent 5: 149-155, 1995.

7. Ismail AI. The role of early dietary habits in dental caries development. Spec Care Dent 18 (1): 40-45, 1998.

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8. Kaste LM, Marianos D, Chang R, Phipps KR. The assessment of nursing caries and its relationship to high caries in the permanent dentition. J Public Health Dent 52: 64-68, 1992.

9. Li Y, Wang W, Caufield PW. The Fidelity of the Mutans Streptococci Transmission and Caries Status Correlate with Breast-Feeding. Caries Res 34: 2: 123-132, 2000.

lO.Mattee MEN, Mikx FHM, Maselle SYM, van Palenstein Helderman WH. Rampant caries and linear hypoplasia. Caries Res 26: 205-208, 1992.

11.Murphy PE. Analyzing markets. In: Frederiksen LW, Solomon LJ, Brehony KA, editors. Marketing health behavior. Principles,

techniques, and

applications. New York; Plenum: 41-58, 1984.

12.0'Sullivan DM, TinanofFN. The association of early dental caries patterns in pre-school children with caries incidence. J Public Health Dent 56: 81-83,

1996.

IS.Oulis CJ, Berdouses ED, Vadiakas G, Lygidakis NA. Feeding practices of Greek children with and without nursing caries. Pediatr Dent 21: 409-416,

1999.

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14. Ramachandran VK. On Kerala's development achievements. Dreze J, Sen A, editors. Indian Development: 205-236, 1997.

15. Ravn JJ. The prevalence of dummy and finger sucking habits in Copenhagen children until the age of 3 years. Comm Dent Oral Epidemiol 2: 316-322,

1974.

16. Roberts GJ. Patterns of breast and bottle feeding and their association with dental caries in 1 to 4 year-old children. A case control study with nursing caries. Comm Dent Health 11: 38-41, 1994.

17. Rossow I, Kjaeraes U, Hoist D. Patterns of sugar consumption in early childhood. Comm Dent Oral Epidemiol 18: 12-16, 1990.

18. Seow WK. Enamel hypoplasia in the primary dentition: a review. J Dent Child 58:441-452,1991.

19. Schroeder U, Widenheim J, Peyron M, Hagg E. Prediction of caries in 1 Vfc year old children. SwedDentJ\%\ 95-104, 1994.

20. Serwint JR, Mungo R, Negrete VF, Duggan AK, Korsch BM. Child rearing practices and nursing caries. Pediatr 92: 233-237, 1993.

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21. Stacey MA, Wright FAC. Diet and feeding pattern in high-risk preschool childrea AustDentJ36: 421-427, 1991.

22.Wendt LK, Hallonsten AL, Koch G, Birkhed D. Oral hygiene in relation to caries development and immigrant status in infants and toddlers, Scand J Dent Res 102: 269-273, 1994.

23. WHO. Oral Health Surveys-basic methods. Geneva, WHO, 1997.

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Chapter 6

Paper H Early childhood caries and possible risk indicators in pre-school children in Kerala, India

57

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Early childhood caries and possible risk indicators in pre-school children in Kerala, India Jose B, King NM Paediatric Dentistry and Orthodontics, Faculty of Dentistry, The University of Hong Kong, Hong Kong SAR

Submitted to Pediatric Dentistry,

Journal of American Academy of Pediatric Dentistry

Correspond to:

Professor Nigel King, Paediatric Dentistry and Orthodontics, 2/F, Prince Philip Dental Hospital, 34 Hospital Road, Sai Ying Pun, Hong Kong SAR.

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Abstract No data are available on possible risk indicators or the prevalence of caries, for preschool children under 4 years of age in Kerala, southern India. Therefore, the aims of this study were to gather data on caries frequency and distribution; then to determine any possible associations with feeding habits and oral health care practices. A sample of 530 children, aged from 8 to 48 months (mean=2.53 + 0.96 years), who attended thirteen Day Care Centres were clinically examined for caries using a disposable mouth mirror, tongue spatula and a torch. There were 513 dentate children. The caregiver of each child then completed, by interview, a structured questionnaire. Amongst the group of 252 girls and 278 boys, the dmft was 1.84 + 2.87 with 56.1% (288/513) of the children being caries free. Fifty-nine (11.5%) were considered to have early childhood caries (ECC) based on the criteria that all four maxillary incisor teeth exhibited caries. Breast-feeding was practiced by 99.1% of the mothers and 4.7% (25) did so exclusively. Generally, breast-feeding was on demand. Statistically significant correlations were found between caries and the child's dental condition, as perceived by the mother or caregiver (p< 0,0001), the dental status of the caregiver (p=0.0417), consumption of snacks (p=0.0177), giving of sweets as a reward (p< 0.0001), cleaning of the child's mouth (p< 0.0001), oral hygiene status of the child (p< 0.0001) and low socio-economic status (p< 0.0001).

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Introduction Early childhood caries (ECC) is a serious socio-behavioural and dental problem that afflicts infants and toddlers (Tsubouchi et al 1995, Douglass et al 2001). The appearance of a single carious lesion, on any tooth surface in an infant or toddler, must be considered a serious health problem and ECC needs to be defined as the occurrence of any sign of any sign of dental caries on any tooth surface during the first three years of life (Ismail 1998). The first sign of dental caries in infants who develop ECC is the appearance of white demineralisation areas in the cervical regions of the maxillary anterior teeth. This serves to indicate a high caries activity in children (Steiner et al 1992). Early childhood caries has a complex aetiology and there are still several unexplained interactions among factors such as infection with Mutans streptococci, education status of mothers, dental knowledge, stress, self-esteem, social status, family structure, and the use of baby bottles, or nursing on demand (Litt et al 1995).

Dental caries is a multifactorial disease. These factors include susceptible tooth and host, fermentable carbohydrates in the diet, cariogenic micro-organisms and time (Tanzer 1989). Children with caries in the primary dentition have a greater chance of developing caries in the permanent dentition than children who are caries free in the primary dentition (Kaste et al 1992). Initial primary incisor caries before four years of age is a risk factor for future dental caries (Al-Shalan et al 1997), Therefore, caries preventive initiatives can be planned and taken for preschool children who are identified as being at risk.

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India, with a population that exceeded one billion in 2001, is the second most populous nation in the world. Eighty percent of the population lives in rural areas. The oral health care system consists of medical research institutes with departments of dentistry, more than 120 dental schools spread throughout its5 27 states, medical colleges with departments of dentistry in cities and district headquarters, and private dental clinics. However, the majority of dental care is provided in private dental clinics.

Kerala is a southwestern state with an area of 39,000 km2 and a population of 31 million. The state has universal primary education, near total literacy; high life expectancy, low birth rate and low infant mortality rate comparable to developed countries (Ramachandran 1997). Pre-school children attend both government sponsored and private Day Care Centres. The drinking water, which is not fluoridated, is supplied through a public water supply. The other main sources for drinking water are from wells and tube-wells.

Currently, no data are available on the caries prevalence or possible etiological factors for pre-school children in Kerala, southwestern India. Therefore, an investigation to gather information on the caries prevalence and any possible associations with feeding habits and oral care practices was undertaken.

Materials and Methods The sample consisted of children attending both government sponsored and private Day Care Centres who were below the age of 48 months. Thirteen Day

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Care Centres were randomly selected, by an administrative assistance, for inclusion in the sample. The caregivers of the children attending the above centres were informed of the nature of the investigation through pamphlets and notices. Informed consent was obtained prior to enrolment in the study. An interview, with the caregiver, was conducted by a trained nurse using a structured questionnaire, which included questions about the infant's dietary habits, feeding habits, oral hygiene habits along with the oral health knowledge and attitudes of the caregiver. The interview was followed by an oral examination by a sole examiner using a disposable mirror, wooden tongue spatula and a torch. Radiographs were not taken due to practical reasons. The modified WHO criteria (1997) for caries were used to diagnose dentinal caries. No attempt was made to use a dental probe to confirm cavitation of the lesions due to the young nature of the children.

Intra-examiner calibration was carried out using Cohen's Kappa coefficients (Fleiss et al 1979) by, the administrative assistant, randomly selecting 10% of the sample for re-examination.

Statistical analysis GraphPad InStat version 3.00 for Windows 95, GraphPad software, San Diego, California (www.graphpad.com) was used for the statistical analysis. Tests of the association between caries status and single variables were carried out using Chisquare test and Fisher's exact test. The Fisher's exact test and the Chi-square test were used with the probability level of 0.05 set to be highly

statistically

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significant. Two-sided P value was calculated for each statistical test along with the relative risk and the 95% confidence interval using the approximation of Katz.

Results Determination of the intra-exarniner variability was done by randomly selecting ten percent of the sample for re-examination and the Cohen's Kappa value for intra-examiner variability was 0.96.

Caries prevalence The caries prevalence in the sample of 278 boys and 252 girls, with a mean age of 2.53 ± 0.96 years, was 43.9%. The caries group included 125 boys and 100 girls. There was no statistically significant difference in the caries prevalence between boys and girls (p=0.3147). Maxillary central incisors were the teeth most often involved by caries. Of the 932 teeth with caries, only 0.43% (n=4) was restored. The earliest caries experience in the sample was for an eleven months old child (Fig.l and Fig. 2). Fifty-nine (11.1%) of the infants were considered to have early childhood caries (ECC), based on the criteria that all four maxillary incisor teeth exhibited caries.

Feeding habits In the sample of 530 children, 99.1% (525/530) were breast fed, and 55.2% (290/525) of the children were breast-fed up to two years of age. Breast-feeding, on demand, accounted for 517 children (98.5%), Breast-feeding was still being practiced by 32.6% of the children (171/525). Formula milk was given to 108

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(20.4%) of the children in addition to breast milk. Traditional preparations along with breast milk were given to 392 children (73.9%). Twenty-five (4.8%) of the children were exclusively breast-fed.

Nursing bottle was used by only 20.6% (109/530) of the infants. Sugar was regularly added to the feeding bottle of 75.2% (82/109) of the children. Bedtime use of a baby-feeding bottle occurred for 40.4% (44/109) of the children, and 61.4% (27/44) of the children had milk inside the bottle. The bedtime bottle was taken away after the child fell asleep in 52.3% (23/44) of the cases. The mean age of weaning for the children who had been weaned was 9.22 + 5.00 months.

Consumption of snacks Snacks were consumed by 83% (426/513) of the dentate children (Table 1). Sweets were given as rewards to 83.8% (430/513) of the children (Table 2). Statistically significant positive correlations were found between caries and consumption of snacks (p=O.Q177), and the giving of sweets as a reward (p< 0.0001). Non-nutritive digit sucking habits were prevalent in 8.11% (43/530) of the children and 16 (37.2%) of the children still continued the habit.

Oral hygiene and oral hygiene habits The caregivers cleaned the mouths of 90% (478/530) of the children. However, only six reported that they started cleaning the child's mouth soon after birth. A statistically significant association was found between cleaning of the child's mouth by the caregiver and caries in the child (pO.OQQl).

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A tooth-brushing habit was reported in 58.1% (298/513) of the children. The frequency of tooth-brushing was observed twice daily for 42.6% (127/298), while an adult brushed the teeth in 61.1% (182/298) of the children. The remaining brushed their teeth themselves (Table 3). Toothpaste was used by 39.3%(117/298) of the children who brushed their teeth (Table 4). A statistically significant association was found between caries and the use of toothpaste (p=0.0005). Toothpaste usage by the child brushing by themselves was 61.5% (72/117), of which, 23 (31.9%) had caries (Table 5). A statistically significant association was found between caries and the toothpaste use by the child who brushed his/her own teeth (p=0.0010).

Plaque accumulation was seen in 63.9% (328/513) of the children, and 169 children from this group had caries. A statistically significant association was found between caries and plaque accumulation (p< 0.0001).

Socioeconomic, education status of the parents and health status of the children All of the children were born and raised in Kerala. The higher the income of the parents, the less the caries experienced by the child. Basically, the parents with the higher educational level had children with the lowest caries. Only 11 children out of 31 children whose fathers' had tertiary education had caries when compared to 161 out of 374 fathers who had high school education (Table 6). Similarly, 21 children out of 56 mothers, who had tertiary education, had caries when compared to 125 children with caries out of the 285 mothers with high school education (Table 7). Of the 34 children with parents having the highest incomes in the

65

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sample, only seven had caries compared to 57 children with caries out of 121 who were of lower income status.

The caregivers reported that 26.2% of the children (139/530) had been sick for more than 2 weeks at least once during infancy and that 42.5% of these children (59/139) had experienced dental caries. Moreover, 126 of the caregivers (126/530) reported that the child had taken long term medication, for more than 2 weeks, during infancy and that 40.5% of these children (51/126) had caries.

Oral health knowledge and attitudes of the caregivers The majority of the caregivers 78.5% (416/530) knew about the causes of dental caries and 85.1% of them (451/530) knew ways to prevent caries. However, 58.5% (310/530) were not sure whether primary teeth needed to be restored. There was no necessity for a dental check-up for children before the age of one year according to 18.7% (99/530) of the caregivers and the majority 76.1% (403/530) indicated that they would visit the dentist only if a dental problem arises.

The child's dental and oral condition was reported as good by 52.6% (279/530) of the caregivers. However, 21.1% (59/279) of the children in this group had caries. Above average dental condition was reported for 43.4 % (230/530) of the caregivers and there was a statistically significant association (p=0.0417) between the dental status of the caregiver and the caries experience of the child (Table 8). Greater than ninety percent (n=430) of the caregivers reported that they were not

66

Paper I I

provided with any antenatal and/or post-natal oral health related messages. The caregivers that had never visited a dentist before amounted to 46.9% (249/530) while 49.8% (264/530) reported that they visited a dentist for some type or form of treatment.

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0-11

12-23

24-35

36-48

age (months)

Figure 1. The distribution by age of the 225 children with dental caries.

Caries distribution among 530 children aged between 8 and 48 months 400

0-11

12-23

24-35

36-48

age (months) D Caries-free Group • Caries Group

Figure 2. Caries distribution among 530 children aged between 8 and 48 months.

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Table 1. The caries status of the 513 dentate children out of the group of 530 children from Kerala who had a snacking habit (statistically significant association between having caries and the consumption of snacks, p=0.0177). Caries status

Snacks n

%

No snacks n %

Caries

197 38.4

28

5l

Caries-free

229 44.6

59 11.5

Table 2. The caries status of the 513 dentate children from Kerala who received sweets as a reward (statistically significant association between having caries and the giving of sweets as a reward, pO.OOOl). Caries status

Sweets

No sweets

n %

n %

Caries

214 41.7

11

Caries-free

216 42.1

72 14.1

2.1

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Table 3. The caries status of the 298 children who had a tooth-brushing habit out of the group of 513 dentate children from Kerala (statistically significant association between caries and the tooth-brushing of the child, p=0.0084). Caries status

Aided tooth-brushing n

Caries Caries-free

115

%

3^6

67 22.5

Unaided tooth-brushing n

%

55 18.5 61 20.4

Table 4. The caries status and the use of toothpaste by the 298 Kerala children who brushed their teeth out of the group of 513 dentate children (statistically significant association between caries and the use of toothpaste, p=0.0005). Caries status

Toothpaste n

%

No toothpaste n

%

Caries

52 17.4

118 39.6

Caries-free

65 21.8

63 21.2

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Table 5. The caries status and the toothpaste usage of the 117 children who brush their own teeth (statistically significant association between caries and the toothpaste use by the child who brushed his/her own teeth, p=0.0010). Caries status

Toothpaste n

No toothpaste

%

n

%

Caries

23 19.7

29 24.8

Caries-free

49 41.9

16 13.6

Table 6. The caries status of the 530 children from Kerala according to the education status of the father. Education status

Caries (n\-225)

of the Father

Caries-free (n2=305)

n

/o

n

/o

No schooling

2

0.4

0

0

Primary school

37

6.9

42

7.9

High school

161

30.4

213

40.2

Pre-Degree

14

2.6

30

5.7

Degree

9

1.7

16

3.0

Postgraduate

2

0.4

4

0.8

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Table 7.

The caries status of the 530 children from Kerala according to the

education status of the mother. Education status of the mother

Caries

Caries-free

(ni=225)

(n2=305)

n

%

n

%

No schooling

2

0.4

0

0

Primary school

28

5.3

35

6.6

High school

125

23.5

160

30.2

Pre-Degree

49

9,2

75

14.2

Degree

18

3.4

31

5.8

Postgraduate

3

0.6

4

0.8

Table 8. The caries experience of the child who had a caregiver with an above average dental condition in the group of 530 children from Kerala (statistically significant association between the dental status of the caregiver and the caries experience of the child, p=0.0417). Caries status

Above average dental

Below average dental

condition

condition

n

Caries Caries-free

%

n

%

86 16.2

139 26.3

144 27.1

161 30.4

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Discussion The Day Care Centres for the study were randomly selected, by a non-dental administrator, so as to enhance the representivity of the sample. The advantage of involving healthcare workers closely linked to the district medical offices was that it ensured extensive propaganda regarding the investigation through pamphlets and notices. This, in turn, resulted in a high level of participation in the study. Since there were no invasive procedures involved in the investigation, this raised the level of compliance of the caregivers.

All strata of the society attended the selected Day Care Centres; however, the sample for this investigation was slightly biased towards the middle class families. From this study, a caries experience of 43.9% (225/513 dentate children) and a mean dmft of 1.84 were determined. Socio-economic status measured by income has been shown, at least in Hong Kong children, to be inversely related to dmft scores (Tang et al 1997). Of the 34 children with parents in the highest income bracket in the sample, seven had caries; compared to 57 out of 121 children with caries that had a lower income status. Thus, the findings of this study confirm those of Tang and her co-workers (1997).

The education level of parents has been reported to be inversely related to the dmft score of their children (Tang et al 1997). In this study, the parents with the higher educational level had children with the lowest dmft scores; for example, only 11 out of 31 children whose fathers had received a tertiary education had

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Paper II

caries when compared to 161 out of 374 children whose fathers who had only attained a high school education.

The criteria used to diagnose caries in this study were based entirely on a visual examination; and no effort was made to mechanically probe for cavitation. This certainly resulted in an underscoring of the actual caries status; hence, the true caries prevalence could have been slightly higher than reported in this study. This highlights the need for care to be practiced when comparing the data from different studies. While epidemiological evidence indicates that noncavitated caries is more prevalent than cavitation during the first 18 months of life (MattosGraner et al 1996), it should be remembered that the clearer the diagnostic criteria, the higher the level of reproducibility and reliability that can be achieved, and this is important when dealing with young children so as to ensure their compliance with the examination and not to adversely affect their co-operation and behavior in the dental environment in the future.

The acquisition of Mutans streptococci in young children most likely takes place during a ccwindow of infectivity" from 19 to 31 months of age (Caufield et al 1993). In this study, the earliest caries experience, based on cavitation, was seen on the primary maxillary incisors in an eleven months old child which confirms the finding by Douglass et al (2001) that maxillary anterior caries can develop as early as 10-12 months of age. Thus, it is apparent that given the ideal predisposing conditions, caries can be initiated within a relatively short period of time after tooth eruption and that rapidly progresses to cavitation. The latter characteristic

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was also found by Weinstein and co-workers (1994) who reported that incipient carious lesions could progress to cavitation within 6 to 12 months. This rapid rate of progression is consistent with the evidence from an in vitro study, which suggested that dental caries could progress from enamel to dentin in 3.4 weeks (Ericsson etal 1998).

Even though the state of Kerala has pride of place in India because of achieving near total literacy, the importance of infant oral health has been overlooked. The importance of educating the caregivers to perceive the consequences of ECC is undoubtedly understood from various studies that have shown that individuals with a better understanding of the aetiology of dental caries will make a more concerted effort to prevent dental caries. Therefore, educating the caregivers, of children in Kerala, on the preventive aspects of dental caries has to be stressed.

In this study, it was found that a high level of breast-feeding is practiced in Kerala and yet the caries level is high. This could be due to the addition of sugar in local snack food preparations and the increasing frequency of snacking. Furthermore, this may have been a factor that has affected data from other studies were breastfeeding was high; that is, this may serve as a warning to communities that the good practice of breast-feeding, may be counter-acted by adverse factors that are not reported by caregivers and that these factors maybe cultural or social in nature. These findings support the notion that further investigations are required to determine the prevalence of ECC in exclusively breast-fed children, and to clarify

75

Paper II

whether or not other practices, such as eating snacks could contribute to caries in breast-fed children (Johnsen et al 1980).

Fluoride is one of the most effective methods of caries prevention available for ECC (Weinstein et al 1994). The current emphasis regarding the cariostatic effects of fluoride is on the topical effects, rather than the decreasing of enamel solubility through the incorporation of fluoride in the developing enamel from systemic sources (Fejerskov and Clarkson 1996). The topical effects of fluoride are complex, and include changes to the mineral phases (Fejerskov and Clarkson 1996), as well as the modulation of metabolic effects on Mutans streptococci and other bacteria in dental plaque (Hamilton and Bowden 1996). The water supplies are not fluoridated in Kerala. The major source of fluorides for children in this study was toothpastes. However, only 117 out of 298 children with a toothbrushing habit used toothpaste; consequently, this may be one of the reasons for the high prevalence of caries in this group of pre-school children possibly because in Ayurveda, the practice of traditional Indian medicine, the use of fluorides is considered to be harmful.

Children with ECC generally have a high frequency of sugar consumption, not only from fluids given in the nursing bottle (Winter 1980, Holt et al 1982, Wendt et al 1991, Weinstein et al 1992), but also from sweetened solid foods (Gordon and Reddy 1985, Tsubouchi et al 1995). This dietary characteristic cannot be ignored as being one of the most significant caries risk factors in ECC. This association was established long ago (Gustaffsson et al 1954). In this study,

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Paper II

statistically significant correlations were seen between caries and the consumption of snacks (p=0.0177), and the giving of sweets as a reward (pO.GOOl). Mothers constituted the majority of caregivers in this study and sweets were frequently given as a reward to the child or even on demand by the child. The magnitude of this feeding practice is culturally based.

Apart from age, the parents' level of education and income has also been found to be associated related to the caries experience of their child. High parental educational attainment was found to be related to lower caries experience; conversely, low parental income was related to higher caries experience (AlHosani and Rugg-Gunn 1998). Social class may influence caries risk in several ways. Individuals from the low socio-economic strata experience financial, social, and material disadvantages that compromise their ability to care for themselves, obtain professional health care services, and live in a healthy environment (Chen 1995), all of which lead to a reduced resistance to oral and other diseases (Holm 1990). In this study, a statistically significant correlation (pO.OQOl) was found between caries and low socio-economic status.

If the oral hygiene is less than satisfactory, children can develop sub-surface demineralization, enamel lesions and even frank caries by the age of two years. In this regard, a statistically significant correlation was found in the present study, between caries and cleaning of the child's mouth (pO.OOOl), and the oral hygiene status of the child (p9

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