Anna Jurczak1, Dorota Kościelniak1, Iwona Gregorczyk-Maga1, Iwona Kołodziej1, Jadwiga Ciepły1, Dorota Olczak-Kowalczyk2, Monika Komasara3, Magdalena Wąsik3, Monika A. Papież4, *Wirginia Krzyściak3
Wpływ czynników socjoekonomicznych i żywieniowych na rozwój próchnicy wczesnej u dzieci w wieku 1-6 lat
Influence of socioeconomic and nutritional factors on the development of early childhood caries in children aged 1-6 years
1Department of Pediatric Dentistry, Institute of Dentistry, Jagiellonian University Medical College, Kraków
Head of Department: Anna Jurczak, MD, PhD
2Department of Pediatric Dentistry, Medical University of Warsaw
Head of Department: prof. Dorota Olczak-Kowalczyk, MD, PhD
3Department of Medical Diagnostics, Pharmacy Faculty, Jagiellonian University Medical College, Kraków
Head of Department: Ryszard Drożdż, MD, PhD
4Department of Cytobiology, Pharmacy Faculty, Jagiellonian University Medical College, Kraków
Head of Department: prof. Gabriel Nowak, MD, PhD
Introduction. The high incidence of early childhood caries (ECC) highlights the need to analyze the causes.
Aim. Evaluation of the impact of diet and socioeconomic conditions on the risk of ECC development in children.
Material and methods. A group of 686 pediatric patients aged 1-6 from the University Dental Clinic in Krakow was examined for caries. The parents were asked to complete a questionnaire on the eating habits of children and on the sociodemographic factors.
Results. Children aged 1-2 from rural areas and average education of parents constitu-ted a significant factor affecting the intensity of ECC. Consumption of sugary foods at night increased the occurrence of caries by more than 3.5 times in 1–2-year-olds, and by 4 times in 5-year-olds. Frequent consumption of fruit juices and carbonated beverages had a significant impact on the occurrence of caries in 6-year-olds.
Conclusions. Dietary pattern is a major cause of ECC. The relationship between ECC and the place of residence, low parental education and poor economic status indicates the target group for intensive educational activities for the prevention of dental caries.
The current definition of early childhood caries (ECC), proposed in 2013 by the World Health Organization and the American Dental Association, states it to be a pathological process of extracorporeal origin, which leads to decalcification and proteolytic degradation of the dental hard tissues. ECC is defined as the presence of one or more decayed, missing due to caries, or filled teeth in children less than 6 years of age (exactly up to 71 months, i.e. 5 years and 11 months). Also, this is a multistep and multifactorial disease, which occurs because of the following causes:
– behavioral, psychosocial, and genetic factors,
– specific interactions occurring between microorganisms and the host,
– biochemical changes in the oral cavity, such as the metabolism of sugars from food to acids which decreases pH of the environment leading to enamel demineralization and formation of carious lesion.
Currently, in countries with a high prevalence of caries, the fundamental problem is the low value given in health care services toward prevention of diseases of the oral cavity. In Denmark, Germany, and Norway (where in 2013, the frequency of caries was estimated to be 24, 28.6 and 11%, respectively), health care services directed toward prevention/treatment are distributed on a 1:1 scale (1, 2) and in Poland, financing of services aimed at prevention in the aspect of health of the oral cavity is transient (3). Hence, Poland is in the forefront of countries with the highest proportion of children with caries: 84% among the compared European countries (4).
ECC is a serious health problem worldwide. Societies of the so-called Third World, developing, as well as the highly developed countries face this problem.
Numerous studies have been conducted to determine the causes of occurrence of ECC and the factors that increase the risk of its occurrence. Most of these studies focused primarily on the impact of nutritional eating habits of children and their families on the occurrence of ECC. Socioeconomic factors such as income, lifestyle, and availability of health care have an equally significant impact on the risk of ECC development. In this study, particular attention was paid to the consumption of carbonated beverages, snacking on sugary foods at night, and the methods of infant feeding. Furthermore, among the socioeconomic factors, place of residence, parents’ education, and material condition of the families were subjected to analysis.
Aim of our study was the evaluation of the impact of diet and socioeconomic conditions on the risk of ECC development in children.
Material and methods
This study was conducted between 2010 and 2013 and included 686 pediatric patients (clinical evaluation) and their legal guardians (interview) from the Department of Pediatric Dentistry, the University Dental Clinic in Krakow, Poland. Before analyzing the results, the study group was divided into four age categories (90: 1–2-year-olds, 291: 3–4-year-olds, 138: 5-year-olds, and 167: 6-year-olds). In a clinical evaluation of patients with oral cavities, the presence of tooth decay in deciduous and permanent teeth (d/D), number of teeth removed due to caries (m/M), and number of filled teeth (f/F) were assessed. This study describes the indexes of caries (dmf/DMF) and caries prevalence, and was conducted following the criteria established by the World Health Organization for the diagnosis of ECC (5) and the International Caries Detection and Assessment System (ICDAS) II (6) ((d/D) was considered to be ≥ 3 in ICDAS II) under artificial lighting using a dental mirror (Kavo Lux 1415, Germany) and a periodontal probe (WHO LM 8-550 B XSI, LM, USA). ECC was dichotomized as absent or present. The examiners used appropriate equipment to protect against individual cross-infection, with all necessary instruments and materials being packed and sterilized. The DMF index (D – decayed; M – missing; F – filled teeth) for permanent teeth and the dmf index (d – decayed; m – missing; f – filled teeth) for primary teeth because of dental caries were calculated.
This study was conducted by qualified dentists (internal examiners) with many years of experience in epidemiological studies of the oral cavity. One team consisting of six researchers (two examiners and four assistants) was installed at each health care unit (Department of Pediatric Dentistry, Medical University of Warsaw and Department of Pediatric Dentistry, Institute of Dentistry, Jagiellonian University Medical College in Krakow). Prior to the clinical work, the examiners underwent a calibration and training exercise for the diagnosis of ECC and DDE (diffuse opacity, demarcated opacity, and enamel hypoplasia) based on standards developed by the American Academy of Pediatric Dentistry, 2014 (7-11).
The calibration exercise consisted of three stages. The theoretical stage involved a discussion of the criteria for the diagnosis of DDE (12) and ECC and the participants analyzed case studies and an oral clinical examination (OCE) to demonstrate their proficiency in diagnosis, treatment planning, and clinical care. A specialist in pediatric dentistry was the mentor and partner in the theoretical framework and coordinated this step, instructing 10 general dentists on how to perform the examination. An analysis of photographs was performed on two separate occasions with a 2-week interval between sessions. Data analysis involved the calculation of Kappa coefficients for both inter-examiner and intra-examiner agreement. The Kappa coefficient was set at 0.92 in the pilot studies, which indicates the internal examiner’s reliability. As the Kappa coefficients were very good, the examiners were considered capable of conducting the epidemiological study.
After clinical evaluation, the children or their legal guardians answered a few questions prepared in accordance with the closed questions in the questionnaire. The first part of the questionnaire was related to their sociodemographic profile and consisted of three closed questions (material status, parents’ education, place of residence), while the second part was related to the children’s dietary habits (frequent consumption of fruit juices and carbonated drinks, snacking on sweetened foods at night, type of feeding: natural/artificial/mixed, etc.).
The data were collected from the questionnaire (Appendix 1) and subjected to statistical analysis.
A data set was analyzed using SPSS version 12. Data were presented as frequencies in percentage and were analyzed using the chi-square test, where the p-values were considered significant at p < 0.05. The type of correlation between different variables and the ECC was evaluated using Karl Pearson correlation. To measure the impact of possible risk factors of childhood caries, multiple logistic regression was used for which the odds ratio (OR) was calculated for selected factors of the ECC development. The results of logistic regression are summarized in table 1.
Table 1. Influence of particular variables on the incidence of caries in different age groups (logistic regression).
|Age group||Feeding||Snack of sweetened foods at night||Frequent consumption of fruit juices and carbonated drinks||Toothpaste for children|
|95% Confidence interval for OR||0.436||0.436||1.174||0.774||0.447|
|Level of significance||0.405||0.309||0.025||0.122||0.197|
|95% Confidence interval for OR||0.445||0.669||0.826||1.252||0.033|
|Level of significance||0.995||0.242||0.203||0.006||0.006|
|95% Confidence interval for OR||0.195||0.28||1.411||0.838||0.164|
|Level of significance||0.713||0.966||0.008||0.112||0.632|
|95% Confidence interval for OR||0.239||0.665||0.542||1.031||0.351|
|Level of significance||0.392||0.114||0.681||0.042||0.942|
Logistic regression – statistical method which allows calculation of OR for selected factors (called explanatory variables)
Odds ratio (OR) – describes the odd of an event occuring in the study group compared to the control group
Consents were obtained from all patients and the study procedure was approved by the Bioethical Committee of the Jagiellonian University in Krakow (No. KBET/194/B/2011).
The prevalence of caries in the investigated population was observed to be 66%. The highest proportion of children affected with caries was observed in the group of 5-year-olds (72%), while the lowest was in the group of 1–2-year-olds (59%) (tab. 2).
Table 2. The prevalence of caries in different age group of children from Kraków and surrounding areas.
|Age||1-2||3-4||5||6||All groups |
|Absence of caries||37||41||97||33||39||28||57||34||230||34|
In the group of 5-year-olds, the index of intensity for primary teeth was dmf score = 4.35 ± 3.62, while in the group of 1–2-year-olds, it was dmf score = 4.14 ± 4.52, wherein this number mainly constituted the number of teeth affected by active caries (p < 0.001) (tab. 3).
Table 3. Prevalence and intensity of caries measured with average dmf score for primary teeth and average DMF score for permanent teeth in particular age groups.
| || || || || || || || || || || || || || || || |
|1–2|| || || || || || || || || || || || || || || || |
|3–4|| || || || || || || || || || || || || || || || |
|5|| || || || || || || || || || || || || || || || |
|6|| || || || || || || || || || || || || || || || |
m – average, SD – standard deviation, p – analysis of variance (ANOVA)
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