|Year : 2016 | Volume
| Issue : 1 | Page : 36-42
Association of severe early childhood caries with iron deficiency anemia
Kalpana Bansal1, Meetu Goyal2, Renuka Dhingra2
1 Division of Pedodontics and Preventive Dentistry, Centre for Dental Education and Research, All India Institute of Medical Sciences, New Delhi, India
2 Department of Pedodontics and Preventive Dentistry, Faculty of Dental Sciences, SGT University, Gurgaon, Haryana, India
|Date of Web Publication||2-Feb-2016|
Division of Pedodontics and Preventive Dentistry, Centre for Dental Education and Research, All India Institute of Medical Sciences, New Delhi
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Severe tooth decay is known to affect the health and well-being of young children. However, there has been minimal research showing the association of severe early childhood caries (S-ECC) and iron deficiency anemia (IDA). Aims: The primary aim of this study was to investigate an association between S-ECC with IDA. The secondary objective was to find an association between severe caries and body weight of the child. The oral health-related quality of life of children with S-ECC was also assessed. Materials and Methods: Following the ethical approval, 60 children aged 2-6 years (30 with S-ECC and 30 controls with caries status <2) were recruited for this cross-sectional association study. Each child received a clinical examination for dental caries status using deft index and a blood investigation to determine various parameters; hemoglobin (Hb), mean corpuscular volume (MCV), mean corpuscular hemoglobin concentration, and packed cell volume (PCV). Children underwent venipuncture after due parental consent, and 2.5 mL blood was collected from each child to evaluate the above parameters. Following this, the parents filled up a 10 point questionnaire to determine the child's quality of life. Data were then analyzed by t-test and Fischer's exact t-test. Result: On comparison of percentage of children with IDA in S-ECC and control group, it was found that children with S-ECC were more likely to have IDA odds ratio (95% confidence interval): 10.77 (2.0, 104.9), (P = 0.001). In addition to this, S-ECC children were significantly more likely to have low Hb, MCV, and PCV levels (P < 0.001) which imply that S-ECC may be a risk marker for the development of anemia. More children (93%) with severe caries were found to have less body weight than ICMR standard weight for age as compared to children with low caries (P < 0.05%). Conclusion: S-ECC is strongly associated with the anemia due to iron deficiency, and efforts should be made toward the preventive and curative aspects of ECC, which may improve the general well-being and quality of life of a child.
Keywords: Anemia, body weight, quality of life, severe early childhood caries
|How to cite this article:|
Bansal K, Goyal M, Dhingra R. Association of severe early childhood caries with iron deficiency anemia. J Indian Soc Pedod Prev Dent 2016;34:36-42
|How to cite this URL:|
Bansal K, Goyal M, Dhingra R. Association of severe early childhood caries with iron deficiency anemia. J Indian Soc Pedod Prev Dent [serial online] 2016 [cited 2019 Sep 19];34:36-42. Available from: http://www.jisppd.com/text.asp?2016/34/1/36/175508
| Introduction|| |
Early childhood is an important stage in child's life. Normal growth and development at this stage can be hindered by the common, but preventable, conditions of early childhood caries (ECC). 
ECC is an infectious disease that can start as soon as an infant's teeth erupt  and has been defined as "the presence of one or more decayed (noncavitated or cavitated lesions), missing (due to caries), or filled tooth surfaces" in any primary tooth in a child 71 months of age or younger. Severe-ECC (S-ECC) is defined as any sign of smooth surface caries in children younger than 3 years of age. From ages 3 through 5, one or more cavitated, missing (due to caries), or filled smooth surfaces in primary maxillary anterior teeth or a decayed, missing, or filled score of ≥4 (age 3), ≥5 (age 4), or ≥6 (age 5) surfaces constitutes S-ECC (American Academy of Pediatric dentistry). 
ECC has been considered at epidemic proportions in the developing countries. ,,,, Traditionally, dental caries has been considered separately from systemic disease  but in recent years researches relating S-ECC to nutritional status imply that S-ECC can extend beyond the oral cavity as it affect childhood health and well-being. Many with S-ECC are believed to be malnourished, anemic, underweight, and have altered somatic growth patterns.  Thus, lead to nutritional deficiency anemia particularly iron deficiency  and poor oral health-related quality of life (OHRQOL). 
Two recent reports on the iron status and severe caries provide evidence that the relationship between the two is salient. , Several plausible explanations have been given as to why the anemia and severe caries can be associated. One hypothesis says that low hemoglobin (Hb) levels in S-ECC children may be attributed to the body's inflammatory response to chronic pulpitis. The later triggers a series of events that ultimately leads to production of cytokines which in turn may inhibit erythropoiesis and thus reduce the level of Hb in blood. , Second, pain experienced by S-ECC children may lead to altered eating habits that may lead to anemic conditions due to poor diet. Young children with extensive caries were found to be physically underdeveloped, especially in height and weight, symptoms that may be caused by aversions to eating because of tooth pain or a high sucrose diet that can compromise the intake of other nutrients. Thus, despite the epidemic nature of both dental caries and iron deficiency worldwide, there has been little research as to whether an association exists between the two conditions.
Thus, the main objective of this study was to evaluate the association between S-ECC and iron deficiency anemia (IDA) and the secondary objective was to find an association between S-ECC and the body weight. Further, the impact of S-ECC on the quality of life in young children was explored using a 10 point questionnaire.
| Materials and Methods|| |
Ethical clearance to carry out the study was obtained from the Ethical Committee of Institute, and a written informed consent was obtained from parents or caregivers of participating children prior to the investigation. The procedures, possible discomforts or risks, and possible benefits were explained fully to the parents or guardians of the human subjects involved.
Study settings and sample selection
This cross-sectional study was conducted in a hospital setting in semi-urban area in the district of Gurgaon, Haryana. From July 2013 to June 2014, healthy children below the age of 6 years with S-ECC were recruited from the OPD of the Department of Pedodontics at SGT Dental College and Hospital. Age- and sex-matched control subjects were enrolled from the OPD of the department of Pediatrics at SGT Medical Hospital. It was ensured that the children selected for the study were not having any serious, chronic medical problem but visited the hospital for mild infections or fever. Moreover, children should not have taken medicines affecting serum Hb levels.
A total of 72 children of age 2-6 years were screened by one of the pediatric dentists for the presence or absence of S-ECC according to the AAPD guidelines  and were divided into 2 groups - study group (cases) and control group. For inclusion in the study group, the child should have an otherwise noncontributory medical history and had not previously received invasive dental treatment. Children with S-ECC and having pulpal involvement of at least 2 teeth were eligible for inclusion in the study group. Comparison subjects having caries status equal to or below two as based upon clinical evaluation obtained from the same low socioeconomic status and matched to the S-ECC cases on the basis of age and gender formed the control group. Out of total 72 children screened, 60 children consented to participate in the study. All patients enrolled in the study received comprehensive dental treatment in the hospital operating room by a pediatric dentist.
A total of 60, 2-6-year-old children were divided into 2 groups - 30 children-cases with S-ECC, 30 children-control group. The dental caries status, measurement of weight, and blood sample analysis were done for both groups. The blood sample collected was used for estimation of following parameters such as Hb, mean corpuscular volume (MCV), mean corpuscular hemoglobin concentration (MCHC), and hematocrit packed cell volume (PCV) to diagnose anemia. Reference ranges for Hb, MCV, MCHC, and PCV were 12 g/dl;  76-100 μm 3 ; 33-37 g/dl; 39-49%, respectively.  In addition, IDA (having two out of three abnormal blood tests for Hb, ferritin, and/or MCV) was also determined.  Weight measurements were taken for each child in light clothes and no shoes using the standard weighing machine after calibration. The weight of children of both groups was then compared with weight for girls and boys for age according to ICMR norms. 
Assessment of oral health related quality of life of study group
A self-designed 10 point questionnaire was used to measure the quality of life. Questionnaire consisted of questions which includes physical, psychological, and social aspects of quality of life and was filled by parents of children of the study group. Each question was scored on a four-point-scale: Never; occasionally; sometimes; and quite frequently and given the score of 0, 1, 2, and 3, respectively. Total scores thus ranged from 0 to 30. Scores on all 10 questions were summed up. If score was 0-10; OHRQOL was considered to be good, if score was 11-20; OHRQOL was considered to be moderate, if score was 21-30; OHRQOL was considered to be poor [Table 1].
Sample size estimation
0The sample size estimation was based on the study done by Shaoul et al.  who reported that 65% of children with S-ECC had IDA. Anticipating the same prevalence of IDA among S-ECC children and assuming a 30% reduction in control group, 80% power, and 5% level of significance, the estimated sample size was determined as 30 per group.
Clinical and questionnaire data were entered into an Excel (Microsoft Office) database. Statistical analysis was carried out using Stata 11.0 software (college station, Texas., USA). Data were presented as number (%) or mean + standard deviation/median (Min.-max.) as appropriate. Demographic characteristics between the groups were compared using Chi-square test or Student's t-test/Wilcoxan rank sum test (nonnormal). The primary outcome, IDA between the groups were compared using Fisher's exact test. The results were reported as odds ratio (OR) (95% confidence interval). The difference in means of Hb, MCV, MCHC, and PCV (secondary outcomes) were compared between the groups using Student's t-test for independent samples. The P < 0.05 was considered statistically significant.
| Results|| |
A total of 60 out of 72 children were recruited 30 cases and 30 controls (83% response); twelve parents did not give consent for the study. Data collected from a total of 60 children enrolled, were compiled and subjected to statistical analysis. There was no statistically significant difference between groups regarding age, male/female ratio between two groups. The mean age of cases was 4.9 ± 0.9 years and that of controls was 4.3 ± 1.4 years [Table 2].
|Table 2: Sample distribution in study and control group (male/female, age, and caries status)|
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The mean weight of children in S-ECC group was 15.4 ± 2.2 kg and in the control group was 15.7 ± 2.9 kg; did not differ between the two groups significantly (P = 0.638).
The data on primary outcome and secondary outcomes were compared between the groups. The primary outcome was presence or absence of IDA in the participants of two groups. IDA has been defined as 2 of 3 abnormal blood tests:
- Serum ferritin;
- Hb; and
- MCV. 
Various blood variables; Hb, MCV, MCHC, and PCV, were the secondary outcomes of the study and the data of the same is presented in [Table 3].
On comparison of the percentage of children with IDA in two groups [Table 4], out of a total of 30 cases of S-ECC children, 13 (43%) children had IDA as determined by below normal Hb and MCV values, whereas in controls, only 2 (7%) had IDA giving an OR of 10.7 (2.0, 104.9) (P = 0.001).
Data on secondary outcome variables revealed that Hb, MCV, and PCV level differed significantly between the groups, but MCHC levels did not differ significantly between the groups [Table 3]. Mean Hb levels differ significantly between the groups (11.3 ± 1.5 g/dl S-ECC vs. 12.80 ± 2.0 g/dl control, P = 0.002). Likewise, there is a significant difference in MCV levels between those with and without S-ECC (74.0 ± 7.5 μm 3 in S-ECC vs. 87.52 ± 10.99 μm 3 in control, P < 0.000). There was also statistically significant difference in the PCV levels in both groups (34.7% ± 2.5% in S-ECC vs. 38.5% ± 6.0% in control, P = 0.002). There is no significant difference in MCHC levels in children with and without S-ECC (32.8 ± 2.6 g/dl S-ECC vs. 33.2 ± 1.7 g/dl control, P = 0.415).
While assessing the quality of life of S-ECC, 6 patients have good quality of life, 21 children have moderate quality of life, and 3 children have poor quality of life. The mean score of children with good, moderate and poor quality of life is 7.5, 13.28, and 21.67, respectively [Table 5]. ECC children were rated by their parents as having significantly poor oral health (pain, trouble sleeping, trouble eating hard foods, and trouble eating hot or cold foods). Thus, ECC children were rated as having poor physical functioning. Parents of ECC children also reported greater impact on child's mental and social functioning due to child's teeth or mouth such as child feels angry or upset; often miss preschool or day care; not interested in playing with other friends; and also avoid smiling due to poor condition of teeth.
|Table 5: Association of S-ECC with OHRQOL of S-ECC children (study group)|
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| Discussion|| |
Dental caries in preschool children has long been recognized as a unique entity with distinguishing clinical characteristics. Despite the dramatic decline in the prevalence of dental caries in children in countries of the Western world, it affects significant percentages of preschool populations, in both developed and developing countries and unevenly distributed through the population.  Although pain and infection may be the primary effects of nursing caries, the condition also may affect general health. The association of ECC with three key areas of childhood and well-being cannot be thus ignored:
- Nutritional deficiency anemia,
- Growth and development, and
This is a cross-sectional association study conducted in a total of 60 children of age 2-6 years. According to WHO, affected eating pattern can rapidly manifest in younger children of 3-6 years of age  and also definition of S-ECC describes the status of caries present in children younger than 6 years.  Hence, this age group was selected for the study. Any child who had a chronic medical illness, which would affect normal growth, was excluded from the study. The pediatric dentist who selected and designated the children in the groups (S-ECC and control) was trained for the clinical examination of the caries status hence the possibility of bias in the selection of sample is eliminated. The blood sample was collected in the laboratory setting of the hospital by a trained laboratory technician and was blind to the caries status of the children, so any bias in the reporting of blood parameters of cases and controls is eliminated.
The mean weight of test group (15.38 ± 2.20 kg) is less than mean weight of control group (15.70 ± 2.93 kg) but this difference is not statistically significant (P = 0.636).
However, the weight data revealed that 93% of the children in S-ECC group were underweight, whereas 70% of children in control group also had low weight as compared to standard ICMR norms; the difference between the groups being statistically significant (P < 0.05%) overall, 49 (81%) children in the entire sample were underweight. Approximately, 47% of India's below-five population is underweight  and further this study has been conducted in a rural area, constituted the sample children from low/moderate socioeconomic status background family. Studies had ,, reported that children with caries significantly weighed less than control groups, but a recent study done by Malek Mohammadi et al.  reported no significantly underweight children in caries group than control group. Although their finding suggest that extraction of carious teeth in children promotes weight gain and possibly growth. Thomas and Primosch  also found that regardless of the low socioeconomic status of the children, a slight gain in percentile weight following dental rehabilitation was not indicative of a "catch-up growth" phenomenon.
Children with S-ECC have significantly lower mean Hb levels than controls (11.34 ± 1.45 g/dl S-ECC vs. 12.80 ± 2.03 g/dl control, P = 0.002, [Table 3]). It has been found that 25% (n = 15/60) of the entire study sample have IDA [Table 4]. Of this group of children, 86.7% (n = 13) are from the study group compared with 13.3% (n = 2) in the control group. This is largely congruent with findings from other studies which reported that 18.9% of the entire sample had IDA out of which 83.3%were from the S-ECC group.  Clarke et al. in their study on S-ECC children reported a significant proportion of children with unacceptably low level of Hb and high prevalence of anemia  Sadeghi et al.  concluded in their cross-sectional study that an inverse, statistically significant association was demonstrated between serum iron levels and caries experience in young children aged 24-71 months and suggested that testing of IDA should be considered in children affected by S-ECC.
Data regarding MCV also suggest that there is a significant difference in MCV levels between those with and without S-ECC (74.00 ± 7.5 S-ECC vs. 87.5 ± 11.0 control, P < 0.001, [Table 3]). Low level of MCV serve as an indicator of microcytic anemia.  It has been found that 33.33% (n = 20/60) of entire study sample have less MCV. Out of which 85% (n = 17) are from the S-ECC group compared with 15% (n = 3) in the caries-free group. Shaoul et al.  also reported statistically significant difference for the MCV values between the treatment and control groups at baseline (P < 0.0001) but Schroth et al.  in 2013 reported no significant difference in MCV levels between those with and without S-ECC (78.3 ± 5.3 vs. 78.5 ± 3.8, P = 0.74).
Statistically significant difference were also found in the PCV levels in both groups (34.7 ± 2.5 S-ECC vs. 38.5 ± 6.0 control, P = 0.002, [Table 3]). On comparison of the observed PCV value with the reference value, it has been found that 71.7% (n = 43/60) of entire study sample have less PCV; out of which 65% (n = 28/43) are from the S-ECC group.
Recently, Tang et al.  investigated the relationship between the caries status of the children and anemia and showed that S-ECC was strongly associated with anemia. Shaoul et al. in 2012  had also shown the similar significant relationship between IDA and dental caries and have demonstrated for the 1 st time that the resolution of dental caries leads to a parallel resolution of IDA without iron treatment. Koppal et al. also reported a definite observation of iron deficiency in children with ECC.
There are different mechanisms for how untreated dental caries may affect systemic health.  One hypothesis is that the low Hb levels often observed in S-ECC children may be attributed to the body's inflammatory response, which may accompany rampant forms of dental caries (especially those involving pulpitis or abscesses). Inflammation associated with S-ECC inhibits erythropoiesis and thus reduce the level of Hb in the blood (and, therefore, the level of iron). It is also recognized that the pain experienced by children with S-ECC may lead to altered eating habits.  Moreover, it has been stated that a highly cariogenic diet tends to also be poorly nutritious-the so called "empty calories" which could lead to poor growth.  Poor sleep quality resulting from dental pain may contribute to decreases in the production of glucosteroids, which may also impair growth. 
IDA is defined as 2 of 3 abnormal blood tests:
- Serum ferritin;
- Hb; and
- MCV.  In this study, various blood parameters studied were Hb, MCV, MCHC, and PCV.
To determine IDA, Hb, and MCV values were taken into consideration. Among cases of S-ECC, 43% children had IDA, while among controls only 7% were found to have IDA [Table 4]. Children in this study showed evidence of malnutrition with significant proportions with low values for Hb and MCV. In public health terms, iron deficiency is by far the first cause of nutritional anemia worldwide.  Thus, this study shows that S-ECC and anemia are definitely interrelated, and S-ECC can be identified as a risk marker for under nutrition. Based on this, it can be suggested that pediatric dentists, pediatricians, and family physicians should recommend the assessment of anemia in S-ECC patients regardless of their clinical nutritional status.
As far as the OHRQOL is concerned in the children having S-ECC, 21 children (out of 30) complained of pain sometimes (once in month/weekly basis), whereas 6 children did not complain of pain ever or occasionally (once in 2-3 months). Overall, three children reported pain frequently and had a poor OHRQOL. Thus, this study demonstrates that S-ECC does affect the quality of life in children which has been judged by the self-designed questionnaire. Similar findings were reported by Low et al. in 1999  who concluded that although all the children were severely afflicted with carious lesions, it was surprising to find that only 48% indicated that they had pain or discomfort. It is difficult to measure the degree of pain or discomfort in young children because of their level of cognitive and language development. Cunnion et al. in 2010 also reported that ECC children were more likely to have fair or poor oral health. 
In this study, children with S-ECC have been significantly associated with anemia due to iron deficiency and moderate OHRQOL in children.
However, this study had few limitations. The study design was cross-sectional, which does not allow for the determination of true cause and effect. It was extremely challenging to find caries free age matched controls to participate in the study. The study sample was small; hence the findings of the study need to be confirmed in large sample groups.
Another limitation of the study was that questionnaire being filled by the parents of children of the study group. Filstrup et al. in 2003 advocates children as an important diagnostic tool when assessing children's needs for dental care as children themselves can better provide a subjective perspective and feelings about their health.  Parents perception about child's pain may be different from the actual experience of the child. Hence, the OHRQOL scores may not be realistic.
Despite the limitations, the clinical importance of this study is that S-ECC has been identified as a risk marker for IDA. The results suggest, however, that physicians and dentists treating young children should consider that S-ECC is a risk marker for anemia. For physicians, nutritional deficiencies should alert them to the possibility that S-ECC is present and is a possible explanation for the deficiencies in their patients. For dentists, children presenting with S-ECC should be considered at risk for nutritional deficiencies that may affect long-term health and well-being.
| Conclusion|| |
S-ECC is a virulent form of dental caries that can destroy the primary dentition of preschool children. This study identifies S-ECC as a risk marker for anemia due to iron deficiency, as well as the poor nutritional status as determined by low weight in children. Primary care providers and dentists should be aware of this oral-systemic relationship. Further long-term studies using large sample size are needed to determine the interrelationship between S-ECC and malnourished and anemic children and to see the effect of full mouth rehabilitation on the resolution of IDA (without iron supplements). Preventive strategies should be developed to reduce the risk of anemia, poor quality of life, and impaired weight gain in children with S-ECC.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]