Year : 2009 | Volume
: 27 | Issue : 3 | Page : 164--169
Evaluation of caries experience in 3-6-year-old children, and dental attitudes amongst the caregivers in the Ludhiana city
M Simratvir, GA Moghe, AM Thomas, N Singh, S Chopra
Department of Pedodontics and Preventive Dentistry, Christian Dental College, Ludhiana, India
Department of Pedodontics and Preventive Dentistry, Christian Dental College, Ludhiana
Early Childhood Caries (ECC) is a lifestyle disease that begins when the child«SQ»s teeth erupt in the oral cavity. The distinctive pattern of decay rapidly spreads from one tooth to another and involves the surfaces of teeth that are usually not at risk. Detection of disease is crucial to control the oral condition using preventive and therapeutic regimes. The aim of this study was to determine the prevalence of caries in children of age 3-6 years in Ludhiana and to examine the relationship between age and caries experience. A total of 609 children in the age group of 3-6 years were examined using def index. To determine dental care seeking attitude, 105 caregivers were interviewed. Results revealed that 52.87% of children in the age group of 3-3.11 years, 45.1% of children in the age group of 4-4.11 years and 58.55% of children in 5-5.11 age groups suffered from caries. The mean def index was 1.82, 1.57 and 2.21, respectively. Interview of caregivers of children revealed that out of 105 only 12 (11.4%) children had previously been to a general dentist. None of them knew about Pedodontics as a specialty. The results of the present study can be used mainly for screening child populations in need of treatment, helping public workers and planners to develop dental health programs to aid early intervention and prevention.
|How to cite this article:|
Simratvir M, Moghe G A, Thomas A M, Singh N, Chopra S. Evaluation of caries experience in 3-6-year-old children, and dental attitudes amongst the caregivers in the Ludhiana city.J Indian Soc Pedod Prev Dent 2009;27:164-169
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Simratvir M, Moghe G A, Thomas A M, Singh N, Chopra S. Evaluation of caries experience in 3-6-year-old children, and dental attitudes amongst the caregivers in the Ludhiana city. J Indian Soc Pedod Prev Dent [serial online] 2009 [cited 2020 Jan 23 ];27:164-169
Available from: http://www.jisppd.com/text.asp?2009/27/3/164/57097
Dental caries is one of the most common diseases of childhood. American Academy of Pediatric Dentistry (AAPD) describes Early Childhood Caries 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 of age 71 months or younger.' 
In developed countries the primary risk factor is considered to be the use of a nap time bottle that contains a fermentable carbohydrate food such as milk, milk with sugar, sweetened milk formula, fruit juice, sugar solution or other sweetened solutions,  whereas in the developing countries other factors such as linear enamel hypoplasia of primary teeth associated with malnutrition may contribute to the prevalence of this condition.  Complex interactions between the use of sweetened pacifiers, nursing on demand, neglected oral hygiene, Streptococcus mutans, maternal education and dental knowledge, family structure and social status make its etiology complex.
In general, the prevalence of caries in preschool children seems to be on the decline or the trend has reached a plateau in most of the developed countries, , but may be increasing in some developed and several developing countries. , A considerable proportion of preschoolers thus are still affected by dental caries.
Clinically, decay is first found in maxillary primary incisors, later it spreads to maxillary molars, mandibular molars and rarely mandibular incisors. 
In Asia, in the Far East region, which seems to have one of the highest prevalence and severity for the disease, the prevalence in three-year-olds ranges from 36 to 85%, ,,,,, while in India a prevalence of 44% has been reported for caries in 8- to 48-month-olds.  Mahejabeen et al. found that the caries prevalence was 54.1% in the preschool children of Hubli and Dharwad city. 
The short-term consequences of untreated decay in children's teeth include pain, with up to 12% of 5-year-olds reported to have experienced tooth ache, systemic infection and abscesses.  Long-term follow-up reveals that children who experience Early Childhood Caries (ECC) are much more likely to develop further dental problems as they grow older. In addition, poor dental health has a significant impact on the growth and cognitive development of child by interfering with nutrition, concentration and subsequently school participation. Increasingly, dental caries if left untreated is being recognized as a part of the more general phenomenon of child neglect. This is particularly appropriate, given that psychosocially, poor oral health can effect not only speech development, communication and self image but also social functioning and hence further impact an infant's quality of life.
Caries can be effectively prevented and controlled through a combination of community, professional and individual actions. Detection of disease is, in most cases, crucial to control the oral condition using preventive and therapeutic regimes. Oral health belief model is based on the theory that behaviors are directed by perceptions and beliefs, and suggests that whether or not a person engages in preventive health action depends on these beliefs. 
Hence the main aim of this study is to determine the prevalence of caries in children of age 3-6 years in Ludhiana and to examine the relationship between age and caries experience. Also the dental care seeking attitude of the caregivers/parents would be evaluated.
Materials and Methods
The study was conducted on 608 children in six schools randomly selected in and around Ludhiana city. Children in the age group of 3-6 years were selected from both genders and varied socioeconomic strata. The caregivers of the children attending these centers were informed about the nature of investigation through circulars.
The examination was carried out by a single examiner and subjects were evaluated using plain mouth mirror, wooden tongue spatula and gauze piece on an upright chair in adequate natural light. The diagnostic criterion was limited to the lesions at d 3 level (clinically detectable lesions in dentine open/close);  def score was recorded. 
To prevent bias, children were not informed previously about the check so that they could not purposely absent themselves from the school on the day of the examination.
To determine the dental care seeking attitude of the masses, parents/caregivers of 105 children of the first school examined were interviewed as regards to professional dental visits and oral hygiene practices.
The parents and teachers of the study participants were given clear explanations about the objective of the study and verbal informed consent was taken. Those who required dental care were referred to the mobile clinic or to the dental OPD of the institution. It was ensured that adequately sterilized instruments were used for oral examination to prevent cross-infection.
Data entry and analysis
Data that was obtained was entered in an MS-Excel spreadsheet and analyzed using Chi-square test.
A total of 608 children were examined: 191 (3-3.11 years complete), 142 (4-4.11 years complete), 275 (5-5.11 years complete).
Results revealed that 52.87, 45.1 and 58.55% of children in the age groups of 3-3.11, 4-4.11 and 5-5.11 age groups, respectively, suffered from caries.
Of these it was seen that 31.41% of children (3-3.11 years) had involvement of one or more anterior teeth and the percentage rose to 40.8% in 4-4.11-year-old children, while 38.91% children in the age group of 5-5.11 years had anterior teeth involved.
The mean def index was 1.82 (age group 3-3.11 years), 1.57 (age group 4-4.11 years) and 2.21 (age group 5-5.11 years). Chi-square test (p  It is a disease that may be never eradicated because of the complex interplay of social, behavioral, cultural, dietary and biological risk factors that are associated with its initiation and progression. 
Belterami (1952) described the early caries in children in 1930s as 'Les dents noire de tout-petits', which means, 'black teeth of the very young'.  Fass (1962) is perhaps the best known in this regard as for using the term 'nursing bottle mouth'.  Since 1962, a variety of other terms have been used to identify the caries in young children including the terms baby bottle tooth decay, nursing bottle syndrome, bottle mouth caries, nursing caries, rampant caries, nursing bottle mouth, milk bottle syndrome, breast milk tooth decay and facio-lingual pattern of decay.
Early Childhood Caries is a lifestyle disease that begins when the child's teeth erupt in the oral cavity. The distinctive pattern of decay rapidly spreads from one tooth to another and involves the surfaces of teeth that are usually not at risk. The lesion usually progresses in the following stages: initial lesion, damaged carious lesion, deep lesions and the Traumatic stage where the teeth fracture due to excessive undermining caries.
Caries was recorded using the def index. To aid higher level of reproducibility and reliability, the diagnostic criterion in this study was limited to d 3 level. No attempt was made to use a dental explorer to confirm cavitation of the lesions due to the young age of the children. This ensured their compliance with the examination without adversely affecting their cooperation and behavior in the dental environment in future. Moreover studies reveal that the use of probe disrupts the surface layer and prevents the possibility of reversing the noncavitated area through re-mineralization.  Visual examination without the use of explorer has been shown to have a sensitivity of 0.45 and a specificity of 1.00.
Results of this study revealed that 52.87% of children in the age group of 3-3.11 years, 45.1% of children in the age group of 4-4.11 years and 58.55% of children in 5-5.11 age groups suffered from caries.
The mean def was 2.21 for 5-5.11-year-old age group, 1.57 for 4-4.11-year-old children and 1.82 in the 3-3.11-year-olds.
As caries was diagnosed entirely on visual examination, this certainly resulted in an underestimation of the actual caries status; hence it would not be wrong to say that the true carious lesion prevalence would be higher than reported in this study. Recent epidemiologic research has shown that noncavitated lesions have been more prevalent than cavitated dentine lesions. However, the major problem in the early diagnosis is the relative lack of discoloration of an early lesion. Even while using an air syringe, only a well-trained eye can take notice of the caries in the superficial brilliance of the enamel. Taking into account the above factors the prevailing conditions of actual disease in the population may have been underestimated.
Mandibular second molars were the most commonly involved teeth in all the three age groups. This is in accordance with previous studies of Grindefjord and Amarante that the occlusal surfaces of the second molars were the most caries affected surfaces in 3.5-year-olds and approximal surfaces of the molars are the sites with the highest prevalence of decay in 5-year-olds, respectively. , Lack of dexterity in this age group and negligence on the part of caretakers might have accounted for poor oral health.
Of these it was seen that 31.41% of total children (3-3.11 years) had involvement of one or more anterior teeth and the percentage rose to 40.8% in 4-4.11-year-old children, while 38.91% children in the age group of 5-5.11 years had anterior teeth involved. It is note worthy that more than 50% of the children, who had decay, had anterior tooth involvement as well; clearly indicative of the fact that besides oral hygiene, erratic nursing habit might also have contributed to the etiology.
The mean def is seen to increase with age. Most of the lesions recorded were of d category (decayed teeth, which required treatment). Chi-square test reveals that a significant correlation exists between the mean def and age of children. The statistics clearly reflect the ignorant attitude of masses towards dental health.
The fact that out of 105 parents, only 12 had been to a dentist for tooth decay indicates lack of awareness among the masses. A total of 38 of those who were faced with tooth ache took their children to general physicians but none knew about the existing specialty of Pediatric dentistry. There was no concept of fluoride application at all.
Two major demographic factors have been addressed regarding the risk for ECC: socioeconomic status (SES), and race or ethnicity. Socioeconomic status is usually a mix of years of education, current income and occupation held. , Social class may influence caries risk in several ways: individuals from lower SES groups experience financial, social and material disadvantages that compromise their ability to care for themselves, obtain professional healthcare services and live in a healthy environment (Reisine and Douglass, 1998).  In addition, low-SES individuals have more fatalistic beliefs about their health and have a lower perceived need for care, leading to less self-care and lower utilization of preventive health services. The possible influence of SES on dental health may also be a consequence of differences in dietary habits and the role of sugar in the diet. In their summary evidence on inequalities in oral health, Sheiham and Watt state that the main causes of inequalities in oral health are differences in patterns of consumption of non-milk sugars and fluoride toothpaste. 
In this study the schools included mainly had children from the middle class. Since this stratum comprises more than 50% of the Indian population; the results are indicative of the attitude of the majority towards dental care.
Health behaviors are closely connected with ways of living. Theories from sociology, education and psychology describe learning and behavioral change in any individual as well as in mothers of young children. The Health Belief Model (HBM) is useful in predicting the likelihood of an individual's compliance with recommendations for preventive health behaviors (Overton Dickinson, 2005). It is based on the theory that behaviors are directed by perceptions and beliefs and suggests that whether or not a person engages in preventive health action depends on these beliefs. Additionally, cues or triggers such as a comment from a trusted friend or even a piece of information on the television that foster the behavior must be present.
This necessitates the implementation of anticipatory guidance for oral health in the healthcare system in Ludhiana. It can be broadly defined as a process of providing practical, developmentally appropriate health information about children to their parents on anticipation of significant physical, emotional and psychological milestones.  It should be practiced by health professionals in all areas such as obstetrics, gynecology, pediatric care and well baby care. This is the only way how pediatric and preventive dentistry can be promoted through other fields of medical science in our country. The development of AG model should be hastened because early intervention and prevention is cost-effective and parents have an increasing need for health information.
Early Childhood Caries prevention can be focused on educational programs to alter children's feeding practices and to reduce the level of mutans streptococci infection. Manuals, counseling booklets posters and stickers with messages about preventing baby bottle decay should be distributed at mass levels in schools and especially at the medical centers of general physicians.
Additional methods to foster preventive behaviors in parents whose children are at risk for ECC should be explored by dentists in particular. Psychological approaches such as self-efficacy enhancement and performance feedback techniques may increase parent's confidence in their ability to carry out recommendations and perform oral health preventive behaviors for their children.
Motivation, which can be explained as the will to act, is an important factor in learning. Motivation, support and educations are the key factors in prevention programs that need to be emphasized in the future. The motivating and learning approach appears to be useful in dental settings, especially in periodontal maintenance.  Motivation counseling can help in reducing dental caries in young children. 
Reinforcement by external motivation supports behavioral change, and early oral health education combined with some external motivation can be a valuable tool to prevent caries in young children.
Limitations of the study
The survey was done in the schools around the institution. This might have biased the study results, as the sample taken is not representative of the population.
Early white spot lesions were not included for the purpose of the study. This might have underestimated the actual caries prevalence.
General health practitioners, pediatricians and nurses should be encouraged to integrate oral health education into health instructions delivered to parents of young children.
Parents should be encouraged to realize that they play the dominant role as models for their children. Parents' own oral health behaviors and their active role in performing oral cleaning for their children should be emphasized in dental and general health settings. Public health centers, which provide counseling for expectant parents should cover oral health topics in their education.
When the goal is to establish programs to improve children's oral health partnerships of health professionals with educational institutions should be built upon the assets and strengths of each other.
Whenever possible dental and dental hygiene students should be included in community and school-based programs to provide a service learning experience.
To provide dental care for impoverished children, institution-based preventive programs that use portable dental equipment or mobile dental vans can be used.
Appropriate targeting for such programs include identifying schools with a high percentage of children who qualify for Government of India's mid-day meal scheme (indicative of low-income group), who are least likely to receive regular dental care and are at a high risk for dental caries.
The results of the present study can be used mainly for screening child populations in need of treatment, helping public workers and planners to develop dental health programs to aid early intervention and prevention.
Our sincere thanks to Principals, Pothohar Khalsa Public School, Dashmesh Senior Secondary School, Sargodha Khalsa High School, S.P. Jain Public School, Kalgidhar Khalsa Girls High School and Ewing Christian School and all the children and their parents who participated in this study. We also acknowledge the efforts of our statistician Mr. Gurinderjit Singh (Guru Nanak Dev University, Amritsar, India) for the data analysis.
|1||American Academy of Pediatric Dentistry. Definition of Early Childhood Caries (ECC). Pediatr Dent 2005;27:13.|
|2||Ribeiro NM, Ribeiro MA. Breastfeeding and early childhood caries: a critical review. J Pediatr (Rio J) 2004;80:S199-210.|
|3||Oliveira AF, Chaves AM, Rosenblatt A. The influence of enamel defects on the development of early childhood caries in a population with low socioeconomic status: A longitudinal study. Caries Research 2006;40:296-302.|
|4||Nordblad A, Souminen-Taipale L, Rasilainen J, Karhunen T. Suun terveydenhuoltoa terveyskeskuksissa 1970-luvulta vuoteen 2000 (Oral Health Care at Health Centers from the 1970s to the year 2000). Helsinki: National Research and Development Center for Welfare and Health (STAKES), Report 278, 2004.|
|5||Holm AK. Caries in the preschool child: international trends. J Dent 1990;18:291-5.|
|6||Center for Disease Control (CDC). Oral health improving for most Americans, but tooth decay among preschool children on the rise. Centers for Disease Control and Prevention. Available from: http://www.cdc.gov/nchs/pressroom/1june 07newsreleases/oral health.htm.|
|7||Pitts NB, Palmer JD. The dental caries experience of 5-year-old children in Great Britain. Surveys coordinated by the British Association for the Study of Community Dentistry in 1993/94. Community Dent Health 1995;12:52-8.|
|8||Ripa LW. Nursing caries: a comprehensive review. Pediatric Dentistry 1988;10:268-82.|
|9||Tsai AI, Chen CY, Li LA, Hsiang CL, Hsu KH. Risk indicators for early childhood caries in Taiwan. Community Dent Oral Epidemiol 2006;34:437-45.|
|10||Carino KM, Shinida K, Kawaguchi Y. Early childhood caries in northern Philippines. Community Dent Oral Epidemiol 2003;31:81-9.|
|11||Jin BH, Ma DS, Moon HS, Paik DI, Hahn SH, Horowitz AM. Early childhood caries: prevalence and risk factors in Seoul, Korea. J Public Health Dent 2003;63:183-8.|
|12||Douglass JM, Wei Y, Zhang BX, Tinanoff N. Caries prevalence and patterns in 3-6-year-old Beijing children. Community Dent Oral Epidemiol 1995;23:340-3.|
|13||Mayanagi H, Saito T, Kamiyama K. Cross-sectional comparisons of caries time trends in nursery school children in Sendai, Japan. Community Dent Oral Epidemiol 1995;23:344-9.|
|14||Fujiwara T, Sasada E, Mima N, Ooshima T. Caries prevalence and salivary mutans streptococci in 0-2-year-old children of Japan. Community Dent Oral Epidemiol 1991;19:151-4.|
|15||Jose B, King NM. Early childhood caries lesions in preschool children in Kerala, India. Pediatr Dent 2003;25:594-600.|
|16||Mahejabeen R, Sudha P, Kulkarni SS, Anegundi R. Dental caries prevalence among preschool children of Hubli: Dharwad city. Journal of Indian Society of Pedodontics and Preventive Dentistry 2006;24:19-22.|
|17||Gussy MG, Waters EG, Walsh O, Kilpatrick NM. Early childhood caries: Current evidence for etiology and prevention. Journal of Pediatrics and Child Health 2006;42:37-43.|
|18||Overton Dickinson A. Community oral health education. In: Mason J, editor. Concepts in Dental Public Health. Philadelphia: Lippincott Williams and Wilkin; 2005. p. 139-57.|
|19||Pitts NB. Modern concepts of caries measurement. Journal of dental research 2004;83(Spec Iss C):C43-7.|
|20||Peter S. Essentials of preventive and community dentistry. 1 st ed. Arya (medi) Publishing House; 1999. p. 503.|
|21||World Health Organization (WHO). Global strategy for infant and young child feeding. Geneva: WHO; 2003.|
|22||Ismail AI, Tanzer JM, Dingle JL. Current trends of sugar consumption in developing societies. Community Dent Oral Epidemiol 1997;25:438-43.|
|23||Belterami G. Les dents noires de tout-petits. Siθcle Mιdical. In: Belterami G, editor. La mιlandontie infantile. Marseille: Leconte; 1952.|
|24||Fass E. Is bottle feeding of milk a factor in dental caries? J Dent Child 1962;29:245-51.|
|25||Stookey G, Hamilton JC. Should a dental explorer be used to probe suspected carious lesions? JADA 2005;136:1526-32.|
|26||Grindefjord M. Prediction and development of dental caries in young preschool children. Thesis. Stockholm: Karolinska Institutet; 1995.|
|27||Amarante EC. Prevalence of dental caries and periodontal disease in 5-, 12-, and 18-yearold children in Bergen, Norway. Thesis. Bergen: University of Bergen, 1995.|
|28||Burt BA. Concepts of risk in dental public health. Community Dent Oral Epidemiol 2005;33:240-7.|
|29||Reisine ST, Psoter W. Socioeconomic status and selected behavioral determinants as risk factors for dental caries. J Dent Educ 2001;65:1009-16.|
|30||Reisine ST, Douglass JM. Psychological and behavioral issues in early childhood caries. Community Dent Oral Epidemiol 1998;26:32-44.|
|31||Sheiham A, Watt RG. The common risk factor approach: a rational basis for promoting oral health. Community Dent Oral Epidemiol 2000;28:399-406.|
|32||Casamassimo PS, Warren JJ. Examination, diagnosis, and treatment planning of the infant and toddler. Pediatric dentistry: Infancy through adolescence. 4ed. Pinkham; 2005. p. 208.|
|33||Wilson TG Jr. How patient compliance to suggested oral hygiene and maintenance affect periodontal therapy. Dent Clin North Am 1998;42:389-403.|
|34||Weinstein P, Harrison R, Benton T. Motivating parents to prevent caries in their young children: one-year findings. J Am Dent Assoc 2004;135:731-738.|