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Journal of Indian Society of Pedodontics and Preventive Dentistry Official publication of Indian Society of Pedodontics and Preventive Dentistry
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Year : 2006  |  Volume : 24  |  Issue : 4  |  Page : 177-181

Early childhood caries and dental plaque among 1-3-year-olds in Tehran,Iran

1 Institute of Dentistry, University of Helsinki, Helsinki, Finland; Shahid Beheshti University of Medical Sciences, Tehran, Iran
2 Institute of Dentistry, University of Helsinki, Helsinki, Finland
3 Shahid Beheshti University of Medical Sciences, Tehran, Iran

Correspondence Address:
Simin Z Mohebbi
Department of Oral Public Health, Institute of Dentistry, University of Helsinki,P. O. Box 41, FIN-00014 Helsinki, Finland

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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0970-4388.28073

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The association between plaque and caries in older children and adults has been poor, however, some studies show that there may be a relationship in younger children. The aim was to study the relationships between dental caries and dental plaque among 12-36-month-olds in Tehran, Iran. A cross-sectional study among a stratified random sample of 504 children aged one to three years from 18 public health centres in Tehran. Mothers were interviewed about their child's date and order of birth, gender, primary caregiver, the mother's age and the educational level of both parents. Dental examination was carried out according to the WHO criteria. Early childhood caries (ECC) was defined as the presence of any dmf teeth. Dental plaque was visually inspected on the labial surfaces of upper central incisors. Data analysis included Chi-square test, t -test, anova and logistic regression modelling. The prevalence of ECC ranged from 3 to 33% depending on age group, with a mean dt of 1.1 for 26- to 36-month-olds. No gender-differences existed in ECC prevalence and mean dt. Dental plaque was visible on at least one index tooth for 65-75% of the children. Presence of ECC was related to the presence of dental plaque (OR=1.5; 95% CI 1.0-2.3) when controlling for background factors by means of logistic regression. The high occurrence of visible plaque and rather high ECC prevalence call for improvement in oral health promotion programs of the children.

Keywords: Dental caries, infants′ oral health, parents′ education

How to cite this article:
Mohebbi SZ, Virtanen JI, Vahid-Golpayegani M, Vehkalahti MM. Early childhood caries and dental plaque among 1-3-year-olds in Tehran,Iran. J Indian Soc Pedod Prev Dent 2006;24:177-81

How to cite this URL:
Mohebbi SZ, Virtanen JI, Vahid-Golpayegani M, Vehkalahti MM. Early childhood caries and dental plaque among 1-3-year-olds in Tehran,Iran. J Indian Soc Pedod Prev Dent [serial online] 2006 [cited 2022 Oct 1];24:177-81. Available from: http://www.jisppd.com/text.asp?2006/24/4/177/28073

   Introduction Top

Early childhood caries (ECC) is a devastating form of caries that may affect the primary dentition as soon as infant teeth erupt.[1],[2] ECC has been defined as the presence of any decayed, missing or filled teeth in the dentition of children under 6 years of age[3],[4] and severe ECC (S-ECC) as any smooth surface caries in children under 3 years of age.[5],[6],[7],[8] The prevalence of caries in pre-school children seems to be on the decline in most of the developed countries but is increasing in many developing countries.[9] The World Health Organization (WHO), however, has no database on the oral health of children less than three years of age. Dental plaque and its early accumulation have been related to the caries experience among children.[10],[11],[12],[13],[14] Despite that, neither the WHO database, nor the national report in Iran has denoted any data regarding the dental plaque in the young children. The aim of the present study was to investigate the relationships between dental caries and dental plaque among 12- to 36-month-olds in Tehran, Iran.

   Materials and Methods Top

The present study was implemented in the public health centres of Tehran city. These centres consist of offices for general oral, occupational and family health and for vaccination and assessment of child development. Children of all socio-economic backgrounds receive childhood vaccinations offered in the public health centres. In Iran, the children under 6 years of age account for about 13% of the total population.[15]

The present cross-sectional data were collected from January to March 2005. Target subjects included children between 12 and 36 months of age and their mothers attending the vaccination and development assessment offices of the public health centres of Tehran city. Using a list provided by the Ministry of Health and Medical Education, 18 out of 102 public health centres were selected to represent the regions in Tehran. The number of selected centres was proportional to the total number of centres in that region. Four working days were devoted to each health centre. On these days, all target-age children visiting the centre were selected, resulting in 20-35 children per centre. The mothers were asked to give their consent to participate in the study; only two refused.

Mothers were first interviewed with a pre-tested, structured questionnaire and after that, the child was examined. The questionnaire covered background factors such as child's date and order of birth, gender, primary caregiver, the mother's age and the educational level of both parents. The age of the child was determined within an accuracy of one day.

Information about the child's primary caregiver was obtained along with alternatives such as mother, father, grandmother and others. For the mother's age, the accuracy was within one year. The level of education was assessed separately for father and mother using a 7-point-scale ranging from illiterate to doctorate degree. The educational level of parents was defined as the highest level of either parent's education and then categorized into three: low (primary school or illiterate), moderate (diploma or high school education) and high (university education). For some further analyses, this was dichotomized as having a university education or not.

For the clinical dental examinations, one of the authors (SM), having a five-year experience as practicing dentist, was further trained by an experienced paediatric dentist, head of the university paediatric department. The training ended into double examination of 10 children and the intra-examiner reliability, a Cohen's kappa value, was 0.8 for recordings on dental plaque and 1.0 on caries. Dental examination was carried out with the help of a headlamp and a plane dental mirror with the mother and examiner sitting in a knee-to-knee position, the child on their laps and the mother controlling his/her feet and hands.

Dental diagnoses were recorded for each tooth. Every tooth was recorded as present when visible in the mouth, otherwise as absent. The criteria for caries diagnoses were according to the WHO recommendations.[16] Decayed teeth (dt) included the teeth with visually diagnosed cavitated lesions. If doubt existed, the surface was investigated with a WHO probe. When the tip failed to enter the lesion, the tooth was recorded as sound (non-carious). ECC was defined as the presence of any dmf teeth and severe ECC (S-ECC) as caries on smooth surfaces.[3],[4],[5] Dental plaque was visually inspected on the labial surfaces of upper central incisors and recorded as (0) no plaque, (1) plaque present at gingival margin only and (2) abundant dental plaque covering more than gingival margin of the tooth.

The mothers gave informed consent to participate in the study. The subjects were entered into the database with a numerical code only. There was no remuneration except for the disposable dental mirror by which the clinical examination of the child was done.

Evaluation of the statistical significance of the differences between subgroups was carried out by means of the t -test and anova for comparison of mean values and the Chi-square test for frequencies. The odds ratio (OR) was determined as a cross-product and by means of logistic regression modelling, controlling for the child's age. For the mean values and ORs, the corresponding 95% confidence intervals (95% CI) were determined. Goodness of fit was assessed by means of the Hosmer and Lemeshow test. A P -value less than 0.05 denoted statistical significance.

   Results Top

A total of 504 children, 254 boys and 250 girls were enrolled. Four age groups were formed for the data analysis (12-15, 16-19, 20-25 and 26-36 months). The two youngest age groups became over-represented due to the recommended vaccine shots at 12 and 18 months of age. More than half of the children were the first born in the family and for 91%, mothers were the primary caregivers. The mothers' ages ranged from 15 to 46 years (mean 27.8, 95% CI 27.4-28.3) with no differences by children's age group ( P =0.4) or gender ( P =0.1). Parents' level of education was low for 19% of children, moderate for 47% and high for 34%, with no differences between the age groups or genders of the children.

Dental state of the 1- to 3-year-olds is described by age group in [Table - 1]. On average, the youngest age group had 6.2 teeth while the 26- to 36-month-olds had 19.2. For the latter group, the mean number of dt was 1.1. No gender-differences existed in these figures within the age groups. Almost all dmft was due to untreated caries (dt) except for one 26-month-old girl who had two filled teeth making mean dmft for the oldest group 1.2. The youngest children experiencing decay were three 12-month-olds with caries on their upper central incisors.

Prevalence of ECC in the youngest age group (12-15 months) was 3%, being 9% for 16- to 19- and 14% for 20- to 25-month-olds and 33% for the 26- to 36-month-olds ( P <0.001). There was no gender-difference in the ECC prevalence within the age groups ( P >0.05). ECC prevalence was not related to the child's birth order, his/her primary caregiver (mother or else) or to parents' level of education. For the three youngest age groups, all caries were on smooth surfaces; the prevalence of S-ECC for these age groups was equivalent to that of ECC. In the oldest age group, 26- to 36-month-olds, the prevalence of S-ECC was 27%.

[Table - 2] shows mean number of dt by parent's level of education. Among all children, those of more highly educated parents exhibited lower dt ( P <0.05) than did the others. By age group, the difference was most prominent for the 20- to 25-month-olds.

Visible dental plaque appeared on at least one upper central incisor for 65% of the 12- to 15-month-olds and for 75% of the 26- to 36-month-olds ( P <0.001). [Table - 3] shows percentages of the 1- to 3-year-olds having dental plaque, separately for each age group according to the parents' level of education. The only difference exceeding statistical significance was that for the 12- to 15-month-olds ( P =0.02). Abundant dental plaque dominated among the children 16 months of age and older, being present for more than half of them [Table - 4]. Abundant plaque occurred more frequently among those children with lowly educated parents (OR=1.5; 95% CI 1.1-1.9), when analyzed by means of a logistic regression model, controlling for the child's age. No more than 31% of the children with university educated parents, but 43% of the other children had abundant dental plaque (OR=1.6; 95% CI 1.1-2.4).

Regarding the occurrence of ECC among the 26- to 36-month-olds, that was more likely (OR=3.3; 95% CI 1.2-9.1) among those with abundant dental plaque. The bivariate analysis showed no such difference for the younger age groups.

For all children, the presence of ECC was more likely the older the children (OR=1.1; 95% CI 1.1-1.2) and the more dental plaque (OR=1.5; 95% CI 1.0-2.3) they had as shown in a logistic regression analysis controlling for child's age and gender and parents' level of education [Table - 5]. The model fitted well ( P =0.78).

   Discussion Top

The present cross-sectional study provided valuable information on oral health of the children in the age group of 12- to 36-month-olds, included neither in WHO database nor in the National Oral Health Survey in Iran, despite their increased risk for ECC.[2] The results reveal serious problems in the dental state and oral cleanliness of 1- to 3-year-olds in Tehran, indicating a lack of proper oral health care for children in this age group.

Our stratified random sampling procedure, designed to provide a group representative of 12-36 month-olds in Tehran city, resulted in a good coverage of population throughout the city. In Iran, opposite to many countries where mother and child centres predominantly serve lower socio-economic populations,[17] children's vaccinations are widely taken in the public centres regardless of a family's socio-economic situation, thus providing a representative sample in the present study. In addition, the distribution of the present child population by the parents' level of education is comparable to that of urban population in Iran.[15],[18] Among the age groups, the youngest ones were over-represented due to the recommended vaccine shots at 12 and 18 months of age.

Using the WHO criteria in definition of dental caries generally allows for reliable diagnoses, on the other hand, such a rough criterion could result in slightly under-estimated prevalence figures due to excluding the white spots.

In the present study, the prevalence of ECC ranged from 3 to 33% in the four age groups. Unfortunately, recent reports for the same-age children in neighbouring countries are rare. However, the present results correspond fairly well with that witnessed in Jordan for 1-year-olds.[19],[20],[21] For the older ones, the figure was somewhat higher in Iran (33% vs . 21-25%). In general, more international variation in ECC prevalence exists for those aged two years and older but not for the younger ones. For corresponding age groups, the reported prevalence of ECC ranges from 3% to 59% in Western Pacific and South-East Asia, with the highest being for Philippines[22],[23],[24] and in the Middle East, from 5% to 47% with the highest standing for Abu Dhabi.[19],[20],[25] In developed countries, the corresponding figures are between 4 and 56% in U.S. with the higher values standing for Native Americans while being as low as 0.5-2% in European countries such as Finland and Sweden as summarized by Douglass et al .[8]

Mean dmft for the present children was lower than that of Abu Dhabi (1.2 vs . 2.2),[25] but was the same as that of Jordan for the same age group.[19] Mean dt in the present children was only about one fourth of that in South-East of Asia (1.1 vs . 4.2),[22] but being almost totally S-ECC, it should therefore be considered problematic. No gender-difference appeared in the prevalence of caries or in mean dmft, which concurs with several previous studies,[19],[22],[23],[26],[27] but contrasts with some recent studies reporting more dental caries in boys.[11],[28] Compared to the younger age groups, mean values of dt and prevalence of ECC for the older children of the present study were greater which concurs with some previous findings.[16],[19],[25]

An alarming finding was the high occurrence of dental plaque among these 1- to 3-year-olds; the present figures exceed those of some recent studies.[11],[12] The clear relationships between the presence of ECC and of dental plaque verified for the present children by both bi- and multivariate analyses are in line with earlier studies.[10],[11],[12],[13],[14] Although the prevalence of ECC for the present 12 to 19 month-olds was rather low, the high occurrence of dental plaque indicates their increased risk for future caries calling for imperative procedures to reduce that risk factor.

Lower prevalence of dental caries and lower mean dmft scores have been associated with higher levels of education either of both parents or of the mother or father alone.[10],[18],[23],[25],[26],[29],[30] The present study revealed this same relationship, which may indicate the importance of both parents shared roles in maintaining children's oral health in today's society.

In conclusion, due to the result that ECC was more prevalent in children with more dental plaque, the high occurrence of visible plaque, especially in the children of lowly educated parents and rather high prevalence of ECC call for an improvement in children's oral health maintenance among all who serve as the dominant primary caregivers of the children. Oral health promotion programmes should be extended to all health care facilities where children from all socio-economic levels are visiting from infancy on.

   Acknowledgment Top

Financial support by the Iran Center for Dental Research (ICDR) is warmly acknowledged.

   References Top

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27.Masiga MA, Holt RD. The prevalence of dental caries and gingivitis and their relationship to social class amongst nursery-school children in Nairobi, Kenya. Int J Paediatr Dent 1993;3:135-40.  Back to cited text no. 27    
28.Peressini S, Leake JL, Mayhall JT, Maar M, Trudeau R. Prevalence of early childhood caries among First Nations children, District of Manitoulin, Ontario. Int J Paediatr Dent 2004;14:101-10.  Back to cited text no. 28    
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[Table - 1], [Table - 2], [Table - 3], [Table - 4], [Table - 5]

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[Pubmed] | [DOI]
29 Feeding habits as determinants of early childhood caries in a population where prolonged breastfeeding is the norm
S. Z. Mohebbi,J. I. Virtanen,M. Vahid-Golpayegani,M. M. Vehkalahti
Community Dentistry and Oral Epidemiology. 2008; 36(4): 363
[Pubmed] | [DOI]
30 Feeding habits as determinants of early childhood caries in a population where prolonged breastfeeding is the norm
Mohebbi, S.Z., Virtanen, J.I., Vahid-Golpayegani, M., Vehkalahti, M.M.
Community Dentistry and Oral Epidemiology. 2008; 36(4): 363-369
31 Mothers as facilitators of oral hygiene in early childhood
Mohebbi, S.Z., Virtanen, J.I., Murtomaa, H., Vahid-Golpayegani, M., Vehkalahti, M.M.
International Journal of Paediatric Dentistry. 2008; 18(1): 48-55
32 Relation of the oral health state to some socioeconomic factors in children aged 2-5 [Relación del estado de salud bucal con algunos factores socioeconómicos en niños de 2-5 años]
Quiñones Ybarría, M.E. and Ferro Benítez, P.P. and Martínez Canalejo, H. and Rodríguez Valdéz, Y. and Seguí Ulloa, A.
Revista Cubana de Estomatologia. 2008; 45(3-4)


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