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Year : 2008  |  Volume : 26  |  Issue : 4  |  Page : 153-157

The prevalence of nursing caries in Davangere preschool children and its relationship with feeding practices and socioeconomic status of the family

Senior Lecturer, I.T.S. CDSR Dental College and Hospital, Delhi-Meerut Road, Muradnagar, Ghaziabad, UP, India

Correspondence Address:
R Tyagi
I.T.S. CDSR Dental College and Hospital, Delhi-Meerut Road, Muradnagar, Ghaziabad, UP
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0970-4388.44030

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The aim of the present study was to find the prevalence of nursing caries in Davangere preschool children and its relationship with feeding practices and socioeconomic status of the family. Materials and Methods: A total of 813 children aged 2-6 years were screened for the present study from randomly selected three kindergarten schools each from Government, Government aided, and private managements. Clinical examination was done inside the respective schools. At the time of examination, a proforma was filled for each child comprising of DFS index. The questionnaire by Winter et al. was modified and used in this study. The completed proformas were statistically analyzed to find if any correlation existed between the nursing caries to the feeding practices and socioeconomic status of the family. Results: Duration of breastfeeding increases the number of children with nursing caries and the mean DFS. There is a strong and significant relationship between the severity of nursing caries and the degree of feeding abuse. Children from low socioeconomic status have increased early childhood caries. Conclusion: The prevalence of nursing caries was 19.2% in Davangere preschool population. Nursing caries were more in children who were taking a feeding bottle to bed at night and were increasingly seen in large families and lower socioeconomic groups.

Keywords: Feeding practices, nursing caries, preschool, socioeconomic status

How to cite this article:
Tyagi R. The prevalence of nursing caries in Davangere preschool children and its relationship with feeding practices and socioeconomic status of the family. J Indian Soc Pedod Prev Dent 2008;26:153-7

How to cite this URL:
Tyagi R. The prevalence of nursing caries in Davangere preschool children and its relationship with feeding practices and socioeconomic status of the family. J Indian Soc Pedod Prev Dent [serial online] 2008 [cited 2022 Oct 4];26:153-7. Available from: http://www.jisppd.com/text.asp?2008/26/4/153/44030

   Introduction Top

Nursing caries is a form of rampant caries in primary teeth of young children. The feature that distinguishes nursing caries as defined here from classical rampant caries is the specified absence of lesions on the mandibular incisors, which are protected by action of tongue and lower lip during feeding, and pooled sublingual saliva. [1]

Nursing-bottle caries, nursing-bottle mouth, nursing-bottle syndrome, night-bottle syndrome, bottle mouth, baby bottle caries, nursing mouth, [2] and maternal derived  Streptococcus mutans Scientific Name Search are terms that have been applied to a unique pattern of dental caries in young children. In 1985, the term 'baby bottle tooth decay' was proposed by the healthy mothers-healthy babies coalition. Early childhood caries is relatively a new term that describes rampant dental caries in infants and toddlers. [3]

The etiology of nursing caries is indistinguishable from other coronal carious lesion, representing the interaction between pathogenic microorganisms, fermentable carbohydrate substrate, host susceptibility, and time. Uniquely, lesions progress rapidly when cariogenic challenge overwhelms the protective mechanisms. Time is an essential factor in the development of nursing caries and prolonged nursing, especially at night, is a major contributor. [4],[5]

In addition to biological factors, demographic factors such as age, oral hygiene, socioeconomic, and cultural characteristics can affect the development of nursing caries. Most studies have found an inverse relation between oral hygiene status and the incidence of nursing caries. Low parental education, family income, and single marital status may also predispose to nursing caries. [4]

Nursing caries is a frustrating condition that is difficult to treat in infants and very young children. It may retard the child's health, is infectious, and results in impairment of nutrition and esthetics with accompanying psychological problems. [6]

Various studies have been done to determine the prevalence of nursing caries. In England the prevalence has been reported ranging from 6.8-12% and in USA prevalence being reported from 11.0-53.1%. [7] A very few prevalence studies have been done in India. One such study done in Udupi district of Karnataka has reported nursing caries prevalence of 19.44%. [8]

Aims and Objectives

The present study was undertaken with the main aims and objectives of:

  1. Finding the prevalence of nursing caries in Davangere preschool children.
  2. Determining the relationship of nursing caries with feeding practices and socioeconomic status of the family.

   Materials and Methods Top

The present study was conducted on 813 children between 2-6 years of age. These children were examined at random from various kindergarten schools in Davangere, Karnataka.

Armentarium used were sterile mouth mirror, explorer, tweezers, kidney tray, instrument pouch, enamel tray, and Dettol, disposable surgical latex gloves, disposable mouth masks, questionnaire, and a torch.


Clinical examination was done inside the respective schools. The children, aged 2-6 years, were made to sit on a small chair during dental examination. The knee-to-knee examination method was also utilized in very young children.

Screening procedure


All the children were examined by the same examiner inside the respective schools. To minimize the intraexaminer variability, the children who were observed on the previous day were reexamined before examining a new batch of children.

For each child a format was filled which comprised of:

  1. Number of teeth present.
  2. DFS index (according to Gruebbel criteria). [9]
  3. The criteria used for nursing caries, that is, the presence of caries on the labial or lingual surfaces of at least two maxillary incisors with absence of caries in mandibular incisors. [1],[10],[11]


The questionnaire by Winter et al. [10] was modified and used in this study. The questionnaire consisted of two parts. The first part consisted of feeding practices and the tooth brushing, and the second part consisted of social factors and social class which had to be filled by the parents of the child with nursing caries.

Socioeconomic status or social classification

All over the world, the social scientists have considered occupation as the most important determinant of the level of social standing of an individual in society. In India, Prasad's classification of 1961, further modified in 1968 and 1970, is based on per capita income. Prasad's classification has been used in most Indian studies and has been quite effective in their task. The income limits emphasize only the need for updating this classification with time. Realizing this need, Kumar [12] linked Prasad's classification with the All India Consumer Price Index as both of them shared the same base year of 1961.

Thus, using the above method, the Prasad's classification was modified to the year January 2003. We considered class I and II as high socioeconomic groups, class III as middle, and class IV and V as low socioeconomic groups.

The completed proformas were statistically analyzed to find if any correlation existed between the nursing caries to the feeding practices and socioeconomic status of the family.

   Results Top

In age-wise distribution of nursing caries, out of 23, 63, 342, 237, and 148 children examined in the respective age groups of two, three, four, five, and six years, 9 (39.1%), 7 (11.1%), 53 (15.5%), 58 (24.5%), and 29 (19.6%) children were diagnosed with nursing caries, respectively. Thus of total 813 children examined, 156 had nursing caries with a prevalence rate of 19.2%. In the sex-wise distribution of nursing caries, 79 (20.0%) of 395 male children were infected and 77 (18.4%) of 418 female children were infected. The results were not statistically significant.

The DFS in relation to the presence or absence of nursing caries group ranged from 2-19 with a mean of 7.7 ± 3.4. In the general population, the DFS ranged from 0-15 with a mean of 0.9 ± 1.6. This result was highly significant with P < 0.

Out of 156 children diagnosed with nursing caries, bottlefeeding was present in 79 (51%) and was absent in the 77 (49%). There was significant increase in mean DFS in the children who were bottlefed (8.5 ± 3.7) compared to children not being fed in bottle (6.9 ± 3.0). Of 156 nursing caries children, the mean DFS increased from 7.0 ± 4.0 to 8.1 ± 4.0 as the duration of breastfeeding increased, but was not statistically significant [Table 1]. Of 79 bottlefed children, there was no significant difference in the mean DFS between the presence and absence of nocturnal bottlefeeding [Table 2].

Sixty-three percent of the bottlefed children were using other substances in the bottle (DFS = 8.5 ± 3.5), whereas 37% were not using any other substances in the bottle (DFS = 8.6 ± 4.0). However, there was no significant difference in the mean DFS. Nearly 7% of the children were using sweetened nipple, while 93% of the children were not. The respective mean DFS scores were 9.5 ± 4.4 and 7.6 ± 3.3, which was not significant. The dummy was used by 5% of children with a mean DFS of 10.1 ± 5.5 and was not used by 95% of children with a mean DFS of 7.6 ± 3.3. The difference in mean DFS was significant. The mean age at which the brushing started was 2.4 years with a range of 1-5 years. Seventy-one percent of the children with nursing caries were being brushed with the help of their mothers and 29% of children brushed themselves. Among the nursing caries children, 72% brushed once in a day and 28% brushed twice a day.

Of the total 156 nursing caries children, 5.8% were from class I category, 20.5% from class II, and 20.5% from class III category. Forty-two point three percent were from class IV category and 10.9% from class V category. Thus, 26.3% of children were in high socioeconomic group, 20.5% in middle socioeconomic group, and 53.2% children in low socioeconomic group [Table 3]. Thirty-seven children (24%) were from a family with ≤4 members. One hundred and nineteen children (76%) were from the family with >4 members.

   Discussion Top

A total of 813 children aged 2-6 years were screened for the presence of nursing caries from randomly selected three kindergarten schools each from Government, Government aided, and private managements, so that it represented the different categories of schools in Davengere.

The prevalence of nursing caries in the present study was 19.2%, which is same as that shown by Tandon and Sethi [8] in Udupi District of Karnataka. The prevalence reported in Western countries is varied, ranging from 1-75%. [7] Criteria used in our study is similar to that used by Winter et al. [10] who reported a prevalence of 8% (1971) and 12%. Matee et al. [13] have reported an overall prevalence of 10.6% in Tanzania and Raadal et al. [14] have reported a prevalence of 5.5% in Sudan, whereas Broderick et al. [15] have reported a prevalence of 72% and 55% in Navajo and Cherokee children, respectively. Weinstein et al. [16] have reported a prevalence of 29.6% in United States.

Discrepancies within and between studies may occur because there is no universally accepted definition of nursing caries and no suitable epidemiologic index for nursing caries has been developed. Some investigators have established diagnosis of nursing caries solely on the basis of caries affecting one, two, or three maxillary incisors, caries of maxillary incisors or primary molars, or the labiolingual pattern of decay affecting maxillary incisors. Application of different schemata for nursing caries to the same population yields different nursing caries prevalence rates. [7]

There has been no significant difference in the incidences of nursing caries between males and females. This is in agreement with the study of Dilley [2] and Wyne et al. [1]

In our present study, the mean DFS was 7.7 ± 3.4 in the nursing caries children which is significantly higher compared to children with no nursing caries. This is in agreement with that of Harrison et al. However, the DFS in our study was not as high as of Harrison et al. [17] who reported a DFS of 22.3 ± 13.4. Louie et al. [18] reported a DFS range of 4.80-16.55, whereas Trubman [19] has reported DFS of 2.33 in 3-year-old and 9.99 in 6-year-old children.

We observed that duration of breastfeeding increases the number of children with nursing caries and the mean DFS. The controversial issue of cariogenecity of human milk is still unresolved. [5] There are suggestions from case reports that prolonged and excessive breastfeeding is associated with rampant tooth decay in infants. [20],[21],[22] Small epidemiological studies have suggested that frequent breastfeeding is associated with caries prevalence of around 5-10%. [13],[23] However, the relationship between breastfeeding and dental caries is likely to be complex, as it is confounded by many biological variables such as mutans streptococci infection, enamel hypoplasia, intake of sugars, as well as social variables, such as parental education and socioeconomic status. [23]

Our investigation showed that 51% nursing caries children were bottlefed and 49% children with nursing carries were not fed by bottle. This is in agreement with study by Eronat, [24] where among 71 patients with rampant caries, bottlefeeding was present in 57.75% and absent in 42.25%. The mean DFS in our study was 8.5 ± 3.7 in bottlefed nursing caries children which is significantly higher in comparison to children who were denied bottle feeds. This is supported by the study of Babeely et al. [25] who concluded that there is a strong and significant relationship between the severity of nursing caries and degree of feeding abuse. Another important criterion is the content of the bottle. Sixty-three percent of children who were bottlefed were using other substances like Horlicks, sweet water, and juices. Added sugar is one of the important factor that provides the carbohydrate source and when used for prolonged periods can promote high acid production by mutans streptococci. [5]

In our study, 66% of nursing caries children took bottle to bed at night, while 34% did not. This finding is similar to that of Febres, [26] where in a group of children with baby bottle tooth decay, 78.9% children slept with the bottle in comparison to 21.1% who slept without the bottle. However in our study, the mean DFS did not show an increase between the children with or without nocturnal bottlefeeding. Several studies have reported that the majority of US preschool population take, or have taken, a bottle to bed. Tinanoff and Sullivan [3] in their study of US head start children concluded that 86% of children with caries of the maxillary anterior incisors were reported to have taken a bottle to bed, but surprisingly 69% of those who did not have maxillary anterior caries also reportedly were in the habit of taking a bottle to bed. So, blaming sleeping with a bottle of milk may oversimplify the cause of nursing caries.

According to this study, the comforter bottle and dummy use were limited to a very few children in the population. Only 7% of the nursing caries group used comfort bottle and dummy was used by 5% of the total nursing caries children. However, the mean DFS has shown a higher value in the case of comforter bottle and dummy users. These dummies are usually dipped in sugar solution or honey. Numerous reports have indicated an association between use of sweetened pacifier and nursing caries in preschool children. [10],[27],[28]

Our investigation revealed that although almost all children received the benefits of oral hygiene, the practice was not initiated until the mean age of 2.4 years. By this time, all the primary teeth would have probably erupted. Studies have suggested that oral hygiene measures should begin shortly after the first tooth erupts. In our present study, it is of interest that 71% of nursing caries children are being brushed by the mothers which is similar to the study by Dilley et al. [2] Studies have shown that the preschool child does not have the understanding or the manual dexterity to maintain good oral hygiene. However, it is surprising to see that children who have been brushed by mothers are shown to have more nursing caries. The frequency of brushing was once in a day in 72% of children which is in contrast to the study by Reisine S. [29] These results are difficult to explain and suggest more indepth questioning about oral hygiene behavior are needed to evaluate the effects of oral hygiene on nursing caries.

More children with nursing caries were from class IV and class V social groups. This relationship between low socioeconomic status and caries agrees with earlier observation by Grytten et al. , [30] Chosack et al. , [31] Grindefjord et al. , [32] and Louie et al. [18] Individuals from lower socioeconomic status experience financial, social, and material disadvantages that compromise their ability to care for themselves, obtain professional healthcare services, and to live in a healthy environment, all of which lead to reduced resistance to oral and other diseases. Chen [33] cites numerous studies demonstrating the low socioeconomic status individuals have more fatalistic beliefs about their health and have lower perceived need for care, leading to less selfcare and lower utilization of preventive health services.

In the present study, 76% of children were from large family with more than four members. These findings tend to agree with Silver's [34] and Muller's [35] conclusion that a crowded home seems to favor the development of nursing-bottle syndrome. When the number of siblings is high, the attitude shown by the parents varies significantly in terms of their ethnic origin. The mother, unequal to the task of coping adequately with the overlarge household, has no time, therefore to cuddle her latest born. She resorts to bottle or the pacifier to calm the child and to give him pleasure. [2],[34]

   Conclusion Top

The prevalence of nursing caries was 19.2% in Davangere preschool population and there was no statistical significance in the incidences of nursing caries between male and female children. Conclusion from the present study has it that the percentage of nursing caries children and mean DFS increases as the duration of breastfeeding increases. Also, nursing caries increases in children who carry a bottle to bed at night. Mean age o f starting brushing is 2.4 years among nursing caries group, which is very late. Nursing caries were seen more in larger family and lower socioeconomic group.

The outcome of this study gives a brief insight to the prevalence and relationship of nursing caries with feeding practices and socioeconomic status of the family among preschool children in the Indian suburb. It is however prudent to carry out an indepth screening survey on a larger preschool child population to draw definite conclusion about nursing caries.

   References Top

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  [Table 1], [Table 2], [Table 3]

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 © 2005 - Journal of Indian Society of Pedodontics and Preventive Dentistry | Published by Wolters Kluwer - Medknow 
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