|Year : 2022 | Volume
| Issue : 2 | Page : 124-131
Correlation of caries occurrence in primary teeth using human leukocyte antigen typing and maternal and physiochemical factors
Shraddha Saikia1, Shivani Mathur1, Manvi Malik1, Nikita Gulati2
1 Department of Pediatric and Preventive Dentistry, I.T.S Dental College, Ghaziabad, Uttar Pradesh, India
2 Department of Oral and Maxillofacial Pathology and Microbiology, I.T.S Dental College, Ghaziabad, Uttar Pradesh, India
|Date of Submission||21-Feb-2022|
|Date of Decision||09-May-2022|
|Date of Acceptance||08-Jun-2022|
|Date of Web Publication||15-Jul-2022|
Dr. Shraddha Saikia
I.T.S Dental College, Muradnagar, Ghaziabad - 201 206, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Dental caries being the leading health issue worldwide has no specific cure due to its multifactorial etiology and genetic susceptibility. Hence, this paper attempted to correlate the clinical and hereditary factors between mother and child, to predict the caries occurrence in child in future, and thereby implement early preventive measures. Aim: The aim of the study was to look for an association between maternal and child's human leukocyte antigen (HLA)-DR4 levels and relate it with other physiochemical factors to assess caries susceptibility in children. Methodology: Saliva samples were collected from children who were in the age group of 0–6 years and their mothers by spitting method and swab method. The clinical indicators such as Decayed, Missing, and Filled Teeth, decayed, extraction needed, and filled teeth, salivary flow rate, and pH were recorded by clinical evaluation. The Streptococcus mutans count was measured by culture plate followed by colony count method, and the HLA-DR4 factor was assessed using ELISA. Results: The results revealed a statistically significant correlation between the physiochemical factors of the mother and the child. The genetic factor in which the HLA-DR4 caries indicator was checked also has a strong association between the mother and the offspring. Thus, a strong caries prediction formula was derived through which probability of caries occurrence in the child could be determined prematurely. Conclusion: Thus, it can be concluded that using the clinical and genetic factors, the caries prediction can be done for the child and preventive protocol can be started before disease occurrence.
Keywords: Children, correlation, dental caries, human leukocyte antigen genotyping, mother, physiochemical factors
|How to cite this article:|
Saikia S, Mathur S, Malik M, Gulati N. Correlation of caries occurrence in primary teeth using human leukocyte antigen typing and maternal and physiochemical factors. J Indian Soc Pedod Prev Dent 2022;40:124-31
|How to cite this URL:|
Saikia S, Mathur S, Malik M, Gulati N. Correlation of caries occurrence in primary teeth using human leukocyte antigen typing and maternal and physiochemical factors. J Indian Soc Pedod Prev Dent [serial online] 2022 [cited 2022 Oct 5];40:124-31. Available from: http://www.jisppd.com/text.asp?2022/40/2/124/351051
| Introduction|| |
Dental caries is a complex, chronic, multifactorial disease and is one of the most prevalent diseases worldwide. It affects more than 80% of the population in the world. The factors affecting dental caries have been studied for a long time, and those chiefly contributing are found to be mainly environmental factors such as diet, oral hygiene, fluoride content, and level of colonization of the cariogenic bacteria and host factors such as salivary flow, salivary buffering capacity, position of teeth relative to each other, surface characteristics of tooth enamel, and depth of occlusal fissures on the posterior teeth. Dental caries is also found to have a strong genetic predisposition. It is often caused by the bacterial fermentation of sugars and other dietary carbohydrates, which leads to the decay of tooth mineral.
In spite of all documented studies about the disease, it appears to be more concentrated in specific groups of individuals. The phenomenon is termed as polarization and its cause remains obscure. However, studies like the Vipeholm study proved the evidence of an individual's resistance to caries despite being on highly cariogenic diet. This suggests that susceptibility and resistance to caries could be the result of one or more genotypic, phenotypic, and environmental influences.,,,,
Studies reveal that heredity has for long been associated with caries occurrence in scientific literature. In 1899, G. V. Black wrote that if the family remains in one locality, with the children living under conditions similar to those of their parents in their childhood, the susceptibility of caries will be very similar in majority of the cases.
It has been noticed that evidence of contribution to caries is based on inheritance altered due to the dental hard tissues, the immune response, sugar metabolism and consumption and salivary flow, salivary constituents, and salivary defense systems.
Both hereditary and environmental factors have influence on dental caries, and because of hereditary factor differences, certain environmental factors are potentially more cariogenic for some people than for others. Microorganisms such as mutans streptococci (MS) are one of the most important etiological factors of dental caries, and the individual's immune system, which defends the body against microorganisms, can have an important role. Colonization of MS is often considered to occur after the eruption of primary dentition, during the so-called window of infectivity, when the bacteria are provided with a nonshedding tooth surface to attach to. The actual mechanism of MS colonization has not been identified although studies have shown that the primary source of transmission is through the mother. Other sources of transmission could possibly be from the fathers, siblings, and other children under the same day-care facilities.
Various studies conducted on monozygotic twins have revealed a strong association of genetics and caries susceptibility. Human leukocyte antigen (HLA) or major histocompatibility complex (MHC) molecules have important roles in the immune responsiveness. Multiple studies of genetic etiology of diseases have focused on HLA, which regulates immune response to foreign antigens. HLA is an inherent system of proteins that are encoded by genes of the human MHC and is highly variable among unrelated individuals. The HLA gene complex is divided into two major regions called HLA Class I and HLA Class II. Immune cells of the nonspecific immune defense can bind peptides from foreign antigens to the HLA Class II molecule and display them on the cell surface. This enables activation of the specific immune defense system and production of antibodies. Several studies have also observed an association between the HLA Class II antigen and the etiology of caries. A connection between caries susceptibility and HLA DR4 was also shown. Differences in MHC molecules may cause some variations in immune responses against microorganisms and may influence the child's susceptibility to early childhood caries (ECC). Positive HLA-DRB*04 may increase the risk of ECC by ten times. Genes within MHC, especially the DR4 group, can influence susceptibility to dental caries.
Therefore, when an extracellular organism like bacteria enters the body, antigen-presenting cells like macrophages first process it, then the processed antigen (as a peptide) is linked to the HLA Class II molecule, and this complex is presented to the T-helper cells of the immune system, which activates the immune response. Differences in MHC molecules may cause some variations in immune responses against microorganisms and may influence children's susceptibility to ECC.
Alterations in the immune response to cariogenic bacteria may increase the incidence of caries. Some studies report that there is a relationship between HLA types and an increased incidence of dental caries.,
Literature presented that there have not been many studies that showed an association between dental caries and HLA alleles. Thus, the purpose of this study was to report the possible association between HLA-DR4 complex levels of mother and child for determination of susceptibility to dental caries of the child. Moreover, HLA-DR4 allele was reported to have a part controlling dental caries and to be associated with the levels of microorganisms.,, It is highly difficult to explain this association, since caries formation depends on many other factors in addition to levels of cariogenic organisms and immune responsiveness, such as tooth anatomy, diet, and overall health.
It is probable that there could be patterns of polymorphisms in MHC that renders an individual susceptible or resistant to a given pathogenic organism.
Thus, the aim of this study was to look for an association between maternal and child's HLA-DR4 levels and relate it with other physiochemical factors to assess caries susceptibility in children.
- To evaluate and correlate the presence of HLA-DR4 levels in children and their mothers to detect caries susceptibility in children
- To relate the probability of occurrence of caries in primary teeth by assessing maternal factors
- To assess the MS counts in children
- To evaluate all related physiochemical factors, i.e., salivary pH, salivary flow rate, and salivary buffering capacity that contribute to dental caries
- To record the Decayed, Missing, and Filled Teeth (DMFT) and decayed, extraction needed, and filled teeth (deft) of the mothers and their children, respectively.
| Methodology|| |
The study has been conducted in the Department of Pediatric and Preventive Dentistry, ITS Centre for Dental Studies and Research, Muradnagar, in children aged 12–71 months. Prior approval of the study was taken from the Ethical Committee of the Institution. Informed consent was obtained from each subject's parents/guardians before enrolling them in the study. Using the software OpenEpi version 3 (Atlanta, Georgia, United States of America), a sample size of 40 for each group was calculated.
To evaluate human leukocyte antigen-DR4 immunity factor
Sample size and grouping are described in [Table 1].
Study group consists of:
- Patients in the age group of 12–71 months
- Patients accompanied by their mother.
- Individuals free of any systemic disease
- No allergy to any drug such as local anesthetic (LA)
- Not medically compromised
- No history of congenital and genetic problems.
The patients who were accompanied by their mother and were in the age group of 0–6 years were selected. An extensive case history along with the diet history of the child was recorded. The clinical examination was carried out for both the mother and the child in whom DMFT and deft indexes were recorded. The subjects were then asked to collect their saliva samples in Eppendorf tubes which were then stored at −20°C in a refrigerator. Furthermore, the salivary flow rate and the salivary pH were recorded. The samples were used in the laboratory to derive culture plates for Streptococcus mutans colony counts. The HLA-DR4 kit was used for evaluation of the genetic component, and the testing was done using ELISA.
The data were entered into Microsoft Excel XP software program. Statistical analysis was done by the Statistical Package for the Social Sciences (SPSS) software package (SPSS 16 Inc., Chicago, IL, USA). The normality of data was tested by Shapiro–Wilk's test. The descriptive statistics frequency was calculated. The correlation between parameters was calculated by Spearman's correlation, and linear regression was used to predicate HLA score of child as a dependent variable and pH, flow rate, deft, and S. mutans count as independent variables. The binomial logistic regression was used to predict the presence of caries with DMFT and HLA score of mother and risk ratio for caries calculated. The level of significance and confidence interval will be 5% and 95%, respectively, i.e., P < 0.05.
| Results|| |
Association of Streptococcus mutans count of child and other clinical caries indicators of child
Results showed that S. mutans was seen to have a weakly negative correlation with flow rate, a very strongly positive correlation with deft score, and a weakly positive correlation with DMFT score. The association between S. mutans score and DMFT score was found to be statistically significant, highly statistically significant with deft score, and very highly statistically significant with flow rate indicating an increase in S. mutans with an increase in DMFT score and deft score and a decrease of flow rate [Table 2].
|Table 2: Association of Streptococcus mutans count and other clinical caries indicators|
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Association of human leukocyte antigen score of child with clinical caries indicators of child
Results showed that HLA score of child was seen to have a weak negative correlation with flow rate, a weak positive correlation with DMFT score, a negligible positive correlation with deft score, and a negligible negative correlation with S. mutans count [Graph 1]. The association between HLA score of child and flow rate was statistically significant with flow rate, highly statistically significant with DMFT score, and statistically not significant with deft score and S. mutans count [Table 3] and [Graph 2] and [Graph 3].
|Table 3: Association of human leukocyte antigen score of child with clinical caries indicators|
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Association of human leukocyte antigen score of child with physiochemical factors of child
t-test results show that HLA score of child had a positive correlation with deft score whereas a negative correlation was found with pH, flow rate, and S. mutans count. None of the results were found to be statistically significant [Table 4].
|Table 4: Comparison of human leukocyte antigen score (child) and physiochemical factors|
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Association of Decayed, Missing, and Filled Teeth score of mother with clinical caries indicators of child
Results showed that DMFT score was seen to have a weakly negative correlation with flow rate and a weakly positive correlation with S. mutans count. The association between DMFT score and flow rate was found to be very highly statistically significant whereas, with deft score and S. mutans, it was found to be statistically significant indicating an increase of DMFT score with the decrease of flow rate, increase of deft score, and increase of S. mutans count [Table 5] and [Graph 4].
|Table 5: Association of Decayed, Missing, and Filled Teeth score of mother and other clinical caries indicators|
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Association of human leukocyte antigen score of mother with clinical caries indicators of child
Results showed that HLA score of mother was seen to have a weak negative correlation with flow rate and a negligible positive correlation with deft score and negligible negative correlation with DMFT score and S. mutans count. The association between HLA score of child and all the clinical factors other than flow rate was not statistically significant. The association between HLA score of child and flow rate was found to be statistically significant, indicating that an increase in HLA score of mother is associated with a decrease of flow rate [Table 6].
Human leukocyte antigen predictability of child
Binomial logistic regression method was used to assess the predictability of the HLA of the child from the clinical indicators such as pH, flow rate, deft score, and the S. mutans count [Table 7].
|Table 7: Association of human leukocyte antigen score of mother with clinical caries indicators|
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Thus, HLA of child predictability can be done from an equation derived from the above result as follows:
HLA (child) predictability = 16.213 − 0.616 × pH − 4.581 × flow rate + 0.554 × DMFT score − 0.225 × S. mutans count [Graph 5].
Caries predictability of child
Binomial logistic regression method was used to assess the odds ratio (OR) indicating the risk of the child developing dental caries to be 2.054 times higher if mother's DMFT is increased and a risk of 1.99 times higher chances of caries development with increased HLA of mother [Table 8].
|Table 8: Risk assessment of caries development in the child from mother's caries factors|
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Thus, caries predictability can be done from an equation derived from the above results as follows:
Caries predictability = −8.378 + 0.720 × DMFT score + 0.691 × HLA mother [Graph 6].
| Discussion|| |
Dental caries has been acknowledged by the WHO that it is a major health problem in most industrialized countries, where 60%–90% of children and the vast majority of adults are affected by it. ECC, formerly referred to as nursing bottle caries and baby bottle tooth decay, remains a significant public health problem. The prevalence of dental caries in studies conducted throughout the world was investigated, and it was reported that the overall prevalence of dental caries in primary teeth in children was 46.2%.
ECC is an aggressive form of dental caries that is characterized by a heavy MS infection, which at times exceeds 30% of the cultivable plaque-biofilm flora. Infants whose mothers have high levels of MS, a result of untreated caries, are at greater risk of acquiring the organism earlier than children whose mothers have low levels. Correlations between caries or MS levels in mothers and those in their children may be explained in part by common genetic or environmental factors.
New tools for bacterial identification (e.g., polymerase chain reaction techniques and 16s rRNA gene sequencing) are revealing the complexity of the oral microbiome and other bacterial species that may be associated with ECC. Several studies have also tried to establish a correlation between the dental caries and the genetic profile of the parents and children which is additionally superimposed by environmental factors. Multiple studies of genetic etiology of diseases have focused on HLA, which regulates immune response to foreign antigens. It has been established in the literature that the DR4 allele of HLA Class II is a caries indicator that can be utilized for caries prediction. There is a need to establish the association of HLA inheritance from mother to child and its effect on caries risk in the child.
Association between child's salivary flow rate and his caries indices
In the present study, there was very high statistical significance in the association between flow rate and DMFT score and deft score, indicating an increase in deft score and an increase in DMFT score with a decrease in flow rate.
- Decreasing child's salivary flow rate α increase of his deft score (caries indices)
- Decreasing mother's salivary flow rate α increase of her DMFT score (caries indices).
This was in accordance with the study conducted by Sakeenabi and Hiremath where caries experience among 6-year-old school-going children in Davangere city, India, was assessed. A highly significant (P < 0.01) correlation was seen between the mean caries score and the salivary flow rate. This result is in contrast to the studies conducted previously by Sullivan (1990) and Russell (1990) which showed no significant difference between the salivary pH and salivary flow rate and the mean caries score.,
Association of child's salivary flow rate and his Streptococcus mutans count
Results in the present study showed that flow rate was seen to have a weak negative correlation with S. mutans count. The association between flow rate and S. mutans count was found to be highly statistically significant indicating an increase of bacterial count, with a decrease in flow rate.
Decreasing child's salivary flow rate α increase of his S. mutans count.
Association of deft score of child and his Streptococcus mutans count
In the present study, results showed that the deft score was seen to have a very strong positive correlation with S. mutans count. The association of deft score with S. mutans count was found to be very highly statistically significant.
Increase of deft score of child α increase of his S. mutans count.
This was in accordance with the study conducted by Zhou et al. where the results of the final logistic regression analysis showed that ECC indicator deft score was significantly associated with the S. mutans count (OR = 3.80). Similar results were observed by ElSalhy et al. where S. mutans was significantly (P < 0.05) correlated with DMFS/dmfs score in 122 children below the age of 12 years.
Association of deft score of child and Decayed, Missing, and Filled Teeth score of mother
In the present study, results showed that the deft score was seen to have a weakly positive correlation with DMFT score. The association of deft score with DMFT score was statistically significant indicating that an increase in DMFT score is associated with an increase in deft score. This could be attributed to improper maintenance of oral hygiene and highly cariogenic diet passed on from the mother to the child.
Increase Decayed, Missing, and Filled Teeth (DMFT) score in mother is α (Directly Proportional ) to the increase deft score in child.
Similar results were found in various previous studies. Mothers' caries status was related to preschool children's caries status in Turkey (Ersin et al., 2006), Thailand (Thitasomakul et al., 2009), and New York (Smith et al., 2002).
Association of Decayed, Missing, and Filled Teeth score of mother and child's Streptococcus mutans count
The present study showed that DMFT score was seen to have a weakly positive correlation with S. mutans count. The association between DMFT score and S. mutans count was found to be statistically significant indicating an increase of DMFT score with an increase of S. mutans count. The possible reason for this observation could be the higher vertical transmission of the bacterial load from mother to the child.
Increase of mother's Decayed, Missing, and Filled Teeth score α increase of S. mutans count in child.
This was in accordance with Babaeekhou et al. study where mean comparison analysis showed that there is a strong relationship between S. mutans existence in mouth flora and DMFT scores (P < 0.0001). Similar results were seen by Pannu et al. showing a positive correlation of dental caries with increasing titers of S. mutans.
Association of human leukocyte antigen score with clinical caries indicators
In the present study, results showed that the association between HLA score of child and clinical caries indicators such as salivary flow rate and DMFT score was strong, but with deft score and S. mutans count, it was found to be weak. Results also showed that the association between HLA score of mothers and all the clinical factors other than flow rate was not statistically significant. Thus, it can be observed that the genetic factor for caries development of the mother can be used to predict the caries risk of the child as the present study revealed the existence of a strong association between the genetic factor of the mother and both genetic and clinical caries indicators of the child.
- Increase of HLA score of child α decrease of his salivary flow rate
- Increase of HLA score of mother α decrease of salivary flow rate of child
- Increase of DMFT score of mother α increase of HLA score of child.
The results of the present study were in accordance with the results observed by Bagherian et al. where the results revealed a significant increase in the frequency of HLA alleles in the ECC patient group (P = 0.019) in comparison to the caries-free children. Antony and Munshi concluded in their study that there was a definite quantifiable relationship between mother's caries experience and prevalence of caries in their children. Caufield et al. reached a similar conclusion in their study where the levels of S. mutans found in the saliva of the mother correlated with levels found in her child, demonstrating a quantitative relationship within mother-child pairs.
- Association of child's salivary flow rate and his S. mutans count: it was observed that a decrease in the child's salivary flow rate led to an increase of his microbial count ing the oral cavity
- Association of deft sore of child and his S. mutans count: A direct relationship was established between these two parameters where increase of deft led to an increase of the microbial count
- Association of DMFT score of mother and child's S. mutans count: A positive correlation was found between these two parameters
- Association of deft score of child and DMFT score of mother: A directly proportional correlation was found where both deft and DMFT increase
- Association of HLA score with clinical caries indicators: The results of this parameter were as follows: increase of HLA score of child led to a decrease of his salivary flow rate, increase of HLA score of mother caused decrease of salivary flow rate of child, and increase of DMFT score of mother showed an increase of HLA score of child.
Clinical significance of the study
- The study has established all the possible correlations of caries occurrence between a mother and the child
- A prediction formula has been obtained that can be applied clinically for calculating caries risk occurrence of the child right at infancy
- A chairside diagnosis can be done by identifying some of the clinical parameters of the mother.
Limitations of the study
- For further validation of the findings, a multicenter will be required that targets a bigger population
- Specific gene mapping has to be done that is known to have caused caries
- Other microbial colonies have to be checked.
Why this paper is important to pediatric dentists?
- This paper will help in caries prediction in children at an early age
- Caries can be prevented before the carious activity starts
- The prediction correlates the genetic and biological factors so is accurate and the preventive protocol if applied can be maximally beneficial.
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], [Table 6], [Table 7], [Table 8]