Journal of Indian Society of Pedodontics and Preventive Dentistry
Journal of Indian Society of Pedodontics and Preventive Dentistry
                                                   Official journal of the Indian Society of Pedodontics and Preventive Dentistry                           
Year : 2019  |  Volume : 37  |  Issue : 4  |  Page : 339--344

A cross-sectional study to assess the prevalence of early childhood caries and associated risk factors in preschool children in district Mandi, Himachal Pradesh

K Sharma, KK Gupta, A Gaur, AK Sharma, V Pathania, VB Thakur 
 Department of Pedodontics and Preventive Dentistry, Himachal Dental College, Himachal Pradesh University, Mandi, Himachal Pradesh, India

Correspondence Address:
Dr. K Sharma
Department of Pedodontics, Himachal Dental College, Sunder Nagar, Mandi - 175 002, Himachal Pradesh


Aim: The aim of this cross-sectional study is to investigate the prevalence and related risk factors of early childhood caries (ECC) in preschool children of district Mandi, Himachal Pradesh, India. Materials and Methods: A total sample of 2859 children aged between 2 and 6 years were selected from various parts of district Mandi. The status of dental caries and decayed missing and filled teeth (DMFT) score was recorded. Results: ECC increased significantly with age. Boys had significantly higher caries prevalence and mean DMFT score as compared to girls. Children who belonged to low socioeconomic group showed higher caries prevalence and mean DMFT score. Children aged 3–6 years who brushed their teeth twice daily had the least prevalence of dental caries as well as DMFT score when compared to children with one time and no brushing. Conclusion: The early identification of poor oral hygiene and improper feeding habits should be considered in preventive health promotion in low socioeconomic communities of district Mandi, Himachal Pradesh.

How to cite this article:
Sharma K, Gupta K K, Gaur A, Sharma A K, Pathania V, Thakur V B. A cross-sectional study to assess the prevalence of early childhood caries and associated risk factors in preschool children in district Mandi, Himachal Pradesh.J Indian Soc Pedod Prev Dent 2019;37:339-344

How to cite this URL:
Sharma K, Gupta K K, Gaur A, Sharma A K, Pathania V, Thakur V B. A cross-sectional study to assess the prevalence of early childhood caries and associated risk factors in preschool children in district Mandi, Himachal Pradesh. J Indian Soc Pedod Prev Dent [serial online] 2019 [cited 2021 Apr 15 ];37:339-344
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Early childhood caries (ECC) is a devastating form of caries that may affect the primary dentition as soon as infant's teeth erupt.[1] ECC is a term proposed by the American Academy of Pediatric Dentistry and Centers for Disease Control and Prevention in 1994. It was used after recommendation by the National Institute of Dental and Craniofacial Research in 1999 and replaced the old names that described its etiology, such as nursing caries and baby bottle tooth decay.[2]

Studies have found that the frequency of ECC has high prevalence of 50%–80% in high-risk group which is greater among children in families with a larger number of siblings [3] and those whose mothers are younger.[4] Other factor that are related to greater dental prevalence rate are low education of parents, low monthly household income, children with night time bottle feeding & breastfeeding, poor oral hygiene, low socioeconomic status and poor fluoride exposure.[5] According to the literature, young parentage, a low level of education, and insufficient knowledge regarding oral health may lead to a greater prevalence of ECC among children.[6]

The numbers of studies in India have determined the prevalence of ECC in its various parts in the range of 27%–58%. Despite the seriousness of problems due to ECC, there has been a paucity of prevalence studies in Himachal Pradesh, which may be due to the difficulty of access to this age group. The knowledge on the prevalence and associated factors of ECC is necessary to develop targeted interventions for the prevention of subsequent tooth decay, and to decrease the number of children that require emergency treatment. Hence, the aim of this study was as follows:

To determine the prevalence of ECC in preschool children in district Mandi, Himachal PradeshTo determine possible association of ECC with factors such as chronological age, birth weight, geographical distribution, socioeconomic status, educational status of the mother, feeding habits, and quality of oral hygiene and child-related aspects.

 Materials and Methods

Mandi, popularly, also known as “Chotta-Kashi” is centrally located district of Himachal Pradesh with population of 999,777. A total of 2859 preschool children both males and females aged between 2 and 6 years, attending playschools, primary and private schools in different urban and rural parts of district Mandi, Himachal Pradesh, were chosen. American dental association type III examination technique was used. Permission was taken from school authorities prior to the checkup of children. Each child was examined on an ordinary upright chair with the help of mouth mirror and explorer in an adequate natural light. The examination was carried by one examiner only to eliminate error. The data were recorded on a modified WHO Oral Health Assessment form 2013. The clinical and questionnaire data were then analyzed using the IBM SPSS Statistics for Windows (Version 22.0, IBM Corp., Armonk, New York, USA). Pearson's Chi-square and Student's t-test were done to know the effect of each variable and to reveal the statistical significance. The P < 0.05 was considered to be statistically significant.


The caries prevalence and DMFT (decayed missing and filled teeth) of 2859 children of district. The caries prevalence as well as DMFT score increased with age and became significant by the child reached 5 years of age [Table 1]. In the present study, males had more caries prevalence and mean DMFT than females [Table 2]. The more number of children affected with ECC in rural areas than children of urban areas [Table 3]. The bottle-fed children showed higher caries prevalence and DMFT followed by breastfed and glass fed children [Table 4]. The occurrence of ECC and mean DMFT was found to be higher in children of low socioeconomic status and the children of schooling only mothers group [Table 5] and [Table 6]. The caries prevalence and mean DMFT score was highest in children who did not brush their teeth as compared to children who brushed their teeth once or twice daily [Table 7]. The caries prevalence and DMFT score in relation to birth weight of children were not significant in the present study [Table 8].{Table 1}{Table 2}{Table 3}{Table 4}{Table 5}{Table 6}{Table 7}{Table 8}


Oral health is one component of general health and also an important factor in the normal development of a child. The oral health of preschoolers is an overlooked aspect of childhood health and well-being, especially in cases of ECC.


In the present study, the prevalence of dental caries increased with age and became significantly higher by the time child reached 5 years of age, which was in accordance with study done by Goel et al.[7] with similar results. There is an increased number of erupted primary teeth which becomes exposed to the oral environment and cariogenic challenges. In addition, as children grow older there is a change in the dietary habits and hygiene practices leading to increase in dental caries, Berkowitz et al.,[8] however, reported no age difference in the occurrence of ECC.[9] Furthermore, in the present study, mean DMFT score increased with age, and became highest in the 5–6 years of age group at 3.67, but it was not statistically significant and was in accordance with a study by Jain et al.(2015) who also did not found any significant difference.


The present study showed that boys had higher caries prevalence as compared to girls. Similar results were shown by Ferraro and Vieira.[10] The increased prevalence in boys may be due to their habits of taking soft drinks and other sweetened snacks during their longer outside stay; according to Ferraro, there are differential effects of genes influencing dental caries in boys, and this may partially explain the sex differences. Our study was in contrast to the results obtained by Kalayni and Govindranjan (2004)[11] with a higher prevalence in girls than in boys. In the present study, boys also had more mean DMFT score as compared to girls which was in accordance with a study done by Panwar et al.[12] who showed similar results, but Rai et al. (2006),[13] Al-Samadani (2017)[14] found that females had more mean DMFT score than males.

Geographic location

In the present study, children who were residing in rural areas had a greater prevalence of ECC in comparison to those residing in urban areas, and the difference was found to be statistically significant. Our study were in accordance with study done by Irigoyen,[15] Perinetti [16] who showed similar results. Isolation from urban centers, restricted or inadequate knowledge regarding oral health care and inefficient bacterial control practices seemed to explain the high level of ECC among children residing in rural areas.[17] Oral health care in rural areas is limited due to the shortage of dental workforce, financial constraints, and the lack of perceived need for dental care among rural masses.[18] However, a study by Srisilapanan et al.[19] showed a high prevalence of dental caries in urban areas than rural.

Feeding practice

In the present study, bottle-fed children had the highest caries prevalence of 58.9% followed by breastfed children at 54.8%. Glass milk-fed children had the least prevalence of 50% among all the groups, which was in accordance with similar results of Avila et al.[20] The caries prevalence was highest in bottle-fed children due to improper feeding patterns like bottle feeding beyond 1 year. Prolonged or on-demand breastfeeding and children put to bed with nursing bottle tends to have an increase in the exposure time of primary teeth to fermentable carbohydrates.[21] Frequent bottle feeding and prolonged contact of enamel with bottle milk results in acidogenic condition leading to softening of enamel.[22] The present study showed that DMFT score was also highest in bottle-fed children followed by breastfed children, which was in accordance with study by Mohammadi et al.[23]

Mother education

Mothers are the primary caregivers of a child. Low maternal education is related to higher caries prevalence in their children.[24] In the present study, the mother education level was found to be associated with the level of caries experience in their children, as schooling only mother group children had higher caries prevalence as well as high mean DMFT scores, and it was statistically significant than graduate mother group. These results were in accordance with Al-Meedani and Al-Dlaigan,[25] Prakash et al.[26] who also found an association between low maternal education with increased caries activity, whereas Ramos-Gomas (2014)[27] found that the mother's level of education had no association with ECC in their study. From these finding, it is evident that all mothers should be imparted with knowledge and skills on oral health care of their children regardless of their education levels.

Socioeconomic status

Social class may affect caries risk in many ways. Low income affects the degree of education, health, values, lifestyles and access to health-care information, thereby increasing susceptibility to caries.[28] The present study showed that higher the socioeconomic status, lower the caries prevalence, which is similar to the results obtained by Saldūnaitė et al.,[29] Gao et al.,[30] Tiberia et al.[6] Low socioeconomic status may be at an increase ECC risk in several way because of the poor financial, social condition, and material disadvantages that compromise their ability to care for themselves, maintenance for good oral hygiene involving the use of clean toothbrushes which should be changed every 6 months, obtain professional oral health-care services and live in a healthy environment, all of which lead to reduced resistance to oral and other diseases. It has also been reported that children from low socioeconomic background have more fatalistic health beliefs and poor eating habits. However, a study by Popoola et al.[31] found more caries prevalence in high socioeconomic status children followed by middle and low socioeconomic status. The present study showed that mean DMFT score also was higher in low socioeconomic status children when compared to middle and high socioeconomic group, which is in accordance with study by Stephen et al.,[32] whereas Babo Soares et al.[33] found more DMFT score in middle socioeconomic status children.

Oral hygiene

In the present study, the prevalence of caries in the children with no brushing group was significantly higher than in those children who brushed their teeth two times a day which was in accordance with studies done by Soroye and Braimoh [34] Veiga [35] Parasuraman et al.[36] who reported that increased frequency of tooth brushing is an important determinant in decreasing the prevalence of dental caries and mean DMFT in children. This suggests that tooth brushing with a frequency of at least twice a day may spare the teeth from developing caries by removing dental plaque more effectively and decreasing the risk of caries among children. Children who brushed their teeth one time a day also had higher caries prevalence as well as mean DMFT score than children who brushed their teeth twice a day; however, their caries prevalence and mean DMFT score was lower when compared with children of no brushing group, and this was found to be nonsignificant.

Birth weight

Ala Ershiedt (2014) found that low birth weight and preterm births, predisposes to high levels of streptococcal colonization, in addition to favoring the development of enamel hypoplasia and salivary disorders and hence higher dental caries. However, in the present study, there was no significant difference for the caries prevalence and mean DMFT score between below and above 2.5 kg birth weight. The results were in accordance with the study done by Tanaka and Miyake.[37]


ECC is the multifactorial disease. This study aimed to analyze all the factor responsible for the effect on ECC such as age, sex, feeding, oral hygiene, maternal education, socioeconomic status, geographical distribution, birth weight and found that prolonged bottle and breast feeding, low-level maternal education, low socioeconomic status had a significantly deleterious effect on ECC, whereas birth weight and geographical distribution did not have any significant effect on ECC.

As a child grew older, there was a significant increase in no of teeth affected with ECC and DMFT score because of increased in the no of tooth surfaces presented with cariogenic challenge. Hence, there is a need for greater maternal education, social awareness, proper feeding habits, and oral hygiene practices to make our society caries-free.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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