REVIEW Congiu ARTICLE et al
Early Childhood Caries (ECC) Prevalence and Background Factors: A Review Giovanna Congiua/Guglielmo Campusa/Pier Franca Luglièb Purpose: To describe the prevalence of early childhood caries (ECC) by reviewing published reports and to assess the role of background factors in ECC prevalence. Materials and Methods: The studies included here consisted of reviews, meta-analyses and randomised clinical trials (RCT) which assessed the prevalence of ECC and included more than 100 subjects and subjects without any stated medical condition. These were in vivo studies published between January 1, 2000 to May 31, 2011. The patients’ age range for inclusion was zero (0) to five (5) years of age. Results: Database searching showed 411 findings as potentially eligible. After abstract review, eight (8) papers were retrieved as full text and assessed for eligibility: three using ECC as mesh word, four using the term early childhood caries and one using severe-ECC (S-ECC) as mesh word. Conclusion: The main risk factor for ECC is the low socioeconomic status of the parents. ECC is a public health problem and it requires the involvement of all health professionals that provide care to children together with efforts from family members. Key words: background factors, caries, children, ECC, epidemiology Oral Health Prev Dent 2014;1:71-76
Submitted for publication: 11.01.12; accepted for publication: 19.10.12
doi: 10.3290/j.ohpd.a31216
D
ental caries is an epidemic disease especially affecting young people, but it is preventable and can be stopped and even potentially reversed during its early stages. Caries prevention should start during pregnancy and continue with the mother, the paediatrician and the child during preschool. There are several intervention points possible, such as cariogenic feeding practices, the primary acquisition of cariogenic microflora, antimicrobial and fluoride therapy. People remain susceptible to the disease throughout their lives, but children in the age range of 12– 30 months have a special caries pattern which differs from that in older children (Drury et al, 1999). The disease develops in and affects the maxillary primary incisors and first primary molars in a way that reflects the pattern of eruption: the longer the a
Dentist, Department of Surgery, Microsurgery and Medicine, Dental School, University of Sassari, Italy.
b
Surgeon, Department of Surgery, Microsurgery and Medicine, Dental School, University of Sassari, Italy.
Correspondence: Dr. Guglielmo Campus, Department of Surgery, Microsurgery and Medicine, Dental School, University of Sassari, Viale san Pietro 43/C I-07100 Sassari, Italy. Tel: +39-079-228540, Fax: +39-079-228541. Email:
[email protected]
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tooth has been present and exposed to the caries challenge, the more it is affected. Thus, the maxillary teeth are the most vulnerable, while mandibular teeth are protected by the tongue and saliva from submandibular and sublingual glands. This pattern of dental caries has been labeled variously as ‘bottle caries’, ‘nursing caries’, ‘baby bottle tooth decay’, or ‘night bottle mouth’. These terms suggest that the prime cause of caries in early childhood is inappropriate bottle feeding. Current evidence shows that use of a sugary liquid in a bottle at night is a crucial aetiological factor (Tyagi, 2008; Feldens et al, 2010), although not necessarily the only one. Therefore, it is recommended that the term Early Childhood Caries (ECC) be used when describing any form of caries in infants and preschool children. Various systems of classification have been used to define ECC (Drury et al, 1999; Psoter et al, 2003). Two commonly accepted classifications for ECC include simple ECC and severe ECC, as defined by the American Academy of Pediatric Dentistry (AAPD, 2008) and used in this study: 1. simple ECC is the presence of one or more decayed, missing or filled tooth surfaces in any deciduous tooth in a child under 6 years of age; 2. severe ECC
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is any sign of smooth-surface caries in children under 3 years of age, with 1 or more cavitated, missing or filled smooth surfaces in the primary maxillary anterior dentition in children between the ages of 3 and 5, or decayed, missing or filled scores of ≥ 4 (ages 3 to < 4), ≥ 5 (ages 4 to < 5) or ≥ 6 (ages 5 to < 6). The main purpose of this systematic review was to describe the prevalence of ECC by reviewing published reports and also to assess the role of background factors in ECC prevalence.
MATERIALS AND METHODS The protocol for this review was the PRISMA 2009 checklist (available at www.prisma-statement.org).
Eligibility criteria To be eligible for inclusion, the studies had to meet the following criteria. • Review, meta analysis or randomised clinical trial assessing the prevalence of ECC and including more than 100 subjects. • Subjects without any stated medical condition. • In vivo studies • Published between January 1, 2000 and May 31, 2011. • Children’s age range was zero to five years of age. • Only studies published in English language were considered due to the low number of research published in other languages that were found from preliminary electronic database searches. • Assessed prevalence and morbidity outcomes for ECC and background variables. • Measured dental caries as dmft and/or dmfs index according to WHO standards. • Reported dietary, oral hygiene habits and socioeconomic status (SES) of the family. • Clearly described objective, methods and results, with no significant discrepancies. • Case reports, case series, outbreak investigations and abstracts were excluded. Possible outcomes for included studies were: • Increased risk of developing ECC in familes from lower socioeconomic groups. • Increased risk of developing ECC associated with dietary habits. • Increased risk of developing ECC associated with behavioural and/or oral hygiene habits.
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Information sources and search Starting in March 2011, the following electronic databases were searched: Medline, Embase, The Cochrane Library and Google Scholar. Two preliminary searches were conducted in June 2011 to obtain an overall idea of findings and to refine search terms (MeSH words) and limits. The MeSH words were accessed to identify entry terms and compose the final Boolean search: Caries, ECC, Severe ECC, Severe Early Childhood Caries, Baby Bottle Caries associated with epidemiology and background factors. The time period covered was from January 1, 2000 to May 31, 2011. No topic related nor relevant finding resulted from either The Cochrane Library or Google Scholar; these electronic databases were therefore excluded from final Boolean search. The final search was conducted on September 29, 2011. Reference lists of included and relevant papers were reviewed and an abstract was collected for each finding.
Study selection and data collection process One reviewer (GiC) screened all collected findings and registered title, author and entire reference in two Excel files (one for included and one for excluded findings, according to eligibility criteria) using a screening guide based on eligibility criteria. The source type was registered as a reason for exclusion. The same reviewer conducted a new and independent screening after 15 days. Duplicates from different electronic databases were excluded. The full text of all studies judged potentially eligible in at least one screening were retrieved. One reviewer (GiC) used a standardised and pilot-tested form to abstract data, screened the full text for inclusion using a screening guide, and a second reviewer (PfL) screened all findings and data abstraction. When disagreement occurred, a third reviewer (GC) was consulted.
Data items The abstracted data included study design, PICOs (patient, problem or population/intervention/comparison/outcome), population, exposure, outcomes, methodological features, results and findings and were defined through the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) Statement (von Elm et al,
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2007), a checklist of items that should be included in reports of observational studies. The overall quality of evidence for each outcome was rated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.
RESULTS Figure 1 displays the flow chart of the study. Database searches showed 411 findings as potentially eligible (a full list of the 411 papers retrieved by MeSH search is available from the authors upon request). After abstract review, 8 papers were retrieved as full text and assessed for eligibility: three using ECC as the MeSH word, four using the term Early Childhood Caries and one using Severe ECC. Aside from this single finding, reference list checking highlighted a large number of duplicates with database search results. Table 1 describes characteristics of included studies assessing the prevalence of ECC. One study (Bernabè and Hobdell, 2010) was a review paper on the prevalence of ECC in 22 different
411 abstracts MeSH words caries
411 abstracts screened
countries; the results confirmed that ECC is strictly related to the SES level of the family. The authors observed that dental caries prevalence and levels decrease as the Gini coefficient (a measure of income inequality which varies between 0, total equality, and 1, maximum inequality) per capita increases. According to World Bank criteria, the countries were divided into rich and poor countries. In rich countries, income inequality is the strongest factor associated with ECC. Further epidemiological data must be gathered through surveys in other countries to support oral health programmes. The awareness of diagnosis, prevention and treatment of ECC among healthcare workers – including paediatricians, physicians, nurses and midwives – must be increased. Especially access to facilities for preventive dental work (fluoride varnish/gel application, fissure sealants) should be improved. Two papers from North America (Tiberia et al, 2007; Nunn et al, 2009) reported quite different prevalence rates: 74.0% in Canada and 3.0% in the US. However, the two groups were not comparable. Tiberia et al (2007) reported on a sample selected from surveys of parents seeking dental care for children in five Canadian dental practices; thus, an
ECC
3 papers
ECC-Epidemiology
0 papers
ECC-Background Factors
1 paper previously selected
Early Childhood Caries
5 papers (1 previously selected)
Early Childhood Caries-Epidemiology
1 paper previously selected
Early Childhood Caries-Background Factors
1 paper previously selected
S-ECC
2 papers (1 previously selected)
S-ECC-Epidemiology
1 paper previously selected
Severe Early Childhood Caries
0 papers
Severe Early Childhood Caries-Epidemiology
0 papers
Early Childhood Caries-Background Factors
0 papers
Baby bottle – Caries
0 papers
Baby bottle – Caries Epidemiology
0 papers
8 papers selected
Fig 1 Flow chart of the study design.
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important selection bias was present. In the USA, Nunn et al (2009) compared data of ECC prevalence among 1- to 3-year-old children sampled from paediatric clinics in the Boston area and compared ECC prevalence among these children with similarly aged children surveyed as part of the Third National Health and Nutritional Examination Survey (NHANES III). The overall ECC prevalence in Boston children was 3.0% compared to twice that in children derived from NHANES III (6.3%). In contrast, two other studies originated from BRICS (Brazil, Russia, India, China, South Africa) countries (Tyagi 2008; Feldens et al, 2010), finding a prevalence of 19.2% of ECC in India and 63.0% in Brazil. Tyagi (2008) described a cross-sectional study on 813 children aged 2 to 6 years living in Davangore (India), finding no statistically significant difference between genders in terms of ECC. No figures were provided on how the sample was selected or if it was representative of the area. Feldens et al (2010) performed a birth cohort study on southern Brazilian 4-years-olds. 500 infants were recruited at birth and the paper focussed only on severe ECC at 4 years of age (final sample 340 subjects). Twenty-six percent presented simple ECC and 37.0% severe ECC. In Japan, Niji et al (2010) performed a cross-sectional investigation on the relationship between mother’s age and behavioural habits and caries prevalence in children. Overall, 646 mother-child pairs were examined and the ECC prevalence was 41.0%. In Greece, a cross-sectional study on ECC, intraoral distribution of the carious lesions and treatment needs was conducted (Maragakis et al, 2007), showing ECC prevalence to be high (60.1%). In contrast, a longitudinal observational community-based study was performed in Thailand (Thitasomakul et al, 2009) using negative binomial regres-
sion to analyse data. There, the mean dmfs ranged from 0.1 ± 0.4 to 2.8 ± 2.7. Table 2 describes the background factors associated with ECC. The paper of Maragakis et al (2007) was excluded, because no association with background factors was made. The socioeconomic status of the family (variously recorded using several proxy variables such as the Gini coefficient, annual household income or low income of the family) was reported to be associated with ECC in four papers (Nunn et al, 2009; Thitasomakul et al, 2009; Barnabé et al, 2010; Feldens et al, 2010). Dietary and behavioural habits such as breastfeeding, sweetened food, bottle feeding at night, holding liquids in the mouth for prolonged time periods, between-meal snacks consumed more often than 4 time a day and mother’s age at childbirth were positively associated with ECC in six studies (Tiberia et al, 2007; Tyagi, 2008; Thitasomakul et al, 2009; Feldens et al, 2010; Nij et al, 2010).
DISCUSSION The prevention and management of Early Childhood Caries should be an important objective of public health. The onset of the disease is in children under 2 years old. Prevention should begin during the prenatal period, continuing with the mother and the child during preschool in collaboration with paediatrician, paediatric dentist and teacher (Kawashita et al, 2011). Screening for dental caries should start as soon as the first primary tooth erupts or not later than one year of age. Oral health programmes should be established focusing on mothers, caregivers, community health workers, preschool teachers and children.
Table 1 Papers selected for the review
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Authors
Age groups
Size
Country
Prevalence/dmft mean
Thitasomakul et al (2009)
9–18 months
495
Thailand
Mean range 0.1 ± 0.4 to 2.8 ± 2.7
Nunn et al (2009)
1–3 years
787
United States
3.0%
Barnabé et al (2010)
5–6 years
–
22 countries
1.68 ± 0.59 mean (0.70–3.31 range)
Niji et al (2010)
1.5–3 years
646
Japan
41%
Maragakis et al (2007)
2–6 years
684
Greece
60.1%
Tyagi (2008)
2–6 years
813
India
19.2%
Tiberia et al (2007)
1–5 years
137
Canada
74.0%
Feldens et al (2010)
4 years
340
Brazil
26.0% simple ECC, 37.0% severe ECC
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This purpose of this review was to describe and analyse the prevalence of ECC and relative risk factors. A previously published comprehensive review (Milnes, 1996) including studies from Europe, Africa, Asia, the Middle East and North America reported a prevalence of ECC of about 70% in socially disadvantaged groups. Many risk factors are associated with ECC, but the main one is low socioeconomic status of the parents. In the papers selected for this review, the ECC prevalence had a wide range, i.e. from 3.0% (Nunn et al, 2010) to 74.0% (Tiberia et al, 2007). Children with ECC have a high frequency of sugar consumption, not only of fluids given in the nursing bottle, but also of sweetened solid foods; this is likely to be one of the most significant caries risk
factors. The World Health Organization (WHO) recommends that non-milk products and cellular extrinsic sugar should not represent more than 10% of the total daily caloric intake of children, and that sugars should comprise no more than 10% to 20% of the human diet. While the scientific basis of the health benefits of breastfeeding for general health is well accepted, prolonged and nocturnal breastfeeding is associated with an increased risk of ECC. However, the evidence for such an association is limited and inconsistent, and is based primarily on cross-sectional studies relying on retrospective recall of infant feeding practices. The use of medication, mainly antibiotics, was associated with ECC, as they cause ecological and environmental changes in the oral cavity (Alaki et
Table 2 Association between background factors (socioeconomical status, dietary habits, oral hygiene) and ECC Authors
Background factors associated
Thitasomakul et al (2009)
Children aged 12 to 18 months Low income Mothers did not have a daily intake of milk No calcium during pregnancy Children who were breastfed Mother’s poor oral health status Mothers had only primary school education Mothers with 10 or more decayed teeth Children who were not fed cooked rice or commercial cereal by the age of 3 months Children who had soft drinks at 9 months Children who had local traditional desserts at 9 months Children who had started eating vegetables later than 6 months Sweetened food Sugary food by the age of 5 months Soft drinks Sugary snacks Children who did not have their teeth brushed at 9 months
Nunn et al (2009)
Race History of a child’s visit to the dentist Parent’s education Annual household income
Barnabé et al (2010)
Gini coefficient
Niji et al (2010)
Mother’s age at childbirth (< 22 years) Frequency of between meal snacks more than 4 time a day Child’s caries activity tests score at the age of of 1.5 years equal to or greater than +1.5
Tyagi (2008)
Children who were bottle fed Use of dummy/pacifier
Tiberia et al (2007)
Leaving the bottle with the child Having problems brushing Holding liquids in the mouth for prolonged time Being Caucasian
Feldens et al (2010)
Breastfeeding duration Frequency of breastfeeding Night-time bottle use for liquids other than milk High density of sugar High density of lipids Maternal schooling Per capita income Teeth at 12 months
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al, 2009). Only one paper (Tiberia et al, 2007) took the use of medication into account as risk factor for ECC, but no statistically significant association with ECC prevalence was found. The number of children taking medications was too low and the potential association to ECC was too weak. The mother or primary caretaker has been blamed as the principal source of bacterial infection of the child via ‘vertical transmission’ (Caufield et al, 1993; Milgrom et al, 2000). S. mutans strains isolated from mothers and their children exhibit similar or identical bacteriocin profiles and identical plasmid or chromosomal DNA patterns (Emanuelsson et al, 1998). No papers selected for this review take into account the ‘window of infectivity’ (the period when the child could be inoculated with mutans streptococci) as a risk factor for ECC development. Cariogenic flora such as mutans streptococci are considered to be the aetiological agents of dental caries, but bacterial infection is necessary but not sufficient for developing clinical disease. Primary care clinicians should be familiar with effective interventions for the youngest children before they require dental services. Oral health cannot be seen as separate from general health, and the objective of dentistry must surpass the conservation of teeth; its purpose is to maintain oral and systemic health. Prevention is inexpensive, but it also demands efforts from family members, who are sometimes unaware of the consequences of caries or when they do realise that there is a problem, the disease is already established. The consequences affect both the child and the family’s life.
CONCLUSION This review of the literature showed that the most crucial factors involved in the ECC development are the socioeconomic status of the family – where ECC is strongly associated with SES – and the role played by parents/caregivers as the main source of attitudes toward oral care and values. Therefore, in order to decrease the risk factors for caries development, it is necessary to establish a partnership with the family, having prevention as the main focus.
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2. American Academy of Pediatric Dentistry (2008). Definition of Early Childhood Caries (ECC). http://www.aapd.org/media/policies_guidelines/d_ecc.pd 3. Bernabè E, Hobdell MH. Is income inequality related to childhood dental caries in rich countries? J Am Dent Assoc 2010;141:143–149. 4. Caufield PW, Cutter GR, Dasanayake AP. Initial acquisition of mutans streptococci by infants: evidence for a discrete window of infectivity. J Dent Res 1993;72:37–45. 5. Drury TF, Horowitz AM, Ismail AI, Maertens MP, Rozier RG, Selwitz RH. Diagnosing and reporting early childhood caries for research purposes. A report of a workshop sponsored by the National Institute of Dental and Craniofacial Research, the Health Resources and Services Administration, and the Health Care Financing Administration. J Public Health Dent 1999;59:192–197. 6. Emanuelsson IR, Li Y, Bratthall D. Genotyping shows different strains of mutans streptococci between father and child and within parental pairs in Swedish families. Oral Microbiol Immunol 1998;13:271–277. 7. Feldens CA, Giugliani ER, Vigo Á, Vítolo MR. Early feeding practices and severe early childhood caries in four-year-old children from southern Brazil: a birth cohort study. Caries Res 2010;44:445–452. 8. Kawashita Y, Kitamura M, Saito T. Early childhood caries. Int J Dent 2011;2011:725320. 9. Maragakis GM, Kapetanakou DN, Manios Y.Caries prevalence and location and dental treatment needs in preschoolers in Athens–-GENESIS project. Community Dent Health 2007;24:264–267. 10. Milgrom P, Riedy CA, Weinstein P, Tanner ACR, Manibusan L, Bruss J. Dental caries and its relationship to bacterial infection, hypoplasia, diet, and oral hygiene in 6- to 36-monthold children. Community Dent Oral Epidemiol 2000; 28: 295–306. 11. Milnes AR. Description and epidemiology of nursing caries. J Public Health Dent 1996;56:38–50. 12. Niji R, Arita K, Abe Y, Lucas ME, Nishino M, Mitome M. Maternal age at birth and other risk factors in early childhood caries. Pediatr Dent 2010;32:493–498. 13. Nunn ME, Dietrich T, Singh HK, Henshaw MM, Kressin NR. Prevalence of early childhood caries among very young urban Boston children compared with US children. J Public Health Dent 2009;69:156–162. 14. PRISMA. Accessible at http://www.prisma-statement.org 15. Psoter WJ, Zhang H, Pendrys DG, Morse DE, Mayne ST. Classification of dental caries patterns in the primary dentition: a multidimensional scaling analysis. Community Dent Oral Epidemiol 2003;31:231–238. 16. Thitasomakul S, Piwat S, Thearmontree A, Chankanka O, Pithpornchaiyakul W, Madyusoh S. Risks for early childhood caries analyzed by negative binomial models. J Dent Res 2009;88:137–141. 17. Tiberia MJ, Milnes AR, Feigal RJ, Morley KR, Richardson DS, Croft WG, Cheung WS. Risk factors for early childhood caries in Canadian preschool children seeking care. Pediatr Dent 2007;29:201–208. 18. 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;26:153–157. 19. von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP. Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: guidelines for reporting observational studies. Bulletin WHO 2007;85:867–872.
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