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Assessment of behavioral factors associated with dental caries in pre-school children of high socioeconomic status families

Authors:
  • Tishk International University

Abstract and Figures

Background: Many Iraqi children of high socioeconomic status (SES) families attend dental clinics presenting predominantly cavitated and painful multiple carious lesions. The factors responsible for dental caries within this sector of society need to be identified. Purpose: The aim of this study is to assess the dental care behavior of mothers and its relationship with the prevalence of dental caries in pre-school age children drawn from high SES families in northern Iraq. Methods: A study was conducted to assess the prevalence of dental caries and its relationship to oral hygiene habits in 440 pre-schoolers living in Erbil, northern Iraq. An oral hygiene questionnaire was distributed among the families. Dental examination of the children was performed to calculate the dependent factor of decayed, missing and filled teeth due to caries (dmf). All data was analyzed by means of the SPSS Microsoft statistical system using descriptive tables to identify the relationship between the dependent and independent variable dmf indexes. In order to find the significances, a Chi-square test, a Fisher’s exact test and a likelihood ratio test were used at level of p<0.05. Results: 67% of the children in the sample had dental caries (mean dmf=3.25±3.77) with 5-year-olds being more affected by dental caries (74%) than 4-year-olds (60%). A strong correlation was found in this study between the dependent factor, dmf, and the following independent factors: frequency of snack consumption, the need to assist the child during brushing, maternal caries and the mother’s education. Conclusion: Despite being members of high SES families, the children examined were significantly subject to dental caries, a fact directly correlated with inappropriate behavior on the part of their caregivers in relation to the essential aspects of oral health care.
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66
Dental Journal
(Majalah Kedokteran Gigi)
2019 June; 52(2): 66–70
Research Report
Assessment of behavioral factors associated with dental caries
in pre-school children of high socioeconomic status families
Bushra Rashid Noaman
Department of Pedodontics
Faculty of Dentistry, Tishk International University
Erbil, Kurdistan region – Iraq
ABSTRACT
Background:
Many Iraqi children of high socioeconomic status (SES) families attend dental clinics presenting predominantly cavitated
and painful multiple carious lesions. The factors responsible for dental caries within this sector of society need to be identified.
Purpose:
The aim of this study is to assess the dental care behavior of mothers and its relationship with the prevalence of dental caries
in pre-school age children drawn from high SES families in northern Iraq.
Methods:
A study was conducted to assess the prevalence of
dental caries and its relationship to oral hygiene habits in 440 pre-schoolers living in Erbil, northern Iraq. An oral hygiene questionnaire
was distributed among the families. Dental examination of the children was performed to calculate the dependent factor of decayed,
missing and filled teeth due to caries (dmf). All data was analyzed by means of the SPSS Microsoft statistical system using descriptive
tables to identify the relationship between the dependent and independent variable dmf indexes. In order to find the significances,
a Chi-square test, a Fisher’s exact test and a likelihood ratio test were used at level of p<0.05.
Results:
67% of the children in the
sample had dental caries (mean dmf=3.25±3.77) with 5-year-olds being more affected by dental caries (74%) than 4-year-olds (60%).
A strong correlation was found in this study between the dependent factor, dmf, and the following independent factors: frequency of
snack consumption, the need to assist the child during brushing, maternal caries and the mother’s education.
Conclusion:
Despite
being members of high SES families, the children examined were significantly subject to dental caries, a fact directly correlated with
inappropriate behavior on the part of their caregivers in relation to the essential aspects of oral health care.
Keywords:
dental caries; dmf index; oral health; preschoolers; socioeconomic status
Correspondence: Bushra Rashid Noaman, Department of Pedodontics, Faculty of Dentistry, Tishk International University, Erbil,
Kurdistan region, Iraq. Email: bushra.rashid@ishik.edu.iq
INTRODUCTION
Early childhood is defined as the period between birth and
the 71st month during which dental caries affect children.1
An important element within Primary Care is early
examination of the child. Dental caries constitute a disease
caused by bacteria and, consequently, is transmissible
from mother to child thereby negatively affecting the
dentition status of the latter.1 Dental caries caused by
aciduric and acidogenic bacteria transform sugar into lactic
acid subsequently resulting in the dissolution of the tooth
enamel.2
Although high SES exerts a noticeable positive
influence on the general and oral health of individuals,3
numerous other factors may cause dental caries, such as
poor oral hygiene, the absence of assistance to children
during the brushing of their teeth and a high daily
consumption of snacks. The incidence of dental caries in
young children may be higher due to the frequent intake
of snacks, especially sweets. Therefore, restricting the
frequency of children’s consumption of snacks allied with
consistently regular meals is recommended.4 Dental caries
in early childhood may be the result of bottle feeding or
breastfeeding while the infant in question is asleep.2,5
Regular visits to the dentist and the professional
application of fluoride are essential factors in the prevention
of dental caries6 which negatively impact on the psychology
of children due to aesthetic problems which can negatively
Dental Journal (Majalah Kedokteran Gigi) p-ISSN: 1978-3728; e-ISSN: 2442-9740. Accredited No. 32a/E/KPT/2017.
Open access under CC-BY-SA license. Available at http://e-journal.unair.ac.id/index.php/MKG
DOI: 10.20473/j.djmkg.v52.i2.p66–70
67Bushra Rashid Noaman/Dent. J. (Majalah Kedokteran Gigi) 2019 June; 52(2): 66–70
affect their self-esteem and ability to eat when the lesions
are cavitated.7 In the USA, it has been proved that caregivers
presenting tooth loss due to caries negatively influenced the
dental health of their young children who also suffered from
the same condition.8 The level of education enjoyed by the
mother is an important influencing factor in the incidence
of dental caries in a child, together with such variables as
income and the frequency of their visits to the dentist.9 The
aim of this study was to assess the influence of maternal
behavior on the prevalence of dental caries in pre-schoolers
drawn from high SES families in northern Iraq.
MATERIALS AND METHODS
This study was undertaken in four selected private
kindergartens located in the north, south, west and east of
Erbil, Northern Iraq. 440 children aged 4-5 years old were
examined for dental caries, while information concerning
their oral hygiene habits was also collected from their
families by means of a questionnaire. All the children
were drawn from families in which the parents occupied
high income jobs.
The number of subjects drawn from the kindergartens
totaled 486. After the application of specific inclusion and
exclusion criteria, 46 children were rejected, of which 21
failed to submit their questionnaires, six did not attend on
the day of the examination, 18 did not return their oral
habit questionnaires and one was excluded due to his being
asthmatic. The research population of the study, therefore,
comprised 440 individuals.
All subjects satisfying the following criteria were
included in the study: aged 4-5 years, free of systemic
disease, parental agreement provided, comprehensive oral
habits data and complete dental records which could be
reviewed by the observers. Failure to meet these criteria
was considered justifiable grounds for exclusion.
The questionnaire included items concerning the
tooth-brushing habits of each subject, the timing and
duration of their feeding during infancy, their eating
routine, untreated caries and use of fluoride, together with
the level of education of his/her mother. An oral hygiene
habits questionnaire in Kurdish, the regional language,
was prepared by the author which included the factors
potentially causing dental caries9 (Table 1) and distributed
among the families who completed the questionnaire one
week before the dental examinations were conducted.
Dental examinations involving the use of a plan mouth
mirror and CPI probe were conducted under natural light
in the well-lit hall of the kindergartens with the subject
seated on an ordinary chair. The dentition status for
children, Annex 2, WHO (2013)10 was used to register the
examination results. Dental caries were recorded when
a lesion in a pit or fissure, or on a smooth tooth surface,
constituted an observable cavity, damaged enamel due
to caries, or a visibly softened floor or wall. Temporarily
restored teeth, or ones previously restored but also carious,
were classified as decayed. A tooth was considered to be
present even if only parts of it remained in the mouth. In
cases of uncertain tooth presence, caries were not recorded
as existing. In order to enhance the reliability of clinical
judgments, four dentists were trained to collect the dental
examination data. The dmf index was used to measure
the prevalence of dental caries. In order to quantify intra-
observer validity, a pediatric dentist repeated ten of the
observations previously performed by each dentist, thereby
acting as a calibrator. A level of intra-observer validity
between the pedodontics specialist and each dentist was
achieved. The research was initiated after approval by
the scientific committee of Tishk International University
(Document No. IU.FA.FR. 137E. Decree No. 4, 2018), and
that of the families of the subjects had been secured.
IBM SPSS system 22 was used to analyze the data
collected. Descriptive tables were used to indicate the
Table 1. Oral habits questionnaire
No. Questions Answers
Q1 Does the child suffer from any systemic disease? Yes No
Q2 Does the mother have caries? Yes No
Q3 The feeding time of the child during infancy daytime hours only both daytime and
nighttime hours
Q4 Does the child demonstrate poor eating habits, such as consuming
cakes, sweets, chocolate, soda drinks and potato chips?
Yes
1-2 times a day
>3 times a day No
Q5 Does the child brush his/her own teeth? Yes No
Q6 Do you assist your child during tooth-brushing? Yes No
Q7 Has the child ever undergone professional fluoride application? Yes No
Q8 Education level of the mother or caregiver Primary school
Secondary school
Undergraduate degree
Postgraduate degree
Dental Journal (Majalah Kedokteran Gigi) p-ISSN: 1978-3728; e-ISSN: 2442-9740. Accredited No. 32a/E/KPT/2017.
Open access under CC-BY-SA license. Available at http://e-journal.unair.ac.id/index.php/MKG
DOI: 10.20473/j.djmkg.v52.i2.p66–70
68 Bushra Rashid Noaman/Dent. J. (Majalah Kedokteran Gigi) 2019 June; 52(2):66–70
total research population together with the gender of
each and his/her relationship to the dependent variable
dmf index. A chi-squared test, a Fisher’s exact test and a
likelihood ratio test were used to compare the relationship
between the dependent variable (dmf) and the independent
variables; tooth-brushing habits, the frequency of feeding
during infancy, eating habits, untreated maternal caries,
professional fluoride application and the level of education
of the mother. The p-value was measured at a level of
p<0.05.
RESULTS
440 pre-school children were examined during this study,
67% of whom had dental caries (mean dmf=3.25±3.77).
The 5-year-olds were more affected by dental caries (74%)
than their 4-year-old counterparts (60%) with respective
dmf indexes of 3.8±4.33 and 2.9±3.4 which represented a
statistically significant difference. The contents of Table
2 confirm that males were more affected by dental caries
(70%), than females (52%) and had a higher dmf index
(3.6±3.76).
Table 2. Distribution of age and gender and dmf index in the
sample
Variables Factors N Caries
(%)
Mean
dmf±SD p-value
Age 4 years 160 60.00 3.8±4.33 0.021*
5 years 280 74.00 2.9±3.40
Total 440 67.00 3.25±3.77
Gender Boys 240 70.00 3.6±3.76 0.25
Girls 200 52.00 2.8±3.78
*significant difference at the level p<0.05
Table 3. The relationship between mean dmf and tooth brushing
habits in the sample
Variable Typ e NCaries
(%)
Mean
dmf±SD p-value
Tooth
Brushing
1/day 304 63 3.5 ± 3.87
0.244
2-3/day 96 40 1.9 ± 2.7
None 40 80 4.6 ± 4.59
Table 4. The relationship between mean dmf and brushing
assistance habit
Variable Typ e NCaries
(%)
Mean
dmf±SD p-value
Brushing
assistance
No 240 67 3.93 ± 4.06
0.05*
Yes 200 50 2.37 ± 3.29
*p-value at the limit of significance
Table 5. The relationship between the mean dmf and snack
consumption
Variable Typ e NCaries
(%)
Mean
dmf±SD
p-
value
Snacking
Once
and
twice/
day
232 58.60 2.75 ± 3.02
0.001*
>3/day 104 84.00 5.46 ± 4.85
*significant difference at level p<0.05
Table 6. The relationship between mean dmf and nursing time
during infancy
Variable Typ e NCaries
(%)
Mean
dmf±SD
p-
value
Nursing
Time
Day and
night 56 85.70 5.42 ± 3.58
0.001*
Day 384 56.25 2.93 ± 3.71
*significant difference at the level p<0.0
Table 7. The relationship between mean dmf and topical
fluoride application
Variable Typ e NCaries
(%)
Mean
dmf±SD p-value
Topical
Fluoride
Yes 64 62.50 3.75 ±4.18
0.214
No 376 59.50 3.17± 3.71
Table 8. The relationship between mean dmf and dental caries
among the children’ mothers
Variable Typ e N
Caries
(%) of
children
Mean
dmf±SD p-value
Mother
caries
Yes 184 60.00 3.4 ± 3.72
0.025*
No 256 59.40 3.12 ± 3.83
*significant difference at the level p<0.05
Table 9. The relationship between the mothers’ education and
dmf in the sample
Variable Typ e NCaries
(%)
Mean
dmf±SD
p-
value
Mo th er ’s
education
Post-
graduate 48 16.6 0.16±0.38
0.001*
Bachelor 200 56 2.26±2.6
Secondary 120 73.3 5.9 ±4.7
Primary 72 77.7 3.55±3.29
*significant difference at the level p<0.05
Dental Journal (Majalah Kedokteran Gigi) p-ISSN: 1978-3728; e-ISSN: 2442-9740. Accredited No. 32a/E/KPT/2017.
Open access under CC-BY-SA license. Available at http://e-journal.unair.ac.id/index.php/MKG
DOI: 10.20473/j.djmkg.v52.i2.p66–70
69Bushra Rashid Noaman/Dent. J. (Majalah Kedokteran Gigi) 2019 June; 52(2): 66–70
The dmf index was higher in the research subjects who
did not brush their teeth (4.6±4.59) and who were most
susceptible to caries (80%) than those who brushed once
or twice a day, but it showed no statistically significant
difference (Table 3). Responses to the question about
brushing assistance showed that 240 mothers did not
provide this to their children. Of the subjects who were not
assisted with tooth brushing, 67% had caries with a higher
dmf index (3.93 ± 4.06) than those who were assisted
(2.37 ± 3.29). However, the difference was not statistically
significant (Table 4).
Of 440 children, 232 consumed snacks once or twice a
day and 104 more than three times daily. The highest dmf
index in subjects was that relating to more than three times
(5.45±4.85); 84% were affected by dental caries and the
difference was statistically significant (Table 5). Responses
relating to the intensity of breastfeeding showed that 56
mothers breast fed their infants both during the day and at
night and 85.7% of their children had dental caries. The
other 384 children were breast fed only during the day
and 56.25% were affected by dental caries, indicating a
respective dmf index of 5.42 ± 3.58 and 2.93 ± 3.71 which
constituted a statistically significant difference (Table 6).
Topical fluoride was applied to only 64 subjects in
the sample who still recorded a high caries index (dmf =
3.37±4.18). 62.5% were affected by dental caries, almost
the same percentage as those who did not received fluoride
(59.5%) with no statistically significant difference (Table
7). The question concerning whether the mothers were
affected by dental caries, showed that 184 had dental caries,
while 60% of their children were affected by dental caries
with a dmf of 3.4 ±3.72. These was a statistically significant
difference in comparison with the caries index of children
whose mothers were free of dental caries (mean dmf = 3.12
± 3.83) (Table 8).
With regard to the education level of mothers and its
relationship to the incidence of dental caries, the results
of this study showed that the highest percentage of dental
caries was found in those children whose mothers had
only gained a primary school education (77.7%, dmf =
3.55±3.29). In contrast, only 16.6% of the children whose
mothers had undergone higher education were affected
(dmf = 0.16±0.38). There was a highly significant statistical
difference between the level of the education of the mother
in terms of the prevalence of caries in their children,
namely; p<0.05 (Table 9).
DISCUSSION
As dental caries develops over time, it can be argued
that those detected in the subjects of the current study
largely began in infancy due to their inappropriate dietary
habits becoming increasingly prominent from the point
of weaning until the time of the examination (4-5 years).
This viewpoint agrees with that contained in the study
conducted by Moynihan and Petersen.11 Caregivers lacked
knowledge about the negative impact of frequent snacks.
Moreover, high SES families in Iraq purchase sweets for
their children to make them feel content. In addition, there
was considerable inconsistency regarding the appropriate
point in time to wean infants which rendered dental
treatment for the entire family essential. There is a need to
introduce this practice in Iraq.
There are numerous potential causative factors of
dental caries which comprise: the host, the mediator and
the environment. The primary one is mutans streptococcus
(MS) bacteria. The adherence of MS to the tooth surface will
result in the formation of plaque. MS ferments sugar and
converts it into lactic acid which leads to demineralization
of the enamel.12 Families need to be aware of the effect of
these bacteria in forming dental caries and how to prevent
this by tooth brushing, assisting the child during brushing,
diet counseling and regular visits to the dentist.
Pediatric dentists, in particular, have a major role to
play in educating mothers to manage the oral health of their
children. All dentists who treat adults with caries should
ask the patient about the oral health of their children.13
One of the measures to prevent dental caries in infants
and toddlers is that of treating the dental caries of their
caregivers since these may be induced in the child.14 Of the
mothers featured in the current study, 46% suffered from
dental caries. However, this figure may represent a case
of under-reporting which can be considered a limitation of
this study. Preventive methods should be established such
as oral hygiene improvement, fluoride application, the use
of pit and fissure sealants, decreased frequency of snacks
during the day and educating caregivers.15 In this study, the
mothers with caries themselves were found to have children
suffering from high levels of this condition.
The components of the SES are the level of parental
education, house ownership, family income and type of
parental occupation.16 In the current study, the families
of the research subjects were all owner-occupiers of their
homes and earn high incomes, but their children were
found to be strongly affected by dental caries. In the current
study, one of the factors that directly influenced the dental
health of those individuals was the level of their mothers’
education. The highest dmf score was found in children
whose mothers had only attended primary school, while the
lowest was in those whose mothers had progressed to higher
education. Several studies2,5,7,8 concur that the education
level of a mother influences the advice she gives her child
with regard to diet and duration of brushing, as well as the
regularity of both her own visits and those of her child to
the dentist in order to monitor their respective oral health.
Educational programs can be introduced into schools and
may prove beneficial in increasing the health awareness of
school children in Iraq17 which will, in turn, have a positive
impact on subsequent generations.
This study is subject to certain limitations in that
it relates only to Iraq. Despite being drawn from high
SES families, the subjects of this study demonstrated a
significant incidence of dental caries. The causative factors
Dental Journal (Majalah Kedokteran Gigi) p-ISSN: 1978-3728; e-ISSN: 2442-9740. Accredited No. 32a/E/KPT/2017.
Open access under CC-BY-SA license. Available at http://e-journal.unair.ac.id/index.php/MKG
DOI: 10.20473/j.djmkg.v52.i2.p66–70
70 Bushra Rashid Noaman/Dent. J. (Majalah Kedokteran Gigi) 2019 June; 52(2):66–70
underpinning their high rates in these children were related
to inappropriate behavior on the part of the caregivers
with regard to the essential aspects of oral health care.
On this point, the author recommends the introduction of
educational programs for all categories of Iraqi society
using a variety of media and methods and activating
community dentistry to increase the awareness of families
regarding oral health care.
ACKNOWLEDGEMENTS
The author wishes to extend her appreciation to the
Presidency and Deanery of Dentistry Faculty of Tishk
International University for their financial support of the
research reported here, to research assistants, Dr. Saya
Hadi Rauf, Dr. Lava Sabir and Dr. Zahraa Emad, for their
invaluable assistance in examining children during the study
and to Dr. Zhakaw Amang for her support in formatting
the tables contained in the article.
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Open access under CC-BY-SA license. Available at http://e-journal.unair.ac.id/index.php/MKG
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Ossification is a tightly regulated process, performed by specialized cells called osteoblasts. Dysregulation of this process may cause inadequate or excessive mineralization of bones or ectopic calcification, all of which have grave consequences for human health. Understanding osteoblast biology may help to treat diseases such as osteogenesis imperfecta, calcific heart valve disease, osteoporosis, and many others. Osteoblasts are bone-building cells of mesenchymal origin; they differentiate from mesenchymal progenitors, either directly or via an osteochondroprogenitor. The direct pathway is typical for intramembranous ossification of the skull and clavicles, while the latter is a hallmark of endochondral ossification of the axial skeleton and limbs. The pathways merge at the level of preosteoblasts, which progress through 3 stages: proliferation, matrix maturation, and mineralization. Osteoblasts can also differentiate into osteocytes, which are stellate cells populating narrow interconnecting passages within the bone matrix. The key molecular switch in the commitment of mesenchymal progenitors to osteoblast lineage is the transcription factor cbfa/runx2, which has multiple upstream regulators and a wide variety of targets. Upstream is the Wnt/Notch system, Sox9, Msx2, and hedgehog signaling. Cofactors of Runx2 include Osx, Atf4, and others. A few paracrine and endocrine factors serve as coactivators, in particular, bone morphogenetic proteins and parathyroid hormone. The process is further fine-tuned by vitamin D and histone deacetylases. Osteoblast differentiation is subject to regulation by physical stimuli to ensure the formation of bone adequate for structural and dynamic support of the body. Here, we provide a brief description of the various stimuli that influence osteogenesis: shear stress, compression, stretch, micro- and macrogravity, and ultrasound. A complex understanding of factors necessary for osteoblast differentiation paves a way to introduction of artificial bone matrices.
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