1. health and fitness
2. disease

• O.S.T. - T.D.J
Juin/June 2011, Vol. 34, N°2•
Caries prevalence and caries risk in a sample of Lebanese
preschool children
CHEDID NR.¹, BOURGEOIS D.², KALOUSTIAN H.3, BABA NZ.4, PILIPILI C.5
Abstract
Objectives: This study describes early childhood caries prevalence and caries risk in a group of Lebanese preschoolers.
Method and materials: 99 healthy children, aged four years or less, were recruited at the Dental
medicine faculty, Saint-Joseph university, Beirut, Lebanon. After parental consent, questionnaires
investigated children’s dietary and oral hygiene habits and parents’ education and health behaviors.
Oral examinations, with bite-wing radiographs when necessary, determined decayed-filled surfaces and
plaque scores. Salivary testing assessed buffer capacity and streptococcus mutans (Sm) and lactobacillus (Lb) presence. The three tests (questionnaire, oral examination, salivary testing) established a
caries risk assessment tool, determining subjects’ caries risk scores, classified as low (C0), moderate
(C1), high (C2) or very high (C3).
Results: 25.3% of subjects were caries-free, 24.2% had 4 carious lesions or less, 28.3%, 5 to 9
lesions and 22.2% over 10 lesions. 11.1% of plaque scores were low to mild, 18.2% moderate, 46.4%
high, and 24.3% very high. Salivary buffer capacity was: 29.3% high, 57.6% medium and 13.1% low.
High levels of Sm, (66.7%) correlated with plaque presence and proximal caries. High levels of Lb
(52.5%) correlated with plaque presence and smooth-surface caries, and correlated significantly with
occlusal caries. Regular tooth brushing yielded lower plaque, but not significantly lower caries levels.
Systemic fluorides were associated with lower plaque and caries scores. Children of educated parents
with regular dental visits and oral hygiene had lower plaque and caries scores. Caries risk distribution
was: C0: 16.2%, C1: 29.3%, C2: 15.1% and C3: 39.4%.
Conclusion: Most subjects had at least one carious lesion (74.7%), and 70.7% showed high to very
high plaque scores. Over half the sample presented high or very high caries risk. These findings deserve further investigation of the Lebanese preschoolers’ population.
1. Dpt pediatric
community dentistry,
Dental medicine faculty,
Saint-Joseph Univ.,
Beirut, Lebanon.
2. Faculté odontologie,
université Claude
Bernard Lyon France.
3. Dpt endodontics,
Dental medicine faculty,
Saint-Joseph Univ,
Beirut, Lebanon.
4. Dpt restorative
dentistry, Loma Linda
university, California.
5. Dpt pediatric
dentistry, école
Médecine dentaire
stomatologie, université
catholique Louvain,
Brussels, Belgium.
Keywords:
Early childhood
caries, caries risk,
dental prevention,
diet, fluoride,
oral hygiene
Résumé
Prévalence de la carie et risque carieux dans un groupe d’enfants libanais d’âge
préscolaire
Objectifs : Cette étude décrit la prévalence et le risque de carie dans un groupe d’enfants libanais
d’âge préscolaire.
Matériel et méthodes : 99 enfants sains, âgés de quatre ans ou moins, ont été recrutés à la Faculté
de Médecine Dentaire, Université Saint-Joseph, Beyrouth, Liban. Après consentement parental, trois
tests (questionnaire pour l’hygiène bucco-dentaire et alimentaire de l’enfant, le niveau d’éducation et
les attitudes parentales vis-à-vis de la santé, examen bucco-dentaire pour les scores de surfaces
cariées-obturées et de plaque dentaire, test salivaire de capacité tampon et présence de Streptococcus mutans (Sm) et Lactobacillus (Lb)) ont servi à évaluer le risque carieux, le classant en : bas (C0),
modéré (C1), élevé (C2) ou très élevé (C3).
Résultats : 25.3% des sujets étaient sans carie, 24.2% présentaient 4 lésions carieuses ou moins,
Copyright © 2011 APIDPM Santé tropicale. Tous droits réservés.
Mots-clés :
Carie de la petite
enfance,
risque carieux,
prévention dentaire,
alimentation,
fluor,
hygiène buccodentaire
• Caries... •
28.3%, 5 à 9 lésions et 22.2% plus de 10 lésions. 11.1% des scores de plaque étaient bas, 18.2% modérés, 46.4% élevés, et 24.3% très élevés. La capacité tampon salivaire était élevée chez 29.3% des
sujets, moyenne chez 57.6% et basse pour 13.1%. Les taux élevés de Sm (66.7%) étaient corrélés
avec la plaque et les caries proximales. Les taux élevés de Lb (52.5%) étaient corrélés avec la plaque
et les caries des surfaces lisses, et significativement corrélées avec les caries occlusales. L’hygiène bucco-dentaire régulière résultait en moins de plaque, mais non significativement moins de caries. La fluoration systémique était associée à moins de plaque et de caries. Les enfants de parents associant
niveau académique élevé, contrôles dentaires professionnels et hygiène bucco-dentaire réguliers
avaient moins de plaque et de caries. La distribution du risque carieux était : C0 : 16.2%, C1 : 29.3%,
C2 : 15.1% et C3 : 39.4%.
Conclusion : La majorité des sujets présentait au moins une carie (74.7%), et 70.7% montraient des
taux de plaque élevés ou très élevés. Plus de la moitié de l’échantillon avait un risque carieux élevé ou
très élevé. D’autres investigations de la population libanaise d’âge préscolaire devraient approfondir ces
résultats.
Introduction
32
Caries prevalence and caries risk in a sample
surfaces from demineralization.
of Lebanese preschool children recent epide-
Preexisting dental caries (caries prevalence) as
miological studies in cariology show a trend
well as new carious lesions appearing during a
towards finding the highest numbers of carious
given period (caries incidence) are also consi-
lesions in a relatively small percentage of the
dered predictors of future caries development
general population. Children are amongst the
(24-36). Studies show that a child developing a
most vulnerable groups, as well as adolescents,
high DMFT (Decayed-Missing-Filled permanent
persons presenting with certain physical condi-
Teeth), count before the age of five has a
tions or disabilities and socio-economically chal-
higher risk of becoming an adolescent with a
lenged groups (1). More particularly, very
high DMFT count and later becoming an adult
young children (aged less than four years) can
with the same problem (27, 29-31). Dental pla-
present with certain forms of primary dentition
que presence is yet another etiological factor in
caries, collectively designated today under the
dental caries development. Very young children
name of early childhood caries (centers for
with visible dental plaque and gingival inflam-
disease control, Atlanta, U.S.A, 1994) (2, 3).
mation will tend to develop several carious
Multiple factors influence caries development
lesions in the following years, as opposed to
in the preschool children’s age group (4-11).
children with adequate oral hygiene (34).
One of these factors is oral bacteria, including
The mother also plays an important part in the
Lactobacilli (Lb) and Streptococcus mutans
(Sm). The latter is transmitted to the young
child by the primary caregiver, generally the
mother (12-16) especially if maternal Sm
counts are high (more than 10 6 CFU/ml).
Research has shown that salivary Sm levels
can be considered predictors of future dental
caries (17-23). Saliva is another factor to be
taken into account in predicting caries risk.
Salivary secretion rate, mineral content and
buffer capacity (32, 33) help protect dental
young child’s carious process, because she is
usually responsible for introducing the child to
oral health and dietary habits (36, 37). Another factor linked to caries is diet; its role and
effects on the carious process have been
widely studied (32, 38-43) including physical
properties of ingested foods, ingestion frequency, sugar content, and the presence of
remineralizing agents such as calcium or fluoride. To date, fluoride is the best known cariostatic agent, (44-47) with literally thousands
• O.S.T. - T.D.J • Juin/June 2011 Vol. 34, N°2 •
Copyright © 2011 APIDPM Santé tropicale. Tous droits réservés.
• Caries... •
of publications concerning its use in dental
public health, at the community level and as
an individual patient’s prescription (48-50).
In recent years, a paradigm shift has occurred
in the management of dental caries, according
to the National Institutes of Health’s Consensus Development Conference Statement Diagnosis and Management of Dental Caries
Throughout Life (2001) (51). This paradigm
shift advocates improved diagnosis of early
non cavitated lesions, and treatment for prevention and arrest of such lesions. While indicated in both dentitions, this approach to dental caries management is well suited to the
primary dentition, because it would mean
shorter, less invasive, easier to tolerate dental
treatment for the young child, instead of the
more complex procedures needed when
lesions are allowed to develop into deeper
caries. This is especially true in the case of
very young children affected by early childhood caries.
Given that dental caries is a multi-factorial
process, the caries risk to which a child may
be exposed and the role played by each of the
factors in compounding this risk should be determined as early as possible, so that appropriate measures to prevent dental caries development can be implemented. With this preventive aim in mind, a study of caries risk in
Lebanese preschool children was undertaken.
Reports on the prevalence of early childhood
caries have been published for many countries
around the world, but none yet for Lebanon.
One study assessing dental caries in Lebanese
primary school children (52) was published
over 35 years ago; no data concerning caries
prevalence in the preschool children’s age
group in Lebanon have been recently published, although one epidemiological study has
shown caries prevalence to be very high in 6
year-old as well as 12 year-old Lebanese children (53). The present report is part of a clinical study undertaken to determine caries pre-
valence and caries risk distribution in a group
of preschool children to whom preventive
measures were then applied according to
caries risk category. The effect of these measures on initial caries risk was later evaluated
by comparison to a control group where only
standard preventive measures were applied.
The purpose of the present article is to describe caries prevalence and caries risk distribution in a Lebanese preschoolers’ group attending a university dental clinic, using a caries
risk assessment tool established for the young
child.
Materials and methods
The study population included 99 healthy children, 54 males and 45 females, aged 4 years or
less at the time of enrollment. The children
were patients at the dental clinic of the faculté
de médecine dentaire, université Saint-Joseph,
Beirut, Lebanon. The study protocol was approved by the university’s ethics committee and
written parental consent for participation in the
study was obtained for each child.
A parental questionnaire comprising 48 itemized multiple choice questions was completed
for each child participating in the study. It
covered areas such as demographics, parental
dental health behaviors and beliefs, children’s
oral hygiene habits, and children’s dietary
habits. Answers to items for the parental
questionnaire were coded into numerical scales (example: child’s tooth brushing; if none,
the score was 4; if less than once a day, score
was 3; if once a day, score was 2; if twice a
day, score was 1; if more than twice a day,
score was 0). Item scores were added to form
individual questionnaire scores (scale 4 to 44).
Depending on the individual score, a questionnaire was classified as Q-1 and awarded one
point (score 4-10), Q-2 and awarded 2 points
(score 11-20), Q-3 and awarded 3 points (score 21-30) or Q-4 and awarded 4 points (score
31-44).
• O.S.T. - T.D.J • Juin/June 2011 Vol. 34, N°2 •
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33
• Caries... •
Oral examinations were carried out by the
same examiner for all the children participating in the study, investigating the presence of
carious lesions and plaque. Visible carious
lesions were recorded and bite-wing radiographs were obtained when posterior proximal
surfaces were not accessible to examination
by mirror and explorer. The number and type
of tooth surface affected was noted (DFS score) as well as the severity of the lesion (enamel, dentin or pulp involvement). A dental plaque score was obtained after using a disclosing solution. The amount of tooth surface
covered by plaque was measured and plaque
scores were attributed according to the following categories, modified from Axelsson’s
Plaque Formation Rate Index (PFRI).
Plaque score 1: 1 to 20 % of dental surfaces
affected (very low to low score).
Plaque score 2: 21 to 30 % of dental surfaces affected (moderate score).
Plaque score 3: 31 to 40 % of dental surfaces affected (high score).
Figure 1: Salivary buffer capacity test (CRT Buffer®,
Ivoclar, Vivadent, Schaan, Liechtenstein)
a. Sample provided by manufacturer for test results reading
b. High salivary buffer capacity: blue color
c. Medium salivary buffer capacity: green color
d. Low salivary buffer capacity: yellow color
Buffer® capacity
High
Medium
Low
1a
1b
34
1c
1d
Plaque score 4: more than 40 % of dental
surfaces affected (very high score).
Each child’s oral examination resulted in a DFS
score depending on which a caries score was
attributed: 0 (no carious lesions), 1 (one to
four carious lesions), 2 (five to nine carious lesions), or 3 points (10 or more carious lesions).
Each child’s oral examination also yielded a plaque score on a scale of 1 to 4 as explained
above.
Salivary samples were obtained according to
the test manufacturer’s instructions, after
ensuring that the child had received no antibiotic medications, antiseptic medications or
professional fluoride treatments within the
preceding two weeks. After salivary flow stimulation was achieved by giving the child a
paraffin pellet to chew on, the child spat in a
disposable cup, from which salivary samples
were removed and placed on a pH sensitive
strip (CRT Buffer®, Vivadent-Ivoclar, Schaan,
Liechtenstein) to assess salivary buffer capacity. The result was obtained five minutes after
placing the salivary sample on the strip. Depending on the color of the saliva- saturated
strip, salivary pH was classified as indicated by
the manufacturer as high (dark blue color),
medium (green color) or low (yellow color)
(figure 1). Additional salivary samples from
the child were transferred to the double-sided
plates of the bacterial salivary test (CRT Bacteria®, Vivadent, Ivoclar, Schaan, Liechtenstein) which was incubated for 48 hours at a
temperature of 37°C (Cultura® incubator, Vivadent, Ivoclar, Schaan, Liechtenstein). The test
results were then read on each side of the
agar plate (blue side for Sm, green for Lb) and
classified as high or low bacterial counts by
comparing the cultures obtained for each
patient to the visual sample results scale provided by the manufacturer (figures 2 and 3),
with a number of Colony Forming Units (CFUs)
superior to 105 indicating high bacterial
counts.
• O.S.T. - T.D.J • Juin/June 2011 Vol. 34, N°2 •
Copyright © 2011 APIDPM Santé tropicale. Tous droits réservés.
• Caries... •
Figure 2: Salivary Streptococcus mutans assessment test (CRT
Bacteria®, Ivoclar, Vivadent, Schaan, Liechtenstein)
a. Sm < 105 Colony Forming Units: Sm count low
b. Sm > 105 Colony Forming Units: Sm count high
c. Sample test provided by manufacturer for test results reading
Figure 3: Salivary Lactobacilli assessment test (CRT Bacteria®,
Ivoclar-Vivadent, Schaan, Liechtenstein)
a. Lb < 105 Colony Forming Units: Lb count low
b. Lb > 105 Colony Forming Units: LB count high
c. Sample test provided by manufacturer for test results reading
Mutans Streptococcus
3a
3b
2b
2a
Lactobacilli (CFU/ml Saliva)
2c
3c
< 105
≥ 105
< 105
≥ 105
A caries risk assessment tool was established,
dual questionnaire scores (scale 4 to 44). De-
based on the three tests: parental question-
pending on the individual score, a questionnai-
naire, child’s oral examination and child’s sali-
re was classified as Q-1 and awarded one point
va testing, and a caries risk score was obtain-
(score 4-10), Q-2 and awarded 2 points (score
ed for each participant in the study, as ex-
11-20), Q-3 and awarded 3 points (score 21-
plained below.
30) or Q-4 and awarded 4 points (score 31-44).
Then, each child was attributed a caries score
First, answers to items for the parental ques-
resulting from the DFS score obtained through
tionnaire were coded into numerical scales
oral examination. Caries scores were: 0 (no
(example: child’s tooth brushing; if none, the
carious lesions), 1 (one to four carious le-
score was 4; if less than once a day, score was
sions), 2 (five to nine carious lesions), or 3
3; if once a day, score was 2; if twice a day,
points (10 or more carious lesions). Each
score was 1; if more than twice a day, score
child’s oral examination also yielded a plaque
was 0). Item scores were added to form indivi-
score on a scale of 1 to 4 as explained above.
• O.S.T. - T.D.J • Juin/June 2011 Vol. 34, N°2 •
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35
• Caries... •
Table I: Parent’s age and education distribution
Parent
age
(years)
< 25
26 - 35
36 - 45
> 46
N/s*
Total
Parent education
Primary
school
Junior high
school
High
school
University
degree
Post
graduate
N
%
N
%
N
%
N
%
N
%
4
6
4
6.1
2
10
6
2
10.1
6.1
1
15
8
1
1.0
15.2
8.1
1
25
11
1
25.3
11.1
1
4
2
4.0
2
10
10.1
18
18.2
25
25.3
37
37.4
N
%
6
6.0
Total
N/s*
N
%
N
%
1
1
2
2
3
58
34
2
2
3
58.6
34.4
2
2
3
3
99
100
Table II: Parents’ oral health characteristics
Parents’ oral health habits
Frequency
Tooth brushing
< 1/day
1/day
≥ 2/day
N/s**
Total
11
24
63
1
99
11.1
24.2
63.7
1.0
100
Tooth brush replacement
Every 3 months
Every 6 months
When worn
Other - n/s**
Total
37
34
22
6
99
37.4
34.3
22.2
6.1
100
Dental visits
Never
Only if necessary
≤ 1/year
2 /year
N/s**
Total
3
56
25
14
1
99
3.0
56.6
25.3
14.1
1
100
*n/s: not specified
Salivary test results too were given numerical
scores: salivary buffer capacity had a score of
either 0 (high buffer capacity), 1 (medium buffer capacity) or 2 (low buffer® capacity). Sm
and Lb test results as well were attributed
each a score of 1 for counts below 10 (5) and
2 for counts above 10 (5).
Finally, each patient’s scores for the risk factors investigated, is the questionnaire, DFS,
plaque, salivary buffer capacity and Sm and Lb
counts, were added together. Depending on
36
this final score, each patient was classified in a
risk category. The caries risk categories were
the following, adapted from Axelsson’s caries
risk categories: C0 for low caries risk (score
4), C1 for moderate caries risk (score 5 to 9),
C2 for high caries risk (score 10 to 14) and C3
for very high caries risk (score 15 to17).
After data collection was completed, statistical
analysis was performed using a statistical software program (SPSS 15.0 Evaluation Version).
Student’s t-test was used for quantitative data
and Pearson’s correlation test was used to
determine relationships between quantitative
variables.
Results
The children in the study sample were 54 boys
and 45 girls. Their ages were as follows: 15%
were 2 years old, 56% were 3 years old and
29% were 4 years old (mean age: 43.1 ± 7.2
months). A vast majority of the parents answering the questionnaire were women (85%),
about half were aged between 26 and 35
years and 68.7% of responding parents had
achieved a high school education or more,
with 37.4% of the total having a university
degree (table I).
More than half the parents in our sample
(63.7%) declared they brushed their teeth twi-
• O.S.T. - T.D.J • Juin/June 2011 Vol. 34, N°2 •
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• Caries... •
Table IV: Children’s dietary habits
Table III: Children’s oral hygiene habits
*n/s:
not specified
Children’s oral hygiene
N
%
Tooth brushing
frequency
None
< 1/day
1/day
≥ 2/day
N/s*
Total
7
21
29
41
1
99
7.1
21.2
29.3
41.4
1
100
Tooth paste type
None
Same as parents
Children's
N/s*
Total
6
14
78
1
99
6.1
14.1
78.8
1
100
Who brushes
child's teeth ?
Nobody
Child
Mother
Father
Other - N/s*
Total
3
21
65
4
6
99
3
21.2
65.7
4
6.1
100
Child’s dietary habits
N
%
Bottle
weaning
<1y
1-2y
2-3y
3-4y
Not yet
N/ s*
Total
15
20
29
4
30
1
99
15.2
20.2
29.3
4
30.3
1
100
Soft drinks
frequency
Never
< 1/week
1 - 3/week
1/day
> 1/ day
N/s*
Total
23
37
18
11
8
2
99
23.2
37.4
18.2
11.1
8.1
2
100
Meals daily
number
<3
3
4
5
>5
N/s*
Total
12
39
34
8
3
3
99
12.1
39.4
34.4
8.1
3
3
100
Snacks
daily
number
0
1
2
3+
N/s*
Total
13
31
40
12
3
99
13.1
31.4
40.4
12.1
3.0
100
ce a day, while 11.1% brushed less than once
a day. Over a third of the parents changed
their toothbrush every 3 months (37.4%) and
another third every 6 months (34.3%). A
majority (56.6%) of the parents visited the
dentist only when in need of treatment,
25.3% made regular yearly dental checkups
and only 14.1% saw the dentist every six
months (table II).
Concerning their children’s oral hygiene,
41.4% of the parents declared that the child’s
teeth were brushed twice a day, 29.3% once a
day and 21.2% less than once a day, while
7.1% declared the child’s teeth were never
brushed. It was usually the parents who brushed the child’s teeth, most often the mother
(65.7%) while only 4% of our sample’s children had their teeth brushed by their father (table III). Systemic fluorides were taken by a
had been weaned off the bottle between the
ages of one and two years and 29.3% between the ages of two and three years, while
30.3% had not yet been weaned at the time
data was collected. Soft drinks were allowed
less than once a week for 37.4% of the children and 23.2% never drank such beverages
while 8.1% ingested them on a daily basis.
Three quarters of the subjects had three to
four regular meals a day, and a majority
(40.4%) had two between-meals snacks per
day while 31.4% had only one (table IV).
minority of subjects (13.1%).
As for dietary habits, 20.2% of the subjects
The results of the children’s oral examinations
for caries prevalence and plaque presence are
• O.S.T. - T.D.J • Juin/June 2011 Vol. 34, N°2 •
Copyright © 2011 APIDPM Santé tropicale. Tous droits réservés.
37
• Caries... •
while the presence of dental plaque decreases
with age (p = 0.0078).
There was a negative correlation between systemic fluoride supplementation and the presence of plaque (p = 0.027) as well as between systemic fluoride supplementation and
the presence of carious lesions (p = 0.0018).
Children with systemic fluoride supplementation showed plaque and caries scores lower
Caries free children represented 25.3% of the
than those of children without systemic fluorisample, while 24.2% suffered one to four
de supplementation.
carious lesions and 28.3% of the group had
Higher educational levels in parents were
five to nine carious lesions, with 22.2% preassociated with lower plaque (p = 0.0121)
senting over ten carious lesions. Plaque scores
and caries (p = 0.0071) scores in their childwere as follows: 11.1% low to mild (category
ren. Regular parental dental visits were asso1), 18.2% moderate (category 2), 46.4% high
ciated with lower plaque levels in children (p
(category 3), and 24.3% very high (category
= 0.0329) and parent’s regular tooth brushing
4). The presence of plaque was correlated to
was correlated with lower caries levels in their
the occurrence of caries in general (p =
children (p = 0.043).
0.0001) particularly buccal and lingual/palatal
Children with regular tooth brushing had lower
caries (p = 0.002). Correlation analyses showplaque levels (p = 0.0252) than children with
ed that the presence of proximal caries
irregular oral hygiene, but there was no signiappears to increase with age (p = 0.0025),
ficant relationship between children’s regular
tooth brushing and lower caries
Table V: Sample distribution of ds category according to age
levels. The absence of toothpaste was
Number of decayed surfaces (ds)
linked to the presence of caries (p =
Age
0
1
to
4
5
to
9
>
10
Total
0.0466), and more specifically proxi(months)
N
%
N
%
N
%
N
%
N
%
mal caries (p = 0.034). There was an
increase in the number of carious
24 - 35
5
5
4
4
2
2
2
2
13
13
lesions (p = 0.0095), especially occlu36 - 47
14
14.2
16 16.2
14
14.2
13 13.1
57 57.7
sal caries (p = 0.0353), if the child
> 48
6
6.1
4
4
12
12.1
7
7.1
29 29.3
used the same toothpaste as the
Total
25 25.3
24 24.2
28 28.3
22 22.2
99 100
parents, while the use of children’s
toothpaste was correlated with lower
Table VI: Sample distribution of plaque category according to age
numbers of carious lesions (p =
Plaque category*
0.0034), especially occlusal caries (p
Age
= 0.0203).
1
2
3
4
Total
(months)
The consumption of soft drinks was
N
%
N
%
N
%
N
%
N
%
correlated with the presence of occlu24 - 35
0
0
2
2
5
5
6
6.1
13
13.1
sal caries (p = 0.0045) and plaque (p
36 - 47
6
6.1
8
8.1
31
31.3
12
12.1
57
57.6
= 0.016), and inbet-ween meals
> 48
5
5
8
8.1
10
10.1
6
6.1
29
29.3
snacking increased levels of caries (p
Total
11
11.1
18
18.2
46
46.4
24
24.3
99
100
= 0.0491), especially proximal caries
(p = 0.0131).
*Note: 1: Plaque deposits low to mild - 2: Plaque deposits moderate
3: Plaque deposits high - 4: Plaque deposits very high
A negative correlation was found
summarized in tables V and VI. Statistical analysis by comparison of means independent
sample t-test (t-test for equality of means)
showed no significant differences between
male and female subjects in caries and plaque
levels. None of the patients had any teeth filled prior to joining the study.
38
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• Caries... •
Table VII: Sample’s salivary tests results
Salivary buffer capacity
Age
(months)
High
Medium
Sm
Low
Lb
High
Low
High
Low
Total
N
%
N
%
N
%
N
%
N
%
N
%
N
%
N
%
24 - 35
36 - 47
> 48
4
18
7
4
18.2
7.1
7
30
20
7.1
30.3
20.2
2
9
2
2
9.1
2
10
36
20
10.1
36.4
20.2
3
21
9
3
21.2
9.1
6
26
20
6.1
26.2
20.2
7
31
9
7.1
31.3
9.1
13
57
29
13.1
57.6
29.3
Total
29
29.3
57
57.6
66
66.7
33
33.3
52
52.5
47
47.5
99
100
13 13.1
Table VIII: Sample’s caries risk distribution
Caries risk category
C0 - low
C1 - moderate
C2 - high
C3 - very high
Total
between milk bottle use
and the overall presence of
caries (r = -0.2411, p =
16
16.2
0.0186). The consumption
29
29.3
15
15.1
of milk as a snack was also
39
39.4
negatively correlated with
the presence of plaque (p
99
100
= 0.0421) and caries (p =
0.0028), especially proximal lesions (p =
0.001).
Children’s salivary test results are shown in
table VII. Salivary buffer® capacity was medium in a majority of subjects (57.6%), Sm
counts were high for two-thirds of the patients and Lb counts were high for slightly
over half the patients. t-test for equality of
means showed buffer capacity to be related to
plaque levels and number of carious le-sions,
particularly pro-ximal caries.
Results showed a correlation between low salivary buffer capacity and the presence of caries
(p = 0.0473). This correlation was significant
for smooth surface (buccal, lingual or palatal)
lesions (p = 0.0024).
N
%
High levels of Sm were correlated with the
presence of plaque (p = 0.0248), carious
lesions (p = 0.0067) and specifically proximal
surface caries (p = 0.0106). High levels of Lb
were also correlated to the presence of plaque
and buccal or lingual/palatal caries (p =
0.0286), and significantly correlated to the
presence of caries in general (p = 0) and
occlusal caries in particular (p = 0). Levels of
Lb were more strongly correlated with the presence of caries and with higher significance
than levels of Sm. Correlation analyses showed that the presence of proximal caries
appears to increase with age (p = 0.0025),
while the presence of dental plaque decreases
with age (p = 0.0078).
The patient’s caries risk distribution, presented
in table VIII, was as follows: 16.2% were in
the C0 category (low caries risk), 29.3% in the
C1 category (moderate caries risk), 15.1%
were found to be in the C2 category (high
caries risk) and 39.4% were in the C3 category (very high caries risk).
Discussion
Parental factors
The typical parent of a child participating in
the present study was a woman, aged less
than 35 and having achieved at least a high
school education. This portrait is demographically representative of mothers of preschool
aged children at the present time in Lebanon.
The association between parental health behaviors and the prevalence of caries in their children was the subject of several investigations,
especially where mothers are concerned (9, 65,
75). Results showed a relationship between the
children’s caries experience and the mother’s
number of missing teeth, dental attendance
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39
• Caries... •
pattern and level of education (57, 78) as well
as her Lb counts (77). In the present sample,
higher parental educational levels were correlated with lower plaque and caries levels in
children. Regular parental dental visits were
correlated with lower plaque levels in children
and regular parental tooth brushing was correlated with lower caries levels in children. Educated parents seem to value dental health
more; therefore they may demonstrate more
preventive health behaviors such as regular
dental check-ups and oral hygiene practices
for themselves and their children. They may
also have better incomes, and therefore an
improved financial access to care in Lebanon,
where the costs of dental treatment are supported solely by patients, given the absence of
any type of third party coverage for dentistry.
This is confirmed by other studies (76, 61),
which concluded to the association of ECC
(Early Childhood Caries), with lack of access to
dental care, its significant correlation with lack
of dental insurance, as well as its inverse correlation with both family income and the educational level of the mother.
Children’s oral hygiene and fluoride
consumption
In the present study, although more than half
the parents (57%) declared they brushed their
teeth twice a day, only 40% declared that the
child’s teeth were brushed twice a day. This
may mean that while most adults are aware of
the need for their own oral hygiene, all do not
see the importance of maintaining primary
teeth through tooth brushing, the generally
admitted albeit erroneous belief in the lay
public being that these teeth will be soon
replaced. This seems confirmed by the 28% of
parents declaring their child’s teeth were brushed less than once a day, or even never brushed.
Interestingly, there was an increase in the
number of carious lesions if the child used the
40
same toothpaste as the parents, while the use
of children’s toothpaste was correlated with
lower numbers of carious lesions. A possible
reason for this could be the minty, somewhat
spicy taste of adult toothpastes that young
children tend to dislike; therefore they would
probably tolerate this type of toothpaste a
shorter time inside their oral cavity than children’s toothpaste, which usually comes in fruity
flavors. The fluoride component of the adult
toothpaste would not be in contact with tooth
surfaces for enough time to have any noticeable preventive effects. The preventive effects
of fluoride were on the other hand clear when
children with systemic fluoride supplementation showed less plaque and less carious
lesions, principally proximal caries, than those
who had no systemic fluoride supplementation, therefore seeming at a lower risk for
developing ECC. This rejoins findings by DROZ
et al. (61) that among variables significantly
associated with caries were fluoride consumption and the level of knowledge about fluoride.
Another interesting finding in the present study was that despite the fact that regular tooth
brushing was associated with lower plaque
levels, there was no significant relationship
between children’s regular tooth brushing and
lower caries levels, indicating that factors
other than oral hygiene also play a part in the
carious process.
Dietary factors
Among these factors, dietary habits have often
been investigated where ECC is concerned,
particularly sugar consumption, snacking and
baby bottle use. In the present study, three
quarters of the subjects had three to four
regular meals a day, and snacking was regular
for 70% (30% with one between-meals snack
per day and 40% having two snacks), which
was associated with increased levels of caries,
especially proximal lesions. This is in accordance with what has been reported in the lite-
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• Caries... •
rature, and could be explained by the frequent
ingestion of food resulting in frequent drops in
salivary pH below the critical demineralization
level, thereby providing a favorable environment for the initiation of carious lesions.
Nonetheless, in cases where milk was the
snack, a negative correlation existed with the
presence of plaque and caries, particularly
proximal lesions. These findings prompt interrogations concerning a potential protective
effect of milk against carious lesions. Conversely, the correlation found in our sample between the presence of occlusal caries and plaque and the consumption of soft drinks makes
it a somewhat disquieting finding that even
though most of the study subjects rarely or
never drank such beverages, about 8% ingested them on a daily basis.
As for baby bottle feeding practices, a child’s
age and age at weaning (70 ,72), as well as
the frequency of sweet drinks consumption
(72) and snacking (54, 63, 64) are significantly related to caries risk according to several
investigations (71, 74). In our study, bottle
weaning had occurred between the ages of
two and three years for 29% of the children,
and although none of the subjects was less
than two years old, 30% had not yet been
weaned at the time data was collected. Clearly
most of our sample’s parents do not subscribe
to the recommended age for bottle weaning
according to AAPD guidelines (one year) (84),
yet we found a negative correlation between
milk bottle use and the overall presence of
caries in this sample. This finding somewhat
conflicts with what is generally reported in the
literature, but agrees with MOHAN et al.’s (69)
finding that children whose bottles contained
sweetened beverages had a statistically significant, four-fold increase in the odds of colonization by Sm relative to children who consumed milk and KOLKER et al.’s (83), finding that
milk was associated with lower DMFS scores in
3 to 5 year old African American children.
Plaque and cariogenic bacteria
Also implicated in the carious process are the
factors of dental plaque and cariogenic bacteria. A majority of children in our sample
(70.7%) had high to very high plaque scores.
While correlated to the occurrence of caries in
general, and particularly buccal and lingual/
palatal caries, the presence of dental plaque
decreased with the child’s age increasing,
which could be related to oral hygiene being
practiced more for older children in the sample, therefore eliminating at least some plaque.
Concerning the presence of cariogenic bacteria® and its relationship to caries prevalence,
high levels of Sm were found in two thirds of
our sample, a greater proportion than what
MOHAN et al. (69), reported in their study of
6-24-month-old children, where Sm were
detected in more than one-third of the sample
and colonization was more likely with increasing age and number of teeth. In the present
sample, high levels of Sm were correlated with
the presence of plaque and carious lesions,
specifically proximal surface caries. High levels
of Lb, found in 52.5% of the sample, were
also correlated to the presence of plaque and
the occurrence of buccal or lingual/palatal
caries, and significantly correlated to the presence of caries in general and occlusal caries
in particular. Levels of Lb were more correlated with the presence of caries and with higher
significance than levels of Sm in the study
sample. This association between the presence
of plaque, cariogenic bacteria and the occurrence of ECC rejoins results by previous studies. BANKEL et al. 65) found an association
between early childhood caries and the presence of Sm as well as visible plaque, nocturnal
meals and frequent sugar consumption.
MOHEBBI et al. (60) reported that dental plaque was visible on at least one index tooth for
65-75% of their subjects and that occurrence
of ECC was related to the presence of dental
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41
• Caries... •
plaque. After finding a statistically significant
association between caries and oral hygiene
quality, SANTOS and SOVIERO (62), suggested that the presence of a thick biofilm on
tooth surfaces was the most important factor
for early childhood caries in their sample.
Caries prevalence
None of our subjects had any dental treatment
prior to joining the study; no teeth had been
either filled or extracted before the oral examinations conducted for the study, so that the
recorded DMFS actually represented carious
lesions prevalence. About 75% of the patients
had at least one carious lesion, and therefore
suffer from ECC according to the AAPD definition of the disease (at least one carious lesion
in a child aged 71 months or less) (84). Early
childhood caries’ reported prevalence has varied according to different studies (54-64), going from 12% of preschool children in Kerala,
India (54), to 37.5% of 4-year-old children in
France (61), 41.6% among Brazilian children
(62) under 36 months and 48% for children in
JORDAN (63), while in TAIWAN (64) the total
prevalence of early childhood caries was 56%.
In the present study, 74.7% of the sample had
at least one decayed tooth, which places the
subjects in the highest caries prevalence
group. Another finding was that 22.2% of the
subjects presented over ten carious lesions.
This skewed distribution of ECC is in accordance with a study by BANKEL et al. (65) and studies of caries in 1-, 2- and 3- year-old Bulgarian children which also reported marked dental caries polarization, supporting the assertion
that early childhood caries affects predominantly high-risk individuals (66-68).
The prevalence of proximal caries seems to be
higher in older children within the sample.
This could be due to proximal contacts becoming tighter and diastemas closing over time,
entrapping more plaque and acid- producing
bacteria®. It could also be explained by the
42
changes in diet that accompany the child’s
growth; a child capable of accepting or rejecting certain foods may indulge in a more cariogenic diet than a younger child ingesting a
parent-chosen menu. The presence of proximal caries in our study was also linked to brushing the child’s teeth without toothpaste, and
this may be explained by the lack of fluoride
coming in contact with tooth surfaces on a
regular basis.
The predictive value of ECC as an indicator of
future caries is a matter of interest because
such a predictor would affect the timing and
nature of preventive measures that can be
used to reduce caries incidence among children. ALMEIDA et al. (79) found that children
treated for ECC were still highly predisposed
to greater caries incidence in later years. This
finding rejoined the earlier conclusion of AL
SHALAN et al. (80) who reported in a retrospective study that ECC was a risk factor for
future caries development. The same conclusion was drawn in a longitudinal study (81),
where preschool children with ECC had significantly more new carious surfaces per year
than children who were caries-free at baseline. Early childhood risk factors of poor dental
health seem to be stable even after 10 years
of life and the changing of dentition from primary to permanent according to a prospective
10 year study by MATTILA et al. (9), where a
high DMFT at 10 years of age was associated
with the child’s nocturnal juice drinking at 18
months and with frequent consumption of
sweets, infrequent tooth brushing, and the
presence of plaque and caries at age 3 years.
Among family factors, mothers’ education and
caries incidence and fathers’ infrequent tooth
brushing were significant. In the present study, some of the risk factors identified among
the patients with ECC are similar to the behavioral and demographic factors identified by
MATTILA, and a longitudinal follow up would
most likely bring interesting information as to
whether these factors remain stable in our
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• Caries... •
sample as well over time (8).
The sample size in the present study was too
small to allow generalization of its findings.
Furthermore, the population was recruited
among patients attending a dental school clinic, which may mean this population presents
specific characteristics not necessarily found in
all Lebanese preschool children. Nonetheless,
the results shown here demonstrate the existence of a trend towards high caries risk in
Lebanese preschool children that deserves further investigation.
Conclusion
This article reported on Early Childhood Caries
(ECC), prevalence and risk factors in a group
of Lebanese preschoolers attending a university dental clinic and describes for the first time
caries risk demographics in a Lebanese preschoolers’ population. About 75% of the sample showed at least one carious lesion, a
somewhat alarming caries rate. Also, two
thirds of the group demonstrated high to very
high plaque scores. Caries risk was distributed
among the study population as follows: 16.2%
low, 29.3% moderate, 15.1% high and 39.4%
very high caries risk. Therefore more than half
the study population was at high or very high
risk for caries development.
These results suggest that risk factors and the
role they each play in initiating or increasing a
child’s exposure to early childhood caries
should be determined as soon as possible, so
that appropriate, early prevention can be
implemented. However, our sample size and
the fact that the patients were selected from a
group seeking treatment at a university dental
clinic preclude generalization of the results.
Therefore further investigations are needed to
ascertain the present findings, and encourage
preventive measures to be applied early on in a
child’s life, allowing the optimal development of
a healthy, functional and esthetic oral cavity.
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• O.S.T. - T.D.J • Juin/June 2011 Vol. 34, N°2 •
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