Dental Caries Experience in Children in Public Kindergartens of Sarajevo, Bosnia and Herzegovina

Abstract

Objectives

Dental caries first occurs within primary dentition in toddlers and preschool children, in a form of early childhood caries (ECC). In every day’s busy and employment burdened parenting, caretakers and institutions have become important even more nowadays, not only for forming child general behavior and character, but also for maintenance of their general and oral health as well.

Aims

To evaluate the presence and severity of ECC in children who attended public kindergartens in Sarajevo, and to offer basic information for the maintenance and improvement of child oral health to their parents and kindergarten teachers.

Methods

The study included 1722 preschool children aged 3-6 years who attended kindergartens within Sarajevo public kindergarten institution, together with their parents and kindergarten teachers. Dental team members gradually visited all kindergartens situated in four Sarajevo city municipalities and examined kindergarten children according to the WHO Oral Health Survey Manual. Oral health promotion material for parents and kindergarten teachers was also distributed simultaneously during sequential visits.

Results

ECC was present in preschool kindergarten children in Sarajevo, with its high prevalence (67.71%); dmft-value (3.97) and severity (SiC index 8.79). There was also a significant lack of dental healthcare to examined children mostly related to lack of visiting dental offices by children’s parents (CI=10.55%, RI=10.80%, TI=12.98%).

Conclusion

Parental role in preserving and improving of their children oral health should be systematically and profoundly improved. Kindergarten officials and staff should recognize the importance of anticariogenic diet menus and oral hygiene maintenance within their institutions.

Introduction

Dental caries first occurs within primary dentition in toddlers and preschool children in the form of early childhood caries (ECC). ECC is a specific form of dental caries from many aspects, including its pathogenesis, treatment and prognosis, as well as the causes for its occurrence (1-3). The unjustified routine of lack of oral hygiene maintenance and uncontrolled consumption of added sugars, together with nocturnal feeding, was established and well known within a large number of families, which continued in preschool period. All of this is usually followed with the lack of, or complete absence, of dental visiting. These bad habits can result in early forms of ECC, sometimes in younger toddlers, which can even result in severe forms of ECC (S-ECC). Furthermore, toddlers and preschool children have been nowadays more taken care of by others than by their parents (grandparents, nannies, kindergartens), which can strengthen expression and results of bad habits. The treatment of ECC is usually complicated due to several main factors: lack of cooperation in dental office, more frequent appearance of S-ECC and dental emergencies, and consequent bad prognosis of ECC-affected primary teeth. If ECC is not resolved on time, dental caries disease just mercilessly continues to affect and waste newly emerged permanent teeth (1-3).

Bad oral habits within families in Bosnia and Herzegovina had their origin in lack of oral health literacy. This situation was not recognized by state health legislation and not supported with implementation of public oral health preventive programs in our country, also without continuous interdisciplinary preventive collaboration between dentists and other healthcare workers (gynecologists, pediatricians) (3-5). The parents were consequently left to themselves and intentionally became self- taught, mostly under influence of mass media (internet, TV commercials, etc.). Also, this self-education was usually not specifically related to the level of personal formal education.

In every day’s busy and employment burdened parenting, caretakers and institutions have become important even more nowadays, not only for forming child general behavior and character, but also for maintenance of their general and oral health as well (3, 6, 7). There are many obstacles and challenges within this process, especially in institutionally oriented nurturing places (kindergartens) (3, 6, 7).

The aim of this study was to evaluate presence and severity of ECC in children who attended public kindergartens in Sarajevo, and to offer basic information for the maintenance and improvement of child oral health to their parents and kindergarten teachers.

Patients and methods

This cross-sectional observational prospective study included preschool children aged 3-6 years who attended kindergartens within Sarajevo public kindergarten institution „Djeca Sarajeva“, together with their parents and kindergarten teachers, during the period from February to December, 2022. This research was approved by the Ministry of Education and Child Care of Sarajevo Canton and conducted by dental teams of Clinic for Preventive and Pediatric Dentistry of Faculty of Dentistry with Dental Clinical Center of Sarajevo University, in concordance with Helsinki declaration (8). Informed written consent was obtained from participants' parents and from the kindergarten children prior to study research.

Research design was based upon Austrian Oral Health Promotion Program (9). In brief, during research period dental team members gradually visited all kindergartens situated in four Sarajevo city municipalities. Plan of visits to kindergartens was created in advance, and in coordination with teachers who were in charge of this project. Each dental team consisted of two members. Child participant single record consisted of general information (age and gender), total number of present teeth, and number of decayed (d), missing (m) and filled (f) primary teeth. Examination of teeth in the field conditions was performed according to the 5th edition of WHO Oral Health Survey Manual (10), where 12 examiners were previously calibrated in order to be able to conduct the study research. Oral health promotion material for parents and kindergarten teachers was also distributed simultaneously during sequential visits. Parents obtained information about their children oral health and its importance, and the parental roles and ways for its maintenance and improvement; in specially designed video material in Bosnian language entitled «Healthy Teeth, Healthy Child, Happy Parent». Each parent was encouraged to access, download and watch this YouTube video via the following link https://youtu.be/VhKXF2nBJO4. The kindergarten teachers received similar printed promotion materials adjusted for them and their roles in oral health maintenance and improvement of kindergarten children. Dental team members also discussed, together with teachers, the current conditions for possible existence of possibility of anticariogenic nutrition and oral hygiene maintenance conditions within each visited kindergarten.

Descriptive results obtained in study research were presented in tables and figures. Paired sample t-test was used for analysis of related samples, and one-way ANOVA with Bonferroni post-hoc test for analysis of independent samples. The Chi-square test was used for analysis of contingency tables. All statistical analyses were performed with the Microsoft Excel software version 2021 and IBM Statistical Package (IBM, Armonk, NY, USA) for Social Sciences software version 23 (SPSS Inc., Chicago, IL, USA) for the Windows operative system, at 0.05 level of significance.

Results

Public preschool educational institution “Djeca Sarajeva” included 37 kindergartens with 2595 enrolled children aged 3-6 years in total for the research period. All kindergartens were gradually visited by research teams on 48 occasions, with 1722 examined children in total, 876 boys (50.87%) and 846 girls (49.13%). The difference of 873 children (33.64%) between the number of all kindergarten children and examined participants was due to their current absence (731 children, 28.17%) or lack of cooperation for examination (142 children, 5.47%), during the time of planned, previously announced visit to specific kindergarten. The descriptive characteristics of examined children distributed in kindergartens by city municipalities are presented in Table 1.

Table 1. Descriptive characteristics of child participants examined within kindergartens.

Table 1 Descriptive characteristics of child participants examined within kindergartens
kindergarten organizational municipality units	age	3-year-olds		4-year-olds		5-year-olds		6-year-olds
		254		591		595		282
	gender	boys	girls	boys	girls	boys	girls	boys	girls
Centar	396	18	20	53	60	75	68	61	41
Novi Grad	745	76	89	145	145	122	109	28	31
Novo Sarajevo	350	7	11	50	49	72	76	43	42
Stari Grad	231	19	14	49	40	36	37	22	14
total	1722	120	134	297	294	305	290	154	128

Field oral health survey of examined children showed further dental caries experience characteristics in primary dentition represented in Table 2 and Figures 1a-1c. The results showed that younger 3-year-old and 4-year-old children had statistically significant more caries-free individuals and those with all sound primary teeth than in the older ones (chi-square test, p<0.001), without any other determined statistically difference among other variables. Examined children showed statistically more caries-free individuals than those with all sound teeth, within all observed variables (chi-square test, p<0.001, for all comparisons). Older 5-year-old and 6-year-old participants had statistically higher caries prevalence values than the younger ones (chi-square test, p<0.001), without any other statistical significance confirmed between observed variables in this matter.

Table 2. Prevalence of individuals with all sound, caries-free and carious primary teeth among examined child participants.

Table 2 Prevalence of individuals with all sound, caries-free and carious primary teeth among examined child participants
	total sample		boys				girls
sound	n=506	29.38%	n=260		29.68%		n=246		29.08%
caries-free	n=556	32.29%	n=280		31.96%		n=276		32.62%
carious	n=1166	67.71%	n=596		68.04%		n=570		67.38%
age	3-year-olds		4-year-olds			5-year-olds		6-year-olds
sound	n=117	46.06%	n=214	36.21%		n=117	19.66%	n=58		20.57%
caries-free	n=119	46.85%	n=221	37.39%		n=143	24.03%	n=73		25.89%
carious	n=135	53.15%	n=370	62.61%		n=452	75.97%	n=209		74.11%
municipality	Centar		Novi Grad			Novo Sarajevo		Stari Grad
sound	n=116	29.29%	n=217	29.13%		n=95	27.14%	n=78		33.77%
caries-free	n=127	32.07%	n=233	31.28%		n=113	32.29%	n=83		35.93%
carious	n=269	67.93%	n=512	68.72%		n=237	67.71%	n=148		64.17%

Sound – study participant without decayed, missing or filled teeth, with all sound teeth; caries-free – study participant without carious/decayed primary teeth; carious – study participant with one or more carious/decayed primary teeth; n – number of study participants

Figure 1.

(a) Mean values of dental caries experience indexes in primary dentition among examined child participants in total sample. (b) Mean values of dental caries experience indexes in primary dentition among examined child participants according to their age. (c) Mean values of dental caries experience indexes in primary dentition among examined child participants within municipalities

It was obvious that decayed primary teeth have been highly statistically dominating in dmft-structure within all observed variables, with the missing teeth as statistically lowest ones (paired sample t-test, p <0.001, for all comparisons). Although with higher mean value the dmft-values in boys were not statistically significant, younger children showed statistically lower dmft-values than older ones. The lowest values were for 3-year-olds (one-way ANOVA, p=0.001) followed by for 4-year-olds (one-way ANOVA, p<0.001). Children in Canter municipality kindergartens showed statistically highest dmft-values (one-way ANOVA, p=0.05). SiC index was statistically higher than dmft-index in all observed variables, as expected (paired sample t-test, p <0.001, for all comparisons). Dental caries disease was most severe in older children, with the highest SiC-index mean value in 6-year-olds (one-way ANOVA, p=0.004), followed by 5-year-olds (one-way ANOVA, p=0.008). There were no statistically significant differences related to child gender or specific municipality kindergartens.

Levels of oral health care provided for examined child participants by dental healthcare system are shown in Table 3. All of three dental healthcare implementation indexes were statistically higher in girls (one-way ANOVA; p=0.011 for CI, p=0.018 for RI, and p=0.050 for TI), older children (one-way ANOVA; p<0.001 for 6-year-ols, and p<0.001 for 5-year-olds, for all three indexes), and with the lowest values for Novi Grad municipality kindergartens (one-way ANOVA; p values from 0.007 – 0.001, for all three indexes).

Table 3. Descriptive characteristics of determined dental healthcare indexes in examined child participants.

Table 3 Descriptive characteristics of determined dental healthcare indexes in examined child participants
oral health care levels		total sample	boys	girls
	CI (%)	10.55	8.82	12.32
	RI (%)	10.80	9.17	12.48
	TI (%)	12.98	11.54	14.46
age	3-years-olds	4-years-olds	5-years-olds	6-years-olds
CI (%)	3.39	5.93	13.70	15.98
RI (%)	3.39	5.93	13.95	16.97
TI (%)	3.52	6.23	16.46	22.71
municipality	Centar	Novi Grad	Novo Sarajevo	Stari Grad
CI (%)	11.80	6.08	16.58	13.61
RI (%)	12.47	6.13	16.79	13.91
TI (%)	14.89	7.42	19.95	17.06

CI – care index; RI – restorative index; TI – treatment index

YouTube promotive research video material for parents has been seen more than 1890 times since it was first uploaded in January 2022. Printed promotional material was distributed to 96 teachers during sequential visits to kindergartens. During targeted conversations with the teachers, they have stated that the needs and actions for the establishment of anticariogenic diet through planning daily, weekly and monthly menus, and specific places for maintaining oral hygiene of children within kindergartens, have not been recognized so far, mostly with expressed disbelief that this would be established in the future within kindergartens.

Discussion

It was approximately 30 years ago when the first Global burden of diseases (GBD) study was conducted by WHO and World Bank, and at similar time ECC was finally stated by the US Centers for Disease Control and Prevention (11, 12). But, only after GBD study from 2010, there was a clearer global picture about ECC and its prevalence, when the first global oral health report was published (13). Nowadays GBD studies offer better ways for global observing of oral diseases including ECC, with recent issuing of the Global Oral Health Status Report in 2022 (14). The latest known data related to GBD 2019 study were that the global pooled ECC prevalence was 48% with more than a half billion of children worldwide suffering from it (14, 15). The pooled prevalences across continents were as follows: Africa 30%, Americas 48%, Asia 52%, Europe 43, and Oceania 82% (15). Findings close to GBD 2017 study showed global ECC prevalence of 23.8 for toddlers and 57.3% for preschool children (16). In the European Union countries, ECC prevalence for children under 5 years old was 37.2%, with higher values in boys than in girls (17). So far there have been two national studies from Bosnia and Herzegovina, where ECC prevalence in primary teeth of 6-year old children was observed. In the first one that was conducted 35 years ago, with other republics of former Yugoslavia with joint collected data, the ECC prevalence was 97.3% (18). In another study that was conducted almost 20 years ago, the prevalence was 93.2% (19). In the absence of more recent national oral health surveys, there were several local or regional studies that discussed ECC in preschool children. For toddlers and preschool children, the ECC prevalence in our country varied and declined over time from 86% to 53% (studies conducted in the last 20 years, from southwest Herzegovina, northwest and east Bosnia and areas of Banja Luka, Mostar and Sarajevo) (20-24). In the neighboring countries, several studies showed further results in determining ECC prevalence: in Serbia results varied from 30.50-52.80% (25, 26), in Croatia 56.50% (17), in Slovenia 56.50% (17), and in Kosovo 86.31% (27). The ECC prevalence in primary dentition of our study participants has reached pretty high values (Table 2), and went over the most of recent local, regional, international and global findings, with reversive tendency to previous higher values. Furthermore, our study participants had statistically a larger number of caries-free primary teeth than all of sound primary teeth. The ECC prevalence also increased with age of participants.

For the dmft-index, previous domestic national surveys, and one regional, showed values for 6-year-olds with declining tendency: from 8.4 (1988) to 6.71 (2004), and 4.9 (2003) (18, 20, 28). More recent local and regional findings for preschool children conducted studies showed further declining of dmft-values: 6.8 (2016, Sarajevo area) (22), 3.94 (2016, Banja Luka area) (23) and 2.99 (2022, Mostar area) (24). Decayed/carious teeth were dominating ones in all mentioned findings, and dmft-values increased with age of the examined participants (Figure 1). Although missing teeth were mostly the rarest ones, filled teeth significantly increased only in 6-year-olds. Our findings could be in accordance with the trends showed in previous studies regarding mean dmft-value (3.97), its structure (decayed/carious teeth were dominating ones), and increasing over time (higher values present in older preschool children).

Severity of ECC in preschool children and toddlers, as its major public oral health and clinical problem, was observed in several studies, since significant caries index (SiC) has been first introduced for 12-year-old children in 2000 (29-31). As expected, SiC-values were statistically higher than dmft-values with increase over time, which was similar to our findings (Figure 1). However, in our study participants, the differences were mostly 2-2.5 times higher. Furthermore, in our 3-years-old children, there have already been 4.72% of those with at least half decayed primary teeth. In 4-year-olds, there already have been 8.97% of them. This prevalence slightly further increased to 11.60% in 5-year-olds and 12.41% in 6-year-olds, even with sporadic cases of all 20 decayed teeth in 4-, 5- and 6-year-olds.

Not less important were the findings regarding the level of oral health care provided for our child participants (Table 3). Mostly as a result of absence of dental visiting by their parents, CI, RI and TI values in children were extremely low, especially in younger participants. These facts showed obvious lack of prevention in a very critical period and should raise quite a lot of general concern. Prevention of ECC was well known and easily conductive in general (1-3). Parents have to know that they need to visit the dentist to obtain guidelines for caries prevention in order to prevent the occurrence of ECC. If they had not done it on the very start (infant period), they should have to be obliged to perform it in crucial toddler period. Although it was previously considered as late, preschool period can still offer important ways for intervention in established ECC processes, if the disease has already not been prevented (1-3, 32). This should be the way to create reasonable circumstances not to intervene later in dental caries process of (young) permanent teeth in children and adolescents. If not, ECC would only mercilessly continue to endanger newly erupted permanent teeth (1-3). Therefore, the worst traditional prejudice about non-importance of primary teeth in our country only showed its worst side. This was obviously the case in our research, where mostly traditionally self-taught parents were left to themselves, without any valuable oral public health state program that could meet significant oral health preventive needs of children in our country and support parents to take over their roles in maintaining and improving oral health of their children (1-4). Our findings also showed the lowest levels of oral healthcare provided to children from Novi Grad municipality kindergartens. This municipality had the biggest demographic size, not only in Sarajevo city, but also in our country. It was comprised not only from urban, but from suburban and somewhere rural areas as well, and was the most specific among other municipalities in our research. Access to oral healthcare was not completely equal for its citizens as it was to the other more urban Sarajevo city areas. This could be the explanation, among others, why oral healthcare index values were the lowest.

These were only the initial considerations of the current situation, and much wider than this paper intended to offer, but rather to point to the problem itself. Solving of endangered oral health in toddlers and preschool children, as crucial for better future oral health, would also be time and money consuming. In this process, the healthcare network of dental professionals should have to be reorganized and updated to obtain dental healthcare system capable to improve prevention of oral diseases. Until its future establishment and development it would be necessary to design and implement oral healthcare promotion program apart from current healthcare system. This study research was our first step to evaluate levels of oral health in preschool children through their dental caries experience. Furthermore, our very important intention was to inform their parents about the roles they should be obliged to take and implement in preserving and improving of their children’s oral health (3, 9, 33). The study research was conducted in kindergartens; hence the teachers should not be left out but included as active participants in this ongoing promotion process. The plan would be to promote and perform these activities over time, and to expect first real accomplishments in improving oral health when our current 3-year-olds preserve their determined dmft-values on the same levels before going to school, and afterwards.

This study has shown several limitations as well. Regarding the number of examined children, this research has encompassed approximately 14.71% of all 3–6-year-old children that live in these four studied city municipalities by the latest census, and was designed as public kindergarten population-based study. But, at the same time, population of private kindergarten preschool children and also those who were taken care of at home were initially excluded. Although the study was not designed to observe causes of ECC in examined children, the study design itself offered solid circumstances for having all main socioeconomic and educational levels within families of kindergarten children, who additionally have lived in various urban, suburban or rural areas of Sarajevo. These two variables were crucial in determining dental caries experience in the most objective manner. Parents of the examined children were not contacted directly, but with help of kindergarten teachers. Although there were certain numbers of YouTube promotional video views, it could not be more precisely determined how many parents have really watched it and acted to improve their aforementioned parental roles. Finally, printed promotional material was given to kindergarten teachers, with an aim to distribute it to all other kindergarten employees. But, it remained unclear if the material was studied and further distributed to all kindergarten teachers and officials afterwards in order for them to start creating proper anticariogenic diet and oral hygiene environments in these public preschool institutions. Establishment of these environments within kindergartens should be a final long-term objective. It is known that this could pose problems for decision makers who often have extra financial burden in their minds in this matter only. However, they are not aware that investment in prevention of disease, especially in children, will and could only pay off drastically in the future (34, 35).

Conclusions

ECC was present in preschool kindergarten children in Sarajevo, with its high prevalence (67.71%), dmft-value (3.97) and severity (SiC-index 8.79). There was also a significant lack of dental healthcare to examined children mostly related to lack of visiting dental offices by children’s parents (CI=10.55%, RI=10.80%, TI=12.98%). Parental role in preserving and improving of their children oral health should be systematically and profoundly improved. Kindergarten officials and stuff should recognize the importance of establishing environments for anticariogenic diet menus and oral hygiene maintenance within their institutions.