Risk Factors of Early Childhood Caries Among Preschool Children in Eastern Saudi Arabia

Abstract

This study aimed to determine the risk factors of early childhood caries (ECC) among preschool children from eastern Saudi Arabia. In this cross-sectional study, 241 carers and their children from 10 daycares were recruited and asked to complete a questionnaire aimed at assessing their sociodemographic profile and oral health-related behaviors. This was followed by a dental examination of the children by two calibrated dentists. Caries status was recorded using the dmft index. Chi-square and logistic regression tests were used to analyze the data (p < 0.05). The mean dmft of the children was 4.39 (SD ± 4.25). According to logistic regression analysis, children who were bottle-fed between 7 and 12 months (Adjusted Odds Ratio (AOR): 0.110) or breastfed between 13 and 18 months (AOR: 0.028) were less likely to have ECC than those with a prolonged feeding duration (>18 months). Also, those with smoking carers (AOR: 0.176) were less likely to have ECC than those with nonsmoking carers. On the other hand, children who had working carers, mainly mothers, in the education sector (AOR: 11.105), were more likely to have ECC (p < 0.05). The risk factors associated with the presence of ECC among preschool children in eastern Saudi Arabia include the mother’s occupation and the carer’s smoking status, as well as feeding practices (particularly bottle feeding). These factors can be modified by encouraging carers to completely wean their children (particularly from the bottle) by 18 months of age and advising working mothers to perform tooth brushing for their children in the morning before they go to work and in the evening before the children go to bed.

Introduction

The American Academy of Pediatric Dentistry (AAPD) defines early childhood caries (ECC) as the presence of one or more decayed (non-cavitated or cavitated lesion), missing (due to caries), or filled tooth surfaces in any primary tooth in a child 71 months of age or younger. ECC is a chronic transmissible infectious disease and multifactorial in nature. ¹ Without treatment, ECC can progress rapidly, causing pain and dental infection with a major impact on quality of life and the ability to function in affected children. ² Health care costs will also increase as dental treatment under general anesthesia might become required for untreated severe cases and uncooperative children. In developing countries, it is very common for children to be hospitalized because of ECC.^3–8 Several studies have evaluated and categorized the risk factors of ECC, such as sociodemographic factors, dietary factors, oral hygiene factors, and factors related to oral bacterial flora as well as breast and bottle feeding.^9,10 However, the degree to which different risk factors are associated with ECC remains unclear. Significant gaps have been observed in the collective evidence on risk factors known to cause ECC. For example, some studies have suggested that an increased duration of breastfeeding could be associated with the development of ECC.^11,12 In vitro studies have also shown that human milk is relatively cariogenic ¹³ and that its cariogenic potential can increase significantly when sugar is added. ¹⁴ However, other studies have not found an association between ECC and breastfeeding. ¹⁵ In Saudi Arabia, ECC is prevalent among preschool children (27.3%), as reported by Wyne et al. ¹⁶ and Al-Malik et al. ¹⁷ (73%). Moreover, gaps in the knowledge of carers (parents) about it were reported. ¹⁸

The risk factors of ECC were never assessed among Saudi preschool children. ECC risk factors can differ according to population. Identification of risk factors specific to the Saudi population is crucial to better direct public health mitigation efforts toward them. Therefore, this study aimed to determine the risk factors associated with ECC among preschool children in the eastern region of Saudi Arabia.

Methods

Ethical approval

Ethical approval of the present study was obtained from the institutional review board of armed forces hospitals of the eastern region of Saudi Arabia (reference number: AFHER-IRB-2020-016) before the start of the study. Also, all participants in the present study were informed of their rights, the aim of the study, the procedures involved, and the benefits of their participation. The confidentiality of personal identification and demographic data was assured so that participation was entirely voluntary.

Study population

This was a cross-sectional study conducted on a convenience sample of 241 preschool children (<71 months of age), and their carers, who attended 10 daycares drawn from the three biggest cities in the eastern region of Saudi Arabia (Dammam, Dhahran, and Al-Khobar) during the period between January and April 2020. A convenience sampling approach was selected due to the coronavirus disease 2019 (COVID-19) pandemic which adversely impacted the flow rate of preschool children to daycares during the study period. The selected daycares in the present study were drawn from a list that had been previously prepared according to the daycares enlisted by the ministry of labor and social development in these cities (64 in total). Every third daycare on that numbered list was selected until a total of 10 daycares was selected. Three of the daycares were from Dammam and Dhahran cities while four daycares were from Al-Khobar city. An almost equal number of children was included from each daycare.

The inclusion criteria for the study were:

• Children aged up to 71 months at the time of clinical examination.

• Children with no significant health problem.

• Children who allowed dental examination.

• Carers who were residents of the eastern region of Saudi Arabia and who spoke and understood the Arabic language.

• Carers must have signed informed written consent.

The exclusion criteria were:

• Children older than 71 months of age.

• Children with a significant health problem.

• Uncooperative children who did not allow dental examination.

• Carers who were not residents of eastern Saudi Arabia or who did not speak the Arabic language.

• Carers who refused to participate in the study or sign a written consent.

Carers in the current study were either the mothers or the fathers of the children. Both were the legal guardians of the children.

Study measures

Carers (either the father or the mother) completed a questionnaire in the Arabic language, aimed at assessing their sociodemographic profile and oral health-related behaviors using a face-to-face interview. The questionnaire was written initially in the English language. A few questions (a limited proportion of the questionnaire) were brought from the questionnaire adopted by Tanaka and Miyake. ¹¹ Additional questions were added by the authors to meet the study objectives. The questionnaire was then translated into the Arabic language and then back into the English language to ensure accuracy. The English and Arabic versions were validated by two independent investigators to ensure the similarity of the content of both versions. In addition, to ensure content validity and clarity of the questions, the questionnaire was piloted among a sample of 20 carers. Neither the questions nor the answers were modified following the pilot study, and the pilot sample was excluded from the study’s main sample. The questionnaire included two sections: participants’ sociodemographic background and oral health-related behaviors. The sociodemographic background section included questions on the child’s gender and age group; the carer’s education level, occupation, and smoking status; and the perinatal period (the mode of delivery and birth status, i.e. whether the child was preterm or full-term). The oral health-related behaviors section included questions on breast and bottle feeding, children’s oral hygiene practices, diet, and dental history.

Dental examination

Following the completion of the carers’ questionnaires, dental examination of the children was carried out by two trained and calibrated dentists using the daylight, disposable mirror, and explorer. The kappa score for both intra- and inter-examiner reliability was 0.94.

Younger children (up to 3 years of age) were examined using knee-to-knee examination while older children (over 3 years of age) were seated on a small chair during the dental examination. All children were examined on the daycare premises. Dental caries was measured using the decayed (d), missing (m), and filled (f) teeth (dmft) index according to the WHO criteria. Teeth missing (m) or filled (f) contributed to the overall dmft score only if teeth were missing or filled because of dental caries. A dmft score above null indicates the presence of ECC, whereas a null score indicates the absence of dental caries. ¹⁹

Data analysis

Data were statistically analyzed using the SPSS computer software (Statistical Package for the Social Sciences Version 22, Chicago, IL, USA). Descriptive statistics were obtained and a chi-square test (univariate approach) was used to detect any significant difference in the association of ECC with the assessed independent variables, namely: gender and age group of the child, education level of carers, occupation of carers, smoking status of carers, delivery mode, birth status (preterm/full-term birth), breastfeeding and its duration, bottle feeding and its duration, nocturnal feeding (feeding during sleep), age of starting tooth brushing, carer’s assistance with tooth brushing, frequency of tooth brushing per day, use of fluoridated toothpaste, frequency of main meals per day, frequency of snacks per day, having received advice on oral health issues, and dental visits during pregnancy. Binary logistic regression modeling (multivariate approach) was further used to explore the association of the independent variables with ECC. Probability values of p < 0.05 were considered to be statistically significant.

Results

Of the total 241 children examined 66 (27.4%) were found to have ECC. The mean dmft for the study population was 4.39 (SD ± 4.25). Description of participants’ sociodemographic background and oral health-related behaviors is summarized in Tables 1 and 2, respectively.

Table 1.

Sociodemographic background of children with and without early childhood caries.

Variables	Category	N (%)	Early childhood caries		p Value°
			No (n = 175) n	Yes (n = 66) n (%)
Gender	Boy	142 (58.9)	97	45 (68.2)	0.05
	Girl	99 (41.1)	78	21 (31.8)
Age (in months)	12–24	8 (3.3)	3	5 (7.6)	0.005*
	25–36	67 (27.8)	45	22 (33.3)
	37–48	78 (32.4)	54	24 (36.4)
	49–60	60 (24.9)	46	14 (21.2)
	61–71	28 (11.6)	27	1 (1.5)
Pre-term birth	Yes	24 (10.0)	22	2 (3.0)	0.018*
	No	217 (90.0)	153	64 (97.0)
Delivery mode	Vaginal	144 (59.8)	105	39 (59.1)	0.506
	C-section	97 (40.2)	70	27 (40.9)
The educationlevel of themother	Primary orintermediateschool	3 (1.2)	3	0 (0.0)	0.168
	Secondary school	22 (9.1)	19	3 (4.5)
	University	216 (89.6)	153	63 (95.5)
The educationlevel of thefather	Primary orintermediateschool	1 (0.4)	0	1 (1.5)	0.123
	Secondary school	15 (6.2)	13	2 (3.0)
	University	225 (93.4)	162	63 (95.5)
Occupation ofmother	Education sector	66 (27.4)	53	13 (19.7)	0.346
	Health sector	23 (9.5)	17	6 (9.1)
	Other than thehealth oreducation sector	53 (22.0)	35	18 (27.3)
	Unemployed	99 (41.1)	70	29 (43.9)
Occupation offather	Education sector	21 (8.7)	18	3 (4.5)	0.187
	Health sector	15 (6.2)	12	3 (4.5)
	Other than thehealth oreducation sector	200 (83.0)	140	60 (90.9)
	Unemployed	5 (2.1)	5	0 (0.0)
Carer’s smokingstatus	Yes	55 (22.8)	34	21 (31.8)	0.033*
	No	186 (77.2)	141	45 (68.2)

^°According to chi-square and Fisher’s exact tests.

^*Indicates a statistically significant difference (p < 0.05).

Table 2.

Oral-health related behaviors of children with and without early childhood caries.

Variables	Category	N (%)	Early childhood caries		p Value°
			No (n = 175) n	Yes (n = 66),n (%)
Breastfeeding	Yes	223 (92.5)	161	62 (93.9)	0.421
	No	18 (7.5)	14	4 (6.1)
Breastfeedingduration (in months)	0–6	149 (61.8)	118	31 (47.0)	0.018*
	7–12	36 (14.9)	23	13 (19.7)
	13–18	28 (11.6)	15	13 (19.7)
	Morethan 18	28 (11.6)	19	9 (13.6)
Bottle feeding	Yes	203 (84.2)	156	47 (71.2)	0.001*
	No	38 (15.8)	19	19 (28.8)
Bottle-feedingduration (in months)	0–6	45 (18.7)	23	22 (33.3)	<0.0001*
	7–12	24 (10.0)	14	10 (15.2)
	13–18	22 (9.1)	15	7 (10.6)
	Morethan 18	150 (62.2)	123	27 (40.9)
Nocturnal feeding	Yes	164 (68.0)	116	48 (72.7)	0.212
	No	77 (32.0)	59	18 (27.3)
Carer’s assistancewith tooth brushing	Yes	139 (57.7)	97	42 (63.6)	0.158
	No	102 (42.3)	78	24 (36.4)
Starting age of toothbrushing (in months)	0–12	78 (32.4)	53	25 (37.9)	0.231
	13–24	110 (45.6)	79	31 (47.0)
	25–36	41 (17.0)	31	10 (15.2)
	37–48	9 (3.7)	9	0 (0.0)
	>48	3 (1.2)	3	0 (0.0)
Use of fluoridetoothpaste	Yes	87 (36.1)	56	31 (47.0)	0.038*
	No	74 (30.7)	61	13 (19.7)
	Unsure	80 (33.2)	58	22 (33.3)
Tooth brushingfrequency per day	None	11 (4.6)	5	6 (9.1)	0.010*
	Once	88 (36.5)	68	20 (30.3)
	Twice	128 (53.1)	88	40 (60.6)
	Trice ormore	14 (5.8)	14	0 (0.0)
Dentist visitduring pregnancy	Yes	81 (33.6)	59	22 (33.3)	0.542
	No	160 (66.4)	81	44 (66.7)
Number of mainmeals/day	One	6 (2.5)	5	1 (1.5)	0.854
	Two	43 (17.8)	30	13 (19.7)
	Three	180 (74.7)	132	48 (72.7)
	Morethan 3	12 (5.0)	8	4 (6.1)
Number ofsnacks/day	None	6 (2.5)	5	1 (1.5)	0.194
	One	23 (9.5)	16	7 (10.6)
	Two	122 (50.6)	82	40 (60.6)
	Three ormore	90 (37.3)	72	18 (27.3)
Received adviceon oralhealth issues	Yes	147 (61.0)	110	37 (56.1)	0.207
	No	94 (39.0)	65	29 (43.9)

^°According to chi-square and Fisher’s exact tests.

^*Indicates a statistically significant difference (p < 0.05).

More than one-third (36.4%) of the children with ECC were within the age group of 37–48 months with more than two-thirds (68%) being males. In addition, the majority (97%) were born full term. With regards to oral-health-related behaviors, just less than half (47%) of the carers reported breastfeeding for a duration up to 6 months as well as bottle feeding (41%) for >18 months. Around two-thirds (72.7%) of the children with ECC were either breast or bottle-fed at night time with more than one-third (47%) of the carers reported initiation of tooth brushing between the first and second year of their child’s life. Using a chi-square test, a statistically significant association was found between ECC and the following variables namely child’s age group, preterm birth, carer’s smoking status, breastfeeding duration, bottle feeding, and its duration, use of fluoridated toothpaste, and frequency of tooth brushing (p < 0.05). However, using binomial logistic regression analysis after adjusting for all the independent variables, four factors were found to be significantly associated with ECC, these were carer occupation, carer smoking status, and duration of the breast as well as bottle feeding (p < 0.05) (Table 3). The rest of the factors were not associated with ECC (p > 0.05).

Table 3.

Logistic regression analysis of risk factors of early childhood caries.

Independentvariables	Group	B	SE	Odds ratio	95% CI		Sig.
					Lower	Upper
Occupationof mother	Education sector	2.407	0.749	11.105	2.559	48.194	0.001*
	Health sector	1.259	0.875	3.522	0.634	19.569	0.150
	Other than the healthor education sector	1.283	0.685	3.607	0.941	13.822	0.061
	Unemployedreference
Carer’s smoking status	Yes	−1.736	0.767	0.176	0.039	0.793	0.024*
	Noreference
Breastfeedingduration	0–6	−2.398	1.458	0.091	0.005	1.582	0.100
	7–12	−2.903	1.513	0.055	0.003	1.064	0.055
	13–18	−3.588	1.181	0.028	0.003	0.280	0.002*
	More than 18reference
Bottle-feedingduration	0–6	−0.192	1.324	0.825	0.062	11.062	0.885
	7–12	−2.208	0.852	0.110	0.021	0.585	0.010*
	13–18	−1.161	0.787	0.313	0.067	1.465	0.140
	More than 18reference

Nagelkerke R² = 0.549.

The word “reference” refers to the group to which the comparison was made.

B: unstandardized regression coefficient; SE: standard error.

^*Indicates statistically significant difference (p < 0.05).

Compared to children of non-working mothers (unemployed mothers who acted as the reference group), children of working mothers, particularly of those working in the education sector, had 11 (95% confidence interval [CI]: 2.559–48.194) times higher odds to have ECC, while those of smoker carers had 5.7 (CI: 0.039–0.793) times less odds of having ECC than those of nonsmoker carers (reference group). On the other hand, children who were breastfed between 13 and 18 months had 35.7 (CI: 0.003–0.28) times less odds to have ECC than those who were breastfed for >18 months. In addition, those who were bottle-fed between 7 and 12 months had 9 (CI: 0.021–0.585) times less odds to have ECC than those who were bottle-fed for >18 months (reference group).

Discussion

The World Health Organization (WHO) recommended reporting caries status in the primary dentition (ECC) of children at 5 years of age. According to our findings, around one-third of the preschool children had ECC. In addition, the mean dmft of the children (4.39) fell within the range reported for the other regions of Saudi Arabia (2.92–8.6),^16,17,20 as well as for other countries (0.9–7.5). ²¹

In the current study, other than the working status of the mother, the socio-demographic factors assessed were not risk factors associated with ECC. Alhabdan et al. ²² also found that socio-economic factors were not predominantly associated with dental caries in Saudi school children. Children of working mothers in general; and those working in the education sector, in particular, were significantly more likely to have ECC than those of non-working mothers in the current study. A similar finding was reported by Mahesh et al. ²³ who found that children of working mothers spent a considerable time of their day in daycares, where caregivers there do not routinely perform or supervise tooth brushing for children as part of their daily routine. It is also likely that the diet of those children is more cariogenic in nature with sugary food and beverages being more likely consumed as compared to children of non-working mothers who are naturally fed meals that are home prepared. Consequently, these possibilities should be conveyed to working mothers as part of oral health programs; the working mothers should also be encouraged to perform tooth brushing for their children before they go to work and before the children go to bed.

On the other hand, the findings of this study concerning the association of ECC with the smoking status of the parents are in contrast to those reported in the literature, where carers’ smoking was not found to be associated with a higher risk of ECC in their children but lower risk. Secondhand smoking by children was linked to ECC by several epidemiological studies as reviewed by Hanioka et al. ²⁴

Of all oral health-related behaviors assessed in the current study, long periods of breastfeeding and bottle feeding (>18 months) were risk factors for ECC; breastfeeding duration between 13 and 18 months and bottle feeding duration between 7 and 12 months were associated with significantly less likelihood to have ECC in preschool children than prolonged breast/bottle feeding duration (>18 months). Cut-off points for breastfeeding duration have varied in the literature, for example, some studies that have investigated the association between dental caries and breastfeeding duration used cut-off points for prolonged breastfeeding as equal or lesser than 12 months.^25–27 However, according to the WHO, children should be breastfed up to 24 months or beyond, with this age also being used as a cut-off point by other studies. ²⁸ Our findings were consistent with those studies which used 18 months as a cut-off point for prolonged breastfeeding;^29–31 beyond that age breastfeeding increases the risk of ECC; therefore, consultation with a dentist is necessary for examination and preventive advice regarding dietary practices.^1,32 Our findings also indicate that 18 months is a cut-off point for bottle feeding as well. Prolonged bottle-feeding was reported as a risk factor for ECC in a previous study. ³³

On the other hand, this study couldn’t link ECC with the age of starting tooth brushing, carer’s assistance with tooth brushing, frequency of snacking, and nocturnal feeding. These factors were not associated with ECC starting from the univariate analysis. Hartwig et al. ³⁴ couldn’t also link ECC with the age of starting tooth brushing, while Ozen et al. ³⁰ couldn’t link the carer’s assistance in tooth brushing with ECC. One explanation for that might be that some questions were addressed in yes/no format (e.g. nocturnal feeding), according to Gao et al. ³⁵ reductions of data to simple yes or no answer may result in losing some information; for example, there was no consideration for the frequency of feedings during sleep. In addition, some snacks can be caries friendly (e.g. cheese) as no dietary analysis was performed in this study for the children which can be considered a limitation it is difficult to ascertain whether the reported snacks by carers were all cariogenic in nature. This can to some extent explain our previous finding on the carer’s smoking status and ECC risk as it is likely that carers smoked infrequently or outside their homes therefore the chance of exposing the children to secondhand smoke would be less. Other limitations would be that we could not collect information about the presence of enamel defects and levels of Streptococcus mutans. These two factors were reported by Kirthiga et al. ³⁶ in an updated systematic review and meta-analysis as the two strongest risk factors associated with ECC among preschool children in high- or upper-middle-income countries. Another limitation would be that the use of a convenience sample may not represent the entire population, and may limit the generalizability of the results, despite that different social, economic, and educational diversities were included in the studied population, nevertheless, some of the findings likely reflect those of the community at large. For instance, this study found that almost one-third of preschool children in eastern Saudi Arabia had ECC, a figure that is so close to that reported in the capital city (Riyadh) (27.3%). ¹⁶ The former also falls within the range reported by Chen et al across the globe (23%–90%). ²⁰ Therefore, the present results can still provide baseline data that need to be explored further in future studies conducted on representative samples of preschool children and their carers. Further limitations would be that we did not ask the carers of the children about the number of preschool children in their family as well as the order of the examined child among the rest of the siblings, as it is likely that carers who take care of several preschool children have less free time to take care of oral health of their children and supervise or perform tooth brushing for their children. In addition, the timing of establishing a dental home for the examined children, where carers generally receive information from a dentist about oral health for their children and oral hygiene practices as well as children receive an oral examination, is unknown. Of particular note; however, is that around two-thirds of the examined children in the present study did not seem to have that established, as per recommendations of the AAPD, by 12 months of age, ³⁷ as the reported age of initiating tooth brushing for them was beyond that age.

Conclusion

Sociodemographic factors (working status of the carer, mainly the mother, and carer’s smoking status) along with oral health-related behaviors (breastfeeding and bottle feeding duration) were risk factors associated with ECC among preschool children in the eastern region of Saudi Arabia. To improve children’s oral health status, the ministry of health should implement oral health programs for carers in the region, to raise their awareness about ECC and its risk factors and encourage them to completely wean their child (particularly from the bottle) by 18 months of age. Working mothers should also be advised to perform tooth brushing for their children in the morning before they go to work and in the evening before the children go to bed.

Author biographies

Sanaa N. Al-Haj Ali is an Associate Professor of Pediatric Dentistry at Qassim University College of Dentistry, Saudi Arabia. She is actively involved in research related to pediatric dentistry, general dentistry, and pediatrics in general. She has several publications in these fields.

Faisal Alsineedi is a Consultant Pedodontist and director of the dental department at King Fahad Military Medical Complex, Dhahran, Saudi Arabia.

Nouf Alsamari is currently a Dental Resident at the dental department of King Fahad Military Medical Complex, Dhahran, Saudi Arabia.

Ghaida Alduhayan is currently a Dentist at King Abdulaziz Naval Base Armed Forces Hospital, Jubail, Saudi Arabia.

Alaa BaniHani is a Clinical Lecturer and Specialist Registrar in Pediatric Dentistry at Leeds University Dental school, Uk. She has a particular interest in research related to Pediatric Dentistry and has several publications in this field.

Ra’fat I. Farah is an Associate Professor of Prosthetic Dentistry at Qassim University College of Dentistry, Saudi Arabia. He is actively involved in Fixed Prosthodontics and Dental Materials related research and has several publications in journals from the field of Prosthetic and Esthetic dentistry.