Lupine Publishers | Journal of Dentistry
Abstract
Severe early childhood caries (Severe-ECC) is an aggressive form of
dental caries in the primary dentition associated with
specific patterns of dietary intake in young children. The objective of
this study was to compare oral hygiene status of children aged
3 – 5 years with Severe Early Childhood Caries (ECC) and the oral
hygiene of children without caries, infant feeding, and weaning
practices.
One hundred and ninety-six children aged between stage between
thirty-six to sixty months were selected using purposeful
sampling.There were eighty-one children with severe early childhood
decay were chosen from amongst the patients who had sought
dental treatment at the dental clinic at the Nyanza Provincial General
Hospital (NNPGH). However, 115 children who were caries
free were selected from children attending the maternal child health
clinic at NNPGH. Odds Ratio (OR) and 95% Confidence Interval
(CI) were used to estimate the strength of association between
variables. The significance level was at a confidence interval of 95%.
Ninety-four (48%), of the children, were breastfed or bottle-fed for 24
months or more. Among the children with severe ECC and
children without caries 55 (67.9%) and 70 (60.9%) were exclusively
breastfed respectively. In conclusios children with fair oral
hygiene status were 148 (75.5%) of whom 64 (79.1) had severe ECC while
84(73.0%) had healthy teeth. The children with poor
oral hygiene were in total 10( 5.1%) of whom three had severe-ECC, and
five had no decay. Children with Severe – ECC were fed on
demand, and their oral hygiene was poor compared to children without
caries also.
Keywords: Infant feeding habits, Weaning practices, Severe-ECC, Oral hygiene
Introduction
The definition of Early childhood caries (ECC) is that there is
decay in one or more teeth bein on-cavitated or cavitated lesions.
Also. Teeth missing due to caries, or filled tooth surfaces in any
primary tooth in a child 71 months of age or younger.Children
younger than three years of age, smooth surface caries is indicative
of severe early childhood caries [1]. Severe ECC is associated with
children from the age of 3 years through to 5 years, where there
is a presence of one or more cavitated, missing (due to caries), or
filled smooth surfaces in primary maxillary anterior teeth. Also,
decayed, missing or filled score of ≥ 4 (age 3), ≥ 5 (age 4), ≥6 (age
5) constitutes Severe - ECC [1]. ECC has been associated with
bacteria in the streptococcus family in particular Streptococcus
mutans and Streptococcus sobrinus another related pathogen is
Bifidobacteria. S, sobrinus, and Bifidobactira have been associated
with recurrent decay in children with ECC [2]. However current
research has reported more bacteria such as Streptococcus mutans,
Streptococcus cristatus, Scardovia Wiggsiea, Veillonella parvula,
and Actinomyces gerensceriae which have neem related to ECC
[3]. However, Scardovia Wiggsiae has been found to be present
in cases of severe-ECC in the absence of the other bacteria hence
implicated as a pathogen of severe-ECC. The bacteria use the refined
carbohydrates as substrates where they generate acid resulting in
the demineralisation of the enamel of the deciduous teeth resulting
in severe-ECC [4]. ECC can rapidly destroy the primary dentition of
young children, and left untreated can lead to pain, infection and
speech problems [2]. Specific feeding practices, such as bedtime bottle
feeding, at will breastfeeding, while intake of sugary snacks
and drinks regularly contribute to the development of ECC [5,6].
Studies have also shown that children with severe caries have more
plaque and gingival inflammation than caries-free children [7].
Material and Methods
One hundred and ninety-six children aged between 3 to 5 years
were recruited for this study. Purposive sampling was done to
select Eighty-one children with Severe - ECC chose from amongst
the patients who had sought dental treatment at the dental clinic
at the Nyanza Provincial General Hospital (NNPGH). However, 115
children who were caries free were selected from amongst the
children attending the maternal child health clinic at NNPGH over
a period of three months. Severe – ECC was defined as decayed,
missing or filled a score of ≥ 4 (age 3), ≥ 5 (age 4), ≥ 6 (age 5). A
semi-structured questionnaire was administered to the caregiver
in a face to face interview, and information was collected on infant
feeding and weaning practices. The Intraoral examination was
carried using dental mirrors and a Michigan O dental probe under
natural light as the child sat on an ordinary upright chair. Silness
and Löe (1964) plaque index were used to assess the oral hygiene
status [8]. Six reference teeth 55, 51, 65, 75, 71, and 85 based on
the FDI dental nomenclature plaque scores for each tooth were
recorded from the distal, buccal, mesial, and lingual surfaces of six
teeth[9].The recorded plaque scores for each reference tooth were
added, together, and a mean score for was obtained by dividing the
total derived score with the six teeth to give the mean plaque score.
The scores between 0.0 to 0.1 were excellent oral hygiene, 0.9 to
1.0 good, fair oral hygiene had a score of 1 to 1.9, while a rating
of between 2.0-3.0 was poor oral hygiene status. The inclusion
criteria were that a child was 3-5 years of age, was medically
healthy, and the parent or caregiver was willing to consent. The
study design, protocol, and informed consent were approved by
the Ethics and Research Committee of the University of Nairobi
and Kenyatta National Hospital, Kenya. Data collected were coded
and analyzed using SPSS version 17.0 (SPSS Inc, Chicago Illinois,
USA) for Windows and Microsoft Office Excel 2007. Pearson’s Chisquare
tests were used to test the strength of association between
categorical variables. To determine the significant relationship all
exposure variables were associated with the dependent variable.
Results
There were 196 children aged between 3-5-years-old who
were recruited into the study, eighty-one children with S - ECC
(41.3%) and 115(58.7%) without caries. The children’s mean age
was 4.1+0.6 years, and it ranged between 3 and five years with a
high proportion of the children (62.2%) aged four years. There
was a statistically significant difference in age distribution among
children with Severe. ECC and children without caries (χ2=28.36,
d.f =2, p<0.001). The majority of the children with caries were aged
four years (84.0%) compared to those without caries (47.0%).
Gender distribution was comparable with boys slightly more
(51.0%) than girls (49.0%) Table 1.
Table 1: Effect of group on prevalence of number of analgesic tablets at pre-treatment time interval.
*Pearson’s Chi-square
Out of 3,240 deciduous teeth for 81 children aged 3-5 years
sixty one 1.9% of the teeth were missing due to decay hence 3179
teeth were examined of whom 605 (19%) were decayed... The caries
pattern was that the maxillary teeth were more affected compared
to the mandibular teeth. In the mandible the least affected were the
canines. However the first primary molar had high prevalence of
between 71.6% - 82.7%. In the mandible the most affected teeth
were the second deciduous molars which had a prevalence range
of 88.9% - 98.7% Figure 1 the study and they did not have ECC had
been exclusively breastfeeding. However, 71 (36.2%) out of the 196
respondents had had both breast/bottle feeding. Out of the seventyone,
those who had breastfeeding supplemented with bottle feeding
were 29(35.8%), and they had severe ECC while 42(36.5%) out 115
of those without caries. Children who were exclusively bottle fed
were eight of whom five 6.2% had severe ECC while three 2.6% did
not have caries Figure 2. There were no differences in the methods
of breastfeeding with a Pearson Chi-square =3.51, d.f= 2, p=0.173
at 95 % CL.
Figure 1: Prevalence of number of analgesic tablets in the
two groups after 24hr.
Figure 2: Percent distribution of children by the method of feeding in infancy and toddler stage.
Forty children, 20.4% had breast or bottle feeding or combined
feeding for a ≤12 month exclusively. Sixty-two (31.6%) 12≤ 24
months while 94(48%), for ≥24 months. There were 16 (19.8%) of
the children with severe-ECC had either breastfed or bottle fed or
both for a time duration of ≤12 months while those without decay
were 24 (20.9%). Similarly, 23 (28.4) children with severe-ECC had
a duration of 12≤ 24 months while those without caries were 39
(33.9%). Forty-two (51.9%) and 52(45.2%) of children with severe
ECC and children without caries had respectively been breastfed
for ≥24 months, Figure 3. However, there were no significant
differences between the breastfeeding period for the children with
severe –ECC and those without decay with a Pearson Chi-square =
0.92, d.f=2, p=0.630 at 95%CL.
Figure 3:Percent distribution of duration of feeding practices in infants and toddlers with severe-ECC and those without
decay aged 3-5 years.
The effect of amoxicillin with clavulanic acid antibiotic
premedication on pretreatment pain after administration
of antibiotic and before initiation of endodontic treatment
(Pretreatment pain) was assessed for patients using a four step
pain scale (No pain, Mild , Moderate, Severe). The results showed no
statistically significant difference detected between both groups.
The results are illustrated in the following images 3.
Figure 3: Effect of group on prevalence of pain score at pretreatment time interval.
One hundred and twenty-five (63.8) children had exclusive
breastfeeding while the remaining 71 (36.2%) had either
breastfeeding supplemented with bottle feeding or exclusive bottle
feeding. The seventy71 who had breastfeeding and supplement
or had exclusive bottle feeding the breast milk complement or
supplement used was either cow’s milk, porridge, milk mixed with
porridge. Milk was the most common beverage bottle content for
both groups of severe ECC and those without decay for 47 (66.2%)
out of the sixty-three children who had been bottle fed; six 8.5%had
porridge, For eighteen (25.4%) children the bottle content was a
mixture of milk and porridge. Fifteen (18.5%) children with severe-
ECC had milk as the bottle content while 3(3.7%) the content was
porridge and eight ((9.9%) children the bottle content was milk
and porridge Figure 4. There were no differences for the different
practices about the breast milk complements or supplements with
a Pearson Chi-square 1.39 d.f=2 p=0.500 at 95% CL.
Figure 4: Percent distribution of children of on breast milk supplements and complements using the bottle.
Eighty-nine (45.4%) children out of 196 were fed on demand
while 107 (54.6%) were not fed on demand. Out of the 81 children
with severe ECC 54(66.7%) were fed on demand compared to 35
(30.4%) out of 115 who did not have decay. However, 27 (33.3%)
children out of 81 of those who had severe-ECC were not fed on
demand. Similarly, 80 (69.6%) of the 115 who did not have decay
were not fed on demand Figure 5. The difference was statistically
significant with a Pearson Chi square= 25.17 d.f= 1.0, p≤0.001 at
95%CL.
Figure 5: Percent children of children who were fed on demand and those not feeding on demand for those with severe-ECC
and those without decay.
Six (3.1%) children had excellent oral hygiene, and they were
from the group of children without decay. Children with good
oral hygiene were 32 (16.3%) of which 10 (12.3) were from the
group with severe-ECC and 22 (19.!%) from the group without
dental decay.The oral hygiene of 148 (75.5%) children had affair
oral hygiene, those with severe-ECC were 64 (79%) out of 81, and
those without decay 84 (73%) out of 115 had fair oral hygiene. Only
ten (5.17%) had poor oral hygiene of out of whom – (8.6%) had
severe –ECC and three (2.6%) did not have decay, Figure 5. There
was significant the difference in the oral hygiene status of children
with S - ECC and children without caries with a Pearson Chi-square
2=9.18, df1, p=0.027).
Discussion
Severe early childhood caries (Severe–ECC) is an aggressive
form of dental caries in the primary dentition associated with
specific patterns of dietary intake in young children [1.10]. Most
of the children 125(63.8%)were breastfed while 71(36.2%)
were put on breastmilk compliments/ supplements early in
infancy and some of them stayed on the bottle after the second
birthday. Mothers in Kenya are encouraged to practice exclusive
breastfeeding [8-14]. It is documented that nursing mothers in
Kenya have a high breastfeeding frequency pattern occurring
in 93% of mothers wherein a twenty-four hour period in the
daytime the infant according to UNICEF a mother is recommended
to breastfeed three times a day. However, Kenyan mothers are
encouraged to breastfeed as much as possible and some of them
breastfeed on demand as many as seven times in the daytime and
five times at night on demand [11-13]. In the current study 63%
of the children were exclusively breast fed and this finding is in
agreement with the national value of 61% breastfeeding mothers
who practice exclusive breastfeeding at least the first six moths
of infancy. In order to enhance good oral health and the general
health of and infant there is a need to provide information on the
benefits of good oral hygiene for the breasting mother and the
breastfed infant or toddler so that frquency of nocturnal at will
breastfeedin is minimised . Thse may reduce the sustrate which
the cariogenic bacteria require to produce acid and it will also
reduce the production of the plaqure which holds the acid close to
the enamel resulting in enamel dimineralisation. The oral health
information and education may be incorporated in the prenatl
clinics as information available to the expectantnt mothers.
It is currently documented that exclusive on demand
breastfeedng may lead to severe- ECC which is a debilitating oral
disease condition and it may be a confouder to malnutrition of the
child who is in pain is unable to jew food properly and this may lead
to nutritional deficiencis. The deficieneces may interfere with the
proper pysical and mental growth and development of the child.
Secondly vital nutional deficiences may lower the immunity of the
child thus making the infant and toddler with severe –ECC to be
vulnerable to early childood diseases.
The children who had exclusive breastfeeding were 63.7% of
the study group and the breastfeeding period was ≥24 months
which was slightly higher than the reported duration of exclusive
breastfeeding [11,13]. Children who were fed on demand were
45.6% of the sample size out of whom 66.7% had severe ECC, and
the difference was significant with a Pearson Chi-square p≤0.001.At
will breastfeeding/ bottle-feeding on demand pauses a particular
risk to the deciduous dentition which has low mineral content and
thin enamel. In the current study out of 81 children with severe-
ECC 55(67.9%). Out of the ninety-four children with prolonged
breastfeeding 49(51.9%) had severe-ECC and had beyond twentyfour
months. Though breastfeeding is good for the child, the
nocturnal breastfeeding and the high frequency in the daytime
which is twice what is recommended by UNICEF the stagnation
of milk around the newly erupted teeth may be fermented by the
anaerobic bacteria thus producing large quantities of acid. There
is a need to encourage the mothers in breastfeeding but give them
the knowledge to clean the infant’s mouth and to avoid nocturnal
breastfeeding [11-13].
The dietary weaning practices included the use of a bottle where
the breast milk supplement or complement was, milk, porridge or
porridge mixed with milk. The introduction of a bottle has been
associated with diarrheal disease in early childhood. The early
childhood diseases further weakens the child’s immunity resulting
in a vicious circle of disease and malnutrition in early childhood
which may result in a child not being able to thrive.
Majority of the children with Severe -ECC were fed on demand
(66.7%) compared to those without caries (30.4%), and this was
statistically significant Pearson chi-square with p≤0.001. The
difference in the oral hygiene status of children with Severe - ECC
and children without caries were substantial with a Pearson Chisquare
=2=9.18, df2 p=0.027).
Figure 6:Oral hygiene status for children with severe-ECC and those without caries.
The most critical period of feeding at will has been reported
to be twelve months.The period of twelve months is when most of
the deciduous teeth with a thin and poorly mineraised enamel are
fully erupted in the mouth. In the presence of the virulent anerobic
bacteria Streptococcus Mutans Scardovia Wiggsiae the denttion
is dimineralised [3,14]. The sustrate and bacteria presence are
confounded by the factor that at one year there are no oral hygiene
paracties for the toddler and the vist to the dentist is not yet hence
emanel demineralisation may progress unabated Figure 6.
The feeding on demand results in having acid producing
bacteria resulting in prolonged periods of a low pH resulting in the
demineralization of the dentition. Recent research has incriminated
the bacteria Scardovia wiggsiea as an anew pathogen which has
been found at the sites of severe EC lesions in the absence of other
pathogens which had previously been associated with severe ECC
[2,3]. Ultimately, prolonged exposure of the teeth in the acidic
environment causes dental caries. There were differences in the
oral hygiene status of the children with severe –ECC compared with
those who had no caries which was statistically significant.
A study in Saudi Arabia has reported similar findings where
caries was associated with a high presence of debris [6]. The high
caries debris could probably be due to poor oral hygiene practices
among children with severe– ECC. National Oral health survey has
reported poor utilisation of oral health services where a sample of
2,126 individuals age 5-15, nine hundred and only three (46.7%)
had never visited an oral health facility. Out of those who had never
visited a dentist, 57.7% were from the rural community where
the services were scarce due to distance or resources were not
available to provide oral health services for both the children and
the adults [15,16].
The challenge may be overcome by having information and
education incorporated in the well established maternal health,
and well-child clinics on simple preventive remedied for good oral
health practices to minimize plaque deposits and severe ECC.The
preventative measures may ensure that the children have healthy
teeth for mastication and digestive processes would also improve
the quality of life for the children.
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