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Abstract
Severe early childhood caries (Severe-ECC) is an aggressive,
infectious and preventable form of dental caries that affects very
young children. The survey purposed to examine any differences in the
severity of poor nutrition in children without decay and
those children with dental decay in the age group between thirty-six and
sixty months. Sampling was purposeful and 196 children
aged between 3 to 5 years for this study. The study was hospital-based
where eighty-one children with severe dental decay who had
attended the Nyanza Provincial General Hospital (NNPGH). Similarly, one
hundred and fifteen children who were caries free were
chosen from amongst the children attending the maternal child health
clinic at NNPGH over a period of three months. Odds Ratio
(OR) and 95% Confidence Interval (CI) were used to estimate the strength
of association between Severe ECC and nutritional status.
The mean dmft for the children with severe Early Childhood Caries (ECC)
was 7.5±19. The prevalence of malnutrition was reported
among both groups of children with severe ECC and without decay as 28
(14.3%) underweight, wasting 5(2.5%), and stunting
9(4.6%). The malnutrition in children with, Severe-ECC was observed as
27(14%) underweight; 10(4.9%) of the children were
wasted, and 5(2.5%) were stunted. However among the children without
caries 26 (13.9%) were underweight while 5 (2.6% were
wasted, and 12 (6.1%) were stunted. Both children those with severe ECC
and those with decay, however, the children who were
likely to be underweight at 1.23 times were those affected with severe
ECC at 1.23 times compared to the children without decay.
Hence other factors may be playing a role in malnutrition of children
aged 3-5year old.
Keywords: Severe-ECC; Nutritional status; Caregivers demographics
Introduction
Early childhood caries (ECC) is defined as the presence of one
or more decayed (non-cavitated or cavitated lesions), those missing
(due to caries), or filled tooth surfaces in any primary tooth in a
child 71 months of age or younger. Severe Early Childhood Caries
reported in children below three years of age as smooth surface
caries1. One or more cavitated, missing teeth due to caries has
been associated with age s 3-5years.The filled smooth surfaces in
primary maxillary anterior teeth or a decayed, missing or filled a
score ≥ 4 for age 3years, a score of ≥ five is associated with 4years
while cavitation, restored tooth and missing due to caries a score of
≥6 is for children in the 5-year-old group. All these scores constitute
Severe – ECC [1].
Disadvantaged groups have been found to be vulnerable to
ECC in both developed and developing countries and even within a
single country disparity by social standing there exist, differences
due to diet, fluoride use, and social empowerment. Disparities in
social empowerment may persist due to lack of access to dental
care and inadequate utilisation of dental care even when available
[2]. Untreated caries and associated infections can cause pain,
discomfort, reduced intake of foods because eating is painful
[3]. Pain may also because the child refuses the caregiver from
maintaining good oral hygiene for the child. There is a paucity of
literature on the prevalence of Severe -ECC in Kenya. However, a
study conducted in nursery school children in Nairobi on the on
dental caries and dietary patterns reported a prevalence of 63.5%
among 3-5 years old [4]. A survey conducted in Kiambaa division in
Kiambu County, a peri-urban population, reported ECC prevalence
in 3 - 5-year-olds of 59.5% [5]. Several studies on nutritional status
and dental caries have reported variable results. A retrospective
survey on the body mass index was done in the United States of
America, and it involved two hundred and ninety-three children
aged two to five years with Severe - ECC receiving dental treatment
under general anaesthesia. In the study, the weight groups were
defined by being assigned the CDC body mass index about on age
and gender of the children. Results showed that the distribution
of subjects by percentiles and the children who were underweight
were 11%; of the study sample. However the children whose weight
was normal weight 67%; at risk of overweight 9%; overweight
11%. This study concluded that significantly, more children in the
sample were underweight than in the reference population [6].
However comparative research on the nutritional status and dental
caries among a large sample of four and five-year-old South African
children found no significant association between the prevalence of
caries and stunting or wasting. However, a relationship was found
between decayed, missing and filled surfaces and wasting [7]. This
study, therefore, aimed to compare the nutritional status of children
aged 3 – 5 years with Severe-ECC and the nutritional status of those
aged 3-5 years without caries.
Severe ECC is also associated with oral Microbiota, and in
particular anaerobic bacteria of the species Scardovia Wigggsiae
and others have been found in abundance in severe ECC lesions [8]
Materials 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 was 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 amongst
the children attending the maternal child health clinic at NNPGH
over a period of three months. Inclusion criteria were: the child
was 3 – 5 years of age, was medically healthy, and the parent or
caregiver was willing to consent. A semi-structured questionnaire
was administered to the caregiver in a face to face interview, and
information was collected on the socio-demographic background
of the children. There gathered data included education level, age,
gender, and the caregiver’s, occupation, and area of residence of
the caregivers. The Intraoral examination was carried using dental
mirrors and a Michigan O dental probe under natural light as the
child sat on an ordinary chair facing the light. Severe ECC was
defined as decayed, missing or filled a score of ≥ 4 (age 3), ≥ 5 (age
4), ≥ 6 (age 5). Before dental caries diagnosis, each tooth was dried
using a piece of sterile gauze. WHO 1997 caries diagnosis criteria
were used, and dental caries was diagnosed when there was a
clinically detectable loss of tooth substance and when such damage
had been treated with fillings or extraction [9]. Anthropometric
measurements were determined to assess the nutritional status of
the children and height of the children were obtained by measuring
the child standing when standing erect and barefoot, using a
measured with a standard height board to the nearest 0.5cm. Weight
for age was measured using a Salter scale to the nearest 0.1kg. Each
parameter of height and weight had three measurements taken,
and an average of each was then recorded. The Cut-offs +2 standard
deviations (SD) were used to identify children at significant risk for
either delayed (<-2SD) or excessive (>+2SD) growth. The indicators
were weight-for-age (WAZ), height-for-weight (HAZ), weight-forheight
(WHZ) based on the World Health Organisation(WHO) 2005
recommended reference standard [10]. The collected data collected
were coded, cleaned and analysed using SPSS version 17.0 (SPSS
Inc, Chicago Illinois, USA) for Windows and Microsoft Office Excel
2007. Nutritional data was analyzed using Epi-Nutri program of
Epi-Info version 3.5.1. Descriptive statistics such as proportions
were used to summarize categorical variables while measures of
central tendency such as mean, standard deviations and ranges
were used to summarise continuous variables. The strength of
association was established between categorical values using a
Pearson’s Chi-square tests. Odds Ratio (OR) and 95% Confidence
Interval (CI) were used to estimate the strength of association
between independent variables and the dependent variable. The
multivariate analysis was done using binary logistic regression at
a statistical significance set at p≤0.05. The relevant research and
ethics approving institutions approved the study.
Results
A total of 196 children aged 3-5 years were recruited into the
study, eighty-one children with S - ECC (41.3%) and 115(58.7%)
without caries. The study group had a mean age of 4.1 + 0.6years,
and it ranged from 3- 5 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%).
Sixty-five children (33.2%) lived in the rural community, and
131(66.8%) lived in the urban area. The differences in the area
of residence were significant with a Pearson chi square=13.36,
df=1, p≤0.001) for the children with severe ECC and those children
without decay. It was noted that sixty-six (81.5%) out of 81
children with Severe ECC lived in an urban setting when compared
to children who were caries- free who had 65 (56.5%) out of 115
children who were caries free. Some sixty-eight caregivers had
had primary school education of whom 24 (29.6% had severe ECC
while 44 (38.3%)) were caries free. However, 103 caregivers had secondary school education of whom 43 (53.1% had severe-ECC
and60 (52.2%), while 21 (10.7%) their caregivers had tertiary
education and 14 (17.3%) and seven 6.1% were caries free. Also,
children whose caregivers had a primary level of education had
the highest prevalence of severe-ECC followed by those whose
caregivers had secondary education. The differences in the severecares
prevalence were significant with a Pearson Chi-square =9.41
d.f 3, p≤0.024 Table 1 & 2.
Table 1: Age and gender distribution of children with Severe - ECC and children without caries.
Table 2: Level of education, demographics for the caregivers, place of residence, level of education, and occupation.
The mean dmft of 7; 5±1.9 d was observed among children with
Severe – ECC, and it ranged from 5 to 12 scores. Scores. However,
the mean dmft for the males was 7.5±1.8 and for females (7.5±2.0),
which was statistically insignificant difference found between the
two groups (t=0.15, p=0.88). The mean dmft score for children
aged three years was 6.9 ± 2.2, four years was 7.6 ± 1.9, and for
five-year-olds was 7.2 ±1.2 and all the dmft ranged from 5-12. The
dmft progressively increased with age and peaked at age four years.
There were no statistically significant differences found between
the age groups (t=1.59, p=0.248). Figure 1.
Figure 1: Distribution of decayed, missing, and filled teeth by age and gender.
Overall the decayed component of the dmft contributed 92.3%.
The missing and filled component of the dmft contributed 7.4%
and 0.3% respectively. The overall prevalence of underweight for
acute malnutrition, stunting, and wasting for chronic malnutrition
was 14.3%, 4.6%, and 3.6% respectively. There were more females
17(17.7%), 4 (4.2%), and 5 (5.2%) who were underweight,
wasted and stunted respectively when compared to males, but
this difference was not statistically significant Pearson Chi-square
respectively for underweight, stunted and wasted were 1.80,df=1,
p=0.180 ; 0.19,d. f=1, p=0.660 and 0.16, d.f=1, p=0.686 Figures 2
& 3.
Figure 2: Prevalence of malnutrition for children aged 3-5 n=196.
Figure 3: Nutritional status by gender distribution.
Table 3: Underweight among children with caregivers place residence, level of education, and occupation.
When the caregiver’s residence, level of education, and occupation
were considered the children who lived in the rural areas had
higher prevalences of were underweight 10(15.4%), when
compared to the children in the urban areas 18(13.7%) resided in
urban areas. Sixty-eight children had caregivers whose education
was of a primary level, and 11(16.2%) of the children were
underweight while 57 (83.8%) had normal weight for age. Children
whose parents had a secondary education were 103 of whom 14
(13.6% were underweight, and 89 (86,4%) had normal weight for
an age while caregivers who had higher education were eighteen
of whom 3(14.3%) were underweight, and 15( 85.7%) had normal
weight. There were more underweight children 24(15,7) out of 153
when weight for age was examined about the caregivers who were
informally employed, However, the differences in the children who
were underweight with the caregiver’s various demographics were
not significant Table 3.
According to the educational level, the children who were
stunted and whose parents had a primary education were four
(9.3%)), secondary 6(8.8%), and higher education were 5(7.7%).
The caregivers who had formally employed were from the urban
area while those who were informally employed and had primary
school education were from the rural areas Table 4. There were
statistically insignificant differences in the caregiver’s place of
residence, the level of education, and occupation among children
who stunted and those who were not stunted.
Table 4: Stunting among children about caregivers place of residence, level of education, and occupation.
For the children who were wasted five 7.4% of the caregivers
lived in the Urban area and had a primary level of education; also
6(3.9%) of the caregivers had informal employment, and 2(3.1%)
resided in rural areas Table 5. There statistically insignificant
differences in the caregiver’s place of residence, the level of
education, and occupation among children who wasted and those
who were not wasted.
Table 5: Wasting among children about caregivers place of residence, level of education, and occupation.
There was a slightly higher prevalence of underweight
14’8% for the children suffering from severe ECC compared with
children without decay 13.9%. Although there were differences
in the nutritional status of children with severe- ECC and children
without caries the differences were insignificant for stunting with
p=0.311; also underweight was insignificant with p=0.859 while wasting had p=0.451). A child identified with Severe- ECC at risk
1.08 more times likely to become underweight when compared to
a child who did not have decay odds ratio lower and upper limits of
0.48 and 2.4 at 95% CL Table 6.
Table 6: Comparison of the nutritional status of children with Severe ECC and children without caries.
Multivariate analysis was done to determine the relationship
between underweight and Severe- ECC among the participating
children. Five factors associated with underweight and Severe-
ECC at P≤0.05 during bivariate analysis were considered for
multivariable analysis upon fitting the factors using binary logistic
regression. Adjusting for child’s age in years, child’s oral hygiene
status, child feeding on demand, place of residence and caregiver’s
level of education, the occurrence of S-ECC was not significantly
associated with underweight (AOR=1.23; 95% CI: 0.45 – 3.35;
p=0.689). However, a child with S – ECC was 1.23 times more
likely to have low weight for an age when compared to a child
who was caries – free. However adjusting for other factors, age
three years was found to be statistically significantly associated
with underweight with an Adjusted Odds Ratio value =2.83; 95%
CI: 1.15 – 6.96; p=0.023 Table 7. A child aged three years was 2.83
times more likely to be underweight when compared to one aged
four years.
Table 7: Logistic Regression Predicting underweight using caries status, Child’s age in years, Child’s oral hygiene status, Child
feeding on demand, Place of residence and Caregivers level of education.
Discussion
In the current study found that children with severe ECC were
mainly from urban areas in comparison to children who were
caries free. The finding of a high prevalence of severe –ECC in the
urban children is similar to other studies in Kenya and elsewhere
that have shown that children residing in urban areas have a
higher caries experience than their rural counterparts [4,5,11,12].
The mean dmft of children with severe ECC in the present study
was 7.5+1.9 which is comparable to a study carried out among
preschool children of low socioeconomic status in India which
reported a mean dmft of 8.9 [13]. Studies in the USA, and Canada
among preschool children found mean dmft scores of 9.6±3.6 and
10.5 respectively [13-15]. The differences in the mean dmft may be
due to variations in dietary practices among different populations.
Also, decayed component accounted for 92.3% of the dmft, and
this finding was similar to a study in South Africa [14]. Untreated
tooth decay reflects a low utilisation of oral health services or lack
and inaccessibility of preventive and curative dental services to the
caregivers, or if the facilities are available, they are too costly.
Higher caries experience was observed in the children from the
urban areas when compared to their rural counterparts [11]. The
mean dmft of children with severe ECC in the present study was
7.5+1.9. The caries experience for severe-ECC in the present study
is comparable to a study carried out in a low social, economic status
in India among preschooler and reported a mean dmft of 8.9[112].
Studies in the USA, and Canada among preschool children have
reported mean dmft scores of 9.6±3.6 and 10.5 respectively [13,14].
The differences in the dmft could be due to variations in dietary
practices among different populations. The decayed component in
the current study accounted for 92.3% of the dmft, which similar
to other studies elsewhere [14]. Untreated tooth decay reflects a
low availability and accessibility of preventive and curative dental
services.
In this study, there were more females were underweight,
stunted, and wasted when compared to males when referenced
on the WHO reference standard. However, the differences were
insignificant. The WHO child growth standards reference was used
to evaluate nutritional status. The WHO growth reference provides
a scientifically reliable yardstick of children’s growth achieved
under desirable health and nutritional conditions and establishes
the breastfed infant has been used as a reference against whom
other alternative feeding practices are measured to and compare
to regarding growth, health, and development of in children [9].
The children with severe-ECC who were underweight were 4.9%,
stunted 2.5%, and those who were wasted were 14.8%. The presence
of underweight, stunting, and wasting may be associated with the
inability of the children with severe-ECC to chew the available
food and absorb enough nutrients resulting in faltering nutritional
status. In comparison a study carried out in Italy among 2- 6 years
old found that 11% were e underweight, 11.11% overweight and
22.2% to be at risk of overweight [15]. A study in the USA reporting
on the BMI of children with severe ECC noted those who were
underweight as 11.%, overweight 11%, and those who were at risk
of overweight were nine %6. These findings were insignificant may
be due to differences in cultural, dietary practices and the primary
determinants of nutritional status among the different populations.
In Kenya, the primary determinants of nutritional status among
children under five years of age include poverty, hunger, and
drought [16]. The low weight for age observed with urban children
is similar to previous research from other countries where children
with high prevalence with severe-ECC had low weight for age [17].
Children who were malnourished were also noted to have
severe ECC compared to children who were caries free. There are
high levels of malnutrition in Nyanza as reported in the Kenya
Demographic and Health Survey 2008-2009 where 19%, 2%, and
14%of the children under five years were underweight, wasted and
stunted respectively [18]. Considering the caregiver’s demographic
factors children who had low weight for age, wasting and
stunted, resided in rural areas. Also, their caregivers had informal
employment and had a primary level of education.The finding may
be related to the low socioeconomic status and affect access to
health care, food security and hence changing overall nutritional
status [16,17].
The differences in the nutritional status of the children with ECC
and those without ECC was insignificant. South African children
aged between four and five years reported similar findings as what
has been observed in this study. Njoroge et al. reported 60% in a
study population of 338 children aged five years and below[4]. The
most affected dentition were the upper central incisors however
the severity of decay increased with age and the first and the second
deciduous molars had the highest prevalence ranging between 57%
-66%. In this study, the caregivers knew the importance of good
oral hygiene and significance of snacks about caries formation.
However, the infant feeding habits and the weaning practices were
not reported on in this study [19,20].
The South African Study found no relationship between the
prevalence stunting or wasting with dental caries. However,
they reported an association between Wasting with the decayed,
missing and filled tooth surfaces [7]. Children with severe ECC
were 1.23 times more likely to be underweight when compared to children without caries. Severe ECC may affect general health
and development because a toothache associated with caries may
affect food intake and sleep [1]. Poor oral health associated with
pain may interfere with the intake, mastication digestion of food
and nutrients which may lead to decrease in good nutritional health
and reduced quality of life for a child [1].
In summary, the difference in the nutritional status of children
with severe ECC and children without caries and stunting was
insignificant p=0.311, Underweight p=0.859 and wasting p=0.451.
However, children with Severe ECC were 1.23 .times more likely to
be underweight than children without caries.
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