Experience of Early Childhood Caries(ecc) in Children at Fatima Jinnah Dental College Hospital, Karachi and Its Relationship With Feeding Practices

Experience of Early Childhood Caries(ecc) in Children at Fatima Jinnah Dental College Hospital, Karachi and Its Relationship With Feeding Practices
Nadia Inayat*, Fauzia Mujeeb**, Masood Alam Shad***, Saqib Rashid****, Tasleem Hosein*****

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J Pak Dent Assoc 2010;19(1): 34 - 41


The aim of the study was to find the experience of early childhood caries (ECC) in children at Fatima Jinnah dental college hospital, Karachi in the period of six months and its relationship with feeding practices.


A total of 521 children 2- 6 years of age were screened for the present study who came to Fatima Jinnah dental college hospital Karachi in the period of Sept-Dec 2008 and June- July 2009. Examination and detection of the caries was solely based on visualization. A parent or a caregiver was asked to complete a questionnaire regarding information about the child, their oral hygiene, social class and feeding practices. The modification of Kuppuswami scale was used to classify the socioeconomic status. The rate and pattern of caries were analyzed and each child was classified as mild, moderate or severe ECC.


There is a strong and significant relationship between the presence of early childhood caries and the degree of feeding abuse. Children from low socioeconomic status have increased early childhood caries. CONCLUSION:The experience of early childhood caries was 50.1% in the children attending dental opd of Fatima Jinnah Dental College Hospital in the period of six months. Early childhood caries were more in children who were always taking a feeding bottle especially to bed at night and those who consume cariogenic snacks and were increasingly seen in lower socioeconomic groups.


Early childhood caries, bottle-feeding, socioeconomic status, cariogenic snacks.


The American Academy of Pediatric Dentists defines the condition Early Childhood Caries (ECC) as” The presence of one or more decayed (non cavitated or cavitated lesions), missing (due to caries lesions) or filled tooth surfaces in any primary tooth in a child 71 months (six years) of age or younger.

The American Academy of Pediatrics dentistry and The American Dental Association adopted the definitions listed above. Previously this condition has been commonly referred to as Baby Bottle Syndrome, Baby Bottle tooth Decay, Nursing Caries, Nursing Bottle Syndrome, Bottle Mouth and Nursing Decay1

Early childhood caries (ECC) is a particularly aggressive form of dental caries that can rapidly destroy the primary dentition of toddlers and small children.2 ECC is a major public health problem that continues to affect toddlers and small children worldwide with prevalence varying among populations Many studies on ECC have been conducted to identify the etiology, prevalence, risk factors and treatment of this disease over the past 40 years .3

Early childhood caries is a frustrating condition that is difficult to treat in infants and very young children. It may retard the child’s health, is infectious, and results in impairment of nutrition and esthetics with accompanying psychological problems.

Some investigators detected significant relationships between ECC with feeding practices, snacking habits, oral hygiene status, socioeconomic background, education level, awareness of parents and so on but some other studies did not show such relationships .4,5,6

Infant bottle-feeding habits (either allowing a child to sip from a bottle during the day or put to sleep at night) was a significant determinant for both anterior caries pattern and severity of ECC in 4-5year-old children.7 Children with ECC have frequent and prolonged consumption of sugars from liquids. Caries-promoting sugars such as sucrose, glucose and fructose, contained in fruit juices and many infant formula preparations, the use of nursing bottles and “sippy cups” enhances the frequency of exposure. This type of feeding behavior during sleep intensifies the risk of caries, as oral clearance and salivary flow rate are decreased during sleep.8

Epidemiological surveys also mentioned association between prolonged and unrestricted breastfeeding and ECC. However study done by Hiroko Iida et al in 2007 indicates that infant breastfeeding and its duration, whether overall, full, or exclusive, is not associated with any increased risk for ECC or S-ECC.10

The American Academy of Pediatric Dentistry currently recommends weaning from bottle or breastfeeding by the age of 12 to 14 months and discourages bedtime infant feeding, especially after the eruption of the first tooth, to prevent ECC.11 Rosenblatt A in their study of 1- to 4-year-old brazil children, reported that children who were breastfed for 12 months had a lower level of caries than those bottle fed or bottle and breastfed for 12 months, the current study provides no evidence that breastfeeding for 1 year decreases or increases the risk for ECC or dfs counts.12

Intake and frequency of the cariogenic snacks between the meals also play an important role in developing the early childhood caries among children. Many studies have shown a significant relationship between cariogenic snacks, such as chocolates, sweets, dates, bakery products and ice cream and caries rate.13

Another factor, which plays a significant role in dental caries, is socioeconomic status and its relation with the caries has been demonstrated in various studies.14 It has been found that children from educated and high socioeconomic status are more conscious about brushing and visiting the dentist regularly, while children from low socioeconomic status exhibit higher levels of caries prevalence fewer sealants and untreated disease. Prevention of ECC can start very early, even before birth. Reducing the mother’s/primary caregiver’s/sibling(s) MS levels (ideally during the prenatal period) to decrease transmission of cariogenic bacteria. Saliva-sharing activities (e.g., sharing utensils) between an infant or toddler and his family/cohorts should be minimized Cariogenic snacks between meals should be limited. Sugar should never be to weaning foods. Foods and drinks containing sugar should be kept to mealtimes only. Children should not carry around juice or soda pop in a bottle or sippy cup children should not allow to fall asleep with a bottle in their mouth. Children who insist on a bottle before bed should be encouraged to finish the bottle while awake. If a baby is put to bed with a bottle it should only contain plain water As soon as the infant has teeth, parents should be encouraged to clean the teeth. Flossing should be initiated when adjacent tooth surfaces can not be cleansed by a toothbrush Using the dummies dipped in honey, jam or other sugary substances may cause tooth decay and should be avoided.11,After each feeding, gently wipe your child’s teeth and gums with a clean washcloth or gauze to remove plaque

By considering all these factors present study was done to assess experience rate and the risk factors for early childhood caries in2-6years old children in Karachi. The study was conducted in operative department of Fatima Jinnah dental college hospital. The present study was undertaken with the main aims and objectives of: Finding the experience of early childhood caries (ECC) in Fatima Jinnah dental college, hospital, Karachi.

Determining the relationship of ECC with feeding practices and socioeconomic status of the family


The present cross-sectional data were collected from September to December 2008 and June to July 2009 Target subjects included children less then 6 years of age and their mothers/caregivers attending the out patient department of Fatima Jinnah dental College, Hospital, Karachi.

Armentarium used were sterile mouth mirror, probe, tweezers, disposable surgical latex gloves, disposable mouth masks, questionnaire, and a dental unit.

Screening Procedure:


After cleaning the teeth with sterile gauze, dental examination was conducted using dental unit light and a mirror and a probe. Caries were detected only by visual examination No radiographs were taken. All examinations were conducted with the patient in the supine position. While the dentist was examining the children, their parents filled out the questionnaires. The same examiner performed all the records. Aseptic techniques were adopted for each child. Approval to conduct the study was obtained from the local research ethics committee.

Statistical analysis was done using SPSS version 11. Chi-square test was used for analyzing the data. Statistical significance was set up at = 0.05.


The questionnaire consisted of questions related to the feeding practices, tooth brushing, social factors and social class which had to be filled by the parents of the child with early childhood caries.

Family socio economic status in this study was based on the modification of Kuppuswami scale meant to determine the socioeconomic status of family based on education and occupation of head of the family and per capita income per month. At the end of questionnaire, dental caries status was recorded and classified as in mild

moderate and severe.

Types Of ECC

Type I (mild to moderate) ECC

The existence of isolated carious lesion(s) involving molars and/or incisors.

Type II (moderate to severe) ECC

Labiolingual carious lesions affecting maxillary incisors, with or without molar caries depending on the age of the child and stage of the disease, and unaffected mandibular incisors.

Type III (severe) ECC

Carious lesions affecting almost all the teeth including the lower incisors.


Two hundred sixty one children showed ECC among 521 children screened. Therefore the prevalence was 50.1%. The prevalence was inversely proportion by the age group (Table 1). The highest prevalence of 90.5% was among the 2-years old children. And the lowest was at the age of 5 and 6. The male children showed the prevalence of 51%, while females showed the prevalence of 49% (Table1). The difference was not statistically significant (P>0.05). The prevalence of ECC was highest in the lowest socio-economic group (81.8%).

The bottle feeding was present in 244 (93.5%) of the

children. Among the bottled feeding children, 95 use the bottle in most of the time and 87 needed mostly in night. Majority of the children (57.9%) started brushing after 2 years of age. Only 24.5% of the children with ECC were being brushed with the help of mothers. Mother of 244 children (93.5%) indicated that their children were taking cariogenic snakes. Prevalence of ECC among the children who were taking bottled feeding without cariogenic snakes was 32.1%, while with cariogenic snakes was 90.1% (Table 2).


The over all experience of ECC in Fatima Jinnah Dental College Hospital, Karachi is high. It must be pointed out that decalcifications were not considered as carious lesion in this study, which is early evidence that the disease process is active an such teeth may be remineralized by appropriate preventive measures. Similarly radiographs were also not used in this study, which may have increased and the number of untreated proximal lesions undiagnosed. It means that the true rate of ECC, true carious lesion could be higher than reported as caries were diagnosed entirely on visual examinations. Based on new definition a study conducted by Mohebbi SZ in 2009 reported the prevalence of ECC ranged from 3 to 33%.22

These results correspond fairly well with that witnessed in Jordan for 1-year-olds23. For the older ones, the figure was somewhat higher in Iran (33% vs. 21-25%). For corresponding age groups, the reported prevalence of ECC ranges from 3% to 59% in Western Pacific and South-East Asia, with the highest being for Philippines24 and in the Middle East, from 5% to 47% with the highest standing for Abu Dhabi25. In developed countries, the corresponding figures are between 4 and 56% in U.S. with the higher values standing for Native Americans while being as low as 0.5-2% in European countries such as Finland and Sweden as summarized by Douglass et al26. Many other studies have been carried out in different countries on the prevalence of ECC but the criteria for diagnosis of ECC were different. Some researchers claimed that a minimum of one infected incisor is a sufficient criterion for diagnosing the condition. Others believed that a minimum of two infected teeth is required, whereas some reported that at least three infected maxillary incisors are required27 In these studies, the ECC prevalence has been variously reported from 1% to 70% .

Socioeconomic status (SES) has been reported as an important risk factor for ECC in several studies28 In the present study we used the modification of Kuppuswami scale 19 20 meant to determine the socioeconomic status of family based on education and occupation of head of the family and per capita income per month. Relationship between the SES and ECC was statistically significant. Another study investigating dental caries prevalence in preschool children (5months to 4 years) in Arizona also supported that caregivers’ level of education and reported family income were negatively associated with ECC. 25. Study by Dumitrache MA in 2008 also showed that Children borned in low-income families are more likely to have low birth weights which impacts oral health ; influence health literacy, which, in turn, affects oral health29. Among factors related to feeding practices, two variables had statistically significant relationship with ECC.They included Frequency of bottle feeding (With ECC P=0.000) and intake and frequency of snacking habits (with ECC P= 0.000) .Reisine and Douglass30 showed in their study that the critical period of developing ECC may be soon after the eruption of teeth into the mouth and that early use of the bottle containing sweet fluids supports the early establishment and dominance of cariogenic micro flora. This may be more important than bottle use after 12 months. Gussy et al31. in 2006 also found that the use of the bottle at nighttime was associated with sugar intake. The mothers who reported nighttime bottle use were also more likely to have children with a higher sugar intake.

Many studies found an association between the intake and frequency of snacking and dental caries 15 In this study, cariogenic snacks were also related to ECC experience in 2 – 6year old children. This is also supported by Eissa Al-Hosani in 2006 that consumption of sugar is positively associated with increased experience of dental caries13 in the Gulf countries, it can be noted that some studies in these countries have shown an increase in consumption of sweets in children’s diet. For example, a study in Riyadh, Saudi Arabia, showed that young children aged 17 months had started to eat cariogenic snacks, such as chocolates, sweets, dates, bakery products and ice cream about twice a day, with no proper oral hygiene: the mean dmft of children aged 4-6 years in this study was reported to be 6.9. In Kuwait, 12% of pre-school children had experienced nursing caries and the study highlighted the use of sweetened drinks in bottles by these children.13 This supports nutritional recommendations of limiting snacking times among children and encouraging regular meals.

Among factors related to oral hygiene practices, two variables were statistically used. The age of starting tooth brushing and the person responsible for child’s oral hygiene. From these two variables, the age at which brushing starts had a significant relationship In the present study, children who started brushing at a later age had a higher prevalence of ECC These finding are in agreement with the study conducted on Australian children32 Thus, promotion of early hygiene care should be strongly encouraged. In this study, 75.5 % of children with ECC brushed on their teeth, which was more than twice that of children who were assisted by parents. Parents or caregivers must assume total responsibility for the tooth cleaning of infants and young children


The experience of ECC was 50.1% among children attending OPD of Fatima Jinnah dental college hospital, Karachi and there was no statistical significance in the incidences of Early childhood caries between male and female children. Conclusion from the present study is that the percentage of ECC increases in children who always carry a bottle especially to bed at night and those who had cariogenic snacks upon demand. The highest age of starting brushing is more than 2 years among ECC group, which is very late. ECC were seen more in the lower socioeconomic group. The outcome of this study gives a brief insight to the experience and relationship of early childhood caries with feeding practices and socioeconomic status of the family among children in the particular area in Karachi, Pakistan.. It is however prudent to carry out an in-depth screening survey on a larger child population to draw definite conclusion about early childhood caries


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