Marium Iqbal*, Laeeq uz Zaman**, Mohsina Noor Ibrahim***
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J Pak Dent Assoc.2011; 20 (2): 93-97
The prime objective of the study was to determine the prevalence of practices in children under six years of age, which are known to affect occurrence of dental caries.
This was a cross-sectional study. Data was collected using questionnaire, sent to the parents of preschool children through school administration. Total 630 questionnaires were sent out. Parents were addressed for fact finding. Various risk factors were identified during literature review. We added certain other factors based on our local experience, and finally selected the most relevant factors. Subjects were included based on age and parental consent to share information
We found a mixed prevalence of flawed and beneficial practices among the subjects of our study. However, most were comparable or encouraging when compared to the international literature, including studies from more developed nations.
In conclusion, we could recommend that in a mixed prevalence of practices, awareness programs emphasizing the good practices and discouraging the unhealthy practices could play a significant role in practice improvement at this age .
Dental caries, children, practices, preschool, risk factors .
he seriousness and social costs of dental caries in Tpreschool children are enormous. Compromised oral health not only compromises mastication and speech of an individual but also his/her social well being.
The prevalence of dental caries is still high in the children living in developing countries while it is known to have declined in the developed countries.2 WHO considers dental caries as the third most important non-communicable chronic disease, globally, that should be attended for prevention.3 Pre school years are the formative years of life, during which a child’s oral hygiene practices are established and thereby foundation of adult oral health is laid.4 Therefore, assessment and modification of a child’s oral hygiene practices can help assess and modify future risk of dental caries, as well as assist in identifying the areas of intervention in the practices. Parker and colleagues have found that more than 40% of children in his study were suffering from dental caries by the time they reached kindergarten.1
While searching the literature, we could find very few base lines studies, and virtually none in Karachi. We decided to conduct a survey in various pre-schools of urban Karachi. The main objective of the survey was to determine the prevalence of oral hygiene practices and dietary habits that could affect prevalence of caries in preschool children, since this is a stage for habit building and liable to favorable modification.
This was a cross-sectional study. Data was collected using questionnaire, sent to the parents of pre-school children through school administration. Considering the various limitations while ensuring the practicality of the survey study, we sent out letters of invitation to various schools enrolling pupils below six years of age (irrespective of whether they enrolled older students too). We selected five schools from amongst those who consented to participate. About 630 questionnaires were sent out. Parents were addressed for fact finding. We received 578 filled forms and after elimination of very poorly filled, we found 556 fit for analysis. In 33 questions we inquired for 11 practices and certain demographic information. During the literature review, we identified a number of oral hygiene practices that could have a bearing on the incidence of dental caries. We added certain others based on our local experience, and finally selected those most relevant, clinically, socially and culturally. Subjects were included based primarily on age. All children attending the selected schools and were below six years of age were included in the study and others were excluded
While the study was conducted in Pakistan, a developing country, the results should be viewed with the fact in mind that this survey was conducted on children whose parents could afford to send them to pre-school facilities, in the largest urban town and economic hub of the country. This represents a lean in favor of the more privileged socioeconomic stratum of society. It then, in most cases also made it suitably comparable to the results of similar studies conducted in the developing countries
Tooth Brushing: We observed that most of the subjects, 50.0% brushed their teeth only once a day, while 43.6% did it twice and 3.6% did not brush their teeth at all. Majority of the children, 46.7%, were brushing their teeth ahead of breakfast only, and 11.9% were brushing their teeth only before going to bed, while 4.4% were brushing after breakfast and before bed, and 2.2% were brushing them after every meal. Tooth brushing was mostly supervised, 92.0%, and the rest unsupervised.
Dentifrice Use: We found that 97.8% of the respondents were using tooth paste.
Dental Flossing: Dental flossing was used regularly or at least sometimes followed by 24.8% and almost never by 17.0%. There were 58.2% missing responses. We found the last finding significant and it is discussed later.
Milk: We found that milk was taken regularly by 94.3% of the children. 63.9% were drinking milk sweetened with sugar, honey, or syrup and 31.1% were taking it unsweetened.
Feeders while sleeping: In our study, 10.9% subjects slept with milk feeder in mouth, compared with 89.1% who did not.
Sweets and candies: 94.2% children consumed chocolates, candies and toffees, while only 5.8% reported as non-consumers.
Sticky Foods (unsweetened): Foods like biscuits, chips and packed snacks were often consumed. Their proportion based on frequency of consumption was: 21.4% twice or more a day; 78.6% once or less than once a day.
Cheese: Only 27.9% children were consuming cheese, compared to 72.1% who were not.
Fresh Fruits and Vegetables: 66.4% of the children were using salads, fresh fruits and/or vegetables. 33.6% were not using the above stated items.
Drinks: Children were using various drinks. We inquired for the frequency of use of aerated drinks, packed juices (not necessarily fruit juices) and fresh fruit juices. Overall, the regular consumers of packed juices were most 14.8%, those of fresh juices 12.0%, both of which were more than twice as many as those regularly consuming aerated drinks 5.6%. Further details of the results are shown in the Table 01.
Dental Visits: Only about 7.1% children were taken for annual or biannual dental visits and about 83.0% turned up at the dental clinic only when there was a dental problem. 9.9% respondents did not answer
Dental caries is an acquired chronic infective disease caused by the acidic by products of bacteria and has been ranked third amongst all the non-communicable chronic diseases that should be attended for prevention.3 A number of factors in combination determine the prevalence of dental caries in children. These include susceptible teeth; colonization of teeth with cariogenic bacteria; and the type and frequency of exposure of cariogenic foods to the cariogenic bacteria.5,6 The diet mediated shift in oral environment allows for multiplication of cariogenic microorganisms. Sticky sugars consumed at high frequency increase caries risk manifolds. The ability of sucrose to form glucans qualifies it as the most cariogenic sugar. Sucrose forms glucans which enhance bacterial adhesion to the teeth and limits diffusion of acid and buffers in the plaque. Various studies have identified risk factors associated with childhood caries, like nocturnal bottle feeding with milk, use of sweeteners in milk, frequent use of aerated drinks, consumption of sweets, etc,7,8,9 There is still limited data available to document dental caries risk factors in preschool children in urban Pakistan ORAL HYGIENE PRACTICES
The habit of tooth brushing, like all habits of hygiene, is acquired during the socialization process of the child. When this habit is taught in early childhood, it is naturally ingrained in the daily routine of the child. With only positive reinforcement needed later, it could persist throughout life without a major shift.10,11 The effects of tooth-brushing on caries risk have been cited in literature. Some studies found its strong and consistent relationship with caries prevalence while others report no such relationship.12 Our study found that 95.7% children brushed their teeth once or more than once a day as opposed to 3.6% who did not brush at all. In a study done on 4-6 year olds in Riyadh, Saudi Arabia, Wyne et al observed that 41.2% of the children were not brushing their teeth.13 A survey conducted on children in Hong Kong revealed that only 42.3% practiced tooth brushing.14
Namal reported that 64% of Turkish preschoolers regularly brushed their teeth once or twice daily.15
Researchers have stated that children who brush their teeth independently experienced more caries as compared to those who were supervised by their mothers.16,17 The scientific support for flossing in this age category is not as explicit, as most studies focus on children at least 4 yrs of age and older. Dental flossing in very young children is debated for its practicality, its usefulness, and how it must be administered.
Researchers have suggested that the risk of interproximal caries could be higher in the dentition with closed contact points rather than open, particularly in the posterior primary dentition in children under six years of age.18 We found that 58.2% of the respondents did not reply in ‘yes’ or ‘no’ to the question. It is likely that these many parents do not know about dental flossing, let alone be aware of its use.
Use of Toothpaste
Interestingly, our data shows that 97.8% of our respondents used toothpastes. The reason for a higher percentage using toothpaste could be the advertisement (mass media) and affordability of these users. Tooth paste is also a readily available source of topical fluoride. Chan and co-workers in their research found that approximately half of the preschool study population used toothpastes.14
Sugar consumption and bottle feeding
Frequency of sugar consumption is a major dietary component in caries etiology.19 Bottles or sippy cups containing sweetened liquids, frequent snacking and use of aerated drinks contribute to early childhood caries.20
Sayegh’s and Al-Ghaneim also concluded that extrinsic sugars increase the risk of caries prevalence and severity.7,9
One research on children with nursing caries stated that 93.2% of all children were taking sweets in different forms.21 Results of our study show that 94.2% consume sweets in one form or the other. The easy availability, low cost of these items, lack of awareness and changing trends (social pressures) may have contributed to this. Scroth et al observed that 86.1% mothers put their children to bed with the feeder.22 Caries rate was significantly higher among children who had sugar or sweeteners added to bottle feed. Fortunately, only 10.9% mothers in our study reported putting their children to sleep with feeders.
Snacks and drinks
Lack of awareness and changing trends in dietary likes and dislikes seem to be the major cause of unhealthy practices amongst preschoolers. 21.4% of the school children we researched snacked (meaning biscuits, chips, and other packed snacks as specified in the questionnaire) twice or more each day. Sayegh has reported a much higher consumption of snacks like biscuits and cakes in preschool children in Amman, Jordan. Amongst the most popular high in NME sugar (non-milk extrinsic sugar) snacks, confectionery was reported to be regularly consumed by 76% and biscuits and cakes by 71% of them.9 The same study also showed that 50% of the preschoolers had carbonated drinks. The consumption of drinks in our study population is high and is comparable to the study of Wyne et al and Saalfield and co-workers.21,23
These and other studies have reported observing more caries with increased consumption of drinks.24
Consumption of cheese, salad, fresh fruits and fresh vegetables
Consumption of fresh fruits and vegetables was found to be relatively low (66.4%) in our study population probably because of refined food becoming more popular. The other reason could possibly be the lack of awareness regarding the protective role of cheese against caries and, the cleansing action, within the mouth, of fibrous foods like fresh fruits and salads which also may contribute to the protective effect against caries.25
Frequency of dental visits
Only 7.1% of the studied children were visiting a dentist annually or biannually, while 83% visited a dentist only when there was a dental problem. It may be an extension of imagination, but the rest of the 9.9% had perhaps not visited a dental surgeon yet. This would underscore the lack of awareness of parents regarding the significance of regular dental visits.
We observed that there was a mixed prevalence of well known flawed and good practices, the former of which predispose to dental caries. Lack of awareness and changing trends in dietary likes and dislikes could be a major player in unhealthy practices amongst preschoolers. Since maintaining oral hygiene can mean a lifetime of good oral health, awareness programs need to be organized; both school based as well as community based.
We understand that this data could work as a marker in the direction of improving habits that can predispose to the development of carious lesions by increasing awareness. Along with nutritional factors, a comprehensive approach to preventing dental caries in preschool children must include improved general dietary habits, good oral hygiene, appropriate use of fluorides, and access to preventive and restorative dental care.
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