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Year : 2017  |  Volume : 35  |  Issue : 3  |  Page : 193-197

Assessment of maternal risk factors and its relationship with early childhood caries among preschool children in Mangaluru city

1 Department of Pedodontics, Yenepoya Dental College, Mangalore, Karnataka; Department of Preventive Dentistry, Yenepoya Dental College, Mangalore, Karnataka, India
2 Department of Pedodontics; Preventive Dentistry, Yenepoya Dental College, Mangalore, Karnataka, India
3 Department of Pedodontics, Yenepoya Dental College, Mangalore, Karnataka, India
4 Department of Public Health Dentistry, Yenepoya Dental College, Mangalore, Karnataka, India

Date of Web Publication31-Jul-2017

Correspondence Address:
K M Ramya
Lecturer, Department of Pedodontis and Preventive Dentistry, A. J. Shetty Institute of Dental Sciences, Mangaluru - 575 004, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JISPPD.JISPPD_187_16

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Aim: The aim of this study is to assess the maternal risk factors and its relationship with early childhood caries (ECC) among preschoolchildren in Mangaluru city. Methods: Children aged 3–5 years attending preschool (Anganwadi) and their mothers were included in the study. A total of 120 child–mother pairs participated in the study. The maternal risk factors were assessed by a pretested questionnaire. After obtaining the consent, the mother and their children were clinically examined for dental caries using the WHO criteria (1997). Results were analyzed using SPSS 18.0. Results: Significant difference was found in mother's caries activity, high level of Streptococcus mutans, brushing frequency, diet of the mother, and their child's caries experience. Conclusion: A relationship between maternal risk factors and ECC is a result of a multifactorial and a comprehensive model that includes psychological and behavioral aspects. Caries prevention strategy should be that every child should receive oral care before age of one so that needful children can be instituted with preventive measures and their parents can be targeted for educational programs.

Keywords: Early childhood caries, maternal, preschool

How to cite this article:
Bhat SS, Hegde S, Bhat V, Ramya K M, Jodalli P. Assessment of maternal risk factors and its relationship with early childhood caries among preschool children in Mangaluru city. J Indian Soc Pedod Prev Dent 2017;35:193-7

How to cite this URL:
Bhat SS, Hegde S, Bhat V, Ramya K M, Jodalli P. Assessment of maternal risk factors and its relationship with early childhood caries among preschool children in Mangaluru city. J Indian Soc Pedod Prev Dent [serial online] 2017 [cited 2022 Aug 16];35:193-7. Available from: http://www.jisppd.com/text.asp?2017/35/3/193/211844

   Introduction Top

Dental caries is an infectious disease caused by the interaction of bacteria, mainly Streptococcus mutans, and sugary foods on tooth enamel. S. mutans are believed to be spread from mother to baby in saliva during infancy and can inoculate even predentate infants. These bacteria break down sugars for energy, causing an acidic environment in the mouth, and results in demineralization of the enamel of the teeth and dental caries.[1]

It is a serious socio-behavioral and dental problem that afflicts infants and toddlers worldwide. The definitions of early childhood caries (ECC) in the published literature vary, making comparisons among studies difficult. For example, some of the definitions have included 1 or more incisors with decay, 2 or more incisors with decay, and even 3 or 4 maxillary incisors with decay. Therefore, in 2003, the American Academy of Pediatric Dentistry defined ECC as the presence of one or more decayed (noncavitated or cavitated), missing (due to caries) or filled tooth surfaces in any primary tooth in a child up to 71 months of age or younger. The academy also specifies that, in children younger than 3 years of age, any sign of smooth surface caries is indicative of severe ECC (S-ECC). From ages 3 through 5, 1 or more cavitated, missing (due to caries) or filled smooth surfaces in primary maxillary anterior teeth or decayed, missing, or filled score of ≥4 (age 3), or ≥5 (age 4), or ≥6 (age 5) surfaces constitutes S-ECC.[2]

ECC is a multifactorial disease, in particular, is more common in children from low socioeconomic groups with lower levels of maternal education. It is also associated with pregnant mothers who have carious teeth, periodontal disease, high S. mutans levels, and a high rate of sugar consumption.[3]S. mutans are spread from mothers to their infants during a discrete window of infectivity. Some researchers have found bacteria to be present even before this in as many as 50% of infants 6 months of age and in infants as young as 3 months of age.[4] It is believed that the earlier the infant or young child contracts S. mutans, the more likely the child is to have dental caries.[5]

ECC is a serious public health problem in very young children, and although it is not life-threatening, if left untreated it may lead to pain, bacteremia, compromised chewing ability, and toxic overdose of analgesics (acetaminophen) administered during the early stages, followed by malocclusion in permanent dentition, phonetic problems, suboptimal health, lower self-esteem, and failure to thrive. Furthermore, it has been demonstrated that dental caries can gradually reduce a child's ability to gain weight, which may get reversed after complete oral rehabilitation.[6]

Despite the seriousness of problems due to ECC, there has been a paucity of prevalence studies in Mangaluru, which may be due to the difficulty of access to this age group. The most tragic fact about ECC may be that measures, which could render the condition entirely preventable. Hence, knowledge on prevalence and associated factors of ECC is necessary to develop targeted interventions for the prevention of subsequent tooth decay and to decrease the number of children that require emergency treatment. For this reason, the study was undertaken with the objective to assess the maternal risk factors and its relationship with ECC among preschoolchildren in Mangaluru City.

   Materials and Methods Top

Ethical considerations

This study proposal was reviewed and cleared by the Department of Bioethics, Yenepoya University, Mangaluru.

Source of data/sampling method

  • Preschoolchildren 3–5 years attending the preschools (Anganwadi) accompanied by their mother present on the day of examination were included in the study
  • Mangaluru city was divided into four zones (North, South, East, and West)
  • Three preschools from each zone were randomly selected to obtain a total 12 of preschools
  • Ten children per preschool aged 3–5 years were randomly selected to obtain a sample of 120 children.

Sample size (including sample size calculation)

  • Randomly 120 preschoolchildren fulfilling the inclusion criteria and present on the day of examination were included in the study
  • Sixty participants in case group (with one or more active caries)
  • Sixty participants in control group (caries free).

Procedural steps

Method of obtaining data

Data were collected by three procedural steps

  1. Questionnaire - A pro forma, designed in local language (Kannada) (Annexure III) for collecting all the required information, was used. Pro forma-included questions regarding personal data, socioeconomic profile (Kuppuswamy's socioeconomic status [SES] scale), oral hygiene practices, sugar consumption, family income, and educational level of mothers
  2. Clinical examination - Clinical examination was carried out for dental caries based on the WHO criteria (1997)[7] using plain mouth mirror and CPI probe. The participant was made to sit comfortably on the chair under natural lighting, and Type III clinical examination was carried out. Each mother whose child was found to have at least one frank active or restored carious lesion was enrolled in the case group to make the sample of sixty participants. For each participating mother in the case group, the mother of the next caries-free child screened was offered a place in the control group (60 participants)
  3. Saliva collection - Unstimulated saliva from the dorsum of the tongue of the mother and the child was collected with the help of micropipette using steralizable tips, and 10 μl of saliva was collected and carried to the laboratory in the transport medium thioglycolate and incubated for 48 h. The samples were inoculated on the prepared culture media (MSB Agar– selective medium for S. mutans) and incubated for growth. After 48 h, the colonies grown on the media were subjected for colony counting on a digital colony counter (HiMedia Pvt Ltd.,), according to the manufacturer's instructions. Depending on the colony count of S. mutans categorized into four different scores. The Colony Forming Units (CFU) were recorded and scored as follows: Score 1 < 104 CFU/ml, Score 2< 105 CFU/ml, Score 3< 105 - 106 CFU/ml and Score 4 >106 CFU/ml.

Statistical analysis

The statistical analysis was done using SPSS (Statistical Package for Social Sciences Analysis Software) Released 2009. Version 18.0. Chicago: SPSS Inc.

   Results Top

[Table 1] shows the correlation of mother's caries experience and microbial level with the child's caries experience; a significant positive correlation was found between DMFT of the mother and def of child, whereas, highly significant positive correlation was observed between mothers microbial count, child's age and microbial count with the def of child. No correlation found between mothers age and child's caries experience. [Table 2] shows the correlation of mother's caries experience and microbial level with the child's caries microbial level; there is a highly significant correlation between DMFT of the mother, mother's microbial count, child's age, and def of child with the child microbial count, i.e., 0.03 whereas no correlation found between mother's age with child's microbial count.
Table 1: Correlations between caries experience of mother and mother's microbial level with child's caries experience

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Table 2: Correlations between caries experience of mother and mother's microbial level with child's microbial level

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   Discussion Top

Tooth decay is a multifactorial disease that occurs due to interaction of certain casual factors. The inter-relation of cariogenic microbiota with the appropriate substrate, in a susceptible host, within a certain time, permeated by broad social, economic, and cultural factors, influence the development, and evolution of caries.[8]

The present study was conducted with an aim to assess the maternal risk factors and its relationship with ECC among preschoolchildren. A total of 12 preschools were selected, and a total of 120 children and their mothers were included in the study. The children in the age group of 3–5 years were selected because below 3 years, it would be difficult to get the cluster of the sample at a common place, uncooperative behavior of such young child, and difficult in detailed examination of the oral cavity.

The present study of 3–5 years preschoolchildren shows the mean DMFT value at (1.58 ± 2.513).A similar trend of caries in children was reported in rural areas of Sikkim by Mandal et al.[9] and Hugoson et al.[10] However, a higher trend of caries was reported in studies done by Mahejabeen et al.,[11] WHO collaborating agency in Gujarat.[12]

The lesser prevalence of caries in our study may be due to the age of the children presence of preventive program in these places (widespread use of fluoride in different forms and preventive programs) which are practiced at various levels in these places. This may be due to the early age dietary and oral hygiene practices related to dental caries are mostly controlled by parents/caregivers.

Relationship between mothers (decayed, missing and filled teeth) and child caries (decayed, extracted, and filled teeth)

The mothers in the study exhibited high caries level when compared to that of their children, with mean DMFT (3.63 ± 3.00). A significant positive correlation (r = 0.450 at the 0.05 level, 2-tailed) was seen between mothers DMFT and child def indicating that those mothers who had higher DMFT had children with def. The findings given by Zanata et al.[13] were similar to our study who reported a strong positive association between caries activity of mother–child couples.

Ersin et al.[14] reported that the mothers who harbored high levels of S. mutans with high DMFT scores shared the similar genotypes of S. mutans with their children. The findings given by Smith et al. were similar to our study in which they have found S. mutans, maternal active caries, brushing frequency, and staple food as a strong risk indicator for child's caries experience. The mother's oral health factors such as high MS levels and high caries experience are important risk indicators for caries in their children.

In this study, a two-tailed correlation indicated that mother DMFT score was an impact factor for caries experience in their children, and this was in accordance with studies by Smith et al.[15] and Vachirarojpisan T.[16] Thus, mothers with high S. mutans levels may affect the child's early infection with S. mutans, resulting in an increase of ECC.

Early childhood caries prevalence in relation to the socioeconomic status

It was seen in the study that there was no significant difference between the SES and the DMFT/def of mother/child. The risk of ECC was not dependent on the SES of the mother which may be attributed to the majority of mothers belonging to the upper lower and upper class, and they perceived moderate oral hygiene practices, but it was also observed that the utilization of dental services was completely not found in the present study.

Smith et al.[15] Bjarnason et al.[17] and Owusu et al.[18] in many parts of the world have consistently recorded that social class is strongly associated with dental caries prevalence in children. This may have a direct independent effect and is a consequence of differences in education.

However, the disparities in the distribution of caries can be attributed to the social class, family income, and the degree of education which can affect food selection, nutrient intake, health values, lifestyles, and access to health-care information and susceptibility to childhood infections.

Early childhood caries prevalence in relation to oral hygiene habits and practices

The results of the current study did not show any association between prevalence of caries and type of dentifrices used but had an association between caries experience and frequency of brushing (P < 0.056). Previous studies by Vázquez-Nava et al.[19] and Nakano et al.[20] reported similar results showing few or tremendous effect. The fact that the association between caries and brushing effectively and correctly can be associated with the mothers level of education and SES.

The present study showed that all of mother and their children (100%) used toothpaste (fluoridated/nonfluoridated) as a type of material used as a cleaning aid. This can be attributed to the education and SES of the mothers.

However, no significant association between type of dentifrice used by mother and caries in child could be established statistically (P = 0.416) rather a statistically significant difference was seen between the mothers DMFT and the frequency of brushing. The results of the study indicated a diminutive relationship between oral hygiene practices and the occurrence of dental caries. It was seen in this study that the mother's of caries-active children brushed only once, whereas the mothers of caries-free children brushed twice daily, a highly statistically significant difference was seen when compared (0.039); this can be attributed to the fact that mothers who brushed twice also brushed their child's teeth twice.

The above findings in the present study though appear to defy the usual notion that proper oral hygiene does prevent caries, it provides enough impetus to conduct a systematic investigation to understand the intricacies related to oral hygiene habits, aids, and dental caries.

Early childhood caries prevalence, frequency of sugar intake, and diet

The study demonstrated mothers who consumed sugar after meals and in between meals had higher caries prevalence with a mean DMFT of 3.71 ± 3.03 and 3.40 ± 2.94, respectively. No significant association between mother's frequency of sugar consumption and caries in children was seen.

Majority of the study participants consumed a mixed type of diet (73.1%), and wheat was consumed as a staple diet; a highly statistical significant correlation was seen in the DMFT of mothers and the wheat consumption. There was a significant difference in the type of diet between caries-free and caries-active children, comparatively high proportion of caries-free children consumed mixed diet; the reason being may be the consumption of fish in the mixed type of diet which is proved to have a protective effect on caries because of the high fluoride content (P < 0.040). Similar findings were reported by Gordon and Reddy,[21] King,[22] and Asher et al.[23] showing that children acquire their dietary and oral hygiene habits from parents. It also seems that children are being trained to accept a sweetened diet early in childhood by mothers transmitting their own, well-established taste patterns to their children.


  • The present study has a few limitations of its own. The relatively small sample size, age limitation of the study population, does not allow us to draw definite conclusions about the prevalence of ECC
  • Noncavitated lesions could not be recorded in our study. Although clinical assessment showed high intrareliability in our study, it is not sufficient to detect early interproximal caries. Radiographic ECC assessment and transillumination assessment in conjunction with clinical assessment are a more sensitive measure. However, given the age of the sample, radiographic methods in children could not have been applied.

   Conclusion Top

There was a positive association of mothers' caries activity and their child's caries experience (correlation at 0.05 level). Significantly higher proportion of children whose mothers had >50 mutans colonies had caries (P < 0.001). A moderate positive correlation (r = 0.554) between number of carious teeth of mothers and number of caries exposed teeth of children was also significant (P < 0.001). Other factors associated with child's caries included level of educational attainment of mothers, SES, and frequency of maternal sugar consumption (P < 0.001). The traits such as frequency of toothbrushing and use of dentifrice were not statistically significant.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

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Wan AK, Seow WK, Purdie DM, Bird PS, Walsh LJ, Tudehope DI. A longitudinal study of Streptococcus mutans colonization in infants after tooth eruption. J Dent Res 2003;82:504-8.  Back to cited text no. 2
American Academy of Pediatric Dentistry Reference Manual 2002-2003. Policies on early childhood caries: Unique challenges and treatment options. Pediatr Dent 2003;23:24-5.  Back to cited text no. 3
Diagnosis and Management of Dental Caries Throughout Life. National Institutes of Health Consensus Development Conference Statement, March 26–28, 2001. J Dent Edu 2001;65:101162-8.  Back to cited text no. 4
Caufield PW, Cutter GR, Dasanayake AP. Initial acquisition of mutans streptococci by infants: Evidence for a discrete window of infectivity. J Dent Res 1993;72:37-45.  Back to cited text no. 5
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Hugoson A, Koch G, Hallonsten AL, Norderyd J, Aberg A. Caries prevalence and distribution in 3-20-year-olds in Jönköping, Sweden, in 1973, 1978, 1983, and 1993. Community Dent Oral Epidemiol 2000;28:83-9.  Back to cited text no. 10
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  [Table 1], [Table 2]

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