Dental caries status and related factors of 5-year-old children in Shanghai

doi:10.21203/rs.3.rs-3298704/v1

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Dental caries status and related factors of 5-year-old children in Shanghai

https://doi.org/10.21203/rs.3.rs-3298704/v1

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Background

Dental caries in young children is a difficult global oral health problem. In the last decade, China has put much effort into reducing the prevalence of caries. This study, which is part of the China Population Chronic Disease and Nutrition Surveillance 2021, aims to investigate the prevalence of dental caries among children aged 5 in Shanghai, China, and investigate the factors affecting the incidence of caries and the direction for future improvement.

Methods

A total of 1281 children aged 5 years from 6 districts in Shanghai were selected by a stratified sampling method. The survey consisted of an oral health questionnaire and an oral health examination. The questionnaire included questions on oral health knowledge, attitudes, and behaviours. Oral health examination using WHO standards. After screening, the data were input and analysed. Chi-square and logistic regression analyses were used to study the relevant factors affecting dental caries.

Results

The prevalence of caries in 1281 children was 51.0%, the dmft was 2.46±3.45, the Significant Caries Index (SiC) score was 6.39±2.40 and the SiC10 score was 10.35±3.17. Caries experience was related to the frequency of intaking sweet drinks, the age of starting tooth brushing, eating habits after brushing, whether they had received an oral examination provided by the government, and the mother's education level but was not related to gender, the use of fluoride toothpaste, the frequency of brushing, whether the parents assisted brushing, or the frequency of flossing. Logistic regression analysis showed that the region of young children, eating after brushing and the age of starting brushing were associated with caries.

Conclusions

The caries prevalence of 5-year-old children in Shanghai has been gradually reduced with the support of government investment and various policies, but it is still higher than that of developed countries. The government still needs to further increase investment and improve the oral awareness of the whole society.

Early childhood caries

Risk factors

Previous caries experience

China

Dental caries is one of the most common diseases worldwide. Nearly 200 million people worldwide suffer from dental caries in permanent teeth, and more than 353 million children suffer from caries in primary teeth[1]. The occurrence of caries in children under 6 years old is called early childhood caries (ECC). ECC is related to the low mineralization degree of primary teeth, poor oral hygiene habits, parents' neglect and the overall economic development degree of society. ECC progresses rapidly, and caries accumulate as the child grows. Children with poor chewing ability and low nutrient intake capacity will experience slow growth and development. In addition, many studies have demonstrated that early tooth loss, malnutrition and stunted growth due to dental caries can have an enormous impact on children's quality of life[2, 3].

The prevalence of caries varies in different regions. Developing countries have higher caries rates than developed countries, and Asia has higher caries rates than Europe and Latin America[4]. The third and fourth national oral health epidemiological surveys in China showed that the prevalence of ECC at the age of 5 years increased from 66.0% (2005) to 71.9% (2015) [5]. With increasing age, the prevalence of ECC increased and remained at a high level. Global data show that ECC remains highly prevalent but is rarely treated[6].

In the past two decades, China has launched various programmes to promote children's dental health, ranging from the "Happy Mouth, Happy Family" programme organized by the National Health Commission to the comprehensive intervention programme for caries of primary teeth in preschool children[7].

However, China is a vast country with uneven development, and the oral health status of preschool children is still a serious and intractable public health problem. As an important development city in China, Shanghai has achieved rapid development in all aspects since the economic policy in the 1990s. In the past two decades, it has ranked first in domestic GDP and ranked in the top five in global GDP in the past five years. The advantages of medical care and education have attracted a large number of talents at home and abroad to settle down, and the permanent population of Shanghai in 2022 will be 24.76 million, ranking second in China. In the last 10 years, Shanghai has increased medical expenditure, mobilized the strength of all sectors of society, and gradually carried out oral programmes. Therefore, it can represent the oral health status of better-developed cities to a certain extent.

At present, the sample age of most articles is 3–5 years old, among which the sample size of the 5-year-old age group is small and poorly targeted[8–10]. As dental caries is a socioeconomic-related disease, rapid urban development and changes in medical policies may bring about changes in dental caries status[11]. Therefore, the aim of this study was to investigate the dental caries status of 5-year-old children in Shanghai and its related influencing factors. The findings will provide a basis for the development of appropriate strategies and programmes to improve the oral health of these schoolchildren in the future.

Participants

This study is part of the Chinese Residents Chronic Disease and Nutrition Monitoring project in 2021, which monitors the oral health status of key populations. According to the principle of stratified random sampling, the Jing 'an, Xuhui, Putuo, Hongkou, Minhang and Pudong districts were selected to conduct an oral health survey. The kindergarten-based sampling method is adopted, and 4 kindergartens in each district are selected as the investigation unit, among which 50 children aged 5 are randomly selected from each kindergarten (if the number of children in a single kindergarten cannot meet the sampling conditions, the number of kindergartens can be appropriately expanded). The inclusion criteria for this study were healthy 5-year-olds. Children who are uncooperative or have a serious systemic illness are excluded.

Survey content and methods

Two components were included: an oral health questionnaire and an oral health examination.

Oral health questionnaire

Each questionnaire was collected by face-to-face interviews with parents of children at the site of oral health examination. The questionnaire mainly included oral health knowledge, attitude and behavior, oral disease experience, and oral health service utilization. The informed consent form was signed by the child's guardian and kept centrally by the surveyor.

Oral health examination

Caries, missing teeth and fillings need to be recorded. Dental caries was determined according to the criteria recommended by the WHO[12]. The examination should be carried out visually under artificial light, combined with a 0.5 mm ball-tipped CPI probe and a disposable dental mirror. Instruments include a plane mouth mirror and CPI probe, with the aid of a cotton swab to remove food if necessary. Only the crown of the child's teeth are examined, not the roots.

Indices Used

In this study, the following indicators were used: prevalence of caries in the primary teeth, number of caries, extractions or fillings due to dental caries (dmft), Significant Caries Index (SiC), calculated as the mean of the top 1/3 of dmft scores, and SiC10 (mean of the top 10% of dmft scores)[13, 14]

Quality control

A total of 6 examiners qualified as dental practitioners and had been practicing dentistry for at least 3 years, and the examiners received uniform training and underwent standard consistency testing. During the oral health examination, survey respondents were reviewed by another examiner according to a 5% review rate. In the on-site survey, before each respondent leaves the site, the enumerator conducts a thorough check of all the contents of the questionnaire. When errors and omissions are found, they are added and corrected. After carefully verifying that there are no errors before signing for acceptance and sealing the report.

Analysis methods

Two independent surveyors entered the data by using Epidata (EpiData Association, Odense, Denmark), and the two sets of data were compared. If inconsistencies were found, the original data were rechecked and amended accordingly. Then, all statistical analyses were performed using SPSS Statistics for Windows software (version 27.0, IBM Corp. Armonk, NY, USA). Frequencies of the variables were calculated by descriptive statistical analysis. The chi-square test was used to assess the association between caries prevalence and the independent variables (gender, region, frequency of sweet consumption, frequency of brushing, frequency of flossing, frequency of toothpaste use, level of parental education and having received government examinations). P < 0.05 values were considered statistically significant. Logistic regression analysis was used to examine all potential variables associated with caries experience.

Of the 1281 respondents (Table 1), 648 (50.6%) were boys and 633 (49.4%) were girls, with a mean age of 5.5 years ± 0.3 years. A total of 653 had caries, with a caries rate of 51.0%. Among them, 342 males had caries, with a caries rate of 52.8%, and 311 females had caries, with a caries rate of 49.1%. There was no significant difference by sex (p>0.05). The dmft was 2.46, the SiC score was 6.39, and the SiC10 score was 10.35. The children’s prevalence of caries in urban areas (48.7%) was lower than that in suburban areas (55.7%), with a statistically significant difference (p<0.05).

Figure 1 shows the proportion of decayed and filled teeth at each tooth position (the loss of 20 primary teeth is not shown in the figure because the percentage of decay loss is less than 0.1). The X-axis is the position of the primary teeth in the upper and lower dental arches. The Y-axis is the percentage of decayed (blue) and filled (yellow) teeth at each tooth position. The maxillary central incisors had the highest caries prevalence (23.6%), while the mandibular bilateral primary molars had the highest caries filling rate (11.6%).

Table 2 presents the correlation between dental caries and oral health-related behaviours in children. There was no correlation between having dental caries and eating desserts (including cakes, biscuits, chocolate, etc.), but there was a correlation with consuming beverages (such as milk, yogurt, milk tea, soya milk, etc.) (p<0.05). There was a significant correlation between caries and the age of starting to brush teeth and whether to eat after brushing (p<0.001) and a correlation with the mother's education and whether receiving government-provided oral examination (p<0.05). However, there was no statistically significant difference between caries experience and the use of fluoride toothpaste, frequency of brushing, whether parents assisted with brushing, or frequency of flossing (p> 0.05).

Logistic regression analysis of the variables with p<0.05 revealed (Table 3) that district, eating after brushing and age of starting to brush teeth were significant risk factors associated with dental caries. Children living in suburban areas were 1.34 times more likely to have dental caries than children living in urban areas. The risk of dental caries was 1.83 times higher for those who ate after brushing every day than for those who never ate after brushing at night.

Compared to the data from the Fourth National Oral Health Survey (2015), the prevalence of dental caries at age 5 in Shanghai (68.3%) is lower than that nationally (71.9%) and continues to show a downwards trend in 2020 (51.0%) [2, 15, 16]. This may be related to the annual fluoride application programme in kindergartens that has been vigorously carried out in the past five years, which focuses on inspecting all children in kindergartens and providing feedback on the results to parents. In addition, some districts have launched several popular dental education activities in the form of carnivals, including not only lectures and talks but also games, performances and other participatory forms to engage children and parents, enhancing parent‒child interaction while effectively transmitting oral health knowledge to the public.

The results show a decreasing trend compared to previous domestic studies[2, 15, 16], and the caries prevalence rate is lower than that in other developing countries[8, 9, 17], such as India (65.1%), Turkey (74.9%), and Thailand (84.6%), but compared to that in developed countries[18–21], such as Sweden (18.9%), Australia (36.4%), Italy (35.0%), and the Netherlands (31.7%), the prevalence rate is still high. Thus, future investment in oral prevention-related healthcare still needs to be scaled up, and oral health education still needs to be strengthened.

Studies have shown that there is no significant difference between the use of dental floss, frequency of brushing, help with brushing, and use of fluoride toothpaste and the occurrence of caries, which is essentially the same as the results of two papers reported in 2022 in Nigeria and Yunnan Province, China [22, 23]. However, a study conducted in Beijing in 2019 found that caries were related to the frequency of tooth brushing and fluoride toothpaste, not related to whether parents helped with brushing or not [24]. The survey in Shanghai Xuhui district in 2018 found that the prevalence was associated with parental help with brushing but not with the frequency of tooth brushing. Previous studies have found that intervention in brushing at school can effectively reduce the occurrence of dental caries [25], explained as school intervention can help children to better master the method of brushing. In practice, we find that many parents have misconceptions, which can explain the seemingly "contradictory" results above, i.e., brushing and flossing does not mean that the teeth can be brushed well, and it does not mean that caries will not occur as well. The first misconception is that many parents take a "laissez-faire" approach to their children's teeth, not helping them to brush or checking after brushing. They brush their teeth, but the result of relying only on the children's subjective initiative is that the brushing effect is poor and the tooth surface is not completely cleaned. The EAPD suggests that parents should help brush their children’s teeth before the age of seven[26]. The second misconception is that fluoride toothpaste is not used or that the amount of toothpaste used is insufficient. The AAPD recommends that the use of fluoride toothpaste can effectively reduce the incidence of caries, and the use of fluoride toothpaste with the size of a grain of rice should be used for children under three years old, and the use of pea-sized toothpaste for children between three and six years old[27]. The third misconception is that flossing is not standardized and that it is not possible to floss every tooth adjacent to the surface. The above three points are the contents that need to be popularized in the future. It is also the direction that the future investigation can be further refined and studied.

The survey results showed that the prevalence of dental caries is significantly affected by location in suburban or urban areas, which is consistent with the results of previous studies[2]. The possible reasons are related to lower economic levels, poor medical resources and inconvenient transportation. In addition, there was a significant difference between eating habits after brushing and the starting age of brushing and caries. The results show that with more frequent eating after brushing and a later age of initiation of brushing, the incidence of caries increases, which indicates the significance of good oral hygiene habits for children at an earlier age.

This study also attempted to analyse the significance of government oral examinations, as previous studies have paid less attention to the correlation between the prevalence of caries and government examinations. This study found that government examinations reduce the prevalence of caries. As parents are asked to sign an informed consent form before examinations are conducted in Shanghai and the results are given back to parents, the examinations can help parents focus on oral hygiene and help their children develop good oral habits.

There are still some advantages and limitations in this study. The advantage is that compared with previous articles, the sample of respondents in this survey is larger, there are no invalid questionnaires, and the consistency test results of inspectors are good, so the statistical results are more representative. A limitation is that although the frequency of brushing and fluoride toothpaste use were studied, the association with caries could be better analysed by more specific categorizations, such as the time length of brushing, the amount of toothpaste use and the use of electric/manual toothbrushes.

The caries prevalence of 5-year-old children in Shanghai has been gradually reduced with the support of government investment and various policies, but it is still higher than that of developed countries. The government still needs to further increase investment, carry out various education activities, and improve the oral awareness of the whole population.

SIC: Significant caries index

SIC10: mean of the top 10% of dmft scores

ECC: Eearly childhood caries

dmft: Number of caries, extractions or fillings in primary teeth due to dental caries

Ethics approval and consent to participate

This study was approved by [China Oral Health Foundation of Oral Medicine Ethic Committee/COHF #2021-001] .

Availability of data and materials

The datasets analysed in the current study are available from the corresponding author upon reasonable request.

Consent for publication

Not applicable.

Acknowledgements

We would like to thank the children and their parents who participated in this survey, as well as the kindergarten teachers, the dentists and researchers who conducted the examination.

Funding

This study is part of the Chinese Residents Chronic Disease and Nutrition Monitoring project in 2021, which monitors the oral health status of key populations.

Authors’ Contributions

XZ, YZ, QC, HS, ZW, HS, and JY designed this study. YJ, HW, and JY implemented the project and collected the data. HZ and YL performed the data analysis. DD revised the table and figure. YL wrote this manuscript. YZ revised the draft. All authors have read and approved the final manuscript.

Competing interests

The authors declare that they have no competing interests.

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Dental caries status and related factors of 5-year-old children in Shanghai

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