Oral health has been an important aspect of an adult, as well as, children well-being and quality of life. Untreated dental caries associated with discomfort/pain can affect weight gain, normal growth and child’s development, therefore preventive and therapeutic measures must be based on the most current scientific and clinical knowledge available [3]. Although the Health Insurance Fund of Bosnia and Herzegovina covers full costs of dental care for children younger than 15-years, the ECC prevalence is extremely high and most of the lesions are untreated [3]. In countries like Bosnia and Herzegovina, with high caries prevalence, caries risk assessment is very important, but there is only data about caries risk assessment in the 12-years-old children [19] and pregnant women [30].
In the present study, the majority of participants (women and children) were at high risk of caries according to Cariogram. It was found that 22.50% of 4-years-old children are in a very high and 26.25% of 4-years-old children are in high risk group. Garg et al. also showed the highest percentage of 5-years-old children (66.2 %) developed new caries lesions in the category of high risk group by Cariogram [29]. Stecksen-Blickset al. investigated the existing caries risk factors in 2- years- old children and displayed that 51% of the sample had a low chance (or very high risk) of avoiding caries in the future [24]. Study concerning Greek (2-6 years old) preschool children reported the highest number of patients in a moderate caries risk group (65%) and only 29% in a high risk group by Cariogram [26]. The study conducted in Macedonia among 4-5-years-old children showed that 55.10% children had a moderate dental caries risk and 40.82% children had a high dental caries risk according to Cariogram [28].
It is very difficult to compare the results of Cariogram for pregnant women in the present study, as no studies were conducted on pregnant women and their offspring for caries risk assessment by Cariogram. Study performed in children and adult populations in Turkey showed that the majority of their participants had a high risk for caries, while Celik et al. reported the majority Turkish adults (20–21 years old) with medium and low caries risk by Cariogram (33% and 24%, respectively) [32,33]. In the study of Sonbul et al. the prevalence rates of caries risk in adults by Cariogram with several dental restorations in Saudi Arabia were high [34]. On the other hand, there are many studies with different models for caries risk assessment focusing mother’s caries risk at pregnancy and subsequent risk of their children in the future. The studies suggest that infants acquire mutans streptococci from their mothers and only after the eruption of primary teeth [35, 36]. There have been numerous studies that have linked the presence of caries in mothers with the incidence of caries in children. The influence of maternal caries status on the same in preschool children was also confirmed in studies in Turkey [37], Thailand [38] and New York [39], while it was not significant in the Japanese study [40].
In a cross-sectional study conducted on the eight-year-old child- mother couples in Mendota, California, in a low-income rural community of Hispanics, it was found that the presence of untreated caries in mothers almost doubled untreated caries in children [41]. A study by Roberts et al in Iowa, states that tooth loss due to caries in caregivers was significantly associated with the prevalence of caries in their children [42]. A study in the African-American population in Detroit found that the incidence of caries in parents or caregivers increased the likelihood of caries lesions in children [43]. Studies in Finland from 2000 and 2005 also confirm the importance of family-related factors [44,45].
Factors such as low socioeconomic status, low maternal education, and unemployed mother are significant in many studies [46-51].
In the review of Kirthiga M. et al. from 2019 the important risk factors (OR greater than one) amid high-income countries were: low maternal education; smoking during pregnancy; maternal age younger than 25 years and negative parental attitudes [52].
In the early caries risk assessment by Cariogram studies, researchers identified and measured various caries related factors and correlated them to the current caries status of the individual, i.e. after 1-3 years, in longitudinal studies. Data obtained from these studies often used a simple correlation for analyses. Stamm et al. state that useful risk assessment program should be one with high simplicity, sensitivity, and specificity [53]. Often, it may be very impractical to be achieved simultaneously simplicity and accuracy. But in more recent years, sensitivity/specificity, predictive powers, and Youden's index have been applied for validation in Cariogram studies [54-56].
The principle of sensitivity/specificity is to use a specific cut-off value for the factor under investigation and to define a specific outcome of the test. In present study, the relatively high negative predictive values are found for both cut-off and both aims: (1) to validate baseline caries risk classifications according to Cariogram with the actual caries development over a 4-year period in a group of women; (2) validate (baseline?) caries risk classification of pregnant women according to Cariogram with the offspring actual caries development after 4 years. The similar results are found in Holgerson longitudinal study in Sweden, which showed that validation of a modified Cariogram in 2-years-old preschool children resulted in high sensitivity for future caries 5 years later, but the method lacked precision and accuracy [25].
The predictive ability of Cariogram for pregnant women at both cut-off points had specificity lower than 70%, which may be categorized in high-risk group some individuals with actual low caries risk and unnecessary preventive measures may be taken. But, on the other hand, according to PPV (>78%) in both cut-offs, it can be seen that a higher percentage of patients will develop caries. PPV is even higher (95%-cut off 1, 85%-cut off 2) for a possibility of caries developing in offspring if pregnant women are in a higher risk of caries according to Cariogram.
In recent studies from Hong Kong, the results showed that the Cariogram for preschool children generally exhibited a higher accuracy [27,57]. In the present study, for validation of caries experience in children using Cariogram model of their mothers during pregnancy, accuracy was higher than 70% for both cut-offs. Also, validation used in this study obtained clinically useful values according to Youden’s index, when moderate and two lowest risk groups have combined.
The limitations of the study are the relatively small sample size, which is a consequence of the factors for inclusion in the study and the small number of pregnant women in the region of Banja Luka. Early childhood caries is associated with many other factors not included in the Cariogram program, so this would also be the limitation of the current study. Although Cariogram requires laboratory tests it is easily applicable and according to research, it was valid for certain population groups [15, 23, 25, 27, 29, 54, 55, 56]. Guided by this, the main reason for use of Cariogram in this study and the strength of the study was that an important aspect is a benefit to the children, i.e. early preventive measures which would be taken for children based on high risk of caries of their mothers in pregnancy.