Socio-behavioral associates of Early Childhood Caries among preschool children aged three to four years in Gampaha district, Sri Lanka: A cross sectional study

doi:10.21203/rs.3.rs-4887600/v1

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Socio-behavioral associates of Early Childhood Caries among preschool children aged three to four years in Gampaha district, Sri Lanka: A cross sectional study

https://doi.org/10.21203/rs.3.rs-4887600/v1

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Background

Early Childhood Caries (ECC) is a highly prevalent disease among preschoolers in Sri Lanka, and its prevalence has stagnated over the decades. Therefore, it is important to determine the socio-behavioural associations of ECC among preschoolers to reduce the country’s ECC burden.

Methods

A cross-sectional study using a multistage cluster sampling technique with a probability proportionate to size sampling was conducted to select three- to four-year-old preschoolers to determine the socio-behavioural associations of ECC among three to four-year-old preschoolers in the Gampaha district.

Results

The prevalence of ECC was 56.3% (95% CI: 53.1–59.3). Below mentioned factors were significantly associated with ECC. Consuming sweets between meals had a higher odds ratio compared to consuming sweets after main meals (OR = 1.72, 95% CI:1.25–2.35), consumption of sweets every day had a higher odds ratio compared to consumption of sweets several times a week or less (OR = 2.89, 95% CI: 2.02–4.13), consumption of sweetened drinks every day had a higher odds ratio compared to consumption of sweetened drinks several times a week or less (OR = 1.73, 95% CI: 1.07–2.79), and the presence of maternal caries had a higher odds ratio compared to the absence of maternal caries (OR = 1.74, 95% CI: 1.12–2.69). The use of adult fluoridated toothpaste compared to not using adult fluoridated toothpaste (OR = 0.64, 95% CI:0.48–0.85), tooth brushing twice per day compared to not brushing twice per day (OR = 0.67, 95% CI:0.51–0.89), and supervised toothbrushing compared to not supervised toothbrushing (OR = 0.61, 95% CI: 0.41–0.93) were negatively associated with ECC.

Conclusions

ECC is highly associated with sweet consumption patterns and oral hygiene behaviours among preschoolers in Gampaha District. Therefore, interventions should focus on the oral health behaviours of preschoolers to reduce their ECC burden.

Behavior

Dental Caries

Oral Health

Preschool Child

Early Childhood Caries (ECC) is a dental decay found in children under six years of age. It is defined as “the presence of one or more decayed (non-cavitated or cavitated lesions), missing (due to caries), or filled tooth surfaces in any primary tooth in a child under the age of six”[1]. The prevalence of ECC varies in different parts of the world, ranging from 17–63% among one- to five-year-old children [2]. ECC is a highly prevalent disease in Sri Lanka. The prevalence of ECC has stagnated over the decades in Sri Lanka, according to National Oral Health Surveys (NOHS) conducted over the years. According to the latest NOHS in 2015/2016, the prevalence of dental caries in the deciduous dentition of five-year-olds was 63.1%, and the mean dmft was 3.0 (± 3.5). Approximately 96.2% of five-year-old children have active dental caries [3]. This high prevalence reflects the burden of untreated caries in the deciduous dentition of Sri Lankan children. Several other studies conducted in Sri Lanka have also revealed a high prevalence of ECC in young children [4, 5]. ECC has a multifactorial aetiology [6]. As most of the etiological factors of ECC are related to unhealthy oral health behaviours, interventions in the early stages are crucial, as it cause pain and compromise all oral health-related activities. The main oral health-related behaviours responsible for ECC are excessive dietary sugar consumption, poor oral hygiene, and unsatisfactory dental attendance patterns. Generally, most children start preschool life at the age of three years [7]. Preschool age enables the child to become independent and interact with the social environment [8]. Therefore, it is crucial to assess the social and behavioural factors related to ECC among three-year-old preschoolers because early interventions for improving oral health behaviours are more successful than interventions at later ages [9]. Although a few studies have been carried out among three-to five-year-old preschoolers in the country several years ago, no study has assessed these factors among three-to four-year-old preschoolers who are freshers in the preschool environment. This study was conducted in the Gampaha district of Sri Lanka. No study has assessed the association of ECC among three to four year old preschool children in the entire district. Therefore, considering the above facts, we decided to conduct the present study in the Gampaha district, and this study aimed to assess the socio-behavioural associations of ECC among three-to four-year-old preschool children to provide insights into prevention programs to reduce the ECC burden among preschool children.

Study design and sampling

A cross-sectional study was conducted among three-to four-year-old children of registered preschools in the Gampaha district. The calculated sample size was 1080 children from 72 preschools, according to a standard formula [10]. A multistage cluster sampling technique, with a probability proportional to size sampling, was used to select preschools. The first stage involved selecting clusters/preschools from the district. According to the national census of early childhood development centres in Sri Lanka in 2016, approximately 73% of preschools were registered under the provincial council’s early childcare authority [7]. The list of registered preschools in the Gampaha district was taken from the Department of Education, Western Province. Preschools are listed according to the Divisional Secretariat (DS) areas in Gampaha district. The probability proportionate-to-size sampling technique was used to determine the exact number of preschools to be selected from each DS division. One preschool was considered one cluster, and the cluster size was 15. Studies conducted in preschools in Sri Lanka used different cluster sizes. One study used 10 [4], and another used 12 and 23 [11] as the cluster sizes. As a smaller cluster size is preferable to reduce the design effect, the cluster size was taken as 15 for the present study, considering the previous literature and expert opinion. A total of 72 preschools were selected from all registered preschools in the Gampaha district. Fifteen, three to four-year-old preschool children were selected from each selected preschool using a simple random sampling method. The preschool register was used as the sampling frame. Computer-generated random numbers were used. Preschool children who completed their third birthday and those who had not completed their fifth birthday on the day of data collection were selected.

Study instruments

The study instruments used were a questionnaire with interviewer-administered and self-administered components to assess associates and, oral health assessment forms to record ECC and maternal caries which are the dental caries of the mothers of preschool children in the sample. ECC and maternal dental caries were recorded according to the standard criteria of the fifth edition of the WHO survey method and dmft/DMFT index. The questions on the self-administered component consisted of the child’s gender, birth order, type of family, mother’s educational status, mother’s occupational status, and monthly family income. If the mother was separated, divorced, died, or migrated, and did not live with the child, the main person who took care of the child was considered the caregiver. Sweet consumption, oral hygiene behaviors, and dental attendance patterns of preschoolers were the components of the interviewer-administered questionnaire. These associates of ECC were selected based on the results of a series of in-depth interviews conducted in a previous component of the current study and relevant literature. The considered associates were finalized by expert consensus.

Most questions for the interviewer-administered component were developed based on the NOHS 2015/2016 of Sri Lanka and the relevant literature. Judgmental validity in terms of face, content, and consensual validity was achieved for each component of the questionnaire. Face validity was achieved by assessing whether the questionnaire had been developed to achieve the objective of the study relevant to the research area. A literature survey, findings of qualitative studies conducted by the PI, and expert opinions were obtained to achieve the content validity of every component of the questionnaire. Expert opinion was obtained at every step in the development of the questionnaire by obtaining consensus from a panel of experts to ensure consensual validity. The questions were worded using simple language and arranged in a logical sequence. Most of the questions were closed-ended, and leading questions were not included in the questionnaire. Standard translation and back-translation procedures were followed to develop the questionnaires. Oral health assessment forms for preschool children have achieved face and content validity. Pretesting of self-administered and interviewer-administered questionnaires and oral health assessment forms was performed on 25 mother/child dyads. The reliability of the questionnaire was assessed using the test-retest method and the kappa coefficient was 0.93.

Outcome measures

The main aim of the study was to determine the associates of ECC. The dependent variable considered was the presence (dmft ≥ 1) or absence (dmft = 0) of ECC. The independent variables or the associates of ECC considered were gender, monthly family income (≤ 50,000 Rs / >50,000 Rs), educational status of the mother (up to Ordinary level/ above Ordinary level), occupational status of the mother (employed/unemployed), birth order of the child (first/second or more), type of family (nuclear/extended), frequency of sweet consumption; biscuits, buns, cakes, toffees, chocolates, ice-creams or any sweet ( consumes every day or consume several times a week or less), sweetened drinks consumption ; flavoured milk packets, fruit juice, carbonated drinks (drinks every day or drinks several times a week or less), time of sweet consumption during last 24 hours (between meals/after main meals only), ingredient used for toothbrushing (use adult fluoridated toothpaste/do not use adult fluoridated toothpaste), frequency of toothbrushing (brush twice per day/do not brush twice per day), supervision of toothbrushing (supervised by an adult/not supervised), dental visit (ever visited/never visited), and maternal dental caries (present; DMFT ≥ 1 /absent; DMFT = 0).

Data collection

Information sheets and consent forms for the mothers/caregivers of preschoolers were distributed by the Primary Investigator (PI) and got down via the preschool teacher. The data collection team comprised the PI, two interviewers, a data recorder, and an assistant. PI was the only person who performed the oral examination and was trained and calibrated under a Consultant in Community Dentistry. The achieved Kappa coefficients for active dental caries, missing teeth, and filled teeth of examining three to four-year-old children were 0.90, 1.0 and 1.0 respectively. Two female sociology undergraduates were trained as interviewers in a one-day program. They were provided with interviewer guides to minimize bias. The kappa coefficient of the inter-interviewer reliability was 0.89. Once each mother completed the self-administered questionnaire, the interviewer interviewed them in a place where privacy could be maintained within the preschool premises. Oral examination was performed in a place with good natural daylight. Standardized sterilized dental instruments, which were Community Periodontal Index (CPI) probes and plane mouth mirrors, were used for the oral examination procedure. Preschoolers and their mothers/caregivers were provided with health education after data collection. Children who had oral health treatment needs, including ECC, were referred for treatment with PI after data collection. Data collection was done over 4 months from September to December in 2019.

Data analysis

Data were analyzed using Statistical Product and Service Solutions (SPSS) 23rd version. The distribution of variables was presented as percentages and 95% confidence intervals. The significance level was taken at 0.05 for statistical significance between the variables considered. Multiple logistic regression analysis was used to assess the relationship between the associates of ECC because the outcome/dependent variable was the presence or absence of ECC. The Hosmer-Lemeshow test was performed to assess the goodness of fit of the model.

A total of 1038 participated in the study, with a nonresponse rate of 4%. The prevalence of ECC was 56.3% (95% CI: 53.1–59.3). As shown in Table 1, half of the study population (51.0%, 95% CI:48.1–54.0) were females. Approximately 56.2% (95% CI:53.7–59.8) were living only with their nuclear family in the house. As shown in Table 2, 82.3% of the study population (95% CI:79.8–84.5) had sweets every day, and 10.0% had sweetened drinks every day. Most children used adult fluoridated toothpaste (67.1%, 95% CI: 64.1–69.9). Approximately 54.7% (95% CI: 51.6–57.7) brushed their teeth twice per day. About 59.4% (95% CI: 56.3–62.4) had never visited a dental clinic. According to the multivariable analysis in Table 3, between meal-sweet consumption (adjusted OR = 1.72, CI:1.25–2.35), sweets consumption everyday (adjusted OR = 2.89, CI: 2.02–4.13), sweetened drinks consumption everyday (adjusted OR = 1.73, CI: 1.07–2.79), ever visited a dental clinic (adjusted OR = 1.73, CI: 1.31– 2.27), presence of maternal caries (1.74, CI: 1.12–2.69) were the factors positively associated with ECC. On the other hand, use of adult fluoridated toothpaste (adjusted OR = 0.64, CI: 0.48–0.85) and brushing teeth twice per day (adjusted OR = 0.67, CI: 0.51–0.89) were the factors negatively associated with ECC among preschoolers.

Table 1

Distribution of the sample of three to four-year-old preschool children and their parents according to the socio-demographic associates
	Characteristic	Number (n = 1038)	Percentage (95% Confidence Interval)
Gender of the child	Female	529	51.0 (48.1–54.0)
	Male	509	49.0 (46.0–52.1)
Monthly family income	≤ Rs. 50,000	745	72.3 (69.4–75.0)
	˃ Rs. 50,000	285	27.7 (24.7–30.2)
Educational level of the mother	Up to O/L ^§	455	44.0 (40.9–47.1)
	Above O/L ^§	578	56.0 (52.8–59.0)
Occupational status of the mother	Employed	539	51.9 (48.8–55.0)
	Unemployed	499	48.1 (45.0–51.2)
Birth order of the child	First	521	50.2(47.1–53.2)
	≥ Second	517	49.8 (46.7–52.8)
Type of family	Nuclear ^#	579	56.2(53.7–59.8)
	Extended ^γ	451	43.8(40.7–46.9)
ECC	Present	584	56.3 (53.1–59.3)
	Absent	454	43.7 (40.7–46.8)
Maternal caries	Present	931	89.7 (87.6–91.4)
	Absent	107	10.3 (8.5–12.3)
§= G.C.E Ordinary level examination
#=Child lives only with the immediate family members (parents and siblings) in the house
γ = Child lives with immediate family members and relatives of the family

Table 2

Distribution of the sample of three to four-year-old preschool children according to the time of sweet consumption, oral hygiene behaviors and the dental attendance pattern
Characteristics	Number (n = 1038)	Percentage (95% Confidence Interval)
Frequency of sweet consumption
Everyday	854	82.3 (79.8–84.5)
Several times a week or less	184	17.7 (15.4–20.1)
Frequency of sweetened drinks consumption
Everyday	104	10.0 (8.3–12.0)
Several times a week or less	934	90.0 (87.9–91.7)
Time of sweet consumption within the last 24 hours
Between meals	806	77.6 (74.9–80.1)
After main meals only	232	22.4 (19.8–25.1)
Type of ingredient used for toothbrushing
Use adult fluoridated toothpaste	696	67.1 (64.1–69.9)
Do not use adult fluoridated toothpaste	342	32.9 (29.1–34.9)
Frequency of toothbrushing
Twice per day	568	54.7 (51.6–57.7)
Do not brush twice per day	470	45.3 (42.2–48.3)
Supervised tooth brushing
Supervised	900	86.7 (84.4–88.7)
Not supervised	138	13.3 (11.2–15.5)
Dental Visit
Ever visited	421	40.6 (37.5–43.6)
Never visited	617	59.4 (56.3–62.4)

Table 3

Results of the multivariable analysis of associates related to ECC
Factor		Adjusted Odds ratio	Sig.	95% CI^‡
Factor		Adjusted Odds ratio	Sig.	Lower	Upper
Gender	Male	1(Reference group)
	Female	0.91	0.49	0.70	1.19
Occupational status of the mother	Unemployed	1(Reference group)
	Employed	1.15	0.30	0.88	1.50
Type of family	Extended	1(Reference group)
	Nuclear	0.95	0.73	0.73	1.25
Monthly family income	≤ Rs. 50 000	1(Reference group)
	>Rs. 50 000	0.88	0.43	0.65	1.20
Birth order	≥Second	1(Reference group)
	First	1.24	0.11	0.95	1.68
Educational status of the mother	Up to O/L	1 (Reference group)
	Above O/L	0.84	0.24	0.63	1.12
Time of sweet consumption within last 24 hours	After main meals only	1 (Reference group)
	Between meals	1.72	p < 0.01	1.25	2.35
Frequency of sweet consumption^§	Several times a week or less	1 (reference group)
	Everyday	2.89	p < 0.01	2.02	4.13
Frequency of sweetened drink consumption ^¶	Several times a week or less	1(Reference group)
	Every day	1.73	0.02	1.07	2.79
Dental visit	Never visited	1(Reference group)
	Ever visited	1.73	p < 0.01	1.31	2.27
Ingredients used for brushing	Do not use adult fluoridated toothpaste	1(Reference group)
	Use adult Fluoridated toothpaste	0.64	0.01	0.48	0.85
Supervised brushing	Not supervised	1(Reference group)
	Supervised	0.61	0.02	0.41	0.93
Frequency of brushing	Do not brush twice per day	1(Reference group)
	Twice per day	0.67	0.01	0.51	0.89
Maternal caries status	Absent	1(Reference group)
	Present	1.74	0.01	1.12	2.69
‡=Confidence Interval
§=Biscuits, buns, cakes, toffees, chocolates, chewing gums, ice-cream or any type of sweets consumption
¶=Flavoured milk packets, fruit juice and carbonated drinks consumption

This study was conducted to assess the associates of ECC among three to four-year-old preschool children in the Gampaha district of Sri Lanka and identified that ECC is positively associated with sweet consumption patterns, maternal caries, and dental visits and negatively associated with oral hygiene behaviours. The prevalence of ECC in this study was 56.3%. Several studies conducted among preschoolers in Sri Lanka have shown a similar prevalence [12, 13]. However, the age range of the above studies was three to five, although the present study had only three to four-year-old preschoolers. This implies that preschool children of this age group also have a higher prevalence of ECC than expected.

Non-milk extrinsic sugars are the primary substrate for the development of dental caries. The present study revealed that a very high percentage of three to four-year-old preschoolers consume any form of sweets, and most of them eat sweets between their main meals. The high ECC prevalence among them might have resulted from their unsatisfactory sweet consumption pattern, as the consumption of refined sugar-based food several times a day between main meals was identified as a strong unhealthy behavioural factor associated with ECC [14]. Further, the consumption of sweets and sweetened drinks every day, and between meals was strongly associated with the development of ECC according to the multivariable analysis. This finding is consistent with those of other studies [12, 15]. Oral health care providers must be diligent in reducing dietary sugar intake beyond the recommended levels among these three-year-old children to prevent ECC among them in the country.

Oral hygiene behaviours are other important oral health-related factors that are responsible for the prevention of ECC. Brushing teeth twice daily is the best practice for preventing oral diseases. However, only half of the study sample brushed their teeth twice per day, similar to a study conducted in Malaysia [16]. Although most had brushed their teeth under the supervision of an adult, a small percentage (13.3%) of children still had not brushed their teeth under the supervision of an adult which is similar to the findings of a study conducted in Sweden [17]. Children of this age cannot brush their teeth by themselves, and parents or caregivers are responsible for brushing their children’s teeth. Oral hygiene best practices should be encouraged from the start of the eruption of the first tooth, especially brushing teeth twice a day, to inculcate best oral hygiene practices to reduce oral diseases. In multivariable analysis, the use of fluoridated toothpaste and twice-daily toothbrushing were identified as factors negatively associated with ECC among preschoolers in the present study. Nanayakkara [12] reported similar results.

Although mothers are encouraged by the Ministry of Health to take their children to a dental clinic at the age of one year, around 59.4% of the three to four-year-old preschoolers have never visited a dental clinic. However, this implies that mothers do not have the practice of visiting dental clinics. However, according to the analysis, dental utilisation was positively associated with ECC. This implies that most preschool children had visited a dental clinic only after having an oral disease and not as a preventive measure before getting a disease. This is the reason why it has been identified as a positively associated factor in the analysis. Several other studies have reported similar findings [18]. Parents are responsible for preschool children’s oral health. According to the present study, the oral health behaviours of preschoolers in the early years are not satisfactory. Parents should be encouraged to improve the oral health behaviours of their children because oral health best practices should be initiated at this early age.

The relationship between maternal caries and ECC has been evident in several studies worldwide [19, 20]. Similar to other studies, it showed a significant association with ECC in the multivariable analysis. Mothers with high caries have a higher tendency to get their children’s teeth carious. The unhealthy maternal oral health behaviours which have led to the development of caries in mothers might influence the child’s oral health behaviours, leading to ECC development. The present study did not find any significant relationship between these sociodemographic associates and ECC according to logistic regression. A previous study reported similar findings [21].

This study used a probability sampling method to minimize selection bias. The interviewers were trained and provided with guides to reduce interviewer bias. However, there were several limitations in the study. As oral health behaviour data were gathered via questionnaires, social desirability bias may have occurred. Although the questions regarding oral health behaviours were extracted from the standard questions formulated in the National Oral Health Survey 2015/2016 in Sri Lanka, WHO basic survey methods and from previous literature, recall bias might have occurred in assessing the behaviours. Because this study was conducted within one district, the generalisability of the findings to other districts cannot be assured.

The prevalence of ECC is very high among three to four-year-old preschoolers in the Gampaha District of Sri Lanka. Consumption of sweets and sweetened drinks everyday, between meal sweet consumption, having maternal caries, and ever visited a dental clinic have been positively associated with ECC. Using adult fluoridated toothpaste, tooth brushing twice per day, and adult supervision of tooth brushing were found to be negatively associated with ECC among three to four year old preschoolers.

ECC - Early Childhood Caries

PI - Principal Investigator

WHO - World Health Organization

Ethics approval and consent to participate

Ethical clearance was obtained from the Ethics Review Committee of the Faculty of Medicine at the University of Colombo to conduct the study (EC-19-061). Written informed consent was obtained from the mothers/caregivers of preschool children prior to study participation.

Consent for publication

Not applicable

Availability of data and materials

The dataset used in this study is available from the corresponding author upon reasonable request.

Competing interests

The authors declare that they have no competing interests

Funding

This work was funded by the College of Dentistry and Stomatology under research grant 2019/2020.

Authors' contributions

Conceptualization; K.A.M.M, methodology; K.A.M.M , S.D.W and N.C.R, data analysis; K.A.M.M, writing—original draft; K.A.M.M, review and editing; S.D.W and N.C.R

Acknowledgements

The authors are grateful to the preschoolers and caregivers who participated in the study. In addition, this study would not have been possible without the support of the Provincial Director of the Health Services in Western Province and the Regional Director of the Health Services in Gampaha.

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Socio-behavioral associates of Early Childhood Caries among preschool children aged three to four years in Gampaha district, Sri Lanka: A cross sectional study

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Abstract

Background

Methods

Results

Conclusions

Background

Material and methods

Study design and sampling

Study instruments

Outcome measures

Data collection

Data analysis

Results

Discussion

Conclusion

Abbreviations

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References

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