INTRODUCTION:

One of the most prevalent chronic dental disorders affecting children in their early developmental stages is early childhood caries (ECC).¹ It is defined as the presence of one or more decayed (non-cavitated or cavitated lesion), missing (due to caries) or filled tooth surfaces in any primary tooth in a child between birth and 71 months of age.²

The initial stage in the triad of contributing factors to dental caries in children is the introduction of Mutans streptococci to infants by their mother or other primary caregiver, or by sweetening the food they consume to make it more palatable. These practices affect the newly erupted deciduous teeth in the oral cavity predisposing the incompletely calcified infant teeth to the cariogenic environment. In younger children, this would deteriorate over time as unusual, progressive, acute, and rampant patterns known as Severe Early Childhood Caries (S-ECC) in a susceptible mouth.³ The onset of early childhood caries (ECC) has a complicated and multivariate aetiology that is influenced by a child's temperament, sociobehavioral, cultural, and demographic behaviours as well as nursing needs.⁴The negative consequence of these ECC/S-ECC would impact the child's quality of life, causing dental pain eventually leading to tooth loss and impair eating, speaking, sleeping, and socializing.⁵To further indicate the severity of dental disease spread, it is necessary to classify and quantify the effects caused by poor eating habits or inadequate hygiene practices.⁶

AIMS AND METHODOLOGY:

To investigate the knowledge and awareness of parents towards the child’s feeding, oral hygiene practices and its impact on the dental tissues in the oral cavity represented using the ICDAS scores.

This study was conducted at AIMST University Dental Hospital, Kedah, Malaysia after. This cross- sectional survey was conducted using multistage sampling technique. 100 parents and their 100 children between the age of 36-72 months, who visited the Paediatric Dental Clinic of the university were selected to participate in the study after considering the criteria for selection.

Parents of children between 3-6 years, who have accompanied children for their first dental visit, children who were medically fit and cooperative were included in this study. Children with chronic medical conditions/ disease, children with special needs and children accompanied by their carer/guardians/other relatives were excluded.

The questionnaire was first developed in English and later translated to Malay language. Validation of the questionnaire was conducted by performing pilot study on 20 parents who attended Paediatric Dental clinic of the university Hospital. Then, reliability test was conducted to check on the consistency of the responses. Prior to the study, participation information sheet was given, and informed consent was obtained from the parent to fill the questionnaire and to examine their children.

DATA COLLECTION PROCEDURE:

This study was conducted in two phases to record the data.

Phase I: A preformed closed ended questionnaire in Malay language was distributed to parents that recorded the Knowledge, practices and awareness of parent’s feeding and oral hygiene measures followed in their children.

Phase II: Their pre-school children between the age 3-6 years were examined at AIMST Paediatric dental clinic to record the ICDAS scores, using dental mirror and WHO explorer. The child was helped to brush their teeth by the examiner, prior to the examination and the tooth surfaces were cleaned and dried by the examiner before examining each tooth for recording the scores.

RESULTS:

In the Phase 1 of the study, questionnaire filled by the parents were scrutinised for completion. It consisted of close ended questionnaire assessed knowledge, practise and awareness about their wards feeding and oral hygiene measures that were filled by the parents themselves. In Phase 2, ICDAS scores for the deciduous molars and newly erupted young permanent molars were recorded. The data from phase 1 and phase 2 of the study were subjected for statistical analysis using PSSS version.

Table 1 consisted of close ended questions that assessed the practices regarding feeding and oral hygiene measures followed for their children. Parents answered either as Yes, No or Sometimes. Around 71% of the parents confirmed to clean the child’s mouth, yet 64% of the children slept while drinking milk. Even though 68% of the parents expressed their children eat lot of sugar, 62% did not feed sugar added milk and 73% ended the feed with water.

Table 1

Sl No	Practices Items	Yes (%)	No (%)	Sometimes
1.	Have you ever cleaned your child’s mouth before ?”.	71	24	5
2.	Does the child sleep by drinking milk?	64	32	4
3.	Did you feed the children with water after feeding with milk?	73	20	7
4.	Other than breast milk, have you feed others milk.	66	33	1
5.	Do you add sugar in your child’s drink?	37	62	1
6.	Does your child eat a lot of sugar?	68	26	6

Table 2 consisted of close ended questions that assessed the Knowledge of parents regarding dental caries, oral hygiene and feeding practices, that were answered either as Yes/No/Do not know. About 67% were unaware that caries is genetic, and more than half the study population were aware that pregnant mother’ s diet is important in child’s oral health. They had a greater knowledge about dental caries and were aware that intake of sweets (94%), nocturnal feeding (79%) and poor oral hygiene (92%) leads to dental caries in children. 66% of the parents knew that sharing utensils can spread the dental disease. In this study, 82% of the study population knew that brushing is required as soon as the first tooth appears in oral cavity, while 79% introduced toothpaste after one year of age to manage oral hygiene.

Table 2

Sl No.	Knowledge Items	Yes (%)	No (%)	Do not know (%)
1.	Does dental caries occur genetically?	26	67	7
2.	Does pregnant mother’s food pattern affect the child’s dental health?	50	45	5
3.	After the eruption of first tooth is brushing required?	82	14	4
4.	After 1 year can toothpaste be introduced during brushing?	79	13	8
5.	Does night feeding cause dental caries?	79	14	7
6.	Does intake of sweets cause dental caries?	94	4	2
7.	Does poor oral hygiene cause dental caries?	92	5	3
8.	Does sharing of things used by mother cause dental caries in child?	66	22	12

Table 3 demonstrated the awareness on feeding and oral hygiene measures practiced among parents. Around 43% of the parents introduced semi-solid diet to their children by 6 months of their age and 41% by 9 months. The duration of breast feeding was only for 6 months among 37% of the women, however 27% fed up to 1 year and similar percentage of women carried up to 2^nd year. Only 5% were aware that oral cavity needs to be cleaned before appearance of the first tooth. However, 39% of the parents initiated brushing soon after eruption of 1^st tooth in oral cavity. But a larger population (48%) started brushing only after eruption of all the teeth in front region. There was a greater awareness among parents, that 94 % of them brushed their children’s teeth twice a day.

In Phase 2, severity of dental caries experience in the children of the phase 1 participants was assessed by ICDAS criteria. Four dentists, who were familiar to ICDAS coding criteria were briefed regarding the scoring criteria and their scorings were calibrated before examining the study subjects. Prophylaxis of the dental surface in the oral cavity of the patients was done with toothbrush and examination field was well illuminate, dried using suction compression and cotton rolls. The scoring fields were examined with dental mirror, WHO probe and tweezers. The dentists dictated ICDAS codes to the undergraduate student who recorded it in a data entry sheet. The upper and lower deciduous molars and young permanent first molars were examined. For each dental surface, a code for caries status and a code for dental condition (presence and type of restorations) were recorded and afterward the caries conditions of the teeth were categorized according to the worse surface code. The criterion used to dichotomize presence/absence of ECC to aid in the association analysis. Scoring was done based on WHO recommended caries scoring criterion as, ICDAS 0, 1, 2 = no ECC and ICDAS 3, 4, 5 or 6 = presence of ECC.

Table 3

		n	% age	95% CI
1.	Introduction of semi solid food
	Around 6 months	43	43	33.3- 53.3
	Around 9 months	41	41	31.4 - 51.3
	Between 9-12 months	12	12	6.6 - 20.4
2.	Duration of breast feeding
	Upto 6 months	37	37	27.7 - 47.3
	Upto 1 year	27	27	18.8 - 37.0
	Upto 2 years	27	27	18.8 - 37.0
	Beyond 2 years	9	9	4.4 - 16.8
3.	Knowledge regarding tooth brushing initiation
	Before eruption of first tooth	5	5	1.8 - 11.8
	After 1^st tooth erupts	39	39	29.6 - 49.3
	Tooth in front tooth region erupted	48	48	38.0 - 58.2
	After all tooth erupted	8	8	3.8 - 15.6
4.	Knowledge regarding frequency of tooth brushing in children
	Morning	6	6	2.5 - 13.1
	Morning and night	94	94	86.9 - 97.5

Table 4 explains the number of teeth experiencing caries represented as ICDAS scores on deciduous and young permanent molars of the study subjects. Even though ICDAS score 0,1,2 was considered as ‘no ECC’, a larger number of teeth surfaces were having visible changes to distinctly visible changes in the enamel. Likewise, score of 3, 4, 5 or 6 confirmed the presence of ECC in considerable surfaces of the teeth. However, it is interesting to note that the young permanent first molars although were affected, remained in ‘no ECC’ zone. This explains that there is a high statistical significance difference in the molar teeth affected by caries and their ICDAS scores (p<0.001)

Table 4

	ICDAS Score							(P-value) *
Tooth no	0	1	2	3	4	5	6	< 0.001
54, 64	41	4	10	14	11	15	5
55, 65	22	1	11	18	18	18	12
74, 84	29	16	11	10	9	14	11
75, 85	27	4	9	9	11	22	18
16, 26	43	57	0	0	0	0	0
36, 46	32	54	14	0	0	0	0

* Pearson Chi- Square test = 305.28, Likelihood ratio = 377.232, df=30)

DISCUSSION:

Early childhood caries is one the major oral health concern affecting the pediatric population. The reduced attention to primary dentition is one of major reasons behind the global oral problem. Inaccessibility to dental health care, lack of knowledge and varying factors are the contributing to this problem^1,7 In Malaysia almost over 50% of children above 4 years are affected by ECC. This data points towards the significant attention required for addressing this health concern.⁸

Fisher et al introduced a conceptual model of the influences on children's oral health. Among them, the most important levels that were proposed was the family influence as part of the whole community as a primary factor in initiation of dental caries.⁸ This study confirms that multifactorial risk components in an individual is not necessarily a causative factor for dental disease in children, but indeed caries is a complicated interaction between oral health influenced by environment at child, family and community levels.^9-11

Parental factors, such as knowledge, attitudes and behaviors strongly influence their children’s behavior and health. In this study it was noted that the knowledge of the young parents regarding the feeding practices, dental caries and diet (carbohydrates/sugars) were considerably appreciable. The parents were aware of the basic knowledge and were generally positive regarding the child’s diet for their consideration of causation of dental caries. Since mothers are the family's main health representatives, dental caries is effectively prevented by their practices and attitude toward adopting healthy behaviors.^12-14

The most important identified risk factor in development of ECC is use of feeding/bottled feeding beyond one year of life. The awareness among the mothers regarding dental caries having genetic predisposition for its initiation was as low as 26%. Besides, more than half the study population agreed upon the factor that pregnant mother’s diet will affect the child’s dental health. It is during this period that the early acquisition of S. mutans from the mother’s placenta reaches the child, through colostrum during lactation.^4,15-19

In this study, 82% of the parents were knowledgeable on the fact that tooth needs to be brushed soon after they appear in oral cavity, which is in concurs with the study done by Mani et al in Malaysia.²⁰ 79% also introduced toothpastes by first year of life. Although, use of toothpaste enhances the chances of preventing early colonization of microorganisms and the fluoride content helps for post eruptive maturation of the tooth, expressing the proper quantity and selection of right toothpaste must be advised to the parents.^3,21,22

More than 80% of the study population introduced semi solids food between 6-9 months in this study. However, early exposure to semi solids also increases the risk of caries and thus parents should be well advised about the hygiene practices. Even though 2-year-olds have been introduced to solid or semi-solid foods, a significant number of mothers believed that feeding during the night was normal for this age group. The infant sleep through the entire night if they are well-fed (solid or semi-solid) and have totally stopped receiving bottle feedings. As a result, an ecology would be established in the mouth's suitable environment for bacteria to flourish and multiply, initiating the demineralization process.^23,24

Parents need to be educated that milk in any form (breast/bovine/formulas) contains liquid carbohydrates. Nocturnal feeding with/without sugar will accentuate caries progression, as there is reduction in the secretory rate of saliva in oral cavity at night. This study can be correlated with the study of Mani et al., conducted on Malaysian population, where 73% of the parents ended the feeding with plain water. This practice will reduce acidic oral pH to a minimal extent and this cleanse the milk remnants deposited on the teeth.^4,20,25

Another interesting finding in this study, is that 9% of the mothers breastfed beyond the age of 2 years. This attributes to the cultural belief towards development of immunity in children, due to prolonged breast feeding.^4,26 Around 94% of the mothers were aware of brushing teeth both in morning and in the evening, which is exceptionally higher than the other studies.²⁷

It is crucial that most of the parents in this study exercised good oral hygiene measures and were aware of the necessity of leading a healthy lifestyle. However, as this study found, the parents were lacking in a more positive mindset towards implementing them. In this survey, more over 85% of the parents knew that caries is caused by sugar, poor dental care, and nighttime feeding. Nevertheless, their custom of feeding and drinking sugared milk and formulae at night continued.^20,28,29

Comparing the results with the widely employed DMFT reveals a more realistic distribution of early childhood caries. This is a factual example of early childhood caries distribution, compared to widely used DMFT. In this study, there was a statistically significant difference between the caries in posterior deciduous teeth and young permanent teeth measured using ICDAS scorings. Caries was present on most deciduous molar surfaces; however, it was in the reversible stage. Whereas considerable tooth surfaces had enamel breakdown and extensive caries approaching towards the pulp, in contrast to the finding in young permanent molars. The young permanent molars had no carious lesions and has ICDAS scores were 0 and 1 mostly. There was absolutely no breakdown of enamel among all the chosen study samples, that suggested for measures for early remineralisation procedures.^29-31

Health literacy is an important aspect of prevention. It is defined as the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.³² In this study, the knowledge and awareness of the parent did not necessarily translate into good practice. There is need for constant motivation among parents to improve the beliefs and attitude towards oral health. One of the limitations of this study is the assessment of cultural influence of the region. Particularly in south-east Asia regions, practices like prolonged breast feeding, prechewing of the food by the mother before offering to child and many more practices have persisted from generations and remain persistent. ^26,33 In this society, it is unrealistic and complicated to completely abstain from sugars, as the it has an important place in the child’s diet.³⁴ Hence culture has a great influence over people and has the power to override advice or information about health today.

CONCLUSION:

The treatment of early child caries is often problematic, expensive and takes up time of the child and caretaker. Treatment necessitates extensive rehabilitation under general anesthesia, with all its potential complications, as the level of co-operative behavior of infants, toddlers and preschool children is less than ideal. The clinical outcomes for treatment of early childhood caries are not always favorable with high relapse. Hence, this study recommends to investigate the cultural norms that are associated with knowledge, practice and attitude of feeding and oral hygiene practices followed in community and modify their practices in a wise and strategical trajectories to promote health, thereby reducing the burden of oral health in the society.

REFERENCES:

1. Retnakumari N, Cyriac G. Childhood caries as influenced by maternal and child characteristics in pre-school children of Kerala-an epidemiological study. Contemp Clin Dent. 2012; Jan; 3(1): 2-8. https://doi.org/10.4103/0976-237X.94538

2. Drury TF, Horowitz AM, Ismail AI, Maertens MP, Rozier RG, Selwitz RH. Diagnosing and reporting early childhood caries for research purposes. A report of a workshop sponsored by the National Institute of Dental and Craniofacial Research, the Health Resources and Services Administration, and the Health Care Financing Administration. J Public Health Dent. 1999; Summer; 59(3): 192-7. https://doi.org/10.1111/j.1752-7325.1999.tb03268.x

3. American Academy of Pediatric Dentistry. Policy on early childhood caries (ECC): Consequences and preventive strategies. The Reference Manual of Pediatric Dentistry. Chicago, III.: American Academy of Pediatric Dentistry; 2023: 88-91.

4. Lavigne, Valerie. (2013). Breastfeeding and Dental Caries Looking at the Evidence. Clinical Lactation. 4. 12-16. doi: 10.1891/215805313806998435.

5. de Souza PMDES, Proença MAM, Franco MM, Rodrigues VP, Costa JF, Costa EL. Association between early childhood caries and maternal caries status: A cross-section study in São Luís, Maranhão, Brazil. Eur J Dent. 2015; Jan-Mar; 9(1): 122-126. doi: 10.4103/1305-7456.149659.

6. Castilho AR, Mialhe FL, Barbosa Tde S, Puppin-Rontani RM. Influence of family environment on children's oral health: a systematic review. J Pediatr (Rio J). 2013; Mar-Apr; 89(2): 116-23. doi: 10.1016/j.jped.2013.03.014.

7. Jain, Mokshi & Sethu, Gowri. (2015). Dental Caries and Obesity in Children of Age Groups 5–9 Years: A Preliminary Study. Research Journal of Pharmacy and Technology. 8. 1353. doi: 10.5958/0974-360X.2015.00242.5.

8. Bilal S, Abdulla AM, Andiesta NS, Babar MG, Pau A. Role of family functioning and health-related quality of life in pre-school children with dental caries: a cross-sectional study. Health Qual Life Outcomes. 2021; Aug 3; 19(1): 192. doi: 10.1186/s12955-021-01828-3.

9. Fisher-Owens SA, Gansky SA, Platt LJ, Weintraub JA, Soobader MJ, Bramlett MD, Newacheck PW. Influences on children's oral health: a conceptual model. Pediatrics. 2007; Sep; 120(3): e510-20. doi: 10.1542/peds.2006-3084.

10. Laksmiastuti SR, Astoeti TE, Sutadi H, Budiardjo SB. Caries Risk Factors among Children Aged 3-5 Years Old in Indonesia. Contemp Clin Dent. 2019; Jul-Sep; 10(3): 507-511. doi: 10.4103/ccd.ccd_877_18.

11. Gussy MG, Waters EG, Walsh O, Kilpatrick NM. Early childhood caries: current evidence for aetiology and prevention. J Paediatr Child Health. 2006; Jan-Feb; 42(1-2): 37-43. doi: 10.1111/j.1440-1754.2006.00777.x.

12. Finlayson TL, Cabudol M, Liu JX, Garza JR, Gansky SA, Ramos-Gomez F. A qualitative study of the multi-level influences on oral hygiene practices for young children in an Early Head Start program. BMC Oral Health. 2019; Jul 26; 19(1): 166. doi: 10.1186/s12903-019-0857-7.

13. Mansoori S, Mehta A, Ansari MI. Factors associated with Oral Health Related Quality of Life of children with severe -Early Childhood Caries. J Oral Biol Craniofac Res. 2019; Jul-Sep; 9(3): 222-225. doi: 10.1016/j.jobcr.2019.05.005.

14. Rai NK, Tiwari T. Parental Factors Influencing the Development of Early Childhood Caries in Developing Nations: A Systematic Review. Front Public Health. 2018; Mar 16; 6: 64. doi: 10.3389/fpubh.2018.00064.

15. Anil S, Anand PS. Early Childhood Caries: Prevalence, Risk Factors, and Prevention. Front Pediatr. 2017; Jul 18; 5: 157. doi: 10.3389/fped.2017.00157.

16. Deghatipour M, Ghorbani Z, Mokhlesi AH, Ghanbari S, Namdari M. Effect of oral health promotion interventions on pregnant women dental caries: a field trial. BMC Oral Health. 2022; Jul 8; 22(1): 280. doi: 10.1186/s12903-022-02292-1.

17. Bennadi D, Reddy V, Kshetrimayum N. Influence of Genetic factor on Dental Caries. Indian Journal of Research in Pharmacy and Biotechnology. 2014; 2(3): 1196-1207. https://doi.org/10.14419/ijdr.v4i1.5770

18. Kamate WI, Vibhute N, Baad R, Belgaumi U, Kadashetti V, Bommanavar S. Effect of socioeconomic status on dental caries during pregnancy. J Family Med Prim Care. 2019; Jun; 8(6): 1976-1980. doi: 10.4103/jfmpc.jfmpc_283_19.

19. Carletto Körber FP, Cornejo LS, Giménez MG. Early acquisition of Streptococcus mutans for children. Acta Odontol Latinoam. 2005; 18(2): 69-74.

20. Mani SA, Aziz AA, John J, Ismail NM. Knowledge, attitude and practice of oral health promoting factors among caretakers of children attending day-care centers in Kubang Kerian, Malaysia: a preliminary study. J Indian Soc Pedod Prev Dent. 2010; Apr-Jun; 28(2): 78-83. doi: 10.4103/0970-4388.66741.

21. Horst JA, Tanzer JM, Milgrom PM. Fluorides and Other Preventive Strategies for Tooth Decay. Dent Clin North Am. 2018; Apr; 62(2): 207-234. doi: 10.1016/j.cden.2017.11.003.

22. Walsh T, Worthington HV, Glenny AM, Marinho VC, Jeroncic A. Fluoride toothpastes of different concentrations for preventing dental caries. Cochrane Database Syst Rev. 2019; Mar 4; 3(3): CD007868. doi: 10.1002/14651858.

23. Scott JA, Binns CW, Graham KI, Oddy WH. Predictors of the early introduction of solid foods in infants: results of a cohort study. BMC Pediatr. 2009; Sep 22; 9: 60. doi: 10.1186/1471-2431-9-60.

24. Ribeiro IM, Gomes APM, Gomes AMM, Sarmento LC, Dadalto ECV. Feeding Practices of Potential Risk to Dental Caries in Early Childhood and its Relationship with Sociodemographic Variables and Prematurity. Pesqui Bras Odontopediatria Clín Integr. 2019; 19: e4511. https://doi.org/10.4034/PBOCI.2019.191.88

25. Fathima Bareera Rezvi, R. Abilasha. Breast and Bottle Feeding as Risk Factors for Dental Caries - Review. Research J. Pharm. and Tech. 2016; 9(9): 1508-1512. doi: 10.5958/0974-360X.2016.00294.8.

26. Joan Younger Meek, Lawrence Noble, Section on Breastfeeding; Policy Statement: Breastfeeding and the Use of Human Milk. Pediatrics July. 2022; 150 (1): e2022057988. doi: 10.1542/peds.2022-057988

27. Pullishery F, Shenoy Panchmal G, Shenoy R. Parental Attitudes and Tooth Brushing Habits in Preschool Children in Mangalore, Karnataka: A Cross-sectional Study. Int J Clin Pediatr Dent. 2013; Sep; 6(3): 156-60. doi: 10.5005/jp-journals-10005-1210.

28. Gurunathan D, Moses J, Arunachalam SK. Knowledge, Attitude, and Practice of Mothers regarding Oral Hygiene of Primary School children in Chennai, Tamil Nadu, India. Int J Clin Pediatr Dent. 2018; Jul-Aug;11(4): 338-343. doi: 10.5005/jp-journals-10005-1535.

29. Honkala E, Runnel R, Honkala S, Olak J, Vahlberg T, Saag M, Mäkinen KK. Measuring Dental Caries in the Mixed Dentition by ICDAS. Int J Dent. 2011; 150424. doi: 10.1155/2011/150424.

30. Mendes FM, Braga MM, Oliveira LB, Antunes JL, Ardenghi TM, Bönecker M. Discriminant validity of the International Caries Detection and Assessment System (ICDAS) and comparability with World Health Organization criteria in a cross-sectional study. Community Dent Oral Epidemiol. 2010; Oct; 38(5): 398-407. doi: 10.1111/j.1600-0528.2010.00557.x.

31. Mendes FM, Braga MM, Oliveira LB, Antunes JL, Ardenghi TM, Bonecker M. Discriminant validity of the International Caries Detection and Assessment System (ICDAS) and comparability with World Health Organization criteria in a cross-sectional study. Community Dent Oral Epidemiol 2010; 38(5): 398-407. doi: 10.1111/j.1600-0528.2010.00557.x.

32. Baskaradoss JK. Relationship between oral health literacy and oral health status. BMC Oral Health. 2018; Oct 24; 18(1): 172. doi: 10.1186/s12903-018-0640-1.

33. Skaret E, Espelid I, Skeie MS, Haugejorden O. Parental beliefs and attitudes towards child caries prevention: assessing consistency and validity in a longitudinal design. BMC Oral Health. 2008; Jan 23; 8: 1. doi: 10.1186/1472-6831-8-1.

34. Amin MS, Harrison RL. Understanding parents' oral health behaviors for their young children. Qual Health Res. 2009; Jan; 19(1): 116-27. doi: 10.1177/1049732308327243.

Received on 11.12.2023 Modified on 15.04.2024

Research J. Pharm. and Tech 2024; 17(10):4861-4866.

DOI: 10.52711/0974-360X.2024.00748