DOI: 10.1111/ipd.12105
Association between developmental defects of enamel and early childhood caries: a cross-sectional study ˜ O-GONC PATRI´CIA CORREˆA-FARIA1, SUZANE PAIXA ß ALVES1, SAUL MARTINS PAIVA2, ISABELA 2 3 ALMEIDA PORDEUS , LEANDRO SILVA MARQUES & MARIA LETI´CIA RAMOS-JORGE3 1
Department of Pediatric Dentistry and Orthodontics, School of Dentistry, Federal University of Minas Gerais, Belo Horizonte, 2Department of Pediatric Dentistry and Orthodontics, School of Dentistry, Federal University of Minas Gerais, Belo Horizonte, and 3Department of Pediatric Dentistry and Orthodontics, Federal University of Vales do Jequitinhonha and Mucuri, Diamantina, Brazil
International Journal of Paediatric Dentistry 2014 Background. The determination of risk factors for
early childhood caries (ECC) is important to the implementation of preventive and restorative measures. However, few studies have addressed the association between ECC and developmental defects of enamel (DDE). Aims. To investigate the association between DDE and ECC, controlling for socioeconomic factors and the presence of dental plaque. Design. A cross-sectional study was carried out with 387 children aged two to 5 years during the National Immunisation Day held in 2010 in Diamantina, Brazil. Data were collected through clinical examinations and interviews with parents/ guardians addressing socioeconomic indicators.
Introduction
Preschool children can be affected by different adverse oral health conditions, such as early childhood caries (ECC) and developmental defects of enamel (DDE). Indeed, ECC remains one of the most prevalent chronic conditions in childhood. In a national survey carried out in Brazil, 53.4% of five-year-old children had an average of 2.3 teeth with caries1. The high prevalence rate of ECC is influenced by socio-demographic factors and oral hygiene practices. Studies have demonstrated that a low level of education on the part of parents/guardians, insufficient knowledge on oral health, a low income and Correspondence to: Patrı´cia Correˆa-Faria, Av. Antonio Carlos, 6627, Faculdade de Odontologia, UFMG - Campus Universita´rio 31270-901, Belo Horizonte, MG, Brazil. E-mail: [email protected]
Statistical analysis involved the chi-squared test and Poisson regression. Results. The prevalence of DDE and ECC was 33.9% and 43.3%, respectively. Children with DDE had a greater prevalence rate of ECC (PR: 1.325; 95% CI: 1.093–1.607). Early childhood caries was more prevalent among children with unsatisfactory oral hygiene (PR: 2.933; 95% CI: 2.22–3.86), those who resided in rural areas (PR: 1.267; 95% CI: 1.03–1.55) and those from families with a lower monthly household income (PR: 1.501; 95% CI: 1.06–2.12). Conclusions. The presence of ECC was associated with the occurrence of DDE in the primary dentition. Place of residence and monthly household income (socioeconomic indicators) and oral hygiene (behavioural factor) exerted an influence on the occurrence of ECC.
unsatisfactory oral hygiene exert a considerable influence on dental caries experience2,3. Developmental defects of enamel is a common occurrence in primary teeth. The prevalence of DDE in children from different countries ranges from 24.4% to 81.3%4,5. These defects are classified based on clinical appearance as enamel hypoplasia, demarcated opacities or diffuse opacities6,7. The risk of DDE in the primary dentition is related to prenatal, perinatal and postnatal factors. Studies have demonstrated that premature birth8, an absence of breastfeeding9,10, low birth weight10,11, social aspects and systemic problems in childhood11 are the main causes of DDE. A number of studies have found that DDE may be a risk factor for ECC7,12. Teeth with enamel defects have retentive areas that can lead to the build-up of bacterial plaque, facilitating the progression of carious lesions12. Moreover, children with DDE have
© 2014 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
1
2
P. Corr^ea-Faria et al.
a greater amount of streptococci from the mutans group13, which are associated with the aetiology of dental caries14. Despite the importance of this association to the establishment of ECC prevention measures and the identification of susceptible children, few studies have addressed the influence of DDE on the occurrence of ECC, especially among preschool children15–19. Furthermore, a comparison of studies demonstrates the difficulty in establishing a consensus on this association due to the different assessment tools employed for the diagnosis of DDE, the use of specific samples, such as children with nutritional abnormalities, and the consideration of only hypoplasia as DDE. The aim of the present population-based study was to investigate the association between DDE and ECC in children, controlling for socioeconomic factors and the presence of dental plaque. Materials and methods
Study design and sample characteristics A cross-sectional study was carried out in the city of Diamantina, which is located in the northern portion of the state of Minas Gerais in southeast Brazil. The Human Development Index for the city is 0.71620. Diamantina has a population of 45 880 inhabitants, 2537 of whom are children aged to one to 4 years21. The study population included children from 2 to 5 years of age treated at the ten primary health care facilities in the city during immunisation campaigns held in 2010. Diamantina has 90% vaccine coverage. For the sample size calculation, a 53.6% prevalence rate of ECC3, 95% confidence interval and 5% standard error were used, which determined a minimum sample of 383 children. An additional 77 (20%) children were added to compensate for possible losses, totalling 460 children. Systematic sampling was adopted for the randomisation. For such, the children were arranged in a line, with the first child examined, the second not examined, the third child examined, and so on. Children who did not cooperate during the examination were excluded.
Calibration exercise Data acquisition involved clinical oral examination and interviews administered to parents/guardians addressing socioeconomic indicators and characteristics of the child. One team made up of three researchers (an examiner and two assistants) was installed at each health care unit. Prior to the fieldwork, the examiners underwent a calibration and training exercise for the diagnosis of ECC and DDE. The calibration exercise consisted of three stages. The theoretical stage involved a discussion of the criteria for the diagnosis of DDE and ECC and were performed an analysis of photographs and oral clinical examination. A specialist in paediatric dentistry was the gold standard in the theoretical framework and coordinated this step, instructing ten general dentists on how to perform the examination. The analysis of photographs was performed on two separate occasions with a 1-week interval between sessions. Data analysis involved the calculation of Kappa coefficients (K = 0.80– 0.81 for both inter-examiner and intra-examiner agreement). The clinical step was carried out during the pilot study, in which interexaminer agreement was determined (K = 0.90). As the Kappa coefficients were very good, the examiners were considered able to perform the epidemiological study. Pilot study A pilot study involving 30 children who did not participate in the main study was carried out to test the methods, dental examination, administration of the questionnaires and preparation of the examiners. The results of this pilot study indicated there was no need to change the proposed methods. Clinical oral examination Dental examinations were performed at the primary health care facilities during immunisation campaigns held in 2010. A head lamp (Petzl Zoom head lamp; Petzl America, Clearfield, UT, USA), disposable mouth mirror (PRISMA, S~ao Paulo, SP, Brazil) and periodontal probe (WHO-621; Trinity, Campo Mour~ ao,
© 2014 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Early childhood caries and enamel defects
PA, Brazil) were used for the dental examination. In a private room, the examiners were seated in front of the child, who remained standing. The three types of DDE (diffuse opacity, demarcated opacity and enamel hypoplasia) were classified based on the criteria of the Developmental Defects of Enamel Index6. The criteria of the World Health Organization22 were used for the diagnosis of ECC. Early childhood caries was dichotomised as absent or present. Oral hygiene quality was evaluated based on the presence of visible plaque. The tooth surfaces were scraped with a clinical probe and the presence of plaque indicated unsatisfactory oral hygiene. The examiners used appropriate equipment to protect against individual cross-infection, with all necessary instruments and materials packed and sterilised. Non-clinical examination Information on socioeconomic aspects (monthly household income, mother’s schooling and place of residence), child’s age and sex was gathered through interviews with parents/ guardians. Income was categorised based on the Brazilian minimum monthly salary (approximately US$283). Mother’s schooling (years of study) was categorised based on a cut-off point of 8 years, which corresponds to a primary school education in Brazil. Statistical analysis Data analysis was performed using the Statistical Package for Social Sciences (SPSS for Windows, version 19.0; SPSS Inc., Chicago, IL, USA). Associations between ECC, DDE and independent variables were determined using the chi-squared test. Poisson regression with robust variance was performed for the analysis of factors associated with DDE and ECC. The magnitude of the association of each factor with DDE and ECC was assessed using unadjusted and adjusted prevalence ratios (PR), respective 95% confidence intervals (CI) and P-values (Wald test). Explanatory variables with a P-value of ≤0.25 in the bivariate analysis were incorporated into the model.
3
This study received the approval of the Human Research Ethics Committee (register 077/09) of the Federal University of the Jequitinhonha and Mucuri Valleys, Brazil. An invitation letter was then presented to the parents of the selected children, explaining the aim, characteristics, importance and methods of the study and asking for permission for their child’s participation. Results
Among the 387 participants, 50.1% (n = 194) were girls and mean age was 43.39 months (standard deviation: 11.67 months). The majority of parents/guardians had
Association between developmental defects of enamel and early childhood caries: a cross-sectional study ˜ O-GONC PATRI´CIA CORREˆA-FARIA1, SUZANE PAIXA ß ALVES1, SAUL MARTINS PAIVA2, ISABELA 2 3 ALMEIDA PORDEUS , LEANDRO SILVA MARQUES & MARIA LETI´CIA RAMOS-JORGE3 1
Department of Pediatric Dentistry and Orthodontics, School of Dentistry, Federal University of Minas Gerais, Belo Horizonte, 2Department of Pediatric Dentistry and Orthodontics, School of Dentistry, Federal University of Minas Gerais, Belo Horizonte, and 3Department of Pediatric Dentistry and Orthodontics, Federal University of Vales do Jequitinhonha and Mucuri, Diamantina, Brazil
International Journal of Paediatric Dentistry 2014 Background. The determination of risk factors for
early childhood caries (ECC) is important to the implementation of preventive and restorative measures. However, few studies have addressed the association between ECC and developmental defects of enamel (DDE). Aims. To investigate the association between DDE and ECC, controlling for socioeconomic factors and the presence of dental plaque. Design. A cross-sectional study was carried out with 387 children aged two to 5 years during the National Immunisation Day held in 2010 in Diamantina, Brazil. Data were collected through clinical examinations and interviews with parents/ guardians addressing socioeconomic indicators.
Introduction
Preschool children can be affected by different adverse oral health conditions, such as early childhood caries (ECC) and developmental defects of enamel (DDE). Indeed, ECC remains one of the most prevalent chronic conditions in childhood. In a national survey carried out in Brazil, 53.4% of five-year-old children had an average of 2.3 teeth with caries1. The high prevalence rate of ECC is influenced by socio-demographic factors and oral hygiene practices. Studies have demonstrated that a low level of education on the part of parents/guardians, insufficient knowledge on oral health, a low income and Correspondence to: Patrı´cia Correˆa-Faria, Av. Antonio Carlos, 6627, Faculdade de Odontologia, UFMG - Campus Universita´rio 31270-901, Belo Horizonte, MG, Brazil. E-mail: [email protected]
Statistical analysis involved the chi-squared test and Poisson regression. Results. The prevalence of DDE and ECC was 33.9% and 43.3%, respectively. Children with DDE had a greater prevalence rate of ECC (PR: 1.325; 95% CI: 1.093–1.607). Early childhood caries was more prevalent among children with unsatisfactory oral hygiene (PR: 2.933; 95% CI: 2.22–3.86), those who resided in rural areas (PR: 1.267; 95% CI: 1.03–1.55) and those from families with a lower monthly household income (PR: 1.501; 95% CI: 1.06–2.12). Conclusions. The presence of ECC was associated with the occurrence of DDE in the primary dentition. Place of residence and monthly household income (socioeconomic indicators) and oral hygiene (behavioural factor) exerted an influence on the occurrence of ECC.
unsatisfactory oral hygiene exert a considerable influence on dental caries experience2,3. Developmental defects of enamel is a common occurrence in primary teeth. The prevalence of DDE in children from different countries ranges from 24.4% to 81.3%4,5. These defects are classified based on clinical appearance as enamel hypoplasia, demarcated opacities or diffuse opacities6,7. The risk of DDE in the primary dentition is related to prenatal, perinatal and postnatal factors. Studies have demonstrated that premature birth8, an absence of breastfeeding9,10, low birth weight10,11, social aspects and systemic problems in childhood11 are the main causes of DDE. A number of studies have found that DDE may be a risk factor for ECC7,12. Teeth with enamel defects have retentive areas that can lead to the build-up of bacterial plaque, facilitating the progression of carious lesions12. Moreover, children with DDE have
© 2014 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
1
2
P. Corr^ea-Faria et al.
a greater amount of streptococci from the mutans group13, which are associated with the aetiology of dental caries14. Despite the importance of this association to the establishment of ECC prevention measures and the identification of susceptible children, few studies have addressed the influence of DDE on the occurrence of ECC, especially among preschool children15–19. Furthermore, a comparison of studies demonstrates the difficulty in establishing a consensus on this association due to the different assessment tools employed for the diagnosis of DDE, the use of specific samples, such as children with nutritional abnormalities, and the consideration of only hypoplasia as DDE. The aim of the present population-based study was to investigate the association between DDE and ECC in children, controlling for socioeconomic factors and the presence of dental plaque. Materials and methods
Study design and sample characteristics A cross-sectional study was carried out in the city of Diamantina, which is located in the northern portion of the state of Minas Gerais in southeast Brazil. The Human Development Index for the city is 0.71620. Diamantina has a population of 45 880 inhabitants, 2537 of whom are children aged to one to 4 years21. The study population included children from 2 to 5 years of age treated at the ten primary health care facilities in the city during immunisation campaigns held in 2010. Diamantina has 90% vaccine coverage. For the sample size calculation, a 53.6% prevalence rate of ECC3, 95% confidence interval and 5% standard error were used, which determined a minimum sample of 383 children. An additional 77 (20%) children were added to compensate for possible losses, totalling 460 children. Systematic sampling was adopted for the randomisation. For such, the children were arranged in a line, with the first child examined, the second not examined, the third child examined, and so on. Children who did not cooperate during the examination were excluded.
Calibration exercise Data acquisition involved clinical oral examination and interviews administered to parents/guardians addressing socioeconomic indicators and characteristics of the child. One team made up of three researchers (an examiner and two assistants) was installed at each health care unit. Prior to the fieldwork, the examiners underwent a calibration and training exercise for the diagnosis of ECC and DDE. The calibration exercise consisted of three stages. The theoretical stage involved a discussion of the criteria for the diagnosis of DDE and ECC and were performed an analysis of photographs and oral clinical examination. A specialist in paediatric dentistry was the gold standard in the theoretical framework and coordinated this step, instructing ten general dentists on how to perform the examination. The analysis of photographs was performed on two separate occasions with a 1-week interval between sessions. Data analysis involved the calculation of Kappa coefficients (K = 0.80– 0.81 for both inter-examiner and intra-examiner agreement). The clinical step was carried out during the pilot study, in which interexaminer agreement was determined (K = 0.90). As the Kappa coefficients were very good, the examiners were considered able to perform the epidemiological study. Pilot study A pilot study involving 30 children who did not participate in the main study was carried out to test the methods, dental examination, administration of the questionnaires and preparation of the examiners. The results of this pilot study indicated there was no need to change the proposed methods. Clinical oral examination Dental examinations were performed at the primary health care facilities during immunisation campaigns held in 2010. A head lamp (Petzl Zoom head lamp; Petzl America, Clearfield, UT, USA), disposable mouth mirror (PRISMA, S~ao Paulo, SP, Brazil) and periodontal probe (WHO-621; Trinity, Campo Mour~ ao,
© 2014 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Early childhood caries and enamel defects
PA, Brazil) were used for the dental examination. In a private room, the examiners were seated in front of the child, who remained standing. The three types of DDE (diffuse opacity, demarcated opacity and enamel hypoplasia) were classified based on the criteria of the Developmental Defects of Enamel Index6. The criteria of the World Health Organization22 were used for the diagnosis of ECC. Early childhood caries was dichotomised as absent or present. Oral hygiene quality was evaluated based on the presence of visible plaque. The tooth surfaces were scraped with a clinical probe and the presence of plaque indicated unsatisfactory oral hygiene. The examiners used appropriate equipment to protect against individual cross-infection, with all necessary instruments and materials packed and sterilised. Non-clinical examination Information on socioeconomic aspects (monthly household income, mother’s schooling and place of residence), child’s age and sex was gathered through interviews with parents/ guardians. Income was categorised based on the Brazilian minimum monthly salary (approximately US$283). Mother’s schooling (years of study) was categorised based on a cut-off point of 8 years, which corresponds to a primary school education in Brazil. Statistical analysis Data analysis was performed using the Statistical Package for Social Sciences (SPSS for Windows, version 19.0; SPSS Inc., Chicago, IL, USA). Associations between ECC, DDE and independent variables were determined using the chi-squared test. Poisson regression with robust variance was performed for the analysis of factors associated with DDE and ECC. The magnitude of the association of each factor with DDE and ECC was assessed using unadjusted and adjusted prevalence ratios (PR), respective 95% confidence intervals (CI) and P-values (Wald test). Explanatory variables with a P-value of ≤0.25 in the bivariate analysis were incorporated into the model.
3
This study received the approval of the Human Research Ethics Committee (register 077/09) of the Federal University of the Jequitinhonha and Mucuri Valleys, Brazil. An invitation letter was then presented to the parents of the selected children, explaining the aim, characteristics, importance and methods of the study and asking for permission for their child’s participation. Results
Among the 387 participants, 50.1% (n = 194) were girls and mean age was 43.39 months (standard deviation: 11.67 months). The majority of parents/guardians had
