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ObjectiveThe study aimed to assess the prevalence of Early Child Caries and its associated risk factors among a group of Lebanese preschool children.Materials and MethodsAn observational, cross-sectional study design that included 388 children recruited from different schools in Beirut, Lebanon. The parents were interviewed to answer a questionnaire developed by the World Health Organization (WHO, 1997) and Caries Assessment Risk tool developed by the American Academy of Pediatric Dentistry (AAPD, 2019). Then, caries prevalence was assessed by examining the children using the WHO decayed, missed or filled primary teeth (dmft) index and the rating scores of dental caries were classified as very low &lt;1.2, low 1.2 – 2.6, moderate 2.7 – 4.4 and high 4.4 (WHO, 1997).ResultsThe mean age of the children was 4.03 ± 0.82 years. The prevalence of ECC was 71.1% and the mean dmft index was noted to be 3.11 ± 3.67. Based on the risk assessment results, 68% of the preschool children had high caries risk whereas 32% had low caries risk. A statistically significant differences in mean dmft scores were noted in which 3-years-old children exhibited a lower mean dmft value compared to 4 and 5 years olds (p&lt;0.001). In addition, a significant difference was also found in dmft scores between middle socioeconomic status (SES) schools and low SES schools (p=0.016).ConclusionOral health promotion programs are to be implemented on regular basis to enhance the oral health status and general well-being of young children.
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Ahmad  Tarabaih
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Annali di stomatologia
Socio-demographic Factors
Early Childhood Caries Assessment and Related Risk Factors among a Group of Lebanese Preschool Children: A Cross-Sectional Study
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Ahmad  Tarabaih
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Assistant Professor of Pedodontics, Faculty of Dentistry, Beirut Arab University, Beirut, LebanonMaster in Pediatric Dentistry, Faculty of Dentistry, Beirut Arab University, Beirut, Lebanon
1971-1441
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Socio-demographic Factors
en
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Early Childhood Caries Assessment and Related Risk Factors among a Group of Lebanese Preschool Children: A Cross-Sectional Study
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Early Childhood Caries Assessment
and Related Risk Factors among
a Group of Lebanese Preschool
Children: A Cross-Sectional Study


Ahmad Tarabaih                                                                                Authors
                                                                                              Ahmad Tarabaih - Assistant Professor
                                                                                              of Pedodontics, Faculty of Dentistry,
Assistant Professor of Pedodontics, Faculty of Dentistry, Beirut Arab University, Beirut,
                                                                                              Beirut Arab University, Beirut,
LebanonMaster in Pediatric Dentistry, Faculty of Dentistry, Beirut Arab University, Beirut,   LebanonMaster in Pediatric Dentistry,
Lebanon.                                                                                      Faculty of Dentistry, Beirut Arab
                                                                                              University, Beirut, Lebanon.
Corresponding author: Ahmad Tarabaih

ABSTRACT
Objective
                                                                                              License
The study aimed to assess the prevalence of Early Child Caries and its associated             This work is licensed under a Creative
risk factors among a group of Lebanese preschool children.                                    Commons Attribution-NonCommercial-
                                                                                              NoDerivatives 4.0 International License.

Materials and Methods                                                                         Authors contributing to Annali di
An observational, cross-sectional study design that included 388 children recruited           Stomatologia agree to publish
from different schools in Beirut, Lebanon. The parents were interviewed to answer             their articles under the Creative
                                                                                              Commons Attribution-NonCommercial-
a questionnaire developed by the World Health Organization (WHO, 1997) and Car-
                                                                                              NoDerivatives 4.0 International License,
ies Assessment Risk tool developed by the American Academy of Pediatric Dentist-              which allows third parties to copy and
ry (AAPD, 2019). Then, caries prevalence was assessed by examining the children               redistribute the material providing
using the WHO decayed, missed or filled primary teeth (dmft) index and the rating             appropriate credit and a link to the
scores of dental caries were classified as very low <1.2, low 1.2 – 2.6, moderate 2.7         license but does not allow to use the
– 4.4 and high 4.4 (WHO, 1997).                                                               material for commercial purposes and to
                                                                                              use the material if it has been remixed,
                                                                                              transformed or built upon.
Results
                                                                                              How to Cite
The mean age of the children was 4.03 ± 0.82 years. The prevalence of ECC was
                                                                                              A Tarabaih.
71.1% and the mean dmft index was noted to be 3.11 ± 3.67. Based on the risk as-              Early Childhood Caries Assessment and
sessment results, 68% of the preschool children had high caries risk whereas 32%              Related Risk Factors among a Group of
had low caries risk. A statistically significant differences in mean dmft scores were         Lebanese Preschool Children: A Cross-
noted in which 3-years-old children exhibited a lower mean dmft value compared                Sectional Study
to 4 and 5 years olds (p<0.001). In addition, a significant difference was also found         Annali Di Stomatologia, 15(1), 21-26.
                                                                                              https://doi.org/10.59987/ads/2024.1.21-26
in dmft scores between middle socioeconomic status (SES) schools and low SES
schools (p=0.016).

Conclusion
Oral health promotion programs are to be implemented on regular basis to enhance the
oral health status and general well-being of young children.

Key words: Early Childhood Caries, Children, Risk Assessment, Socio-demo-
graphic Factors


INTRODUCTION
ECC is defined as the presence of one or more decayed, missed or filled primary tooth
in children under six years old [1]. ECC starts as white spot lesions along the gingival
margin of maxillary deciduous incisors, leading to a complete crown destruction in the
progression of caries [2]. The main risk factors in the development of ECC can be cat-
egorized as microbiological, dietary, and environmental risk factors [3]. ECC affects both
the child’s oral and general health. Although it is largely a preventable condition, it is
considered as a major oral health problem, mainly in socially disadvantaged populations
and remains one of the most common childhood diseases worldwide [4].


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     Early Childhood Caries Assessment and Related Risk Factors among a Group of Lebanese Preschool Children: A Cross-Sectional Study

     The ECC prevalence has been reported between 1%                     developed the Caries Risk Assessment (CRA) tool to
     and 12% in developed countries but is as high as 70%                help in assessing the caries development risk levels and
     in developing countries. The underlying risk factors for            identifying individual’s specific behaviors or risk factors
     ECC in different populations have been studied through-             [6]. The CRA tool includes risk factors (social, behavior-
     out different developed countries [5]; however, minimal             al, medical, clinical factors), protective factors and dis-
     epidemiological studies described the status of ECC in              ease indicators. The WHO questionnaire demonstrates
     Lebanon. It is of prime importance to build strong base-            the assessment of associated risk factors through gath-
     line data that can help in identifying ECC and, further-            ering data that focuses on socioenvironmental determi-
     more, aid in planning appropriate treatment plans and               nants and modifiable risk factors of oral health in children
     implementing essential preventive measures.                         [9]. The questionnaire includes questions concerning the
     The risk assessment techniques utilized in medical prac-            child’s gender and age, place of residence, oral health
     tices can provide enough data to precisely measure a                status and oral hygiene habits. It also includes dietary
     person’s susceptibility to disease and allow for preven-            habits, personal or social issues experienced due to
     tive interventions. Caries risk assessment (CRA), how-              oral cavity problems and parents’ educational level.
     ever, (1) enhances the treatment process of the disease             The Kolmogorov-Smirnov normality test was conducted
     rather than treating its outcome, (2) aids in individual-           and showed that our data were not normally distributed.
     izing preventive discussions as it allows an understand-            Qualitative data were presented as frequencies and per-
     ing of the disease factors for a specific patient, (3) in-          centages whereas quantitative data were presented as
     dividualizes, chooses, and decides on the frequency of              median, range, mean, and standard deviation values.
     a patient’s preventive and restorative treatment and (4)            The Mann-Whitney U test and Kruskal-Wallis test were
     predicts the progression or stability of caries [6].                used for comparisons between two groups and more
     Therefore, the purpose of the present study is to as-               than two groups respectively. Furthermore, Dunn’s test
     sess the ECC prevalence and its associated risk factors             was used for pair-wise comparisons when the Kruskal-
     among a group of Lebanese preschool children from                   Wallis test was significant. The significance level was set
     different SES schools, assuming that ECC don’t differ               at p ≤ 0.05 and statistical analysis was performed with
     among different study variables.                                    IBM SPSS Statistics for Windows, Version 23.0. Armonk,
                                                                         NY: IBM Corp [10].
     MATERIALS AND METHODS
     Study Settings                                                      RESULTS
     This is an observational, cross-sectional study to de-              Demographic Data
     termine the status of ECC among a group of Lebanese
     preschoolers. The study was conducted between De-                   The study sample included 388 children where 193 chil-
     cember 2021 and March 2022 in which four schools in                 dren were boys (49.7%) and 195 children were girls
     Beirut, Lebanon, were enrolled from two socioeconomic               (50.3%). The mean age of the children was 4.03 ± 0.82
     classes (middle and low). All children between the ages             years. As for the geographic location, 62.6% and 37.4%
     of 3 and 5 years were randomly selected. The study was              of participants lived in urban and peri-urban areas respec-
     approved by the scientific and ethical review committee             tively. The demographic variables are presented in table 1.
     and institutional review board at Beirut Arab University
     (BAU IRB code: 2022-H-0098-D-M-0480).                               Clinical Examination
                                                                         Among clinical examination, 9% of participants had
     Population Settings                                                 non-cavitated (incipient/white spot) lesions or enamel
     The sample size was calculated using the free calcu-                defects, 71.7% of participants had previous history of
     lator on Raosoft.com. The total sample size required                caries (visible cavities/ fillings/ missing teeth) with mean
     was 388 participants considering a 5% margin of error,              dmft index of 3.12 ± 3.67 (Table 2).
     95% confidence level and estimated population size
     of 445,000.                                                         Dental Caries Index
     All children who were medically compromised, defi-                  The present study showed a statistically significant
     nitely negatively cooperated - based on Frankl clas-                difference in mean dmft values between age groups
     sification- during the dental examination [7], or whose             where 3-year-old children exhibited the lowest value
     parents refused to participate in study were excluded.              compared to older groups (p<0.001). Also the mean
                                                                         value of dmft scores were significantly lower among
     Data Collection                                                     middle SES schools in compared to low class group
                                                                         (p=0.016). (Tables 3 and 4)
     Clinical examination was done by one trained and cali-
     brated examiner (κ=87%). The examiner interviewed
                                                                         Dental Care
     the preschool children’s parents at school premises to
     ensure that the questionnaires were understood and                  Dental care had also revealed that 36.4% of the par-
     completed. The child’s dental status was then evaluated             ticipants had dental visits in the past 12 months, 63.1%
     using the dmft index described by the WHO. The dental               didn’t had have visits or received dental care in the past
     status was evaluated using dmft index according to the              12 months. The common reason for last dental visit was
     World Health Organization oral health surveys and the               pain or troubles with teeth, gum or mouth in which 45.4%
     rating scores of dental caries were classified as very low          was shown in responses. As regards to the frequency
     <1.2, low 1.2 – 2.6, moderate 2.7 – 4.4 and high 4.4 [8].           of dental cleaning, it was common to clean once/day
     The American Academy of Pediatric Dentistry (AAPD)                  (43.3%) followed by twice or more times/day (21.9%).


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A. Tarabaih

Table 1. Frequencies (n) and percentages (%) for demographic data of the study participants
           Demographic Data                                    n                                          %

                    Gender

                     Boy                                     193                                         49.7

                      Girl                                   195                                         50.3

                     Age

                      3y                                     125                                         32.2

                      4y                                     126                                         32.5

                      5y                                     137                                         35.3

                 Location

                     Urban                                   243                                         62.6

                Peri-urban                                   145                                         37.4

                    School

       Middle Socioeconomic Status                           175                                         45.1

        Low Socioeconomic Status                             213                                         54.9



Table 2. Descriptive statistics for clinical examination
                             Clinical Examination                                    n                             %

 1. Child has non-cavitated (incipient/white spot) caries or enamel
                                                                                     35                            9
    defects
 2. Child has visible cavities or fillings or missing teeth due to caries            276                          71.7

 3. Child has visible plaque on teeth                                                40                           10.3

 4. Decayed teeth (d): [Mean (SD), Median (Range)]                                        2.86 (3.44), 2 (0-18)

 5. Missing teeth (m): [Mean (SD), Median (Range)]                                         0.06 (0.29), 0 (0-3)

 6. Filled teeth (f): [Mean (SD), Median (Range)]                                          0.19 (0.67), 0 (0-6)

 7. dmft index: [Mean (SD), Median (Range)]                                               3.11 (3.67), 2 (0-18)



Table 3. Frequencies (n) and percentages (%) for dmft
                                         dmft = 0                    dmft >0               Mean ± SD               p-value
                                              n%                         n%
 Gender
              Boy                       48     12.4                145        37.4         3.06 ± 3.18
                                                                                                                  p = 0.765
              Girl                      62     15.9                133        34.3         3.16 ± 3.53
 Age
               3y                       51     13.1                74       19.1           0.85 ± 0.86
               4y                        31        8.0             95       24.5           3.66 ± 3.07            p<0.001*
               5y                        28        7.2             109        28.1         4.68 ± 3.91
 School
          Middle SES                    57     14.7                118        30.4            45.1
                                                                                                                  p = 0.016*
           Low SES                      53     13.6                160        41.3            54.9



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     Early Childhood Caries Assessment and Related Risk Factors among a Group of Lebanese Preschool Children: A Cross-Sectional Study

     Table 4. Multiple Comparison between Age and dmft
      Multiple Comparisons

      Dependent Variable: dmft

                                                       Mean                                             95% Confidence Interval
                        (I) Age      (J) Age                           Std. Error         Sig.
                                                  Difference (I-J)                                   Lower Bound       Upper Bound
                                     4 years         -2.81073*           .28395           .000          -3.4964           -2.1251
                       3 years
                                     5 years         -3.83083*           .34320           .000          -4.6592           -3.0025
                                     3 years         2.81073*            .28395           .000           2.1251            3.4964
       Dunnett T3      4 years
                                     5 years          -1.02010           .43189           .056          -2.0579            .0177
                                     3 years         3.83083*            .34320           .000           3.0025            4.6592
                       5 years
                                                      1.02010            .43189           .056           -.0177            2.0579
      *The mean difference is significant at the 0.05 level.


     Tooth brush and toothpaste were the only cleaning                   Children with low SES had significantly higher dmft scores
     method reported by all participants. Moreover, 35.7% of             compared to children from middle SES (p<0.001). SES
     participants reported using fluoridated tooth paste while           influences dental caries and is determined by the educa-
     42.1% didn’t know if the used toothpaste was fluoridated            tional level, health beliefs and accessibility to health care
     or not.                                                             information [13]. In addition, the low frequency of tooth
                                                                         brushing can be contributed to the low SES in the current
     Dietary Habits                                                      study. In contrary, a higher frequency of tooth brushing
                                                                         was seen in Freire and colleagues’ study due to parental
     The majority of participants consumed cariogenic food,
                                                                         supervision and guidance during teeth brushing [14].
     in which 88.9% of the participants had biscuits, cakes,
                                                                         The majority of the participants (45.3%) visited a den-
     cream cakes, sweet pies, buns and 62.3% of the par-
                                                                         tist due to pain but only 19% continued the treatment.
     ticipants had sweets/candy several times. The major-
                                                                         This is reflected by the participants’ inability to afford
     ity of participants had high consumptions of fresh fruits
                                                                         non-urgent treatments or receive dental care in the past
     (89.7%) several times, while those who consumed tea
                                                                         12 months (63.1%) due to the severe economic crisis
     with sugar were low (24.8%). Moreover, almost half of
                                                                         that Lebanon was going through and therefore, not all
     the participants (49.8%) were given milk daily.
                                                                         participants were capable of continuing their dental treat-
                                                                         ments or receive dental care as costs of treatments were
     Risk Factors, Protective Factors and Risk
                                                                         expensive. This result corroborates with results of other
     Assessment
                                                                         studies [15,16,17]. In contrary, free regular check-ups
     Children who had snacks between meals showed the                    are offered in countries with free public dental health
     highest percentage of participants (68.3%) in risk factors          care services, allowing 90% of children to attend regular
     and 42.5% of the mother/primary caregiver had active                checkup appointments as in Norway [18].
     decay in the past 12 months. Regarding the protective               The importance of fluoride lies in the exertion of its anti-
     factors, 21.9% of the participants brushed daily and                cariogenic action through inhibiting tooth demineraliza-
     6.7% of the participants received fluoride varnish in the           tion, promoting tooth remineralization and inhibiting
     past 6 months. As for the risk assessment, 32% of the               plaque bacteria [19]. Participants reported that they nei-
     participants had a low caries risk compared to 68% of               ther used nor knew if they used fluoridated toothpaste
     the participants who had a high caries risk.                        which is a reflection of parental limited knowledge about
                                                                         fluoride which interprets the high caries level in the cur-
     DISCUSSION                                                          rent study. However, children having lower prevalence of
                                                                         dental caries was a reflection of parents having a better
     ECC is recognized as a major public health problem due              awareness regarding fluoride.
     to its high prevalence and negative health impacts if left          The revealed results of the dietary habits explain the
     untreated [11]. The present study assessed the preva-               high caries prevalence and the high risk of forming ini-
     lence of ECC and its associated risk factors among a                tial lesions. Children usually do not have control over
     group of Lebanese preschool children who aged be-                   their food choices as their eating habits were shaped
     tween 3 and 5 years.                                                by their parents [20], and parents pamper their children
     The mean dmft value of children aged between 4 and 5                with inexpensive, high-sugar-content snacks that con-
     years were significantly higher than 3 years old children           tribute to tooth decay [21]. One assumption regarding
     (p<0.001), indicating that the level of caries increases            these findings could be attributed to cultural factors, as
     with age. Also, the current study’s prevalence of ECC               Middle Eastern countries including Lebanon, habitually
     was still high (71.7%) and yet is similar to that reported          include high sugar snacks in children’s diet intake [22].
     in 2023 by Tabbara (70.4%) [12]. This is reflected by the           The frequent consumption of sugary snacks and bever-
     fact that as children increase in age, they become more             ages causes a frequent drop in the saliva’s pH and its
     susceptible to certain dietary and behavioral attitudes,            acidic media to attack the tooth surface, breaking down
     which increase their teeth’s susceptibility to decay.               the enamel and developing dental caries. Furthermore,



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A. Tarabaih

snacks such as sweets and candies can adhere to the                  2017;5:157. Published 2017 Jul 18. doi:10.3389/
teeth surface for a period of time, causing an interac-              fped.2017.00157
tion between the bacteria and these sugars, leading to         4.    Goswami P. Early childhood caries- a review of its
caries development. In addition, children were exposed               aetiology, classification, consequences, preven-
to high-risk factors associated with dental caries, noting           tion and management. J. Evolution Med. Dent.
that their mothers had active dental caries and those                Sci. 2020;9(10):798-803, DOI: 10.14260/jemds/
children had frequent sugar exposure per day. Moth-                  2020/173
ers are the primary source of Streptococcus mutans,            5.    Rai NK and Tiwari T. Parental Factors Influencing the
and during the first two years of a child’s life, the degree         Development of Early Childhood Caries in Devel-
of vertical transfer of bacteria increases in response to            oping Nations: A Systematic Review. Front. Public
the mother’s poor oral hygiene, exposure to sugar, and               Health 2018; 6:64. doi: 10.3389/fpubh.2018.00064
snacking frequency [3].                                        6.    Caries-risk Assessment and Management for In-
A significant deficiency concerning the protective factors           fants, Children, and Adolescents. Pediatr Dent.
in relation to dental caries was present in brushing daily           2017;39(6):197-204.
using fluoridated toothpaste, which was a reflection of        7.    Frankl, S. N. “Should the parent remain with the
parents’ lack of supervision and parental awareness.                 child in the dental operatory?.” J. Dent. Child. 29
Another protective factor deficiency was observed in                 (1962): 150-163.
receiving fluoride from a health professional, which re-       8.    World Health Organization. (‎1997)‎. Oral health sur-
sulted from Lebanon’s economic crisis that left parents
                                                                     veys: basic methods, 4th ed. World Health Organi-
unable to afford the costs of topical fluoride treatments.
                                                                     zation. https://iris.who.int/handle/10665/41905
The high caries risk percentage can be explained by the
                                                               9.    World Health Organization. (2013). Oral health sur-
presence of visible cavities or fillings or missing teeth
                                                                     veys: basic methods, 5th ed. World Health Organi-
due to caries, visible plaque and non-cavitated (incipi-
                                                                     zation.
ent/white spot caries) or enamel defects. In contrary, a
                                                               10.   IBM Corp. Released 2015. IBM SPSS Statistics for
study reported that the majority of their participants were
                                                                     Windows, Version 23.0. Armonk, NY: IBM Corp.
of moderate risk (71.3%) with less missing teeth due to
caries and less visible plaque [23].                           11.   Naidu R, Nunn J, Donnelly-Swift E. Oral health-
In conclusion, ECC among children is certainly a global              related quality of life and early childhood caries
problem, with consequences extending beyond its clini-               among preschool children in Trinidad. BMC Oral
cal signs and symptoms. Our results revealed a defi-                 Health. 2016;16(1):128. Published 2016 Dec 7.
ciency in oral health care knowledge, and therefore, oral            doi:10.1186/s12903-016-0324-7
hygiene education through awareness campaigns and              12.   Hisham Hassan Tabbara. The Impact of Selected
educational programs is mandatory, along with nutrition              Social Determinants on the Prevalence and Sevirity
promotion campaigns that aim in providing consultation               of Early Childhood Caries among a Group of Leba-
on dietary habits.                                                   nese Preschool Children. Sch J Dent Sci, 2023 Apr
                                                                     10(4): 60-68.
                                                               13.   T S, Kumar B S, Datta M, V T H, Nisha V A. Prevalence,
LIMITATIONS
                                                                     severity and associated factors of dental caries in 3-6
This cross sectional study was conducted between De-                 year old children. J Clin Diagn Res. 2013;7(8):1789-
cember 2021 and March 2022 where the pandemic dis-                   1792. doi:10.7860/JCDR/2013/6201.3277.
ease - Covid-19; was still restricting the country. There-     14.   Freire M, Graça SR, Dias S, Mendes S. Oral health-
fore, difficulties were faced in getting access to variety           related quality of life in portuguese pre-school chil-
of schools from different socioeconomic statuses and in              dren: a cross-sectional study. Eur Arch Paediatr
different locations in Beirut. Moreover, due to the fear of          Dent. 2022;23(6):945-952. doi:10.1007/s40368-
spreading Covid-19, many schools rejected the request                022-00741-7
of being part of the study.                                    15.   Bulut G, Bulut H. Zero to five years: First dental
                                                                     visit. Eur J Paediatr Dent. 2020;21(4):326-330.
Informed Consent Statement: Informed consent was                     doi:10.23804/ejpd.2020.21.04.13
obtained from all subjects involved in the study. Written      16.   Alshahrani NF, Alshahrani ANA, Alahmari MA,
informed consent has been obtained from the patients to              Almanie AM, Alosbi AM, Togoo RA. First dental
publish this paper.                                                  visit: Age, reason, and experiences of Saudi chil-
                                                                     dren. Eur J Dent. 2018;12(4):579-584. doi:10.4103/
Conflicts of Interest: The authors declare no conflict               ejd.ejd_426_17
of interest.                                                   17.   Murshid EZ. Children’s ages and reasons for re-
                                                                     ceiving their first dental visit in a Saudi communi-
                                                                     ty. Saudi Dent J. 2016;28(3):142-147. doi:10.1016/j.
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