Wael A. Sabbah, BDS, DDPH, MSc
Barry L. Stewart, BDSc, LDS, MDSc, FRACDS
Gifty B. Owusu-Agyakwa, BSc, DDS, MSc
North West Armed Forces Hospitals, Department of Dental Services, P.O. Box 100, Tabuk, KSA

The purpose of this study was to measure prevalence of dental caries and identify risk factors among 1-5 year-old Saudi children served by the Northwest Armed Forces Hospitals.  A sample of 574 children was selected to participate in the study.  Five dental therapists and two hygienists were trained and assessed for inter-examiner reliability using the World Health Organization criteria for diagnosis of caries.  Parents completed a questionnaire on relevant socio-economic and behavioural factors.  The prevalence of dental caries was 26.5%.  Males were slightly more affected than females, but the difference was not statistically significant.  Income, parents' education, frequency of eating candies, sweetened beverages, perceived importance of oral health and child's general health were significantly associated with the disease.  In the Logistic Regression analysis, eating candies, perceived importance of oral health, and mothers' education were independently associated with the disease.  The determinants of dental caries in Saudi children were generally similar to those reported in other countries.  The lack of association with bottle-feeding and breast-feeding may be attributed to the late deciduous teeth eruption observed in this region.  The overall results of the study indicated that mothers'

education was the most important determinant of early childhood caries and supported implementation of health promotion strategies that target new and expectant mothers.

Early childhood caries (ECC) is a multi-factorial disease that affects infants and toddlers, affecting their general health, growth patterns and quality of life.1,2  The disease also affects parents' lives as they are obliged to take time off work to look after the children and take them to the dentist.3 At the same time, treatment of the disease is very costly, complicated and time-consuming.4

Studies on ECC have identified several risk factors associated with this condition, such as high Streptococcus mutans counts, diet, feeding habits, family income, education of the mother and parental attitude towards oral health.5-10 In Saudi Arabia, Wyne et al. examined a number of socio-economic and behavioural characteristics of the children with ECC and recommended that studies should be conducted to measure prevalence of the disease and compare the characteristics of those with and without the condition.11

In the community served by the Northwest Armed Forces Hospitals (NWAFH), Tabuk, Saudi Arabia, Stewart et al. (2000) reported that more than 92% of 6-year-old children had caries in primary teeth.12 No other studies examined dental caries among younger children, but observation suggested that the caries problem starts much earlier.  Therefore, it was important to examine prevalence of dental caries and assess the risk factors among younger children in the NWAFH community to help make decisions regarding selecting and implementing appropriate preventive interventions.

This study aimed at assessing the prevalence of ECC among 12- to 60-month-old children attending the Well Baby Clinic (WBC) in NWAFH for vaccinations, and examining the behavioural and socio-economical risk factors associated with this disease.

The average reliability in diagnosing children dental caries for all the examiners and the paediatric dentist was high, average kappa = 0.84.

Of the 574 children included in the study, 51.2% were males.  Approximately 99% of the children had at least one erupted tooth.  The prevalence of dental caries was 26.5% with males slightly more affected (male 29.6%, female 23.6%), but the difference was not statistically significant.  The mean dmft was 1.17, with a range 0-19 (Table 1). Approximately, 13% of children between 12 to 30 months, 50% of children aged 31 to 59 months and 76.7% of children at age 60 months had the disease (Table 2).

Table 3 shows the factors significantly associated with dental caries in the Chi-square analysis. These factors included lower family income, lower level of mother/father education, eating normal diet, having milk with sugar in the bottle, eating sweets, drinking sweetened fluids, parent's perception of oral health as less important than general health, children's perceived poor general health, and parent's perceived poor general/ oral health.

When controlled for confounding factors, only three of these variables showed significant association with dental caries namely, mother's education, eating sweets and perception of the importance of oral health (Table 4).  Children, who frequently ate sweets, were 3.66 times more likely to have the disease.  Also, children of parents, who perceived oral health less important than general health, were 3.76 times more likely to have decayed teeth.  Finally, children of mothers with elementary school education or less were 1.8 times more likely to have dental caries compared to those of mothers with higher levels of education.

When children between 12 to 25 months were examined separately, the factors showing significant association with dental caries were mother's education, eating normal diet, eating sweets, drinking sweetened fluids, perception of oral health less important than general health, and parent's perceived general health and oral health.

In the Logistic Regression analysis for this age group, two factors showed independent association with dental caries.  Children of mothers with lower level of education were 3.83 times more likely to have dental caries, and children of parents with self-perceived poor oral health were 2.65 times more likely to have the disease (Table 5).

For 26- to 60-month-old children, parent's education, tooth brushing, eating sweets, perceived importance of oral health, children's perceived general health, and parent's perceived oral health were significantly associated with the disease. In the Logistic Regression analysis for these older children, eating sweets, perceived poor general health in children and mother's education were the only variables that showed independent association with caries. Children frequently consuming sweets were 2.58 times, and children with perceived poor general health were 2.17 times more likely to have caries.  Finally, children of mothers with lower level of education were 1.82 times more likely to develop the disease (Table 6).

The average reliability in diagnosing children dental caries for all the examiners and the paediatric dentist was high, average kappa = 0.84.

Of the 574 children included in the study, 51.2% were males.  Approximately 99% of the children had at least one erupted tooth.  The prevalence of dental caries was 26.5% with males slightly more affected (male 29.6%, female 23.6%), but the difference was not statistically significant.  The mean dmft was 1.17, with a range 0-19 (Table 1). Approximately, 13% of children between 12 to 30 months, 50% of children aged 31 to 59 months and 76.7% of children at age 60 months had the disease (Table 2).

Table 3 shows the factors significantly associated with dental caries in the Chi-square analysis. These factors included lower family income, lower level of mother/father education, eating normal diet, having milk with sugar in the bottle, eating sweets, drinking sweetened fluids, parent's perception of oral health as less important than general health, children's perceived poor general health, and parent's perceived poor general/ oral health.

When controlled for confounding factors, only three of these variables showed significant association with dental caries namely, mother's education, eating sweets and perception of the importance of oral health (Table 4).  Children, who frequently ate sweets, were 3.66 times more likely to have the disease.  Also, children of parents, who perceived oral health less important than general health, were 3.76 times more likely to have decayed teeth.  Finally, children of mothers with elementary school education or less were 1.8 times more likely to have dental caries compared to those of mothers with higher levels of education.

When children between 12 to 25 months were examined separately, the factors showing significant association with dental caries were mother's education, eating normal diet, eating sweets, drinking sweetened fluids, perception of oral health less important than general health, and parent's perceived general health and oral health.

In the Logistic Regression analysis for this age group, two factors showed independent association with dental caries.  Children of mothers with lower level of education were 3.83 times more likely to have dental caries, and children of parents with self-perceived poor oral health were 2.65 times more likely to have the disease (Table 5).

For 26- to 60-month-old children, parent's education, tooth brushing, eating sweets, perceived importance of oral health, children's perceived general health, and parent's perceived oral health were significantly associated with the disease. In the Logistic Regression analysis for these older children, eating sweets, perceived poor general health in children and mother's education were the only variables that showed independent association with caries. Children frequently consuming sweets were 2.58 times, and children with perceived poor general health were 2.17 times more likely to have caries.  Finally, children of mothers with lower level of education were 1.82 times more likely to develop the disease (Table 6).

The prevalence of dental caries among 12 to 60-month-old children in Tabuk, Saudi Arabia was consistent with that reported in other Saudi studies.12,14 Lower income, lower level of mother's education, eating sweets and perception of oral health less important than general health were the most common factors associated with dental caries. These findings were similar to that reported in other studies on ECC.5-9 However, other factors suggested in the literature such as bottle feeding,5,11 breast feeding,7 use of pacifier,15,16 other feeding patterns and habits7,17 did not show the expected association with ECC in this study.  This may be explained by the late eruption observed in the population, so that by the time teeth erupted the child had already made the transition to a more solid food intake.

Very few studies examined the effect of parental attitude towards oral health on children's caries.9,18 In this study, parents' attitude towards oral health and belief in its importance were very important factors influencing development of dental caries in children.  Children of parents, who perceived oral health less important than general health, were more likely to get dental caries.  Also, children of parents with self-perceived poor oral health were more likely to get the disease.

Mother's level of education was the most important determinant of children's caries in this study, as it persistently showed a significant association in all statistical analyses for different age groups.  The World Health Organization has identified women's educational level and social status as major risk factors for child morbidity and mortality,19,20 and studies on children's caries, including the present study, have indicated similar association with dental caries.5,9 This implies that improvement in mother's education and social status is one of the most important interventions for the prevention of dental caries in children.

It is worth noting that the results of this study and other studies on the prevention of ECC21,22 support the current preventive programs in NWAFH, involving education of new mothers, screening of children for caries and creating a database for ECC.  The results of the study also necessitate the expansion of mother education activity to include expectant as well as young women, who have yet to bear children.  Continuous monitoring of these activities is essential to evaluate effectiveness of programs designed to reduce dental caries in children.  There is also a need for further studies, which examine the association between Streptococcus mutans counts in children, their mothers and ECC.

Mothers' level of education, along with parents' attitude toward oral health and eating sweets were the most important factors which influenced early childhood caries in Tabuk.  These findings emphasized the importance of health promotion strategies, which target new and expectant mothers, and aim to promote a more positive attitude toward oral health.

The authors wish to gratefully acknowledge the Medical Research Committee at the NWAFH for their support and all Dental Therapists/ Hygienists/ Educators who helped in data collection and entry.

Address reprint requests to:

Dr. Wael A. Sabbah
North West Armed Forces Hospitals
Department of Dental Services
P.O. Box 100, Tabuk, KSA