Caries Patterns in Primary Dentition in 3-To 5-Year-Old Children. Medellín, Colombia
Caries Patterns in Primary Dentition in 3-To 5-Year-Old Children. Medellín, Colombia
Caries Patterns in Primary Dentition in 3-To 5-Year-Old Children. Medellín, Colombia
ORIGINAL ARTICLES
1
Master in Public Health. School of Dentistry, Universidad de Antioquia. E-mail: gescobarp@gmail.com, matilde.escobar@udea.edu.co
2
Master in Epidemiology. School of Dentistry, Universidad de Antioquia. E-mail: zerimar761@gmail.com, blanca.ramirez1@udea.edu.co
3
Master in Epidemiology. School of Dentistry, Universidad de Antioquia. E-mail: lgonzalvarez@gmail.com, lgonzalo.alvarez@udea.edu.co
ABSTRACT
Introduction: early childhood caries (ECC) is a public health problem. Recognizing caries patterns in
affected children can help improve oral health programs focused on the preschool population. The aim of
this study was to identify caries patterns in 3- to 5-year-old children in a low to middle-low socioeconomic
area. Methods: a calibrated dentist recorded caries lesions using ICDAS criteria in 548 children attending
four day-care centers in a low to middle-low socioeconomic area. ECC and S-ECC prevalence and the
proportion of affected teeth/surfaces by lesion type for homologous teeth were calculated. Results: a total
of 419 (76.5%) and 238 (43.4%) children had ECC and S-ECC, respectively. Average dmft was 3.7±3.7 and
average affected surfaces were 5.8±7.7. Occlusal surfaces showed the highest caries experience, varying
from 17.7% to 36.1%, showing statistical significance when compared to other molar surfaces. The upper
smooth anterior surfaces were affected from 0.2% to 17.2%, while lower smooth anterior surfaces showed
Key Words: values between 0.0% and 6.8%. The percentage of dental caries experience in second molars varies from
dental caries, 37.1% to 42%, while in lower central and lateral incisors the values range from 1.8% to 4.6%. Conclusion:
preschooler, early the specific caries pattern in preschool children with high prevalent ECC from a middle-low-income area
childhood caries, indicate the need to design programs aimed at detecting early sings of dental caries in specific locations, as
primary dentition well as disease control strategies.
RESUMEN
Introducción: la caries de la infancia temprana (CIT) es un problema de salud pública. Identificar el patrón
de caries en los niños afectados puede ser útil para mejorar los programas de salud bucal centrados en la
población preescolar. El objetivo del presente estudio consistió en identificar patrones de caries en niños
de 3 a 5 años de edad en un área socioeconómica baja y media-baja. Métodos: un dentista calibrado
registró lesiones de caries utilizando criterios ICDAS en 548 niños que asisten a cuatro guarderías de un
área socioeconómica baja y media-baja. Se calculó la prevalencia de CIT y CIT-S (severa) y la proporción de
dientes/superficies afectados por tipo de lesión para dientes homólogos. Resultados: hubo un total de 419
(76,5%) CIT y 238 (43,4%) CIT-S. El cpod promedio fue de 3,7 ± 3,7 y el promedio de superficies afectadas
fue de 5,8 ± 7,7. Las superficies oclusales presentaron la mayor experiencia de caries, en un rango de entre
17,7% y 36,1%, lo que indica una significación estadística en comparación con otras superficies molares.
Las superficies lisas anteriores superiores se vieron afectadas entre el 0,2% y el 17,2%, mientras que las
Palabras clave: superficies lisas anteriores inferiores mostraron valores entre 0,0% y 6,8%. El porcentaje de experiencia
caries dental, de caries dental en los segundos molares varía del 37,1% al 42%, mientras que en los incisivos centrales
preescolar, caries y laterales inferiores oscila entre el 1,8% y el 4,6%. Conclusión: el patrón específico de caries en niños en
de la infancia edad preescolar con alta prevalencia de CIT en un área de ingresos medios-bajos indica la necesidad de
temprana, diseñar programas que incluyan acciones destinadas a detectar caries dentales en lugares específicos, así
dentición primaria como estrategias para el control de la enfermedad.
Submitted: March 15/2019 - Accepted: May 28/2019
How to quote this article: Escobar-Paucar GM, Ramírez-Puerta BS, Álvarez-Sánchez LG. Caries
patterns in primary dentition in 3- to 5-year-old children. Medellín, Colombia. Rev Fac Odontol Univ
Antioq. 2019; 31(1-2): 47-56. DOI: http://dx.doi.org/10.17533/udea.rfo.v31n1-2a4
Revista Facultad de Odontología Universidad de Antioquia - Vol. 31 N.o 1-2 - Second semester, 2019 / ISSN 0121-246X / ISSNe 2145-7670 47
Caries patterns in primary dentition in 3- to 5-year-old children. Medellín, Colombia
In Colombia, the latest National Oral Health The aim of this study was to identify caries
Survey showed that dental caries affects 83% patterns in children aged 3 to 5 years living in
of three-year-old children, reaching 88.8% in a low to middle-low socioeconomic area in
five-year-old children when both cavitated Medellin, Colombia, based on the ICDAS
and non-cavitated lesions are included.6 detection system, which records lesions at
Moreover, dental caries, as one of the most different severity stages.15
prevalent chronic conditions in spite of the
intensive preventive programs implemented
in many countries, illustrates the limitations METHODS
of such programs to deal with the disease
burden and highlights the importance of A cross-sectional descriptive study was
additional information to design programs performed in children under six, attending
aimed at the early childhood according to preschool day care institutions located in a
the available evidence on control strategies.7 middle-low socioeconomic neighborhood
from the northeastern area of Medellin. The
The studies on carious lesions distribution study was carried out in four out of twelve
show that it is not uniform, suggesting the private institutions with government funding
lack of random effect of contributing factors, and was approved by the Ethics Committee
as well as the presence of specific patterns of the Universidad de Antioquia School of
in terms of teeth position and characteristics. Dentistry. All children aged three, four and
Some authors suggest that there is no real five years attending selected infant day-care
right/left symmetry, although certain groups centers were examined, prior presentation of
of teeth show similar susceptibility to lesion an informed consent by the legal guardians
development.8 Caries patterns may vary in of all participants in the study. A total of
primary dentition, with the upper central 548 available records from participants
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Caries patterns in primary dentition in 3- to 5-year-old children. Medellín, Colombia
aged three to five were included for data of the upper anterior primary teeth have
processing and results. cavitated lesions, are filled or lost due to
caries, or when the number of carious, filled
Dental status was recorded according to or lost surfaces by caries is ≥4 at 3 years, ≥5
International Caries Detection and Assess- at 4 years, and ≥6 at 5 years of age.18
ment System (ICDAS),16 including the mo-
dification suggested for this type of studies The collected data were analyzed in the
(ICDAS epi), merging ICDAS lesions level 1 IBM-SPSS® program, version 23.0. The
with those of level 2.17 A calibrated dentist percentages of affected teeth and tooth
(intraexaminer Kappa 0.77 and interexami- surfaces were estimated for the whole
ner 0.71) registered caries lesions. Prior to group and by single age, using frequency
clinical examination, an adult brushed each distribution. The percentage of surfaces
child’s teeth; cotton pellets were used to affected by homologous teeth was
isolate the examination area, and dental sur- calculated and differences were analyzed
faces were dried with gauze and air. Visual with the Epidat 3.1 software, using either the
inspection of all present tooth surfaces was Chi square test or the Fisher’s exact test.
carried out, and a probe (Ball-tip Screening)
was used when needed.
The presence of early childhood caries (ECC) RESULTS
and severe early childhood caries (S-ECC)
From a total of 548 children evaluated,
was recorded according to the guidelines set
76.5% showed early childhood caries (ECC)
forth by the American Academy of Pediatric
and 43.4% had severe early childhood caries
Dentistry. ECC is defined as the presence
(S-ECC). In terms of dmft (including non-cavi-
of one or more primary teeth surfaces with
tated lesions), each child had an average of
caries (either cavitated or non-cavitated),
3.7±3.7 teeth and 5.8±7.7 surfaces affected
filled or missing by caries, in children under
by dental caries, varying from 3.0±3.4 and
six years of age. The severe form (S-ECC)
4.3±6.1 in 3-year-old children to 4.0±3.9
is identified in the presence of any sign of
and 6.8±9.5 in 5-year-old children (Table 1).
caries on smooth surfaces in children under
3 years, when one or more smooth surfaces
Table 1. Distribution of children with ECC and S-ECC, mean dmft (SD) and mean dmfs (SD) by age
4 year-old (n=216) 172 79.6 74.2; 85.0 101 46.8 40.1; 53.5 4.1 (4.0) 3.6; 4.6 6.3 (7.3) 5.3; 7.3
5 year-old (n=159) 127 79.9 73.7; 86.1 67 42.1 34.4; 49.7 4.0 (3.9) 3.4; 4.6 6.8 (9.5) 5.3; 8.3
Total (n=548) 419 76.5 72.9; 80.1 238 43.4 39.3; 47.5 3.7 (3.7) 3.4; 4.0 5.8 (7.7) 5.2; 6.4
*: Early childhood caries. **: Severe early childhood caries. CI: Confidence Interval 95% †: decay, missing and filled teeth index. ‡: decay,
missing and filled surfaces index
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Caries patterns in primary dentition in 3- to 5-year-old children. Medellín, Colombia
A total of 47,711 surfaces were examined, affected. The individual teeth with the highest
with the occlusal surface showing the highest proportion of dental caries experience were
values of caries lesions experience, varying 55 (42%), 75 (40%), 85 (38.3%) and 65
from 17.7% to 36.1%. These were followed (37.1%); the lowest experience was found
by upper smooth anterior surfaces affected in 71 (1.8%), 81 (2.2%), 72 (2.9%) and 82
in 0.2% to 17.2%. The lower smooth anterior (4.6%). The proportions of dental caries
surfaces showed the lowest values, from 0.0 experience by tooth and tooth surface are
to 6.8%, and as observed in upper anterior shown in Figure 1.
teeth, the lingual surfaces were the least
a) All children (n= 548)
Figure 1. Dental caries experience (% affected) in primary teeth for 3- to 5-year-old children, by tooth and tooth surface levels.
Source: by the authors
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Caries patterns in primary dentition in 3- to 5-year-old children. Medellín, Colombia
The analysis of caries experience by tooth Figure 2 illustrates the distribution of caries
type showed that 39.5% of the upper second presence per tooth surface in homologous
molars and 39.2% of the lower molars were teeth, showing predominance of occlusal
affected, followed by upper first molars lesions in primary molars and buccal
(29%) and upper central incisors (23.2%). surfaces in lateral upper incisors. In the
The lowest values were observed in lower upper central incisors, lesions appear in a
central and lateral incisors, with 2.0% and similar proportion in the bucal, mesial and
3.8% respectively (Figure 2). lingual surfaces.
a) All children
30
%
20
10
0
51/61 71/81 52/62 72/82 53/63 73/83 54/64 74/84 55/65 75/85
Tooth type
b) Three-year-old children
Figure 2. Distribution of affected teeth surfaces per tooth type (% with caries experience).
Source: by the authors
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Caries patterns in primary dentition in 3- to 5-year-old children. Medellín, Colombia
Table 2 shows the caries pattern for each when the occlusal surface is compared with
homologous tooth in terms of the most the rest of upper and lower molar surfaces.
affected surfaces, comparing each surface, It was also found in anterior teeth, when the
referred to as “caries attack rates” by Gizani labial or facial surfaces were compared to
et al.19 Each individual surface was compared lingual surfaces, with the exception of the
with others by Chi square test or Fisher’s upper central incisors.
exact test. Statistical significance was found
Table 2. Comparison of caries experience among homologous teeth surfaces (D: distal, B: labial or facial, M: mesial, L:
lingual, O: occlusal)
Age Tooth type Caries pattern D-B D-M D-L D-O B-M B-L B-O M-L M-O L-O
3 to 5 years 51/61 B>M>L>D *** *** *** ns ns *
71/81 B>M>L>D *** ns ns ** *** ns
52/62 B>M>L>D * * *** *** *** ns
72/82 B>M>L>D *** ** ns * *** *
53/63 B>L>D>M *** * ns *** *** **
73/83 B>M>L>D *** * ns *** *** ns
54/64 O>B>D>M>L ns ns ns *** ns * *** ns *** ***
74/84 O>B>L>D>M *** ** ns *** *** *** *** ** *** ***
55/65 O>L>B>M>D *** ns *** *** *** *** *** *** *** ***
75/85 O>B>L>M>D *** ns *** *** *** *** *** *** *** ***
3 years 51/61 B>M>L>D *** * ns ns * ns
71/81 B ** † † * * †
52/62 B>M>L>D *** *** * ns * ns
72/82 B>M ** ns † ns ** ns
53/63 B>L *** † ns *** ** ns
73/83 B>M *** ns † ** *** ns
54/64 O>B>M>L>D *** ns ns *** ns ns *** ns *** ***
74/84 O>B>L>D>M *** ns ns *** *** *** ** ns *** ***
55/65 O>L>B>D>M ns ns *** *** * *** *** *** *** ***
75/85 O>B>L>D>M *** ns ns *** *** *** * * *** ***
4 years 51/61 B=M>L>D *** *** *** ns ns ns
71/81 B>M>L=D * ns ns ns ns ns
52/62 B>M>L>D *** *** ** *** *** ns
72/82 B>M>L=D *** * ns ns *** ns
53/63 B>L>D *** ns ns *** *** ns
73/83 B>M>L>D *** ns ns *** *** ns
54/64 O>B>M>D>L ns ns ns *** ns ns *** ns *** ***
74/84 O>B>D>L>M *** ns ns *** *** *** *** ns *** ***
55/65 O>L>B>D>M ** ns *** *** *** *** *** *** *** ***
75/85 O>B>L>M>D *** ns *** *** *** *** * ** *** ***
5 years 51/61 B=L>M>D * ns * ns ns ns
71/81 B>L>M * ns ns ns ns ns
52/62 B>L>M>D *** ** ** * * ns
72/82 B>M>L>D * ns ns ns ns ns
53/63 B>L>D>M *** ns ns *** *** ns
73/83 B>M>L *** ns ns *** *** ns
54/64 O>D>B>L>M ns ns ns *** ns ns *** ns *** ***
74/84 O>B>L>D>M * * ns *** *** ns *** * *** ***
55/65 O>L>B>M>D ns ns *** *** ns *** *** *** *** ***
75/85 O>B>L>M>D *** ns ** *** *** *** ** ** *** ***
*p value < 0.05, **<0.01, ***<0.001 (chi square test/Fisher’s test) ns: no significance, †: caries free surface
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Caries patterns in primary dentition in 3- to 5-year-old children. Medellín, Colombia
this is an important information about the stated in Brussels by the EAPD13 and Pitts
distribution of caries presence according to et al,24 non-invasive therapies have proven
tooth surface by tooth type. For all posterior to be effective for caries prevention and
teeth, regardless of age groups, the most the management of pre-cavitated carious
affected surfaces are the occlusal ones, lesions. Knowing the most commonly
showing statistically significant differences involved teeth and surfaces in a specific
between the occlusal surface and the others, population is key to guide dental screenings
as compared individually. For anterior teeth, aimed to identify early signs and to promote
the most affected surface is the labial or adequate oral hygiene practices and fluoride
facial, but consistent statistically significant use to stop lesions, according to the caries
differences are only observed between control concept.25
buccal and lingual surfaces. A limitation of
the present study is that it did not evaluate
symmetry (the spatial distribution between CONCLUSION
the right and left homologous teeth) as
showed by Vanobbergen et al14 because the A group of children living in a high prevalent
total number of teeth in each group would ECC middle-low-income community shows
not be enough. specific patterns of caries lesion distribution,
with primary molars being the most
While information about occlusal
commonly affected, especially the occlusal
susceptibility is highly relevant in terms
surfaces, followed by the upper central
of screening focus, treatment needs and
incisors. These data are useful for programs
preventive strategies, it could be inadvisable
aimed at families and communities to detect
to wait until molar eruption—occurring later
early sings of dental caries, and to guide
during early childhood—for risk assessment
dental care services in timely diagnosis and
and early childhood preventive programs
lesion progression strategies.
based on this data only. Dental teams and
children’s health providers are increasingly
aware of the need of implementing
preventive measures from the first year of life. CONFLICT OF INTEREST
Non-dental healthcare providers could be of
The authors declare that they have no
great help by identifying any single lesion,
conflict of interest.
irrespective of its location, and referring the
child for treatment and establishment of a
dental home.21,22 An oral check-up after the
first tooth eruption should be integrated into CORRESPONDING AUTHOR
the existing health programs like vaccinations
and general medical check-ups.2 Gloria Matilde Escobar Paucar
Universidad de Antioquia
Many attempts are made to deal with caries (+57) 219 6772
burden. For Seiham,23 caries prevention is gescobarp@gmail.com,
preferable to treatment, but the high levels matilde.escobar@gmail.com
of caries worldwide suggest that current Calle 64 #52-59
preventive approaches are not working. As Medellín. Colombia
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Caries patterns in primary dentition in 3- to 5-year-old children. Medellín, Colombia
REFERENCES
1. Do LG. Distribution of caries in children: variations between and within populations. J Dent Res. 2012;
91(6): 536-43. DOI: https://doi.org/10.1177/0022034511434355
2. World Health Organization. WHO expert consultation on public health intervention against early
childhood caries: report of a meeting. Bangkok: World Health Organization; 2017.
3. Finucane D. Rationale for restoration of carious primary teeth: a review. Eur Arch Paediatr Dent. 2012;
13(6): 281-92
4. Sheiham A, Alexander D, Cohen L, Marinho V, Moyses S, Petersen PE et al. Global oral health inequalities:
task group-implementation and delivery of oral health research and strategies. Adv Dent Res. 2011; 23(2):
259-67. DOI: https://doi.org/10.1177/0022034511402084
5. Watt RG. Social determinants of oral health inequalities: implications for action. Community Dent Oral
Epidemiol. 2012; 40 (Suppl 2): 44-8. DOI: https://doi.org/10.1111/j.1600-0528.2012.00719.x
6. Colombia. Ministerio de Salud. IV Estudio Nacional de Salud Bucal – ENSAB IV: situación en salud bucal.
Bogotá: Minsalud; 2014.
7. Whelton H. Overview of the impact of changing global patterns of dental caries experience on caries clinical
trials. J Dent Res. 2004; 83(Spec No. C): C29-34. DOI: https://doi.org/10.1177/154405910408301s06
8. El Batawi H, Fakhruddin KS. Patterns of dental caries among school children assessed using caries
assessment spectrum and treatment tool. Eur J Dent. 2017; 11(2): 168-73. DOI: https://doi.org/10.4103/
ejd.ejd_120_17
9. Bruzda-Zwiech A, Filipińska R, Borowska-Strugińska B, Żądzińska E, Wochna-Sobańska M. Caries
experience and distribution by tooth surfaces in primary molars in the pre-school child population of Lodz,
Poland. Oral Health Prev Dent. 2015; 13(6): 557-66. DOI: https://doi.org/10.3290/j.ohpd.a34371
10. Elfrink ME, Veerkamp JS, Kalsbeek H. Caries pattern in primary molars in Dutch 5-year-old children. Eur
Arch Paediatr Dent. 2006; 7(4): 236-40. DOI: https://doi.org/10.1007/BF03262558
11. Ferro R, Besostri A, Olivieri A. Caries prevalence and tooth surface distribution in a group of 5-year-old
Italian children. Eur Arch Paediatr Dent. 2009; 10(1): 33-7.
12. Sowole A, Sote E, Folayan M. Dental caries pattern and predisposing oral hygiene related factors in
Nigerian preschool children. Eur Arch Paediatr Dent. 2007; 8(4): 206-10. DOI: https://doi.org/10.1007/
BF03262598
13. Van Loveren C, Van Palenstein Helderman W. EAPD interim seminar and workshop in Brussels May
9 2015: non-invasive caries treatment. Eur Arch Paediatr Dent. 2016; 17: 33-44. DOI: https://dx.doi.
org/10.1007%2Fs40368-015-0219-3
14. Vanobbergen J, Lesaffre E, García-Zattera MJ, Jara A, Martens L, Declerck D. Caries patterns in primary
dentition in 3-5- and 7-year-old children: spatial correlation and preventive consequences. Caries Res.
2007; 41: 16-25. DOI: https://doi.org/10.1159/000096101
15. International Caries Detection and Assessment System. Rationale and evidence for the International Caries
Detection and Assessment System (ICDAS II). Indianapolis: ICDAS II; 2012.
16. Pitts N, Ismail AI, Martignon S, Ekstrand K, Douglas G, Longbottom C. Guide for Practitioners and
Educators. International Caries Classification and Management System (ICCMSTM). Implementation
Workshop held June 2013. King’s College London; 2014. Disponible en: https://www.iccms-web.com/
uploads/asset/5928471279874094808086.pdf. Acceso: noviembre 2019.
Revista Facultad de Odontología Universidad de Antioquia - Vol. 31 N.o 1-2 - Second semester, 2019 / ISSN 0121-246X / ISSNe 2145-7670 55
Caries patterns in primary dentition in 3- to 5-year-old children. Medellín, Colombia
17. Pitts N. How the detection, assessment, diagnosis and monitoring of caries integrate with personalized
caries management. In: Detection, assessment, diagnosis and monitoring of caries. Monographs in oral
science. Vol. 21. Editors: Lussi A, Whitford GM. Switzerland: Karger; 2009, pp 1-13.
18. American Academy of Pediatric Dentistry (AAPD). Policy on early childhood caries (ECC): classifications,
consequences, and preventive strategies. Oral Health Policies. 2016; 40(6): 60-62.
19. Gizani S, Vinckier F, Declerck D. Caries pattern and oral health habits in 2- to 6-year-old children exhibiting
differing levels of caries. Clin Oral Investig. 1999; 3(1): 35-40.
20. Nørrisgaard P, Qvist V, Ekstrand K. Prevalence, risk surfaces and inter-municipality variations in caries
experience in Danish children and adolescents in 2012. Acta Odontol Scand. 2016; 74(4): 291-7. DOI:
http://dx.doi.org/10.3109/00016357.2015.1119306
21. American Academy of Pediatric Dentistry (AAPD). Policy on early childhood caries (ECC): unique
challenges and treatment options. Oral Health Policies. 40(6): 63-4.
22. Watt RG, Williams DM, Sheiham A. The role of the dental team in promoting health equity. Br Dent J.
2014; 216(1): 11-4. DOI: https://doi.org/10.1038/sj.bdj.2013.1234
23. Sheiham A. Dental caries affects body weight, growth and quality of life in pre-school children. Br Dent J.
2006; 201(10): 625-6. DOI: https://doi.org/10.1038/sj.bdj.4814259
24. Pitts N, Ismail AI, Martignon S, Ekstrand K, Douglas GVA, Longbottom C. ICCMS™ Guide for practitioners
and educators. London: King’s College; 2014.
25. Nyvad B, Fejerkov O. The caries control concept. In: Fejerskov O, Nivad B; Kidd E. Dental caries the
disease and its clinical management. Oxford: Wiley Blackwell; 2015, pp. 235-43.
56 Revista Facultad de Odontología Universidad de Antioquia - Vol. 31 N.o 1-2 - Second semester, 2019 / ISSN 0121-246X / ISSNe 2145-7670