healthcare

Article
Cross Sectional Study on the Association between Dental
Caries and Life Habits in School Age Italian Children
Massimiliano Ciribè 1 , Angela Galeotti 1, *, Chiara Dolci 1 , Livia Gargiullo 2 , Martina Mammone 1 , Erika Cirillo 1 ,
Paola Festa 1 and Giuseppe La Torre 3

1 Dentistry Unit, Bambino Gesù Children’s Hospital, IRCCS, Viale Ferdinando Baldelli 41, 00146 Rome, Italy;
massimiliano.ciribe@opbg.net (M.C.); chiara.dolci@opbg.net (C.D.); martina.mammone@opbg.net (M.M.);
erika.cirillo@opbg.net (E.C.); paolafesta1@gmail.com (P.F.)
2 Pediatric Unit, Bambino Gesù Children’s Hospital, IRCCS, Piazza Sant’Onofrio 4, 00165 Rome, Italy;
livia.gargiullo@opbg.net
3 Department of Public Health and Infectious Diseases, Sapienza University of Rome, Piazzale Aldo Moro 5,
00185 Rome, Italy; giuseppe.latorre@uniroma1.it
* Correspondence: angela.galeotti@opbg.net

Abstract: Dental caries is still a major public health issue and influences the overall health of children.
The risk factors for caries include biological, socio-behavioral, and environmental factors. Our aim is
to assess the association between dental caries and the life habits of children and their parents. A
cross-sectional study was conducted in Rome (Italy) among primary school children aged 5 to 11.
Parents completed the anamnestic questionnaire, and a dental clinical examination was performed on



333 children. Caries prevalence was 38.7% overall, 47% in males and 31.9% in females. The association


between bottle night-time feeding and caries was statistically significant (43.2%; p = 0.013). Usage
Citation: Ciribè, M.; Galeotti, A.;
of a honeyed pacifier was also significantly associated with the presence of caries (72.7%; p = 0.027).
Dolci, C.; Gargiullo, L.; Mammone,
Finally, higher caries prevalence was found among male children (47% vs. 31.9%; p = 0.005). The
M.; Cirillo, E.; Festa, P.; La Torre, G.
Cross Sectional Study on the
present study shows that the percentage of caries is still high in the paediatric population, and caries
Association between Dental Caries prevalence is associated with life habits. Our results highlight the importance of oral health education
and Life Habits in School Age Italian programs at primary school that involve teachers and parents to contribute to improving lifestyles.
Children. Healthcare 2022, 10, 607.
https://doi.org/10.3390/ Keywords: dental caries; caries risk; epidemiology; school age population; sweetening agent
healthcare10040607

Academic Editors: Joseph Nissan,

Gavriel Chaushu and
Takahiro Kanno
1. Keynotes
Dental caries is still a major public health issue. This study aims to assess the associa-
Received: 10 January 2022
tion between dental caries and the life habits of children and their parents. The analysis
Accepted: 22 March 2022
of the parameters highlights a statistically relevant association between caries and the
Published: 24 March 2022
following variables: bottle night-time feeding, use of a honeyed pacifier, and male sex.
Publisher’s Note: MDPI stays neutral
with regard to jurisdictional claims in 2. Introduction
published maps and institutional affil- In recent years, Western countries experienced a significant reduction in the onset
iations. of dental caries due to oral health education promoted by the scientific community, and
evidence-based prevention measures [1]. Nevertheless, dental caries is still a major public
health issue in many countries. According to recent evidence reported by the World Health
Organization (WHO), 21.6% of children aged 4 and 43.1% aged 12 suffer from dental caries
Copyright: © 2022 by the authors.
in Italy [1,2]. Italian national guidelines highlighted the importance of undergoing a first
Licensee MDPI, Basel, Switzerland.
This article is an open access article
dental visit at the age of 18–24 months so that any oral disease can be diagnosed early [1].
distributed under the terms and
Many studies widely show that dental caries prevention is essentially based on daily dietary
conditions of the Creative Commons
and oral hygiene practices [1,3–6]. Parental oral health behaviors may have a significant
Attribution (CC BY) license (https:// impact on the development of their children’s oral hygiene habits and, consequently, on the
creativecommons.org/licenses/by/ prevalence of oral diseases, children’s tooth brushing, and dietary habits (high sugar diet,
4.0/).

Healthcare 2022, 10, 607. https://doi.org/10.3390/healthcare10040607 https://www.mdpi.com/journal/healthcare

Healthcare 2022, 10, 607 2 of 9

feeding practices, and nocturnal breastfeeding) [4]. Free sugar in the diet, in fact, represents
an important risk factor for dental caries [7].
Scientific evidence shows that promoting oral health in the earliest stages of life
is the best approach to establish good personal habits, which will be reinforced during
adolescence and endure through adulthood [1–3].
School is obviously one of the best contexts where to deliver good life habits, so it
can be an important meeting point for healthcare professionals and children, their parents,
and teachers. Health prevention programs can thus be created to teach children relevant
knowledge on oral health and the right oral hygiene maneuvers to perform at home [1–3].
Furthermore, school is an important source for carrying out epidemiological surveys
and analysing the interaction between students’ oral health and other conditions.
In line with these statements, the correlation between oral diseases and life habits
should be analysed. Although there are many studies that show a correlation between
the number of dental caries and life habits, most of these studies show conflicting results,
especially about breastfeeding [8–10].
The study hypothesis stated that there is a correlation between dental caries and the
life habits of children and parents. The aim of this study is to evidence the association
between dental caries and children’s life habits as well as those of their parents in children
aged 5 to 11.

3. Materials and Methods

A cross-sectional study was conducted in Rome (Italy) at Comprehensive Institute
“VIRGILIO” between October 2018 and January 2019. The study was approved by the Chief
Medical Office of Bambino Gesù Children’s Hospital, IRCCS (Rome). Parents of primary
school children were invited to fill out an anamnestic questionnaire aimed to investigate the
life, eating, and oral hygiene habits of both parents and children (Supplementary Materials
Table S1). In particular, the following parameters were investigated:
• Breastfeeding
• Bottle feeding
• Night-time feeding
• Child allergies
• Child mucolytics or cough suppressants
• Child mouth breathing
• Child systemic fluoride
• Child daily number of brushings
• Fluoride toothpaste
• Child dental flossing
• Pacifier
• Bacterial Colonization
• Honey
• Night-time bottle
• Child sex
• Single mother
• Mother No. of children
• Smoking mother
• Mother caries
• Mother annual dental visits
• Mother daily brushing
• Mother systemic fluoride during pregnancy
• Smoking father
• Father annual dental visits
• Father caries
Parents were asked to sign a release to consent to dental examinations and participation
in the study.
Healthcare 2022, 10, 607 3 of 9

All school children were included in the study except those who did not have parental
consent. Clinical examination was performed on 333 children. The visits were all carried out
by the same operator with 10 years of experience in pediatric dentistry to avoid any diver-
gence of assessment. Dental examination was performed using a WHO periodontal probe
under natural light and a standard size-4 mirror, following the WHO recommendations for
oral health surveys [11].
The following parameters were recorded during the visit for each examined child:
• Sex
• Age
• Presence/absence of caries
• Number of decayed teeth

4. Statistical Analysis
The exposure variables in the current study were social and demographical character-
istics (child sex, child age) and the child’s oral behavior (night-time feeding, honey), while
the outcome variable was the child’s oral hygiene status (presence of caries).
The recorded clinical data were summarised in a table and subjected to statistical
analysis. Contingency tables were used to carry out the analysis. Each i value of the variable
is associated with the ni number of times in which that value occurs in N observations or
its relative frequency (ni/N).
The statistical analysis was performed using the Pearson chi-square test or Fisher exact
test, where applicable, to analyse the prevalence of dental caries and their association with
all other variables analysed in this study.
The statistical significance level was set at p value < 0.05. Dental caries prevalence in
children with an average age of 7 years old was expected to be around 22%. Our survey on
338 subjects revealed an estimate of caries prevalence with a ±2% error and a 95% interval
of Confidence (CI).
The statistical analysis was carried out using the statistical software SPSS, release 26.0.

5. Results
Clinical examination was performed on 333 (98.5%) children (168 males and 165 fe-
males) with an average age of 7.86 years and a standard deviation of 2.4. Clinical examina-
tion was performed after obtaining signed informed consent from their parents.
Two children were excluded from the study because they did not cooperate during
the dental visit. Three children were excluded from the study because the questionnaires
were not completely filled out by parents. The prevalence of caries was 38.7% overall, 47%
in males and 31.9% in females.
Table 1 shows all the variables with the complete results. The association between
bottle night-time feeding with milk or a drink except water and caries was statistically
significant (43.2%; p = 0.013; 95% CI: 0.147–1.008). Usage of a honeyed pacifier was also
significantly associated with caries presence (72.7%; p = 0.027; 95% CI: 0.725–14.098). Finally,
higher caries prevalence was found among male children (47% vs. 31.9%; p = 0.005; 95% CI:
0.365–1.066).
No statistically significant association was shown between dental caries and all other
variables. However, some variables show differences in percentage terms. For example,
46 of the 333 children took systemic fluoride, had a prevalence of caries of 50% compared
to 38.3% of children who did not take systemic fluoride. On the other hand, usage of
fluoridated toothpaste was associated with caries presence with a prevalence of caries of
37.7% compared to 47.9%. Higher caries prevalence was found among children whose
mothers had caries (41.5% vs. 29.4%).
Healthcare 2022, 10, 607 4 of 9

Table 1. Presence of caries compared with the variables analyzed and p value.

Caries
Variables p
NO YES
NO 20 (55.6%) 16 (44.4%)
Breastfeeding 0.551
YES 164 (60.7%) 106 (39.3%)
NO 72 (54.5%) 60 (45.5%)
Bottle feeding 0.106
YES 109 (63.7%) 62 (36.3%)
NO 119 (57.8%) 87 (42.2%)
Night-time feeding 0.179
YES 62 (66%) 32 (34%)
NO 154 (60.9%) 99 (39.1%)
Child allergies 0.365
YES 27 (54%) 23 (46%)
Child mucolytics or NO 124 (59.3%) 85 (40.7%)
0.994
cough suppressants YES 57 (59.4%) 39 (40.6%)
NO 143 (58.6%) 101 (41.4%)
Child mouth breathing 0.448
YES 39 (63.9%) 22 (36.1%)
NO 156 (61.7%) 97 (38.3%)
Child systemic fluoride 0.138
YES 23 (50.5%) 23 (50%)
0 0 (0%) 1 (100%)
1 28 (65.1%) 15 (34.9%)
Child daily number of
2 133 (58.1%) 96 (41.9%) 0.276
brushing
3 23 (69.7%) 10 (30.3%)
4 0 (0%) 1 (100%)
NO 38 (52.1%) 35 (47.9%)
Fluoride toothpaste 0.119
YES 147 (62.3%) 89 (37.7%)
NO 178 (60.8%) 115 (39.2%)
Child dental flossing 0.177
YES 7 (43.8%) 9 (56.3%)
NO 73 (56.6%) 56 (43.4%)
Pacifier 0.29
YES 112 (62.6%) 67 (37.4%)
NO 124 (61.4%) 78 (38.6%)
Bacterial colonization 0.489
YES 59 (57.3%) 44 (42.7%)
NO 176 (60.7%) 114 (39.3%)
Honey 0.027 *
YES 3 (27.3%) 8 (72.7%)
NO 147 (56.8%) 112 (43.2%)
Night-time bottle 0.013 *
YES 31 (77.5%) 9 (22.5%)
F 109 (68.1%) 51 (31.9%)
Child sex 0.005 *
M 88 (53%) 78 (47%)
NO 181 (60.5%) 118 (39.5%)
Single mother 0.878
YES 7 (58.3%) 5 (41.7%)
1 49 (58.3%) 35 (41.7%)
2 94 (64.8%) 51 (35.2%)
Mother No. of children 0.199
3 34 (56.7%) 26 (43.3%)
4 2 (28.6%) 5 (71.4%)
NO 134 (61.5%) 84 (38.5%)
Smoking mother 0.648
YES 54 (58.7%) 38 (41.3%)
NO 36 (70.6%) 15 (29.4%)
Mother caries 0.107
YES 151 (58.5%) 107 (41.5%)
0 9 (56.3%) 7 (43.8%)
Mother annual 1 77 (59.7%) 52 (40.3%)
0.966
dental visits 2 99 (61.5%) 62 (38.5%)
3 2 (66.7%) 1 (33.3%)
Healthcare 2022, 10, 607 5 of 9

Table 1. Cont.

Caries p
Variables
NO YES
1 7 (70%) 3 (30%)
Mother daily brushing 2 112 (60.2%) 74 (39.8%) 0.825
3 67 60.4%) 44 (39.6%)
Mother systemic fluoride 0 154 (61.1%) 98 (38.9%)
0.613
during pregnancy 1 31 (57.4%) 23 (42.6%)
NO 115 (60.8%) 74 (39.2%)
Smoking father 0.645
YES 61 (58.1%) 44 (41.9%)
0 22 (66.7%) 11 (33.3%)
Father annual
1 76 (62.8%) 45 (37.2%) 0.39
dental visits
2 78 (56.1%) 61 (43.9%)
NO 40 (56.3%) 31 (43.7%)
Father caries 0.486
YES 136 (61%) 87 (39%)
* Statistically significant variables.

6. Discussion
This study investigated dental caries prevalence in children aged 5 to 11 and assessed
the association between dental caries and the life habits of children and parents.
The new guidelines published by WHO in 2015 recommended reducing the intake of
free sugars (mono and disaccharides such as glucose, fructose, and sucrose) to less than
10% and of sugars (honey, juice, etc.) to below 5% of total energy intake both in adults
and children [12]. Although the use of traditional preventive methods has been successful
in reducing dental caries, there is still a need to develop and evaluate new preventive
approaches. Caries should be detected and monitored in its early stages when the reversal
of the carious process can still occur [13].
Our results showed an association between using a honeyed pacifier and dental
caries, as already suggested in previous studies [14,15]. A systematic review showed that
breastfeeding beyond the age of 12 months associated with nighttime feeding increases
the prevalence of caries [14]. Another systematic review from the literature, carried out by
Tham et al. in 2015 and including 63 papers about the risk of caries related to breastfeeding,
highlighted that children who were breastfed for more than 12 months had an increased
risk of developing caries compared to those who were breastfed for a shorter amount of
time (69.3%). Amongst children breastfed for more than 12 months, those who were also
fed during the night or more frequently had a further increase in caries risk (77.1%) [15].
As to dental caries prevalence related to sex, our data show a higher prevalence in
boys. Our data were not aligned with the information suggested in the literature [16].
Recent papers studied the association between dental caries and sex. A recent study
conducted in the United Kingdom showed no gender difference in caries formation in
prepubescent age, while from the age of 12 years, an increase was shown in the female
population. Studies in the adults confirmed dental caries developed more in the female
population, in contrast to the results of this study [17,18].
Our sample did not show statistically relevant associations between dental caries
prevalence and allergies or mucolytics, cough suppressants and nasal sprays adminis-
tered to the subjects. Our results are aligned with the information suggested in previous
studies [19,20], even though the literature suggests conflicting data on the matter. Mouth
breathing is one of the greatest risk factors highlighted and analysed when studying the
development of dental caries. In-depth studies have shown that those patients who breathe
through their mouth for different reasons complain of having a dry mouth, especially
during their sleep or upon awakening [21,22]. These symptoms result from sleep-related
xerostomia, which may reduce local antibacterial effects of saliva or reduce its salivary
Healthcare 2022, 10, 607 6 of 9

cleansing action [23], leading consequently to a possible increase in dental caries, erosion
and gingival inflammation [24–29].
Scientific evidence suggests that sleep-related xerostomia is linked with respiratory
disorders, such as asthma. These relationships result from a decrease in salivary production
due to circadian rhythms and dry mouth, mainly caused by breathing during sleep [30,31].
Data on the association between asthma and dental caries are conflicting [30]—some
studies report a higher frequency in caries [32,33], while others find no association [21,22].
Furthermore, the symptoms of asthma overlap with those of allergic rhinitis [20,32,34].
Numerous studies show that allergic rhinitis does not constitute a risk factor for dental
caries [20], even though oral breathing is the main complication for both of them. It is
furthermore essential to consider that asthma and allergic rhinitis often coexist [34].
No relevant differences related to dental caries prevalence emerged in subjects who
took systemic fluoride and those who did not in this study. Substantive evidence shows that
fluoride, through different applications and formulas, works to control caries development.
However, the actual mechanism of fluoride action is still a subject of debate. The early
studies of Dean et al. (1942) [35] and McKay (1952) [36] suggested that fluoride needs to be
ingested to act beforehand in dental caries prevention. During that period, various clinical
studies showing the systemic pre-eruptive validity of fluoride were conducted [37–39].
In the following years, doubt was cast on the exclusively pre-eruptive effect of fluoride.
They concluded that fluoride has a post-eruptive effect and that fluoride supplementation
starting from birth is unnecessary [40–44]. It should also be considered that fluoride
supplementation increases the risk of fluorosis [45–47]. The anti-caries effects of fluoride
are primarily topical [48]. Since the fluoride benefit is mainly topical, perhaps it is better to
deliver the fluoride directly to the tooth instead of ingesting it [49,50].
No evidence of significant differences between breastfed and bottle-fed children is
shown, but night-time bottle feeding with milk, milk and biscuits, milk and honey or
camomile emerged as a significant risk factor. This result may be associated with a higher
quantity of sugar in bottle content and with prolonged habit [51].
Results also show interesting data with respect to dental caries association in parents
and their children. Our results showed a trend of association between dental caries in
mothers and the presence of decayed teeth in children, even if not statistically significant.
These results may be hypothetically associated with several factors such as familiarity and
oral hygiene habits. Two studies confirmed an important relationship between mothers’
oral health and their children’s [52,53].
The main limitations of our study are that the subjects’ study comes from only one
school in the same city, even if in different locations throughout the city of Rome, the
socio-economic status is quite homogeneous in the sample, and the sample size is small.
However, the prevalence of caries was 57.1% in children whose parents have a middle
school education level. Prevalence is reduced to 34.3% in children whose parents have
university degrees.
Some variables could be statistically significant by increasing the sample size. There-
fore, it would be interesting to investigate a larger sample in future research.

7. Conclusions
The present survey shows that the percentage of caries is still high in the paediatric
population, and caries prevalence is associated with life habits. Our results highlight the
importance of oral health education programs at primary school that involve teachers and
parents to contribute to improving lifestyles. Since paediatric dentistry plays an important
role in oral health care prevention, children should undergo a first dental visit within 24
months of life.

Supplementary Materials: The following supporting information can be downloaded at: https:
//www.mdpi.com/article/10.3390/healthcare10040607/s1, Table S1: School questionnaire; Table S2:
Dental clinical record.
Healthcare 2022, 10, 607 7 of 9

Author Contributions: M.C., E.C. and P.F. performed the review of literature and equally contributed
to the final writing of the manuscript. L.G. carried out a revision of the manuscript. C.D., M.M., M.C.
and E.C. managed the patients during the first visit. G.L.T. contributed to the multidisciplinary path
and to the revision of the manuscript. A.G. is the Responsible of the Dentistry Unit of Bambino Gesù
Children’s Hospital and supervised the entire process, from clinical examination to writing of the
manuscript. All authors have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Ethical review and approval were waived for this study
because it is a part of a dental study carried out in the territory authorized by the health department
of Bambino Gesù Children’s Hospital, IRCCS (Rome).
Informed Consent Statement: Informed consent for the publication of this paper was obtained from
the patient’s parents.
Data Availability Statement: Data sharing are available at Bambino Gesù Children’s Hospital.
Acknowledgments: The authors acknowledge Comprehensive Institute “VIRGILIO” of Rome for
allowing the epidemiological investigation to take place.
Conflicts of Interest: The authors declare no conflict of interest.

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