nursing caries, Pediatric Dentistry, self-administered questionnaire, carbonated beverages, BDS, Saudi Arabia, weaning from the bottle, BDSNazeer Khan, Dilley GJ, baby bottle tooth decay, dental caries, American Academy of Pediatric Dentistry, Dent Pract, ASDC J Dent Child, children at risk
Feedin andsocioeconomcicharacteristics of nursingcaries childrenin a Saudipopulation
AmjadHussainWyne,BDS, BSc, MDSJosephO. Adenubi, BDS, MSc,MPH,FMCDS Taqib Shalan, BDSNazeer Khan, PhD
N ursing caries is a frustrating condition that is difficult to treat in infants andveryyoungchildren. It mayretard the child's health, development,and speech. It can be painful, is infectious, and results in impairmentof nutrition and esthetics with accompanyingpsychological problems
.1 The risk factor
s for nursing caries vary from population to population, and someadditional factors maybe present in a population due the sociocultural difference
s in different geographical locations. The aim of this investigation was to study characteristics of nursing caries children in central Saudi Arabia
by obtaining information about their socioeconomicstatus, feeding practices, use of sweetened pacifiers, and other relevant information mentionedin the literature byvarious researchers,2 5 by using a self-administered questionnaire. Such a profile mayhelp identify high-risk groups, which in turn may help target preventive measuresto children at high risk for nursing caries. Methodsand materials This cross-sectional study used a conveniencesample of 96 children from those seeking treatment or referred to College of Dentistry, both in the Dariyah and Malaz campusesof KingSaudUniversity in Saudi Arabia. Any child aged 6 years or younger diagnosed as having nursing caries was included in the study. The criterion used for the diagnosis of nursing caries was caries on the labial surfaces of at least two maxillary primary incisors. A dental examination was performed in the dental operatory setting and findings recorded. Information about feeding patterns, pacifier use, socioeconomicstatus, and first visit to a dentist wasobtained from parents through a self-administered questionnaire. The questionnaire was produced in Arabic and assistance was provided to the parents if required. Data were entered into a computer and Statistical Analyses System (SAS) was used to formulate one-way and two-wayfrequency distribution tables.
Results Socioeconomcicharacteristics Parents of 96 nursing caries children, 53 maleand 43 female, completed the questionnaire. The meanage of the children was 55 months (+ 17.0). The meannumber of children per familywas4.36 (+ 2.48). Forty-two(43.8%) children werethe first or second born, while 23 (23.9%) werethird or fourth and 31 (32.3%)were fifth or above. Agreat majority (94.8%)of the children wereliving with both parents. Onlyfive (5.2%) children wereliving with the father only, motheronly, or other relatives. The percentage of nursing caries children (14.7%) with fathers of very high socioeconomicclass was very low (Table 1). Agreat majority (75.6%)of mothers full-time housewives. Many(41.7%) of the mothers had only primary or lower education, while the opposite wastrue for the fathers (Table2). Brushingpractices Fifty-nine (61.5%) children had commenced toothbrushing, but only 16 (16.7%) started brushing before age 24 months. The meanage whenthe brushing commencedwith or without assistance was 34 months(+ 16.7).
TABLE1. SOCIOECONOMCILCASSOF THE PARENTS OF NURSINGCARIESCHILDREN
Mt other (%)
Middle High Very High
41 (43.2) 40 (42.1) 14 (14.7)
6 (6.7) 13 (14.4) 3 (3.3)
Ї Missing frequency= 1. t Missing frequency = 6 (68 [75.6%] motherswere full-time housewives).
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of Pediatric Dentistry 451
TABL2E. EDUCATIONLEVELS OF THE PARENTSOF NURSINGCARIES CHILDREN
Bottle feeding with cow's milk was muchless common(19.8%) than breast Education feeding (70.8%) or bottle feeding with Level
milk formula (70.8%). Meanage for Primary or below stopping breast-feeding was half of the middle school
meanage for bottle feeding with milk Highschool/ technical formula, but breast feeding before sleep University/ professional was practiced in much higher number ,
20 (20.8) 13 (13.5) 19 (19.8) 44 (45.8)
40 (41.7j 17 (17.7) 23 (23.9) 16 (16.7)
of children than bottle feeding with for-
mula(Table 3 ). Aconsiderablenumbe(r69.6%)of chil- TABLE 3. FEEDING PRACTICES AMONGTHE SAMPLE
dren were breast-fed on demandduring sleep.
Three-quarters (75%) of the children took fruit juice
s and soft drinks in the feeding bottle. About
Practicedbeforesleep/ Feeding Type Yes (%) takento bed(%)
one-fifth (21.9%) of the children took a bottle con- Breast feeding 68 (70.8)
taining fruit juices or soft drinks to bed.
Drinking froma cupand container Morethan half (69.8%) of the children started drinking from a cup after age 12 months. The mean age for starting to drink from a cup was19.4 months (+ 9.0). A large numbertook sweetenedmilk (42.7%),
(cow's milk) 19 (19.8) Bottle feeding (formula) 68 (70.8) Bottle feeding (other fluids)72 (75.0)
11 (11.5) 38 (39.6) 21 (21.9)
27.4+ 11.1 34.9+ 14.1.... NA
fruit juices (78.1%), and carbonated beverages (44.8%)from a cup (Table Three-quarters (75.0%)of the children consumedfruit juices, fruit drinks, and soft drinks directly froma container. Morethan half (56.3%) started drinking from container at or before age 24 months. The meanage the
breast feeding before sleep, on-demand nocturnal breast feeding, taking a bottle with milk to sleep, and use of sweetened pacifier. Three of the six remaining children had a history of frequent consumptionof soft drinks and fruit drinks directly from a container.
children started drinking from a container was 20.4 (+ Discussion
9.2) monthsand the frequency per day was 2.0 (+ 1.5). Socioeconomcicharacteristics
Useof solid foods High-carbohydrate solids were eaten by a large number of children starting from a young age and given about twice a day. The details about meanage whenthese children started using these foods and their
The average numberof 4.36 children per family in the sample appears high as compared with current trends in Westerncountries but it is in accordancewith the local cultural traditions
. Themajorityof the children were first or second born. birth order
has been related
respective frequencies are given in Table 5. Pacifier use About one-quarter (28.1%) of the children ever used a pacifier. Twenty-onechildren (21.9%) used pacifier day and night, but only 6.3%of parents coated the pacifier with a sweetener. Medicalhistory Noneof the study children had a history of any se- rious or prolonged illness. Similarly, only six (6.3%) mothers had a history of serious medical problems during pregnancy, labor, or delivery.
to nursing caries, with the first-born children presenting a higher experience of nursing caries. 5 This can be attributed to the relative lack of experienceon the part of newparents in managinga child's behavior, and lack of dental Health Education
and dietary counseling. A majority of the children had middle socioeconomic class fathers and less educated mothers, whichagrees with findings that nursing caries tends to be associated with low educational level of mothers6, 7 and lower Socioeconomic status
. 6 A study by Johnsen8 showedthat parents of nursing caries children wereless likely to have attended college. Higher prevalence of nursing caries
Firstdentalvisit Very few (13.5%)children had madetheir first visit to the dentist for a routine checkup. Evenfewer (12.5%) madetheir first visit at age 12 monthsor younger. A
in lower socioeconomic groups also has been reported by manystudies3, 6 and attributed to lack of information and education about child dental care. A large number of mothers were full-time housewives. This again indi-
majority (64.6%)of the children madetheir first dental cated a cultural trend, wheremost womenof child-bearvisit after age 36 months. Themeanage of first dental ing age concentrate on child-rearing.
visit was 42.4 months(+ 17.6).
It is usually recommendedto parents that tooth
Only six (6.25%) of the children had none of the cleaning should start as soon as first teeth erupt. The established risk factors
like birth order of the child, meanage of 34 months (+ 16.7) in our study whenthe
452 American Academy of Pediatric Dentistry
Pediatric Dentistry - 17:7, 1995
tooth cleaning started with or without assistance was the major cariogenic food in human diet. 14, ~s In our
not only very late compared with present-day recommendations, but also much later than reported in a s6imilar sample by Dilley et al. Feeding practices The controversial issue of cariogenicity of human breast milk is still unresolved. Somereports show that nocturnal and at-will/on-demand breast feeding are associated with nursing caries, 9,10 other studies report that breast-fed children are actually less likely to develop caries than are bottle-fed children2 I, 12 The mean age when the breast feeding stopped of 17.6 months (+ 9.5) was not very high, as expected, but more than half
study parents started giving sweet solids to the children at an early age and with an average frequency of twice a day. High-carbohydrate diet such as bakery products is an important part of the Saudi culture. The effects of this high carbohydrate diet might not be as harmful to the adult population
as it is to children because of delayed onset of tooth cleaning and / or irregular oral hygiene
maintenance. Pacifier use The use of sweetened pacifiers has also been associated with nursing caries. 2, s In this study very few parents (6.3%) gave sweetened pacifiers to their children.
of the children were breast-fed at bed-time, a previously established nursing caries risk factor. In this study, few (19.8%) children were bottle-fed with cow's milk. This may be because fresh cow's milk isn't available and milk formula is considered a better substitute for humanbreast milk. About three-quarters (70.8%) of nursing caries children were bottle-fed with
Pacifier use in general also was low (28.1%). It is a commonobservation that the pacifier use in the study area
is very low. It could be due to the fact that weaning from the bottle is very late and sucking requirements of the child are fulfilled by bottle use. Moreover, use of domestic child care assistance in Saudi Arabia is very commonso children get the required attention, which
infant formula milk, and the mean age of 34.9 months (+ 14.1) for stopping it was considerably higher than normally recommended (about 12 months). The mean age also was higher than that reported by other re-
TABLE 4. VARIOUS'FLUIDS CONSUMEDFROMA CUP
Yes (%) Mean Frequency/Day
Sweetened ~lk : Fruit juices Soft drinks
41 (42.7) 75 (78.1) 43 (44.8)
Z1 + 1.2 1.5 + 0.7 1.4 + 0.7
often eliminates the use of pacifiers for soothing. First dentalvisit The meanage of first dental visit (42.4 months+ 17.6) was much higher than the recommended age for first dental visit. The present recommendations for first dental visit range from as soon as the first teeth erupt to I year of age. It can be expected that an earlier routine visit to a dentist might prevent this condition because it affords the dentist an opportunity to provide parents with information about healthy feeding habits and oral hygiene. This is particularly true of new parents. The aim of this study was to determine the characteristics of nursing caries children in a Saudi popu-
TABLE 5. CONSUMPTIONOF CARIOGENIC SOLID FOODS
lation. Therefore, no comparison group was used. It
Type of Food Yes (%)
Mean Age Started
would be interesting in the future to compare these
with a group of matched, non-nurs-
ing caries children.
i Bakery Ice cream !Sweets Dates
70 (72.9) 39 (40.6) 44 (45.9) 56 (58.3)
16.9 + 9.3 18.8 + 9.9 17.4 + 9.2 17.6 +10.3
1.9 + 0.9 1.3 + 0.6 1.6 + 0.8 1.6 + 0.8
searchers in similar samples. 6,13 Furthermore, more than one-third (39.6%) of the nursing caries children took a bottle to bed. This is not as high as expected or as reported by other research in similar studies in diff6e,1re3nt populations. In our study three-fourths (75%) of children took fruit juices and carbonated beverages in the feeding bottle, and more than one-fifth (21.9%) took the bottle to bed. Consumption of carbonated beverages was rep6orted in children diagnosed with nursing caries. Solid foods The discussion of caries etiology centers on the role of sugar in the form of sucrose, which is reported to be
Dr. Wyneis a lecturer, Dr. Adenubis a professor, Dr. Shalan is a demonstrator(currently graduate student
, pediatric dentistry, Universityof Minnesotai)n the Divisionof Pedodontics, Departmenot f PreventiveDentalSciences; Dr. Khanis biostatistician in the ResearchCenter,all at KingSaudUniversityCollege of Dentistry, Riyadh. This study was supportedby grant # 1060fromthe ResearchCenter of KingSaud University College
of Dentistry. Theauthors thank Ms.SusanWonfgor her excellent secretarial support. 1. Forrester DJ, WagneMr L,FlemingJ: Pediatric Dental Medicine. Philadelphia: Leaand Febiger, 1981,pp 165-67. 2. Winter GB:Problemsinvolved with the use of comforters. Int DentJ 30:28-38,1980. 3. DerksonGD,Ponti P: Nursing bottle syndrome:prevalence and etiology in a non-fluoridated city. CanDentAssoc J 6:389-93,1982. 4. Ripa LW:Nursing caries: a comprehensivereview. Pediatr Dent 10:262-82, 1988. 5. WyneAH,SpencerAJ, Szuster FSP:Prevalenceand risk factors for nursing caries in Adelaidepre-school children. J DentRes 70:654(Abstr #33), 1991.
AmericanAcademyof Pediatric Dentistry 453
6. Dilley GJ, Dilley DH, Machen JB: Prolonged nursing habit: a profile of patients and their families. ASDC J Dent Child 47:102-108, 1980. 7. Weinstein P, Domoto P, Wohlers K, Koday M: MexicanAmerican parents with children at risk for baby bottle tooth decay: pilot study
at a migrant farm workers
' clinic. ASDC J Dent Child 59:376-83, 1992. 8. Johnsen DC: Characteristics and backgrounds of children with nursing caries. Pediatr Dent 4:218-24,1982. 9. Hackett AF, Rugg-Gunn AJ, Murray JJ, Roberts GJ: Can breast feeding cause dental caries. Hum Nutr Appl Nutr 38:23-28, 1984. 10. Eronat N, Eden E: A COMPARATIVE STUDY
of some influencing factors of rampant or nursing caries in pre-school chil-
dren. J Clin Pediatr Dent 16:275-79, 1992. 11. Tank G, Storvick CA: Caries experience of children one to six years old in two Oregon communities. (Coroallis and Albany). 3. Relation of diet to variation of dental caries. J Am Dent Assoc 70:394-403, 1965. 12. Picton DCA, Wiltshear PJ: A comparison of the effects of early feeding habits on the caries prevalence of deciduous teeth. Dent Pract (Bristol) 20:170-72, 1970. 13. Leggott P], Murphy T: A growing oral health problem
-baby bottle tooth decay. J Dent Res 73:103 (Abst #12), 1994. 14. Newburn E: Sucrose, the arch criminal of dental caries. J Dent Child 36:239-48, 1969. 15. Makinen KK, Philosophy L: The role of sucrose and other sugars in the development of dental caries. Int Dent J 22:363-86, 1972.
Future Annual Sessions of the American Academy of Pediatric Dentistry
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