Dental caries is the most common oral health problem in children. It is not a new phenomenon in children. Dental caries can arise in early childhood as an aggressive tooth decay that affects the primary teeth of infants and toddlers. Caries constitutes the single most common chronic disease of childhood, affecting as many as 40-50% of U.S. and British children (Pitts et al., 2007) and 60-90% of children worldwide between the ages of 2 and 11 years (Donahue et al., 2005).
Dental caries is the localised destruction of susceptible dental hard tissues by acidic by-products from bacterial fermentation of dietary carbohydrates (Fejerskov and Kidd, 2003). The signs of the carious demineralisation are seen on the hard dental tissues, but the disease process is initiated within the bacterial biofilm (dental plaque) that covers a tooth surface. Moreover, the very early changes in the enamel are not detected with traditional clinical and radiographic methods.
The disease is initially reversible and can be halted at any stage, even when some dentine or enamel is destroyed (cavitation), provided that enough biofilm can be removed. Dental caries is a chronic disease that progresses slowly in most people. The disease can be seen in both the crown (coronal caries) and root (root caries) portions of primary and permanent teeth, and on smooth as well as pitted and fissured surfaces. It can affect enamel, the outer covering of the crown; cementum, the outermost layer of the root; and dentine, the tissue beneath both enamel and cementum. Caries in primary teeth of preschool children is commonly referred to as early childhood caries.
ECC is an alarming problem because the disease is so common and widespread amongst young children. Example, study done by (Zahara et al., 2010) prevalence of caries among preschoolers age 6 and 5 in Malaysia was 60%. And at rural Manitoba community the prevalence of ECC was 44% (Schroth and Moffatt, 2005).
Previously, caries in the children was described by a variety of terms including nursing bottle caries, nursing caries, baby bottle caries, baby bottle tooth decay, milk bottle syndrome, and prolonged nursing habit caries. But the new terminology, Early Childhood Caries (ECC) helps us to better reflect that this problem is multifactorial etiologic process not only due to inappropriate feedings methods (Warren, 2008; Ismail 2008).
Great needs are need for uniformity when diagnosing and reporting the early childhood caries condition, especially for research purposes. In this respect, a workshop was held in April 1999 in Bethesda, Maryland. In a report for this meeting, (Drury et al., 1999) defined the early childhood caries (ECC) as “the presence of 1 or more decayed (noncavitated or cavitated lesions), missing (due to caries), or filled tooth surfaces” in any primary tooth in a child 71 months of age or younger. In children younger than 3 years of age, any sign of smooth-surface caries is indicative of severe early childhood caries (S-ECC). From ages 3 through 5, 1 or more cavitated, missing (due to caries), or filled smooth surfaces in primary maxillary anterior teeth or a decayed, missing, or filled score of ≥4 (age 3), ≥5 (age 4), or ≥6 (age 5) surfaces constitutes S-ECC.
2.2 Etiology of early childhood caries
Dental caries is an infectious and transmissible disease. Dental caries is a multifactorial disease that starts with microbiological shifts within the complex biofilm and is affected by salivary flow and composition, exposure to fluoride, consumption of dietary sugars, and by preventive behaviours (cleaning teeth). Caries is the result from prolong imbalance in the demineralisation and remineralisation process in the oral cavity. Dissolution of tooth structure by high level of acid concentration which produced by the metabolism of dietary carbohydrate by oral bacteria will promote a demineralisation of tooth structure when the pH of plaque drops below the critical level (pH 5.5) (Riva and Loveren, 2003). However, occurrence of dental caries is not as simple as that. The natural protective factors will try to repair the mechanism by promote remineralisation. It was helps by saliva which play a major role in protecting the teeth from acid challenge. The protective factors of the saliva are, the effective bicarbonate buffering affect, the flow and oral clearance rate and Ca2+, PO43- and fluoride ion contain in the saliva (Mount and Hume, 1998). Reposition of mineral (remineralisation) will occur after the pH of plaque rises (Riva and Loveren, 2003).
Development of dental caries occurs when susceptible tooth surface colonized with cariogenic bacteria and present of dietary source of sucrose or refined sugar is present. (Axelson, 2000, Caufield and Griffen, 2000). Generally, it can illustrate under Figure 2.1 below;
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Figure 2.1: Development of dental caries (Keyes, 1960)
2.2.1 Dental Plaque
Dental plaque plays a major role in contributing a dental caries. Dental plaque is an accumulation of bacteria and intercellular matrix that form the biofilm that adheres to the surfaces of teeth and other oral structures in the absence of effective oral hygiene (Harris et al., 2009).
2.2.2 Dietary factor
Diet plays an important role in preventing and promoting oral diseases including dental caries. Dental caries is a modern, life style dependent disease because of fermentable of carbohydrate. In populations which highly exposed to high sucrose containing food manifested with most severe forms caries (Caufield and Griffen, 2000). Increase frequency of carbohydrate intake will increase the caries risk especially in populations with poor oral hygiene habits and lack exposure to the fluoride. However, in populations with good oral hygiene and expose to fluoride either systemic or topical, frequency of diet intake will become a weak risk factor (Axelson, 2000).
2.2.3 Microbiologic factor
Fitzgerald and Keyes in year 1960, persons who firstly demonstrate that the dental disease is an infectous disease and can be transmissible. The sources of bacteria that cause dental caries derived from bacterial populations in the oral cavity named ‘normal flora’. The most important bacteria in development dental caries are the mutans streptococci. Mutans streptococci are acidogenic and can adhere to tooth surface. It also can produce extracellular and intracellular polysaccharides from sucrose. So, it represent that mutans streptococci fulfill all the requirements of caries to induce bacteria (Axelson, 2000). Mutans streptococci and other bacteria colonies will colonize the oral cavity after emergance of infants first tooth(Caufield and Griffen, 2000). With present of fermentation of carbohydrate, bacteria pathogens will produce lactic acid, and this acid dissolves the hydroxyapatite crystal structure of the tooth (Caufield and Griffen, 2000).
Newborn baby usually have a sterile mouth. Transmission of the microbes to the mouth can be derived from water, food, and other nutritious fluid, but the main route is via saliva. Studies have shown that the transmission of oral streptococci and Gram-negative species in children predominantly from the behaviour of mothers and primary caregivers through their intimate contact, sharing and tasting foods on a spoon or pacifier (Caufield et al., 1993). Infants acquired Mutans streptococci at a median age of 26 months. High level of Mutans streptococci in mothers’ saliva will put their infants to be acquired by these bacteria earlier. It is means that infants exhibit levels of Mutans streptococci corresponding to their mothers’ level (Caufield et al., 1993). Because of that, mothers need to be educating on how the caries transmissible and the importance of have good dental practice for themselves their childrens.
2.3 Determinants of oral health in children
There were correlation between the etiologic factor in dental caries, determinants of caries (diet, fluoride exposure, microbial species) and involvement of cofounders in dental caries such as socio economic status, education level, knowledge, attitudes and behavior as Figure 2.2 below.
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Figure 2.2: Schematic illustration of the determinants of caries process.
(Adapted from Fejeskov and Manji, 1990)
2.3.1 Socioeconomic factors
Socioeconomic factors especially educational levels become the most important external factors related to dental caries nowadays (Axelson, 2000). There is a strong correlation between incidence of caries in children and the socioeconomic status of the families of those children. That is, children with caries tend to come from low-income or lower socioeconomic backgrounds and lower parental educational level (Leake et al., 2008, Finlayson et al., 2007, Schroth and Moffatt, 2005).
2.3.2 Behavioural factors
Behavioural factors such as frequency of consumption of sugar daily, tooth brushing behaviour (Leake et al., 2008), inappropriate feeding practice either bottle feeding or breast feeding (Schroth and Moffatt, 2005, Mohebbi et al., 2008, Tyagi, 2008) and age of first visit to dental clinic (Rayner, 2003, Schroth and Moffatt, 2005) were related to the risk of dental caries especially in children. Parental attitudes towards oral health especially mother are is important to prevent occurrence of dental caries among children (Saied-Moallemi et al., 2008).
2.3.3 Environmental factors
Environmental and cultural factors play a role in the development of caries. In newly industrialized countries, the incidence of dental caries increases when people previously eat a starchy staple foods and now move to refined carbohydrate diet. For most industrialized countries, high risk of caries related to persons in a lower socioeconomic and immigrant groups (Riva and Loveren, 2003).
2.4 The impact of early childhood caries to the children and parents
Extensive dental decay among children, if left untreated will impact on both oral and general health, including quality of life. Physical function will affected because of pain, disturbed sleep, and difficulty to eat hard, hot and cold food. Mentally, dental caries cause fear and angry in children. The social functions also disturbed by missing preschool or day care, avoid playing with friends and not interested to join family activity. Emotionally, children disturbed with difficulty to say certain words (Cunnion et al., 2010). In other words, dental caries in children will effects physical, mental, social and emotional well being of the children. And most important things it causes lower quality of life of the children who are in growing stages.
The impact of ECC on parents
We know that parents contribute in their children oral health. But there are still limited study in investigating the relationship between the parents and their children oral health. (Schroth, 2007) found that parents with a better knowledge and attitude towards their children oral health more likely to have children with better oral health. In this study we are trying to explore the relationship between the parents’ oral health and their children oral health status.
2.5 The availability of children oral health related quality of life assessment
Currently, there has been increase research development in measuring oral health related quality of life. The oral health-related quality of life (OHRQoL) instruments designed and used to investigate the impacts of oral problems in children, and recently have been designed to be use for 6-14 year old children. (Li et al., 2008, Easton et al., 2008, Klaassen et al., 2009, Cunnion et al., 2010). And very few have been developed for use in children mainly specifically for children age less than 6 years old.
Child Oral Impacts on Daily Performances (Child-OIDP) were used to assess the prevalence and severity of the oral impacts in children age 10-12 years old. This questionnaire also can be used to assess oral health needs in population surveys, thus making it useful for planning services. The Child-OIDP assesses oral impacts on the following daily performances like eating, speaking, cleaning teeth, smiling, emotional stability, relaxing, doing schoolwork and social contact (Bernabé et al., 2009).
Instruments to assess oral health related negative impacts for children aged 3-5 years, recently was developed in the United States, in English language by (Pahel et al., 2007) called the Early Childhood Oral Health Impact Scale (ECOHIS) which derived from the Childhood Oral Health Quality of Life (COHQoL) instrument developed by (Jokovic et al., 2002). This questionnaire seems to be adequate to measure quality of life of children in the age 3-5 years old and their families. The instrument is short and concise to be completed by the child’s parent or primary caregiver for use in epidemiological surveys to discriminate the quality of life between children with or without dental disease. (Li et al., 2008) was translated the English version of ECOHIS into French version for the questionnaire can be use in the French language population. (Klaassen et al., 2009) use ECOHIS questionnaire to explore whether oral health related quality of life in young children will improve after oral rehabilitation after general anesthesia. They also study any changes towards dental fear.
Canadian researchers (Jokovic et al., 2002) have developed the Child Oral a health Quality of Life (COHQoL) questionnaire due to their concern about the measurement of child health status preciously was based on the reports by parents and caregivers. In their questionnaire, there are several questionnaires for parent or caregiver (Parental-Caregiver Perceptions Questionnaires, P-CPQ) and Family Impact Scale (FIS) for children aged 6-14 years and three Child Perceptions Questionnaires for children aged 6 to 7(CPQ6-7), 8 to 10 (CPQ8-10), and 11-14(CPQ11-14) years of age.
The Infant Toddler Quality of Life (ITQoL) questionnaire was developed in year 1994 by Landgraf JM. ITQoL was designed to measure a quality of life for children as 2 months up to 5 years old. The ITQOL items and scales developed to measure physical function, growth and development, bodily pain, temperament and moods, behavior and general health perceptions. ITQOL also includes scales to measure parental impact (time and emotions). Study by (Raat et al., 2007), to evaluate feasibility, internal consistency, test-retest reliability, and concurrent and discriminative validity of the ITQoL, found five ITQoL scales showed a ceiling affect. They also suggest for developing and evaluating a shortened ITQoL version to reduce respondent burden. (Easton et al., 2008) were tried to ascertain reliability and validity of the ITQoL. They did a study among 2-6 years old Ohio, United State children to evaluate the effect of dental caries related to pain on pediatric quality of life. That study found that it was valid and reliable index among children there.
2.6 The role of parents to the children
Children age less than 6 years old still depending on the family members especially their parents to take care of their oral health. Their inability to verbalize their emotions and needs increases their dependence on adult. Parents support and involvement in child’s oral health are important in influencing the dental health of the child. Parents play a key role in attempts to achieve the best oral health outcomes for their young children (Cafferata and Kasper, 1985).
Parents need to have an adequate knowledge and attitude towards the important of oral health for their children. Parents need to know the important of baby teeth and primary teeth tooth decay can impact childhood health. (Schroth, 2007) found that parents who believed that baby teeth are important were more likely to have children with better oral health (less decay) compared with those who thought otherwise. And parents of children with ECC were more likely to disagree that dental decay could affect a child’s overall health.
Brushing of young children’s teeth is important to prevent caries, but the parents cannot let their children do it by themselves. Parent need to be motivated and supportive enough to brush their child’s teeth. The parents should belief that home oral hygiene is important and it is a parental duty to establish this behaviour with children (Huebner and Riedy, 2010). Their study also found that nearly all (91%) parents thought that brush a child’s teeth twice daily a day was important, but only 55% reported that they did it every day. Parents reported that the most common barriers to tooth brushing were due to lack of time and uncooperative child.
2.4 Oral health related quality of life of the parents
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