The aim of this study was to investigate factors predisposing to early childhood caries
(ECC) in pre-school children in the city of Zagreb, Croatia. The investigation was
carried out on the sample of 145 children (77 boys and 68 girls) aged between 2 and 5
years, including clinical examination of dental status and survey on the habits among
the parents. The overall prevalence of ECC was 30%: in girls it was 25%, and in boys
48%. The study on the risk factors was designed as a classic case-control study. The
mean value of dmfs index among the cases amounted to 8.6, in comparison to 5.2 in the
control group (p<0.05). Bottle-feeding did not represent a significant risk, but night
consumption of sweet beverages after first 24 months and the lack of introduction of
teeth-brushing habit after first 24 months did (p<0.001 for both predictors). The study
revealed the importance of early introduction of teeth-brushing and giving up the nightly
consumption of sweet beverages in prevention of ECC

D. Glavina

H. Jurić

O. Lulić-Dukić

W. Dukić

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Coll. Antropol. 25 (2001) 1: 297–302UDC 616.314-002:616-053.4Original scientific paperFactors Predisposing to EarlyChildhood Caries (ECC) in Childrenof Pre-School Age in the City ofZagreb, CroatiaO. Luli}-Duki}, H. Juri}, W. Duki} and D. GlavinaDepartment of Pedodontics, School of Dental Medicine, University of Zagreb, Zagreb, CroatiaA B S T R A C TThe aim of this study was to investigate factors predisposing to early childhood car-ies (ECC) in pre-school children in the city of Zagreb, Croatia. The investigation wascarried out on the sample of 145 children (77 boys and 68 girls) aged between 2 and 5years, including clinical examination of dental status and survey on the habits amongthe parents. The overall prevalence of ECC was 30%: in girls it was 25%, and in boys48%. The study on the risk factors was designed as a classic case-control study. Themean value of dmfs index among the cases amounted to 8.6, in comparison to 5.2 in thecontrol group (p<0.05). Bottle-feeding did not represent a significant risk, but nightconsumption of sweet beverages after first 24 months and the lack of introduction ofteeth-brushing habit after first 24 months did (p<0.001 for both predictors). The studyrevealed the importance of early introduction of teeth-brushing and giving up the nightlyconsumption of sweet beverages in prevention of ECC.IntroductionCaries, the most common pathologicalfeature in modern populations, has beenreported as early as during the first sev-eral years of child’s life. Early caries usu-ally presents as a localized destruction ofthe firm, mineralized dental tissue whichinvolves deciduous teeth, most commonlymaxillary incisors. It is a rampant form ofcaries, with a very poor prognosis unlessthe therapy is started during the veryearly stage of the pathological process1.After the year of 1994, and the conferenceof the Center for Disease Control (CDC),it has been recommended to designatesuch clinical finding as the »early child-hood caries« (ECC), since many epidemio-logical investigations repeatedly showedthat baby bottle, night-feeding and sweetbeverages are not the only etiological fac-tor predisposing to early caries in chil-297Received for publication September 15, 2000.dren, which has earlier been widely ac-cepted as a rule2. Statistical data on theprevalence of ECC indicate that in Euro-pean countries it ranges between 7.3%and 12% among two-year-old children,while among three-year-olds the share in-creases up to 28%1,3.The aim of this study was to investi-gate the prevalence of ECC among chil-dren attending one kindergarten in thecity of Zagreb. The goal was to correlatethe clinical findings and the intensity ofdental caries with nutritional habits ofinvestigated children, previous history ofbreast-feeding, level of oral hygiene andlevel of health education of children andtheir parents.Subjects and MethodsThe investigation was carried out onthe sample of 145 children (77 boys and68 girls) aged between 2 and 5 years, allof them affiliated to the kindergarten»Srednjaci« in Zagreb, Croatia. Clinicalexamination included the evaluation ofthe dental status. The results of the in-tensity of caries were expressed throughthe Decayed, Missing and Filled Surface(dmfs) Index4. The examination was car-ried out using the classic dental probeand the mirror on the daily light. Two in-dependent investigators were well-train-ed specialists in pedodontics and werepreviously calibrated. The diagnostic cri-terion for ECC was that at least two offour maxillary incisors had labiopalatalcaries lesions progressed beyond the whi-te or brown spots to cavitation. The dataon potential risk factors for the diseasewere obtained through a simple survey.The control group was the only one withno ECC cases present. Each parent an-swered, in writing, to the open-end ques-tions concerning the present bottle-feed-ing, the age at which their child gave upbottle-feeding, the present drinking ofsweet beverages (milk with sugar, tea orjuice) during the night, the age at whichtheir child gave up that habit, and theage at which their child started brushingthe teeth regularly.The study on the risk factors was de-signed as a classic case-control (retro-spective) study. Before the statisticalanalysis subjects were divided in twogroups: 55 with ECC, and 90 healthy con-trol. Statistical analysis of the results in-cluded  2– test with Yates correction for2  2 cross-tabulation analysis. In the situ-ation of small frequency (<5) in cells oftable were used the Fischer’s exact test.Differences between groups were estab-lished by analysis of variance (ANOVA).Differences was confirmed when p  ResultsTable 1 presents the results of thestudy. The prevalence of ECC in our sam-ple of pre-school children was 30% (thefigure in girls was 25%, and in boys 48%).It can be noted that several statisticallyvery significant differences between thegroup of ECC cases and the control groupwere noted. Primarily, the mean value ofdmfs index among the cases amounted to8.6, in comparison to 5.2 in the controlgroup (p<0.05). Regarding the gender-related differences, it has been shownthat boys are more likely to be among thecases than controls, i.e. that the conditionaffects children of male gender more fre-quently (p<0.05). This effect, however,might be an indirect consequence of high-er prevalence of other predisposing fac-tors in boys, which is discussed in the lastsection of this paper.The analysis of bottle-feeding as a po-tential predisposing factor revealed thatit was, at present, significantly more fre-quent in control group rather that in thegroup of affected children (p<0.05). How-ever, due to relatively small number ofchildren who were presently bottle-fed,the similar analysis was undertaken298O. Luli}-Duki} et al.: Risk Factors for ECC in Children, Coll. Antropol. 25 (2001) 1: 297–302among those who gave up the habit. Ithas been shown that the share of childrenwho gave up bottle-feeding during first 24months was almost identical in bothgroups (45.8%). Therefore, it is reason-able to conclude that bottle-feeding doesnot represent a risk for developing ECC.The share of the children who are stillconsuming sweet beverages during thenight is very similar in both groups, butthe numbers were again too small to war-rant firmer conclusions. The analysis ofthe time of giving up that habit showedstatistically very significant differenceamong the groups: 56.5% of childrenwithout ECC stopped it during first 24months, in comparison to only 19.5% ofchildren with ECC (p<0.001).Another very significant difference be-tween the two groups was noted when an-alyzing the age at which the habit ofteeth-brushing was introduced and con-tinued regularly. In the group of ECCcases, only 3.6% started brushing theirteeth regularly during first 24 months oftheir lives. In the control group, the corre-sponding proportion was 45.6% (p<0.001).DiscussionECC remains a significant problem inboth industrialized and less developedcountries. It is frequent among minoritiesand immigrants in western countries5–7.The wide spectrum of discussed predis-posing factors ranges from socio-econo-mic status of the family in which the childis being brought up, education of the par-ents, cultural values, ethnicity, nutritio-nal and hygienic habits, to the number ofparents raising up the child (single- ortwo-parent-family)8–10.299O. Luli}-Duki} et al.: Risk Factors for ECC in Children, Coll. Antropol. 25 (2001) 1: 297–302TABLE 1CASE-CONTROL ANALYSIS OF POTENTIAL RISK FACTORS PREDISPOSING TO ECC IN THESAMPLE OF 145 EXAMINEES AGED 2–5 YEARS FROM THE CITY OF ZAGREB, CROATIA.ECC Cases(n=55)Controls(n=90)2 of F df pDmfs indexMean value 8.6 5.2 1 < 0.05GenderMale 36 (65.5%) 41 (45.6%)Female 19 (34.5%) 49 (54.4%) 5.43 1 0.020Bottle-feeding at present:Yes 5 (9.1%) 21 (23.3%)No 50 (90.9%) 69 (76.7%) 4.71 1 0.043Gave up bottle-feeding during the: (n=48) (n=59)First 24 months 22 (45.8%) 27 (45.8%)25 months or more 26 (54.2%) 32 (54.2%) 0.00 0.994Night consumption of sweet beveragesYes 8 (14.5%) 7 (7.8%)No 47 (85.5%) 83 (92.2%) 1.69 1 0.194Gave up night consumption of sweetbeverages during the: (n=41) (n=46)First 24 months 8 (19.5%) 26 (56.5%)25 months or more 33 (80.5%) 20 (43.4%) 12.47 1 < 0.001Regular teeth-brushing started during the:First 24 months 2 (3.6%) 41 (45.6%)25 months or more 53 (96.4%) 49 (54.4%) 28.76 1 < 0.001Similarly to other types of caries, ECCis caused by Streptococcus mutans whichdigests food carbohydrates and generatesstrong acids which reduce pH-value pre-disposing to destruction of firm dentaltissues, especially upper incisors. Thepossible pathogenetic mechanism in pre--school children might involve infectionswith cariogenic bacteria (Streptococcusmutans and Lactobacillus), undevelopedimmune system, specific nutritional hab-its in early childhood and introduced be-havior regarding oral hygiene6,11,12.Some very thorough and in-depth stud-ies that correlated nutritional habits andthe development of ECC in children up to3 years of age showed the smaller preva-lence of the condition in children that star-ted taking salty food at the age of 7months. Similar observations were notedamong children consuming milk with nosugar11,13. Furthermore, prolonged breast--feeding seems to represent an additionalimportant predisposing factor, which is of-ten neglected14. Many of the mothers hav-ing children with this type of caries reporta history of breast-feeding longer than twoyears, often even three years, allowing thefeeding in duration of several hours, espe-cially at night, which accelerates the im-plantation of Streptococcus mutans andthe development of caries. The carbohy-drate lactose (C12H22O11), main nutritiouscomponent during breast-feeding years,represents the most prominent predispos-ing factor for ECC in such cases.When analyzing the problem of ECCin children, it is important to note thatthe education of the parents can be veryimportant. Pregnant women can beginwith dispositional prophylaxis, by takingcare of well-balanced nutrition rich inminerals, which are necessary for endog-enous mineralization of the teeth. It isalso helpful to both parents to learn moreabout cariogenic agents, how to fightthem, to find out the scientific facts onthe formation of the plaque, predisposingsites, its visualization through the use ofrelevators, the choice of methods for theright implementation of oral hygiene, theimportance of periodontal status and thepossible consequences of inadequate oralhygiene13,15–18.The results of our study have shownthat the prevalence of ECC in this sampleamounts to 30%, which is the figure simi-lar to those found in other studies19. Thevalues of dmfs index were relatively highin both ECC cases and the control group,which indicates that there is still a needfor substantial improvement of nutritio-nal habits and oral hygiene in all pre--school children in Zagreb. The analysisof our data showed that the share of theexaminees with completely intact teethamounted to 38% in girls, and 27% inboys. The corresponding percentages fromthe world literature range from 16% (CapeTown) to 83% (Oslo), which classifies ourresults among the lowest third of coun-tries with reported data20. Still, an im-provement was observed in comparison toZagreb data from 1987, when the share ofcaries free children was only 12.5%21.Our study did not confirm the impactof baby-bottle feeding on the developmentof ECC. That is in line with the recentfindings from developing countries, whe-re ECC is also a considerable problem inchildren up to 4 years of age, and wherebaby-bottle is very rarely used5.Our study confirmed the role of twovery significant predisposing factors fordevelopment of ECC: prolonged consump-tion of sweet beverages and late introduc-tion of teeth-brushing habit. It appearsthat male gender is only an indirect pre-disposing factor, since the correction forthe first two factors did not confirm thestatistical significance that was foundinitially. Many studies point out that boysare less likely to begin brushing the teethearly, and more likely to consume sweetbeverages during the night for a very pro-longed period of time19,22–26. We may con-300O. Luli}-Duki} et al.: Risk Factors for ECC in Children, Coll. Antropol. 25 (2001) 1: 297–302clude that this study revealed and con-firmed the importance of early introduc-tion of teeth-brushing and giving up thenightly consumption of sweet beveragesin prevention of ECC.R E F E R E N C E S1. HARRIS, N. O., A. G. CHRISTENS: Primarypreventive dentistry. (Appelton and Lanye, Norwalk,1990). — 2. REISINE, S., J. M. DOUGLASS, Commu-nity Dent. Oral Epidemiol., 26 (1998) 32. — 3. SMY-THE, S. S., E. R. SHULMAN, G. PATRISSI, D. DRUM,F. J. FOREMAN, D. E. PAQUETTE, J. W. PREISCH,Pediatr. Dent., 12 (1990) 172. — 4. KLEIN, H., C. E.PALMER, J. W. KNUTSON, Public Health Rep., 53(1938) 751. — 5. MILNES, A., J. Public Health Dent.,56 (1996) 38. — 6. DAVIES, G. N., Community Dent.Oral Epidemiol., 26 (1998) 106. — 7. TSUBBOCHI,J., T. HIGASHI, T. SHIMOTO, P. K. DOMOTO, P.WEINSTEIN, J. Am. Dent. Assoc., 61 (1994) 293. —8. WEINSTEIN, P., J. Public Health Dent., 56 (1996) 51.— 9. GRINDEFJORD, M., G. DAHLOF, B. NILSON,T. MODEER, Caries Res., 29 (1995) 343. — 10.WEINSTEIN, P., D. OBERG, P. DOMOTO, E. JEFF-COTT, B. LEROUX, J. Dent. Child., 63 (1996) 113. —11. SEOW, W. K., Community Dent. Oral Epidemiol.,26 (1998) 8. — 12. RAJI], Z., Z. GVOZDANOVI], S.RAJI]-ME[TROVI], I. BAGI], Coll. Antropol., 24(2000) 151. — 13. ERICKSON, P.R., K L. MCCLIN-TOCK, N. GREEN, J. LA FLEUR, Pediatr. Dent., 20(1998) 395. — 14. MATEE, M., M. VAN´T HOF, S. Y.MASELLE, F. H. M. MIKX, H. VAN PALENSTEIN,W. H. HELDERMAN, Community Dent. Oral Epide-miol., 22 (1994) 289. — 15. MATTOS-GRANER, R. O.,F. ZELANTE, R. C. LINE, M. P. MAYER, Caries Res.,32 (1998) 319. — 16. OLLILA, P., M. NIEMELA, M.UHARI, M. LARMAS, Acta Odontol. Scand., 56 (1998)233. — 17. BRAMBILLA, E., A. FELLONI, M. GAG-LIANI, A. MALERBA, F. GARCIA-GODOY, L. STROH-MENGER, J. Am. Dent. Assoc., 129 (1998) 871. — 18.NAINAR, S. M., J. Dent Child., 65 (1998) 355. — 19.QUARTEY, J. B., D. D. WILLIAMSON, J. Dent. Child.,66 (1999) 85. — 20. SOLANKI, G. C., N. MYBURGH,M. H. MOOLA, Community Dent. Oral Epidemiol., 19(1991) 178. — 21. MILI^I], A., V. GA@I-^OKLICA,R. BR^I], C. MI[OLI], Acta Stomatol. Croat., 27(1993) 175. — 22. LULI]-DUKI], O., S. KI[I], ActaStomatol. Croat., 30 (1996) 299. — 23. O´SULIVAN,D. M., N. TINANOFF, Pediatr. Dent., 15 (1993) 41. —24. GODSON, J. H., S. A. WILLIAMS, CommunityDent. Oral Epidemiol., 13 (1996) 27. — 25. POWELL,D., Calif. Dent. Assoc. J., 4 (1976) 58. — 26. Z. RAJI],S. RAJI]-ME[TROVI], N. VUKU[I], Coll. Antro-pol., 23 (1999) 659.O. Luli}-Duki}Department of Pedodontics, School of Dental Medicine, University of Zagreb,Gunduli}eva 5, 10000 Zagreb, Croatia^IMBENICI KOJI PREDISPONIRAJU RAZVOJU KARIJESA BO^ICE UDJECE PRET[KOLSKE DOBI U ZAGREBUS A @ E T A KCilj ove studije bio je istra`iti ~imbenike koji predisponiraju razvoju tzv. karijesabo~ice u djece pret{kolske dobi u Zagrebu. Studija je provedena na uzorku 145 djece (77dje~aka i 68 djevoj~ica) u dobi izme|u 2 i 5 godina, uklju~uju}i klini~ki pregled den-talnog statusa i anketu o navikama djece provedenu me|u roditeljima. Ukupna preva-lencija karijesa bo~ice iznosila je 30%: u djevoj~ica 25%, a u dje~aka 48%. Istra`ivanjerizi~nih ~imbenika provedeno je klasi~nom retrospektivnom studijom. Prosje~na vri-jednost Kp indeksa me|u zahva}enim slu~ajevima iznosila je 8.6, u usporedbi s 5.2 ukontrolnoj skupini (p<0.05). Hranjenje na bo~icu nije predstavljalo zna~ajan rizik, ali301O. Luli}-Duki} et al.: Risk Factors for ECC in Children, Coll. Antropol. 25 (2001) 1: 297–302su to bili no}na konzumacija slatkih pi}a nakon navr{ena 24 mjeseca `ivota, te izo-stanak usvajanja navike ~etkanja zubi nakon navr{ena 24 mjeseca `ivota (p<0.001).Studija je ukazala na va`nost ranog zapo~injanja ~etkanja zubi te {to ranijeg odvi-kavanja od no}nog konzumiranja slatkih napitaka u prevenciji karijesa bo~ice.302O. Luli}-Duki} et al.: Risk Factors for ECC in Children, Coll. Antropol. 25 (2001) 1: 297–302

Factors Predisposing to Early Childhood Caries (ECC) in Children of Pre-School Age in the City of Zagreb, Croatia

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