|Year : 2022 | Volume
| Issue : 5 | Page : 3-11
Prevalence of early childhood caries in India: A systematic review and meta-analysis
Induja Devan1, Venkitachalam Ramanarayanan2, Chandrashekar Janakiram3
1 PhD Scholar, Department of Public Health Dentistry, Amrita School of Dentistry, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
2 Reader, Department of Public Health Dentistry, Amrita School of Dentistry, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
3 Professor, Department of Public Health Dentistry, Amrita School of Dentistry, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
|Date of Submission||09-Aug-2022|
|Date of Decision||19-Aug-2022|
|Date of Acceptance||19-Aug-2022|
|Date of Web Publication||11-Nov-2022|
Department of Public Health Dentistry, Amrita School of Dentistry, Amrita Vishwa Vidyapeetham, Kochi - 682 041, Kerala
Source of Support: None, Conflict of Interest: None
| Abstract|| |
This review was designed to assess the pooled prevalence of early childhood caries (ECC) in India. An electronic data search was done in PubMed/MEDLINE and Scopus databases in October 2020. Epidemiological surveys assessing the prevalence of ECC were included, and data on gender, geographic region, sampling strategy, feeding habits, and dmft values were extracted. The risk of bias was assessed, and a meta-analysis was performed for pooled prevalence and mean dmft values. The selection of articles, data extraction, and validity assessment were done independently by the two reviewers (ID and RV). A third reviewer (CJ) resolved any conflict between these two reviewers. A total of seventy-one studies were included for quantitative analysis. The pooled prevalence of ECC estimated from 71 studies with 69,330 participants is 46.9% (confidence interval [CI] 46.5–47.2). Males had a higher prevalence of ECC (47%, CI: 46.4–47.6,40 studies, 26,840 participants) than females (43.8%, CI: 43.2–44.2,40 studies, 24,389 participants). Region-wise analysis showed the highest number of studies (44) in southern India, with a sample size of 35,988 with a pooled prevalence of 44.6% (CI: 44–45.1). The pooled mean dmft (random effect) is 2.23 (1.97–2.48), with males having a higher proportion of 2.26 compared to 2.23 in females. The pooled prevalence of ECC was 46.9%, and the pooled mean was 2.23. The results from this study state that one in every two children in India is suffering from ECC, reflecting its public health relevance.
Keywords: Baby bottle caries, children, dmft, early childhood caries, India, prevalence Introduction
|How to cite this article:|
Devan I, Ramanarayanan V, Janakiram C. Prevalence of early childhood caries in India: A systematic review and meta-analysis. Indian J Public Health 2022;66, Suppl S1:3-11
|How to cite this URL:|
Devan I, Ramanarayanan V, Janakiram C. Prevalence of early childhood caries in India: A systematic review and meta-analysis. Indian J Public Health [serial online] 2022 [cited 2022 Nov 28];66, Suppl S1:3-11. Available from: https://www.ijph.in/text.asp?2022/66/5/3/360645
| Introduction|| |
Dental caries of primary dentition is the 12th most prevalent disease affecting about 560 million children globally. According to the United States HHS, early childhood caries (ECC) is five times as frequent as asthma and seven times more common than hay fever. The American Academy of Paediatric Dentistry defines ECC as the “presence of one or more decayed (cavitated or noncavitated), missing due to caries or filled tooth surfaces in any primary tooth in a child of age 71 months or younger.” Multiple risk factors are associated with ECC which includes distal factors like occupation, education, socio-economic conditions, access to dental care, and proximal factors such as lifestyle, dietary habits, and oral health knowledge. Untreated carious lesions can lead to problems ranging from localized pain, swelling, and abscess, causing difficulty in chewing, eating, and speaking, leading to malnutrition, gastrointestinal disorders, and difficulty attending to learning.,
Data from 44 WHO member states/countries reported the ECC prevalence ranging from 0.0% in Nigeria to 98% in Cambodia and Bosnia and Herzegovina. In Asia, especially in the Far East region, the prevalence of the disease in 3-year-old ranges from 36% to 85%; the prevalence in India has been reported in the range of 44%–49% among 8–48-month-old children.
The emotional stress associated with pain affects the overall quality of life of children and parents. School hours lost due to dental illness are estimated to be around 51 million. Poor children's restricted activity days are 12 times more than that of children from upper class families. Though there has been a general decline in the incidence of dental caries among adolescents and young adults, the same has not been observed with ECC.
ECC has been recognized as a significant public health problem. To consider a condition as a public health problem and to implement policies and programs for its prevention and control, credible nationally representative data is required to quantify its burden However, there have only been several point prevalence studies conducted in different parts of the country and also among different sub-groups of the population. There has been no national representation of data except for the solitary national oral health survey in 2002–2003 which reported the caries experience among 5-year-old children only. A recent systematic review conducted on the same topic did not report the pooled prevalence of ECC. A systematic review and meta-analysis on the prevalence of dental caries in India reports an overall prevalence of 54.16% and that of 3–18 years to be 57%. Specific information on age group between 0 and 6 years has not been reported.
Appropriate public health policy programs are required to bring down the prevalence of ECC in India which in turn is dependent on the availability of relevant national data. Since an estimated pooled prevalence of ECC is lacking from the studies published so far, this systematic review and meta-analysis aims to estimate the pooled prevalence and associated factors of ECC in Indian preschool children.
| Methodology|| |
This systematic review was done and reported based on MOOSE Guidelines for Meta-Analyses and Systematic Reviews of Observational Studies. The focused review question was as follows: What is the prevalence of ECC among preschool children in India?.
Eligibility criteria of included studies
Studies that assessed prevalence and severity of ECC (participants of age 71 months or younger using the dmft, dfs, PUFA, WHO pro forma 1997, ICDAS etc., cross-sectional studies).
Definition of outcome
The outcome considered was ECC which is defined as “the presence of 1 or more decayed (or cavitated lesions), missing (due to caries), or filled tooth surfaces in any primary tooth in a child 71 months of age or younger.” For children below 3 years of age, the presence of any sign of smooth surface caries can be considered as severe ECC. The proportion of children who experienced ECC and mean dmft/def/dmfs were assessed.
Information sources and search
An electronic data search was done by the investigator (ID) in MEDLINE, PubMed Central and Scopus. A database customized search strategy for each database was used; MeSH terms: (prevalence) AND (”dentalcaries”) AND (”preschool children” OR “preschool children”) AND (India) (”epidemiology”[MeSH Subheading] OR “epidemiology”[All Fields]) OR “prevalence”[All Fields]) OR “prevalence”[MeSH Terms]) OR “prevalence”[All Fields]) OR “prevalence's”[All Fields]) OR “prevalences”[All Fields]) OR “prevalent”[All Fields]) OR “prevalently”[All Fields]) OR “prevalent”[All Fields]) AND “dental caries”[All Fields]) AND (”preschool children”[All Fields] OR “preschool children”[All Fields])) AND (((”India”[MeSH Terms] OR “India”[All Fields]).(prevalence) AND (”early childhood caries” OR “ECC” OR “nursing bottle caries” OR “baby bottle caries” OR “night bottle caries”) AND (India). Subsequently, based on inclusion/exclusion criteria, title and abstract screening were done. Subsequently, full-text screening was done by two reviewers (ID and RV). Only studies published in the English language were included. Any conflict was adjudicated by a third reviewer (CJ).
Data collection process and data items
Data extraction was done with the aid of a Microsoft Excel spreadsheet and the following information were extracted: bibliographic details, age group included, gender distribution, place of the study (geographic location), number of participants (sample size), technique of sample selection, number of teeth affected by ECC, dmft/deft, PUFA scores, and feeding habits.
Assessment of risk of bias
Quality assessment was done for each included study using a method proposed by Hoy et al. and was performed by two authors (ID and RV). A score of 0–9 was considered for assessing the overall risk of bias for each of the nine types of bias respectively. Any disagreement was resolved by discussion or by a third reviewer (CJ).
Synthesis of findings
Quantitative synthesis was done using a random-effects model using MetaXL developed for use with Microsoft Excel and Comprehensive Meta-analysis software. Pooled prevalence was calculated and reported with 95% confidence interval (CI).
| Results|| |
[Figure 1] shows the flow chart for study selection. 140 citations were retrieved from the database until September 2020. A comprehensive search of cross-references of these retrieved articles yielded 56 additional articles. After removing duplicates, 134 records including the National Oral Health survey was screened for title and abstract of which 55 articles were excluded. The full-text screening was done for 79 studies of which 8 did not meet the inclusion criteria due to missing data (6 studies), retracted (1 study), no full-text access (1 study). Authors were contacted through e-mail for missing data, but no response was obtained. Finally, 71 studies,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, were included for quantitative synthesis.
[Table 1] describes the characteristics of the included studies. A total of 71 studies were included for quantitative synthesis which comprised of 69,330 preschool children. Most of the included studies were from South India and a majority of the studies (n = 28) were published during 2010–2015 followed by 2015–2020 (n = 21). A total of 31 studies used dmft scores for assessing ECC followed by 17 studies that used deft/def scores and 14 studies that used WHO pro forma 1997. All 71 included studies had a low risk of bias according to the assessment made by Hoy et al. criteria.
Synthesis of results
Pooled prevalence of early childhood caries by proportion
The overall prevalence of ECC estimated from 71 studies with 69,330 participants was 46.9% (95% CI: 46.5–47.2) [Figure 2]. Males had a higher proportion of ECC (47%, 95% CI: 46.4–47.6, 40 studies, 26,840 participants) than females (43.8%, 95% CI: 43.2–44.2, 40 studies, 24,389 participants). Regional analysis showed the highest number of studies conducted in Southern India with a pooled prevalence of 44.6% (95% CI: 44–45.1, 44 studies, 35,998 participants). Central India has the least number of studies but reported the highest pooled prevalence of 62.3% (95% CI: 60.2–64.3, 3 studies, 2098 participants) compared to Northern India which had a pooled prevalence of 51.6% (95% CI: 50.9–52.3, 25 studies, 19,355 participants). Eastern and Western India reported a pooled prevalence of 50.4% (95% CI: 48.9 and 51.8, 7 studies, 4464 participants) and 43.8% (95% CI: 42.6–44.97,425 participants) respectively. Sub-group analysis based on the sampling method employed for the studies showed a pooled prevalence of 48.1% (95% CI: 47–48.6, 44,355 studies participants) for random sampling and 44.7% (95% CI: 44.1–45.3, studies, 24,975 participants) for nonrandom sampling [Table 2].
| Discussion|| |
Untreated ECC has multiple consequences as it can lead to problems in eating and phonetics due to early loss of teeth and malocclusion. It ultimately affects learning as it occurs during the years of milestone development of the child. It has been observed that a malnourished child has higher odds (odds ratios 3.46, 95% CI: 1.93–6.29) of experiencing the dental caries compared to those with normal nutritional status in the tribal preschool children in India (add ref). ECC affects more than 530 million children. Underprivileged children, across cultures have greater proportion of vulnerability. Though developed countries are showing a decreasing trend in prevalence of dental caries, prevalence of ECC still remains same in both developing and developed countries. This systematic review attempted to quantify the burden of ECC in India.
The National Oral Health Survey 2002, remains India's solitary National Survey using the WHO methodology, estimating the burden of ECC. However, there exists a number of point prevalence studies estimating the ECC in India. Thus, a comprehensive review of these studies was warranted to estimate the burden of ECC in India. Previous attempts on this front had limitations of being narrative in nature and performing only a qualitative synthesis, and did not attempt to provide the pooled estimate of the prevalence of ECC in India.
According to our estimates, nearly one in two preschool children experience ECC in India. A similar prevalence of ECC was observed in Australia which is more than 50% in 6-year-old children. ECC is recognised as a major public health problem in several countries with the prevalence ranging from 11.4% in Sweden to 7%–19% in Italy to 76% and 83% in Palestine and the United Arab Emirates respectively. The national surveys from some countries, such as Greece (36%), Brazil (45.8%) and Israel (64.7%), showed inconsistent prevalence of ECC. The existing prevalence of ECC in developed countries may be attributed to its population living in slums. There are more urban slums in passive economies; and these economies are associated with higher consumption of caries-promoting diets.
Previous systematic review done in India 2016 estimated a prevalence of 49.6% compared to our observation of 46.9%. This difference could be due to the higher number of included studies and wider search strategy used in this review.
A gender wise analysis showed males have higher prevalence of ECC than females. A heterogeneity of 97%–100% was observed probably due to the variation in population and use of different indices to assess ECC. A region wise analysis revealed that most of the studies were done in Southern India, especially in Karnataka. Eastern India and Central India has very few studies and showed a high prevalence (60.2%). Further studies are needed in these areas for precise estimation of results.
More number of included studies compared to previous the systematic review and meta-analysis using both proportion and mean deft/dmft/dfs are the strengths of our study, which makes for a more comprehensive quantitative synthesis of ECC prevalence in India. Representativeness of our results are reasonable for two reasons, one the included studies were from 13 (geographical) out of 30 Indian states and one nationally representative data and second, the number of included studies is large (n = 71) which reflects a close estimate of prevalence of ECC. Despite the strengths of the study, the study findings need to be interpreted with caution because of the possible fallacies associated with included cross-sectional studies and variation in the indices used to measure the ECC may underestimate the pooled value.
With a high burden of ECC in India, it is imperative to adopt measures to control and prevent the same. The World Health Organization expert consultation on public health interventions against ECC outlines few strategies which include caries risk assessment, brushing with fluoride toothpaste, fluoride varnish applications, and certain behavioral interventions that affect preventive self-care. Early and periodic dental visits could contribute to its prevention. The World Health Assembly also recommends a shift from curative approach to preventive approach beginning from family, schools and workplaces including comprehensive and inclusive care within the primary health-care system for improving oral health.
| Conclusion|| |
Results from this study indicate that one in every two preschool children in India is suffering from ECC reflecting its social relevance. This data would be useful for planning and policy making.
The authors wish to thank Dr. Vineetha Karuveetil (Department of Public Health Dentistry, Amrita School of Dentistry, Kerala) for her valuable inputs in the preparation of this article.
Financial support and sponsorship
This study is a part of the Indian Council of Medical Research Nurturing Clinical Scientist fellowship awarded to Dr. Induja Devan for which contingency is being availed.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2]