Received: 21 October 2019 

|  Revised: 22 December 2019 

|  Accepted: 12 January 2020

DOI: 10.1111/ipd.12617

ORIGINAL ARTICLE

Adverse birth outcomes and the risk of dental caries at age

3 years

Fernanda Cunha Soares1   | Göran Dahllöf1,2,3   | Anders Hjern4   |

Annika Julihn1,2,5

1
Division of Orthodontics and Pediatric
Dentistry, Department of Dental Medicine,
Abstract
Karolinska Institutet, Stockholm, Sweden Background: Since birth outcome is associated with maternal and newborn health,
2
Center for Pediatric Oral Health Research, it can be a predictor of the future health of the child.
Stockholm, Sweden
Aim: To investigate the association between adverse birth outcomes and dental
3
Center for Oral Health Services and
caries.
Research, Mid-Norway, TKMidt,
Trondheim, Norway Design: The present registry-based cohort study included all children born in 2000-
4
Clinical Epidemiology, Department of 2003, residing in Stockholm County, Sweden and who received a dental examination
Medicine, Karolinska Institutet and Centre at the age of 3 years (n = 74 748). National registries supplied data on socioeconomic
for Health Equity Studies, Stockholm,
Sweden conditions, maternal health, maternal health behavior, and birth outcomes. Forward
5
Department of Pediatric Dentistry, stepwise binary logistic regression was performed to determine predictors of caries
Eastman Institute, Public Dental Service, experience in the 3-year-olds.
Stockholm, Sweden
Results: Of the subjects, 6.0% had caries experience (decayed, extracted, and filled
Correspondence teeth [deft] ≥ 1), 5.6% were born preterm (<37 weeks); 2.2% were born small (SGA)
Fernanda Cunha Soares, Division of and 3.7% large (LGA) for gestational age. Of the studied adverse birth outcomes,
Orthodontics and Pediatric Dentistry,
Department of Dental Medicine, Karolinska
only SGA was significantly associated with caries experience at 3 years of age, and
Institutet, Stockholm, Sweden. only for mothers who had refrained from smoking during pregnancy.
Email: fercsoares@gmail.com Conclusions: SGA is associated with caries experience in 3-year-old children; how-
ever, this relationship occurs only in mothers who did not smoke during pregnancy.

KEYWORDS
child dentistry, oral health, risk indicator, small for gestational age

1  |   IN T RO D U C T ION
From a life course perspective, birth outcome is particularly
relevant as an indicator of maternal and newborn health; birth
outcome represents both reproductive outcomes of the mother
and predictors of well-being of the child.1-3 Infants with ad-
verse birth outcomes are vulnerable to serious medical prob-
lems. The most common causes of neonatal morbidity are
preterm birth and low birth weight due to intrauterine growth
retardation.4 In Sweden, low birth weight occurs in 2.5% of
newborns, 6% are born preterm, and ~2.5% are born small
for gestational age (SGA). These levels have remained un-
changed over the past decade.4
Viral infections, as well as various maternal diseases such
as diabetes, conditions like preeclampsia, and maternal life-
style factors such as smoking and stress affect fetus growth,

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original
work is properly cited.
© 2020 The Authors. International Journal of Paediatric Dentistry published by BSPD, IAPD and John Wiley & Sons Ltd

Int J Paediatr Dent. 2020;00:1–6.  |

wileyonlinelibrary.com/journal/ipd     1
 |
2       SOARES et al.
and thus newborn birth weight.5-7 Children born preterm are
more often SGA than those born full-term.8 SGA is asso-
ciated with increased risks of metabolic and cardiovascular
complications as well as suboptimal cognitive development
later in life.9 Children born very preterm run a higher risk
of developing chronic lung disease,10 cerebral palsy, and im-
paired vision4 and hearing.11 In addition, children with high
birth weight (≥4000  g) have been reported to have higher
risks of being overweight during adolescence,12 and later in
life, of developing obesity,13,14 cancer,15 and diabetes.16
An adverse birth outcome may also affect the oral health
of the preschool child.17,18 Preterm birth has been associated
with enamel defects in the dentition,19 with molar incisor
hypomineralization, and with other developmental defects
in first molars.20,21 These types of developmental defects
in enamel may increase susceptibility to dental caries.22,23
Although the association of dental caries with adverse birth
outcomes such as preterm birth, low and high birth weight,
and SGA has previously been studied, the results were in-
conclusive.24-27 Julihn et al28 show that high birth weight
(>4500  g) is associated with higher caries risk in teenag-
ers, most likely due to an increased risk of obesity and other
chronic disorders.
In light of these conflicting results concerning the associ-
ation between adverse birth outcomes and dental caries, we
designed the present registry-based study. We hypothesized
that adverse birth outcomes would be significantly associated
with caries experience in 3-year-old children.
2  |  M AT E R IA L S A N D ME T HODS
In the present registry-based cohort study, data were obtained
from the Public Health Care Administration in Stockholm
and registries at the National Board of Health and Welfare
and Statistics Sweden (SCB). The complete methodology
was previously published.29 This study included all children
residing in Stockholm County, Sweden, who were born in
2000-2003 and had a dental examination at 3 years of age at
a Public Dental Service clinic; with a private practitioner; or
at the Department of Dental Medicine, Division of Pediatric
Dentistry, Karolinska Institutet. The Regional Ethics Board
in Stockholm and the Swedish Data Inspection Board, a na-
tional agency that serves as an institutional review board for
studies using database linkage, approved the protocol for this
study (Daybook no. 2010/1563-31/1).
Data on manifest caries lesions and on extracted and filled
teeth were collected from clinical and radiographic examina-
tion records. The decayed, extracted, and filled primary teeth
(deft) index measured the severity of the caries experience in
children aged 3 years. Manifest caries was defined as caries
on smooth surfaces at the lowest level that can be verified as a
cavity and detectable by probing or, in fissures, by a catch of
Why this paper is important for paediatric
dentists
• There is a stable incidence of adverse birth out-
comes such as low birth weight, preterm birth, and
small for gestational age.
• In this large cohort, small for gestational age was
associated with caries experience at 3  years of
age, but only in mothers who had refrained from
smoking during pregnancy.
• The results suggest that adverse birth outcomes
should be explored as part of a comprehensive
history, since this information can contribute to
caries risk assessment of the child.
the probe under slight pressure. Proximal manifest caries was
diagnosed on bite-wing radiographs and defined as a lesion
clearly extending into the dentin.30 Only when indicated were
children radiographically examined.
This study analyzed these adverse birth outcomes: SGA,
large for gestational age (LGA), microcephaly, the Apgar
score, gestational age, weight at birth, and resuscitation. We
retrieved birth outcomes from the Medical Birth Register
(MBR) at the Swedish National Board of Health and Welfare.
SGA and LGA were based on the intrauterine growth curve
and calculated using the cut-offs of weight <10th percentile
(SGA) and >90th percentile (LGA). Weight at birth was clas-
sified as low (<2500  g), normal (≥2500 and ≤4000  g), or
macrosomic (>4000 g). The head circumference was catego-
rized into tertiles, considering microcephaly children in the
smallest tertile.
We grouped the 5-min Apgar score into ≤8 or >8 and
gestational weeks into <37 weeks or ≥37 weeks. From the
MBR, we also retrieved data on maternal smoking habits
during early pregnancy (yes or no), maternal obesity, and
maternal age at delivery: <25, 25-34, or ≥35  years. Body
mass index (BMI) of the mother was calculated and grouped
into <30 and ≥30. The Swedish National Tax Board supplied
information on disposable family income in 2003; we cate-
gorized income as ≤20% (the lowest quintile) and >20% (all
other quintiles).
2.1  |  Statistical analysis
We used STATA (Version 14.0; StataCorp LP) to manage and
statistically analyze all data. Differences between categori-
cal variables were assessed using the chi-square test. Forward
stepwise binary logistic regression was done to determine pre-
dictors of caries experience in the 3-year-olds. The dependent
variable was dichotomized into caries free (deft = 0) and caries
SOARES et al.   
   3
|
experience (deft ≥ 1) at 3 years of age. All variables with a P- 3  |  RESULTS
value lower than 0.05 in the chi-square test were entered in the
regression models as independent variables. Odds ratios (OR) The study sample of 3-year-olds comprising 74 748 children
with a 95% CI and all Ps < 0.05 were considered significant, had a slightly higher proportion of boys (51.2%). Mean birth
based on two-tailed tests. We tested two models to verify the weight was 3539  ±  581  g, and mean gestational age was
association between adverse birth outcomes and caries expe- 39.4 ± 1.9 weeks. In the study sample, 5.8% of the children
rience. In addition, the analyses were stratified into maternal had untreated caries and 0.2%, dental restorations.
smoking and no maternal smoking. At birth, 5.6% were preterm (<37 weeks); 2.2%, SGA; and
3.7%, LGA. Prevalence of microcephaly was 1.2%, and 0.6%
had been resuscitated. A 5-minute Apgar score of <8 was re-
T A B L E 1   Prevalence of adverse birth outcomes among all ported for 2.1%, and low birth weight, for 4.0% (Table 1).
Stockholm County 3-year-olds born 2000-2003 (n = 74 748) Table 2 presents a univariate analysis of the association be-
Birth outcomes Category n % tween adverse birth outcomes and caries experience (deft ≥ 1)
at 3 years. SGA was the only outcome associated with caries
SGA No 70 421 97.8
experience (OR, 1.49; 95% CI  =  1.24-1.78). A multivariate
Yes 1553 2.2
logistic regression model adjusting for gender, family income,
LGA No 69 294 96.3
maternal age at delivery, and maternal obesity found SGA to be
Yes 2680 3.7 significantly associated with caries experience at 3 years of age.
Apgar 5 ≥8 72 407 97.9 The second model adjusted for all of the first-model factors and
<8 1529 2.1 added maternal smoking, which was found to attenuate the OR
Gestational age (wk) ≥37 70 458 94.4 of the association of SGA with caries experience by approxi-
<37 4154 5.6 mately 50%, rendering this estimate non-significant (P = .102).
Weight at birth (g) Low 2986 4.0 To explain the relationship between maternal smoking,
SGA, and caries experience at 3 years of age, we stratified
Normal 56 828 79.7
the analyses by maternal smoking and no maternal smoking
Macrosomic 14 499 20.3
during pregnancy. There was no association between SGA
Resuscitation No 74 294 99.4
and caries experience at 3 years of age when evaluating ma-
Yes 454 0.6 ternal smoking during pregnancy; however, in analyses of
Abbreviations: LGA, large for gestational age; SGA, small for gestational age. non-smoking mothers only, we observed that children who

T A B L E 2   Adverse birth outcomes and

deft ≥ 0 deft ≥ 1
the potential risk of caries experience at age
3 years Variable Category n % n % P
SGA No 66 317 94 4104 6 <.001
Yes 1422 91 131 9
LGA No 65 215 94 4079 6 .887
Yes 2524 94 156 6
Head circumference, Lowest 26 623 94 1686 6 .199
tertile Medium 32 516 94 2033 6
Highest 9565 95 554 4
Apgar 5 ≥8 68 169 94 4238 6 .788
<8 1442 94 87 6
Gestational age, ≥37 66 334 94 4124 6 .557
weeks <37 3920 94 234 6
Weight at birth, g Low 2791 94 195 6 .209
Normal 53 499 94 3329 6
Macrosomic 13 673 94 826 6
Resuscitation No 69 949 94 4345 6 .191
Yes 434 96 20 4
Abbreviations: SGA, small for gestational age; LGA, large for gestational age; deft, decayed, extracted, and
filled teeth.
 |
4       SOARES et al.

were small for their gestational age were 1.3 times (OR, 1.3;

.343
95% CI = 1.01-1.71) more likely to have caries experience

P
compared with those who were not (Table 3).

Adjusted I

(0.77-2.12)
(CI 95%)
4  |   D IS C U SS ION

1.28
OR

Notes: Adjusted I: maternal age, family income, gender, foreign-born mother, maternal obesity. Adjusted II: maternal age, family income, gender, foreign-born mother, maternal obesity, maternal smoking.
1
This study found a significant association between SGA and

T A B L E 3   Crude and adjusted logistic regression analysis models exploring the association between small for gestational age (SGA) and caries experience at age 3 years

.235
Maternal smoking

P
caries experience in 3-year-old children; however, the as-
sociation between SGA and caries experience at the age of

(0.85-1.94)
(CI 95%)
three was only significant if the mother had refrained from

Crude
smoking during pregnancy.

1.28
OR
The reported prevalence of adverse birth outcomes in this

1
study are similar to in other population-based studies. In a

.044
registry-based study of singleton birth in women with autism,

P
Sundelin et al (2018) reported that among controls, the prev-

Adjusted I

(1.01-1.71)
alence of preterm birth was 4.7%; of SGA, 9.5%; of LGA,

(CI 95%)
9.9%; and of Apgar 5 < 7, 1.3%.31 The corresponding figures

1.31
OR
in this study are 5.6% for preterm birth, 2.2% for SGA, and

1
3.7% for LGA.

No maternal smoking

<.001
This study found registry reports of caries experience in
6.0% of the study sample among 3-year-old children. In 2006,

P
the Swedish Board of Health and Welfare reported the national

(1.19-1.83)
caries experience in 3-year-olds to be 5%, less than we found.32

(CI 95%)
Crude
One consideration is that our cohort lived in Stockholm County,

1.48
OR
where the capital is situated. In Sweden, dental health in metro-

1
politan areas is somewhat poorer than elsewhere.32

.116
The association between various adverse birth out-
P
comes and dental caries has not been extensively studied,
Adjusted II

and most of the studies have had few participants. Despite

(0.95-1.53)
(CI 95%)

an epidemiological-sized cohort, the present registry-based

study was also unable to show a significant association 1.21
OR

between adverse birth outcomes and caries experience in

3-year-old children, except for the variable SGA in moth-
.012
P

ers who had refrained from smoking during pregnancy.

The mechanism proposed in the literature is that develop-
Adjusted I

(1.07-1.69)
(CI 95%)

mental defects of enamel increase susceptibility to dental

caries.23,33,34 Several studies have failed to find a higher
1.34
OR

prevalence of dental caries in children born preterm or

1

with low birth weight and have been unable to establish an

<.001

association between developmental defects of enamel and

P

dental caries.35-37
This study found an association between SGA and caries
(1.24-1.79)
(CI 95%)

experience at 3 years of age, but this association occurred

Crude
Total

only in mothers who did not smoke during pregnancy.

1.49
OR

When we only analyzed mothers who smoked during preg-

nancy, there was no association between SGA and caries
Birth outcome (SGA)

experience, probably because smoking during pregnancy

is a known risk factor of SGA.38 Cigarette smoking during
pregnancy is the single most important risk factor for SGA,
Not SGA

and the relationship between SGA and smoking is dose-de-

pendent.39 Nicotine, the active ingredient in tobacco, has
SGA

been found to have a 15% higher concentration in the

SOARES et al.
placenta than the maternal blood. Nicotine causes uterine
vasoconstriction by inducing maternal catecholamine re-
lease.40 Furthermore, maternal smoking increases carboxy-
hemoglobin levels of the umbilical arteries, which results
in fetal hypoxia.41
Apart from an association with enamel hypoplasia, low
Apgar scores have been found to be associated with compro-
mised immunity and impaired resistance to infection, both of
which may increase susceptibility to dental caries.42 In our
study, however, a low Apgar score was not associated with
caries experience.
An important strength of this study is that adverse birth
outcome data could be sourced from national registries of high
quality. In contrast, most previous studies collected information
on birth outcomes via questionnaires to the parents. In partic-
ular, questions regarding perinatal health are difficult to verify
without access to medical records. The sample size we used
was large and made possible by the public health care admin-
istration in Stockholm; this reduced the possibility of selection
bias and increased generalizability of the results.
The limitations were the dental examination performed by
Public Dental Service dentists, who were not calibrated for
this study; however, the large size of the study lowered the
effect of random errors compared with smaller studies, and
continuing to increase the size of the study by adding data
from other Swedish counties would have reduced such errors
even more.43 Our study involved a cohort of 74,748 children;
thus, the risk of random error is minor. No information on
dietary or oral hygiene habits could be retrieved, because
Swedish national registries do not collect this information.
Since data on oral hygiene and other factors related to oral
health in general were not collected, the results of this study
should be interpreted with caution.
5  |   CO NC LU S ION
This study found an association between small for gestational
age and caries experience in 3-year-old children; however,
the association was only significant in mothers who refrained
from smoking during pregnancy. The results suggest that ad-
verse birth outcomes should be explored as part of a com-
prehensive history, since this information can contribute to
caries risk assessment of the child.
ACKNOWLEDGEMENTS
This study was supported by grants from the Swedish Patent
Revenue Research Fund.
CONFLICT OF INTEREST
The authors declare no conflict of interest concerning author-
ship or publication of this article.
  
   5
|
AUTHORS' CONTRIBUTION
FC Soares contributed to data acquisition, analysis, and in-
terpretation; she also drafted and critically revised the manu-
script. G. Dahllöf and A. Hjern contributed to design, data
analysis, and interpretation; they also drafted and critically
revised the manuscript. A. Julihn, contributed to conception,
design, data acquisition, analysis, and interpretation; she also
drafted and critically revised the manuscript. All authors
gave their final approval of the text and agree to be account-
able for all aspects of the work.
ORCID
Fernanda Cunha Soares  https://orcid.
org/0000-0001-6465-3164
Göran Dahllöf  https://orcid.org/0000-0001-8536-5292
Anders Hjern  https://orcid.org/0000-0002-1645-2058
Annika Julihn  https://orcid.org/0000-0002-3052-6017
R E F E R E NC E S
1. Rich-Edwards JW, Buka SL, Brennan RT, Earls F. Diverging asso-
ciations of maternal age with low birthweight for black and white
mothers. Int J Epidemiol. 2003;32(1):83-90.
2. Kuh D, Ben-Shlomo Y. A Life Course Approach to Chronic Disease
Epidemiology. New York, NY: Oxford University Press; 2004.
3. Misra DP, Caldwell C, Young AA, Abelson S. Do fathers matter?
Paternal contributions to birth outcomes and racial disparities. Am
J Obstet Gynecol. 2010;202(2):99-100.
4. Hjern A. Children's health: Health in Sweden: The National Public
Health Report 2012. Chapter 2. Scand J Public Health. 2012;40(9
Suppl):23-41.
5. Kramer MS. Determinants of low birth weight: methodolog-
ical assessment and meta-analysis. Bull World Health Organ.
1987;65(5):663-737.
6. Cnattingius S, Haglund B. Decreasing smoking prevalence during
pregnancy in Sweden: the effect on small-for-gestational-age
births. Am J Public Health. 1997;87(3):410-413.
7. Borders AEB, Grobman WA, Amsden LB, Holl JL. Chronic stress
and low birth weight neonates in a low-income population of
women. Obstet Gynecol. 2007;109(2 Pt 1):331-338.
8. Ray JG, Vermeulen MJ, Bharatha A, Montanera WJ, Park AL.
Association Between MRI Exposure During Pregnancy and Fetal
and Childhood Outcomes. JAMA. 2016;316(9):952-961.
9. Saenger P, Czernichow P, Hughes I, Reiter EO. Small for gestational
age: short stature and beyond. Endocr Rev. 2007;28(2):219-251.
10. Greenough A. Long-term pulmonary outcome in the preterm in-
fant. Neonatology. 2008;93(4):324-327.
11. Jiang ZD, Brosi DM, Wilkinson AR. Hearing impairment
in preterm very low birthweight babies detected at term
by brainstem auditory evoked responses. Acta Paediatr.
2001;90(12):1411-1415.
12. Rugholm S, Baker JL, Olsen LW, Schack-Nielsen L, Bua J,
Sorensen TIA. Stability of the association between birth weight
and childhood overweight during the development of the obesity
epidemic. Obes Res. 2005;13(12):2187-2194.
13. Wang T-N, Tseng M-H, Wilson BN, Hu F-C. Functional perfor-
mance of children with developmental coordination disorder at
home and at school. Dev Med Child Neurol. 2009;51(10):817-825.
 |
6       SOARES et al.
14. Zhao G, Ford ES, Li C, Tsai J, Dhingra S. Balluz LS. Waist circum-
ference, abdominal obesity, and depression among overweight and
obese U.S. adults: national health and nutrition examination survey
2005–2006. BMC Psychiatry. 2011;11:2005-2006.
15. Risnes KR, Vatten LJ, Baker JL, et al. Birthweight and mortality in
adulthood: a systematic review and meta-analysis. Int J Epidemiol.
2011;40(3):647-661.
16. Harder T, Rodekamp E, Schellong K, Dudenhausen JW, Plagemann
A. Birth weight and subsequent risk of type 2 diabetes: a meta-anal-
ysis. Am J Epidemiol. 2007;165(8):849-857.
17. Seow WK. Effects of preterm birth on oral growth and develop-
ment. Aust Dent J. 1997;42(2):85-91.
18. Paulsson L, Bondemark L, Soderfeldt B. A systematic review of
the consequences of premature birth on palatal morphology, dental
occlusion, tooth-crown dimensions, and tooth maturity and erup-
tion. Angle Orthod. 2004;74(2):269-279.
19. Cruvinel VRN, Gravina DBL, Azevedo TDPL, de Rezende CS,
Bezerra ACB, de Toledo OA. Prevalence of enamel defects and
associated risk factors in both dentitions in preterm and full term
born children. J Appl Oral Sci. 2012;20(3):310-317.
20. Brogardh-Roth S, Matsson L, Klingberg G. Molar-incisor hy-
pomineralization and oral hygiene in 10- to-12-yr-old Swedish
children born preterm. Eur J Oral Sci. 2011;119(1):33-39.
21. Arrow P. Risk factors in the occurrence of enamel defects of the
first permanent molars among schoolchildren in Western Australia.
Community Dent Oral Epidemiol. 2009;37(5):405-415.
22. Seow WK. Developmental defects of enamel and dentine: chal-
lenges for basic science research and clinical management. Aust
Dent J. 2014;59(Suppl 1):143-154.
23. Nelson S, Albert JM, Lombardi G, et al. Dental caries and
enamel defects in very low birth weight adolescents. Caries Res.
2010;44(6):509-518.
24. Lai PY, Seow WK, Tudehope DI, Rogers Y. Enamel hypoplasia
and dental caries in very-low birthweight children: a case-con-
trolled, longitudinal study. Pediatr Dent. 1997;19(1):42-49.
25. Nelson S, Albert JM, Geng C, et al. Increased enamel hypoplasia
and very low birthweight infants. J Dent Res. 2013;92(9):788-794.
26. Tanaka K, Miyake Y. Low birth weight, preterm birth or
small-for-gestational-age are not associated with dental caries in
young Japanese children. BMC Oral Health. 2014;14(1):38.
27. Saraiva MCP, Chiga S, Bettiol H, Silva AA, Barbieri MA. Is low
birthweight associated with dental caries in permanent dentition?
Paediatr Perinat Epidemiol. 2007;21(1):49-56.
28. Julihn A, Jansson P, Regnstrand T, Modeer T. Is congenital mal-
formation a risk factor for caries development in Swedish adoles-
cents? Acta Odontol Scand. 2013;71(6):1636-1644.
29. Brandquist E, Dahllöf G, Hjern A, Julihn A. Caesarean section
does not increase the risk of caries in Swedish children. JDR Clin
Transl Res. 2017;2(4):386-396.
30. Koch G. Effect of sodium fluoride in dentifrice and mouthwash on
incidence of dental caries in schoolchildren. Odontologisk Revy.
1967;18(Suppl. 12):1-125.
31. Sundelin HE, Stephansson O, Hultman CM, Ludvigsson JF.
Pregnancy outcomes in women with autism: a nationwide popula-
tion-based cohort study. Clin Epidemiol. 2018;10:1817-1826.
32. Landsting H. sjukvårdsnämndens förvaltning. S läns. Tandhälsans
utveckling bland barn och ungdomar i Stockholms län.
TANDHÄLSORAPPORT.2008; 2009.
33. Targino A, Rosenblatt A, Oliveira A, Chaves A, Santos V. The re-
lationship of enamel defects and caries: A cohort study. Oral Dis.
2011;17(4):420-426.
34. Caufield PW, Li Y, Bromage TG. Hypoplasia-associated se-
vere early childhood caries – a proposed definition. J Dent Res.
2012;91(6):544-550.
35. Takaoka LAMV, Goulart AL, Kopelman BI, Weiler RME. Enamel
defects in the complete primary dentition of children born at term
and preterm. Pediatr Dent. 2011;33(2):171-176.
36. Prokocimer T, Amir E, Blumer S, Peretz B. Birth-weight, preg-
nancy term, pre-natal and natal complications related to child's
dental anomalies. J Clin Pediatr Dent. 2015;39(4):371-376.
37. Wagner Y. Developmental defects of enamel in primary teeth
- findings of a regional German birth cohort study. BMC Oral
Health. 2017;17(1):10.
38. Cardenas VM, Cen R, Clemens MM, et al. Use of electronic nic-
otine delivery systems (ENDS) by pregnant women I: Risk of
small-for-gestational-age birth. Tob Induc Dis. 2019;17(May):1-12.
39. Cnattingius S. The epidemiology of smoking during pregnancy:
Smoking prevalence, maternal characteristics, and pregnancy out-
comes. Nicotine Tob Res. 2004;6(Suppl 2):125-140.
40. Horta BL, Victora CG, Menezes AM, Barros FC. Environmental
tobacco smoke and breastfeeding duration. Am J Epidemiol.
1997;146(2):128-133.
41. Lambers DS, Clark KE. The maternal and fetal physiologic effects
of nicotine. Semin Perinatol. 1996;20(2):115-126.
42. Willwerth BM, Schaub B, Tantisira KG, et al. Prenatal, perinatal,
and heritable influences on cord blood immune responses. Ann
Allergy Asthma Immunol. 2006;96(3):445-453.
43. Rothman K. Biases in study design. In: Epidemiology: An
Introduction. New York, NY: Oxford University Press; 2002:94-95.
How to cite this article: Soares FC, Dahllöf G, Hjern
A, Julihn A. Adverse birth outcomes and the risk of
dental caries at age 3 years. Int J Paediatr Dent.
2020;00:1–6. https​://doi.org/10.1111/ipd.12617​