Original Article

Nutritional Status, Prevalence of Early Childhood Caries, and its

Association among Preschool Children in Northeast India

Abstract Nandita
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Background: Early childhood caries (ECC) is a common public health problem in developing Kshetrimayum1,
countries. Children with severe decay can also have altered eating habits and preferences. Sibyl Siluvai2,
Therefore, ECC can influence nutritional health. Aim: The aim is to find the prevalence of ECC
and nutritional status and to evaluate its association among preschool children in Northeast India. Prabhat Kumar
Chaudhuri3,
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Study Design and Data Collection Methods: This descriptive cross‑sectional study was conducted
among 384 preschool children aged 2–6 years. The sampling unit comprised the children attending Talisunup
the pediatric dentistry department of one dental college. Information regarding sociodemographic Longkumar1,
factors, child feeding habits, and child oral hygiene practices was obtained from the parents using Darshana Bennadi4,
a pretested questionnaire. Weight and height were evaluated to assess the nutritional status. The
decay, missing, filled teeth index for primary teeth was used to determine the dental caries status. Victor Rakesh
Results: The mean value of carious teeth for 384 children aged 2–6 years was 5.6 ± 2.43. Most Lazar5
kids who had caries (74.7%) belonged to the moderate category (dmft >7), followed by the low 1
Public Health Dentistry, Dental
sort, which was 16.7%, and then by those in the higher class (8.6%). The body mass index (BMI) College, Regional Institute
for age revealed that 5.2% were overweight, 15.1% were thin, and 8.3% were obese. Most of of Medical Sciences, Imphal,
those with high caries (i.e., dmft >7) were underweight or in the normal weight category. Pearson Manipur, India, 2Public Health
Dentistry, SRM Kattankulathur
correlation showed no significant correlation between ECC with BMI‑for‑age (r = 0.04, P > 0.05). Dental College and Hospital,
Conclusion: The prevalence of dental caries among children below the age of 5 years in Imphal was SRM Institute of Science and
high. The risk factors for ECC included age, low maternal education, improper feeding, and oral Technology, Potheri, Tamil Nadu,
hygiene habits. However, the results revealed no significant relationship between ECC and BMI. India, 3Centre for Dental
Education and Research, All
Keywords: Body mass index, early childhood caries, preschool children India Institute of Medical
Sciences, New Delhi, India,
4
Public Health Dentistry, Sree
Introduction being overweight is now the most common Siddhartha Dental College and
childhood medical condition, with the Hospital, SAHE University,
Early childhood caries (ECC) is a common Tumkur, Karnataka, India,
prevalence having doubled over the past
public health problem in developing 5
Medical and Imaging Technology
20 years. Dentists must be aware of how &RSO, SRM Medical College
countries, where malnutrition is still an
nutrition impacts general and oral health and Hospital, SRM Institute of
issue. ECC occurs due to an imbalance Science and Technology, Potheri,
and how dental treatment can impact the
between risk and protective factors.[1] It Tamil Nadu, India
patient’s nutritional status.[11] There is a
is the most common chronic disease of Submitted : 21‑Jun‑2023
strong influence on oral health by the daily
childhood and is defined as any decay in the Revised : 11‑Sep‑2023
intake of food; on the other hand, oral health Accepted : 23‑Oct‑2023
primary dentition of children <72 months
can also play a significant role in nutritional Published : 19-Dec-2023
of age. This decay pattern develops rapidly
intake and general health status.[12] Children
in preschoolers, affecting tooth surfaces Address for correspondence:
with severe decay can also have altered Dr. Sibyl Siluvai,
that are naturally caries‑prone.[2‑5] Several
eating habits and preferences.[13] Therefore, SRM Kattankulathur Dental
studies have documented the adverse effect
ECC can influence nutritional health. College and Hospital,
of severe forms of ECC on the quality SRM Institute of Science
While several studies suggest that children
of life of young children.[6‑9] Similar to and Technology, Potheri,
with ECC are underweight, new evidence Tamil Nadu, India.
dental caries, nutritional status in children
suggests that these individuals fall at either E‑mail: sibyls@srmist.edu.in
in preschool age is a severe public health
extreme of the normal distribution for body
problem, with multifactorial etiology, with
mass index (BMI).[14]
diet as a common factor.[10] Access this article online
Data on dental caries in the northeastern
According to the American Academy of Website:
states of India are minimal. There is no https://journals.lww.com/cocd
Pediatrics, Committee on Nutrition (2003),
study available on the prevalence of ECC in DOI: 10.4103/ccd.ccd_290_23
Northeast India. Based on this, the current Quick Response Code:
This is an open access journal, and articles are
distributed under the terms of the Creative Commons
Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows
others to remix, tweak, and build upon the work non‑commercially, How to cite this article: Kshetrimayum N, Siluvai S,
as long as appropriate credit is given and the new creations are Chaudhuri PK, Longkumar T, Bennadi D, Lazar VR.
licensed under the identical terms. Nutritional status, prevalence of early childhood
caries, and its association among preschool children
For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com
in Northeast India. Contemp Clin Dent 2023;14:300-6.

© 2023 Contemporary Clinical Dentistry | Published by Wolters Kluwer ‑ Medknow 300

 Kshetrimayum, et al.: Nutritional status and ECC

study aims to find the prevalence of ECC and nutritional
status and to evaluate its association among preschool
children in Northeast India.
Aims and objectives
• To assess the nutritional status of preschool children in
Northeast India
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questionnaire, the correlation between the responses on the
English and Tamil versions was done. Pearson’s correlation
and Cronbach’s reliability level for internal consistency
was 0.87. The questionnaire was pilot tested and adjusted
accordingly before being used in the main study. Clinical
investigations to record ECC were conducted by a single
researcher. Decay, missing, filled teeth index (deft index)

• To evaluate the prevalence of ECC in Northeast India was used for dental caries, and codes and criteria using the
• To determine the association between nutritional status recommendations of the WHO were followed.[16]
and ECC.
Anthropometric evaluations were performed using the BMI,
Materials and Methods
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which is a division of weight by the square root of height.

This descriptive cross‑sectional study was conducted for The children’s weight was obtained using a precision digital
8 months among preschool children aged 2–6 years. In scale and a tape measure for their height. The BMI for age
Northeast India, there are three dental colleges. One college was calculated according to the WHO standard deviations
was randomly selected. unit tables, and the WHO standard (Z‑scores) was used to
calculate the nutritional status according to the age of male
Sampling method and female subjects.[17]
The sampling unit comprised the children attending the Statistical analysis
pediatric dentistry department of one of the dental colleges.
There are no collective data present regarding the preschool Data were analyzed using the Statistical Package for the
children population of Northeast India. World Health Social Sciences (SPSS) version 17.0 (SPSS Inc, Chicago, IL,
Organization (WHO) guidelines for estimating population USA.) statistical software. Descriptive statistics were reported
proportion were used to calculate the sample size.[15] Using for numerical variables, and frequency and percentages
that as a reference, the minimum sample size required was were reported for categorical variables. Caries and other
estimated to be 384 children. related variables were measured using a Chi‑square test, and
correlation (Spearman’s) was used to find the relationship
Consent and permissions between nutritional status (BMI‑for‑age) (categorical). The
Ethical permission from the institution’s ethical committee significance was set at <0.05.
was taken before the commencement of the study. Approval
was obtained from the principal of the selected dental college Results
to carry out the analysis, and consent was also taken from The mean value of carious teeth for 384 children aged
the parents or guardians. A simple random sampling method 2–6 years was 5.6 ± 2.43. Most kids who had caries (74.7%)
was adopted to acquire the required sample size.
Exclusion criteria Table 1: Prevalence of early childhood caries and
nutritional status of preschool children
i. Children with dentofacial deformities or any syndrome
Caries experience mean±SD
ii. Uncooperative, medically, and physically compromised
Overall dmft 5.6±2.4
patients
dt 4.8±2.0
iii. Children on long‑term medication mt 0.3±0.9
iv. Children were undergoing orthodontic treatment. ft 0.4±0.7
Method of data collection Caries experience category, n (%)
Caries free (dmf 0) 0
Information regarding sociodemographic factors, child Low (≤3) 64 (16.7)
feeding habits, and child oral hygiene practices was Moderate (4–6) 287 (74.7)
obtained from the parents using a pretested questionnaire. High (≥7) 33 (8.6)
The questionnaire was translated into the native language. Nutritional status, mean±SD
The questionnaire was linguistically and culturally adapted BMI‑for‑age 15.6±2.6
to our setting using the back translation technique. In BMI‑for‑age category, n (%)
this procedure, translations were independently made by Obese 32 (8.3)
two bilingual specialists, and produced a native version, Overweight 58 (5.2)
which was translated back into English by a professional Normal 274 (71.4)
English native translator who had never seen the original Underweight 20 (15.1)
version. The conceptual equivalence between the Total 384 (100)
original instruments and the back‑translated versions was SD: Standard deviation; BMI: Body mass index; dt: Decayed teeth;
compared. To check the accuracy of the translation of the mt: Missing teeth; ft: Filled teeth; dmf: decayed missing filling teeth

301 Contemporary Clinical Dentistry | Volume 14 | Issue 4 | October-December 2023

 Kshetrimayum, et al.: Nutritional status and ECC

belonged to the moderate category decayed missing filled was (16.7%), and then by those in the higher class (8.6%).
teeth (dmft >7), followed by the low category, which No child was found to be caries‑free [Table 1]. More

Table 2: Prevalence of early childhood caries in relation to gender and age

Caries Total, n (%) Inference (P)
Low, n (%) Moderate, n (%) High, n (%)
Gender
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Male 33 (8.6) 166 (43.2) 21 (5.5) 220 (57.3) 0.48

Female 31 (8.1) 121 (31.5) 12 (3.1) 164 (42.7)
Total 64 (16.7) 287 (74.7) 33 (8.6) 384 (100.0)
Age (years)
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2 6 (1.6) 10 (2.6) 0 16 (4.2) 0.03

3 8 (2.1) 25 (6.5) 5 (1.3) 38 (9.9)
4 10 (2.6) 37 (9.6) 5 (1.3) 52 (13.5)
5 20 (5.2) 57 (14.80) 7 (1.8) 84 (21.9)
6 20 (5.2) 158 (41.1) 16 (4.2) 194 (50.5)
Total 64 (16.7) 287 (74.7) 33 (8.6) 384 (100.0)

Table 3: Proportion of children with early childhood caries according to the mother’s educational status
Education status Caries Inference (P)
of the mother Low, n (%) Moderate, n (%) High, n (%) Total, n (%)
Primary school 8 (2.1) 84 (21.9) 8 (2.1) 100 (26.0) 0.009
Secondary school 44 (11.5) 168 (43.8) 16 (4.2) 28 (59.4)
Undergraduate 8 (2.1) 31 (8.1) 8 (2.1) 47 (12.2)
Postgraduate 4 (1.0) 4 (1.0) 1 (90.3) 9 (2.3)
Total 64 (16.7) 287 (74.7) 33 (8.6) 384 (100.0)

Table 4: The proportion of children with early childhood caries according to feeding habits
Variables Caries Total, n (%) Inference (P)
Low, n (%) Moderate, n (%) High, n (%)
Feeding frequency
3 times 51 (13.3) 235 (61.2) 29 (7.6) 315 (82.0) 0.719
5–10 days 10 (92.6) 44 (11.5) 4 (1.0) 58 (15.1)
>10 days 3 (0.8) 8 (2.1) 0 11 (2.9)
Total 64 (16.70) 287 (74.7) 33 (8.6) 384 (100)
Type of feeding
Bottle 54 (14.1) 272 (70.9) 30 (7.8) 354 (92.7) 0.010
Breastfeeding 5 (1.3) 6 (1.6) 1 (0.3) 12 (3.1)
Combination 5 (1.3) 9 (2.3) 2 (0.5) 16 (4.2)
Total 64 (16.7) 287 (74.7) 33 (8.6) 384 (100)
Initiation of feeding
1st day 60 (15.6) 257 (66.9) 31 (8.1) 348 (90.6) 0.01
2nd day 4 (1.0) 30 (7.8) 1 (0.3) 35 (9.1)
3rd day 0 0 1 (0.3) 1 (0.3)
Total 64 (16.7) 287 (74.7) 33 (8.6) 384 (100)
On‑demand breastfeeding
Yes 12 (3.1) 13 (3.4) 3 (0.8) 28 (7.3) 0.00
No 52 (13.5) 274 (71.4) 30 (7.8) 356 (92.7)
Total 64 (16.7) 287 (74.7) 33 (8.6) 384 (100)
Duration of feeding
Present now 9 (2.3) 15 (3.4) 1 (0.3) 23 (6.0) 0.000
<1 year 5 (1.3) 1 (0.3) 3 (0.8) 9 (2.3)
1–2 years 10 (2.6) 47 (12.2) 8 (2.1) 65 (16.9)
>2 years 40 (10.4) 226 (58.9) 21 (5.5) 287 (74.7)
Total 64 (16.7) 287 (74.7) 33 (8.6) 384 (100)

Contemporary Clinical Dentistry | Volume 14 | Issue 4 | October-December 2023 302

 Kshetrimayum, et al.: Nutritional status and ECC

boys and girls were in the moderate category, with a
higher percentage of boys (43.2%) than girls (31.5%).
Gender and dental decay did not show any significant
difference (P > 0.05), which is presented in [Table 2].
According to the WHO (2006) classification,
anthropometric measurements (BMI‑for‑age) were used to
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The Pearson relationship of caries, BMI‑for‑age,
and socioeconomic variables showed no significant
correlation (r = 0.04, P > 0.05).
Discussion
ECC is a common disease of childhood which is highly

record the data regarding malnutrition among preschool
kids. The average BMI for age was 71%; about 15.1%
were overweight, and 8.3% were obese. The data revealed
that 5.2% of the study participants were underweight.
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prevalent. Preschool children are most affected by this
condition as they usually rely on their parents or other
primary caregivers for diet and dental hygiene practices.
In spite of preventive measures and access to dental care,

Furthermore, overweight/obesity was observed more
among girls (12.7%), and the percentage of underweight
was higher in boys (3.4%) than girls (1.8%). A significant
difference was observed between gender and BMI for
age (P < 0.02). Table 1 shows the occurrence of caries
among various age groups, which was seen to be increasing
with age [Table 2].
Our study evaluated the number of children affected
with ECC corresponding to the mother’s education
level [Table 3], feeding habits [Table 4], and oral
hygiene habits [Table 5]. Table 6 shows the distribution
of the severity of ECC based on nutritional status.
Most of those with moderate caries (i.e., dmft >7)
were underweight or in the normal weight category.
our study revealed an elevated prevalence rate. A moderate
caries experience of 74.7% was seen in our study with a
mean dmft of 5.6 ± 2.4, which is much higher than other
studies.[18,19] Preschoolers are difficult to reach and often
unwilling to cooperate, making it challenging to determine
the prevalence rate of caries in this age group.[20] Similar
to the results of the previous studies, the present study also
showed that caries prevalence increased significantly with
age.[21‑23] This finding was as expected because there is an
increasing number of erupted primary teeth which become
exposed to the oral environment and cariogenic challenge.
Furthermore, as children grow older, changes in their
dietary habits and oral hygiene practices pose a greater
cariogenic challenge.

Table 5: The proportion of children with early childhood caries in relation to oral hygiene habits
Variables Caries Total, n (%) Inference (P)
Low, n (%) Moderate, n (%) High, n (%)
Tooth cleaning
Child cleaning 47 (12.3) 265 (69.2) 27 (7.0) 339 (88.5) 0.00
Mother cleaning 4 (1.0) 7 (1.8) 1 (0.3) 12 (3.1)
Child cleaning under supervision 13 (3.4) 14 (3.7) 5 (1.3) 32 (8.4)
Total 64 (16.7) 286 (74.7) 33 (8.6) 383 (100)
Frequency of cleaning
Once 38 (9.9) 201 (52.3) 21 (5.5) 260 (67.7) 0.224
Twice 26 (6.8) 86 (22.4) 12 (3.1) 124 (32.3)
Total 64 (16.7) 287 (74.7) 33 (8.6) 384 (100)
Tooth cleaning at night
Yes 40 (10.4) 181 (47.2) 17 (4.4) 238 (62.0) 0.807
No 24 (6.2) 106 (27.6) 16 (4.2) 146 (38.1)
Total 64 (16.7) 287 (74.7) 33 (8.6) 384 (100)
Dentifrice used
Fluoridated 61 (15.9) 286 (74.5) 30 (7.8) 377 (98.2) 0.00
Nonfluoridated 3 (0.8) 1 (0.3) 3 (0.8) 7 (1.9)
Total 64 (16.7) 287 (74.7) 33 (8.6) 384 (100)
Initiation of tooth cleaning (months)
6–12 3 (0.8) 1 (0.3) 0 4 (1.0) 0.011
13–18 6 (1.6) 10 (2.6) 1 (0.3) 17 (4.4)
19–24 46 (12.0) 239 (62.4) 30 (7.8) 315 (82.2)
>24 9 (2.3) 36 (9.4) 2 (0.5) 47 (12.3)
Total 64 (16.7) 286 (74.7) 33 (8.6) 383 (100)
Method of cleaning
Finger 0 0 0 0 0.00
Cloth 0 0 0 0
Baby brush 64 (16.7) 287 (74.7) 33 (8.6) 384 (100)

303 Contemporary Clinical Dentistry | Volume 14 | Issue 4 | October-December 2023

 Kshetrimayum, et al.: Nutritional status and ECC

Table 6: Distribution of early childhood caries according to body mass index‑for‑age

BMI‑for‑age category Caries Total Inference
Low Moderate High (P)
Overweight 0.01
Count 7 12 1 20
Percentage within BMI 35.0 60.0 5.0 100.0
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Percentage within caries 10.9 4.2 3.0 5.2

Percentage of total 1.8 3.1 0.3 5.2
Normal
Count 38 214 22 274
Percentage within BMI 13.9 78.1 8.0 100.0
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Percentage within caries 59.4 74.6 66.7 71.4

Percentage of total 9.9 55.7 5.7 71.4
Thinness
Count 16 38 4 58
Percentage within BMI 27.6 65.5 6.9 100.0
Percentage within caries 25.0 13.2 12.1 15.1
Percentage of total 4.2 9.9 1.0 15.1
Obese
Count 3 23 6 32
Percentage within BMI 9.4 71.9 18.8 100.0
Percentage within caries 4.7 8.0 18.2 8.3
Percentage of total 0.8 6.0 1.6 8.3
Total
Count 64 287 33 384
Percentage within BMI 16.7 74.7 8.6 100.0
Percentage within caries 100.0 100.0 100.0 100.0
Percentage of total 16.7 74.7 8.6 100.0
BMI: Body mass index

Preschoolers’ hygiene practices are modeled by their
families, especially by mothers, whose actions are related
to the prevalence of caries in their children. As mothers
are the primary caregivers of a child, low maternal
education is related to higher caries prevalence in their
children.[23,24] The results of this study are similar to other
studies, which show a strong association between mother’s
education and the presence of caries in their children.
This may be attributed to the lack of information and
education about oral health care for children in uneducated
mothers.[18,23,24] However, recent research has shown a lack
of any association between ECC and the education level of
the mother.[25]
The caries prevalence was higher in infants who were
exclusively bottle‑fed than in those who were breastfed.
However, some other studies reported that solely breastfed
kids had higher caries experience.[26,27] Therefore, the
influence of infant feeding per se on ECC remains a
complex and somewhat controversial issue. Many studies
have shown that regular tooth brushing may counteract the
effects of a cariogenic diet.[28,29] Therefore, variables such
as tooth brushing under supervision, frequency of brushing,
type of dentifrice, and tooth cleaning aids were analyzed in
this study. In the present study, researchers discovered that
the prevalence of caries in children who practiced tooth
brushing by themselves was higher than in those who had
their parents help them do it. This finding is supported by a
previous study that showed that children who did not have
their mothers’ help were at high risk of developing early
childhood dental caries.[18]
Research has stated that preschool kids do not have the
skills to practice and follow suitable oral hygiene measures.
This impairs their ability to prevent the development of
caries.[30] Hence, parents must monitor/brush their kids’ teeth.
This practice can help remove plaque, maintain good oral
hygiene among their children, and reduce the risk of dental
caries occurrence.[26] However, this contradicted the study
conducted by Hallett et al., which suggested that supervision
of children’s tooth brushing had no significant association
with caries prevalence.[24] In our study, BMI for age was
not associated with dental caries. This finding is consistent
with studies done by Moreira et al.[31] and Assi et al.[32] as
well as in an Indian study.[33] Contradicting the results of our
study ‑ There was a positive association between obesity and
dental caries, but the causative direction of this relationship
is unclear, as reported in a systemic review.[34]
Conclusion
It can be concluded, according to the study results, that
caries prevalence in preschool children of Imphal city was

Contemporary Clinical Dentistry | Volume 14 | Issue 4 | October-December 2023 304

 Kshetrimayum, et al.: Nutritional status and ECC

high, with a mean deft of 5.6 ± 2.4, and the risk factors
for ECC included age, low maternal education, improper
feeding, and oral hygiene habits. Our study could not find a
significant association between nutritional status and ECC.
The importance of proper hygiene and feeding habits can
be established early in life as a preventive health promotion
strategy.
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children of West Godavari district, Andhra Pradesh, South India:
An epidemiological study. Int J Clin Pediatr Dent 2016;9:251-5.
6. Gaur S, Nayak R. Underweight in low socioeconomic status
preschool children with severe early childhood caries. J Indian
Soc Pedod Prev Dent 2011;29:305-9.
7. Gradella CM, Bernabé E, Bönecker M, Oliveira LB. Caries
prevalence and severity, and quality of life in Brazilian
2-  to 4-year-old children. Community Dent Oral Epidemiol

Limitations of the study include a smaller population and
8.
analysis that provides for categorizing the children based
on other parameters such as pulp involvement, pain, or
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8K2+Ya6H515kE= on 01/02/2024
2011;39:498-504.
Vania A, Parisella V, Capasso F, Di Tanna GL, Vestri A, Ferrari M,
et al. Early childhood caries underweight or overweight, that is
the question. Eur J Paediatr Dent 2011;12:231-5.

difficulty chewing were not included in the study. Despite
considering the limitations, the study results give added
evidence to the literature to understand the complexity of
the relationship between ECC and BMI.
Recommendation
• This study will be an essential contribution to the data
on the prevalence of ECC among preschool children
in India, as no data is available from this region. Data
collected will help in conducting public health programs
to plan strategies for the prevention and treatment of
nutritional disorders and improvement in standards of
oral health
• The assessment of such factors will contribute to
population‑based studies that aim to identify selected groups
to receive care in public services to find more appropriate
methods to educate parents regarding the prevention of
ECC, given the magnitude of the accumulated needs
• Overall, the study results can form part of baseline
data for oral health assessment among children below
6 years.
Acknowledgments
The authors would like to acknowledge ICMR for
providing financial assistance.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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