|Year : 2022 | Volume
| Issue : 3 | Page : 157-168
Prevalence of early childhood caries and associated factors among a group of preschool children in El-Gharbia Governorate
Samaa W.S Mahmoud Abdallah, Fatma A.E El Hendawy, Ahmed I El Dosoky
Department of Pediatric Dentistry, Oral Health and Preventive Dentistry, Faculty of Dentistry, Tanta University, Egypt
|Date of Submission||24-Apr-2022|
|Date of Decision||30-May-2022|
|Date of Acceptance||31-May-2022|
|Date of Web Publication||14-Sep-2022|
Samaa W.S Mahmoud Abdallah
BDS, Faculty of Dentistry, Tanta University, Tanta
Source of Support: None, Conflict of Interest: None
Early childhood caries (ECC) is considered one of the most prevalent diseases in young children. It is a public health problem with oral and general consequences that adversely affects the quality of child life. This study aimed to determine the prevalence of ECC among preschool aged children in Gharbia Governorate and its related risk factors.
Patients and methods
A cross-sectional study conducted among 2700 Egyptian children 3–6 years old, a stratified cluster sampling methods was utilized to choose the enrolled children, a consent and a self-administered questionnaire about sociodemographic characteristics, dental service, dietary and oral hygiene behaviors applied to parents before the dental examination. The study approved by Research Ethics Committee at Faculty of Dentistry, Tanta University.
The prevalence of ECC among preschool aged children in Gharbia Governorate was (68.5%), it was higher in older children and in rural areas. Data revealed associations between prevalence of ECC and sex, mother education and family income. As well using bottle at bed time and drinking soda or juice were significant factors. Brushing frequency especially at bed time, parent believes about the important of brushing their children teeth also were significant factors.
This study showed high prevalence of ECC in the study population. ECC prevalence was associated with age, sex, family socioeconomic status, drinking soda or juice, night bottle feeding and teeth brushing. Results reveal the need for new preventive strategies to increase awareness about ECC, promoting good oral hygiene practices and enhancing mothers' knowledge of oral health.
Keywords: early childhood caries, preschool children, prevalence, risk factors
|How to cite this article:|
Mahmoud Abdallah SW, El Hendawy FA, El Dosoky AI. Prevalence of early childhood caries and associated factors among a group of preschool children in El-Gharbia Governorate. Tanta Dent J 2022;19:157-68
|How to cite this URL:|
Mahmoud Abdallah SW, El Hendawy FA, El Dosoky AI. Prevalence of early childhood caries and associated factors among a group of preschool children in El-Gharbia Governorate. Tanta Dent J [serial online] 2022 [cited 2023 Jan 30];19:157-68. Available from: http://www.tmj.eg.net/text.asp?2022/19/3/157/356078
| Introduction|| |
Dental caries remains a serious epidemic problem affects both children and adolescents in developing and developed countries despite all new preventive methods in oral health field that have been achieved through the last few decades ,. Caries in young children is a difficult challenge due to its exceptional pattern. Since children are predisposed to caries as soon as the first tooth appear . Many terms have been used to describe caries in young children, such as: baby bottle tooth decay, nursing caries and rampant caries . Finally for better representation of the multifactorial etiology, the term early childhood caries (ECC) has been used to explain caries in infants and preschool children . Recently the American Academy of Pediatric Dentistry defined ECC as the presence of one or more decayed, missing (due to caries), or filled tooth in a child aged up to 71 months of age .
ECC caused chiefly by interface of microorganisms and fermentable carbohydrates on the tooth surface ,. Despite its multifactorial nature many factors were associated with ECC as: socioeconomic and behavioral factors (dietary and oral hygiene behaviors). Regarding socioeconomic status a strong association was established between higher level of caries and low mothers' education. Also the prevalence of ECC was found to be much higher in children in low-income families than children in high-income families  because children with poor economic conditions do not visits dental office until dental problems happen, or at an older age .
Dietary habits are considered one of the most important factors that affect ECC. The connection between breastfeeding and ECC is not instantly recognizable , but breast feeding at night and it's duration, particularly over 18 months, have been set as a risk factor . However, nighttime bottle feeding specially sucrose containing fluids found to be major risk factor for ECC ,. Cleaning of children teeth especially at bed time protect them from being exposed to a higher risk of ECC. Hence parental guidance is of important role until the children get older enough to use the brush themselves . Also, using of fluoridated toothpaste twice a day was believed to be an important prophylactic measure .
Untreated ECC in young children can lead to severe problems  affecting both oral and general health of the child. The oral effects included rapid destroying of the primary dentition, pain, and acute infection , while the effects on general health can be categorized into: developmental, social, and economic effects. The developmental effects of ECC may be suffering from underweight, iron deficiency, and growing at a slower rate because of their inability to eat due to associated pain, discomfort, and teeth loss . On the other hand, the social effects could be loss of school days, limited child activities and his ability to learn . Another indirect social consequence of ECC is impaired speech development and reduced self-esteem due to early tooth loss . At the same time as economically treatment of ECC may be frequent and more expensive than expected .
In developed countries as north-western European countries (England, Sweden, and Finland) prevalence of ECC was found below 1–32% ,. Amongst the Canadian children it was less than 5%. While in developing countries as Sri Lanka it was 32.19% among children aged 1–2 years , moreover in Philippines ECC prevalence ranged from 59 to 94% . In Arabian countries such as United Arab Emirates and Saudi Arabia the Prevalence of ECC was found 42  and 92% , respectively. While in Egypt there were two studies have been conducted showing high prevalence of dental caries in preschool children up to 60.4%  in Tanta city and 96.6%  in El-Kaliobia Governorate.
Prevention of ECC is a responsibility of all society as a whole, not only the dental profession ,. Therefore, studies about prevalence of ECC and its associated factors are very important for the preventive programs used to decrease the risk of the disease.
The study was carried in order to assess prevalence of ECC among a group of preschool children in El-Gharbia Governorate. And the associated socioeconomic and behavioral factors related to ECC.
| Patients and methods|| |
This observational study was carried out on kindergarten children, Gharbia Governorate, Egypt, from October 2019 to May 2020. A total 2700 of both sexes children of aged more than or equal to 6 years were enrolled in this study.
Study design: cross-sectional observational study.
Study location: the study was carried out in kindergartens in El-Gharbia Governorate, Egypt.
Study duration: October 2019 to May 2020.
Sample size: 2700 children.
Sample size calculation: the sample size was calculated using Epi-Info software statistical package created by WHO and center for Disease Control and Prevention, Atlanta, Georgia, USA, version 2002. Assuming that, expected prognostic value is estimated at 69.9% with a margin of error of 5%, at 95% confidence level. The calculated sample size was 2700 of both sexes from El-Gharbia Governorate.
Patients and selection method: stratified random sampling method used to recruit the study sample. In the first stage, three centers selected: Al Mahala Center, Tanta and Zefta, and 900 children examined in each. In the second stage, city and village had been chosen from each center then three kindergartens were selected from each of them, and in the third stage three kindergartens classes representing children from three aged groups: 3–4 years, 4–5 years, and 5–6 years old were randomly chosen from each enrolled kindergarten.
Approval for this study obtained from Research Ethics Committee at Faculty of Dentistry, Tanta University, Ministry of Social Solidarity, Social Affairs, and Kindergartens Authorities. Informed consents to examine the children were taken from their parents after sending letters to explain the aim of the study according to the guidelines of Research Ethics Committee at Faculty of Dentistry, Tanta University.
- Healthy Egyptian children.
- Children between 3 and 6 years old participated in this study.
- Children whose parents authorized the examination to be performed by a written consent.
- Children suffering from systemic disease excluded from the study.
- Children with special needs and those who did not cooperate during the oral examination.
- Children with enamel hypoplasia.
- Presence of permanent incisors or first permanent molars.
The parents of children attending the selected kindergartens had been informed about the nature of the investigation prior to examination of the children. Self-administrative questionnaire was given , which require information on the following:
- Sociodemographic characteristics (region, sex, age, family size, parental education level, average annual income).
- Dietary behaviors (type of child feeding, duration, use of pacifier and bed time bottle feeding).
- Oral hygiene behaviors (brushing, frequency of tooth brushing and oral hygiene habits).
- Use of a dental service (dental visit in the past and parents having received oral health care instruction).
A validated Arabic version of the questioner was adopted for this work .
Infection control measures
The examination was carried out using masks, disposable gloves and check retractors that were changed for every participant, while alcohol hand rubbing performed before examination for every child. Used gloves, masks and used gauze pads or tongue blades were disposed in a waste bag.
The examination was carried according to WHO diagnostic criteria  by the same examiner. The children were examined on a chair with suitable backrest under day light. Gauze pads were used to clean and dry the teeth surfaces before examination and tongue blades were used for examination. Dental caries recorded as cavity in the dentin and/or enamel according to WHO criteria and all non-cavitated carious lesions was disregarded. (dmft) index used as the following: the tooth was recorded decayed (d) if visible evidence of cavitation was observed, filled (f) if the tooth was restored, and missed (m) if extracted because of caries and the case considered as sever ECC if a dmft score more than or equal to 4 (age 3–4 years), more than or equal to 5 (age 4–5 years), or more than 6 (age 5–6 years). Data was recorded in the examination sheet.
Finally all the participants, mothers, and teachers had been received instructions related to oral hygiene at the end of the clinical examination. While the children who needed dental treatment were referred to the pediatric dental clinic at Pedodontics Department, Faculty of Dentistry and provided them with appropriate treatment.
The collected data from examination and questionnaire were categorized, coded and entered to Excel sheets, then presented and statistically analyzed using Statistical Package for Social Sciences program (version 22.0; SPSS Inc., Chicago, Illinois, USA), descriptive analysis including mean, median and SD were calculated in addition to χ2 test at a significant level of 0.05. Categorical was also described as frequency and percentage.
| Result|| |
Prevalence of early childhood caries
Prevalence of early childhood caries in Gharbia Governorate
Prevalence of ECC in Gharbia Governorate was 68.5%. The prevalence of ECC was found to be higher in children aged 5–6 years old (81.8%) than aged 4–5 years old (76.3%), the prevalence of caries significantly increased with age with mean dmft 2.2, 4.2 and 4.6 in children age 3–4 years, 4–5 years and 5–6 years, respectively, and a significant association was found between child age and ECC occurrence (P < 0.001) [Table 1]. Also, 73% of children in rural areas had ECC and the mean dmft was 3.9. Significant association was found between different socioeconomic areas in the government and ECC occurrence (P < 0.001). At the same time, ECC significantly affects male more than female as 73.7% of male had dental caries while 63.3% of female had dental caries experience.
|Table 1: Prevalence of early childhood caries among different age groups, areas and sex in Gharbia Governorate|
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[Table 2] shows that 42.1% of the children included in the study were second child. While most of the children at the sample 81.7% were born with weight more than 2.5 kg. Data also proved that the older the child order among his siblings the more the ECC occurrence. Since the study examined 741 first child and finds that 269 (36.3%) of them were presented ECC. While 472 (63.7%) were caries free. A 76.6% of the second child were presented ECC. As well as 85.6% of third child were presented ECC. Therefore a significant association was found between child order and ECC occurrence (P < 0.001). But no association was found concerning child birth weight and ECC occurrence.
|Table 2: Association between presence of early childhood caries and demographic risk factors|
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According to the percentage distribution of children parents' educations which appears in table (V-1), most of fathers had a high school education 45.7% and only 1.6% of the fathers were postgraduate degree. While most of the mothers have a college education 47.9% and only 3.4% of the mothers were postgraduate degrees.
Moreover, family income and children's parents had a great impact on the occurrence of ECC at their own children. Though the education level of mothers found to be significantly associated with ECC occurrence (P = 0.001), as well as the education level of fathers (P = 0.007). However, mother work status was not (P = 230).
Nevertheless, when measuring the connection between monthly family income and the occurrence of ECC among children, results in [Table 3] showed that 71.8% of children belong to a family with monthly income less than 1200 bounds presented ECC compared to 66.7% of children belong to family with income more than 1200 bounds. Hence, a significant association was found between occurrence of ECC and family monthly income (P = 0.007).
|Table 3: Association between occurrence of early childhood caries and dietary habits risk factors|
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Looking back into the feeding patterns history of the child during early years, the study showed that 61.3% of the sample received natural breast feeding, while 26% of children received bottle feeding, and 12.7% received both as appear in table (V-2). Only 1360 (50.4%) of the participant answered the question about lactation duration which revealed that most of them lactate more than 12 months. Furthermore there is no association found between ECC occurrence and neither type of feeding nor the duration of child lactation in this study.
Regarding receiving bottle feeding at bed time as a risk factor for ECC, results revealed that it had a strong association to occurrence of ECC (P < 0.001). The results revealed that 54.1% of the participants received bottle feeding at bed time as their mothers answered. When asking about bottle content most of mother's answers (85.6%) were only milk. And only 16.4% of mothers were adding sugar to their baby bottle while 83.6% are not. Moreover, bottle content does not showed a significant association with ECC occurrence (P = 0.699). Despite that, ECC prevalence found to be 68.7, 60 and 67.7% among the children whose bottle contain milk, juice or both, respectively.
The occurrence of ECC noticed to be higher for those children whose mothers added sugar to their bottles (94.7%) more than it was at the participants whose mothers were not 63.2%, and association was found between ECC occurrence and adding sugar to the baby bottle in the present study (P < 0.001).
The study demonstrated that 30.3% of the children used pacifier. Moreover 9.9% of mothers who were using pacifier were adding sugar to their pacifier. While the pacifier usage does not show any significance with ECC occurrence (P = 0.864), adding sugar to it shows a great significant in this research results (P = 0.001) and children who used pacifier dipped in sugar shows higher ECC prevalence 91.4% than children who used pacifier without adding sugar to it (65.8%).
Results demonstrated that 68.7% of the children in the sample were drinking soda. While 75.9% of the sample were drinking juice as showed in table (V-3). However, both factors soda and sugared juice having a great significant association with ECC occurrence (P < 0.001) [Table 4].
|Table 4: Association between occurrence of early childhood caries and hygienic habits risk factors|
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Regarding teeth brushing habits 55.8% of families reported that their children brushed their teeth, while 44.2% of the children do not. Furthermore, most of the children who regularly brushed their teeth were brushing once per day 70.7%, while 23.1% brushed their teeth twice per day and only 93 (6.2%) brushed their teeth three times per day as showed in table (V-3).
Among those who were brushing their teeth, results showed that most of them start brushing at 4 years old, 690 (45.8%). As well 65.3% of them were brushing their teeth before sleep, and 48.9% of them were using especial tooth paste as described in table (V-4). Moreover, both brushing frequency and brunching before bed were found to be significantly associated with occurrence of ECC (P < 0.001, 0.008).
When asking the parents of children if they help their children in brushing their teeth, 51.6% of the parents answered yes. But neither using especial children toothpaste nor parent supervision during teeth brushing found to be associated with occurrence of ECC (P = 0.063, 0.536) [Table 5].
|Table 5: Association between occurrence of early childhood caries and parent's knowledge and attitude risk factors|
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Table (V-5) showed that 78.1% of the parents consider brushing their children's teeth is important. Over and above, those parents who do not think that brushing a child's teeth is important return that for many reasons. Forty-eight percent think that children's teeth are primary and they will be replaced. While some (5.1%) do not find enough time to help their children and 24.2% do not know that it is important to brush their children teeth at early age. Others (14.7%) find other reasons.
Regarding parent's oral health knowledge and its association to occurrence of ECC, the results show that 82.2% of children whose parents believe it is not important to brush their child teeth had ECC. While only 64.7% of children whose parents think it is imperative to brush their child teeth had ECC as explained in table (V-4). Thus parent's oral health knowledge found to be significantly associated with occurrence of ECC.
Parent's poor knowledge about the importance of brushing their child's teeth at early age, having no time and thinking that those teeth will be replaced were the most reasons of lowering the importance of baby's teeth brushing which have highest ECC prevalence (86.7, 83.3, 82.7%), respectively.
The results revealed also that only 15.8% of parents receive an advice regarding their child oral health. Yet, receiving previously dental advice about their child's oral health has no significant association with the prevalence of ECC in this study.
Furthermore, 27.9% of the children visited dentist in past, as well as pain feeling was the most reason for that visit (63.6%). Both past dentist visit and the reason of that visit found to be strongly significant with the prevalence of ECC.
| Discussion|| |
Despite the considerable improvement in preschool children's oral health over the past decade, dental caries remains an imperative childhood disease affecting a huge proportion of young children . Besides, the changing lifestyle and dietary patterns had markedly raised the caries incidence . Furthermore, studying the prevalence of ECC and associated risk factors is essential to develop interventions for the prevention of subsequent teeth caries and it is consequent complications  in addition to implementation of effective oral healthcare programs .
Epidemiological surveys play an important role in screening and assessing dental needs in the community ,. Therefore, there is a continuous demand to estimate the caries prevalence and severity information . Although many researches in different populations have been performed to assess the prevalence of ECC and associated risk factors, only few epidemiological studies have been performed and reported in such centers in Egypt.
Moreover there is no recent published study in Gharbia government studying ECC prevalence. Thus, this study was carried out to clarify the prevalence of ECC and associated socioeconomic and behavioral factors among a group of preschool children in El-Gharbia Governorate.
The sample of this study was selected randomly from rural areas and urban areas that allowing access to children of different socioeconomic status to give the ability to study the effect of socioeconomic factors and its association to ECC prevalence. Also, the children age ranged between 3 and 6 years because their primary dentition mostly accomplished their eruption by this age and WHO chosen them as the index age group in most of the oral health surveys that concerning about primary dentition .
The examination was carried using tongue blades, on a chair with suitable backrest under day light according to WHO diagnostic criteria  by the same examiner which is currently a recommended method for detecting caries. Also, it is found to be feasible when epidemiological surveys were conducted.
In the present study the prevalence of ECC in Gharbia Governorate was 68.5% while a study in Kalubia government, almost a decade ago reported a lower prevalence (60.4%) . Another one conducted at Public Maternal and Child Health Care in Tanta city found that prevalence of ECC was 69.6%  which is near to our results that covered a wider area. Recently, a study at Abo El Rish Hospital  with an age range between 2 and 5 years old revealed that 91.8% of the sample were suffering from ECC. This higher prevalence may be a result of a smaller sample (294) than the present study.
Internationally, the prevalence of ECC had a wide range. Yet, the outcomes of the present search showed a result much higher than developed countries as in Turkey (45%) , Italy (8.2%) , and in German (49.7%) . As well as it complied with the results of developing countries ,. However, the ECC prevalence of our study is higher than ECC prevalence in some developing countries such as Sri Lanka (32.2%)  and 16% Salem in India  which were relatively lower due to various factors, for example endemic fluorosis at these areas.
The prevalence of ECC in the rural areas of Gharbia was relatively higher (73%) than in the urban areas (64.1%) in Gharbia government. The present results confirmed by Correa-Faria et al.  study. And this may be attributed to poor awareness regarding oral health care and ineffective bacterial control practices along with wrong feeding practices in rural areas.
Additionally, the prevalence of ECC in urban areas in Gharbia still very high in comparison with another urban areas like in urban Boston, USA which was 3.0%, while ECC prevalence among 1- to 3-year-old children was 6.3% . Yet, Nunn et al.  did not find this difference statistically significant opposite to the present study. It could be because of inadequate dental manpower, economic constraints or neglecting the necessary dental care at the younger aged children in our study sample.
Whilst Henry et al. , Stephen et al. , and Slabšinskienė et al.  showed lower prevalence (40.6, 16 and 50.6%), respectively, in urban areas than the present search which may be explained by the difference in the dietary behavior. Also, due to their younger age range 0–3, 1.5–6 and 3 years old, respectively, of the children included in their study.
In this study ECC significantly affects males more than females. This finding agreed with previous investigations ,. But, girls were found to have caries more than boys with a sex significant in a study by Nagarajappa et al. . However, unlike this, Stephen et al. , Koya et al. , along with Alsalim et al.  found that there was no statistically significant association between ECC and sex of the child. Nevertheless the plausibility of biological factors such as sex being risk factors for ECC is hard to understand and may require further studies to investigate sex in caries risk practices or tooth anatomy differences in between them in this study location to find appropriate reasons for the observation .
Regarding age as risk factors for ECC, statistical analysis in the present study obviously showed that prevalence of ECC significantly increased with age which agreed with Nunn et al. , Subramaniam and Prashanth , Nobile et al.  and Alsalim et al. . Also Seminario and Ivancaková  referred to increasing of detectable level of Streptococcus mutants up to 60% at 15 months of age.
In relation to the position of child in the family, the data proved significant association between child order and ECC presence. Seeing that the lower the child order between his siblings the more incidence of having ECC. The same relation had been found by Abu Hamila  while Samara  had not, this may be explained with the different traditions in Samara's study community that used to had a large number of children in each family. Also, most of mothers (77.7%) were nonemployed house wives.
The present study found that parents' education is a significant predictor for ECC and the prevalence of ECC was higher among children with primary educated parents and found to be the lowest among children with parental education at college or postgraduate searches level. The study analyzed the schooling of fathers, differing from the majority of studies, in which only the association with the mother's education and ECC evaluated. Since both parents become currently the main caregivers and educators of their children. Our end results agreed with Nunn et al. , Stephen et al.  and Kabil and Eltawil  results. The reasons for this may be that mothers from lower education levels may have objects, social, and financial difficulties that lead them unable to be concerned their oral health rather than their own children oral health.
On the other hand Koya et al.  counter them. While Alsalim et al.  stated that father education is not significant risk factor, in counter mother education is important risk factor for ECC. In opposite Jaff Mohammad et al.  showed no significant correlation between mother's education and ECC presence because of very small sample size.
When the family monthly income was evaluated in the present study it was highly significant for ECC which may be attributed to family low income rank affects their ability to afford proficient dental health care, over and above to live in a healthy environment. Besides, the working status of children's mothers did not found to be significant factor for ECC.
Furthermore, Hallett and O'rourke et al. , Nunn et al. , Subramaniam and Prashanth , Moimaz et al. and Li et al.  agreed with our study. But, Hajishengallis et al.  contradicts our results. Since they assumed the social class of the children to be based on the hypothesis that the children who are attending to governmental schools belong to low-income group. The reason for this was reluctant of the parents/caregivers to reveal their real incomes. However, he observed that the prevalence of ECC was much higher in the children who were attending private schools compared to the children were attending government schools. Alsalim et al.  also found no relation.
Although several studies , reported an association between bottle or breast-feeding with ECC, it was not possible, in this study, to prove this association. Yet, effect of breast milk on ECC at these studies could be explained through other factors related to it as duration of feeding, frequency and monthly longevity of feeding. Moreover, our finding supports that nursing caries term was not accurate and had to be substituted with the term ECC, since the etiology of ECC cannot be focused only on baby bottle usage. Olatosi et al. , Paglia et al. , Kabil and Eltawil  and Nagarajappa et al.  confirm the current knowledge of trivial correlation between ECC experience and feeding type.
Many studies ,,,, concluded that children who fed beyond 12 months – a time during which most of the deciduous teeth erupt – increasing the threat of ECC , the present study did not identified feeding duration as a risk factor for ECC. Since the parent's gave inaccurate answers for this type of questions about past things whereas parent's could not remember the exact real answers in the present study. However, Folayan et al.  and Jaff Mohammad et al.  studies agreed with our results and showed no significant correlation between feeding duration and ECC.
Yet, the present study found significant correlation between considered risk factors sleeping with the bottle in the mouth along with adding sugar to the bottle and ECC. Since, it facilitates liquid with sugar to stays for many hours around the teeth giving an excellent source of nutrition for oral bacteria so as to develop ECC.
Makhdoom et al.  study in Pakistan revealed that children who took bottle at nighttime especially with sugar had more caries (72.5%) when compared to those who did not (50%). Moreover, Nagarajappa et al. , Kabil and Eltawil , Elidrissi and Naidoo , Peltzer and Mongkolchati  and Feldens et al.  confirmed the same results. While Jaff Mohammad et al. , Folayan et al.  and Olatosi et al.  found no relation between bottle at nighttime and ECC which could be explained by their smaller sample (70, 479 and 302 contributor, respectively).
Regarding bottle content as a risk factor for ECC results showed no significant relation along with Subramaniam and Prashanth  and countered to Alsalim et al.  study which found bottle content significantly associated.
Although using pacifier did not found to be related to ECC in the present study adding sugar was considered a risk factor for it. Whereas Paglia et al.  found that children with ECC used of pacifier with sugar/honey nine times in contrary to children free of caries. But, Subramaniam and Prashanth  found pacifier use and sugar add both not significant which could be as a result of other protective factors such as water fluorosis in some areas.
On investigating drinking soda as a risk factor for ECC, the results demonstrated that children who used to consume soda have higher mean dmft 5.8 than children who does not 4.4. Hallett and O'rourke  and Olatosi et al.  found the same results. Additionally Paglia et al.  reported that children with ECC drunk amount of soft drink (8.4 ml/day) in contrary to 4.1 ml/day for children free of caries.
Results also showed that consumption of drinks containing free sugars was mainly a vital factor in ECC development which agreed with Schroth et al.  and Paglia et al. , but disagreed with Kabil and Eltawil  which was explained with the smaller sample he used in the study (108 participants) and only 13 participants were selected in each stratum.
In the present study, children who regularly brush their teeth have lower prevalence of ECC. These results are supported by other studies ,,. Yet, no significant associations were found between the prevalence of caries and teeth brushing in other studies , because this factor is cross linked with other factors, such as sugar intake and microorganisms.
Regarding studying teeth brushing as a risk factor for ECC it concerned with brushing frequency, the age at which the child started to brush, brushing before bed and parents assistant's. Our results revealed that brushing frequency especially before bed time were highly significantly related to ECC presence. Additionally Kabil and Eltawil  and Nagarajappa et al.  confirmed these results. While Subramaniam and Prashanth , Olatosi et al. , Moimaz et al.  and Alsalim et al.  conflict with it which may be due to smaller age range as in Subramaniam's study which included only children aged between 8 and 48 months or because of much smaller sample they had than the present study (302, 768 and 491) participants in Olatosi, Moimaz and Alsalim, respectively.
Interestingly in the present study, a parent's help during teeth brushing did not found to be significantly related to presence of ECC in addition this finding does not concur with other studies ,,, which may be due to dishonesty of parent answering this question in our questioner are attributable to social desirability response bias. But, similar finding have been reported in Elidrissi and Naidoo  study.
Whereas the present study showed no significant relation whenever the child begin brushing his teeth at younger age or when using a fluoridated tooth paste in ECC which agreed with Folayan et al. , Olatosi et al.  and Elidrissi and Naidoo . Hence, this suggested that other factors also contributed to prevention of ECC.
On the other hand, Marinho et al.  cleared that regular use of fluoride toothpastes have a caries reduction effect on permanent dentition. But, there is a little evidence about its impact on primary teeth. Furthermore, Nagarajappa et al.  argument the current study and found that fluoridated tooth paste was significantly preventive for ECC, this may contributed to other related factors which were not evaluated by this study that may have a bearing on the results as duration and type of brushing technique.
The outcome of the analysis of association between ECC and the parent's oral health knowledge showed great association. Moreover, 78.2% of parent's answered 'yes' when asked about importance of teeth brushing which reflected well oral health knowledge of the participant parents that explained by the increased percentage of educated people in the last decade plus the influence of the media development and internet with social media effect on raising the health education.
Whereas, 35.3% of children whose parents believe about the importance of teeth brushing were caries free compared to only 17.8% of children whose parents not believed about the importance of teeth brushing and ECC presence. Subramaniam and Prashanth  and Folayan et al.  reported similar findings in their studies.
The answer 'those teeth will be replaced' was the most reason for some participant to neglect their children teeth brushing. Yet, it showed no significance in the present results. Surprisingly, only 15.8% of the parents in the study receive an advice regarding their children oral health which gives an idea about how public educational centers in Egypt, particularly El-Gharbia need to develop new strategies to reach a wide range and more people in the society. Yet, it was not found to be a risk factor for ECC unlike Li et al. .
Also, statistical analysis in the present study showed that 92.2% of children who visited dental clinic in the past are infected with ECC compared to 59.4% children who did not visit dental clinic with a great association between ECC and the past visit to dentists. Moreover, there was an association between the different reasons for access to dental services. Thus, feeling pain is the most reason for children in the sample to visit dental clinic (63.6%) in addition almost 97.7% of them were manifesting ECC.
What is more, Nobile et al. , Moimaz et al.  and Kabil and Eltawil  studies were meeting our results. Nevertheless, Folayan et al.  controversy to our study and find annual dental visits not associated with ECC which may be explained by the smaller sample he had (494 participants).
This study was accomplished with self-reported questionnaire therefore the parent's answers may be affected by social acceptance and a possibility of dishonestly might take place in their answers. As well as if the questions appear to be sensitive to them as question (7). Also some parents did not give all the required information or did not answer the entire questionnaire; hence their children were neglected from this study.
In addition, some parents miss understudied a number of questions and that may have an effect on the accuracy of the end result at some points as question (9–12). As well our study did not focus on complex interrelationship of different factors of ECC or assessment of other factors as drinking water source, frequency of snacking.
| Conclusion|| |
This study showed high prevalence of ECC in the study population. ECC prevalence was associated with age, sex, family socioeconomic status, drinking soda or juice, night bottle feeding and teeth brushing.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]