DOI: 10.1111/ipd.

12105

Association between developmental defects of enamel and

early childhood caries: a cross-sectional study

PATRÍCIA CORRÊA-FARIA1, SUZANE PAIXÃO-GONC

ß ALVES1, SAUL MARTINS PAIVA2, ISABELA
ALMEIDA PORDEUS , LEANDRO SILVA MARQUES & MARIA LETÍCIA RAMOS-JORGE3
2 3

1
Department of Pediatric Dentistry and Orthodontics, School of Dentistry, Federal University of Minas Gerais, Belo
Horizonte, 2Department of Pediatric Dentistry and Orthodontics, School of Dentistry, Federal University of Minas Gerais,
Belo Horizonte, and 3Department of Pediatric Dentistry and Orthodontics, Federal University of Vales do Jequitinhonha and
Mucuri, Diamantina, Brazil

International Journal of Paediatric Dentistry 2014 Statistical analysis involved the chi-squared test
and Poisson regression.
Background. The determination of risk factors for Results. The prevalence of DDE and ECC was
early childhood caries (ECC) is important to the 33.9% and 43.3%, respectively. Children with
implementation of preventive and restorative DDE had a greater prevalence rate of ECC (PR:
measures. However, few studies have addressed 1.325; 95% CI: 1.093–1.607). Early childhood car-
the association between ECC and developmental ies was more prevalent among children with
defects of enamel (DDE). unsatisfactory oral hygiene (PR: 2.933; 95% CI:
Aims. To investigate the association between DDE 2.22–3.86), those who resided in rural areas (PR:
and ECC, controlling for socioeconomic factors 1.267; 95% CI: 1.03–1.55) and those from families
and the presence of dental plaque. with a lower monthly household income (PR:
Design. A cross-sectional study was carried out 1.501; 95% CI: 1.06–2.12).
with 387 children aged two to 5 years during the Conclusions. The presence of ECC was associated
National Immunisation Day held in 2010 in Di- with the occurrence of DDE in the primary denti-
amantina, Brazil. Data were collected through tion. Place of residence and monthly household
clinical examinations and interviews with parents/ income (socioeconomic indicators) and oral
guardians addressing socioeconomic indicators. hygiene (behavioural factor) exerted an influence
on the occurrence of ECC.

unsatisfactory oral hygiene exert a consider-

Introduction
able influence on dental caries experience2,3.
Preschool children can be affected by different Developmental defects of enamel is a
adverse oral health conditions, such as early common occurrence in primary teeth. The
childhood caries (ECC) and developmental prevalence of DDE in children from different
defects of enamel (DDE). Indeed, ECC countries ranges from 24.4% to 81.3%4,5.
remains one of the most prevalent chronic These defects are classified based on clinical
conditions in childhood. In a national survey appearance as enamel hypoplasia, demarcated
carried out in Brazil, 53.4% of five-year-old opacities or diffuse opacities6,7. The risk of
children had an average of 2.3 teeth with DDE in the primary dentition is related to
caries1. The high prevalence rate of ECC is prenatal, perinatal and postnatal factors.
influenced by socio-demographic factors and Studies have demonstrated that premature
oral hygiene practices. Studies have birth8, an absence of breastfeeding9,10, low
demonstrated that a low level of education birth weight10,11, social aspects and systemic
on the part of parents/guardians, insufficient problems in childhood11 are the main causes
knowledge on oral health, a low income and of DDE.
A number of studies have found that DDE
may be a risk factor for ECC7,12. Teeth with
Correspondence to: enamel defects have retentive areas that can
Patrı́cia Corrêa-Faria, Av. Antonio Carlos, 6627, Faculdade
de Odontologia, UFMG - Campus Universitário 31270-901,
lead to the build-up of bacterial plaque,
Belo Horizonte, MG, Brazil. facilitating the progression of carious
E-mail: patriciafaria@outlook.com lesions12. Moreover, children with DDE have

© 2014 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd 1
2 P. Corr^ea-Faria et al.

a greater amount of streptococci from the Calibration exercise

mutans group13, which are associated with
Data acquisition involved clinical oral
the aetiology of dental caries14. Despite the
examination and interviews administered to
importance of this association to the establish-
parents/guardians addressing socioeconomic
ment of ECC prevention measures and the
indicators and characteristics of the child. One
identification of susceptible children, few
team made up of three researchers (an exam-
studies have addressed the influence of DDE
iner and two assistants) was installed at each
on the occurrence of ECC, especially among
health care unit. Prior to the fieldwork, the
preschool children15–19. Furthermore, a com-
examiners underwent a calibration and train-
parison of studies demonstrates the difficulty
ing exercise for the diagnosis of ECC and DDE.
in establishing a consensus on this association
The calibration exercise consisted of three
due to the different assessment tools
stages. The theoretical stage involved a discus-
employed for the diagnosis of DDE, the use of
sion of the criteria for the diagnosis of DDE
specific samples, such as children with nutri-
and ECC and were performed an analysis of
tional abnormalities, and the consideration of
photographs and oral clinical examination. A
only hypoplasia as DDE.
specialist in paediatric dentistry was the gold
The aim of the present population-based
standard in the theoretical framework and
study was to investigate the association
coordinated this step, instructing ten general
between DDE and ECC in children, control-
dentists on how to perform the examination.
ling for socioeconomic factors and the pres-
The analysis of photographs was performed on
ence of dental plaque.
two separate occasions with a 1-week interval
between sessions. Data analysis involved the
Materials and methods calculation of Kappa coefficients (K = 0.80–
0.81 for both inter-examiner and intra-exam-
Study design and sample characteristics iner agreement). The clinical step was carried
out during the pilot study, in which inter-
A cross-sectional study was carried out in the
examiner agreement was determined
city of Diamantina, which is located in the
(K = 0.90). As the Kappa coefficients were
northern portion of the state of Minas Gerais
very good, the examiners were considered able
in southeast Brazil. The Human Development
to perform the epidemiological study.
Index for the city is 0.71620. Diamantina has
a population of 45 880 inhabitants, 2537 of
whom are children aged to one to 4 years21. Pilot study
The study population included children from
A pilot study involving 30 children who did
2 to 5 years of age treated at the ten primary
not participate in the main study was carried
health care facilities in the city during immu-
out to test the methods, dental examination,
nisation campaigns held in 2010. Diamantina
administration of the questionnaires and
has 90% vaccine coverage.
preparation of the examiners. The results of
For the sample size calculation, a 53.6%
this pilot study indicated there was no need
prevalence rate of ECC3, 95% confidence
to change the proposed methods.
interval and 5% standard error were used,
which determined a minimum sample of 383
children. An additional 77 (20%) children Clinical oral examination
were added to compensate for possible losses,
Dental examinations were performed at the
totalling 460 children. Systematic sampling
primary health care facilities during immuni-
was adopted for the randomisation. For such,
sation campaigns held in 2010. A head lamp
the children were arranged in a line, with the
(Petzl Zoom head lamp; Petzl America, Clear-
first child examined, the second not exam-
field, UT, USA), disposable mouth mirror
ined, the third child examined, and so on.
(PRISMA, S~ao Paulo, SP, Brazil) and periodon-
Children who did not cooperate during the
tal probe (WHO-621; Trinity, Campo Mour~ ao,
examination were excluded.

© 2014 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
 Early childhood caries and enamel defects 3

PA, Brazil) were used for the dental examina- This study received the approval of the
tion. In a private room, the examiners were Human Research Ethics Committee (register
seated in front of the child, who remained 077/09) of the Federal University of the Je-
standing. The three types of DDE (diffuse quitinhonha and Mucuri Valleys, Brazil. An
opacity, demarcated opacity and enamel hypo- invitation letter was then presented to the
plasia) were classified based on the criteria of parents of the selected children, explaining
the Developmental Defects of Enamel Index6. the aim, characteristics, importance and
The criteria of the World Health Organiza- methods of the study and asking for permis-
tion22 were used for the diagnosis of ECC. sion for their child’s participation.
Early childhood caries was dichotomised as
absent or present. Oral hygiene quality was
Results
evaluated based on the presence of visible
plaque. The tooth surfaces were scraped with Among the 387 participants, 50.1% (n = 194)
a clinical probe and the presence of plaque were girls and mean age was 43.39 months
indicated unsatisfactory oral hygiene. The (standard deviation: 11.67 months). The
examiners used appropriate equipment to majority of parents/guardians had <8 years of
protect against individual cross-infection, with schooling (63.3%) and monthly household
all necessary instruments and materials income was <2 times the Brazilian minimum
packed and sterilised. wage among 72.9% of the families.

Non-clinical examination Table 1. Socioeconomic and oral characteristics of sample.

Information on socioeconomic aspects Variables n %

(monthly household income, mother’s school-
ing and place of residence), child’s age and sex Sex
Male 193 49.9
was gathered through interviews with parents/
Female 194 50.1
guardians. Income was categorised based on Age
the Brazilian minimum monthly salary 2 117 30.2
(approximately US$283). Mother’s schooling 3 88 22.7
4 159 41.1
(years of study) was categorised based on a 5 23 5.9
cut-off point of 8 years, which corresponds to DDE
a primary school education in Brazil. Absent 256 66.1
Present 131 33.9
Diffuse opacity
Absent 319 82.4
Statistical analysis Present 68 17.6
Demarcated opacity
Data analysis was performed using the Statis-
Absent 311 80.4
tical Package for Social Sciences (SPSS for Present 76 19.6
Windows, version 19.0; SPSS Inc., Chicago, Hypoplasia
IL, USA). Associations between ECC, DDE Absent 368 95.1
Present 19 4.9
and independent variables were determined ECC
using the chi-squared test. Poisson regression Absent 220 56.8
with robust variance was performed for the Present 167 43.2
Place of residence
analysis of factors associated with DDE and Urban area 234 60.5
ECC. The magnitude of the association of Rural area 153 39.5
each factor with DDE and ECC was assessed Household income
≥2 times minimum wage 101 26.1
using unadjusted and adjusted prevalence
<2 times minimum wage 282 72.9
ratios (PR), respective 95% confidence inter- Missing data 4 1.0
vals (CI) and P-values (Wald test). Explana- Mother’s schooling
tory variables with a P-value of ≤0.25 in the ≥8 years 126 32.6
<8 years 245 63.3
bivariate analysis were incorporated into the Missing data 16 4.1
model.

© 2014 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
4 P. Corr^ea-Faria et al.

Table 2. Distribution of DDE according to independent Table 3. Distribution of ECC according to presence of DDE,
variables (place of residence, sex, age, mother’s schooling characteristics of child and socioeconomic indicators.
and family income).
ECC
DDE
Absent Present
Absent Present n (%) n (%) P-value
n (%) n (%) P
Sex
Sex Male 108 (56.0) 85 (44.0) <0.001*
Male 137 (71.0) 56 (31.4) 0.045* Female 112 (57.7) 82 (42.3)
Female 119 (61.3) 75 (38.7) Age (years)
Age (years) 2 86 (73.5) 31 (26.5) <0.001**
2 84 (71.8) 33 (28.2) 0.205** 3 49 (55.7) 39 (44.3)
3 57 (64.8) 31 (35.2) 4 78 (49.1) 81 (50.9)
4 99 (62.3) 60 (37.7) 5 7 (30.4) 16 (69.6)
5 16 (69.6) 7 (30.4) Oral hygienea
Place of residence Satisfactory 158 (78.6) 43 (21.4) <0.001*
Urban area 153 (65.4) 81 (34.6) 0.694* Unsatisfactory 50 (29.1) 122 (70.9)
Rural area 103 (67.3) 50 (32.7) DDE
Mother’s schooling Absent 164 (64.1) 92 (35.9) <0.001*
≥8 years 79 (62.7) 47 (37.3) 0.256* Present 56 (42.7) 75 (57.3)
<8 years 168 (68.6) 77 (31.4) Diffuse opacity
Household income Absent 193 (60.5) 126 (39.5) 0.002*
≥2 times minimum wage 72 (71.3) 29 (28.7) 0.196* Present 27 (39.7) 41 (60.3)
<2 times minimum wage 181 (64.2) 101 (35.8) Demarcated opacity
Absent 190 (61.1) 121 (38.9) 0.001*
DDE = developmental defects of enamel. Present 30 (39.5) 46 (60.5)
*Pearson’s chi-squared test (P < 0.05). Hypoplasia
**Linear trend chi-squared test (P < 0.05). Absent 212 (57.6) 156 (42.4) 0.183*
Present 8 (42.1) 11 (57.9)
The prevalence of ECC was 43.2% (n = 167) Place of residence
Urban area 153 (65.4) 81 (34.6) <0.001*
and 44.4% of the children had unsatisfactory Rural area 67 (43.8) 86 (56.2)
oral hygiene. The prevalence of DDE was Mother’s schoolingb
33.9% (n = 131). The most common type of ≥8 years 69 (54.8) 57 (45.2) 0.506*
<8 years 143 (58.4) 102 (41.6)
DDE was demarcated opacity (19.6%), fol- Household incomec
lowed by diffuse opacity (17.6%) and hypopla- ≥2 times minimum wage 76 (75.2) 25 (24.8) <0.001*
sia (4.9%) (Table 1). Developmental defects of <2 times minimum wage 140 (49.6) 142 (50.4)
enamel was significantly associated with sex
ECC: early childhood caries.
(P = 0.045), as a greater prevalence rate was *Pearson’s chi-squared test (P < 0.05).
found among the girls (Table 2). **Linear trend chi-squared test (P < 0.05).
a
Early childhood caries was significantly Oral hygiene: Data missing from 14 subjects.
b
Mother’s schooling: data missing from 16 subjects.
associated with DDE (P < 0.001). In the c
Household income: data missing from four subjects.
analysis of each type of DDE, EEC was
significantly associated with diffuse opacity In the adjusted multivariate regression
(P = 0.002) and demarcated opacity (P = 0.001), model, DDE (PR: 1.325; 95% CI: 1.093–
but was not associated with hypoplasia. The 1.606), oral hygiene (PR: 2.933; 95% CI:
greatest frequency of ECC was found among 2.224–3.868), place of residence (PR: 1.267;
children with unsatisfactory oral hygiene 95% CI: 1.033–1.555), monthly household
(P < 0.001). Moreover, caries experience income (PR: 1.501; 95% CI: 1.061–2.123)
increased with age, as a greater frequency of and age (Table 4) remained associated with a
ECC was found among older children greater prevalence rate of ECC.
(P < 0.001). Early childhood caries was signif-
icantly associated with place of residence
Discussion
(P < 0.001) and monthly household income
(P < 0.001), whereas no associations were In the present study, DDE was associated with
found with the other independent variables the occurrence of ECC in the primary denti-
(sex and mother’s schooling) (Table 3). tion, as 57.3% of the 131 children with DDE

© 2014 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
 Early childhood caries and enamel defects 5

Table 4. Prevalence ratios and confidence intervals for associations between ECC, DDE and other variables.

Prevalence ratio Prevalence ratio

Variable (unadjusted)* 95%CI P-value (adjusted)* 95%CI P-value

DDE
Absent 1 1
Present 1.593 1.27–1.98 <0.001 1.325 1.09–1.60 0.004
Oral hygiene
Satisfactory 1 1
Unsatisfactory 3.316 2.50–4.39 <0.001 2.933 2.22–3.86 <0.001
Age (years)
2 1 1
3 1.673 1.14–2.45 0.008 1.497 1.10–2.02 0.001
4 1.923 1.37–2.69 <0.001 1.772 1.33–2.35 <0.001
5 2.626 1.75–3.93 <0.001 1.865 1.30–2.66 0.009
Place of residence
Urban area 1 1
Rural area 1.624 1.29–2.03 <0.001 1.267 1.03–1.55 0.023
Household income
≥2 times minimum wage 1 1
<2 times minimum wage 2.034 1.42–2.91 <0.001 1.501 1.06–2.12 0.022

CI: confidence interval.

*Poisson regression with robust variance.

had at least one tooth with decay12. According factory oral hygiene3. Although adequate oral
to cross-sectional and longitudinal investiga- hygiene is considered an effective practice for
tions, DDE predisposes individuals to the devel- the prevention of dental caries by helping
opment of carious lesions due to the structural eliminate cariogenic bacteria and fermentable
defects of the tooth surface, which facilitate the substances24, this practice seems to have been
adhesion and colonisation of cariogenic bacte- compromised in the present sample. In the
ria7,12–14. Moreover, the larger number of strep- age group studied (2–5 years of age), children
tococci from the mutans group in children with do not yet have the manual dexterity needed
DDE also explains this association13. for the maintenance of adequate oral
Despite the consensus on the association hygiene25. Thus, oral hygiene habits need to
between DDE and dental caries, comparisons be implemented, practiced or supervised by
among studies should be performed with cau- parents/caregivers on a daily basis24. While
tion. Previous cross-sectional investigations the practice and supervision of brushing were
have methodological differences in compari- not analysed in the present study, the high
son to the present study, such as the assess- prevalence of unsatisfactory oral hygiene and
ment tools used for the diagnosis of DDE; its association with dental caries may be
while some authors have employed the explained by a lack of accompaniment by par-
Developmental Defects of Enamel Index15,18, ents/caregivers during tooth brushing26 or
others have opted for the modified DDE unawareness and/or insecurity on the part of
Index17,19. It should also be stressed that parents/caregivers regarding adequate oral
some studies only investigated the association hygiene practices27. The practice of adequate
between ECC and quantitative defects on the oral hygiene is all the more important for
enamel (hypoplasia)16, unlike the present children with DDE, as these defects can lead
investigation, in which the associations were to a greater buildup of plaque and microor-
tested for all three types of DDE (hypoplasia, ganisms on the tooth surface.
demarcated opacity and diffuse opacity)17– The frequency of ECC was also greater
19,23
. among children from economically less privi-
In the analysis of other factors associated leged families and residents of rural areas28.
with ECC, this adverse oral condition was The association between children’s oral health
more frequent among children with unsatis- and a low socioeconomic status has been

© 2014 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
6 P. Corr^ea-Faria et al.

described in the literature, demonstrating that Research Foundation (FAPEMIG), Brazil. The
material deprivation and social disadvantages authors certify that they have no commercial
can exert a negative impact on perceived or associative ties that represent a conflict of
needs for care, the capacity for self-care and interest in connection with the manuscript.
the use of health services25,29. However, the
comparison of studies that address the influ-
Conflict of interest
ence of socioeconomic aspects on the occur-
rence of ECC should take into account The authors declare no conflict of interest.
differences among the indicators employed.
In the present study, place of residence,
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