1

Introduction

Dental caries is one of the most prevalent oral ailments of childhood . Globally, 2.4 billion adults and 486 million children had dental caries according to the survey done by Global Burden of Disease Study (2015) . In spite of many scientific advancements in the field of caries prevention, the disease continues to be a major public health problem in most of the developing countries including India .

Dental caries is a multifactorial disease with bacteria, fermentable carbohydrates, susceptible host and time as four main etiological factors. Furthermore, certain socio-demographic and nutritional factors also influence the caries prevalence of an individual which include: age, gender, nutritional status and socioeconomic status . Oral health, being a depicter of general health is sturdily influenced by the intake of sweetened foods and increased caries index is associated with uneven dietary patterns . The most commonly used index to assess nutritional status of an individual is body mass index (BMI) . It may be hypothesized that certain socio-demographic and nutritional factors might affect the prevalence of dental caries in children. Reports of different studies on the association of these factors with dental caries in different parts of India show inconsistent results . Moreover, very few publications were found describing the association of dental caries with socio-demographic and nutritional factors in school children of Guntur district, Andhra Pradesh, India. So, the present study was carried out with two objectives: first, to determine the association of dental caries with socio-demographic factors like age, gender and socioeconomic status; second is to explore the relationship between dental caries and nutritional status in Guntur district school children.

2

Materials and methods

This study was carried out among 5–11 year old school going children in Guntur district, Andhra Pradesh. The study period was for 6 months and the required sample size was estimated based on previous study which showed a prevalence of 45.33% . With this anticipated population proportion of 0.05 and a power of 80%, a sample of 1003 children was needed to be recruited for this study.The sample size was estimated using the formula

where p is the prevalence of dental caries; q = 1-p; Z alpha & Z beta are standard normal variants; d = acceptable margin of error (4.4).

For the purpose of the study, Guntur district was arbitrarily divided into four geographical regions, which correspond to the four varying demographic areas of the district i.e., North, south, east and west. Schools from each region were randomly selected to obtain the desired sample size, such that there was an equal representation from each of the four zones. Six government and six private schools were selected by lottery method to meet the sample size of 1003. A two-stage random sampling method was followed, with schools as the primary sampling unit and individual children were selected proportionate to the number of children in each school by systematic random sampling. All the required and relevant information about the number and location of schools in Guntur district was obtained from the office of the Deputy Director of Public Instruction, Guntur district. The study protocol was approved by the institutional ethical committee. Permission was obtained from the selected school authorities and an informed written prior consent was also obtained from the parents of children who participated in the study.

A total of 1022 children of both the sexes between 5 and 11 years of age group without any known systemic conditions were included. Uncooperative, medically and physically compromised children, children on long term medication, children undergoing orthodontic treatment and children who haven’t returned the questionnaires which were used to assess SES were excluded from the study. Semi-structured questionnaires were utilized to obtain information regarding parent education, parent occupation, family income per month. Questionnaires were distributed to the parents of 1070 children. The answered questionnaires were collected on the next two days from the schools to assess the SES of children. Out of 1070, 1022 (95%) questionnaires were returned, so remaining 48 children were excluded from the study.

SES was assessed according to modified Kuppuswamy SES scale where the children were classified into one of the three clusters: upper class score >25, middle class – total score between 11 and 25 and lower class score <10 .

Anthropometric measurements of children were noted prior to examination of the oral cavity by a single investigator. Height and weight of each individual were recorded to obtain BMI-for-age. The weight of each child without shoes and dressed in a minimum amount of clothing was measured using a portable analog weighing machine. The height was measured to the nearest 0.5 cm, using a portable height measuring unit with the soles of both feet fully supported on a horizontal surface. BMI was calculated using the following formula, i.e., weight in kilograms divided by height in meter square (weight/height ² ). These children were classified into three categories using age- and gender-specific criteria recommended by WHO using revised WHO growth charts-2007 as: Underweight group children with BMI for age <5th percentile; Normal group children with BMI for age ≥ 5th percentile and <85th percentile; Overweight + Obese group children with BMI for age ≥ 85th percentile. The participants falling under overweight and obese were clubbed together under one group.

A second investigator, blinded to the anthropometric measurements, proceeded to record the deft+/DMFT index in a separate operatory. Oral examination of school children was carried out visually, under natural light using plane mouth mirrors and CPI probes; no radiographs/transillumination were used (ADA Type 3 examination). A single investigator examined all the children. Diagnosis of dental caries (deft and DMFT) was established according to World Health Organization guidelines (WHO, 1997). Intra-examiner calibration was performed with respect to the dental caries scores. Significant correlation (Kappa value 0.96, P < 0.05) was noticed. Immediate dental care was given and a referral was made as and when required.

The data obtained was analysed using Statistical Package of Social Sciences (SPSS Version 15; Chicago Inc., USA) software. The tests employed were Chi-Square (X2); Analysis of Variance (ANOVA) and Logistic regression analysis. Regression analysis was performed using dental caries experience as dependent variable and socio-demographic and nutritional factors like age, gender, SES and BMI as independent variables where the significance level was fixed at P < 0.05.

3

Results

Out of 1022 children, 508 (49.7%) were males and 514 (50.3%) were females. Assessment of SES in these children showed that 806 (78.9%) were from the low income group and the rest 216 (21.1%) from the middle income group. The higher income group in this study included none due to non availability. BMI scores showed that 412 children (40.3%) were undernourished and 38 children (3.7%) were overweight/obese. Remaining 572 children (56%) showed normal BMI [ Table 1 ].

Table 1

Demographic variables of the study population.

Age	Frequency	Percent
5	54	5.3
6	106	10.4
7	124	12.1
8	164	16
9	218	21.3
10	184	18
11	172	16.8
Sex	Frequency	Percent
Female	514	50.3
Male	508	49.7
SES	Frequency	Percent
Middle	216	21.1
Low	806	78.9
BMI	Frequency	Percent
Normal	572	56
Overweight	38	3.7
Underweight	412	40.3
Total	1022	100

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