Introduction

Dental caries and gingivitis are diseases that allow us to assess the oral health conditions of a given population. They can be influenced by the different biological and sociocultural factors of the individuals ¹.

Parents’ habits and knowledge about oral health have been observed to have an impact on their children’s oral health ^2,3. Findings also show that a low socioeconomic status in the household ^4,5 and parents’ unfavorable oral health habits ^1,6 may contribute to the development of dental caries. In addition, the mother’s beliefs, habits and behavior and the environment where the child is raised may favor microbial colonization in the child’s oral cavity.

A newborn’s oral cavity is basically free of microorganisms. Soon after birth, numerous bacteria begin to colonize the mouth. Dental eruption provides a surface for Streptococcus mutans colonization, a microorganism that is closely linked to caries risk. Frequent contact between the mother and the child may cause early colonization and bacteria transmission ⁷. Several studies agree that the mother is the child’s primary source of infection through cariogenic bacteria ^8-10. Among the many factors that affect oral health in early childhood, the relevance of mother (caregiver) to child transmission and S. mutans genetic similarity have been shown ¹¹, as well as their correlation to knowledge, attitudes and socioeconomic status ¹². In addition, children with a record of caries in early childhood are more prone to future decay of their permanent teeth ¹³.

As oral hygiene and its quality have also been addressed as key factors for oral health care, it is important to provide the population with information about healthy practices regarding adult and child dental caries.

This work compares the oral health condition of children under the age of three, who attended University Dental Services in Porto Alegre (Brazil) and Córdoba (Argentina), and the potential correlation with social, demographic, cultural, maternal and perinatal aspects.

Materials and methods

Results

We studied 92 children under the age of three. We identified two cohorts based on country of residence. The Brazil cohort: 60 children who live in Porto Alegre, Rio Grande do Sul or nearby communities (F: 48.3%; M: 51.7%), and the Argentina cohort: 32 children who live in Córdoba or nearby. (F: 65.6%; M: 34.4%). The mean age of Brazilian children was 27.0±10.8 months, while in Argentina it was 15.4±6.8 months. These differences turned out to be significant (ANOVA p<0.001).

The reason why both cohorts sought consultation is shown in Table 2. In Argentina, 100% of the cases were for preventive care, while in Brazil only 8.3% of the children sought preventive care and over half, 56.7%, needed caries treatment. (Pearson Chi² test: p<0.001).

In terms of caries experience (table 3), significant differences were found between the cohorts (Fisher: p=0.015; p<0.05): Brazilian children showed a higher percentage of caries activity (38.3%) than Argentinean children (12.5%).

Although differences between cohorts were not significant for the caries-free variable (table 4) (Fisher: p=0.178; p>0.05), Brazilian children (96.7%) showed a higher percentage in the category that presented no etiological factors than children in Córdoba (87.5%).

In terms of healthy and risky oral health habits, we observed that (table 5) the percentage of children who use pacifiers is higher in the Argentinean cohort (46.9%) than in the Brazilian cohort (31.7%). The differences were not statistically significant (Fisher: p=0.177; p>0.05). Children in Argentina do not have oral hygiene habits, which made the difference with the Brazilian cohort significant (Pearson Chi²: p<0.001). Therefore, we found the same results with the use of toothpaste, use of fluoride, daily brushing frequency and time.

Table 6 shows the factors associated to caries experience in a decreasing order of significance. OR were calculated for each factor identifying in each case the reference category considered in relation to the risk of cariogenic activity. The cohort and caries-free variables were the most relevant ones.

Factor significance in relation to cohort is shown in table 7. The variables “frequency of brushing”, “time of brushing”, “use of toothpaste”, and “use of fluoride” were omitted when implementing the model as we had already established that percentage differences between cohorts are very statistically significant. The variables “age” (months), “baby’s diet” and “type of delivery” also showed significant differences between cohorts.

In general, mother’s educational level (table 8) was similar for both cohorts, with no significant differences (Pearson Chi² Test: p=0.138; p>0.05). However, a significant difference was found (p<0.05) in the higher education / University level.

Significant discrepancies were observed between cohorts when considering the baby’s caregiver (table 9) (Pearson Chi² Test: p=0.026; p<0.05), particularly when considering the categories: mother exclusively and shared mother/grandparents (Z tests; p<0.05).

Although some differences were found between cohorts regarding the father’s occupation, these were not significant (Pearson Chi² Test: p=0.309; p>0.05). In addition, the mother’s occupation did not show significant differences between cohorts either.

As shown in table 10, all the children in Argentina developed in a normal pregnancy, while in Brazil, 88.3% did, although the differences are not significant (Fisher: p=0.091; p>0.05).

The differences between cohorts were significant when considering the variable “type of delivery” (table 11), as 87.5% of the children in Córdoba were born through normal delivery, a much higher percentage than the one observed in Porto Alegre, Brazil (56.7%). In this cohort, caesarean sections accounted for 33% (one third) of the children (Pearson Chi²Test: p=0.014; p<0.05).

Regarding mother and infant’s diet (table 12), more children were breast-fed in Brazil (70%) than in Córdoba (53.1%) (Pearson Chi² Test: p<0.05). Over half the mothers in Argentina consumed cariogenic foods during pregnancy, while this percentage was lower in Brazil (36.7%). The differences were not statistically significant (Chi² test; Fisher’s exact test: p=0.184; p>0.05). Statistically significant differences were found in the baby’s diet category (Fisher: p=0.022 p<0.05). Over half the children in the cohort in Córdoba had a cariogenic diet (53.1%), compared to only 26.7% of the children in Brazil.

Discussion

Dental medicine for babies has officially become a worldwide trend in dental care in early childhood, thanks to the development of education programs, the implementation of preventive measures and caries control, primary care and age-specific curative treatments ¹⁵. In addition, oral care can contribute to preserving primary dentition and promoting the child’s wellbeing ^3,4,16.

This study presents the data of children who attended the University Dental Services of the Dental Clinic of UNC School of Dentistry and the Infant Dental Clinic of the UFRGS School of Dentistry. The oldest children were three years old. This is consistent with earlier studies conducted by Figueiredo et al. ¹⁶ in 2008 and Emerim et al. ¹⁷ in 2012, which show a philosophical shift in Pediatric Dentistry. These data show an evolution in the principles of care at University Dental Services, as they reveal a move towards the guidelines of the American Academy of Pediatric Dentistry (AAPD), which recommend the first visit to the Pediatric Dentist should take place between the eruption of the first primary tooth and the child’s first year of life ¹⁸. The first appointments of the children of the Argentinean cohort took place at a mean age of 15.4 ± 6.8 months old. The reasons why patients sought consultation on 100% of the cases was preventive care.

A key aspect for dental care programs in early childhood is education and awareness raising among parents regarding their children’s oral health, as family members play a major role in developing the child’s eating and oral hygiene habits ^19,20,21.

Health habits can apply to all household members, as once parents become more aware, they turn into change agents in favor of oral and overall health. Working with family members is important because humans are social beings subject to biological, psychological and social hazards, and within this context, a person’s family determines their behavior, has an influence on decision-making and helps develop habits. In 2008, Fracasso et al. ²² reinforced this concept when they observed the influence the mother figure has on the oral health condition of children. We must remember this, as the mothers in this study were the main responsible figure at the infants’ appointments in Brazil and Argentina. Another important finding was the significant correlation between the assisted delivery type and the children’s caries risk category, confirming the findings of Benites et al., ²³, who observed that women who had had a vaginal delivery and described a non-cariogenic diet by breastfeeding their children for a longer period tend to have a lower caries incidence.

In addition, diet and nutrition are vital for the physical and psychological development of children from conception; these factors are directly connected to the oral cavity from odontogenesis to the development of oral pathologies. Studies conducted by Adair et al. ³ have shown the influence carbohydrates, especially sugars, have on the occurrence of carious lesions. Poor eating habits, such as the intake of sugary substances in the baby’s bottle, are closely tied to early Streptococcus mutans colonization, one of the main cariogenic bacteria in the oral cavity ^7-10.

The information in this study reinforces the correlation between inadequate eating habits and carious lesions, as both children from Argentina and Brazil with caries experience followed a cariogenic diet: over half the children in the Córdoba cohort and 30% in the Porto Alegre cohort.

These findings reinforce the multifactorial etiology of caries, where the joint action of several etiological factors is needed, that is, a cariogenic diet, poor oral hygiene, susceptible host and Streptococcus mutans oral infection: together they create an environment that promotes the development of carious lesions ^7-10. Regarding healthy habits and oral health risk, we observed that children in Argentina do not have oral hygiene habits, and there was a significant difference with the Brazilian cohort. Therefore, we found the same results with the use of toothpaste, use of fluoride, daily brushing frequency and time.

These findings allow us to stress the importance of sociocultural aspects in the dental care practices of babies, and it also reinforces the need of Latin American children and their parents for access to oral health care programs from the first year of the child’s life. In addition, it warns about the need for these programs to collect epidemiological information for the timely identification of oral habits in early childhood, assessment and counselling for parents, as early diagnosis of new carious lesions is essential to establish oral health promotion efforts.

Finally, this study clearly proves that when working in the field of dental medicine for infants, clinicians establish a link between the scientific community and the population under study, which goes beyond the geographical borders of the countries involved, fostering knowledge exchange between both sides.