Caries patterns in primary dentition

in 3- to 5-year-old children. Medellín, Colombia

Patrones de caries en la dentición primaria de niños
de 3 a 5 años de edad. Medellín, Colombia
Gloria Matilde Escobar Paucar1, Blanca Susana Ramírez Puerta2, Luis Gonzalo Álvarez Sánchez3

ORIGINAL ARTICLES
1
Master in Public Health. School of Dentistry, Universidad de Antioquia. E-mail: gescobarp@gmail.com, matilde.escobar@udea.edu.co
2
Master in Epidemiology. School of Dentistry, Universidad de Antioquia. E-mail: zerimar761@gmail.com, blanca.ramirez1@udea.edu.co
3
Master in Epidemiology. School of Dentistry, Universidad de Antioquia. E-mail: lgonzalvarez@gmail.com, lgonzalo.alvarez@udea.edu.co

ABSTRACT
Introduction: early childhood caries (ECC) is a public health problem. Recognizing caries patterns in
affected children can help improve oral health programs focused on the preschool population. The aim of
this study was to identify caries patterns in 3- to 5-year-old children in a low to middle-low socioeconomic
area. Methods: a calibrated dentist recorded caries lesions using ICDAS criteria in 548 children attending
four day-care centers in a low to middle-low socioeconomic area. ECC and S-ECC prevalence and the
proportion of affected teeth/surfaces by lesion type for homologous teeth were calculated. Results: a total
of 419 (76.5%) and 238 (43.4%) children had ECC and S-ECC, respectively. Average dmft was 3.7±3.7 and
average affected surfaces were 5.8±7.7. Occlusal surfaces showed the highest caries experience, varying
from 17.7% to 36.1%, showing statistical significance when compared to other molar surfaces. The upper
smooth anterior surfaces were affected from 0.2% to 17.2%, while lower smooth anterior surfaces showed
Key Words: values between 0.0% and 6.8%. The percentage of dental caries experience in second molars varies from
dental caries, 37.1% to 42%, while in lower central and lateral incisors the values range from 1.8% to 4.6%. Conclusion:
preschooler, early the specific caries pattern in preschool children with high prevalent ECC from a middle-low-income area
childhood caries, indicate the need to design programs aimed at detecting early sings of dental caries in specific locations, as
primary dentition well as disease control strategies.
RESUMEN
Introducción: la caries de la infancia temprana (CIT) es un problema de salud pública. Identificar el patrón
de caries en los niños afectados puede ser útil para mejorar los programas de salud bucal centrados en la
población preescolar. El objetivo del presente estudio consistió en identificar patrones de caries en niños
de 3 a 5 años de edad en un área socioeconómica baja y media-baja. Métodos: un dentista calibrado
registró lesiones de caries utilizando criterios ICDAS en 548 niños que asisten a cuatro guarderías de un
área socioeconómica baja y media-baja. Se calculó la prevalencia de CIT y CIT-S (severa) y la proporción de
dientes/superficies afectados por tipo de lesión para dientes homólogos. Resultados: hubo un total de 419
(76,5%) CIT y 238 (43,4%) CIT-S. El cpod promedio fue de 3,7 ± 3,7 y el promedio de superficies afectadas
fue de 5,8 ± 7,7. Las superficies oclusales presentaron la mayor experiencia de caries, en un rango de entre
17,7% y 36,1%, lo que indica una significación estadística en comparación con otras superficies molares.
Las superficies lisas anteriores superiores se vieron afectadas entre el 0,2% y el 17,2%, mientras que las
Palabras clave: superficies lisas anteriores inferiores mostraron valores entre 0,0% y 6,8%. El porcentaje de experiencia
caries dental, de caries dental en los segundos molares varía del 37,1% al 42%, mientras que en los incisivos centrales
preescolar, caries y laterales inferiores oscila entre el 1,8% y el 4,6%. Conclusión: el patrón específico de caries en niños en
de la infancia edad preescolar con alta prevalencia de CIT en un área de ingresos medios-bajos indica la necesidad de
temprana, diseñar programas que incluyan acciones destinadas a detectar caries dentales en lugares específicos, así
dentición primaria como estrategias para el control de la enfermedad.
Submitted: March 15/2019 - Accepted: May 28/2019

How to quote this article: Escobar-Paucar GM, Ramírez-Puerta BS, Álvarez-Sánchez LG. Caries
patterns in primary dentition in 3- to 5-year-old children. Medellín, Colombia. Rev Fac Odontol Univ
Antioq. 2019; 31(1-2): 47-56. DOI: http://dx.doi.org/10.17533/udea.rfo.v31n1-2a4

Revista Facultad de Odontología Universidad de Antioquia - Vol. 31 N.o 1-2 - Second semester, 2019 / ISSN 0121-246X / ISSNe 2145-7670 47
 Caries patterns in primary dentition in 3- to 5-year-old children. Medellín, Colombia

INTRODUCTION incisors being the most affected teeth until

the age of three,3,9 and second molar occlusal
Dental caries is one of the most prevalent surfaces the most affected in five-year-old
chronic conditions in industrialized and non- children.4,10,11 Another study showed no age-
industrialized countries. Its onset before six related pattern, with the second molar being
years of age (Early Childhood Caries, ECC) the most affected in preschool children.12
is recognized as a public health problem
with oral consequences and impacts Recognizing specific caries patterns within
on children’s and their families’ quality a given population can be useful for oral
of life.1,2,3 While there is evidence of an health programs and warns clinicians about
overall decline in the number and severity the early detection in preschool children.
of carious lesions, time trends differ among As non-invasive therapies have proven to
countries. Preschoolers are the group that be effective for caries prevention and for
least benefits from measures intended to the management of initial lesions,13 caries
improve oral health, and the disease shows patterns should be an important tool in
a skewed distribution in children living in the changing invasive interventions into a more
same area. These findings suggest that more preventive, caries control approach, leading
actions are needed to deal with oral health to better results for both individuals and
inequalities.4,5 populations.14

In Colombia, the latest National Oral Health The aim of this study was to identify caries
Survey showed that dental caries affects 83% patterns in children aged 3 to 5 years living in
of three-year-old children, reaching 88.8% in a low to middle-low socioeconomic area in
five-year-old children when both cavitated Medellin, Colombia, based on the ICDAS
and non-cavitated lesions are included.6 detection system, which records lesions at
Moreover, dental caries, as one of the most different severity stages.15
prevalent chronic conditions in spite of the
intensive preventive programs implemented
in many countries, illustrates the limitations METHODS
of such programs to deal with the disease
burden and highlights the importance of A cross-sectional descriptive study was
additional information to design programs performed in children under six, attending
aimed at the early childhood according to preschool day care institutions located in a
the available evidence on control strategies.7 middle-low socioeconomic neighborhood
from the northeastern area of Medellin. The
The studies on carious lesions distribution study was carried out in four out of twelve
show that it is not uniform, suggesting the private institutions with government funding
lack of random effect of contributing factors, and was approved by the Ethics Committee
as well as the presence of specific patterns of the Universidad de Antioquia School of
in terms of teeth position and characteristics. Dentistry. All children aged three, four and
Some authors suggest that there is no real five years attending selected infant day-care
right/left symmetry, although certain groups centers were examined, prior presentation of
of teeth show similar susceptibility to lesion an informed consent by the legal guardians
development.8 Caries patterns may vary in of all participants in the study. A total of
primary dentition, with the upper central 548 available records from participants

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 Caries patterns in primary dentition in 3- to 5-year-old children. Medellín, Colombia

aged three to five were included for data of the upper anterior primary teeth have
processing and results. cavitated lesions, are filled or lost due to
caries, or when the number of carious, filled
Dental status was recorded according to or lost surfaces by caries is ≥4 at 3 years, ≥5
International Caries Detection and Assess- at 4 years, and ≥6 at 5 years of age.18
ment System (ICDAS),16 including the mo-
dification suggested for this type of studies The collected data were analyzed in the
(ICDAS epi), merging ICDAS lesions level 1 IBM-SPSS® program, version 23.0. The
with those of level 2.17 A calibrated dentist percentages of affected teeth and tooth
(intraexaminer Kappa 0.77 and interexami- surfaces were estimated for the whole
ner 0.71) registered caries lesions. Prior to group and by single age, using frequency
clinical examination, an adult brushed each distribution. The percentage of surfaces
child’s teeth; cotton pellets were used to affected by homologous teeth was
isolate the examination area, and dental sur- calculated and differences were analyzed
faces were dried with gauze and air. Visual with the Epidat 3.1 software, using either the
inspection of all present tooth surfaces was Chi square test or the Fisher’s exact test.
carried out, and a probe (Ball-tip Screening)
was used when needed.
The presence of early childhood caries (ECC) RESULTS
and severe early childhood caries (S-ECC)
From a total of 548 children evaluated,
was recorded according to the guidelines set
76.5% showed early childhood caries (ECC)
forth by the American Academy of Pediatric
and 43.4% had severe early childhood caries
Dentistry. ECC is defined as the presence
(S-ECC). In terms of dmft (including non-cavi-
of one or more primary teeth surfaces with
tated lesions), each child had an average of
caries (either cavitated or non-cavitated),
3.7±3.7 teeth and 5.8±7.7 surfaces affected
filled or missing by caries, in children under
by dental caries, varying from 3.0±3.4 and
six years of age. The severe form (S-ECC)
4.3±6.1 in 3-year-old children to 4.0±3.9
is identified in the presence of any sign of
and 6.8±9.5 in 5-year-old children (Table 1).
caries on smooth surfaces in children under
3 years, when one or more smooth surfaces

Table 1. Distribution of children with ECC and S-ECC, mean dmft (SD) and mean dmfs (SD) by age

ECC* S-ECC** dmft† dmfs‡

Age
n° % CI n° % CI Mean (SD) CI Mean (SD) CI
3 year-old (n=173) 120 69.4 62.5; 76.3 70 40.5 33.2; 47.8 3.0 (3.4) 2.5; 3.5 4.3 (6.1) 3.4; 5.2

4 year-old (n=216) 172 79.6 74.2; 85.0 101 46.8 40.1; 53.5 4.1 (4.0) 3.6; 4.6 6.3 (7.3) 5.3; 7.3

5 year-old (n=159) 127 79.9 73.7; 86.1 67 42.1 34.4; 49.7 4.0 (3.9) 3.4; 4.6 6.8 (9.5) 5.3; 8.3

Total (n=548) 419 76.5 72.9; 80.1 238 43.4 39.3; 47.5 3.7 (3.7) 3.4; 4.0 5.8 (7.7) 5.2; 6.4

*: Early childhood caries. **: Severe early childhood caries. CI: Confidence Interval 95% †: decay, missing and filled teeth index. ‡: decay,
missing and filled surfaces index

Source: by the authors

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 Caries patterns in primary dentition in 3- to 5-year-old children. Medellín, Colombia

A total of 47,711 surfaces were examined, affected. The individual teeth with the highest
with the occlusal surface showing the highest proportion of dental caries experience were
values of caries lesions experience, varying 55 (42%), 75 (40%), 85 (38.3%) and 65
from 17.7% to 36.1%. These were followed (37.1%); the lowest experience was found
by upper smooth anterior surfaces affected in 71 (1.8%), 81 (2.2%), 72 (2.9%) and 82
in 0.2% to 17.2%. The lower smooth anterior (4.6%). The proportions of dental caries
surfaces showed the lowest values, from 0.0 experience by tooth and tooth surface are
to 6.8%, and as observed in upper anterior shown in Figure 1.
teeth, the lingual surfaces were the least
a) All children (n= 548)

b) Three-year-old children (n=173)

c) Four-year-old children (n=216)

d) Five-year-old children (n=159)

Figure 1. Dental caries experience (% affected) in primary teeth for 3- to 5-year-old children, by tooth and tooth surface levels.
Source: by the authors

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 Caries patterns in primary dentition in 3- to 5-year-old children. Medellín, Colombia

The analysis of caries experience by tooth Figure 2 illustrates the distribution of caries
type showed that 39.5% of the upper second presence per tooth surface in homologous
molars and 39.2% of the lower molars were teeth, showing predominance of occlusal
affected, followed by upper first molars lesions in primary molars and buccal
(29%) and upper central incisors (23.2%). surfaces in lateral upper incisors. In the
The lowest values were observed in lower upper central incisors, lesions appear in a
central and lateral incisors, with 2.0% and similar proportion in the bucal, mesial and
3.8% respectively (Figure 2). lingual surfaces.

a) All children

Surface and teeth

50
Distal Buccal Mesial Lingual Occlusal Teeth
40

30
%
20

10

0
51/61 71/81 52/62 72/82 53/63 73/83 54/64 74/84 55/65 75/85
Tooth type

b) Three-year-old children

50 Surface and teeth

Distal Buccal Mesial Lingual Occlusal Teeth
40
50 Surface and teeth
Distal Buccal Mesial Lingual Occlusal Teeth
30
40
% Surface and teeth
20
30
50
Distal Buccal Mesial Lingual Occlusal Teeth
% 10
40
20
0
30
10
% 51/61 71/81 52/62 72/82 53/63 73/83 54/64 74/84 55/65 75/85
20
0
51/61 71/81 52/62 72/82 Tooth type
53/63 73/83 54/64 74/84 55/65 75/85
10
0 Toothchildren
c) Four-year-old type
Surface and teeth
50 51/61 71/81 52/62
Distal 72/82
Buccal 53/63
Mesial 73/83
Lingual 54/64
Occlusal 74/84
Teeth 55/65 75/85
40 Surface and teeth
Distal Buccal Tooth type
Mesial Lingual Occlusal Teeth
50
30
%40
20 Surface and teeth
30 Distal Buccal Mesial Lingual Occlusal Teeth
50
10
% 20
400
10
30 51/61 71/81 52/62 72/82 53/63 73/83 54/64 74/84 55/65 75/85
% 20
0
51/61 71/81 52/62 72/82 Tooth type
53/63 73/83 54/64 74/84 55/65 75/85
10
0 Surface andtype
Tooth teeth
50
51/61 71/81 Distal
52/62 Buccal
72/82 Mesial
53/63 Lingual
73/83 Occlusal
54/64 Teeth
74/84 55/65 75/85
40 Surface and teeth
50 d) Five-year-old children
30 Distal Buccal Mesial Lingual
Tooth type Occlusal Teeth
% 40
20
30 Surface and teeth
50
% 10
20 Distal Buccal Mesial Lingual Occlusal Teeth
40
0
10
30 51/61 71/81 52/62 72/82 53/63 73/83 54/64 74/84 55/65 75/85
% 0
20 Tooth type
51/61 71/81 52/62 72/82 53/63 73/83 54/64 74/84 55/65 75/85
10
0 Tooth type
51/61 71/81 52/62 72/82 53/63 73/83 54/64 74/84 55/65 75/85
Tooth type

Figure 2. Distribution of affected teeth surfaces per tooth type (% with caries experience).
Source: by the authors

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 Caries patterns in primary dentition in 3- to 5-year-old children. Medellín, Colombia

Table 2 shows the caries pattern for each when the occlusal surface is compared with
homologous tooth in terms of the most the rest of upper and lower molar surfaces.
affected surfaces, comparing each surface, It was also found in anterior teeth, when the
referred to as “caries attack rates” by Gizani labial or facial surfaces were compared to
et al.19 Each individual surface was compared lingual surfaces, with the exception of the
with others by Chi square test or Fisher’s upper central incisors.
exact test. Statistical significance was found

Table 2. Comparison of caries experience among homologous teeth surfaces (D: distal, B: labial or facial, M: mesial, L:
lingual, O: occlusal)

Age Tooth type Caries pattern D-B D-M D-L D-O B-M B-L B-O M-L M-O L-O
3 to 5 years 51/61 B>M>L>D *** *** ***   ns ns   *    
71/81 B>M>L>D *** ns ns   ** ***   ns    
52/62 B>M>L>D * * ***   *** ***   ns    
72/82 B>M>L>D *** ** ns   * ***   *    
53/63 B>L>D>M *** * ns   *** ***   **    
73/83 B>M>L>D *** * ns   *** ***   ns    
54/64 O>B>D>M>L ns ns ns *** ns * *** ns *** ***
74/84 O>B>L>D>M *** ** ns *** *** *** *** ** *** ***
55/65 O>L>B>M>D *** ns *** *** *** *** *** *** *** ***
75/85 O>B>L>M>D *** ns *** *** *** *** *** *** *** ***
3 years 51/61 B>M>L>D *** * ns   ns *   ns    
  71/81 B ** † † * *   †    
  52/62 B>M>L>D *** *** *   ns *   ns    
  72/82 B>M ** ns †   ns **   ns    
  53/63 B>L *** † ns   *** **   ns    
  73/83 B>M *** ns †   ** ***   ns    
  54/64 O>B>M>L>D *** ns ns *** ns ns *** ns *** ***
  74/84 O>B>L>D>M *** ns ns *** *** *** ** ns *** ***
  55/65 O>L>B>D>M ns ns *** *** * *** *** *** *** ***
  75/85 O>B>L>D>M *** ns ns *** *** *** * * *** ***
4 years 51/61 B=M>L>D *** *** ***   ns ns   ns    
  71/81 B>M>L=D * ns ns   ns ns   ns    
  52/62 B>M>L>D *** *** **   *** ***   ns    
  72/82 B>M>L=D *** * ns   ns ***   ns    
  53/63 B>L>D *** ns ns   *** ***   ns    
  73/83 B>M>L>D *** ns ns   *** ***   ns    
  54/64 O>B>M>D>L ns ns ns *** ns ns *** ns *** ***
  74/84 O>B>D>L>M *** ns ns *** *** *** *** ns *** ***
  55/65 O>L>B>D>M ** ns *** *** *** *** *** *** *** ***
  75/85 O>B>L>M>D *** ns *** *** *** *** * ** *** ***
5 years 51/61 B=L>M>D * ns *   ns ns   ns    
  71/81 B>L>M * ns ns   ns ns   ns    
  52/62 B>L>M>D *** ** **   * *   ns    
  72/82 B>M>L>D * ns ns   ns ns   ns    
  53/63 B>L>D>M *** ns ns   *** ***   ns    
  73/83 B>M>L *** ns ns   *** *** ns    
  54/64 O>D>B>L>M ns ns ns *** ns ns *** ns *** ***
  74/84 O>B>L>D>M * * ns *** *** ns *** * *** ***
  55/65 O>L>B>M>D ns ns *** *** ns *** *** *** *** ***
  75/85 O>B>L>M>D *** ns ** *** *** *** ** ** *** ***
*p value < 0.05, **<0.01, ***<0.001 (chi square test/Fisher’s test) ns: no significance, †: caries free surface

Source: by the authors

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 Caries patterns in primary dentition in 3- to 5-year-old children. Medellín, Colombia

DISCUSSION to be age dependent. Do1 states that there

are significant variations in levels of caries
The present study shows a specific pattern of experience as well as in time-trends of caries
dental caries in preschool children living in experience among populations with different
an urban area, belonging to a high prevalent levels of social and economic development.
group where severe forms of Early Childhood
Caries affects more than 40% of examined In this study, the most affected teeth among
children. Even though caries lesions are 3-year-old children were the upper second
present in all teeth, with the exception of a molars and lower second molars, followed
few surfaces from anterior lower teeth in the by first lower molars, first upper molars
entire group, distribution is not uniform by and central upper incisors. For the 4-year-
tooth type, showing that caries lesions are old children, second molars remain the
not evenly distributed. most affected teeth, followed by first lower
molars, but upper central incisors show
The most affected teeth in the three- to higher proportions of caries lesions than
five-year-old group were second molars, upper first molars. By age 5, second lower
followed by first lower molars and upper molars appear as the most affected tooth
central incisors. These findings are similar to type, followed by second upper molars, first
those by Sowole et al12 and Gizzani et al19 lower molars, first upper molars and upper
in terms of anterior primary teeth being less central incisors.
affected than posterior teeth, regardless of
caries levels. But there is a difference with As in other studies, caries prevalence
Gizzani et al, who report first lower molar as increases with age, showing a cumulative
the most affected posterior teeth, followed effect from 3 to 5 years, but no conclusions
by central incisor in a group of 2-6-years-old; could be stated about lesion progression
this also differs from the findings by Ferro and changing patterns by age as these are
et al,11 who reported that mandibular molars cross-sectional data. Cohort studies or cross-
were the most commonly affected teeth in a sectional studies including larger samples
sample of five-year-old children. could provide valuable information on
specific patterns by age, guiding clinicians
The variations among studies could be and program leaders in the formulation of
explained as an effect of grouping children regular screenings for each age group.
by ages, as Vanobbergen et al14 reports
upper central incisors showing the highest In analyzing available data by tooth surface,
caries experience prevalence in the 3-year- not all teeth show the same susceptibility.
old group; trend changing for the 5- and The lingual anterior surfaces were the least
7-year-old kids, in which the highest caries frequently affected in the anterior region,
prevalence level was observed in the and the occlusal were the most affected
mandibular molars. There could also be molar teeth surfaces. These findings are
population differences. As Sowole et al12 similar to those reported in other studies
report, it appears to be a non-significant dealing with either low caries or high caries
age-related caries distribution pattern, experience populations.9,14,19,20 While some
based on clinical examinations in preschool authors refer to specific surface involvement
children, concluding that neither rampant as “caries attack rates”,19 there is no
caries nor simple caries prevalence appear evidence of time sequence of lesions, but

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 Caries patterns in primary dentition in 3- to 5-year-old children. Medellín, Colombia

this is an important information about the stated in Brussels by the EAPD13 and Pitts
distribution of caries presence according to et al,24 non-invasive therapies have proven
tooth surface by tooth type. For all posterior to be effective for caries prevention and
teeth, regardless of age groups, the most the management of pre-cavitated carious
affected surfaces are the occlusal ones, lesions. Knowing the most commonly
showing statistically significant differences involved teeth and surfaces in a specific
between the occlusal surface and the others, population is key to guide dental screenings
as compared individually. For anterior teeth, aimed to identify early signs and to promote
the most affected surface is the labial or adequate oral hygiene practices and fluoride
facial, but consistent statistically significant use to stop lesions, according to the caries
differences are only observed between control concept.25
buccal and lingual surfaces. A limitation of
the present study is that it did not evaluate
symmetry (the spatial distribution between CONCLUSION
the right and left homologous teeth) as
showed by Vanobbergen et al14 because the A group of children living in a high prevalent
total number of teeth in each group would ECC middle-low-income community shows
not be enough. specific patterns of caries lesion distribution,
with primary molars being the most
While information about occlusal
commonly affected, especially the occlusal
susceptibility is highly relevant in terms
surfaces, followed by the upper central
of screening focus, treatment needs and
incisors. These data are useful for programs
preventive strategies, it could be inadvisable
aimed at families and communities to detect
to wait until molar eruption—occurring later
early sings of dental caries, and to guide
during early childhood—for risk assessment
dental care services in timely diagnosis and
and early childhood preventive programs
lesion progression strategies.
based on this data only. Dental teams and
children’s health providers are increasingly
aware of the need of implementing
preventive measures from the first year of life. CONFLICT OF INTEREST
Non-dental healthcare providers could be of
The authors declare that they have no
great help by identifying any single lesion,
conflict of interest.
irrespective of its location, and referring the
child for treatment and establishment of a
dental home.21,22 An oral check-up after the
first tooth eruption should be integrated into CORRESPONDING AUTHOR
the existing health programs like vaccinations
and general medical check-ups.2 Gloria Matilde Escobar Paucar
Universidad de Antioquia
Many attempts are made to deal with caries (+57) 219 6772
burden. For Seiham,23 caries prevention is gescobarp@gmail.com,
preferable to treatment, but the high levels matilde.escobar@gmail.com
of caries worldwide suggest that current Calle 64 #52-59
preventive approaches are not working. As Medellín. Colombia

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 Caries patterns in primary dentition in 3- to 5-year-old children. Medellín, Colombia

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