Prevalence of Early Childhood Caries in a selected districtin Sri Lanka '

Introduction Early childhoodcaries is a widely recognised health problem in manycountries, even though it is a very much neglected problem in Sri Lanka . Objective:The objective of this study was to determine the prevalenceand severity ofearly childhood caries amongchiltiren below five years in the Kalutara district in Sri Lanka, Methodology: This study was carriéd out using the latest diagnostic criteria developed by the National Institute of Dental Cranio Facial Research, USA. A cross sectional descriptive design was adapted to determine the prevalence ofearly childhoodcaries. A total of 830 children below five years participated in the study. A total of 20 clusters was selected by multistage stratified random sampling techniques. A cluster was a Public Health Midwife area, and a minimum of 40 children from each selected PHM area participated in the study. All data collection was carried out by the Principal Investigator, assisted by a recorder. Clinical examination of the teeth of the children was carried out by the Principal Investigator. Results: The prevalence ofearly childhood caries among children below five years was 63%. The prevalence rose sharply after one year from 23.3% to 76.1% during the fifth year. The severity of the disease was found to be high, with the severe componentof early childhood caries being high up to three years. ‘Lecturer, Dental Therapists Training School, Maharagama. 2Course Director, Community Medicine and Community Dentistry, PGIM, Colombo. %Senior Lecturer, Dept. of Community Medicine and Family Medicine, University of Sri Jayawardenapura, Nugegoda. ‘Head, Dept. of Microbiology, Faculty of Medicine, Colombo. Journal ofthe College ofCommunity Physicians ofSri Lanka The mean dmft for children belowfive years was 4.65. A large proportion ofthe decay was untreated. A large proportion of caries was non-cavitated, thereby the need for caries arresting care is high. Conclusions: Early Childhood Caries should be recognised as a priority health problem in Sri Lanka.


Introduction
Dental caries is the most commondisease of childhood. Dental decay in infants and toddlers is now collectively knownas Early Childhood Caries (ECC)(1) This is a virulent form of tooth decaythat affects the primary dentition ofinfants and pre-school children (2). It is a serious socio-behavioural and dental problem that afflicts infants and toddlers in many countries (3). ECC has now been foundto be an infectiousdisease. It is possible for mothers or other caregivers to pass caries causing bacteria to an infant.
ECCis characterizedbydistinctive patterns of smooth surface carious lesions affecting primary maxillary incisors of infants and young children (4). Characteristic lesions develop rapidly in many teeth on surfaces normally considered to be at low risk to decay Q).
'At the workshop conducted by National Institute of Dental & Craniofacial Research Bethesda, USA, ECC hasbeendefined as the presence of one or more decayed (noncavitated or cavitated lesions), missing or filled tooth surfacesin anyprimary tooth(5).
It is now well understood that ECC is a multifactorial disease and has numerous biological (6), psychosocial (1) and behavioural (1) risk factors, Theserisk factors vary from population to population (7).
While the cause of dental caries in young children is multifactorial the disease has an involvement with Streptococcus infection. Streptococcus mutans has now been thought to have a distinct association with ECC. Streptococcus mutans organisms have been found to be present' in these carious lesions, The major reservoir from which an infant acquires Streptococcus mutansis thought to be from the mother(8).
In most cases, the distribution of ECClesions is characteristic with the maxillary primary incisors being the most severely affected, The primary mandibular incisors are generally unaffected. Since primary maxillary incisor teeth are amongthe first teeth to erupt they are also the first teeth to be affected (initially developing broad areas. of enamel demineralization or white spot lesions at the gingival margin) (2).
Thoughno reports are available on prevalence of ECC in Sri Lanka, a study done to determine the oral health status of pre-school children (3years-Syears) 1995, in the Matale district revealed a caries prevalence of 60% (9). The dmft of 6 year old children has been found to be 4.1 and the prevalence ofcaries 76.42% (National Oral Heelth Survey 1993/94) (10) . This prevalence has been reported for six year old children. The diagnostic criteria were the WHO caries diagnostic criteria. These diagnostic criteria included only cavitated lesions.
Though in Sri Lanka prevalence studies have not been reported, a substantial body of literature from numerous countries exists at present which documents the prevalence of ECC.In developed countries the prevalence is reported to vary between1%-12%. Howeverin developing countries and within disadvantaged populations in developed countries the prevalence has been reported to be as high as 70% in the pre-schoolpopulation (11) . Studies in the Asian region are lacking. A study conducted in Indonesia in 1979, among, children less than 5 years reported a prevalence of 48% (2). A recent study conducted to describe the dental caries status of pre-school Journalofthe College ofCommunity Physicians ofSri Lanka children in Hong -Kong, in 1999,by Bedi and Holt revealed a prevalence of 39% (12).
The importance of the primary dentition cannot be underestimated. Even though a permanentdentition would replace the primary dentition it is vital that the primary dentition remainshealthy and is retainedtill such time due to the following reasons: (1) Maintenance of the arch length -the space occupied by the deciduous tooth provides the correct pathway and position for the permanent tooth to erupt.
Premature loss of deciduousteeth leads to development of malocclusion.
(2) For proper nutrition, growth and development of the child a healthy dentition is necessary. When teeth are diseased with caries it may cause discomfort and pain to the child and he may refuse to eat, thus hindering general well-being ofthe child. Lack ofsleep and / orbalanced diet has been found to lead to a significant decrease in a child's ageadjusted weight(13). Decay in deciduous teeth has been associated with general health problems, failure to thrive and nutritional problems.
(3) Caries in the primary dentition can damage the erupting permanent tooth (Turner's Tooth), The developing permanent tooth if damaged appears discoloured and is of different morphology.
(4) It increases the risk of caries in the permanenttooth. Children with ECC have 4 muchgreater probability of subsequent dental caries both in the deciduous and the permanent dentitions (14,15,16,17,18).
(5) The pain caused by caries or dental abscesses is of much distress to the child, parents and the dental surgeon. In severe cases it can lead to ear infection septicaemia, meningitis and such I i threatening situations.
(6) Appearance of the child is of much concern to the child itself and even more, to the parents. A beautiful smile helps to boost a child's self esteem.Healthy smiles play an important role in the development of a positive sense of self esteem. The Volume , 2004 20 cosmetic value of teeth has become more appreciated. The unsightly appearance of carious teeth may be psychologically traumatic to both the child and the parents, The primary dentition is of vital importance for the development of speech (19). Early loss of teeth may slow the development of proper speech (20).
(8) Literature has also shown that the cost for treating ECCis also very high (11,21,23). The US-PHShas estimated a cost between USS 700 -US$ 1200 to treat one child with ECC.If hospitalization is necessary an additional US$ 1000 could be added to the total bill. In another cost-estimate done in the USAit gives a figure of US$ 3000, as treatment is complicated and often several teeth have to be extracted under sedation or under GA in the operating theatre (23).

Objective
To determine the prevalence and severity of Early Childhood Caries (ECC) among children aged five years or less in a selected district in Sri Lanka,

Methodology
A cross-sectional study design was adopted.
The study was conducted among children belowfive years in the Kalutara district, in the Western Province. All children resident in the study area and 5 years or less than 5 years on the day ofinterview and in whom at least one deciduous tooth had erupted were eligible to be included in the study. The upper limit of age was selected to be 5 years. Since the study was carried out during homevisits the upper age limit has to be kept at 5 years, since the school entrance age for Sri Lanka is 5 years, therefore the likelihood of finding children above 5 years would be less.  Males in the study sample were 53.7% and females 46.3%.
TheSinhalese ethnic category comprised the largest proportion ofthe study sample (89.6%); and 9.6% were represented by the Muslim ethnic group. Tamils were represented by less than 1%. The rural sector formed 80% ofthe study sample andthe urban sector 20%.
Journal ofthe College ofCommunity Physicians ofSri Lanka     Table 4 indicates that the severe component of ECC was much higher (56.3%) than the non-severe component of ECC (6.7%). 89.2% of those with ECC had severe type.  Agestratification of the sample was in equal proportions. According to the sample size required (800), 160 subjects in each group had to beseen. Children below 12 months with teeth were difficult to find, thus only 150 subjects were included in the study. (Table 1) As indicated in Table 2, the overall prevalence of ECCin children below 5 years was found to be 63% (figure 3). Theprevalenceof dental caries among year old children in Sri Lanka and the Kalutara district was 76.4% and 78.5% respectively as reported by the National Oral Health Survey 1994 (27). Volume ,2004 24 Theoverall prevalence includes age groups of all children below 5 years, Since the prevalencein the lower age groupsis low there is a dilution effect in the overall prevalence. This is the reason for the overall prevalenceto beless than the caries prevalenceof6 year old children in the National Oral Health Survey (1994/95). The age specific overall prevalence of ECC was observed to increese with age (Table 3). A prevalence of 76.6% was seen in the 49-60 month age group and a prevalence of, 23.2% was observed among children below one year.
It can also be deduced, that a sharp rise in the age specific overall prevalence of ECC occurred after 1 year, and thereafter increased progressively. This is a very important inferenceas it focuses onthe fact that ECC begins at 2 very young age and therefore stresses the need for early attention.
This also emphasizes the fact that awareness, attention and care has not been focused on the deciduous dentition. Many studies have shown that the prevalence of ECC in many developing countries and immigrant populations in developed countries is high. 'These results are in agreement with those studies (2,5,24,25).
Further, it is distressing to note that among children below oneyear of age, a prevalenceof 23.2% of ECC exists. The fact that ECC has commenced almost immediately after eruption ofthe deciduous dentition has to be considered seriously when planning for the prevention of, ECC.
This study employed the latest diagnostic criteria recommended for ECC . An important feature of the diagnostic criteria of ECC in this study was the inclusion of non-cavitated carious lesions (white spots). In a metaanalysis carried out by Ismail and Sohn cavitation had been the commoncriterion used to define dental caries (26). It was also found that there was a wide variation in the case definitions and diagnostic criteria used to diagnose ECC.
The age specific prevalence should be considered seriously in planning oral health services. Severity of ECC wouldbe discussed subsequently.

Journal ofthe College ofCommunity Physicians ofSri Lanka
Theseverity of ECC has been determined by the diagnostic criteria of ECC used in this study . It was found that overall the severe component was high. The -non-severe component formed a minor component (Table   4 and Figure 5 ). On observing age specific prevalence of ECC,proportions of severe ECC washigher in all age groups up to 3 years. Thereafter the proportion of severe ECC declined up to 5 years (Table 5 and Figure 6).
This indicates that the burden of disease in Sri Lanka is high.
Onobserving mean dmift levels ( This further confirms the fact that prevention of ECC and reversibility of the lesion is possible if attendedto at this stage. Preventive care should beginearly and it must be doneso, with theobjective of decreasing the prevalence of ECC. This further emphases the need for a total reorganisation of dental services to meet the needs of the problem of a large burden of disease which should be carried out with short term and longterm planning.
ECChas to be recognisedas a priority health problem among the health personnel andthe community with the main objective of reducing the prevalence of ECC.
Education programs on ECC and training programs to detect early signs of ECC,risk behaviour and referral to the appropriate place for attention, should be conducted amongthe health staff and the community. The health staff includes -© all dental personnel, all dental surgeons and schooldental therapists. © all primary health care personnel * medical officers and paediatricians, The community includes -© all pregnant mothers, parents of children below 5 years and all caregivers. This may require KAP studies to evaluate thelevel of awareness Enhancing preventive dental services -more community dental clinics and preventiveclinics should be provided by the health authorities with facilities to provide fluoride preventive care ( fluoride varnish application, fissure sealents use, fluoride gel application) Thefirst three years of childhood have proved to be more at risk to ECC.
Therefore a system where children are screened early should be developed. Therefore, the integration of ECC preventive services to MCHservices is recommended. The very satisfactory utilisation of MCH services by mothers provides an excellent opportunity to reach mothers and children for prevention of ECC. ECC preventive include -Screening ofall pregnant mothers, all necessary dental treatment should be carried out ( scaling, restoration of carious teeth) so as to achieve low bacterial counts. This would help to reduce the transmission ofbacteria to child.
Early obligatory screening of services should children.
Brushing instructions counseling of risk behaviour groups. Objective: To assess the effectiveness of an intervention on knowledge and practices on breast feeding among mothers in the community and onpracticesatinstitutions.
Methodology: A quasi experimental study design was used. One ofthe two 'health areas' where baseline data on breast feeding practices were available, was identified as the 'study area' and the other, the 'control'. Two Base Hospitals were identified, one as the 'study hospital' and the other, the 'control'. The intervention aimed at training field and institutional health staff along with the provision of supplementary reading material to mothers, was implemented in the 'study' area and the 'study' institution. A postintervention assessment on knowledge and practices was made, six months later.
Results: Duringthe post intervention phase, an increase in the exclusive and predominant breast feeding rate was seen with a reduction in the bottle feeding rate, There was an improvement in the knowledge especially regarding the assessmentof adequacyof breast milk with the percentage of mothers with correct knowledge increasing eightfold. Improvements in the institutional practices were significant,

Introduction
Factorsthat have an influence on how women feed their infants and the length of time they breast feed have been expensively Journal ofthe Community Physician of Sri Lanka reviewed (1,2). Maternal employment (3), influence offamily and husband (4), antenatal education (5), practices in the early neonatal period (6) have all heen shown to influence breast feeding practices. The role of health workers in promoting breast-feedingpractices has been well documented and the important negative influence of inadequate knowledge among health workers and their unhelpful attitudes have beenreported (7.8).
Appropriate training of health workers both basic and in-service, is an essential Tequirement to improve theirability to promote proper breast-feeding practices. In recent years, much emphasis has been paid to develop such training programmes, which resulted in the development of the 'Breast feeding Counseling course', by UNICEF/AWHO(9). In 1999, Rea et al (10) reported that this course has effectively increased the health workers knowledge and their clinical and counseling skills for the support of breast-feeding, In Sri Lanka, the state is the main provider of health services and the promotive and preventive health services including maternal and child health services are provided though geographically defined areas referred to as 'health areas', with a defined population. The expected outcome of training of health workers in breast feeding counseling was to improvepractices at the community level. The present study was carried out with the objective of assessing the effectiveness of an intervention based on the UNICEF/WHO BF Counseling course for health workers Volume9, 2004  supplemented by printed material distributed to mothers during educational programmes conducted by field health staff, on the breast feeding practices at the community level.

Methodology
The study was carried out in Gampaha district, one of the 24 districts in Sri Lanka with a population of approximately 2,066,000. Available institutionalfacilities included one Teaching Hospital, 3 Base Hospitals (intermediate level hospitals), 5 District Hospitals, 3 Peripheral Units and 6 Rural Hospitals, the latter three categories of institutions providing primary medical care. For provision of preventive and promotive health services the district is divided into 14 'health areas'. A baseline study has been carried outin the study area to assess the pattern ofbreast feeding and factors influencing breast feeding. This study included a sample of 1075 mothers with children under one year of age and an assessment of knowledgeand practicesrelated to breast feeding among field staff and institutional staff (13). Using the findings of thebaseline study, an educationalintervention aimed at field health workers and thosein the institutions was planned based on the Guidelines for the WHO/UINCEF Breast Feeding (BF) Counseling Training Programme (9). In addition, a series of booklets providing information to mothers was developed to be given to mothers during educational activities byfield health staff.
A quasi experimental study design with a non equivalent control was used 10 study the effectiveness of theintervention which aimed at improving breast feeding practices in the community through updating knowledge and practices of field health staff and institutional staff.
Oneofthe two health areas in which the baseline study was carried out was identified as the study area (population -120,000 approximately) and the other as the control area (population -125,000 approximately). One Base Hospital was identified for the intervention as the 'study' hospital and another as the 'control'. The educational intervention was carried out for field health staff (22 PHMs)and for institutional staff (20 nurses and midwives).

Journal ofthe Community Physician of Sri Lanka
Printed material providing basic information relevant to breast feeding was distributed to mothers by field health workers during the antenatal and postnatal educational programmes, An assessment of knowledge and practices related to breast feeding was carried out six monthsafter the intervention. The sample size was calculated based on the prevalence of breast feeding observed during the baseline study and the expected changes in the breast feeding practices. Mothers to be included in the study were identified using the same stage sampling procedure adopted in the baseline survey. A total of 247 mothers wereincluded from the study area and 245 from the control area, In the institutions, observations madeby one author (CAJ). The samestudy instruments were used in the baseline (pre intervention) and the post intervention assessments. The effectiveness of the intervention was assessed by comparing the findings of the preintervention and post intervention surveys.
Results. Table 1 presents the changes in the breast feeding practices in the study and control areas before and afterthe intervention. Improvements seen in the exclusive breast feeding rate and the predominant breast feeding rate were significantly higher in the study area compared to the control area. The bottle-feeding rate showed a decline in both areas, the decline being more marked in the study area. Following the intervention, there was a declinein the small percentage ofinfants whoreceived artificial feeding during the first six months in life, in both areas. As shown in Table 2, the practices that promote breast feeding as reported by mothers (the first feed being breast milk and given within one hour, giving colostrum) have shown an increase in the study area, following the intervention. Some improvements in these practices were observed in the control area too, though not statistically significant. The percentage of mothers whoreceived education during the antenatal and postnatal periods shows an increase, especially postnatal education. This percentage was significantly higherin the study area.
In general, there is a marked improvement in the knowledge on breast feeding among mothers in the study area ( Table 3). There was a marked improvement in the knowledge of Volume 9, 2004 29 mothers regarding the assessmentof adequacy ofbreast milk. Following the intervention, the percentage of mothers with correct knowledge increased from 5.2 to 42 percent. This observation is of special importance as a common reason given by mothers for introduction ofartificial milks is 'not having enough milk'.
Theinstitutional data on practices during the early postnatal period were based on the observations made 'by one of the authors (CAD. Significant improvements were seenin practices promoting breast feeding i.e. early skin contact, breast feeding during the first hour after birth, correct positioning and attachment (Table 4). A decline in the negative practices such as giving prelacteal feeds were alsoseen.

Discussion
In assessing the effectiveness of the intervention, information in the study and control areas were obtained from surveys conducted in separate samples of mothers identified from the two areas using the same sampling procedure as the baseline study. This approach eliminated anyinfluence that the pre intervention assessment may have made on the post intervention assessment (14). The observational component of the study at institutions was carried out by the same investigator, to minimize inter-observer bias.
There was a significant improvementin seenin the breast feeding practices and the practices that promotedbreast feeding, in the study area during the post intervention assessment. The control area also showed some improvements e.g. reduction in bottle feeding rate which may be due to other inputs aimed at promotion of breast feeding that are on-going (14). However,the significant improvements seen in the study area indicates thepositive influence ofthe intervention onbreast-feeding practices.
The main componentoftheintervention was training of health workers (field and institutional) with emphasis on how to solve problems on lactation management. In addition, booklets providing information to mothers were distributed to the mothers, by field health workers during their educational activities. It is likely that the availability of written material in the house had an additional spin off effect on the other members of the household,thus contributing to promotion of beast feeding practices.
Journal ofthe Community Physician of Sri Lanka A study conduced in Brazil has shown that training programs based on training guide for beast feeding counseling -40 hour training course (9) had a positive influence on improving the knowledge of health workers (10). The present study has shown that such training with the additional input of documentation provided to mothers by field health workers has had a positive influence on the knowledge and practices on breast feeding, at the community level.
In a population with a high literacy rate of 86 percent (15), as among Sri Lanka women, provision of booklets would serve as an additional input to any educational activities undertaken by health workers. It must be noted that provision of documents was through the field health workers who had to take the initiative to educate the pregnant women and postnatal women on breast feeding, hence could be considered as an additional input, promotedby the health workers. Application ofan intervention is based on the ability to introduce such a programme through the usual system of service provision, with minimal inputs and disruption of the services.
The study also identified that it is feasible to introducean in-service training program based on the UNICEF/WHOcourse, through the existing services