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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 6  |  Issue : 1  |  Page : 31-36

Association of nutritional status and dental health among 3–6-year-old children of a South Indian population


1 Department of Dentistry, Hassan Institute of Medical Sciences, Hassan, Karnataka, India
2 Department of Pedodontics and Preventive Dentistry, The Oxford Dental College, Hospital and Research Centre, Bengaluru, Karnataka, India

Date of Web Publication12-Mar-2019

Correspondence Address:
Priya Subramaniam
Department of Pedodontics and Preventive Dentistry, The Oxford Dental College, Hospital and Research Centre, Bommanahalli, Hosur Road, Bangalore - 560 068,Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sjos.SJOralSci_50_17

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  Abstract 


Background: Nutrition promotes healthy development and maintenance of oral health. Chronic malnutrition affects tooth exfoliation and renders the permanent teeth susceptible to caries.Aim: To assess the nutritional status and dental health in 3–6-year-old children.Materials and Methods: A cross-sectional epidemiological study was conducted on a representative sample of 1459 children, aged 3–6 years, and visiting the Integrated Child Development Centers (anganwadi) of T. Narasipura Taluk, Mysore, India. Nutritional status was evaluated by measuring body mass index (BMI) and mid-upper arm circumference (MUAC). Oral examination was carried out using a noninvasive technique with the child sitting in an upright position under good natural light. Dental caries, enamel hypoplasia, and oral mucosal status were recorded according to the WHO criteria.
Results: Nutritional status according to BMI showed 41% of children to be underweight and according to MUAC only 0.82% of children were undernourished. A highest (41.7%) number of underweight children were seen in 3–4 years age group, with a higher number of females being affected. The prevalence of dental caries was 61.07% and was highest in 3–4 years age group. More number of females were affected with dental caries than males. The prevalence of enamel hypoplasia was 8.7%. Association of dental health status with BMI was significant with dental caries.
Conclusions: Forty-one percent of children were underweight and the prevalence of underweight children increased with age. The prevalence of dental caries and enamel hypoplasia were 61% and 8.7%, respectively.

Keywords: Anganwadi, body mass index, dental caries, dental health, enamel hypoplasia, Integrated Child Development Center, malnutrition, mid-upper arm circumference


How to cite this article:
Girish Babu K L, Subramaniam P, Madhusudan K S. Association of nutritional status and dental health among 3–6-year-old children of a South Indian population. Saudi J Oral Sci 2019;6:31-6

How to cite this URL:
Girish Babu K L, Subramaniam P, Madhusudan K S. Association of nutritional status and dental health among 3–6-year-old children of a South Indian population. Saudi J Oral Sci [serial online] 2019 [cited 2019 Jul 24];6:31-6. Available from: http://www.saudijos.org/text.asp?2019/6/1/31/254032




  Introduction Top


Malnutrition is a serious public health problem and is a primary contributing factor to childhood morbidity and premature mortality worldwide. The complexity of malnutrition transcends health issues, impacting growth and development, productivity, and overall quality of life for millions of people. In comparison to other regions of the world,[1],[2] there is a high prevalence of underweight children in South Asia.[3],[4],[5] Malnutrition is widespread in rural, tribal, and urban slum areas. The causes for malnourishment seen in children can be attributed to overpopulation, poverty, large family size, poor maternal health, adverse cultural practices, destruction of the environment, lack of education, gender inequality, and inaccessible medical care.[6]

About 23 million children in India, who are aged 6 years and below, suffer from malnourishment and are underweight. 48% of Indian children under the age of 5 years have stunted growth due to chronic undernutrition.[7] The prevalence of underweight, stunting, and wasting was estimated to be almost 44% (National Family Health Survey-3) in Karnataka, South India.[7]

To curb malnutrition, the Government of India has implemented an Integrated Child Development Services (ICDS) program for children aged below 6 years and also for pregnant and nursing mothers. Integrated Child Development Center (ICDC; anganwadi) is a part of the ICDS program. In Karnataka, the ICDS program was first launched as a pilot project at T. Narasipura Taluk, Mysore, India. However, malnourishment continues to be a concern in this area.

Nutrition promotes healthy development and maintenance of oral health. Studies have shown that early malnutrition affects tooth structure, causes a delay in tooth eruption, and results in increased dental caries.[8],[9],[10] It has also been found that chronic malnutrition not only affects tooth exfoliation but also renders the permanent teeth susceptible to caries later in life.[10] The presence of enamel hypoplasia may be a predisposing factor in initiation and progression of dental caries and a predictor of increased caries susceptibility in malnourished children.[11] In India, there are only a few reports on the oral health status of malnourished children.[12],[13] Therefore, the aim of the present study was to assess the nutritional status and dental health of 3–6-year-old children in T. Narasipura Taluk, Mysore, India.


  Materials and Methods Top


Study design

This cross-sectional epidemiological study was conducted on a representative sample of 3–6-year-old children visiting the ICDCs of T. Narasipura Taluk, Mysore, India. Before commencement of the study, a list of all ICDC in T. Narasipura Taluk, Mysore, Karnataka, was obtained from the Department of Women and Child Development, Government of Karnataka, India. The Taluk was divided geographically into 5 different zones: north, south, east, west, and central. ICDCs from each of these 5 zones of T. Narasipura were selected randomly.

The sample size was calculated according to the formula given by Daniel,n = Z2 Pq/d2

Based on previous report, P = 25.49, q = 74.50, d = 2.549, Z = 1.96.

n = (1.96) 2 × 25.49 × 74.50/(2.549) 2

n = 1122.79 where n is sample size, Z is level of confidence of 95%, P is expected prevalence and d is precision. The sample was estimated to be 1459 children with a confidence level of 95%.

Ethical clearance to conduct the study was obtained from the Institutional Review Board of The Oxford Dental College and Hospital, Bengaluru, Karnataka, India. Permission was taken from the Department of Women and Child Development, Government of Karnataka, India, to carry out anthropometric measurements and oral examination of children in the ICDC. The nature of the study was explained to the authorities of ICDC and parents/guardians/caretakers. Following initial screening, children who fulfilled the criteria for selection were included in the study. Inclusion criteria included cooperative children, children who were residents of T. Narasipura from birth, children without any preexisting medical conditions, and children who were able to stand unsupported. Exclusion criteria included children who were unwilling/unable to participate, children who were absent on the day of examination, children with special health care needs, and mentally challenged children.

A pro forma was designed to record information about demographic data, anthropometric measurements, and oral findings.

Evaluation of nutritional status

For all children, anthropometric measurements such as body weight, height, and mid-upper arm circumference (MUAC) were measured. All measurements were done by a single investigator to avoid interobserver error. Children were weighed using a portable standard glass electronic digital scale (Hesley Inc, China) in kilograms to the nearest 100 g, without footwear and minimal clothing. Care was taken to ensure that the children did not lean forward or take support which could alter the reading.[14]

A vertical nonstretchable tape was fixed on the wall and was used as a measuring scale.[15] For measurement of height, children were made to stand without footwear, keeping their heels together and with the shoulder, buttocks, and heels touching the vertical support. The child was made to look straight so that the Frankfort plane was parallel to the floor. The height was measured to the nearest 1 cm by keeping the scale parallel to the floor at the highest point of the vertex.[14]

Body mass index (BMI) was calculated dividing the individual child weight in kilograms by his/her height in square meter. The BMI value obtained was plotted on age- and gender-specific charts from the Centers for Disease Control and Prevention 2000.[16] Based on these percentile curves, the children were grouped as underweight, normal, risk of overweight, and overweight.[17]

The device used for the measurement of MUAC of children was the MUAC tape (Ibis Medical Equipment and Systems Pvt Ltd., India) [Figure 1]. It is a colored, plastic insertion tape (incapable of stretching and unresponsive to temperatures) marked in centimeters, with cutoff points at 11.5 cm from red to yellow and at 12.5 cm from yellow to green. The measurement was taken midway between the tip of acromion and the olecranon process with the child keeping the hand in a relaxed position. The tape was placed gently but firmly around the arm to avoid compression of soft tissue. Measurement was taken to the nearest 0.1 cm [Figure 2].[15] Based on MUAC, the children were categorized as shown in [Table 1].
Figure 1: Mid-upper arm circumference tape

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Figure 2: Measurement of mid arm circumference

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Table 1: Mid-upper arm circumference measurement

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Examination of oral cavity

Prior training and calibration of the examiner for oral examination of dental caries, enamel hypoplasia, and oral mucosal lesions was carried out in the department of pedodontics and preventive dentistry. Oral examination was carried out with the child sitting in an upright position under good natural daylight. Sterile mouth mirror and CPI probe was used for examination of each child. Dental caries, enamel hypoplasia, and oral mucosal status were recorded according to the WHO criteria.[18] 10% of children were examined twice for intraexaminer reliability (K = 0.88).

Data obtained were subjected to statistical analysis using student t-test, one-way analysis of variance, and Pearson's correlation coefficient. Significance was considered at P ≤ 0.05. Data were analyzed using Statistical Package for the Social Sciences (SPSS) software 19.0 using windows (IBM SPSS Statistics for Windows, Armonk, NY: IBM Corp).


  Results Top


Nutritional status according to BMI showed 41% of children to be underweight, and 0.82% were undernourished according to MUAC. A highest number of underweight children were seen in 3–4 years age group [Table 2]. There was no significant gender difference among the children with regard to nutritional status.
Table 2: Distribution of children according to body mass index

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The prevalence of dental caries was 61.07% with a higher percentage (41%) of children having lesser number of teeth affected with dental caries [Table 3]. A highest number children (429) affected by dental caries belonged to 3–4 years followed by 4.1–5 years (320) and 5.1–6 years (142) age groups children. More number of females (819) were affected with dental caries than males (640). However, the difference in the mean dental caries score between males and females was not significant (P = 0.4003). One hundred and twenty-seven children presented with enamel hypoplasia and 5.3% children were affected with enamel hypoplasia in 1 or 2 teeth [Table 3]. Only 3 children reported with benign migratory glossitis at the time of examination. Association of dental health status with BMI, showed a significant association of dental caries with BMI (P = 0.012) [Table 4]. There was a significant inverse correlation between BMI and dental caries (P = 0.0013). However, there was no significant correlation between MUAC and dental caries. There was no significant correlation between BMI and MUAC with enamel hypoplasia. On comparison between BMI and MUAC, BMI was found to be more accurate [Table 5].
Table 3: Prevalence of dental caries and enamel hypoplasia

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Table 4: Association of dental health status with body mass index and mid-upper arm circumference

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Table 5: Comparison between body mass index and mid-upper arm circumference

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  Discussion Top


Malnutrition denotes impairment of health arising either from deficiency or excess or imbalance of nutrients in the body.[15] Malnutrition increases susceptibility to infections while an infection aggravates malnutrition by decreasing appetite, inducing catabolism and increasing demand for nutrients. The increased susceptibility to infections may be caused by impairment in immune function due to malnutrition.[19]

ICDS is the program introduced by the Government of India to curb the malnutrition and ill health of children below 6 years and pregnant and nursing mothers. ICDS was launched in 1975 in accordance with the National Policy for Children in India. ICDS programs are implemented in the rural areas of India through ICDCs (anganwadi). Over the years, ICDS has grown into one of the largest integrated family and community welfare schemes in the world. Given its effectiveness over the last few decades, the Government of India has committed toward ensuring universal availability of this program.[20]

ICDC provides basic health care in Indian villages including counseling on family planning, education on nutrition and health, immunization of children and mothers, medical health check-up, referral services, and nonformal preschool education. ICDS program is also intended to combat gender inequality by providing girls the same resources as boys. The widespread network of ICDS has an important role in combating malnutrition especially for children of weaker groups.[20]

The people of T-Narsaipura taluk, Mysore, India, are not much exposed to urbanization and do not encourage the dilution of their native culture. Thus, people shifting out or moving into this place is very limited. The diet of this population is still native and stable in nature unlike the diet of children in cities or semi-urban areas.

Status of malnutrition in children is widely estimated using anthropometric methods such as WHO, IAP standards, BMI, MUAC, weight for age, and height for age. Assessment of nutritional status provides information on growth and body composition. Studies have shown that BMI is one of the best methods to assess malnutrition.[21],[22],[23] However, estimation of BMI requires a child to stand without support, measuring scale, and mathematical calculations. Whereas, measurement of MUAC is simple, easier, and less expensive and requires less expertise than BMI.[24] Thus, it can be considered as a more convenient tool for the assessment of nutritional status. In the present study, assessment of nutritional status by BMI showed 41% of children to be underweight, whereas assessment by MUAC showed only 0.82% of children to be undernourished. BMI was found to be more sensitive and accurate than MUAC.

The prevalence of underweight children in our study increased with age. Similarly, in an Indian study, the highest number of underweight was found in the age group of 48–59 months and lowest in the younger age group.[25] In most of the parts of India, such as T. Narasipura, breastfeeding practices are still adhered to by mothers. Breastfeeding during infancy provides protection to certain extent. The transition from infancy to childhood is a period of rapid growth and development. The demand for nutritional needs by the growing child is high and is frequently not met. Reasons could be low family income, large families, inadequate number of meals, improper or poor diet, lack of access, and/or neglect to medical needs. As a result, older children could suffer from nutritional deficiency in comparison to younger aged children.

In the present study, there was no difference in the nutritional status between male and female children. However, other studies have reported higher prevalence of malnutrition in female children.[26],[27] In the Indian scenario, particularly in the rural areas, preference is still given to a male child. In spite of various schemes in favor of the girl child, most families consider a male child to be more important. Providing better quality of food and health-care facilities to male children increases the possibility of malnutrition seen in female children.

Malnourished children have compromised general health as well as oral health. Early malnutrition may produce defects in teeth during the period of development so that they are more susceptible to subsequent dental caries after eruption. Chronic malnutrition in growing children increases the incidence of dental caries. Increase in primary dentition caries has been associated with wasting and stunted children.[8],[10],[27] A systematic review has highlighted the inverse relationship between dental caries and BMI in developing countries.[28] Similarly, in the present study, a significant association was seen between dental caries and underweight children.

Malnutrition in early childhood is often associated with enamel hypoplasia of the primary dentition.[29],[30],[31] In the present study, the prevalence of enamel hypoplasia was 8.7%. Linear enamel hypoplasia of the primary incisor teeth is commonly seen in children living in malnourished communities throughout the world. Estimates of its prevalence have ranged from 14% to 85% in the developing countries.[29],[32] In our study, the prevalence of linear enamel hypoplasia was greater in boys than in girls. At birth, boys in general weigh more, have more muscle mass, are developmentally behind, and have less subcutaneous fat than girls. Thus, boys would be expected to have greater nutritional requirements and less caloric reserves than girls at birth.

The oral lesions commonly seen due to poor nutrition are fissured tongue, geographic tongue, aphthous ulcers, depapillated tongue, and angular cheilitis. In the present study, the prevalence of oral mucosal lesions was seen only in 0.34% of underweight children. Benign migratory glossitis was seen in 3 (0.2%) children. Recording of oral mucosal status was done only at the time of examination. The validity of self-reports given by children regarding previous oral lesions is questionable and hence was not considered in this study.

It is evident from the present study that malnourished children are prone to compromised oral health. Due to constraints of time, cost and facility, the present cross-sectional study was restricted to clinical examination and anthropometric measurements. Further longitudinal studies on nutritional status and oral health of children need to be carried out.

Motivation of ICDC workers is essential for educating mothers on the relationship between nutrition and oral health. Oral health education for mothers should include feeding and dietary practices. Establishment of dental home is important in these areas to meet the oral health care needs of these children.


  Conclusions Top


The following conclusions were drawn from the present study:

  1. 41% of children were underweight and the prevalence of underweight children increased with age


  2. There was no difference in the nutritional status between male and female children
  3. The prevalence of dental caries was 61% and was seen to increase with age
  4. The mean deft score was 2.82 ± 3.46
  5. The prevalence of enamel hypoplasia was 8.7%
  6. There was a significant inverse correlation between BMI and dental caries
  7. On comparison of BMI and MUAC, BMI was more sensitive, specific, and accurate than MUAC.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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