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Year : 2022  |  Volume : 12  |  Issue : 3  |  Page : 295-308
Prevalence and risk factors for ECC among preschool children from India along with the need of its own CRA tool- A systematic review

1 Department of Pediatric and Preventive Dentistry, Dr. Z.A. Dental College, Aligarh Muslim University, Uttar Pradesh, India
2 Department of Preventive Dental Sciences, Dr. Gerald Niznick College of Dentistry. Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
3 Department of Preventive Dental Sciences, Dr. Gerald Niznick College of Dentistry and Department of Pediatric and Child Health and Community Health Sciences, Max Rady, College of Medicine, Rady Faculty of Health Sciences, Children’s Hospital Research Institute of University of Manitoba, Winnipeg, Canada

Date of Submission24-Feb-2022
Date of Decision08-Apr-2022
Date of Acceptance19-Apr-2022
Date of Web Publication17-Jun-2022

Correspondence Address:
Prof. Saima Yunus Khan
Department of Pediatric and Preventive Dentistry, Dr. Z.A. Dental College, Aligarh Muslim University
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jispcd.JISPCD_56_22

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Introduction: Caries in the deciduous dentition of children under six years of age is termed as early childhood caries (ECC). ECC is prevalent among Indian children and identifying modifiable risk factors is important for prevention. This systematic review was undertaken to describe the burden of ECC in India, its prevalence, associated risk factors along with its repercussions on childhood health. Materials and Methods: A search was conducted for published Indian studies on ECC through electronic databases and complemented with hand search. The protocol for the present systematic review was registered at PROSPERO (Ref No. CRD42022306234) Care was taken to include studies which could represent all parts of India- Central, North, South, East and West. Included papers were reviewed for prevalence of ECC and reported risk factors. Results: Overall 37 studies on ECC in India were identified relating to prevalence, 11 reported risk factors and two reported on the association between severe ECC and nutritional health and well-being. The prevalence of ECC in India in these studies varied from16% to 92.2%. This systematic review revealed that ECC is prevalent among Indian children and highlights the need of preventive intervention and early risk assessment by its own caries risk assessment (CRA) tool. Occurrence seems to be firmly connected with age, snacking frequency, feeding and oral hygiene habits and with social determinants of health including parental education level, low socioeconomic status and number of siblings.

Keywords: Caries risk, Early Childhood Caries (ECC), India, logistic regression, pre school child, prevalence, systematic review

How to cite this article:
Khan SY, Javed F, Ebadi MH, Schroth RJ. Prevalence and risk factors for ECC among preschool children from India along with the need of its own CRA tool- A systematic review. J Int Soc Prevent Communit Dent 2022;12:295-308

How to cite this URL:
Khan SY, Javed F, Ebadi MH, Schroth RJ. Prevalence and risk factors for ECC among preschool children from India along with the need of its own CRA tool- A systematic review. J Int Soc Prevent Communit Dent [serial online] 2022 [cited 2022 Dec 5];12:295-308. Available from: https://www.jispcd.org/text.asp?2022/12/3/295/347774

   Introduction Top

The American Academy of Pediatric Dentistry has defined ECC as “the presence of one or more decayed (non-cavitated or cavitated lesions), missing (due to caries), or filled tooth surfaces in any primary tooth in a child under the age of six”.[1] Early childhood caries (ECC) is a very complex disease, associated with frequent sugar consumption in environment of enamel adherent bacteria that does not always involve bottle feeding.[2]

There are several distinctive factors in young children, which can modify the oral biology such as the immature host defence system, the behavioural patterns associated with feeding and oral hygiene in early childhood. Cultural, genetic and socio - economic differences within a community affect the extent and gravity of the problem.[3] There is variation in prevalence of ECC in different population. Nevertheless, regardless of race, culture or ethnicity, are the disadvantaged subpopulations of children.[4]

In India these disadvantaged children, mostly live in rural and urban slum areas, belong to families of low socioeconomic status (SES), have poor feeding conditions and dietary pattern, have parents with lower education levels and have less awareness regarding health. Health care facilities are beyond their reach. Hence, the burden and extent of ECC is very high among this population.[5] If left untreated, the sequelae may vary from pain, swelling, infection/abscess, disturbed sleep and even malocclusion.[6],[7] These clinical outcomes ultimately have an impact on the quality of life of the child, its growth and development and in some extreme cases may even require hospitalization.[8],[9] Therefore, it can be said that ECC is a social, behavioural, political, medical, psychological, economical and a dental problem.[10],[11]

A number of risk factors influence caries incidence and prevalence like- age, sex, ethnicity, behaviour (dietary and oral hygiene) and SES. Scope and quality of caries preventive program and treatment are dependent on caries prevalence and risk factors information. Hence, there is a constant requirement to assess the prevalence of caries and associated risk factors.[12] The purpose of this systematic review was to identify the burden of ECC in India in pre school children (<6 years of age), specifically its prevalence, associated risk factors, and its effects on health and well-being.

   Materials and Methods Top

The protocol for the present systematic review was registered at PROSPERO (Ref No. CRD42022306234)

Search strategy

Electronic databases were searched for published studies on ECC in India. A sensitive,systematic and separate search was done by two review authors (SYK and FJ) and then a common listing was derived from both. Keywords used alone with Boolean operator “or” and in combinations with the Boolean operator “and” was done. Terms like: “early childhood caries”, ECC, dental caries, caries, caries in primary dentition, caries in deciduous dentition, infant, pre-school, toddler, “severe- early childhood caries”, S-ECC, India, babies, baby, “dent_ and cavit_”were searched. The search terms were used for title and abstract. The literature search spanned the years 1993–2021 and was restricted to publication in English only. Searched electronic databases were Pub Med (Medline), Embase, Cochrane CENTRAL register, Scopus, NLM Gateway, DARE, CANCERLIT, CINAHL, LILACS; PsycINFO and Library catalogue of University of Manitoba. Apart from databases, hand search was done using Google search engine. Care was taken to include studies which could represent all the five parts of India namely Central, North, East, West and South. The PECO question was-Population;Pre-school Indian children ≤ 6 years of age,Exposure; associated risk factors,Comparison;Not applicable,Outocme;prevalence and associated risk factors.

Study selection

The search was guided by the following inclusion criteria. Studies involving children ≤ 6 years of age, Indian children with ECC, dmft>0, dmfs>0, caries prevalence reported in deciduous dentition, associated risk factors for ECC and those examining association between nutrition and ECC were included. In case of any discrepancy with regard to the eligibility, matter was resolved by an experienced third reviewer (RJS).

Quality assessment and data extraction

Data extraction was done by two authors –SYK and FJ as-

  • 1)Name of authors, region where study was conducted

  • 2)Population and age on which study was done

  • 3)Type of study design with reported prevalence

  • 4)Logistic regression or other statistical tests used.

  • 5)Quality of evidence.

Those studies that used logistic regression analysis to investigate the relationship between ECC and risk factors were subsequently reviewed by third author (RJS) as full text articles, to identify whether significant /non significant association existed. GRADE[13] was used for quality evidence by two review authors through consensus. GRADE approach starts with study design- Randomized trials as high and Observational studies as low. This system rates the quality of evidence as high(four plus),moderate (three plus),low(two plus) and very low (one plus) on the basis of study design, risk of bias,inconsistency,indirectness,impression and publication bias.

Indian studies identified common risk factors for ECC with the variables that were assembled into 14 categories: age, education level, SES, family characteristics, eating behaviour (e.g snacking frequency), oral hygiene behaviour (e.g. brushing habits), infant feeding behaviours (e.g breastfeeding and bottle feeding), sex, dental history, fluoride exposure, nutrition, debris, belief and developmental defects. Family characteristics included number of siblings, working mother, birth order and parent’s age at child birth. SES risk factors comprised of variables related to social class, occupation of parents, family income.

   Results Top

The search strategy resulted in 727publications. Hand search yielded 72 articles, making a total 799. Overall, 252 duplicate articles were removed and a total of 547 were reviewed by two authors independently (SYK and FJ). A total of 428 articles were excluded,while 119 full text articles were assessed. Those retracted articles were excluded which lacked on relevant data of Early Childhood Caries pertaining to Prevalence, Risk factors and Age group [Chart 1].
Chart 1: PRISMA flow chart

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Overall, 37 studies on ECC in Indian children were identified. Of the 37 studies, 11reported risk factors for ECC and two found association between severe ECC and nutritional health and well-being [Table 1]. More than 90% of the included studies had a cross sectional study design. A total of 13 studies were conducted on Anganwadhi children, one study included Tibetan immigrants living in India, and the remaining 23 included rural/urban/sub-urban/urban slum preschool children.
Table 1: Published studies on early childhood caries among pre-school children in India

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The prevalence of ECC in India varied from 16% to 92.2% [Table 1]. The highest prevalence of ECC was among Tibetan immigrant preschool children living in India (92.2%). Anganwadhi children were also found to have a high rate of ECC (81.4%). By contrast the lowest rate of ECC was among semi urban and rural preschool dwelling children of Tamil Nadu (16%). Out of 37studies, three studies also reported the prevalence of S-ECC and in one study, prevalence of S-ECC was 94.3% which was higher than the highest reported prevalence of ECC. However, there was also a variation in the prevalence of S-ECC as reported by different studies, which ranged from 21%- 94.3%. Anganwadhi children were having the highest S-ECC rate whereas; preschool children in Himachal Pradesh were having the lowest rate of S-ECC.

To assess significant relationship between ECC and several associated risk factors there were only 11 studies out of 37 that performed multiple logistic regression [Table 2], three studies focused on severe ECC and two examined ECC/S-ECC association with nutritional status of children.
Table 2: Identified risk factors for ECC in Indian studies

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   Risk Factors Top

Childhood age is one of the known risk factors of ECC and has been considered by eight reviewed Indian studies as a significant factor. [Table 3]. The study conducted in 2012 showed that caries prevalence increases with increase in the age. In 8–13 month old age group only one child was found to have caries. The reason that they stated was less number of erupted teeth in this age group.[3] Another study done in 2013 reported an increase in caries prevalence with increasing age (X2for trend = 29.89, p= .0001) which is in support of the above study.
Table 3: Indian studies using Logistic Regression to assess Caries riskfactors

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Thirnganamurthy S et al. stated that in 4 years old, the odds ratio of caries occurrence was 1.73, in 5 years old- it increased to 3.24 and in 6 years old, it went to as high as 3.6.[24] Hence, increase in age, increased the association of developing caries to age. Similarly, another study done in 2018 stated greater caries prevalence of 46% in older age group of 61–72 months (5–6 year) when compared to younger age group of 36–48 months (3–4 year) with prevalence of 21% and in 49–60 months(4–5 year) a prevalence of 33% respectively.[36] Recently, Barjatya et al.[45] and Athavale et al.[47] also found a significant association of ECC with age. A multivariate analysis using logistic regression showed a statistically significant association of age with S-ECCP < 0.0001, with an odds ratio as high as OR=7.059.[32]

Sex was another risk factor studied by four different Indian studies but none reported it as a significant risk factor [Table 2], [Table 3].[3],[17],[36],[38]

Socioeconomic factors like social status/class, occupation and family income were also related to increase the risk of caries development. There were seven studies out of which four reported SES as a significant risk factor [Table 3]. Two of these studies showed low socioeconomic status as a marker for caries occurrence,[24],[45] one study stated low income as a risk factor for ECC(p<0.001, Adj OR=0.35)[3] and another study showed relationship between occupation and ECC with an OR=2.68.[38] Six studies also investigated the level of education of parents/caregivers. Five studies reported significant association between low education level and ECC.[3],[24],[27],[32],[38] Only one study reported the association between ECC and education level of parents as insignificant.[17]

Family characteristics (family size, birth order) were also taken into account for assessing if there was any significant association with ECC [Table 3]. Three studies found significant relationship with ECC. One study showed higher number of siblings to be related to higher occurrence of ECC (P = 0.046, Adj OR= 1.4),[27] another research related birth-order to ECC (P = 0.001, Adj OR= 2.70)[36] and one study considered busy family life as a marker of ECC.[47]

Different behavioural factors were identified and assessed for their association with ECC. Six studies assessed the association and four reported significant association between ECC and behaviour. One study investigated parent’s dental seeking behaviour as a possible risk indicator for ECC and stated it to be of significance in the onset of ECC [Table 2].[27] Out of eight studies, seven reported significant association between snacking behaviour and ECC. Six studies showed relationship between snacking frequency/number of sweets intake with ECC and found it to be significantly associated,[3],[17],[24],[27],[32],[40] three studies investigated in between meal snacking as a possible risk indicator for ECC.[3],[29],[40] Seven studies investigated association of infant feeding behaviour with ECC and all of them found significant association between ECC and feeding behaviour [[Table 2], [Table 3]]. Bottle-feeding at night was observed to be significantly associated with ECC occurrence.[3],[29],[32],[38] Duration of breastfeeding was also one of the risk indicator which was significantly associated with ECC.[36],[45] Similarly, on-demand breastfeeding was significantly associated with ECC.[3] Feeding behaviour was examined by five studies and only one study found it to be significantly associated with ECC [Table 3].

Oral hygiene behaviour was reported by nine studies and six studies found significant association with ECC [Table 3]. Three studies reported significant association between child brushing under no supervision and ECC,[3],[32],[36] two reported frequency of brushing as potential risk indicator of ECC and found it to be significantly associated with ECC.[27],[29] On the contrary, one study found no relation between frequency of brushing and ECC,[38] two studies reported cleaning at night to be non-significant and showed no association with ECC.[3],[29]

Dental history (visit to dentist) was examined by two studies as a possible risk indicator for occurrence of caries [Table 2], [Table 3]. Out of the two studies, one reported it to be significantly associated with ECC[47] while the other reported no significant association.[38]

Only one study showed association between debris score and ECC [Table 3] and reported it to be significantly associated with the ECC (P = 0.00001).[38]

Another factor recognised as a potential risk indicator for caries development is enamel hypoplasia. Only one study had reported it and shown its association with ECC occurrence to be of significance.[38]

One study has viewed beliefs of the parent/caregiver and its influence on ECC [Table 3]. According to the study weaning at a later stage is significantly associated with development of caries(P < 0.01).[17]

Exposure of fluoride was investigated by Subramanian et al. in 2012 [Table 3] which showed significant association between use of non-fluoridated dentifrice and ECC development.[3] According to the study, children who were using fluoridated dentifrice had a significantly lower percentage (18.3%) of caries.

   Nutrition and Well-being Top

In 2018, a cross-sectional study was conducted by Panwar et al. involving 401 Anganwadhi children. They showed that children having low birth weight <2.5kg were affected significantly with ECC when compared with those having birth weight >2.5kg (53.3% vs. 34%; P = 0.001). The logistic regression analyses conducted by them, showed low birth weight as one of the risk factors for ECC.[40] Another study conducted by Athavale et al. in 2020 also reported significant relationship between occurrence of ECC and under nutrition. According to the study, 56% of total children were undernourished, 42% had stunted growth, 36% were underweight and 21% were wasted [Table 2], [Table 3].[47]

   Discussion Top

The aim of this review was to determine the prevalence and the associated risk factors of ECC in Indian preschool children. If the risk factor happens to be modifiable such as feeding behaviour, exposure to fluoride, timing and snacking frequency, then they have the potential to mitigate the risk of developing caries. A total of 37 studies were included in this review which met the criteria of ECC (i.e children of ≤6 years of age and have reported prevalence of ECC too)

In the past few years, several studies have been conducted in India on ECC. Populations considered at high risk for caries were Anganwadhi children, preschool children from slum or rural areas, immigrants have been discussed at length in the aforementioned studies. It is sad to state that despite so many studies, no study can represent the true status of prevalence of ECC in the entire Indian population. The reasons behind this can be that there is no true national representative sample available and there is also underreporting of ECC from certain states. Therefore, we must rely on available regional studies to measure the burden and extent of the disease in the preschool children in India.[3],[32] Further, oral health is a sector greatly neglected by Indian health care system and is viewed as an integral part of childhood health and well being.

Among the reviewed Indian studies on ECC, SES is a well-established risk factor and has been reported by many studies. Low family income, lower social strata and occupation play an important role in increasing the risk of ECC as they limit the access to primary dental care and prevention.[3],[24],[38],[45] Lower economic strata population experience financial, material and social limitations which create a barrier in achieving necessary oral health care and leads to occurrence of oral diseases as described by Jose and King.[48] Parental level of education also influences caries development as low education level is significantly associated with increased risk of ECC.[3],[24],[27] Education is a primary determinant of a person’s labour market position, which in turn influences income, housing and other material resources and makes them aware to use the available services. Studies done by Zhou et al.,[49] Jose and King,[48] Hallet and O’Rourke,[50] Livny and Sgan-Cohen[4] have revealed a strong association between caries presence and education level of mother.

Debris score has also now been shown to be significantly associated with ECC occurance.[38] Plaque acts as a reservoir of nutrients for bacteria and regulates ionic flow across membrane through buffering of acids, thereby increasing caries progression.[51] One study reported enamel hypoplasia as a significant risk factor for ECC.[38]Future research is warranted in this area, to better understand the association between the two. There are several studies which have shown significant correlation between nocturnal bottle feeding and ECC.[3],[29],[32],[38] Hallet and O’Rourke,[50] Ghanim et al.,[52] Creedon and O’Mullane[53] stated that the reason behind this might be the contact of fermentable contents of bottle for a longer duration with teeth. Breastfeeding >24 months has been reported as a risk indicator of ECC.[36] In this current review,statistically significant association was found between ECC and age.[3],[24],[32],[36],[38],[47] With increasing age, there was an increase in development of ECC as well.[38],[40],[45]

Few studies have investigated role of nutrition and well-being with ECC and found significant association between the two.[40],[47] Similarly other studies also found association between ECC and low birth weight.[54],[55] The reason behind this as stated by these studies might be the predisposition of preterm and low birth weight children to colonization by streptococci in high levels, favouring salivary disorders and enamel hypoplasia development.[56] On the other hand, few studies reported no association between birth weight and ECC.[20],[57]

In order to reduce the likelihood of developing ECC, the population under study should be categorized as low, moderate and high risk and preventive and health promotion program should be directed accordingly. Caries Risk Assessment (CRA) tool has made this approach simple and convenient. Several dental and Paediatric organizations in differentcountries, have developed CRA tools, to help the professionals (dental /non dental) in determining children’s likelihood for ECC.

CRA, is an essential key element for decision making and should always precede the treatment undertaken. It serves as a guide in designing of public health intervention, time and resource allocation to those with the greatest need. As the protective and causative risk factors are different and peculiar for a particular country, as evident from the current literature search, so even the CRA tool cannot be same for all countries and hence should be modified accordingly to bring out the true picture.

   Conclusion Top

Findings from this systematic review reveal that ECC is prevalent in India. Strong association between low socioeconomic status, low level of education, increase in age, no of siblings, birthorder, enamelhypoplasia, beliefs of parents and nutritional status were associated with ECC development. Early access to preventive care and implementing CRA may assist in improving the oral health status of Indian children from caries risk group. As the protective and causative risk factors are different and peculiar for a particular country, as evident from the current literature search, so even the CRA tool cannot be same for all countries and hence should be modified accordingly.

This systematic review provides evidence that ECC is prevalent in India, which highlights the need for early caries risk assessment (CRA) and preventive interventions for high risk groups in India. Completing CRA with parents, can reveal important risk factors, including ones which are modifiable and which are not. CRA- can help uncover risk factors during clinical visits and can lead to tailored anticipatory guidance that may ultimately assist parents in reducing their child’s future risk of developing caries.

Risk factors can differ between and within countries, as evident from the current systematic review. Therefore consideration should be given to modifying CRA tools for different countries in order to identify important risk factors.


Saima Yunus Khan holds International Association for Dental Research John Clarkson Fellowship for her training in Public health. Operating funds for this research and related research were provided through this fellowship.

Financial support and sponsorship

This research did not receive any specific grant.

Conflicts of interest

All authors declare that there is no conflict on interest.

Authors contributions

NA; concept, design, acquisition, interpretation, critical analysis, draft preparation, and editing.

Ethical policy and institutional review board statement

Not applicable.

Patient declaration of consent

Not applicable.

Data availability statement

Available on reasonable request.

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  [Figure 1]

  [Table 1], [Table 2], [Table 3]


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