66

Dental Journal
(Majalah Kedokteran Gigi)

2019 June; 52(2): 66–70

Research Report

Assessment of behavioral factors associated with dental caries 
in pre-school children of high socioeconomic status families

Bushra Rashid Noaman
Department of Pedodontics
Faculty of Dentistry, Tishk International University
Erbil, Kurdistan region – Iraq

ABSTRACT
Background: Many Iraqi children of high socioeconomic status (SES) families attend dental clinics presenting predominantly cavitated 
and painful multiple carious lesions. The factors responsible for dental caries within this sector of society need to be identified. 
Purpose: The aim of this study is to assess the dental care behavior of mothers and its relationship with the prevalence of dental caries 
in pre-school age children drawn from high SES families in northern Iraq. Methods: A study was conducted to assess the prevalence of 
dental caries and its relationship to oral hygiene habits in 440 pre-schoolers living in Erbil, northern Iraq. An oral hygiene questionnaire 
was distributed among the families. Dental examination of the children was performed to calculate the dependent factor of decayed, 
missing and filled teeth due to caries (dmf). All data was analyzed by means of the SPSS Microsoft statistical system using descriptive 
tables to identify the relationship between the dependent and independent variable dmf indexes. In order to find the significances, 
a Chi-square test, a Fisher’s exact test and a likelihood ratio test were used at level of p<0.05. Results: 67% of the children in the 
sample had dental caries (mean dmf=3.25±3.77) with 5-year-olds being more affected by dental caries (74%) than 4-year-olds (60%). 
A strong correlation was found in this study between the dependent factor, dmf, and the following independent factors: frequency of 
snack consumption, the need to assist the child during brushing, maternal caries and the mother’s education. Conclusion: Despite 
being members of high SES families, the children examined were significantly subject to dental caries, a fact directly correlated with 
inappropriate behavior on the part of their caregivers in relation to the essential aspects of oral health care.

Keywords: dental caries; dmf index; oral health; preschoolers; socioeconomic status

Correspondence: Bushra Rashid Noaman, Department of Pedodontics, Faculty of Dentistry, Tishk International University, Erbil, 
Kurdistan region, Iraq. Email: bushra.rashid@ishik.edu.iq

INTRODUCTION

Early childhood is defined as the period between birth and 
the 71st month during which dental caries affect children.1 
An important element within Primary Care is early 
examination of the child. Dental caries constitute a disease 
caused by bacteria and, consequently, is transmissible 
from mother to child thereby negatively affecting the 
dentition status of the latter.1 Dental caries caused by 
aciduric and acidogenic bacteria transform sugar into lactic 
acid subsequently resulting in the dissolution of the tooth 
enamel.2

Although high SES exerts a noticeable positive 
influence on the general and oral health of individuals,3 

numerous other factors may cause dental caries, such as 
poor oral hygiene, the absence of assistance to children 
during the brushing of their teeth and a high daily 
consumption of snacks. The incidence of dental caries in 
young children may be higher due to the frequent intake 
of snacks, especially sweets. Therefore, restricting the 
frequency of children’s consumption of snacks allied with 
consistently regular meals is recommended.4 Dental caries 
in early childhood may be the result of bottle feeding or 
breastfeeding while the infant in question is asleep.2,5

Regular visits to the dentist and the professional 
application of fluoride are essential factors in the prevention 
of dental caries6 which negatively impact on the psychology 
of children due to aesthetic problems which can negatively 

Dental Journal (Majalah Kedokteran Gigi) p-ISSN: 1978-3728; e-ISSN: 2442-9740. Accredited No. 32a/E/KPT/2017. 
Open access under CC-BY-SA license. Available at http://e-journal.unair.ac.id/index.php/MKG
DOI: 10.20473/j.djmkg.v52.i2.p66–70

http://dx.doi.org/10.20473/j.djmkg.v52.i2.p66-70


67Bushra Rashid Noaman/Dent. J. (Majalah Kedokteran Gigi) 2019 June; 52(2): 66–70

affect their self-esteem and ability to eat when the lesions 
are cavitated.7 In the USA, it has been proved that caregivers 
presenting tooth loss due to caries negatively influenced the 
dental health of their young children who also suffered from 
the same condition.8 The level of education enjoyed by the 
mother is an important influencing factor in the incidence 
of dental caries in a child, together with such variables as 
income and the frequency of their visits to the dentist.9 The 
aim of this study was to assess the influence of maternal 
behavior on the prevalence of dental caries in pre-schoolers 
drawn from high SES families in northern Iraq.

MATERIALS AND METHODS

This study was undertaken in four selected private 
kindergartens located in the north, south, west and east of 
Erbil, Northern Iraq. 440 children aged 4-5 years old were 
examined for dental caries, while information concerning 
their oral hygiene habits was also collected from their 
families by means of a questionnaire. All the children 
were drawn from families in which the parents occupied 
high income jobs.
The number of subjects drawn from the kindergartens 
totaled 486. After the application of specific inclusion and 
exclusion criteria, 46 children were rejected, of which 21 
failed to submit their questionnaires, six did not attend on 
the day of the examination, 18 did not return their oral 
habit questionnaires and one was excluded due to his being 
asthmatic. The research population of the study, therefore, 
comprised 440 individuals.

All subjects satisfying the following criteria were 
included in the study: aged 4-5 years, free of systemic 
disease, parental agreement provided, comprehensive oral 
habits data and complete dental records which could be 
reviewed by the observers. Failure to meet these criteria 
was considered justifiable grounds for exclusion.

The questionnaire included items concerning the 
tooth-brushing habits of each subject, the timing and 
duration of their feeding during infancy, their eating 
routine, untreated caries and use of fluoride, together with 
the level of education of his/her mother. An oral hygiene 
habits questionnaire in Kurdish, the regional language, 
was prepared by the author which included the factors 
potentially causing dental caries9 (Table 1) and distributed 
among the families who completed the questionnaire one 
week before the dental examinations were conducted.

Dental examinations involving the use of a plan mouth 
mirror and CPI probe were conducted under natural light 
in the well-lit hall of the kindergartens with the subject 
seated on an ordinary chair. The dentition status for 
children, Annex 2, WHO (2013)10 was used to register the 
examination results. Dental caries were recorded when 
a lesion in a pit or fissure, or on a smooth tooth surface, 
constituted an observable cavity, damaged enamel due 
to caries, or a visibly softened floor or wall. Temporarily 
restored teeth, or ones previously restored but also carious, 
were classified as decayed. A tooth was considered to be 
present even if only parts of it remained in the mouth. In 
cases of uncertain tooth presence, caries were not recorded 
as existing. In order to enhance the reliability of clinical 
judgments, four dentists were trained to collect the dental 
examination data. The dmf index was used to measure 
the prevalence of dental caries. In order to quantify intra-
observer validity, a pediatric dentist repeated ten of the 
observations previously performed by each dentist, thereby 
acting as a calibrator. A level of intra-observer validity 
between the pedodontics specialist and each dentist was 
achieved. The research was initiated after approval by 
the scientific committee of Tishk International University 
(Document No. IU.FA.FR. 137E. Decree No. 4, 2018), and 
that of the families of the subjects had been secured.

IBM SPSS system 22 was used to analyze the data 
collected. Descriptive tables were used to indicate the 

Table 1. Oral habits questionnaire

No. Questions Answers

Q1 Does the child suffer from any systemic disease? Yes No

Q2 Does the mother have caries? Yes No

Q3 The feeding time of the child during infancy daytime hours only both daytime and 
nighttime hours

Q4 Does the child demonstrate poor eating habits, such as consuming 
cakes, sweets, chocolate, soda drinks and potato chips? 

Yes
1-2 times a day
>3 times a day  

No

Q5 Does the child brush his/her own teeth? Yes No
Q6 Do you assist your child during tooth-brushing? Yes No
Q7 Has the child ever undergone professional fluoride application? Yes No
Q8 Education level of the mother or caregiver Primary school

Secondary school
Undergraduate degree
Postgraduate degree

Dental Journal (Majalah Kedokteran Gigi) p-ISSN: 1978-3728; e-ISSN: 2442-9740. Accredited No. 32a/E/KPT/2017. 
Open access under CC-BY-SA license. Available at http://e-journal.unair.ac.id/index.php/MKG
DOI: 10.20473/j.djmkg.v52.i2.p66–70

http://dx.doi.org/10.20473/j.djmkg.v52.i2.p66-70


68 Bushra Rashid Noaman/Dent. J. (Majalah Kedokteran Gigi) 2019 June; 52(2):66–70

total research population together with the gender of 
each and his/her relationship to the dependent variable 
dmf index. A chi-squared test, a Fisher’s exact test and a 
likelihood ratio test were used to compare the relationship 
between the dependent variable (dmf) and the independent 
variables; tooth-brushing habits, the frequency of feeding 
during infancy, eating habits, untreated maternal caries, 
professional fluoride application and the level of education 
of the mother. The p-value was measured at a level of 
p<0.05.

RESULTS

440 pre-school children were examined during this study, 
67% of whom had dental caries (mean dmf=3.25±3.77). 
The 5-year-olds were more affected by dental caries (74%) 
than their 4-year-old counterparts (60%) with respective 
dmf indexes of 3.8±4.33 and 2.9±3.4 which represented a 
statistically significant difference. The contents of Table 
2 confirm that males were more affected by dental caries 
(70%), than females (52%) and had a higher dmf index 
(3.6±3.76).

Table 2. Distribution of age and gender and dmf index in the 
sample

Variables Factors N
Caries 

(%)
Mean 

dmf±SD
p-value

Age 4 years 160 60.00 3.8±4.33
0.021*

5 years 280 74.00 2.9±3.40
Total 440 67.00 3.25±3.77
Gender Boys 240 70.00 3.6±3.76 0.25

Girls  200 52.00 2.8±3.78
*significant difference at the level p<0.05

Table 3. The relationship between mean dmf and tooth brushing 
habits in the sample

Variable Type N
Caries 

(%)
Mean 

dmf±SD
p-value

Tooth 
Brushing

1/day 304 63 3.5 ± 3.87

0.2442-3/day 96 40 1.9 ± 2.7

None 40 80 4.6 ± 4.59

Table 4. The relationship between mean dmf and brushing 
assistance habit

Variable Type N
Caries 

(%)
Mean 

dmf±SD
p-value

Brushing 
assistance

No 240 67 3.93 ± 4.06
0.05*

Yes 200 50 2.37 ± 3.29

*p-value at the limit of significance

Table 5. The relationship between the mean dmf and snack 
consumption

Variable Type N
Caries 

(%)
Mean 

dmf±SD
p- 

value

Snacking

Once 
and 

twice/
day

232 58.60 2.75 ± 3.02
 

0.001*

>3/day 104 84.00 5.46 ± 4.85

*significant difference at level p<0.05

Table 6. The relationship between mean dmf and nursing time 
during infancy

Variable Type N
Caries 

(%)
Mean 

dmf±SD
p- 

value

Nursing 
Time

Day and 
night

56 85.70 5.42 ± 3.58

0.001*

Day 384 56.25 2.93 ± 3.71

*significant difference at the level p<0.0

Table 7. The relationship between mean dmf and topical 
fluoride application

Variable Type N
Caries 

(%)
Mean 

dmf±SD
p-value

Topical 
Fluoride

Yes 64 62.50 3.75 ±4.18

0.214

No 376 59.50 3.17± 3.71

Table 8. The relationship between mean dmf and dental caries 
among the children’ mothers

Variable Type N
Caries 
(%) of 

children

Mean 
dmf±SD

p-value

Mother 
caries

Yes 184 60.00 3.4 ± 3.72
0.025*

No 256 59.40 3.12 ± 3.83

*significant difference at the level p<0.05

Table 9. The relationship between the mothers’ education and 
dmf in the sample

Variable Type N
Caries 

(%)
Mean 

dmf±SD
p- 

value

Mother’s 
education

Post- 
graduate

48 16.6 0.16±0.38

0.001*Bachelor 200 56 2.26±2.6

Secondary 120 73.3 5.9±4.7

Primary 72 77.7 3.55±3.29
*significant difference at the level p<0.05

Dental Journal (Majalah Kedokteran Gigi) p-ISSN: 1978-3728; e-ISSN: 2442-9740. Accredited No. 32a/E/KPT/2017. 
Open access under CC-BY-SA license. Available at http://e-journal.unair.ac.id/index.php/MKG
DOI: 10.20473/j.djmkg.v52.i2.p66–70

http://dx.doi.org/10.20473/j.djmkg.v52.i2.p66-70


69Bushra Rashid Noaman/Dent. J. (Majalah Kedokteran Gigi) 2019 June; 52(2): 66–70

 The dmf index was higher in the research subjects who 
did not brush their teeth (4.6±4.59) and who were most 
susceptible to caries (80%) than those who brushed once 
or twice a day, but it showed no statistically significant 
difference (Table 3). Responses to the question about 
brushing assistance showed that 240 mothers did not 
provide this to their children. Of the subjects who were not 
assisted with tooth brushing, 67% had caries with a higher 
dmf index (3.93 ± 4.06) than those who were assisted 
(2.37 ± 3.29). However, the difference was not statistically 
significant (Table 4). 

Of 440 children, 232 consumed snacks once or twice a 
day and 104 more than three times daily. The highest dmf 
index in subjects was that relating to more than three times 
(5.45±4.85); 84% were affected by dental caries and the 
difference was statistically significant (Table 5). Responses 
relating to the intensity of breastfeeding showed that 56 
mothers breast fed their infants both during the day and at 
night and 85.7% of their children had dental caries. The 
other 384 children were breast fed only during the day 
and 56.25% were affected by dental caries, indicating a 
respective dmf index of 5.42 ± 3.58 and 2.93 ± 3.71 which 
constituted a statistically significant difference (Table 6).

Topical fluoride was applied to only 64 subjects in 
the sample who still recorded a high caries index (dmf = 
3.37±4.18). 62.5% were affected by dental caries, almost 
the same percentage as those who did not received fluoride 
(59.5%) with no statistically significant difference (Table 
7). The question concerning whether the mothers were 
affected by dental caries, showed that 184 had dental caries, 
while 60% of their children were affected by dental caries 
with a dmf of 3.4 ±3.72. These was a statistically significant 
difference in comparison with the caries index of children 
whose mothers were free of dental caries (mean dmf = 3.12 
± 3.83) (Table 8).

 With regard to the education level of mothers and its 
relationship to the incidence of dental caries, the results 
of this study showed that the highest percentage of dental 
caries was found in those children whose mothers had 
only gained a primary school education (77.7%, dmf = 
3.55±3.29). In contrast, only 16.6% of the children whose 
mothers had undergone higher education were affected 
(dmf = 0.16±0.38). There was a highly significant statistical 
difference between the level of the education of the mother 
in terms of the prevalence of caries in their children, 
namely; p<0.05 (Table 9).

DISCUSSION

As dental caries develops over time, it can be argued 
that those detected in the subjects of the current study 
largely began in infancy due to their inappropriate dietary 
habits becoming increasingly prominent from the point 
of weaning until the time of the examination (4-5 years). 
This viewpoint agrees with that contained in the study 
conducted by Moynihan and Petersen.11 Caregivers lacked 

knowledge about the negative impact of frequent snacks. 
Moreover, high SES families in Iraq purchase sweets for 
their children to make them feel content. In addition, there 
was considerable inconsistency regarding the appropriate 
point in time to wean infants which rendered dental 
treatment for the entire family essential. There is a need to 
introduce this practice in Iraq.

 There are numerous potential causative factors of 
dental caries which comprise: the host, the mediator and 
the environment. The primary one is mutans streptococcus 
(MS) bacteria. The adherence of MS to the tooth surface will 
result in the formation of plaque. MS ferments sugar and 
converts it into lactic acid which leads to demineralization 
of the enamel.12 Families need to be aware of the effect of 
these bacteria in forming dental caries and how to prevent 
this by tooth brushing, assisting the child during brushing, 
diet counseling and regular visits to the dentist. 

 Pediatric dentists, in particular, have a major role to 
play in educating mothers to manage the oral health of their 
children. All dentists who treat adults with caries should 
ask the patient about the oral health of their children.13 
One of the measures to prevent dental caries in infants 
and toddlers is that of treating the dental caries of their 
caregivers since these may be induced in the child.14 Of the 
mothers featured in the current study, 46% suffered from 
dental caries. However, this figure may represent a case 
of under-reporting which can be considered a limitation of 
this study. Preventive methods should be established such 
as oral hygiene improvement, fluoride application, the use 
of pit and fissure sealants, decreased frequency of snacks 
during the day and educating caregivers.15 In this study, the 
mothers with caries themselves were found to have children 
suffering from high levels of this condition.

 The components of the SES are the level of parental 
education, house ownership, family income and type of 
parental occupation.16 In the current study, the families 
of the research subjects were all owner-occupiers of their 
homes and earn high incomes, but their children were 
found to be strongly affected by dental caries. In the current 
study, one of the factors that directly influenced the dental 
health of those individuals was the level of their mothers’ 
education. The highest dmf score was found in children 
whose mothers had only attended primary school, while the 
lowest was in those whose mothers had progressed to higher 
education. Several studies2,5,7,8 concur that the education 
level of a mother influences the advice she gives her child 
with regard to diet and duration of brushing, as well as the 
regularity of both her own visits and those of her child to 
the dentist in order to monitor their respective oral health. 
Educational programs can be introduced into schools and 
may prove beneficial in increasing the health awareness of 
school children in Iraq17 which will, in turn, have a positive 
impact on subsequent generations.

This study is subject to certain limitations in that 
it relates only to Iraq. Despite being drawn from high 
SES families, the subjects of this study demonstrated a 
significant incidence of dental caries. The causative factors 

Dental Journal (Majalah Kedokteran Gigi) p-ISSN: 1978-3728; e-ISSN: 2442-9740. Accredited No. 32a/E/KPT/2017. 
Open access under CC-BY-SA license. Available at http://e-journal.unair.ac.id/index.php/MKG
DOI: 10.20473/j.djmkg.v52.i2.p66–70

http://dx.doi.org/10.20473/j.djmkg.v52.i2.p66-70


70 Bushra Rashid Noaman/Dent. J. (Majalah Kedokteran Gigi) 2019 June; 52(2):66–70

underpinning their high rates in these children were related 
to inappropriate behavior on the part of the caregivers 
with regard to the essential aspects of oral health care. 
On this point, the author recommends the introduction of 
educational programs for all categories of Iraqi society 
using a variety of media and methods and activating 
community dentistry to increase the awareness of families 
regarding oral health care.

ACKNOWLEDGEMENTS

The author wishes to extend her appreciation to the 
Presidency and Deanery of Dentistry Faculty of Tishk 
International University for their financial support of the 
research reported here, to research assistants, Dr. Saya 
Hadi Rauf, Dr. Lava Sabir and Dr. Zahraa Emad, for their 
invaluable assistance in examining children during the study 
and to Dr. Zhakaw Amang for her support in formatting 
the tables contained in the article.

REFERENCES

 1. Chandna P, Adlakha VK. Oral health in children — guidelines for 
pediatricians. Indian Pediatr. 2010; 47(4): 323–7. 

 2. Mwakayoka H, Masalu JR, Kikwilu EN. Dental caries and associated 
factors in children aged 2-4 years old in Mbeya City, Tanzania. J 
Dent (Shiraz, Iran). 2017; 18(2): 104–11. 

 3. Nicolau B, Marcenes W, Bartley M, Sheiham A. A life course 
approach to assessing causes of dental caries experience: the 
relationship between biological, behavioural, socio-economic and 
psychological conditions and caries in adolescents. Caries Res. 2003; 
37(5): 319–26. 

 4. Jain M, Namdev R, Bodh M, Dutta S, Singhal P, Kumar A. Social and 
behavioral determinants for early childhood caries among preschool 
children in India. J Dent Res Dent Clin Dent Prospects. 2015; 9(2): 
115–20. 

 5. Meyer F, Enax J. Early childhood caries: epidemiology, aetiology, 
and prevention. Int J Dent. 2018; 2018: 1–7. 

 6. Gomes M, Pinto-Sarmento T, Costa E, Martins C, Granville-Garcia 
A, Paiva S. Impact of oral health conditions on the quality of life of 
preschool children and their families: a cross-sectional study. Health 
Qual Life Outcomes. 2014; 12: 1–12. 

 7. Roberts CR, Warren JJ, Weber-Gasparoni K. Relationships between 
caregivers’ responses to oral health screening questions and early 
childhood caries. J Public Health Dent. 2009; 69(4): 290–3. 

 8. Moimaz SAS, Fadel CB, Lolli LF, Garbin CAS, Garbin AJÍ, Saliba 
NA. Social aspects of dental caries in the context of mother-child 
pairs. J Appl Oral Sci. 2014; 22: 73–8. 

 9. Litt MD, Reisine S, Tinanoff N. Multidimensional causal model of 
dental caries development in low-income preschool children. Public 
Health Rep. 1995; 110(5): 607–17. 

10. World Health Organization. Oral health surveys: basic methods. 5th 
ed. World Health Organization; 2013. p. 85. 

11. Moynihan P, Petersen PE. Diet, nutrition and the prevention of dental 
diseases. Public Health Nutr. 2004; 7(1A): 201–26. 

12. Çolak H, Dülgergil ÇT, Dalli M, Hamidi MM. Early childhood 
caries update: a review of causes, diagnoses, and treatments. J Nat 
Sci Biol Med. 2013; 4: 29–38. 

13. Weintraub JA, Prakash P, Shain SG, Laccabue M, Gansky SA. 
Mothers’ caries increases odds of children’s caries. J Dent Res. 2010; 
89(9): 954–8. 

14. Lee Y. Diagnosis and prevention strategies for dental caries. J 
Lifestyle Med. 2013; 3(2): 107–9. 

15. Douglass JM, Li Y, Tinanoff N. Association of mutans streptococci 
between caregivers and their children. Pediatr Dent. 2008; 30(5): 
375–87. 

16. Adler NE, Newman K. Socioeconomic disparities in health: 
pathways and policies. Health Aff. 2002; 21(2): 60–76. 

17. Noaman BR, Rauf SH. Initial impact of an educational program on 
the oral health awareness of Iraqi primary school students aged 12 
years. J Dent Heal Oral Disord Ther. 2017; 8(6): 1–5. 

Dental Journal (Majalah Kedokteran Gigi) p-ISSN: 1978-3728; e-ISSN: 2442-9740. Accredited No. 32a/E/KPT/2017. 
Open access under CC-BY-SA license. Available at http://e-journal.unair.ac.id/index.php/MKG
DOI: 10.20473/j.djmkg.v52.i2.p66–70

http://dx.doi.org/10.20473/j.djmkg.v52.i2.p66-70