Background comparisons of pre-31/2-year-old children with nursing caries in four practice settings.

Background information was compared for children with carious primary h~cisors versus caries-free children in different geographic and practice locations: private practices in Baton Rouge, Louisiana, and Akron, Ohio, and university-affiliated clinics in Cleveland, Ohio, and Morgantown, West Virginia. In several respects nursing caries cuts across geographic boundaries and practice settings. Data were similar among study sites for: family size, age of the child when lesions were first noticed, mother’s optimism about her own dentition, awareness of cariogenicity from sleeping with the bottle, and getting the child to accept water in the bottle. Data in this study are interpreted to support the notion that nursing caries frequently is related to parental overindulgence or lack of control. Nursing caries is a distinct clinical entity. Studies have described the teeth involved, etiology, infectious nature, demographics for certain populations and contributing social/attitudinal factors. Few studies have compared the backgrounds of children with nursing caries in different geographic locations and in different practice settings. If differences exist, there may be important implications for prevention and treatment interventions. The caries pattern associated with excessive bottle feeding is distinctive with minor variations. Maxillary primary incisors are carious in all descriptions of this affliction; more than one incisor is involved. 14 A common finding is that one surface of each incisor is most severely involved for a given patient. The incisal edge is the surface least often involved. 3,4 Maxillary and mandibular first primary molars are frequently carious with the occlusal surface most commonly affected. The lesions are first noticed by the parents at about 20 months. 4 Etiology of this caries pattern has been established as excessive bottle feeding with milk or other fermentable liquid in the bottle, s-l° Instances of carious incisors associated with excessive breast feeding also have been suggested, n,~2 Some evidence indicates that nursing caries is an infectious process characterized by microbial specificity; 13,1~ Streptococcus mutans has been identified as the important pathogen. Therefore, children that harbor this pathogen as part of their oral flora are at significant risk for developing nursing caries. The relationship of organism acquisition to this disease appears to be significant and should be clarified further. One differential diagnosis is enamel hypoplasia. ~ Teeth of the premaxilla (primary incisors) were involved most frequently in children from underdeveloped countries. 1547 The exact etiology has not been established, but may relate to a different level of nutrition to the premaxilla during embryonic and fetal stages of development. Hypoplasia also has been reported in preterm low birth-weight infants and in children with cerebral palsy. ~8,~9 Demographic and socioeconomic factors have been studied to some extent in institution populations.3,4 The suggestion has been made that nursing caries may be due to overindulgence and not abuse. Prior awareness of the hazards of excessive nursing by parents also has been suggested. ~ The purpose of this study is to examine demographic, social, and attitudinal characteristics of children with nursing caries in different geographic and practice settings. Methods and Materials Subject selection was based on age and dental criteria. Consecutive children age three and one-half years or 50 NURSING CARIES~DIFFERENT SETTINGS: Johnsen et at. younger and presenting for a dental examination were considered. Radiographs were not a criterion for inclusion since they were not available in all cases. Inclusion in the study was based on dental caries pattern and not a nursing history. The rationale was that a study conducted at widely dispersed sites would be more sound if information was based on present attitudes or dicotomous data from previous experience; the history of nursing duration and frequency would depend on parents’ memories and the questionnaire. Children were included in the incisor caries group if three incisors had carious lesions which exhibited cavitation. Children with hypoplastic enamel defects but no carious component o the lesion were not included in this study. Children with cleft lip or palate also were excluded. A total of 134 children with carious incisors and 90 caries-free children made up the study sample. Dentists participating in the study were provided with a packet containing a cover letter describing their activities, a notebook with blank data sheets, and exact wording for questions. Wording for each question used in this study was the same as for questions used in the previous study in Morgantown, West Virginia. 4 Dentists returned the notebooks as soon as their respective interviews were completed. The first author analyzed all data. Pedodontists in the two private practice sites performed dental examinations and designated which children were to be interviewed; interviews were conducted by a dental auxiliary. The interview was done by one of the two second-year pediatric dentistry residents at the Cleveland site. Residents performed the dental examination. Parents of consecutive children presenting for dental care and fulfilling the dental criteria were interviewed. The interviewer read all questions and choices of responses to the parent; all questions had an objective format so that no interpretation was necessary by the interviewer (responses were recorded on a data sheet). Details of the interviews at the West Virginia site have been described.4 The chi-square test was used for statistical analysis. 2° Levels of significance of p < 0.05 and p < 0.01 were used. The study was conducted at four sites. The sites and practice/clinic descriptions were as follows: 1. Suburban Baton Rouge, Louisiana. The metropolitan area of 375,000 does not have fluoridated drinking water. The solo practitioner is a Board-certified pedodontist in practice for 15 years at the time of the study. The practice is characterized as middle and upper middle class with mostly self-pay or private insurance-pay patients; Medicaid patients are accepted. Twenty-eight children with incisor caries and 20 caries-free children were studied. 2. Suburban Akron, Ohio. The metropolitan area of 300,000 has fluoridated drinking water. The solo practitioner is a Board-eligible pedodontist in practice for six years at the time of this study. The practice clientele was similar to that in Baton Rouge. Thirty children with incisor caries and 20 caries-free children were studied. 3. Teaching Hospital, Cleveland, Ohio. The metropolitan area of 1.5 million has fluoridated drinking water. The clinic site in Rainbow Babies and Childrens Hospital has a pediatric dentistry residency program affiliated with Case Western Reserve University. Candidates completing the program receive a certificate in pedodontics and are Board eligible. The pedodontic residency program had been in this hospital for 12 years at the time of the study. The clinic is characterized as receiving lower and lower middle-class patients with some University-affiliated patients presenting. Medicaid patients predominate. Two second-year residents participated in the study. Thirty children with carious incisors and 30 caries-free children were studied. 4. Teaching Medical Center, Morgantown, West Virginia. The metropolitan area of 50,000 has fluoridated drinking water, but well water supplying persons in surrounding Appalachia rarely has measurable levels of fluoride.21 The clinic site is at West Virginia University School of Dentistry. Subjects for the study passed through a central screening point for the programs and faculty practice. Data for the reference study at this site have been reported. * Forty-six children with carious incisors and 20 caries-free children were studied.