Original Paper
Caries Res 2008;42:141–147
DOI: 10.1159/000121438
Received: November 9, 2007
Accepted after revision: January 25, 2008
Published online: March 27, 2008
Allergic Rhinitis, Feeding and Oral Habits,
Toothbrushing and Socioeconomic Status
Effects on Development of Dental Caries in Primary Dentition
F. Vázquez-Nava a R.E.M. Vázquez b G.A.H. Saldivar b G.F.J. Beltrán b
A.V.M. Almeida b R.C.F. Vázquez b
a Department
b Department
of Research in Clinical Epidemiology, No. 6 General Hospital, Mexican Institute of Social Security, and
of Research, Faculty of Medicine, Tampico Autonomous University of Tamaulipas, Tampico-Madero City,
Mexico
Abstract
The aim was to determine the effect of feeding and oral habits, toothbrushing, socioeconomic status and allergic rhinitis
on the development of dental caries in primary dentition. In
a cross-sectional study, data were obtained by means of a
structured questionnaire on 1,160 children, 4–5 years old
(mean = 4.5 8 0.5) and born in 1999, 2000 or 2001. The children also had a physical examination by an allergist and dentists. Dental caries was diagnosed according to WHO criteria.
Caries experience was measured as number of deft and defs.
Logistic regression analysis assessed the association between dental caries and independent variables. The dental
caries prevalence was 17.9%, 28.8% of the children had allergic rhinitis symptoms, digit sucking was reported by 9.8%
and pacifier use by 13.6% of the children. The mean number
of deft of the sample was 1.02 (SD = 2.37) and that of defs
was 1.33 (SD = 3.54). Analysis showed that breast-feeding for
112 months (p ! 0.01), toothbrushing frequency (p ! 0.01),
sugar consumption (p ! 0.01) and pacifier use (p ! 0.01) each
had a significant association with dental caries occurrence in
primary dentition. Children with pacifier use and allergic rhi-
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nitis had more than double the risk of dental caries development. Allergic rhinitis alone has no effect on dental caries.
Healthcare professionals attempting to limit dental caries
should consider the effect of prolonged breast-feeding, sugary product consumption between meals and nonnutritive
habits on dental caries.
Copyright © 2008 S. Karger AG, Basel
Dental caries is one of the most prevalent chronic diseases of childhood worldwide [Chu et al., 1999; US Department of Health and Human Services, 2000; StecksénBlicks et al., 2004]. Although diverse investigations show
a diminution in the prevalence of dental caries in some
Western countries, there is evidence of an elevated prevalence and incidence of caries in some population groups,
particularly in children aged !5 years. This prevalence of
caries ranges from 10.7 to 47% and the causes of this increase have not been clarified [Aligne et al., 2003; Curzon
and Preston, 2004; Gadelha et al., 2005; van Palenstein et
al., 2006; Yonezu et al., 2006]. Several reports have suggested that early mutans streptococcus colonization
[Alaluusua and Renkonen, 1983], plaque accumulation
on anterior oral surfaces [Alaluusua and Malmivirta,
1994], certain sociodemographic factors [Chu et al., 1999;
Tiberia et al., 2007], as well as dietary and toothbrushing
Francisco Vázquez-Nava
Calle Matamoros 102, Col. Hipódromo
89560 Ciudad Madero, Tamaulipas (México)
Tel. +52 833 216 5247, Fax +52 833 210 6209
E Mail fvazqueznava@yahoo.com.mx
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Key Words
Bottle-fed ⴢ Breast-fed ⴢ Digit sucking ⴢ Pacifier ⴢ Rhinitis ⴢ
Toothbrushing
Methods
This was a cross-sectional study based on a cohort of 1,160
children, 4–5 years old (mean = 4.5 8 0.5) and born in 1999, 2000,
or 2001, who had been longitudinally followed from the age of 4
months. Detailed descriptions of the sampling strategy have been
described elsewhere [Vázquez-Nava et al., 2006]. Briefly stated,
the study took place in the area of Tampico-Madero-Altamira,
Mexico, located 542 km northwest of Mexico City.
The children who participated in this study were part of a population included in another major multidisciplinary research
project, in which a series of the following specialists took part: an
142
Caries Res 2008;42:141–147
allergy specialist, pediatric dentists, psychologists, nurses, social
workers and dental assistants. The study took place in 2005. The
children attended nursery school as required by the Scheme of
Ordinary Participation and Unique Communitarian Neighborhood Program organized by the Mexican Institute of Social Security and the preschool education school (kindergarten) of the
area. Physical examinations were performed as part of the nurseries’ healthcare activities; weight, height, vaccinations and detection of contagious and noncontagious diseases were recorded.
Validated questionnaires were utilized to obtain sociodemographic data, dietary habits and toothbrushing habits. We collected information on feeding type during or after the first year
of life; breast-feeding frequency during the day and at night; when
the children were bottle fed with different types of milk, sugary
snacks and soft drink consumption between meals or whether the
children had manifested any nonnutritive sucking habit (pacifier
or thumb) during or after the first year of life.
Diagnosis of dental caries was established by direct examination of the mouth under natural light by 2 calibrated dentists using disposable gloves, a dental mirror and a tongue stick. Cotton
swabs and gauze were used for moisture control and removal of
plaque on tooth surfaces when necessary. Oral examination was
carried out annually from the second year of life. Diagnosis of
dental caries was made according to the criterion recommended
by the World Health Organization [1997] (Caries is recorded as
present when a lesion in pit or fissure, or on a smooth tooth surface, has a detectably softened floor, undermined enamel, or softened wall. A tooth with a temporary filling should also be included in this category.) In case of doubt, the cavity was carefully investigated with a sharp probe. The prevalence of caries was
obtained by calculating the number of decayed (d), extracted (e),
filled (f) teeth (t) (deft) or surfaces (defs). The defs scores included
all carious lesions on occlusal and approximal surfaces but not for
initial caries on buccal and lingual surfaces. Molars and premolars were considered to have 5 surfaces and front teeth 4. The criterion for initial caries was a chalky white spot without a break in
the enamel surface. Oral data were recorded on examination. For
analysis, dental caries was coded as 1 = caries present and 0 = caries absent.
The children were diagnosed as having allergic rhinitis when
the parents gave an affirmative answer to the question: Has your
child experienced snoring, itching or a stuffy nose without having
a cold or the flu? Physical examination of the nostrils was performed using a Welch-Allen rhinoscope to determine the size of
the tubular bones and the characteristics of the nasal mucosa. To
diagnose atopy in children who showed allergic rhinitis symptoms, prick sensitivity tests were carried out and considered positive when the child was reactive to at least one of the allergens
used. Skin prick tests were done on the back using 1-mm flanged
lancets and extracts of mixed grass pollen, house dust mites (Dermatophagoides pharinae and D. pteronyssinus), cat and dog fur,
cockroaches, alternaria, aspergillus, and histamine and diluents
as controls. The test solutions used were prepared as single batches by Freeman Laboratories, S.A. de C.V., México. The skin test
reactions to each extract were recorded after 15 min and were
considered positive if the papule diameter was greater than that
of the histamine control wheel.
Children diagnosed as having dental caries, allergic rhinitis or
any other pathology were referred for care of their disease(s) to
the corresponding medical service unit.
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habits [Pienihäkkinen et al., 2004; Ruottinen et al., 2004;
van Loveren and Duggal, 2004] are strongly associated
with caries development. However, the effects of other
factors such as allergic rhinitis and some nonnutritive
suction habits (pacifier use and thumb sucking) on dental
caries development appear unclear based on published
results and require further study [Ollila et al., 1998;
Levine, 1999; Stecksén-Blicks et al., 2004].
Allergic rhinitis is the most frequent chronic respiratory disease in children. The prevalence reported in
different countries ranges between 1.3 and 52% [ICARC,
1999]. The most common symptoms of allergic rhinitis
include obstruction, rhinorrhea, pruritus and sneezing.
During its clinical progression, allergic rhinitis can have
complications such as persistent oral breathing and the
presence of infections in oral tissues [ICARC, 1999; Bessa
et al., 2004; Lee et al., 2004; Vázquez-Nava et al., 2006].
Colonization by mutans streptococci and other cariogenic bacteria in children !5 years old could be a key risk
factor for caries development [Caufield et al., 1992; Seow,
1998]. Previous investigations have demonstrated that
the elements utilized in nonnutritive suction, such as pacifiers and fingers, are reservoirs of potentially infectious
micro-organisms inducing dental caries [Olilla et al.,
1997; Peressini, 2004; Comina et al., 2006].
It is clear that dietary and toothbrushing habits constitute important risk factors that by means of diverse
mechanisms possibly lead to different effects on soft and
hard oral tissues [Bessa et al., 2004; Vázquez-Nava et al.,
2006]. On the other hand, the effect of allergic rhinitis
and nonnutritive sucking habits on caries in children under the age of 5 years is unclear [Ollila et al., 1998; Deery,
2004; Peressini, 2004]. Our aim was to evaluate the influence of breast-feeding, bottle-feeding, socioeconomic
background, oral hygiene, sugar consumption, allergic
rhinitis, pacifier use and digit sucking on the development of dental caries in a large cohort of preschool children aged 4–5 years.
Table 1. Demographic and clinical data of preschool study participants
Children
Total
Age, years
Gender (male)
Dental caries
Breast-feeding
Breast-feeding (>12 months and night)
Bottle-feeding
Low family socioeconomic status
Toothbrushing (≤once per day)
Toothbrushing (≥twice per day)
Sugar consumption
Allergic rhinitis
Nonnutritive sucking habits
Pacifier use
Digit sucking
Allergic rhinitis + pacifier use
Allergic rhinitis + digit sucking
1,160
4–5 (4.580.5)
582
50.2
208
17.9
685
59.1
210
18.1
349
30.1
612
52.8
96
8.3
1,064
91.7
531
45.8
334
28.8
256
22.1
158
13.6
114
9.8
44
3.8
38
3.3
deft1
defs1
1.21 (2.46)
1.21 (2.95)
1.36 (2.57)
2.14 (2.93)
0.64 (1.88)
1.28 (2.51)
2.53 (3.03)
0.97 (2.25)
1.51 (2.65)
1.02 (2.37)
1.29 (2.51)
1.56 (2.70)
1.18 (2.45)
1.70 (2.85)
1.34 (2.67)
1.33 (3.13)
1.10 (2.36)
1.51 (3.26)
2.56 (4.13)
0.69 (2.31)
1.37 (3.06)
2.90 (4.05)
1.06 (2.79)
1.63 (3.26)
1.33 (3.54)
1.39 (3.18)
1.73 (3.59)
1.40 (3.34)
2.57 (5.08)
1.95 (4.40)
Figures in parentheses represent standard deviations.
Parental written, oral and informed consent was requested.
The study was approved by the ethics committee of the No. 6 Regional General Hospital of the Mexican Institute of Social Security and the Faculty of Medicine of the Autonomous University of
Tamaulipas, Mexico.
Statistical Analysis
Data were analyzed by SPSS 10.0 statistical package software.
We utilized dichotomous variables to indicate the presence or absence of a certain characteristic. For analysis, single frequencies
and central tendency measures (medians and standard deviations) were used. A 2 ! 2 contingency table (␹2, odds ratio and a
95% confidence interval) was applied to determine dental caries
risks caused by effect of breast-feeding, bottle-feeding, oral hygiene, sugar consumption, socioeconomic background, allergic
rhinitis, pacifier use and digit sucking by comparing one group
with caries and another without. A logistic regression model was
used to determine the effect of one variable having adjusted for
the other. Any p value !0.05 was considered significant.
Results
A total of 50.2% of the children were males (table 1),
and the dental caries prevalence was 17.9%. Approximately 695 of the children were breast fed; of these, 349
children were breast fed for 112 months and during the
night; the time during which the children were breastfed
was 9.77 8 3.56 months, while the children were bottle
fed for 12.83 8 9.65 months. The nonnutritive sucking
Rhinitis, Pacifier Use, Digit Sucking and
Dental Caries
habit prevalence was 22.6%, and 28.8% reported allergic
rhinitis symptoms. The mean deft value of the sample
was 1.21 8 2.95 and the corresponding defs value was
1.10 8 2.36. The percentages of the other studied caries
risk indicators are shown in table 1.
The dental caries prevalence was slightly higher in
males (19.6%) than in females (16.3%). The percentage of
sugar consumption between meals was higher in males
than females. In terms of breast-feeding, toothbrushing
frequency, allergic rhinitis and nonnutritive sucking habits, we found no important differences in percentage in
relation to gender.
The mean deft value and the corresponding defs value
of the children with breast-feeding, bottle-feeding, low
family socioeconomic status, deficient oral hygiene practices and sugar consumption antecedent has been shown
in table 1, and the effect of these variables on dental caries appears in table 2. The relationships between breastfeeding beyond the age of 12 months, oral hygiene practices, sugar consumption and dental caries were significant (p ! 0.01; table 2).
The pacifier use prevalence was 13.6%, with an evolution time of 16.0 8 9.54 months. Of these children, 41.1%
occasionally used a sweetened pacifier. The mean deft
value of the children with antecedent pacifier use was
1.56 8 2.70 and the corresponding defs value was 1.73 8
3.59. The percentage of children with antecedent pacifier
Caries Res 2008;42:141–147
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1
Percent
Table 2. Effects of breast-feeding, bottle-feeding, family socioeconomic status, toothbrushing frequency and
sugary product consumption on dental caries in 1,160 preschool children
Dental caries
yes
Logistic regression
%
no
Breast-feeding (+)
74
35.2
Breast-feeding (–)
134
14.1
Bottle-feeding (+)
37
10.6
Bottle-feeding (–)
171
21.1
Family socioeconomic status
Low
94
15.4
Higher
114
20.8
Oral hygiene practices (toothbrushing frequency)
≤Once per day
40
41.7
≥Twice per day
168
15.8
Sugary product consumption
Low
77
12.3
Higher
131
24.7
%
Adjusted odds ratio
p value
136
816
312
639
64.8
85.9
89.4
78.9
3.60 (2.51–5.16)
<0.001
0.59 (0.33–1.07)
0.086
517
434
84.6
79.2
0.99 (0.70–1.39)
0.979
56
895
58.3
84.2
3.44 (2.17–5.47)
<0.001
551
400
87.7
75.3
2.22 (1.61–3.07)
<0.001
Figures in parentheses are 95% confidence intervals. (+) = Children with the variable of interest for >1 year;
(–) = children without the variable of interest for >1 year.
Table 3. Effects of allergic rhinitis, pacifier use and digit sucking on dental caries in 1,160 preschool children
Dental caries
Allergic rhinitis (+)
Allergic rhinitis (–)
Nonnutritive sucking habits (+)
Nonnutritive sucking habits (–)
Pacifier use (+)
Pacifier use (–)
Digit sucking (+)
Digit sucking (–)
Allergic rhinitis + pacifier use (+)
Allergic rhinitis + pacifier use (–)
Allergic rhinitis + digital sucking (+)
Allergic rhinitis + digital sucking (–)
Logistic regression
yes
%
no
%
adjusted odds ratio
p value
54
154
54
154
40
168
22
186
12
196
8
200
16.2
18.6
21.1
17.0
25.3
16.8
19.3
17.8
27.3
17.6
21.1
17.8
280
672
202
750
118
834
92
860
32
920
30
922
83.8
81.4
78.9
83.0
74.7
83.2
80.7
82.2
72.7
82.4
78.9
82.2
0.84 (0.59–1.18)
0.321
1.31 (0.59–1.18)
0.319
1.68 (1.13–2.49)
0.010
1.11 (0.68–1.82)
0.667
2.16 (1.02–4.54)
0.042
1.34 (0.57–3.15)
0.495
Figures in parentheses are 95% confidence intervals. (+) = Children with the variable of interest for >1 year;
(–) = children without the variable of interest for >1 year.
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Caries Res 2008;42:141–147
number was 1.18 8 2.45, while the mean defs number
was 1.40 8 3.34. A total of 1.7% more males sucked their
fingers as compared with females. No statistical significance was found in relation to the effect of antecedent
digit sucking habit on dental caries (p 1 0.05; table 3).
The allergic rhinitis prevalence was 28.8%, and the
evolution time was 13.80 8 9.45 months. In this group of
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use was 2.5% higher in females than in males. There was
a statistically significant difference in the prevalence of
dental caries between the groups with and without antecedent pacifier use (p ! 0.01; table 3).
Digit sucking habit was found in 9.8% of the sample;
the mean time of this habit was 12.10 8 4.48 months. In
children with digit sucking antecedent, the mean deft
Discussion
Based on our analysis of 1,160 preschool children, nocturnal breast-feeding for 11 year, irregular toothbrushing, sugary product consumption between meals and
pacifier use constitute important risk factors for the development of dental caries in primary dentition.
The detrimental effect of breast-feeding beyond the
age of 12 months and nocturnal breast-feeding on dental
caries has been reported previously [van Palenstein et al.,
2006], whereas we did not find bottle-feeding to be a risk
factor. Prolonged contact of enamel with human milk has
been shown to result in acidogenic conditions and softening of enamel [Thomson et al., 1996].
Our results show that the prevalence of irregular
toothbrushing is associated with dental caries. Previous
studies have reported conflicting results showing some
[Chu et al., 1999] or no effect [Namal et al., 2005]. It is
possible that the different results are related to the differences in the prevalence of toothbrushing in the studied
populations. Our study data also support previous reports that showed an etiological influence of sugar consumption between meals on dental caries in children,
this effect having been previously reported [Pienihäkkinen et al., 2004; van Palenstein et al., 2006]. The results
obtained in the present study on the effect of toothbrushing and sugary product consumption between meals on
dental caries are of great importance and should be utilized in programs promoting oral health, especially if we
consider that high consumption of sweets and soft drinks
in preschool children has been documented by diverse
authors [Stecksén-Blicks and Borssén, 1999; van Palenstein et al., 2006]. Promoting toothbrushing in preschool
children is of great relevance because this is a way to favor
dental health by maintaining clean teeth and can aid in
counteracting elevated high sugar consumption.
Diverse investigators have reported that caries status
in children was related to socioeconomic background
[Holm et al., 1975; Chu et al., 1999]. The analysis of our
study did not confirm this relationship.
The results of previous studies on the use of pacifiers
in dental caries have been controversial. Ollila et al. [1998]
studied the effect of pacifier use on dental caries in a
group of 166 preschool children. The authors reached
Rhinitis, Pacifier Use, Digit Sucking and
Dental Caries
similar conclusions to those of our group, showing an association. Further, development of dental caries in preschool children increases with pacifier use duration. On
the other hand, authors such as Deery [2004] and Peressini [2004], on studying the relationship between pacifier
use and dental caries, concluded that the evidence does
not suggest a strong or consistent association between
pacifier use and dental caries. At any rate, it is important
to bear this association in mind with the idea of reinforcing preventive dental caries programs.
In our study the analysis shows that digit sucking did
not favor dental caries development. We failed to find
previous reports on the relationship between digit sucking and dental caries.
According to the data of this study, allergic rhinitis
possesses no effect on the development of dental caries in
preschool children. Previous reports are in agreement
with this result on not finding any relationship between
some allergic diseases such as rhinitis and dental caries
[Stecksén-Blicks et al., 2004].
The association between certain nonnutritive suction
habits, particularly pacifier use, and the development of
dental caries has been documented in diverse studies [Ollila et al., 1998; Levine, 1999]. There are several possible
mechanisms through which pacifier use favors dental
caries development. One of these theoretical mechanisms
comprises the role of pacifiers as the generating source of
infectious processes in oral cavity tissues [Adair, 2003].
Diverse groups of investigators, such as those of Ollila et
al. [1997] and Comina et al. [2006], on studying microbial contamination on the surface of used pacifiers, found
that the pacifier is a reservoir of microbes such as Staphylococcus, Candida and salivary lactobacilli.
Decreased salivary flow results in clinically significant discomfort that may manifest itself as increased caries [Llena-Puy, 2006; Mese and Matsuo, 2007]. Hyposalivation is a condition that is frequently encountered in
medical and dental practice; the most common causes
include certain chronic diseases such as allergic rhinitis
[Elad et al., 2006]. Children with allergic rhinitis breathe
through their mouth over a lengthy time period as a result of nasal obstruction. Children often perceive nasal
congestion as normal, so even chronic mouth breathing
may go unnoticed. Mouth breathing causes a dry mouth
and introduces contaminated air that insults and infects
oral cavity tissues, leading in turn to pathologic changes
in oral tissues [ICARC, 1999; Bessa et al., 2004]. It is probable that the risk of developing infectious processes such
as dental caries in children with rhinitis increases with
the evolution time of the symptomatic clinical picture. In
Caries Res 2008;42:141–147
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children, the mean number of deft was 1.02 8 2.37 and
the corresponding number of defs was 1.33 8 3.54. The
relationship between allergic rhinitis and dental caries
was not significant (p 1 0.05; table 3).
our study, the effect of allergic rhinitis on dental caries
was possibly not important because the evolution time of
the allergic disease was short. It is necessary to perform
additional longitudinal studies to answer this question
definitively.
This study possesses some limitations that should be
taken into consideration. The information generated by
this analysis arises from a sample of children that attend
a daycare center that has a preventive odontology program; thus, these results cannot be generalized to open
populations. Diagnosis of dental caries was made visually and with natural light, which possesses low sensitivity and high specificity [El-Housseiny and Jamjoum,
2001]. The prevalence of dietary, oral and toothbrushing
habits is based on that declared by the parents of the par-
ticipating children. Additionally, the information concerning allergic rhinitis in the current study was derived
from self-reports of the children’s parents. However, we
constructed an instrument based on an International
Survey of Asthma and Allergies in Children questionnaire [Mata et al., 2005]. Several studies show that such
questionnaires can be considered effective instruments
to measure allergic rhinitis [Mata et al., 2005].
In conclusion, the results obtained in this study show
an association between nocturnal breast-feeding for 11
year and during the night, irregular toothbrushing, sugar
consumption and pacifier use and the development of
dental caries in primary dentition. This information can
be useful in the design of programs promoting oral
health.
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