DOI: 10.1111/ipd.
12235
Parenting style and oral health practices in early childhood
caries: a case–control study
SUHEL DABAWALA1, BARANYA S. SUPRABHA1, RAMYA SHENOY2, ARATHI RAO1 &
NACHIKET SHAH1
1
Department of Paedodontics and Preventive Dentistry, Manipal College of Dental Sciences, Manipal University, Mangalore,
Karnataka, India, and 2Department of Public Health Dentistry, Manipal College of Dental Sciences, Manipal University,
Mangalore, Karnataka, India
International Journal of Paediatric Dentistry 2016
Background. There is a need to carry out
controlled investigations regarding risk factors for
early childhood caries (ECC).
Aim. To study the type of parenting style and oral
health practices as risk factors among children
with ECC in an Indian preschool population.
Methods. Two hundred and eleven children with
ECC and equal number of controls participated in
this case–control study. A questionnaire was
answered by parents regarding oral health prac-
tices such as oral hygiene methods, feeding habits,
daily sugar intake, and dental attendance pattern
along with socioeconomic and demographic sta-
tus. The parenting style was determined using
Parenting Styles Dimension Questionnaire (PSDQ)
Introduction
Early childhood caries (ECC) is a public
health problem in both developed and devel-
oping countries which affects infants and pre-
school children. The prevalence worldwide is
reported as between 28% and 82%1. In India,
27–62% prevalence has been reported in var-
ious cross-sectional studies2–5. Biological,
behavioral or socioeconomic risk factors are
known to contribute to the caries process
leading to ECC6.
Parents are the primary caretakers of their
children, and hence, their oral health knowl-
edge, attitudes, and preventive practices are
directly related to the oral health of their
children. Parent’s lower self-efficacy, dental
knowledge, and parenting stress are
Correspondence to:
Dr. B. S. Suprabha, Department of Paedodontics and
Preventive Dentistry, Manipal College of Dental Sciences,
Light House Hill Road, Mangalore 575 001, Karnataka,
India. E-mail: suprabha.bhat@manipal.edu
© 2016 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
index. Data were statistically analyzed using
chi-square test and multiple logistic regression
analysis.
Results. Risk factors associated with ECC were
higher birth order, lower socioeconomic status,
non-use of fluoridated toothpaste, breast/bottle
feeding for more than one year, presence of for-
mula milk or milk with sugar in the feeding bottle
while falling asleep, higher sweet scores in the
diet chart, and visiting dentist only when a prob-
lem was perceived. Majority of parents of children
with and without ECC had authoritative parenting
style.
Conclusion. Improper oral health practices are the
risk factors for ECC. The association of parenting
style with ECC could not be confirmed.
associated with increased rate of caries devel-
opment in preschool children7.
Parenting styles are known to influence the
well-being of children. Three types of parent-
ing styles, such as authoritative, authoritar-
ian, and permissive, have been described by
Baumrind8. Authoritative parents are control-
ling but also warm and receptive to the child.
Authoritarian parents are less warm and more
controlling in interactions with their child.
Permissive parents are non-controlling, non-
responsive toward their child and make few
demands on the child. The parenting style of
caregiver can influence disease outcomes. The
environment which they create for the child
can influence oral hygiene, dietary practices,
and dental attendance patterns. As the parent
is responsible for nearly all aspects of the
child’s oral health, it can be assumed that
parenting style of caregiver can influence
early childhood caries9.
In India, a few cross-sectional studies on
various risk factors like oral hygiene, feeding
1
2 S. Dabawala et al.
practices, and maternal characteristics have
been reported10,11. There is a paucity of con-
trolled investigations with regard to biologi-
cal, behavioral, or socioeconomic risk
factors12.
Considering this, a case–control study with
the aim to study the parenting style and oral
health practices such as oral hygiene
methods, dietary habits, and dental atten-
dance pattern as risk factors for early child-
hood caries was designed. The objective was
to find whether there is an association of
these factors with ECC.
Materials and methods
The study group comprised of children and
their parents (both father and mother). The
risk factors for ECC were studied using ques-
tionnaire distributed among the parents. The
study was approved by institutional ethics
committee prior to its commencement.
Sampling and sample size
Sampling was performed from various kinder-
garten schools in Mangalore, a city in South
India. A list of kindergarten schools in Man-
galore city was drawn, and schools were
selected using simple random sampling tech-
nique. Sample size was calculated based on
the data obtained from a pilot study involving
total of 30 cases and controls. Sample size
was determined to be 211 cases with equal
number of controls so that one would be
80% certain of estimating a odds ratio, that
is, at least twofold in magnitude (odds
ratio = 2) and assuming expected proportions
of authoritative parenting style in case and
control groups as 0.66 and 0.5, respectively,
at a significance level of 95% (P = 0.05)13.
The cases were defined as per the definition
of ECC by the American Academy of Paedi-
atric Dentistry (AAPD)14. According to AAPD,
ECC is defined as the presence of one or
more decayed, missing, or filled tooth surface
in any primary tooth in a child of 71 months
of age or younger. Thus, those children with
ECC were cases and those without ECC were
controls. The cases and controls were
matched by age and gender of the children.
© 2016 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Inclusion and exclusion criteria
Children between 3 and 5 years of age with
both the parents living together were
included in the study. Also, only one child
per family was included. Children were
excluded if they were medically compro-
mised, if they were under the care of single
parent, or if parents did not gave informed
consent for participation in the study. In addi-
tion, those with partially filled/unreturned
questionnaire were excluded.
Informed consent. A written informed consent
was obtained from parents to participate in
the study and examine the child for the pres-
ence of dental caries, after explaining the pur-
pose of the study. A written permission was
obtained from school authorities of the six
kindergarten schools before the study. The
overall consent rate of the schools was 100%.
Among the 605 parents of children belonging
to six kindergarten schools who were con-
tacted for the purpose of the study, 550
consented for the study.
Survey procedure
Data collection was carried out with a struc-
tured questionnaire answered by both father
and mother. The questionnaire covered
demographic backgrounds, feeding habits,
oral hygiene habits, and dental attendance
pattern of the child. Prior to administration,
the test–retest reliability of the questionnaire
was assessed by administering the question-
naire to ten parents who were not part of the
study (Kappa statistic = 0.75). Retest was per-
formed after one week from the day of initial
administration of the questionnaire. The
questionnaire was examined for face validity
and content validity by two subject experts
(internal validity) and was found to be satis-
factory. No changes were made in the ques-
tionnaire. The test–retest reliability was
determined by administering to ten parents,
who were not included in the study, at two-
week interval (Cronbach’s a = 0.73).
The socioeconomic status (SES) of the
family was recorded using Kuppuswamy’s
socioeconomic scale, as it was applicable to

Indian population15. Based on the score of
education, occupation, and family income
per month, children were divided into
upper, middle, and lower socioeconomic
status.
Data regarding the daily sugar intake were
recorded using 24-hour recall diet chart.
Sweet score was measured in terms of liquid,
solid, and sticky, slowly dissolving foodstuffs.
The frequency of consumption of these food
stuffs was multiplied by 5, 10, and 15, respec-
tively, and total points so obtained were
added up to obtain the Sweet score of the
individual. Based on the sugar exposures in
the diet, sweet score was calculated, and
then, the subjects were grouped into excel-
lent (≤5), good (6–10), and watch out zone
based on the sweet score (≥15)16.
Parenting style of both father and mother
was assessed with parenting style dimension
questionnaire (PSDQ)17. This questionnaire
consisted of 32 items used to measure char-
acteristics of authoritative, authoritarian, and
permissive parenting styles with fifteen,
twelve, and five items each, respectively.
Both father and mother were asked to com-
plete the questionnaire, and the responses
were based on a 5-point Likert scale. The
parenting style with the highest mean
determined particular parent’s style. The
test–retest reliability was assessed at two-
week interval by administering to ten par-
ents who were not included in the study
and was found to be good (Cronbach’s
a = 0.71).
The researcher delivered the questionnaires
by hand and collected after 48 h. The parents
answered the questionnaire at their homes.
Questionnaires were checked for completion
on receiving, and in case of incomplete ques-
tionnaires, parents were re-requested to fill
the remaining ones.
Selection of cases and controls was carried
out after an oral examination carried out in
kindergarten schools. Pre-sterilized armamen-
tarium was used to carry out the examina-
tions, and standard universal precautions
were followed. The criteria for early child-
hood caries diagnosis were according to
AAPD14. All oral examinations were carried
out by two dentists who were trained and
© 2016 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Risk factors of early childhood caries 3
calibrated by an experienced pediatric dentist.
The interexaminer reliability was calculated
after examining 15 children and was found to
be good (intraclass correlation coeffi-
cient = 0.95).
Finally, 422 children (211 cases and 211
controls) with fully filled questionnaires and
fulfilling the inclusion and extrusion criteria
were considered for data analysis.
Statistical analysis
All data were entered and analyzed using
SPSS16 for Windows release software (SPSS
Inc, Chicago, IL, USA). Chi-square test was
performed for each variable to assess whether
significant differences were observed between
the case and control groups. Fisher’s exact
test was used when the expected frequencies
were <5 in the 2 9 2 table. Risk factors
which were significantly associated with ECC
as per Pearson’s chi-square test/Fisher’s exact
test were entered into a multivariate logistic
regression model. This model was used to
determine the impact of independent vari-
ables when presented simultaneously on the
dependent variable, the presence/absence of
ECC. Odds ratio of cases relative to control
group was determined at 95% confidence
interval. For all the tests, statistical signifi-
cance was reported at P < 0.05 level (two
tailed).
Results
The sample consisted of 197 males and 225
females. The mean age of children was 4.4
years. Pearson’s chi-square test showed no
statistically significant difference between
cases and controls with regard to age
(P = 0.424) and gender (P = 0.558), thus
confirming the matching.
Sociodemographic factors
The difference in SES was statistically signifi-
cant. We found that children without ECC
were more among population with high
socioeconomic status. Higher birth order and
presence of siblings were significantly more
among cases (Table 1).
4 S. Dabawala et al.

Table 1. Comparison of sociodemographic characteristics of children with and without early childhood caries (ECC).

Cases (%) Controls (%) Total (%) Chi-square P value

SES
Upper 92 (43.6) 128 (60.7) 220 (52.1) 13.10 0.001*
Middle 118 (55.9) 81 (38.4) 199 (47.2)
Lower 1 (0.5) 2 (0.9) 3 (0.7)
Birth order
First 117 (55.5) 140 (66.4) 217 (60.9) 26.86 <0.001*
Second 59 (28) 64 (30.3) 123 (29.1)
Third 9 (4.3) 6 (2.8) 15 (3.6)
More than four 3 (1.4) 1 (0.5) 27 (6.4)
Child caretaker during daytime
Mother 163 (77.3) 156 (73.8) 319 (75.5) 0.90 0.824
Grandparent 31 (14.7) 33 (15.6) 64 (15.2)
Other adult 14 (6.6) 18 (8.5) 32 (7.6)
Day care centre 3 (1.4) 5 (2.4) 7 (1.7)
Sibling
Presence 131 (62.1) 109 (51.7) 240 (56.9) 0.90 0.039*†
Absence 80 (37.9) 102 (48.3) 182 (43)

SES, socioeconomic status.

*P < 0.05 – significant.
†Fisher’s exact test.

feeding frequency. The number of children

Oral hygiene factors
There was statistically significant difference
with regard to use of fluoridated tooth paste
among cases and controls. Most of the con-
trols used fluoridated toothpaste, whereas the
number of children who did not use fluori-
dated tooth paste or the parents being not
even aware of it was higher among cases.
There was, however, no statistical difference
with regard to other oral hygiene practices
such as child’s toothbrushing frequency
whether brushing was performed under
supervision, age at which brushing started
and night time brushing (Table 2).
Diet and feeding factors
Most of the children in the sample had been
breastfed during infancy, and difference
between cases and controls in feeding meth-
ods was not significant. Those children who
never slept with bottle were found higher in
number among controls compared to cases.
Children with ECC were fed with formula
milk or milk with sugar just before they went
to sleep, significantly more frequently than
children with no ECC. Greater than 1-year
duration of breast/bottle feeding was signifi-
cantly more among cases. But, there was no
statistically significant difference in night time
with ‘Excellent’ and ‘Good’ sweet scores was
significantly higher among controls indicating
low frequency of consumption of sweet foods.
On the other hand, ‘watch out zone’ was
higher among cases. This difference was
statistically significant (Table 3).
Dental attendance behavior
Parents were allowed to give more than one
response for reasons of dental visit. Most of
the children among cases visited dentist in
three months to one year with a chief com-
plaint of pain in teeth or to get cavities filled.
In the control group, among those who vis-
ited dentist, the reason for dental visit was
dental checkup. The number of children who
missed dental appointments was significantly
higher among cases when compared to con-
trols. When parents were asked about
whether they were afraid of taking the child
to dentist, more parents of children with ECC
stated they had anxiety or fear. The difference
was statistically significant (Table 4).
Parenting style
Majority of fathers and mothers parenting
style were authoritative. The difference in
parenting style of parents of children with

© 2016 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
 Risk factors of early childhood caries 5

Table 2. Comparison of oral hygiene practices of children with and without early childhood caries (ECC).

Cases (%) Controls (%) Total (%) Chi square P value

Child’s toothbrushing frequency

Once a day 108 (51.2) 115 (54.5) 223 (52.8) 1.27 0.530
Two or more times a day 93 (44.2) 90 (42.7) 183 (43.4)
2–3 times a week 10 (4.7) 6 (2.8) 3.8 (16)
Child’s teeth cleaned by
Adult 131 (62.1) 139 (65.9) 270 (64) 0.71 0.701
Self with adult supervision 69 (32.7) 63 (29.9) 132 (31.3)
Self without adult supervision 11 (5.2) 9 (4.3) 20 (4.7)
Age at which child started brushing
First teeth erupt 38 (18) 46 (21.8) 84 (20) 1.34 0.721
Before one year 46 (21.8) 39 (18.5) 85 (20.2)
After one year 117 (55.5) 117 (55.5) 234 (55.6)
Don’t know 9 (4.3) 9 (4.3) 18 (4.3)
Night brushing
Yes 111 (52.6) 101 (47.9) 212 (50.2) 0.381†
No 100 (47.4) 110 (52.1) 210 (49.8)
Tooth paste containing fluoride
Yes 120 (56.9) 160 (75.8) 280 (66.8) 17.12 <0.001*
No 32 (15.2) 15 (7.1) 47 (11.2)
Don’t know 57 (27) 35 (16.6) 92 (22.0)

*P < 0.05 – significant.

†Fisher’s exact test.

Table 3. Comparison of diet and feeding habits of children with and without early childhood caries (ECC).

Cases (%) Controls (%) Total (%) Chi square P-value

Sweet score
Excellent 17 (8.1) 95 (45) 112 (26.5) 1.63 <0.001*
Good 45 (21.3) 93 (44.1) 138 (32.7)
Watch out zone 149 (70.6) 23 (10.9) 172 (40.8)
Feeding method
Breastfeed 131 (62.1) 129 (61.1) 260 (61.6) 0.22 0.898
Bottle feed 9 (4.3) 11 (5.2) 20 (4.7)
Both 71 (33.6) 71 (33.6) 142 (33.6)
Feeding duration
<1 year of age 27 (12.8) 53 (25.1) 80 (19) 0.002*†
>1 year of age 184 (87.2) 158 (74.9) 342 (81)
Contents of bottle
Formula milk 27 (12.8) 13 (6.2) 40 (9.5) 52.75 <0.001*
Milk without sugar 19 (9) 19 (9) 38 (9.0)
Milk with sugar 54 (25.6) 8 (3.8) 62 (14.7)
Never slept with bottle in mouth 111 (52.6) 171 (81) 282 (66.8)

*P < 0.05 – significant.

†Fisher’s exact test.

and without ECC based on father and
mother’s self-report of their own and spouse’s
parenting style was not significant (Table 5).
Multiple logistic regression analysis
A test of the full model against constant only
model was statistically significant indicating
that the predictors as a set, reliably
distinguished between those with ECC and
those without ECC (v2 = 298.788, P < 0.001
with df = 22). Nagelkerke R2 of 0.688 indi-
cated moderately strong relationship between
the predictors and ECC. Prediction success
overall was 85.9% (85.5% for cases and
86.3% for controls).
The Wald criterion demonstrated that the
risk indicators associated with ECC were

© 2016 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
6 S. Dabawala et al.

Table 4. Comparison of dental attendance behavior of children with and without early childhood caries (ECC).

Cases (%) Controls (%) Total (%) Chi square P-value

Child’s dental visit frequency

3 months to 1 year 98 (46.4) 53 (25.1) 151 (35.8) 28.93 <0.001*
Rarely 15 (7.1) 6 (2.8) 21 (5)
Never visited dentist 98 (46.4) 152 (72) 250 (59.2)
Reasons for dental visit
No complaint (just checkup) 47 (22.3) 60 (28.4) 107 (25.4) 66.40 <0.001*
Tooth cleaning 8 (3.8) 12 (5.7) 20 (4.7)
Pain in teeth 32 (15.2) 4 (1.9) 36 (8.8)
To get cavities filled/food gets stuck between teeth 43 (20.4) 4 (1.9) 47 (11.1)
Other reasons 4 (1.9)
Missed dental appointments
Never 69 (32.7) 42 (19.9) 111 (26.4) 30.73 <0.001*
Once in a while 32 (15.2) 15 (7.1) 47 (11.2)
About half of time 4 (1.9) 0 4 (1)
Very often 5 (2.4) 1 (0.5) 6 (1.6)
Always 3 (1.4) 1 (0.5) 4 (1)
Anxious/afraid taking child to dentist
Not at all 140 (66.4) 169 (80.1) 309 (73.2) 12.20 0.016*
Little 47 (22.3) 27 (12.8) 74 (17.5)
Fairly 6 (2.8) 5 (2.4) 11 (2.6)
Mostly 9 (4.3) 8 (3.8) 17 (4.0)
Very much 9 (4.3) 2 (0.9) 11 (2.6)

*P < 0.05 – significant.

Table 5. Comparison of parenting style of parents of greater than 1 year; presence of formula milk
children with and without early childhood caries (ECC) or milk with sugar in the feeding bottle while
based on father and mother’s self-report of their own and
spouse’s parenting style.
falling asleep and higher sweet scores (‘Good’
and ‘Watch out category’) resulted in higher
Chi- odds of having ECC. Children with ECC were
Cases Controls square P value more likely to visit dentist only when a prob-
Father’s report on self
lem is perceived by parents such as to get
Authoritative 206 (97.6%) 204 (96.7%) 0.41 0.815 cavities filled/when pain arises rather than for
Authoritarian 1 (0.5%) 1 (0.5%) routine dental checkups compared to control
Permissive 4 (1.9%) 6 (2.8%)
Mother’s report on self
group. Frequency of dental visits, frequency
Authoritative 205 (97.1%) 208 (98.5%) 1.05 0.789 of missed dental appointments, and parent’s
Authoritarian 4 (1.9%) 2 (0.9%) anxiety about dental appointments were not
Permissive 2 (1%) 1 (0.5%) significantly associated with ECC when other
Father’s report on spouse
Authoritative 198 (93.8%) 202 (95.7%) 3.87 0.275 risk factors were considered (Table 6).
Authoritarian 2 (0.9%) 0
Permissive 8 (3.8%) 4 (1.9%)
Mother’s report on spouse Discussion
Authoritative 184 (94.8%) 199 (97.5%) 4.48 0.214
Authoritarian 2 (1%) 2 (1%) In the present case–control study, the cases
Permissive 4 (2.1%) 3 (1.5%) and controls were matched for age and gender,
as they can be potential confounding factors,
based on the results of previous studies10,11,18.
Sampling bias was minimized by recruiting
being greater than fourth by birth order, controls from the same preschools as the cases.
lower socioeconomic status, parents having Investigator bias was minimized by administer-
no knowledge about use of fluoridated tooth ing a structured questionnaire which the par-
paste or not using fluoridated tooth paste. ents were required to answer in their homes
Among dietary habits, breast/bottle feeding with adequate time frame. As the

© 2016 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
 Risk factors of early childhood caries 7

Table 6. Multivariable model depicting the odds ratio The association of parenting style with ECC
between cases and controls.
could not be determined, as all the three
Odds Confidence types of parenting styles could not be differ-
Variable Wald ratio interval P value entiated in the sample. Majority of parents in
the sample had authoritative type of parent-
Socioeconomic status
Upper (ref) 6.133
ing style. There has been a change in parent-
Middle 0.098 2.24 1.17–4.28 0.015 ing style from authoritarian to permissive
Lower 5.972 0.47 0.004–55.0 0.754 type over decades in western population.20 In
Birth order
First (ref) 9.893
this study carried out in Indian population,
Second 9.189 1.03 0.43–2.44 0.955 however, majority of the parents had authori-
Third 0.003 1.87 0.35–9.97 0.466 tative style of parenting. In a study of ECC
≥Fourth 0.531 59.84 4.09–708.57 0.002* risk factors in children aged below 4 years,
Presence of sibling 0.165 0.85 0.38–1.90 0.684
Sweet score Seow et al.12 reported a tendency for
Excellent (ref) 78.236 increased laxness, verbosity, and over-reac-
Good 66.172 3.72 1.55–8.94 0.003* tion type of parenting behavior among
Watch-out zone 8.664 50.72 19.69–130.63 <0.001*
>1-year feeding 9.994 3.93 1.68–9.17 0.002*
parents of children with ECC compared to
duration caries-free control children, but the difference
Feeding bottle content was not statistically significant. In an earlier
Never slept with 28.851
bottle (ref)
study carried out in children between age
Formula milk 10.406 6.08 2.03–18.21 0.001* group of 2–14 years, no relationship could be
Milk without sugar 0.053 1.14 0.39–3.32 0.817 established between oral health status and
Milk with sugar 23.534 15.05 5.03–45.01 <0.001* parenting style assessed using PSDQ. Race/
Use fluoridated tooth paste
Yes (ref) 14.030 ethnicity, level of parents’ education, and
No 11.700 3.40 1.17–9.92 0.025* socioeconomic status were associated with
Don’t know 5.053 3.92 1.79–8.56 0.001* oral health status21.
Frequency of dental visit
3 months to 2.158
At the preschool age, children are influ-
1 year (ref) enced by or dependent on parents for their
Rarely 2.065 0.62 0.15–0.60 0.510 dietary choices and oral hygiene at this age.
Never visited 0.434 0.49 0.18–1.30 0.151
dentist
This in turn is dependent on parent’s knowl-
Reason for dental visit edge and attitude on oral health practices22.
No complaint/ 17.759 In this study, also oral health practices such
checkup (ref) as lack of use of fluoridated toothpaste, choice
Tooth cleaning 0.228 0.23 0.04–1.21 0.083
Pain in teeth 3.009 6.54 1.67–25.73 0.007* of cariogenic foods, and visiting dentist only
To get cavities 7.405 7.09 1.73–29.07 0.007* when a problem is perceived were associated
filled with ECC. Parenting style has longitudinal
Other reasons 7.235 1.27 0.48–3.36 0.633
Missed dental 0.039 1.03 0.77–1.38 0.843
effects on the behavior of the child. The case–
appointments control design used this study can be limita-
Anxiety about 0.170 0.93 0.66–1.31 0.680 tion in studying the role of parenting style
dental visit
owing to the cross-sectional nature of the
*P < 0.05 – significant. study design23. A longitudinal cohort study in
future may reveal more on the time relation-
ship association of the parenting style with
questionnaire was given prior to dental exami- ECC.
nation of the children, parents were not aware A Cochrane review stated that there is
if their child belonged to case or control cate- strong evidence for the efficacy of fluoridated
gory, thus minimizing responder bias. The use toothpaste in preventing dental caries24. Thus,
of a school based population also increased the lack of use of fluoridated toothpaste among
external validity of the study, as compared to children with ECC, as seen in this study rein-
subjects recruited from outpatient dental forces its role in prevention of dental caries
setup. To enhance the validity, the schools including ECC. Hence, use of fluoridated
were selected by random sampling19. toothpaste, no more than a ‘smear’ or ‘rice

© 2016 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
8 S. Dabawala et al.
size’ amount for children less than three years
of age, no more than a ‘pea-size’ amount for
children aged three to six, and twice daily
should be recommended for the prevention
of ECC25. In a cross-sectional study carried
out in Indian population, whereas improper
dietary and feeding factors were associated
with ECC, use of fluoridated dentifrices was
found to protective factor against the risk of
ECC5.
As per the results of the study, ECC was
associated with higher frequency of consump-
tion of sugary foods which solid and sticky or
slowly dissolving type. This finding is consis-
tent with results of previous observational
studies which showed higher total sugar expo-
sure in children affected by ECC. Increased
frequency of consumption of sugar is associ-
ated with increased Streptococcus mutans level
in plaque, leading to dental caries26. The
results of our study corroborate with results of
a cross-sectional study carried out in sample
of South Indian population. In this study,
children with ECC showed higher frequency
of consumption of snacking in between meals.
Children with ECC also showed preference for
consumption of sticky sugary foods4.
The present study also demonstrated that
greater than 1-year breastfeeding/bottle feed-
ing was more among children with ECC. Pro-
longed breastfeeding/bottle feeding duration
beyond one year has been implicated in ECC
development27. The low buffering capacity of
human breast milk/bovine milk/infant formu-
las along with consumption of sugars in the
diet results in acidogenic environment due to
bacterial fermentation of sugars. This com-
bined with low salivary clearance, as the child
falls asleep after feeding, causes this environ-
ment to be maintained in the oral cavity for
long periods of time causing demineralization
of teeth. Due to this, breast/bottle feeding in
combination with consumption of sugar rich
foods is highly cariogenic28, which was the
case among children with ECC in this study.
In this study, lower socioeconomic status
and higher birth order were associated with
ECC. Similar trends have been observed in
other observational studies10,11,21,22. A sys-
tematic review revealed that children with
higher birth order and belonging to large size
© 2016 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
families are more prone to caries7. Children
with lower socioeconomic status and large
size families may experience financial, social,
and material disadvantages that could com-
promise their home oral care and obtaining
professional oral healthcare services2. In
addition to this, lower education among par-
ents of lower socioeconomic groups could
mean lower level of awareness and informa-
tion about oral health practices4. Low
knowledge of mother regarding oral health,
consumption of sugary snacks, and lower
level of oral hygiene were risk factors in a
cross-sectional study carried out among
Nigerian population29.
In this study, children with ECC showed
improper utilization of dental services and
visited dentist only when a problem was per-
ceived. As the preschool children are depen-
dent on parents for visiting dental clinics, this
behavior may reflect parent’s dental anxiety,
negative beliefs, and attitudes toward dental
care27.
The results of the present study suggest that
dental professionals should educate parents
regarding use of fluoridated tooth paste and
motivate to use them. Guidance is also
required on the dietary habits of children.
Special attention is required from the dental
services to encourage dental attendance of
patients with ECC.
Conclusion
Within the limitations of the design of the
study, the following conclusions can be car-
ried out. (1) The association of parenting style
with ECC cannot be confirmed based on the
results of the study. (2) Lower socioeconomic
status and increased birth order of the child
significantly increase the risk for ECC. (3)
The oral health practices which are significant
risk factors for ECC are as follows: (a) lack of
knowledge and failure to use fluoridated
tooth paste; (b) breast or bottle feeding dura-
tion more than 12 months of age; (c) use of
formula milk or cow’s milk with sugar in the
bottle with which the child falls asleep at
night; (d) higher frequency of solid, sticky,
and slowly dissolving sugar containing foods
in the diet; (e) visit dentist only when a

problem is perceived rather than for preven-
tive dental checkups.
Why this paper is important to paediatric dentists
 This paper focuses on the type of parenting style and
oral health practices as risk factor for early childhood
caries (ECC).
 Through a controlled investigation, the risk factors
associated with ECC are studied, so that the associa-
tion of risk factors with ECC is better established.
 An understanding of faulty oral health practices as
risk factor will help pediatric dentists in patient educa-
tion and motivation.
Funding
No funding has been provided.
Author contributions
Dr. Suhel Dabawala and Dr. Nachiket Shah
carried out the research, Dr. Suhel Dabawala,
Dr. Suprabha B.S, Dr. Arathi Rao, and
Dr. Ramya Shenoy designed the research, Dr.
Suprabha B.S and Dr. Ramya Shenoy
analyzed the data. Dr. Suhel Dabawala and
Dr. Suprabha B.S wrote the manuscript. Dr.
Ramya Shenoy and Dr. Arathi Rao edited the
manuscript.
Conflict of interest
The authors declare no conflict of interest.
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