Dental Caries and Growth in School-Age Children
WHAT’S KNOWN ON THIS SUBJECT: There is conflicting evidence
about the relationship between dental caries in primary teeth and
children’s height and weight.
AUTHORS: Heba A. Alkarimi, MSc, PhD,a,b Richard G. Watt,
MSc, PhD,b Hynek Pikhart, MSc, PhD,b Aubrey Sheiham,
BDS, PhD,b and Georgios Tsakos, MSc, PhDb
aKing
WHAT THIS STUDY ADDS: Findings reveal an inverse linear
association between caries levels and children’s height and
weight. The findings take the argument beyond the presence or
absence of an association and provide a better understanding of
the pattern of this association.
abstract
BACKGROUND AND OBJECTIVE: Dental caries in young children is commonly untreated and represents a public health problem. Dental caries
in children is reported to affect their anthropometric outcomes, but the
evidence is conflicting. Some studies found no association, whereas
others found that caries was associated with underweight or overweight. The objective was to assess the relationship between dental
caries status and height and weight in 6- to 8-year-old Saudi children
with high caries prevalence.
METHODS: This study was a cross-sectional survey in schoolchildren
aged 6 to 8 years attending military primary schools in Jeddah, Saudi
Arabia. Caries status was assessed by using the dmft (decayed,
missing, filled, teeth [primary teeth]) index. Height and weight were
assessed by using z scores of height-for-age (HAZ), weight-for-age
(WAZ), and BMI-for-age (BAZ) calculated by World Health Organization
standardized procedures. Relationships between caries and HAZ, WAZ,
and BAZ were assessed by using regression models.
RESULTS: A total of 417 of the 436 eligible schoolchildren with complete
data were included, with a response rate of 95.6%. Their mean dmft
index was 5.7 6 4.2. There was an inverse linear relationship between
caries status and children’s HAZ, WAZ, and BAZ and significantly lower
anthropometric outcomes for children at each consecutive group with
higher levels of caries. The associations remained significant after
adjusting for dental, social, and demographic variables.
Fahad Armed Forces Hospital, Jeddah, Saudi Arabia; and
Department of Epidemiology and Public Health
University College London, London, United Kingdom
bResearch
KEY WORDS
height, weight, BMI, children, caries
ABBREVIATIONS
BAZ—BMI-for-age
dmft—decayed, missing, filled, teeth (primary teeth)
HAZ—height-for-age
WAZ—weight-for-age
WHO—World Health Organization
Dr Alkarimi conceptualized and designed the study, carried out
the analyses, and drafted the initial manuscript; Drs Watt and
Sheiham conceptualized and designed the study and reviewed
and revised the manuscript; Dr Pikhart contributed to the study
design and data analysis and interpretation and reviewed and
revised the manuscript; Dr Tsakos conceptualized and designed
the study, contributed to data analysis and interpretation, and
reviewed and revised the manuscript; and all authors approved
the final manuscript as submitted.
www.pediatrics.org/cgi/doi/10.1542/peds.2013-0846
doi:10.1542/peds.2013-0846
Accepted for publication Dec 17, 2013
Address correspondence to Heba Alkarimi, MSc, PhD, King Fahad
Armed Forces Hospital (KFAFH), PO Box 54146, Jeddah, 21514,
Saudi Arabia. E-mail: [email protected]
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2014 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have
no financial relationships relevant to this article to disclose.
FUNDING: Funded by the Saudi Ministry of Defense, King Fahad
Armed Forces Hospital.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated
they have no potential conflicts of interest to disclose.
CONCLUSIONS: The inverse linear association between dental caries
and all anthropometric outcomes suggests that higher levels of untreated caries are associated with poorer growth in Saudi schoolchildren. Pediatrics 2014;133:e616–e623
e616
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ARTICLE
There is increased interest in the relationship between caries and growth
in young children and mechanisms
whereby caries may affect growth. Evidence linking caries in primary teeth
and children’s anthropometric outcomes in cross-sectional studies is
contradictory in terms of both the
presence and the direction of the association. Some studies report a relationship between caries and poor
growth.1–9 Two theories may explain
this relationship (Fig 1). The first theory is that the direct impact of extensive untreated caries and associated
pain and inflammation on the child’s
ability to eat may result in undernutrition and growth impairment.1,10–14
The second theory includes the indirect
effects of untreated caries and different body responses to chronic dental
infection. Three mechanisms are suggested. The first concerns immune
responses. Infected dental pulp may affect immunity and erythropoiesis,15–17
which may result in anemia18 and influence bone remodeling,19,20 sleep
patterns,21,22 and food intake.23 This
mechanism is supported by results of
a randomized controlled trial showing
that treatment of severe caries in
children aged 6 to 7 years significantly
improved their appetite.24 The second
mechanism is related to endocrine
responses. The interruption of slowwave sleep due to pain and infection
may lead to impairment of growth
hormone secretion.25 The third mechanism is linked to metabolic responses.
Infections and related inflammation
might result in micronutrient undernutrition through increasing energy
expenditure and metabolic demands
and impaired nutrient absorption.20
In contrast to the studies reporting
a relationship between caries and poor
growth, some studies did not find any
relationship between anthropometric
outcomes and caries26–29 or reported
that caries is related to overweight.30–32
This inconsistency is also observed in
findings from randomized controlled
trials and nonrandom longitudinal
studies.9,11,24,33–35 These inconsistent
associations could be due to methodologic limitations, different caries
definitions and detection methods, relying only on BMI, and using unadjusted
formulas to calculate BMI rather than
the age- and gender-adjusted World
Health Organization (WHO)–recommended
growth references.4,26,32,36–38 Another limitation is the failure to include the full
range of BMI categories in the sample.37,38 In addition, most studies only
focused on 1 direction of the association, either underweight or overweight,
ignoring other possibilities.4,26,28,37–39
Interestingly, a recent systematic review showed a significant association
between obesity and caries when BMIfor-age (BAZ) centiles were reported
and nonsignificant findings when z
scores or nonstandardized scales were
reported.29
To date, no study has examined the
relationship between caries and anthropometric outcomes in young children with high levels of untreated
caries using height and weight as
continuous variables and where no
cutoff points for the diagnosis of underweight and overweight are used.
Therefore, a study was conducted with
the objective of assessing the nature of
the relationship between different levels of caries and height and weight
among 6- to 8-year-old Saudi schoolchildren. No assumptions were made
on the direction of this association.
METHODS
The sample consisted of all schoolchildren aged 6 to 8 years in the firstyear class (grade 1) of all military
primary schools inJeddah, SaudiArabia.
Children with parasitic infections at
the time of the survey and children
whose caregivers did not give consent
were excluded. Children of military
PEDIATRICS Volume 133, Number 3, March 2014
personnel were selected because they
had the highest prevalence of caries in
Saudi Arabia.40 Parents were asked
to complete a sociodemographic and
health status questionnaire. A pilot
study was conducted in 55 randomly
selected children to test the feasibility
of all clinical examinations.
The research was approved, managed,
and monitored by the Research and
Ethics Committee of the King Fahad
Armed Forces Hospital. Parental permission was obtained from the child’s
legal caregivers.
Measurements
Anthropometric Measurements
Anthropometric measurements were
performed by using the Food and Nutrition Anthropometric Indictors Measurement Guide.41 A skilled nurse,
blinded to the child’s dental status,
carried out all anthropometric measurements. Measurements for height
and weight were made to the nearest
0.1 cm and 0.1 kg, respectively. All anthropometric measures were performed in children without shoes and
wearing light clothes. Height was measured by using a portable Harpenden
pocket stadiometer (Chasmors Ltd,
London, United Kingdom). Weight was
measured by using a precalibrated
digital Seca scale (model 767; Seca
GmbH, Hamburg, Germany). All children were weighed at the same time
of day (7:30–8:50 AM) and in the same
relation to their eating time (before
morning break). Three readings for
both height and weight were taken for
each child. The median of these readings was used for the analysis. Height
and weight were assessed by using
the z scores of height-for-age (HAZ),
weight-for-age (WAZ), and BAZ.42 The
calculation of z scores for height, weight,
and BMI was based on the international
reference standards for the assessment
of nutritional status for a specific age
and gender and were automatically
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FIGURE 1
Proposed mechanisms linking severe dental caries and dental pain and infections with height and weight in young children.
managed by using the WHO AnthroPlus
software, which holds the WHO Reference 2007 for ages 5 to 19 years.43 Age
was calculated as the difference between the date of measurement and the
date of birth, which was obtained for all
children from their school files. WAZ, HAZ,
and BAZ were used as indicators for
present and past nutritional status. A
cutoff of less than 22 SDs was used to
report underweight and stunting, whereas
a cutoff of more than +2 SDs was used
to report obesity.42
Dental Measurements
Caries was assessed by using the
decayed, missing, filled, teeth (primary
teeth) (dmft) index (d = decay to cavitation, m = missing due to caries, filled =
restoration, t = total number of primary
teeth) and followed the WHO criteria
and coding.44 Due to the age of the
sample and the subsequent low prevalence of caries in permanent dentition,
e618
the emphasis was on caries experience
in the primary dentition. Caries was
recorded at the cavitation level. Dental
examinations of children were conducted in daylight by using a disposable
dental mirror. No radiographs were
taken. A trained dentist who had no
previous knowledge about the study
rationale conducted the clinical examinations. The reproducibility of clinical dental data was checked by
reexamination of 51 (12%) children.
The k score for caries measurements
was 0.81, representing almost perfect
agreement.45
Statistical Analyses
The variables considered as covariates
were selected on the basis of the scientific literature on the associations
under study. Before constructing multiple regression models, correlations
between the variables were checked
with a correlation matrix. Accordingly,
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the variables chosen and used in the
multiple regressions were age, gender,
parent’s educational levels, and number of teeth present.
Differences in continuous outcomes
such as differences in z scores of
weight and height were assessed by
using a t test for normally distributed
independent data. Where continuous
variables exhibited nonnormal distributions, the Mann-Whitney test was
used instead. The Jonckheere-Terpstra
test was used for testing differences
between .2 means in nonparametric
ordered data. Analysis of variance was
carried out initially to study the association between dmft groups and HAZ,
WAZ, and BAZ. We used analysis of covariance in the next step to further
control for possible confounders.
Means with 95% confidence intervals
were calculated. All analyses were performed by using Stata 10.0 (StataCorp,
College Station, TX).
ARTICLE
RESULTS
Demographic Variables
Four hundred and seventeen (95.6%) of
the 436 eligible children were included.
The mean age of the participants was
82.1 (65.8) months, and 42.0% were
boys. In terms of parental education,
22.3% of fathers and 18.2% of mothers
were educated to the university level or
higher (Table 1). There is no accepted
method for the assessment of socioeconomic position in Saudi Arabia.
Therefore, gross national income per
capita ($24 700 per year or $2058 per
month) was considered in deciding the
most appropriate categorization of
children’s socioeconomic position.46
Because we wanted to include a low
socioeconomic position group, we
chose a considerably lower income
(almost one-third less) than the mean
national income per capita cutoff for
that purpose. More specifically, children whose families had a monthly income ,50 000 Reyals (,$1333) were
considered the low-income group (11.8%),
those with a monthly income between
5000 and 10 000 Reyals ($$1332–$2663)
were considered the middle-income
group (46.5%), and those with a monthly
income .10 000 Reyals (.$2663) were
considered the high-income group
(31.9%).
Anthropometric Outcomes
On the basis of the WHO reference values, 7.0% of children were determined
to be underweight, 6.0% were stunted,
10.1% were overweight, and 9.4% were
obese. Mean (6SD) HAZ, WAZ, and BAZ
were 20.55 6 0.98, 20.31 6 1.39, and
20.01 6 1.4, respectively.
Dental Caries Status
The mean (6SD) number of primary
teeth present was 16.2 6 2.9. The mean
dmft was 5.7 6 4.2 teeth, and the median was 5.0 teeth (Table 2). Only 54
(12.9%) children were caries-free in
their primary teeth, whereas 396
(95.2%) were caries-free in their permanent teeth. Untreated decay (d)
accounted for 89.5% of the dmft; a mean
of 5.1 of a dmft of 5.7 represented
untreated decay (d). Of the 363 (87.1% of
the whole sample) with caries in the
primary dentition, 286 (78.8%) had only
unrestored caries, 9 (2.5%) had only
fillings, and 68 (18.7%) had unrestored
caries and fillings. Because there is no
accepted classification for caries severity for this age group, 2 classifications were used to assess the
inverse-graded association. First, the
data were divided into 3 groups with
comparable group sizes (tertiles);
28.5% of children had dmft in 0 to 2
teeth, 30.1% had dmft in 3 to 6 teeth, and
41.4% had dmft in $7 teeth. We also
used a dmft variable with 4 categories.
For that, caries-free children formed
a distinct group and children with caries were divided into 3 groups with
similar numbers of subjects (approximate tertiles): 12.9% of children were
caries-free, 31.8% had dmft in 1 to 4
teeth, 28.9% had dmft in 5 to 8 teeth, and
26.3% had dmft in $9 teeth. Both classifications were used in the analysis to
check for any differences (Table 3).
Associations Between Caries Levels
and WAZ, HAZ, and BAZ
TABLE 1 Sociodemographic Distribution Profiles of the Sample of Saudi Children
Variable
Gender
Male
Female
Father’s educational level
Cannot read or write
Primary school
Secondary school
High school level
University degree
Above bachelor’s degree
Missing data
Mother’s educational level
Cannot read or write
Primary school
Secondary school
High school level
University degree
Above bachelor’s degree
Missing data
Family monthly income
Low income: ,5000 Reyals (,$1332)
Middle income: $5000–10 000 Reyals ($$1332–$2663)
High income: .10 000 Reyals (.$2663)
Missing data
Frequency, N
Relative Frequency, %
175
242
42.0
58.0
5
31
102
150
72
21
36
1.2
7.4
24.5
36.0
17.3
5.0
8.6
31
80
97
95
75
1
38
7.4
19.2
23.3
22.8
18.0
0.2
9.1
49
194
133
41
11.8
46.5
31.9
9.8
N = 417.
PEDIATRICS Volume 133, Number 3, March 2014
Table 3 displays the results of multiple
regression analyses showing the
means of anthropometric indices by
caries status groups, before and after
adjustment for covariates (gender,
age, father’s and mother’s educational
levels, and number of teeth).
Using dmft tertile classification, unadjusted mean HAZ scores were 20.32,
20.45, and 20.78 (P , .001). The unadjusted mean z scores were higher
for each group with lower levels of
caries. This strong association remained
highly significant even after controlling
for other covariates (adjusted mean HAZ
scores were 20.32, 20.44, and 20.79;
P , .001). A negative linear association
was detected between unadjusted mean
WAZ scores and caries categories (P ,
.001). After adjusting for confounders,
mean WAZ scores were 0.12, 20.31, and
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TABLE 2 Distribution of the dmft, dt, mt, and ft
Number of primary teeth
dmft
dt
mt
ft
Mean 6 SD
Median
Minimum
Maximum
16.2 6 2.9
5.7 6 4.2
5.1 6 4.1
0.2 6 0.8
0.4 6 1.0
17.0
5.0
5.0
0.0
0.0
5.0
0.0
0.0
0.0
0.0
20.0
20.0
16.0
9.0
9.0
N = 417. dt, decayed teeth; ft, filled teeth; mt, missing teeth.
20.62, respectively (P , .001). The same
pattern of inverse linear relationship
between caries categories was detected
in BAZ after controlling for covariates.
The adjusted mean BAZ values were 0.40,
20.12, and 20.21 (P = .001). To place the
significance of the z score variation into
perspective, for a 6-year-old girl in the
highest caries group, the mean difference in height, weight, and BMI from
WHO normal values was 3.3 cm, 1.2 kg,
and 2.7 percentiles, respectively.
There was a similar inverse-graded association between caries in both unadjusted and adjusted models for WAZ,
HAZ, and BAZ scores when the analyses
were repeated with the dmft second
classification (caries-free and tertile
classification). For each category with a
higher prevalence of caries, the adjusted
mean WAZ, HAZ, and BAZ scores were
lower. This result indicates that the
inverse-graded relationship was evident
regardlessofthedmftclassificationused.
DISCUSSION
This cross-sectional survey revealed
a significant and robust inverse linear
association between caries experience
in 6- to 8-year-old children and HAZ,
WAZ, and BAZ. The graded association
remained highly significant after
adjusting for demographic, dental, and
social variables. Although some studies
reported an inverse relationship between anthropometric outcomes and
caries status,6,37,47 no previous study
has reported an inverse-graded relationship.
There are certain limitations when
comparing the present study with
e620
previous studies. First, all previous
community-based studies either used
categories such as underweight, overweight, and obesity6,8,26,27,31,32,36–38,48,49
or unstandardized categories such
as obese and nonobese or at risk of
underweight and normal weight depending on the distribution of their
anthropometric measures,28,39 whereas
the current study used all anthropometric
outcomes as continuous variables. The
reason for not using categories was
that the objective was to study the relationship between caries and anthropometric measures by using all of the
available data and examining the whole
distribution rather than categorizing
data and making assumptions about
the direction of the relationship.
Whereas categorization is sometimes
needed, it undoubtedly results in loss of
information.50 For example, GranvilleGarcia et al28 assessed the relationship between caries in obese and
nonobese Brazilian children and found
that there was no association between
obesity and caries. On the other hand,
they reported a significant association
between high caries levels and not being obese. Due to their categorization
and lack of information, it was difficult
to assess whether the nonobese children were normal or underweight.
Ngoenwiwatkul and Leela-adisorn 39
categorized their data into 2 groups,
BMI ,15th percentile and BMI $15th
percentile, because they had no underweight children and 45% of children
were in the low-weight percentile category (5th percentile , BAZ , 15th
percentile). This categorization made
study comparisons difficult. In addition,
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they could not assess linear associations in their data.
A graded association between dmft and
BMI was detected in a Turkish study6 in
a similar age group and caries prevalence to the current study, but the
authors did not control for confounders. Only tests for correlations
were performed to show the presence
of an inverse association between
caries status and anthropometric outcomes. This inverted linear relationship between caries and BMI was also
evident in an Australian longitudinal
study.8 Interestingly, a Swedish study7
showed an inverted relationship between BMI categories (combined underweight and low-weight group,
normal-weight group, and combined
high-weight and obese group) and untreated caries (d) but not for decayed,
extracted, filled, teeth (primary teeth)
(deft) index. A possible explanation for
the difference in findings for untreated
decay (d) and deft may be that the
inverted relationship exists only when
untreated decay (d) accounts for a high
proportion of the dmft. In the current
study, untreated decay (d) accounted
for almost 90% of the dmft. Therefore,
the inverted relationship was also evident when dmft was used. This finding
suggests that a high filling (f)-to-dmft
ratio in some studies may have biased
the results toward a positive relationship between dmft and a high BMI.
Future studies should report the numbers of decayed teeth (d) and filled
teeth (f).
A second limitation in comparing our
study with other studies is that most
studies used different indices and
definitions of caries. For example, the
American Academy of Pediatric Dentistry criteria include noncavitated
lesions in the definition of severe early
childhood caries in young children,
whereas the WHO criteria for caries
include only cavitated lesions. Studies
using different criteria will result in
0.28 (20.11 to 0.67)
0.20 (20.05 to 0.45)
20.17 (20.43 to 0.09)
20.24 (20.52 to 0.03)
.01
0.25 (20.13 to 0.65)
0.17 (20.08 to 0.42)
20.15 (20.41 to 0.11)
20.22 (20.49 to 0.06)
.02
different prevalence rates and cannot
be compared easily. Even when 1 caries
definition was used, different indices
were reported. For example, some
studies reported dmft, whereas others
reported dmfs (decayed, missing, filled,
surfaces [primary teeth]). Third, studies had differing levels and various
methods of assessing anthropometric
measures. Most studies that assessed
the relationship between caries and
malnutrition in children depended
solely on BMI4,7,31,32,36 and did not report other anthropometric outcomes.
N = 417. CI, confidence interval.
a Analysis of variance.
b Analysis of covariance (adjusted for gender, age, father’s and mother’s educational levels, and number of teeth present).
20.24 (20.50 to 20.01)
20.37 (20.54 to 20.21)
20.68 (20.85 to 20.51)
20.77 (20.95 to 20.59)
,.001
12.9
31.8
28.9
26.3
0.27 (20.53 to 20.01)
20.37 (20.53 to 20.20)
20.68 (20.85 to 20.50)
20.77 (20.95 to 20.59)
,.001
0.05 (20.31 to 0.42)
20.05 (20.28 to 0.18)
20.50 (20.75 to 20.25)
20.62 (20.88 to 20.38)
,.001
0.05 (20.31 to 0.48)
20.06 (20.30 to 0.16)
20.49 (20.74 to 20.25)
20.61 (20.86 to 20.35)
.001
0.40 (0.13 to 0.66)
20.12 (20.37 to 0.13)
20.21 (20.43 to 0.01)
.001
0.44 (0.18 to 0.71)
20.17 (20.43 to 0.08)
20.21 (20.42 to 0.01)
,.001
0.12 (20.13 to 0.37)
20.31 (20.55 to 20.08)
20.62 (20.82 to 20.42)
,0.001
0.14 (20.10 to 0.39)
20.35 (20.59 to 20.12)
20.61 (20.81 to 20.40)
,.001
20.32 (20.49 to 20.14)
20.44 (20.60 to 20.27)
20.79 (20.94 to 20.66)
,.001
20.32 (20.50 to 20.15)
20.45 (20.62 to 20.28)
20.78 (20.92 to 20.63)
,.001
28.5
30.1
41.4
Unadjusted Mean (95% CI)
Adjusted Mean (95% CI)
b
Percentage
Variable
TABLE 3 Association Between Anthropometric Outcomes and dmft
Tertile classification
dmft #2 (lowest-caries group)
dmft = 3–6
dmft $7 (highest-caries group)
P for trend
Caries-free and tertile classification
dmft = 0 (caries-free group)
dmft = 1–4
dmft = 5–8
dmft $9 (highest-caries group)
P for trend
Unadjusted Mean (95% CI)a Adjusted Mean (95% CI)b
a
a
Unadjusted Mean (95% CI)
WHO WAZ
WHO HAZ
Adjusted Mean (95% CI)
b
WHO BAZ
ARTICLE
PEDIATRICS Volume 133, Number 3, March 2014
Fourth, in the current study, the WHO
2007 growth references were used to
assess height and weight. These references have not been applied in the
majority of previous dental studies and
therefore comparison of their results
with the current study should be made
with caution. One study6 did use these
references, and their results agree
with those of the current study. Fifth,
some studies did not provide any evidence on the reliability of clinical
measures and no study indicated the
time when the child was weighed or
took into account the child’s mealtimes.
Sixth, the samples used in some studies included different age groups and
children from different social and ethnic backgrounds. For the reasons outlined above, there are doubts whether
the apparently contradictory findings
were due to methodologic inconsistencies or are a true reflection of
differences.
Due to the cross-sectional study design,
definitive information about causeand-effect relationships cannot be determined. Another limitation of the
current study is that the sample was not
representative of Saudi children. Consequently, it is difficult to extrapolate
findings to the Saudi child population.
However, our aim was not to have
a nationally representative sample but
to assess the association between
caries and anthropometric outcomes in
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a child population with high levels of
untreated caries. A recent systematic
review revealed that many studies have
failed to include samples representing
the full range of BMI categories.51 In that
respect, a strength of this study is that
the sample represented a good range
of BMI values, which included both
under- and overweight children with
different levels of caries experience.
Although several demographic and
socioeconomic variables were controlled for, other potential confounders
such as nutrition, low birth weight, and
appetite were not assessed. All of these
uncontrolled confounders could have
biased our results. In addition, due to
the use of WHO criteria, which include
only cavitated lesions, the prevalence of
caries in this study may have been
underestimated. However, these are
standard epidemiologic criteria for
caries detection and have been used
worldwide. Furthermore, missing data
could have affected our findings. To
overcome that possibility, missing data
in social variables, such as parents’
educational levels, were coded as
a special category and were not excluded from analysis, and missing data
were therefore kept to a minimum.
By demonstrating the inverse-graded
relationship between caries and children’s height and weight, our results
have considerable public health implications, indicating the need for health
promotion programs to address both
oral and general health in high-caries
populations at an early age. Severe
caries is strongly associated with anemia and iron deficiency and thereby
may be a contributing factor for poor
growth in young children.14 Malnutrition
and caries can be addressed efficiently
early in life. Therefore, primary health
care providers and pediatricians have
the potential to play an important role
in actively participating in health promotion interventions with young children.
In terms of future research, longitudinal
studies are needed to determine whether
there is a cause-and-effect relationship
between caries levels and poor
growth. Such a study would benefit
from adequate adjustment for confounding variables and from the use of
continuous outcomes in addition to
categories of malnutrition.
CONCLUSIONS
There was an inverse-graded association between all anthropometric
outcomes and caries levels in 6- to 8year-old Saudi children. Children at
each higher level of caries had significantly lower height and weight
outcomes than those with lower
caries levels. Future longitudinal
studies can help determine whether
there is a cause-and-effect relationship between caries levels and poor
growth.
ACKNOWLEDGMENTS
We thank the sponsor, King Fahad
Armed Forces Hospital, and the schools,
children, and their families who participated. We also thank the study investigators, especially Dr Alya Altaf and Miss
Manal Alamri.
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Dental Caries and Growth in School-Age Children
Heba A. Alkarimi, Richard G. Watt, Hynek Pikhart, Aubrey Sheiham and Georgios
Tsakos
Pediatrics; originally published online February 17, 2014;
DOI: 10.1542/peds.2013-0846
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk
Grove Village, Illinois, 60007. Copyright © 2014 by the American Academy of Pediatrics. All
rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
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Dental Caries and Growth in School-Age Children
Heba A. Alkarimi, Richard G. Watt, Hynek Pikhart, Aubrey Sheiham and Georgios
Tsakos
Pediatrics; originally published online February 17, 2014;
DOI: 10.1542/peds.2013-0846
The online version of this article, along with updated information and services, is
located on the World Wide Web at:
/content/early/2014/02/11/peds.2013-0846
PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1948. PEDIATRICS is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2014 by the American Academy
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
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