{"paper_id":"222bc71b-14ac-463f-a141-96eba43b9765","body_text":"Socioeconomic status, parental country of origin and dental caries in primary dentition amongst preschool children in southeastern Spain: a cross-sectional study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Socioeconomic status, parental country of origin and dental caries in primary dentition amongst preschool children in southeastern Spain: a cross-sectional study Scott Benjamin García-Mabin, José Enrique Iranzo-Cortés, Antonio José Ortiz-Ruiz, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9232360/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Background Childhood dental caries remains the most prevalent chronic disease worldwide and represents a major public health concern. Although reductions in caries prevalence have been reported in several high-income countries, significant socioeconomic inequalities persist. Understanding the role of social determinants in early childhood is essential for designing effective preventive strategies. This study investigated the association between socioeconomic status, parental country of origin and dental caries in the primary dentition of children under six years of age. Methods A cross-sectional epidemiological survey was conducted amongst 2,072 3–6-year-olds from 33 schools in the Region of Murcia between January and June 2025. Dental examinations were performed by calibrated dentists using WHO Oral Health Survey criteria and the International Caries Detection and Assessment System (ICDAS II). Caries indicators included prevalence, dmft, dmfs and the Significant Caries Index (SiC). Socioeconomic status was assessed using parental education and occupation. Associations between caries indicators and sociodemographic variables were analysed using chi-square tests, ANOVA and linear trend analyses. Results Caries prevalence was 22.0% in children aged 3–4 years and 35.4% in children aged 5–6 years. Mean dmft values were 0.77 and 1.24, respectively. A clear socioeconomic gradient was observed: children from lower socioeconomic groups showed significantly higher dmft, dmfs and caries prevalence than those from middle- and upper-class groups (p < 0.001). Children whose parents originated from Africa, Asia and South-central America had significantly higher caries prevalence and severity than those whose parents were born in Spain (p < 0.05). No statistically significant differences were observed between sexes (p > 0.05). Conclusions Dental caries in early childhood in the Region of Murcia shows a clear social gradient associated with socioeconomic status and parental country of origin. These findings highlight the importance of social determinants on oral health and the implementation of targeted preventive strategies to reduce inequalities in early childhood caries. dental caries primary dentition socioeconomic factors parental country of origin health inequalities preschool children epidemiology Background Dental caries is no longer regarded as a multifactorial infectious disease; rather, it is now recognized as a non-communicable multifactorial disease with a dynamic development, mediated by biofilms and influenced by a complex interplay of biological, behavioural, psycho-social, socioeconomic and environmental factors [ 1 ]. The World Health Organization (WHO) considers dental caries in primary dentition to be the most prevalent chronic disease globally, affecting an estimated 514 million children. WHO data further indicate that the decline in caries prevalence observed in the early twenty-first century has been largely confined to high-income countries (HICs). In contrast, low- and middle-income countries (LMICs) have experienced only a modest reduction or, in some cases, an increase in disease burden [ 2 ]. These regional disparities in paediatric oral health outcomes are associated with differences in quality of care, access to dental services and treatment cost, as well as variations in oral health education and overall health literacy [ 3 ]. The most recent Global Burden of Oral Disease study on oral health (1990 to 2021) indicates that the prevalence of untreated caries in deciduous teeth has remained largely unchanged worldwide, with only a 6.5% increase in total cases during this period. Regional trends vary substantially, with increases observed in the African and Eastern Mediterranean regions and reductions reported in the European and Western Pacific regions. Notably, Europe reported the lowest number of prevalent cases globally [ 4 ]. Consistent with these global trends, the national survey conducted in Spain in 2020 found that caries prevalence in deciduous teeth has remained stable since 1993, showing a slight but statistically non-significant decrease. A similar pattern was observed for the mean number of teeth affected by caries, which also exhibited a non-significant decline over time [ 5 ]. The disparity between HICs and LMICs may be partly explained by differences in access to public oral health services. In many developed and developing countries, oral health care is not fully integrated into primary health care systems, resulting in high out-of-pocket expenditures that disproportionately affect disadvantaged populations. These structural inequalities are further compounded by variations in health-related behaviour, including sugar consumption, exposure to fluoride, and oral hygiene practices [ 6 ]. Evidence from multiple countries demonstrates a clear linear trend in which children from LMICs exhibit higher caries indices compared to those from HICs [ 7 – 11 ]. Socioeconomic status (SES) is measured by a series of indicators. Some of the most important SES indicators are family income, occupational status and educational level of parents [ 12 ]. In the present study, parental occupation and educational level were used as indicators of SES. Updated and region-specific analyses are essential given the substantial global shifts in the burden of dental caries and the need for reliable epidemiological data to monitor progress towards the WHO Global Oral Health Action Plan target of a 10% reduction in oral disease prevalence by 2030 [ 13 ]. The absence of recent data addressing socioeconomic disparities in young children within the Region of Murcia represents an important knowledge gap. This study aims to provide updated information on the oral health status of children under six years of age in the region and to analyse its association with selected social determinants. Although the first epidemiological study on oral health in Spain was conducted in 1969 [ 14 ], it was not until 2000 that national surveys began to systematically assess social class differences in children under six years of age in relation to primary dentition [ 15 ]. Since then, socioeconomic indicators have been regularly included in national oral health surveys [ 5 , 16 – 19 ]. However, only two regional oral health surveys have been conducted in the region to date, and neither included an assessment of social class differences in children under six years of age [ 20 , 21 ]. Furthermore, there is no data referring to caries levels in children under 6 years of age in the Spanish National Oral Health surveys. Therefore, the objective of the study was to investigate the association between socioeconomic characteristics, parental country of origin, gender and dental caries status in primary dentition of children under six in the Region of Murcia. Methods Study design This study was designed as a cross-sectional epidemiological survey. All procedures were conducted in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for cross-sectional studies [22]. The study included schoolchildren between the ages of three and four and five and six in the Region of Murcia, which was recorded in 33 schools (28 public and 5 private) between January 2025 and June 2025. Ethical approval The survey protocol was approved by the Human Research Ethics Committee of the University of Murcia (Spain) in December 2024 (approval number: M10/2024/419). Written informed consent was obtained from both participating schools and from the parents or legal guardians of the children prior to participation. All procedures were conducted in accordance with the ethical principles established in the Declaration of Helsinki with applicable data protection regulations [23]. Study population and calibration Sample size estimation was based on dental caries prevalence data from the Valencian Oral Health Surveys of 2018. A minimum sample of 340 participants was required for children aged 3–4 years, and 505 participants for children aged 5–6 years, assuming a 95% confidence level, an absolute precision of four percentage points, and a substitution rate of 10%. The selected schools represented preschool populations from different geographical areas of the region. Children of all genders were included. Those who had already turned six but had not yet reached their seventh birthday at the time of examination were also considered eligible. The fieldwork was carried out by two examiners. The examiners performed a prior calibration to ensure reliability and validity of the results. The two examiners exhibited a good level of agreement, according to the Landis and Koch scale, with a linear weighted Kappa index of 0.902 and 0.929, respectively. Data collection measurement The questionnaire used in this study comprised two main categories: a demographic questionnaire and a clinical oral health questionnaire. The demographic section assessed family and child characteristics, including the child’s age, gender (male/female), place of residence (urban, suburban, rural) and parental origin (Spain, European Union (EU), Europe, Canada/EEUU, South-central America, Asia, Africa, Oceania). For the intergroup analysis, only three origins were analysed (Spain, South-central America and Africa), as the other groups’ size was too small. Data on a child’s parental occupation was recorded and used to determine socioeconomic status (SES). Where parental occupation levels differed, the highest of the two was used. Occupations were categorized by means of the following classification proposed by Domingo and Marcos [24]: I. Professionals, managers, and senior technicians. II. Other managers, middle-level technicians, and commerce. III. Intermediate supervisors and administrative staff. IVa. Skilled manual workers. IVb. Semi-skilled manual workers. V. Unskilled workers. “Unclassifiable”: those with no declared or poorly defined profession, or members of the armed forces. For the purpose of statistical analysis these categories were divided into three classes, “upper class” was formed by categories I and II, “middle class” by III and IVa and “lower class” by IVb and V. The clinical oral health questionnaire was developed following the criteria of the WHO Oral Health Survey: Basic Methods [25] and supplemented by the International Caries Detection and Assessment System (ICDAS II) [26]. Two-digit ICDAS-II coding system was used to record dental caries. However, because the examinations were conducted in field conditions without access to compressed air to adequately dry tooth surfaces, gauze was used as an alternative; therefore, ICDAS-II codes 1 and 2 were combined. Based on these criteria, all five surfaces of molars, the four surfaces of incisors and canines were examined. In addition to recording the presence of caries, the condition of fissure sealants and/or restorations was assessed using the first digit of the ICDAS-II coding system. The second digit recorded the severity of caries, represented by seven codes (0-6). In deciduous dentition, these severity codes are expressed as letters (A=0, C=2, D=3, E=4, F=5, G=6). Since ICDAS-II codes 1 and 2 were merged in this study, the corresponding deciduous dentition codes B and C were both classified as C. Furthermore, a tooth was defined as carious from ICDAS code 4 onwards to facilitate comparison with previous epidemiological research and to be consistent with the methodology employed in similar studies [27]. Together with the examiner-completed questionnaire set out previously, a separate questionnaire was distributed to parents via the school and completed prior to the visit. The Diet and Habits questionnaire gathered further demographic information, including the number of siblings (none, 1, 2, 3, 4, 5, or more than 5), parental age, family structure (two parents, divorced parents, or single parent), and parental employment status. Data collection process Selected schools were contacted and invited to participate by means of a presentation letter describing the objectives and procedures of the study. The schools distributed an information sheet, consent form and a diet and habits questionnaire to parents or legal guardians. Clinical examinations were performed at the schools after completed consent forms had been returned. The examination team consisted of two dentists who had previously undergone training, standardisation and calibration procedures. Children whose parents had provided written informed consent were examined at their schools under standard field conditions typically used in epidemiological oral health surveys. Children presenting with visible caries lesions were referred for dental treatment and provided with a written report for their parents. No x-rays were taken and no treatment was provided during the examinations. Data analysis Data was recorded anonymously by the examiners and encoded in an Excel database. The statistical analysis was performed using IBM SPSS Statistics, version 29.0. A univariate descriptive analysis was carried out, which obtained means for quantitative variables and proportions for dichotomous variables or categorical variables, within the required 95% confidence intervals. For the bivariate analysis between groups (sex, social class and parental origin), Student’s t-tests were employed to assess differences between any two groups, while ANOVA with Bonferroni post-hoc tests was used for continuous variables. In the case of social class, a test for linear trend was conducted in addition to ANOVA to evaluate potential ascending or descending relationships across the groups. Categorical variables were analysed using the Chi-square test. The significance level was set at p < 0.05. Results Sample description The study sample consisted of 931 children aged 3–4 years and 1,141 children aged 5–6 years, with mean ages of 4.03 ± 0.61 years and 6.12 ± 0.59 years, respectively (Table 1). Participation by sex was homogeneous. Amongst children aged 3–4 years, 50.4% were female (n=469), while amongst children aged 5–6 years 50.8% were female (n=580). The sample came predominantly from a lower social class background, where 43.6% (n=294) of 3–4-year-olds and 47.5% (n=527) of 5–6-year-olds were classified as lower class (Table 1). Most children’s parents were born in Spain (68.9% in the 3–4-year group and 64.8% in the 5–6-year group). Amongst children with parents born outside Spain, the largest group corresponded to African countries, representing 19.4% and 21.1% in the younger and older age groups respectively. Table 1. Distribution of the sample by age, sex, social class and parents’ country of origin. 3-4 years old 5-6 years old n=931 n=1141 Age (mean; SD) 4.03 (0.61) 6.12 (0.59) Sex (%) Male 49.6% (n=462) 49.2% (n=561) Female 50.4% (n=469) 50.8% (n=580) Social class (%) Upper 27.1% (n=245) 24.5% (n=272) Middle 29.2% (n=264) 28% (n=311) Lower 43.6% (n=294) 47.5% (n=527) Social class (%) dmfs >0 Upper 10.7% (n=21) 12.8% (n=49) Middle 23% (n=45) 23.2% (n=89) Lower 66.3% (n=130) 64% (n=245) Parental country of origin Spain 68.9% (n= 642) 64.8% (n=739) EU countries 0.2% (n=2) 0.4% (n=4) Non-EU countries 0.2% (n=2) 0.9% (n=10) South-central America 10.2% (n=95) 11.6% (n=132) Asia 1.0% (n=9) 1.3% (n=15) Africa 19.4% (n=181) 21.1% (n= 241) Caries experience The most frequent ICDAS-II code was F in both age groups. Amongst three and four year olds, the prevalence of code F was 0.38 (95% CI 0.30–0.46) at tooth level and 0.48 (95% CI 0.37–0.59) at surface level. In five and six year olds, 0.63 (95% CI 0.55–0.72) of tooth level and 0.77 (95% CI 0.66–0.88) of surface level were classified as code F (Table 2). Table 2. ICDAS codes for primary dentition: mean number of affected tooth or surface level by age cohort (mean, 95% CI). ICDAS codes 3-4 years old n=931 5-6 years old n=1141 Tooth Surface Tooth Surface ICDAS Code C 0.23 0.17-0.29 0.25 0.19-0.32 0.11 0.07-0.14 0.12 0.08-0.15 ICDAS Code D 0.29 0.23-0.35 0.33 0.26-0.41 0.27 0.22-0.32 0.31 0.25-0.37 ICDAS Code E 0.24 0.19-0.29 0.26 0.20-0.31 0.29 0.25-0.34 0.32 0.27-0.37 ICDAS Code F 0.38 0.30-0.46 0.48 0.37-0.59 0.63 0.55-0.72 0.77 0.66-0.88 ICDAS Code G 0.15 0.09-0.21 0.36 0.22-0.51 0.31 0.24-0.37 0.74 0.57-0.92 Filled 0.01 0.00-0.01 0.02 0.00-0.05 0.01 0.00-0.01 0.02 0.00-0.04 The prevalence of caries was 22.0% (95% CI 19.5–24.8) in three and four year olds and 35.4% (95% CI 32.7–38.2) in five and six year olds. The mean dmft score was higher in the older group, reaching 1.24 (95% CI 1.11–1.37), compared with 0.77 (95% CI 0.65–0.90) in three and four year olds. Similarly, the mean dmfs score was higher amongst five and six year olds at 1.85 (95% CI 1.60–2.10). The mean SiC index was 2.32 (95% CI 2.01–2.63) in three and four year olds and 3.66 (95% CI 3.39–3.92) in five and six year olds. The mean number of teeth with ICDAS>0 was 3.51 (95% CI 3.13–3.89) and 3.50 (95% CI 3.24–3.75), respectively (Table 3). Table 3. Caries indicators and concentration of caries in primary dentition by age cohort (mean or percentage, 95% CI). Indicator 3-4 years (n=931) 5-6 years old (n=1141) dmft 0.77 (0.65-0.90) 1.24 (1.11-1.37) dmfs 1.11 (0.90-1.33) 1.85 (1.60-2.10) Prevalence of caries in primary dentition, % 22.0% (19.5-24.8) 35.4% (32.7-38.2) Significant Caries Index (SiC) 2.32 (2.01-2.63) 3.66 (3.39-3.92) ICDAS>0 3.51 (3.13-3.89) 3.50 (3.24-3.75) The prevalence of caries, as well as the mean dmft and dmfs scores, was analysed according to sex in both age groups. Amongst three and four year olds, the prevalence of caries was higher in females at 22.4% (95% CI 18.9–26.4), whereas in five and six year olds it was higher in males at 35.8% (95% CI 32.0–39.9); however, chi-square tests indicated that these differences were not statistically significant. The mean dmft score amongst three and four year olds was 0.84 (95% CI 0.64–1.03) in males and 0.71 (95% CI 0.55–0.87) in females. Amongst five and six year olds, mean dmft scores were 1.16 (95% CI 0.99–1.34) in males and 1.31 (95% CI 1.12–1.51) in females. The corresponding mean dmfs scores were 1.27 (95% CI 0.93–1.61) and 0.96 (95% CI 0.70–1.21) amongst males and females aged three and four years, and 1.68 (95% CI 1.34–2.01) and 2.02 (95% CI 1.64–2.39) amongst males and females aged five and six years, respectively (Table 4). Table 4. Caries indicators in primary dentition by age cohort and sex (mean or percentage, 95% CI). 3-4 years old n=931 5-6 years old n=1141 M c n=462 F c n=469 M n=561 F n=580 dmft 0.84 (0.64-1.03) 0.71 (0.55-0.87) 1.16 (0.99-1.34) 1.31 (1.12-1.51) Student’s t-testᵃ p = 0.318 Student’s t-testᵃ p = 0.277 dmfs 1.27 (0.93-1.61) 0.96 (0.70-1.21) 1.68 (1.34-2.01) 2.02 (1.64-2.39) Student’s t-testᵃ p = 0.153 Student’s t-testᵃ p = 0.185 Prevalence of caries in primary dentition 21.6% (18.1%-25.6%) 22.4% (18.9%-26.4%) 35.8% (32.0%-39.9%) 35.5% (31.2%-39.0%) Chi-square test b p = 0.784 Chi-square test b p = 0.770 ᵃ Comparisons between sexes were performed using Student’s t-test. b Comparisons between sexes were performed using the Chi-square test. c M: male; F: female. These same statistical indicators were analysed according to the social class of the children (lower, middle and upper). In lower class three and four year olds, the prevalence of caries was 33% (95% CI 28.5–37.8), statistically higher than in the other class groups (p<0.001). The mean dmft score in this group was 1.25 (95% CI 1.01–1.49), again statistically higher than the other class groups (p<0.001). The mean dmfs was 1.90 (95% CI 1.46–2.34) in lower class three and four year olds once more statistically higher than in other class groups (p<0.001). In five and six year olds, the mean dmft, dmfs and the prevalence of caries were statistically higher in the lower-class groups than the other groups (p<0.001) (Table 5). Table 5. Caries indicators in primary dentition, by age cohort and social class (mean or percentage, 95% CI). ICDAS E-G 3-4 years old n=903 5-6 years old n=1110 Upper n=245 Middle n=264 Lower n=394 Upper n=272 Middle n=311 Lower n=527 dmft 0.17 (0.08-0.27) 0.52 (0.33-0.70) 1.25 (1.01-1.49) 0.35 (0.23-0.47) 1.05 (0.80-1.30) 1.70 (1.48-1.91) ANOVA and Linear trend p<0.001* ANOVA and Linear trend p<0.001* dmfs 0.18 (0.08-0.27) 0.69 (0.41-0.97) 1.90 (1.46-2.34) 0.42 (0.26-0.58) 1.50 (1.05-1.95) 2.65 (2.21-3.10) ANOVA and Linear trend p<0.001 ANOVA and Linear trend p<0.001* Prevalence of caries in primary dentition 8.6% (5.7%-12.8%) 17.0% (13.0%-22.5%) 33.0% (28.5%-37.8%) (13.9%-23.0%) 28.6% (23.9%-33.9%) 46.5% (42.3%-50.1%) ANOVA and Linear trend p<0.001* ANOVA and Linear trend p<0.001* Parental country of origin: 3-4-year-old group With reference to the parents’ country of origin, the prevalence of caries was statistically higher in South-central America, Asia and Africa compared to Spain. The mean dmft of three and four year old group with parents’ of Spanish origin was 0.36 (95% CI 0.25–0.46), statistically lower than South-central America and Africa which was 1.24 (95% CI 0.8–1.69) and 1.97 (95% CI 1.53–2.41) respectively (p<0.001). This group’s mean dmfs was 0.45 (95% CI 0.31–0.59) statistically lower than South-central America which was 1.66 (95% CI 0.92–2.41) and Africa which was 3.19 (95% CI 2.35–4.02). The prevalence of caries in this group in Africa was 45.9% (38.8-53.1) statistically higher than the other groups (p<0.001) (Table 6). Table 6. Caries indicators in primary dentition of 3–4-year-old children according to parents’ country of origin (mean or percentage, 95% CI). 3–4-year-old n=918 Prevalence of caries in primary dentition dmft dmfs Parental country of origin Spain n=642 13.2% (10.8%-16.1%) Chi-square test p<0.001* 0.36 (0.27-0.46) ANOVA p<0.001* Post hoc Bonferroni Group 1 vs 2 and vs 3 and Group 2 vs 3 0.45 (0.31-0.59) ANOVA p<0.001* Post hoc Bonferroni Group 1 vs 2 and vs 3 and Group 2 vs 3 South-central America n=95 34.7% (25.9%-44.7%) 1.24 (0.80-1.69) 1.66 (0.92-2.41) Africa n=181 45.9% (38.8%-53.1%) 1.97 (1.53-2.41) 3.19 (2.35-4.02) Parental country of origin: 5-6-year-old group The mean dmft score in five and six year olds was 2.73 (95% CI 2.37–3.09), 1.67 (95% CI 0.67–2.66) and 1.62 (95% CI 1.14–2.10) in Africa, Asia and South-central America respectively, whereas in Spain it was 0.69 (95% CI 0.57–0.81) which was statistically lower (p<0.001). The mean dmfs score in Spain was 0.98 (95% CI 0.75–1.21) statistically lower than in South-central America, Asia and Africa, which were 2.33 (95% CI 1.45–3.20), 2.80 (95% CI 0.86–4.74) and 4.29 (95% CI 3.54–5.03), respectively (Table 7). Table 7. Caries indicators in primary dentition of 5–6-year-old children according to parents’ country of origin (mean or percentage, 95% CI). 5–6-year-old n=1112 Prevalence of caries in primary dentition dmft dmfs Parental country of origin Spain n=739 24.1% (21.1%-27.3%) Chi-square test p<0.001* 0.69 (0.57-0.81) ANOVA p<0.001* Post hoc Bonferroni Group 1 vs 2 and vs 3 and Group 2 vs 3 0.98 (0.75-1.21) ANOVA p<0.001* Post hoc Bonferroni Group 1 vs 2 and vs 3 and Group 2 vs 3 South-central America n=132 41.7% (33.6%-50.2%) 1.62 (1.14-2.10) 2.33 (1.45-3.20) Africa n=241 66.4% (60.2%-72.1%) 2.73 (2.37-3.09) 4.29 (3.54-5.03) Discussion The present study analysed the association between socioeconomic status and dental caries in primary dentition amongst preschool children in southeastern Spain. Our findings revealed a clear socioeconomic gradient in caries experience, with significantly higher prevalence and severity amongst children from lower socioeconomic groups. These results reinforce the well-established relationship between social determinants and oral health inequalities in early childhood and highlight the importance of addressing socioeconomic disparities in preventive oral health policies. At the global level, dental caries remains the most prevalent oral disease and one of the most common health conditions worldwide. According to the Global Burden of Disease 2021 study [4], untreated dental caries in permanent teeth affected approximately 2.24 billion individuals globally, while untreated caries in deciduous teeth affected more than 560 million children worldwide, making dental caries the most prevalent oral condition globally [1]. These findings confirm that despite advances in preventive dentistry and oral health promotion strategies, the global burden of dental caries remains substantial. Several indices are available for assessing dental caries, and their findings depend on factors such as diagnostic criteria, measurement validity and detection thresholds [28]. The choice of index also affects the logistical complexity, cost and time required for epidemiological examinations [29]. These methodological aspects may therefore influence the results of epidemiological surveys, which are essential tools for public health authorities when planning oral health programmes. Most epidemiological studies conducted up to the beginning of the 21st century followed the recommendations of the World Health Organization (WHO) and reported caries prevalence using mean dmft values. However, mean-based measures do not adequately capture the typically skewed distribution of caries experience within populations. To better represent this heterogeneity, the Significant Caries Index (SiC Index) was introduced in 2000 [30]. This index complements traditional measures and enables identification of the subgroup of the population with the highest disease burden [31]. Increasing attention has also been given, in recent decades, to the detection of early enamel lesions within the framework of minimally invasive dentistry. As a result, the International Caries Detection and Assessment System (ICDAS) was developed, enabling the identification of both non-cavitated and cavitated lesions [32]. The detection of early lesions provides a more accurate measurement of disease activity and improves preventive monitoring strategies. For this reason, the present study incorporated multiple caries indicators, including ICDAS-based measures together with conventional indices such as dmft and dmfs, in order to provide a more comprehensive assessment of dental caries status in the study population. Dental caries remains highly prevalent in early childhood. A recent meta-analysis estimated a prevalence of approximately 48% amongst children under six years of age [33]. In Spain, the most recent National Oral Health survey, conducted in 2020, reported a prevalence of 28.3% amongst 5–6-year-olds [5]. Regional studies have reported somewhat higher figures; for example, in the Valencian region the prevalence reached 37.4% in preschool children [27]. In the present study, the prevalence was 35.4% in 5–6-year-olds and 22% in 3–4-year-olds, indicating levels comparable with those observed in neighbouring Spanish regions. By contrast, the Global Burden of Disease (GBD) 2021 study estimated the global age-standardised prevalence of untreated caries in deciduous teeth at approximately 7.5% [4], with a stable global burden of disease over the period 1990–2021, which is substantially lower than the prevalence observed in the present study. This discrepancy most likely reflects methodological differences between model-based global estimates and epidemiological survey data. The GBD estimates are derived from statistical modelling based on heterogeneous epidemiological data sources, whereas the present study involved direct clinical examination and diagnostic criteria capable of identifying both cavitated and early lesions. Consequently, the higher prevalence observed in this study may represent a more accurate reflection of the true burden of dental caries in young children. The findings of this study also demonstrated a clear and consistent social gradient in caries experience in primary dentition across both age cohorts. The mean dmft and dmfs values in 3–4-year-olds increased progressively from upper to lower social classes, indicating a substantially higher burden of disease amongst socioeconomically disadvantaged children. This gradient was even more pronounced in the 5–6-year-old cohort, reflecting both cumulative disease experience and widening social inequalities with age. Moreover, the statistically significant ANOVA and linear trend tests confirmed a strong dose–response relationship between socioeconomic disadvantage and increasing caries severity. These inequalities have been widely documented in the international literature, suggesting that the socioeconomic environment in which children grow up plays a key role in shaping oral health outcomes. Socioeconomic disadvantages have been associated with dietary patterns characterised by higher consumption of free sugars, limited access to healthy foods and reduced exposure to preventive dental care, all of which increase the risk of early childhood caries [10, 34, 35]. Age-related differences were also evident. Across all social classes, older children exhibited higher dmft and dmfs values compared with younger children, suggesting progressive accumulation of disease over time in the absence of adequate preventive or restorative care. Moreover, children from lower social classes showed disproportionately greater increases in caries indices with age, highlighting persistent exposure to risk factors and possible barriers to early intervention. The prevalence data further reinforce these inequalities. Amongst 3–4-year-olds, caries prevalence ranged from 8.6% in upper social classes to 33.0% in lower social classes, whereas in 5–6-year-olds prevalence increased sharply from 18.0% to 46.5%, respectively. This marked increase illustrates the cumulative nature of dental caries and suggests that social inequalities intensify as children grow older. No statistically significant differences were observed between boys and girls in either age group. This is consistent with many epidemiological studies in preschool populations, in which gender differences in caries prevalence tend to be minimal [36]. In early childhood, behavioural determinants of oral health such as diet, oral hygiene practices and access to dental services are largely determined by the family environment rather than gender-specific behaviours. In contrast, the country of origin of parents showed a significant association with caries prevalence, with higher levels of disease observed amongst children whose parents were born in Africa, Asia or Latin America as opposed to Spain. These findings highlight the influence of migration-related socioeconomic and cultural factors on oral health. Immigrant families may face barriers such as language difficulties, lower socioeconomic status and reduced access to preventive dental services [8-10]. The persistence of significant differences, after stratification by age, highlights parental country of origin as an important determinant of early childhood caries and likely reflects a complex interplay of socioeconomic conditions, cultural practices, dietary habits, oral health literacy and barriers to accessing dental services. Furthermore, previous studies have emphasised the influence of parental education and knowledge of oral health practices on children’s dental outcomes [9, 37, 38], although some authors suggest that the cumulative effect of multiple social disadvantages may outweigh the influence of any single determinant [38]. From a public health perspective, these findings reinforce the concept that dental caries should not be viewed solely as a biological disease but rather as a condition which is strongly influenced by social and structural determinants. This perspective aligns with the WHO Global Strategy and Action Plan on Oral Health 2023–2030, which emphasises the need to reduce oral health inequalities and strengthen preventive strategies [13]. This study acknowledges the following limitations that should be taken into account. First, its cross-sectional design does not allow causal relationships to be established between socioeconomic factors and dental caries. Second, socioeconomic indicators were based on proxy measures that may not fully capture the complexity of social disadvantage. In addition, certain sections of the questionnaire may have been affected by recall bias, potentially influenced by social desirability bias. Although conducting face-to-face interviews with parents or legal guardians might have reduced this bias, such an approach would have required substantially more time and human resources than were available for this study. Nevertheless, the use of calibrated examiners, standardised diagnostic criteria and a population-based sample strengthen the reliability of the findings. Conclusion In conclusion, this study confirms that socioeconomic inequalities remain a key determinant of dental caries in primary dentition amongst preschool children in the Region of Murcia. The study also observed a clear social gradient, with children from lower socioeconomic groups presenting significantly higher caries prevalence and severity. In addition, children whose parents originated from certain migrant populations, Africa, Asia and South-central America, showed substantially higher levels of caries compared with children whose parents were born in Spain. These findings highlight the importance of addressing the social determinants of oral health from early childhood and the consequent need for appropriate public health strategies. Such strategies should prioritise preventive interventions targeting socially disadvantaged and migrant populations to reduce inequalities in early childhood caries and improve oral health outcomes in vulnerable groups. Declarations Ethics approval and consent to participate The survey protocol was approved by the Human Research Ethics Committee of the University of Murcia (Spain) in December 2024 (approval number: M10/2024/419). Consent for publication Not applicable Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests Funding \"This work has been supported by the Fundación Séneca , Science and Technology Agency of the Region of Murcia (grant code: 22648/PI/24).\" Authors' contributions Following the Contributor Role Taxonomy (CRediT), the authors’ contributins are: SBG-M, Investigation, Formal Analysis and Writing-original draft; JEI-C, Formal Analysis, and Writing-review & editing; AJO-R, M, Methodology and Writing-review & editing; JMM-C, Formal Analysis, and Writing-review & editing; AP-S, Conceptualization and Writing-review & editing; CS-M, Investigation and Writing-review & editing; AV, Methodology and Writing-review & editing; YM-B, Conceptualization, Funding acquisition, Methodology and Writing-review & editing. References Pitts NB, Zero DT, Marsh PD, Ekstrand K, Weintraub JA, Ramos-Gomez F, et al: Dental caries. Nat Rev Dis Primers 2017, 3:17030. Lagerweij MD, van-Loveren C: Declining Caries Trends: Are We Satisfied? Curr Oral Health Rep 2015, 2(4):212–217. Ramos-Gomez F, Kinsler J, Askaryar H: Understanding oral health disparities in children as a global public health issue: how dental health professionals can make a difference. J Public Health Policy 2020, 41(2):114–124. GBD 2021 Oral Disorders Collaborators: Trends in the global, regional, and national burden of oral conditions from 1990 to 2021: a systematic analysis for the Global Burden of Disease Study 2021. Lancet 2025, 405(10482):897–910. Bravo-Pérez M, Almerich-Silla JM, Canorea-Díaz E, Casals-Peidró E, Cortés-Martinicorena FJ, Expósito-Delgado AJ, et al: Encuesta de Salud oral en España 2020. RCOE 2020, 25(4):12–67. Campus G, Cocco F, Strohmenger L, Wolf TG, Balian A, Arghittu A, et al: Inequalities in caries among pre-school Italian children with different background. BMC Pediatr 2022, 22(1):443–4. Theristopoulos A, Agouropoulos A, Seremidi K, Gizani S, Papaioannou W: The effect of socio-economic status on children's dental health. J Clin Pediatr Dent 2024, 48(4):52–60. Du S, Cheng M, Cui Z, Wang X, Feng X, Tai B, et al: Decomposing Socioeconomic Inequality in Early Childhood Caries Among 3 to 5-Year-Old Children in China. Int Dent J 2024, 74(5):968–977. Ellakany P, Madi M, Fouda SM, Ibrahim M, AlHumaid J: The Effect of Parental Education and Socioeconomic Status on Dental Caries among Saudi Children. Int J Environ Res Public Health 2021, 18(22):11862. doi: 10.3390/ijerph182211862. Thakur S, Sharma R, Singhal P, Chauhan D: Prevalence and determinants of early childhood caries among preschool children in district Shimla, North India: a cross -sectional study. BMC Oral Health 2025, 25(1):168–2. Moin M, Maqsood A, Haider MM, Asghar H, Rizvi KF, Shqaidef A, et al: The Association of Socioeconomic and Lifestyle Factors with the Oral Health Status in School-Age Children from Pakistan: A Cross-Sectional Study. Healthcare (Basel) 2023, 11(5):756. doi: 10.3390/healthcare11050756. Braveman PA, Cubbin C, Egerter S, Chideya S, Marchi KS, Metzler M, et al: Socioeconomic status in health research: one size does not fit all. JAMA 2005, 294(22):2879–2888. World Health Organization: Global strategy and action plan on oral health 2023-2030: Geneva: World Health Organization; 2024. Gimeno-de-Sande A, Sanchez-Fernandez Murias, Vińes-Rueda JJ, Gomez-Pomar F, Marińo-Aguiar F: Epidemiologic study of dental caries and oral pathology in Spain. Revista de sanidad e higiene publica 1971, 45(4):361–433. Llodra-Calvo JC, Bravo-Pérez M, Cortés-Martinicorena FJ: Encuesta de Salud Oral en España (2000). RCOE : revista del Ilustre Consejo General de Colegios de Odontologos y Estomatólogos de España 2002, 7(esp):19–63. Bravo-Pérez M, Casals-Peidró E, Cortés-Martinicorena FJ, Llodra-Calvo JC, Álvarez-Arenas Pardina I, Hermo-Señariz P, et al: Encuesta de Salud Oral en España 2005. RCOE : revista del Ilustre Consejo General de Colegios de Odontologos y Estomatólogos de España 2006, 11(4):409–456. Bravo-Pérez M, Llodra-Calvo JC, Cortés-Martinicorena FJ, Casals-Peidró E: Encuesta de Salud Oral de Preescolares en España 2007. RCOE : revista del Ilustre Consejo General de Colegios de Odontologos y Estomatólogos de España 2007, 12(3):143–168. Llodra-Calvo JC: Encuesta de Salud Oral en España 2010. 2012, 17(1):13–41. Bravo-Pérez M, Almerich-Silla JM, Ausina-Márquez V, Avilés-Gutiérrez P, Blanco-González JM, Canorea-Díaz E, et al: Encuesta de Salud Oral en España 2015. 2016, :8–48. Navarro-Alonso JA: Encuesta de salud bucodental en escolares de la Región de Murcia. In Murcia: Consejería de Sanidad.; 1990: Navarro-Alonso JA: II Encuesta de salud bucodental en escolares de la Región de Murcia. In Murcia: Consejería de Sanidad.; 1997: Vandenbroucke JP, von-Elm E, Altman DG, Gøtzsche PC, Mulrow CD, Pocock SJ, et al: Strengthening the Reporting of Observational Studies in Epidemiology (STROBE): explanation and elaboration. PLoS Med 2007, 4(10):e297. Shrestha B, Dunn L: The Declaration of Helsinki on Medical Research involving Human Subjects: A Review of Seventh Revision. J Nepal Health Res Counc 2020, 17(4):548–552. Domingo-Salvany A, Marcos-Alonso J: Proposal of an indicator of \"social class\" based on the occupation. Gac Sanit 1989, 3(10):320–326. World Health Organization: Oral health surveys : basic methods: 5th ed ed. Geneva: World Health Organization; 2013. Dikmen B: ICDAS II criteria (International Caries Detection and Assessment System). J Istanb Univ Fac Dent 2015, 49(3):63–72. Almerich-Torres T, Montiel-Company JM, Bellot-Arcís C, Iranzo-Cortés JE, Ortolá-Siscar JC, Almerich-Silla JM: Caries Prevalence Evolution and Risk Factors among Schoolchildren and Adolescents from Valencia (Spain): Trends 1998-2018. Int J Environ Res Public Health 2020, 17(18):6561. doi: 10.3390/ijerph17186561. Frencken JE, Giacaman RA, Leal SC: An assessment of three contemporary dental caries epidemiological instruments: a critical review. Br Dent J 2020, 228(1):25–31. Diamanti I, Berdouses ED, Kavvadia K, Arapostathis KN, Reppa C, Sifakaki M, et al: Caries prevalence and caries experience (ICDAS II criteria) of 5-, 12- and 15-year-old Greek children in relation to socio-demographic risk indicators. Trends at the national level in a period of a decade. Eur Arch Paediatr Dent 2021, 22(4):619–631. Bratthall D: Introducing the Significant Caries Index together with a proposal for a new global oral health goal for 12-year-olds. Int Dent J 2000, 50(6):378–384. Nishi M, Stjernswärd J, Carlsson P, Bratthall D: Caries experience of some countries and areas expressed by the Significant Caries Index. Community Dent Oral Epidemiol 2002, 30(4):296–301. Pitts NB, Ekstrand KR, ICDAS Foundation: International Caries Detection and Assessment System (ICDAS) and its International Caries Classification and Management System (ICCMS) - methods for staging of the caries process and enabling dentists to manage caries. Community Dent Oral Epidemiol 2013, 41(1):41. Uribe SE, Innes N, Maldupa I: The global prevalence of early childhood caries: A systematic review with meta-analysis using the WHO diagnostic criteria. Int J Paediatr Dent 2021, 31(6):817–830. Suresh A, Srinivasan D, Ar SE, Mahadevan S, Babu HSS: Association of Early Childhood Caries with Body Mass Index, Dietary Habits, and Socioeconomic Status among Preschool Children of Kelambakkam. Int J Clin Pediatr Dent 2023, 16(4):565–571. Peres MA, Macpherson LMD, Weyant RJ, Daly B, Venturelli R, Mathur MR, et al: Oral diseases: a global public health challenge. Lancet 2019, 394(10194):249–260. Ferro R, Besostri A, Olivieri A, Benacchio L: Early Childhood Caries in a Preschool-based Sample in Northeast Italy: Socioeconomic Status and Behavioral Risk Factors. Int J Clin Pediatr Dent 2022, 15(6):717–723. Tiwari T, Sukhabogi JR, Doshi D, Deshpande V, Lunavath P: Intersection of Gender, Religion, and Socio-economic Position in Relation to Untreated Oral Conditions - A Comparative Study. Indian J Dent Res 2025, 36(2):180–186. Liu S, Chongsuvivatwong V, Zhang S, Thearmontree A: Pathway of Effects of Socioeconomic Status on Rural Left-behind Children to Receive Oral Health Services: A Structural Equation Modeling. Int J Environ Res Public Health 2023, 20(2):1068. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 29 Apr, 2026 Editor invited by journal 17 Apr, 2026 Editor assigned by journal 27 Mar, 2026 Submission checks completed at journal 27 Mar, 2026 First submitted to journal 26 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-9232360\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":false,\"archivedVersions\":[],\"articleType\":\"Research Article\",\"associatedPublications\":[],\"authors\":[{\"id\":633159413,\"identity\":\"14c55da7-b920-4a75-8d65-760813a2f13d\",\"order_by\":0,\"name\":\"Scott Benjamin García-Mabin\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"University of Murcia\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Scott\",\"middleName\":\"Benjamin\",\"lastName\":\"García-Mabin\",\"suffix\":\"\"},{\"id\":633159414,\"identity\":\"7554282c-b63f-48b6-a6fe-dc4ac832703e\",\"order_by\":1,\"name\":\"José Enrique Iranzo-Cortés\",\"email\":\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA60lEQVRIiWNgGAWjYBACxgYQaYBgMvCTrkWygWR7DQ4QUMDcwHzscUWBdWI/A3Pbh5876uSMb+QYMHz4g89hbOmGZwzSE2c2MDbP7D3DZmwG1MI4sw2fFh4zyQaDw4kbDjA2M/C28SRuu5GWwMyLx0OMDfzfwFr2A7Uw/m2TSNw8A6jlD16H8bBBbGFgbGbmbTNI3CCRfICZgQ2PlmY2kMPSjWccBmqRbUswljjz+MDBXjx+MWxvfibZ8Mdatr+9/THj27Y6Of72xMYHP/A4zLAZTDGDERwcwK2BgUGeAaZlFIyCUTAKRgEuAABCO0v/mcrVlwAAAABJRU5ErkJggg==\",\"orcid\":\"\",\"institution\":\"University of Valencia\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"José\",\"middleName\":\"Enrique\",\"lastName\":\"Iranzo-Cortés\",\"suffix\":\"\"},{\"id\":633159415,\"identity\":\"ba017fda-4bbd-4145-9798-9ae8777e51c3\",\"order_by\":2,\"name\":\"Antonio José Ortiz-Ruiz\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"University of Murcia\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Antonio\",\"middleName\":\"José\",\"lastName\":\"Ortiz-Ruiz\",\"suffix\":\"\"},{\"id\":633159416,\"identity\":\"b1875012-1562-4ab8-951e-c6f957483e59\",\"order_by\":3,\"name\":\"José María Montiel-Company\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"University of Valencia\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"José\",\"middleName\":\"María\",\"lastName\":\"Montiel-Company\",\"suffix\":\"\"},{\"id\":633159417,\"identity\":\"7d563287-17c5-42b2-9988-3f461f5307d5\",\"order_by\":4,\"name\":\"Amparo Pérez-Silva\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"University of Murcia\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Amparo\",\"middleName\":\"\",\"lastName\":\"Pérez-Silva\",\"suffix\":\"\"},{\"id\":633159418,\"identity\":\"b8e4d224-e1b9-4cee-9417-721788d724d1\",\"order_by\":5,\"name\":\"Clara Serna-Muñoz\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"University of Murcia\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Clara\",\"middleName\":\"\",\"lastName\":\"Serna-Muñoz\",\"suffix\":\"\"},{\"id\":633159419,\"identity\":\"f9d1a5f2-8a84-421c-9bef-ac38ece45eb5\",\"order_by\":6,\"name\":\"Ascensión Vicente\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"University of Murcia\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Ascensión\",\"middleName\":\"\",\"lastName\":\"Vicente\",\"suffix\":\"\"},{\"id\":633159420,\"identity\":\"bf29daff-f6ce-448b-a11d-140cea21877f\",\"order_by\":7,\"name\":\"Yolanda Martínez-Beneyto\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"University of Murcia\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Yolanda\",\"middleName\":\"\",\"lastName\":\"Martínez-Beneyto\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2026-03-26 09:53:08\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-9232360/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-9232360/v1\",\"draftVersion\":[],\"editorialEvents\":[],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":108805735,\"identity\":\"53a15409-744a-4648-8ee5-f0fc628ba062\",\"added_by\":\"auto\",\"created_at\":\"2026-05-08 15:26:45\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":417529,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-9232360/v1/73e596eb-f8ad-4cd7-9329-34a0eaa1116f.pdf\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"\\u003cp\\u003eSocioeconomic status, parental country of origin and dental caries in primary dentition amongst preschool children in southeastern Spain: a cross-sectional study\\u003c/p\\u003e\",\"fulltext\":[{\"header\":\"Background\",\"content\":\"\\u003cp\\u003eDental caries is no longer regarded as a multifactorial infectious disease; rather, it is now recognized as a non-communicable multifactorial disease with a dynamic development, mediated by biofilms and influenced by a complex interplay of biological, behavioural, psycho-social, socioeconomic and environmental factors [\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eThe World Health Organization (WHO) considers dental caries in primary dentition to be the most prevalent chronic disease globally, affecting an estimated 514\\u0026nbsp;million children. WHO data further indicate that the decline in caries prevalence observed in the early twenty-first century has been largely confined to high-income countries (HICs). In contrast, low- and middle-income countries (LMICs) have experienced only a modest reduction or, in some cases, an increase in disease burden [\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e]. These regional disparities in paediatric oral health outcomes are associated with differences in quality of care, access to dental services and treatment cost, as well as variations in oral health education and overall health literacy [\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eThe most recent Global Burden of Oral Disease study on oral health (1990 to 2021) indicates that the prevalence of untreated caries in deciduous teeth has remained largely unchanged worldwide, with only a 6.5% increase in total cases during this period. Regional trends vary substantially, with increases observed in the African and Eastern Mediterranean regions and reductions reported in the European and Western Pacific regions. Notably, Europe reported the lowest number of prevalent cases globally [\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e]. Consistent with these global trends, the national survey conducted in Spain in 2020 found that caries prevalence in deciduous teeth has remained stable since 1993, showing a slight but statistically non-significant decrease. A similar pattern was observed for the mean number of teeth affected by caries, which also exhibited a non-significant decline over time [\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003e The disparity between HICs and LMICs may be partly explained by differences in access to public oral health services. In many developed and developing countries, oral health care is not fully integrated into primary health care systems, resulting in high out-of-pocket expenditures that disproportionately affect disadvantaged populations. These structural inequalities are further compounded by variations in health-related behaviour, including sugar consumption, exposure to fluoride, and oral hygiene practices [\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eEvidence from multiple countries demonstrates a clear linear trend in which children from LMICs exhibit higher caries indices compared to those from HICs [\\u003cspan additionalcitationids=\\\"CR8 CR9 CR10\\\" citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e]. Socioeconomic status (SES) is measured by a series of indicators. Some of the most important SES indicators are family income, occupational status and educational level of parents [\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e]. In the present study, parental occupation and educational level were used as indicators of SES.\\u003c/p\\u003e \\u003cp\\u003eUpdated and region-specific analyses are essential given the substantial global shifts in the burden of dental caries and the need for reliable epidemiological data to monitor progress towards the WHO Global Oral Health Action Plan target of a 10% reduction in oral disease prevalence by 2030 [\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e]. The absence of recent data addressing socioeconomic disparities in young children within the Region of Murcia represents an important knowledge gap. This study aims to provide updated information on the oral health status of children under six years of age in the region and to analyse its association with selected social determinants.\\u003c/p\\u003e \\u003cp\\u003eAlthough the first epidemiological study on oral health in Spain was conducted in 1969 [\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e], it was not until 2000 that national surveys began to systematically assess social class differences in children under six years of age in relation to primary dentition [\\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e]. Since then, socioeconomic indicators have been regularly included in national oral health surveys [\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e, \\u003cspan additionalcitationids=\\\"CR17 CR18\\\" citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e]. However, only two regional oral health surveys have been conducted in the region to date, and neither included an assessment of social class differences in children under six years of age [\\u003cspan citationid=\\\"CR20\\\" class=\\\"CitationRef\\\"\\u003e20\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR21\\\" class=\\\"CitationRef\\\"\\u003e21\\u003c/span\\u003e]. Furthermore, there is no data referring to caries levels in children under 6 years of age in the Spanish National Oral Health surveys.\\u003c/p\\u003e \\u003cp\\u003eTherefore, the objective of the study was to investigate the association between socioeconomic characteristics, parental country of origin, gender and dental caries status in primary dentition of children under six in the Region of Murcia.\\u003c/p\\u003e\"},{\"header\":\"Methods\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eStudy design\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThis study was designed as a cross-sectional epidemiological survey. All procedures were conducted in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for cross-sectional studies [22].\\u003c/p\\u003e\\n\\u003cp\\u003eThe study included schoolchildren\\u0026nbsp;between the ages of three and four and five and six in the Region of Murcia, which was recorded in 33 schools (28 public and 5 private) between January 2025 and June 2025.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eEthical approval\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe survey protocol was approved by the Human Research Ethics Committee of the University of Murcia (Spain) in December 2024 (approval number: M10/2024/419). Written informed consent was obtained from both participating schools and from the parents or legal guardians of the children prior to participation.\\u003c/p\\u003e\\n\\u003cp\\u003eAll procedures were conducted in accordance with the ethical principles established in the Declaration of Helsinki with applicable data protection regulations [23].\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eStudy population and calibration\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eSample size estimation was based on dental caries prevalence data from the Valencian Oral Health Surveys of 2018. A minimum sample of 340 participants was required for children aged 3\\u0026ndash;4 years, and 505 participants for children aged 5\\u0026ndash;6 years, assuming a 95% confidence level, an absolute precision of four percentage points, and a substitution rate of 10%.\\u003c/p\\u003e\\n\\u003cp\\u003eThe selected schools represented preschool populations from different geographical areas of the region. Children of all genders were included. Those who had already turned six but had not yet reached their seventh birthday at the time of examination were also considered eligible.\\u003c/p\\u003e\\n\\u003cp\\u003eThe fieldwork was carried out by two examiners. The examiners performed a prior calibration to ensure reliability and validity of the results. The two examiners exhibited a good level of agreement, according to the Landis and Koch scale, with a linear weighted Kappa index of 0.902 and 0.929, respectively.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eData collection measurement\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe questionnaire used in this study comprised two main categories: a demographic questionnaire and a clinical oral health questionnaire. The demographic section assessed family and child characteristics, including the child\\u0026rsquo;s age, gender (male/female), place of residence (urban, suburban, rural) and parental origin (Spain, European Union (EU), Europe, Canada/EEUU, South-central America, Asia, Africa, Oceania). For the intergroup analysis, only three origins were analysed (Spain, South-central America and Africa), as the other groups\\u0026rsquo; size was too small.\\u003c/p\\u003e\\n\\u003cp\\u003eData on a child\\u0026rsquo;s parental occupation was recorded and used to determine socioeconomic status (SES). Where parental occupation levels differed, the highest of the two was used. Occupations were categorized by means of the following classification proposed by Domingo and Marcos [24]:\\u003c/p\\u003e\\n\\u003cul\\u003e\\n \\u003cli\\u003eI. Professionals, managers, and senior technicians.\\u003c/li\\u003e\\n \\u003cli\\u003eII. Other managers, middle-level technicians, and commerce.\\u003c/li\\u003e\\n \\u003cli\\u003eIII. Intermediate supervisors and administrative staff.\\u003c/li\\u003e\\n \\u003cli\\u003eIVa. Skilled manual workers.\\u003c/li\\u003e\\n \\u003cli\\u003eIVb. Semi-skilled manual workers.\\u003c/li\\u003e\\n \\u003cli\\u003eV. Unskilled workers.\\u003c/li\\u003e\\n \\u003cli\\u003e\\u0026ldquo;Unclassifiable\\u0026rdquo;: those with no declared or poorly defined profession, or members of the armed forces.\\u003c/li\\u003e\\n\\u003c/ul\\u003e\\n\\u003cp\\u003eFor the purpose of statistical analysis these categories were divided into three classes, \\u0026ldquo;upper class\\u0026rdquo; was formed by categories I and II, \\u0026ldquo;middle class\\u0026rdquo; by III and IVa and \\u0026ldquo;lower class\\u0026rdquo; by IVb and V.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eThe clinical oral health questionnaire was developed following the criteria of the WHO Oral Health Survey: Basic Methods [25] and supplemented by the International Caries Detection and Assessment System (ICDAS II) [26]. Two-digit ICDAS-II coding system was used to record dental caries. However, because the examinations were conducted in field conditions without access to compressed air to adequately dry tooth surfaces, gauze was used as an alternative; therefore, ICDAS-II codes 1 and 2 were combined. Based on these criteria, all five surfaces of molars, the four surfaces of incisors and canines were examined.\\u003c/p\\u003e\\n\\u003cp\\u003eIn addition to recording the presence of caries, the condition of fissure sealants and/or restorations was assessed using the first digit of the ICDAS-II coding system. The second digit recorded the severity of caries, represented by seven codes (0-6). In deciduous dentition, these severity codes are expressed as letters (A=0, C=2, D=3, E=4, F=5, G=6). Since ICDAS-II codes 1 and 2 were merged in this study, the corresponding deciduous dentition codes B and C were both classified as C. Furthermore, a tooth was defined as carious from ICDAS code 4 onwards to facilitate comparison with previous epidemiological research and to be consistent with the methodology employed in similar studies [27].\\u003c/p\\u003e\\n\\u003cp\\u003eTogether with the examiner-completed questionnaire set out previously, a separate questionnaire was distributed to parents via the school and completed prior to the visit. The Diet and Habits questionnaire gathered further demographic information, including the number of siblings (none, 1, 2, 3, 4, 5, or more than 5), parental age, family structure (two parents, divorced parents, or single parent), and parental employment status.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eData collection process\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eSelected schools were contacted and invited to participate by means of a presentation letter describing the objectives and procedures of the study. The schools distributed an information sheet, consent form and a diet and habits questionnaire to parents or legal guardians.\\u003c/p\\u003e\\n\\u003cp\\u003eClinical examinations were performed at the schools after completed consent forms had been returned. The examination team consisted of two dentists who had previously undergone training, standardisation and calibration procedures.\\u003c/p\\u003e\\n\\u003cp\\u003eChildren whose parents had provided written informed consent were examined at their schools under standard field conditions typically used in epidemiological oral health surveys.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eChildren presenting with visible caries lesions were referred for dental treatment and provided with a written report for their parents. No x-rays were taken and no treatment was provided during the examinations.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eData analysis\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eData was recorded anonymously by the examiners and encoded in an Excel database. The statistical analysis was performed using IBM SPSS Statistics, version 29.0.\\u003c/p\\u003e\\n\\u003cp\\u003eA univariate descriptive analysis was carried out, which obtained means for quantitative variables and proportions for dichotomous variables or categorical variables, within the required 95% confidence intervals.\\u003c/p\\u003e\\n\\u003cp\\u003eFor the bivariate analysis between groups (sex, social class and parental origin), Student\\u0026rsquo;s t-tests were employed to assess differences between any two groups, while ANOVA with Bonferroni post-hoc tests was used for continuous variables. In the case of social class, a test for linear trend was conducted in addition to ANOVA to evaluate potential ascending or descending relationships across the groups. Categorical variables were analysed using the Chi-square test. The significance level was set at p \\u0026lt; 0.05.\\u003c/p\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eSample description\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe study sample consisted of 931 children aged 3\\u0026ndash;4 years and 1,141 children aged 5\\u0026ndash;6 years, with mean ages of 4.03 \\u0026plusmn; 0.61 years and 6.12 \\u0026plusmn; 0.59 years, respectively (Table 1).\\u003c/p\\u003e\\n\\u003cp\\u003eParticipation by sex was homogeneous. Amongst children aged 3\\u0026ndash;4 years, 50.4% were female (n=469), while amongst children aged 5\\u0026ndash;6 years 50.8% were female (n=580).\\u003c/p\\u003e\\n\\u003cp\\u003eThe sample came predominantly from a lower social class background, where 43.6% (n=294) of\\u0026nbsp;3\\u0026ndash;4-year-olds\\u0026nbsp;and 47.5% (n=527) of\\u0026nbsp;5\\u0026ndash;6-year-olds\\u0026nbsp;were classified as lower class (Table 1).\\u003c/p\\u003e\\n\\u003cp\\u003eMost children\\u0026rsquo;s parents were born in Spain (68.9% in the 3\\u0026ndash;4-year group and 64.8% in the 5\\u0026ndash;6-year group). Amongst children with parents born outside Spain, the largest group corresponded to African countries, representing 19.4% and 21.1% in the younger and older age groups respectively.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eTable 1.\\u0026nbsp;\\u003c/strong\\u003eDistribution of the sample by age, sex, social class and parents\\u0026rsquo; country of origin.\\u003c/p\\u003e\\n\\u003ctable border=\\\"1\\\" cellspacing=\\\"0\\\" cellpadding=\\\"0\\\" width=\\\"434\\\"\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd colspan=\\\"2\\\" rowspan=\\\"2\\\" valign=\\\"top\\\" style=\\\"width: 217px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cem\\u003e\\u0026nbsp;\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 113px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003e3-4 years old\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003e5-6 years old\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 113px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cem\\u003en=931\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cem\\u003en=1141\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 123px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003eAge\\u0026nbsp;\\u003c/em\\u003e\\u003c/strong\\u003e\\u003cem\\u003e(mean; SD)\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 94px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cem\\u003e\\u0026nbsp;\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 113px;\\\"\\u003e\\n \\u003cp\\u003e4.03 (0.61)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e6.12 (0.59)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd rowspan=\\\"2\\\" style=\\\"width: 123px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003eSex\\u003c/em\\u003e\\u003c/strong\\u003e\\u003cem\\u003e\\u0026nbsp;(%)\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 94px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cem\\u003eMale\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 113px;\\\"\\u003e\\n \\u003cp\\u003e49.6% (n=462)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e49.2% (n=561)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 94px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cem\\u003eFemale\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 113px;\\\"\\u003e\\n \\u003cp\\u003e50.4% (n=469)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e50.8% (n=580)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd rowspan=\\\"3\\\" style=\\\"width: 123px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003eSocial class\\u003c/em\\u003e\\u003c/strong\\u003e\\u003cem\\u003e\\u0026nbsp;(%)\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 94px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cem\\u003eUpper\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 113px;\\\"\\u003e\\n \\u003cp\\u003e27.1% (n=245)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e24.5% (n=272)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 94px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cem\\u003eMiddle\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 113px;\\\"\\u003e\\n \\u003cp\\u003e29.2% (n=264)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e28% (n=311)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 94px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cem\\u003eLower\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 113px;\\\"\\u003e\\n \\u003cp\\u003e43.6% (n=294)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e47.5% (n=527)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd rowspan=\\\"3\\\" style=\\\"width: 123px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003eSocial class\\u003c/em\\u003e\\u003c/strong\\u003e\\u003cem\\u003e\\u0026nbsp;(%)\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003edmfs\\u0026nbsp;\\u003c/em\\u003e\\u003c/strong\\u003e\\u003cstrong\\u003e\\u003cem\\u003e\\u0026gt;0\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 94px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cem\\u003eUpper\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 113px;\\\"\\u003e\\n \\u003cp\\u003e10.7% (n=21)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e12.8% (n=49)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 94px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cem\\u003eMiddle\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 113px;\\\"\\u003e\\n \\u003cp\\u003e23% (n=45)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e23.2% (n=89)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 94px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cem\\u003eLower\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 113px;\\\"\\u003e\\n \\u003cp\\u003e66.3% (n=130)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e64% (n=245)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd rowspan=\\\"6\\\" style=\\\"width: 123px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003eParental country of origin\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 94px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cem\\u003eSpain\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 113px;\\\"\\u003e\\n \\u003cp\\u003e68.9% (n= 642)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e64.8% (n=739)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 94px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cem\\u003eEU countries\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 113px;\\\"\\u003e\\n \\u003cp\\u003e0.2% (n=2)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e0.4% (n=4)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 94px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cem\\u003eNon-EU countries\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 113px;\\\"\\u003e\\n \\u003cp\\u003e0.2% (n=2)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e0.9% (n=10)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 94px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cem\\u003eSouth-central America\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 113px;\\\"\\u003e\\n \\u003cp\\u003e10.2% (n=95)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e11.6% (n=132)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 94px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cem\\u003eAsia\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 113px;\\\"\\u003e\\n \\u003cp\\u003e1.0% (n=9)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e1.3% (n=15)\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 94px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cem\\u003eAfrica\\u0026nbsp;\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 113px;\\\"\\u003e\\n \\u003cp\\u003e19.4% (n=181)\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 104px;\\\"\\u003e\\n \\u003cp\\u003e21.1% (n= 241)\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eCaries experience\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe most frequent ICDAS-II code was F in both age groups. Amongst three and four year olds, the prevalence of code F was 0.38 (95% CI 0.30\\u0026ndash;0.46) at tooth level and 0.48 (95% CI 0.37\\u0026ndash;0.59) at surface level. In five and six year olds, 0.63 (95% CI 0.55\\u0026ndash;0.72) of tooth level and 0.77 (95% CI 0.66\\u0026ndash;0.88) of surface level were classified as code F (Table 2).\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eTable 2.\\u003c/strong\\u003e ICDAS codes for primary dentition: mean number of affected tooth or surface level by age cohort (mean, 95% CI).\\u003c/p\\u003e\\n\\u003ctable border=\\\"1\\\" cellspacing=\\\"0\\\" cellpadding=\\\"0\\\" width=\\\"425\\\"\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd rowspan=\\\"2\\\" style=\\\"width: 112px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cem\\u003eICDAS codes\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"2\\\" style=\\\"width: 153px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003e3-4 years old\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cem\\u003en=931\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"2\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003e5-6 years old\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cem\\u003en=1141\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 74px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cem\\u003eTooth\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 78px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cem\\u003eSurface\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 76px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cem\\u003eTooth\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cem\\u003eSurface\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 112px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003eICDAS Code C\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 74px;\\\"\\u003e\\n \\u003cp\\u003e0.23\\u003c/p\\u003e\\n \\u003cp\\u003e0.17-0.29\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 78px;\\\"\\u003e\\n \\u003cp\\u003e0.25\\u003c/p\\u003e\\n \\u003cp\\u003e0.19-0.32\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 76px;\\\"\\u003e\\n \\u003cp\\u003e0.11\\u003c/p\\u003e\\n \\u003cp\\u003e0.07-0.14\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e0.12\\u003c/p\\u003e\\n \\u003cp\\u003e0.08-0.15\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 112px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003eICDAS Code D\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 74px;\\\"\\u003e\\n \\u003cp\\u003e0.29\\u003c/p\\u003e\\n \\u003cp\\u003e0.23-0.35\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 78px;\\\"\\u003e\\n \\u003cp\\u003e0.33\\u003c/p\\u003e\\n \\u003cp\\u003e0.26-0.41\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 76px;\\\"\\u003e\\n \\u003cp\\u003e0.27\\u003c/p\\u003e\\n \\u003cp\\u003e0.22-0.32\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e0.31\\u003c/p\\u003e\\n \\u003cp\\u003e0.25-0.37\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 112px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003eICDAS Code E\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 74px;\\\"\\u003e\\n \\u003cp\\u003e0.24\\u003c/p\\u003e\\n \\u003cp\\u003e0.19-0.29\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 78px;\\\"\\u003e\\n \\u003cp\\u003e0.26\\u003c/p\\u003e\\n \\u003cp\\u003e0.20-0.31\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 76px;\\\"\\u003e\\n \\u003cp\\u003e0.29\\u003c/p\\u003e\\n \\u003cp\\u003e0.25-0.34\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e0.32\\u003c/p\\u003e\\n \\u003cp\\u003e0.27-0.37\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 112px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003eICDAS Code F\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 74px;\\\"\\u003e\\n \\u003cp\\u003e0.38\\u003c/p\\u003e\\n \\u003cp\\u003e0.30-0.46\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 78px;\\\"\\u003e\\n \\u003cp\\u003e0.48\\u003c/p\\u003e\\n \\u003cp\\u003e0.37-0.59\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 76px;\\\"\\u003e\\n \\u003cp\\u003e0.63\\u003c/p\\u003e\\n \\u003cp\\u003e0.55-0.72\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e0.77\\u003c/p\\u003e\\n \\u003cp\\u003e0.66-0.88\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 112px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003eICDAS Code G\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 74px;\\\"\\u003e\\n \\u003cp\\u003e0.15\\u003c/p\\u003e\\n \\u003cp\\u003e0.09-0.21\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 78px;\\\"\\u003e\\n \\u003cp\\u003e0.36\\u003c/p\\u003e\\n \\u003cp\\u003e0.22-0.51\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 76px;\\\"\\u003e\\n \\u003cp\\u003e0.31\\u003c/p\\u003e\\n \\u003cp\\u003e0.24-0.37\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e0.74\\u003c/p\\u003e\\n \\u003cp\\u003e0.57-0.92\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 112px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003eFilled\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 74px;\\\"\\u003e\\n \\u003cp\\u003e0.01\\u003c/p\\u003e\\n \\u003cp\\u003e0.00-0.01\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 78px;\\\"\\u003e\\n \\u003cp\\u003e0.02\\u003c/p\\u003e\\n \\u003cp\\u003e0.00-0.05\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 76px;\\\"\\u003e\\n \\u003cp\\u003e0.01\\u003c/p\\u003e\\n \\u003cp\\u003e0.00-0.01\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e0.02\\u003c/p\\u003e\\n \\u003cp\\u003e0.00-0.04\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003eThe prevalence of caries was 22.0% (95% CI 19.5\\u0026ndash;24.8) in three and four year olds and 35.4% (95% CI 32.7\\u0026ndash;38.2) in five and six year olds. The mean dmft score was higher in the older group, reaching 1.24 (95% CI 1.11\\u0026ndash;1.37), compared with 0.77 (95% CI 0.65\\u0026ndash;0.90) in three and four year olds. Similarly, the mean dmfs score was higher amongst five and six year olds at 1.85 (95% CI 1.60\\u0026ndash;2.10). The mean SiC index was 2.32 (95% CI 2.01\\u0026ndash;2.63) in three and four year olds and 3.66 (95% CI 3.39\\u0026ndash;3.92) in five and six year olds. The mean number of teeth with ICDAS\\u0026gt;0 was 3.51 (95% CI 3.13\\u0026ndash;3.89) and 3.50 (95% CI 3.24\\u0026ndash;3.75), respectively (Table 3).\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eTable 3.\\u003c/strong\\u003e Caries indicators and concentration of caries in primary dentition by age cohort (mean or percentage, 95% CI).\\u003c/p\\u003e\\n\\u003ctable border=\\\"1\\\" cellspacing=\\\"0\\\" cellpadding=\\\"0\\\" width=\\\"539\\\"\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 217px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eIndicator\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e3-4 years (n=931)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e5-6 years old (n=1141)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 217px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003edmft\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e0.77 (0.65-0.90)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e1.24 (1.11-1.37)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 217px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003edmfs\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e1.11 (0.90-1.33)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e1.85 (1.60-2.10)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 217px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003ePrevalence of caries in primary dentition, %\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e22.0% (19.5-24.8)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e35.4% (32.7-38.2)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 217px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eSignificant Caries Index (SiC)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e2.32 (2.01-2.63)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e3.66 (3.39-3.92)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 217px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eICDAS\\u0026gt;0\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e3.51 (3.13-3.89)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e3.50 (3.24-3.75)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003eThe prevalence of caries, as well as the mean dmft and dmfs scores, was analysed according to sex in both age groups. Amongst three and four year olds, the prevalence of caries was higher in females at 22.4% (95% CI 18.9\\u0026ndash;26.4), whereas in five and six year olds it was higher in males at 35.8% (95% CI 32.0\\u0026ndash;39.9); however, chi-square tests indicated that these differences were not statistically significant. The mean dmft score amongst three and four year olds was 0.84 (95% CI 0.64\\u0026ndash;1.03) in males and 0.71 (95% CI 0.55\\u0026ndash;0.87) in females. Amongst five and six year olds, mean dmft scores were 1.16 (95% CI 0.99\\u0026ndash;1.34) in males and 1.31 (95% CI 1.12\\u0026ndash;1.51) in females. The corresponding mean dmfs scores were 1.27 (95% CI 0.93\\u0026ndash;1.61) and 0.96 (95% CI 0.70\\u0026ndash;1.21) amongst males and females aged three and four years, and 1.68 (95% CI 1.34\\u0026ndash;2.01) and 2.02 (95% CI 1.64\\u0026ndash;2.39) amongst males and females aged five and six years, respectively (Table 4).\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eTable 4.\\u003c/strong\\u003e Caries indicators in primary dentition by age cohort and sex (mean or percentage, 95% CI).\\u003c/p\\u003e\\n\\u003ctable border=\\\"1\\\" cellspacing=\\\"0\\\" cellpadding=\\\"0\\\" width=\\\"463\\\"\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd rowspan=\\\"2\\\" style=\\\"width: 127px;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd colspan=\\\"2\\\" style=\\\"width: 163px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003e3-4 years old\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cem\\u003en=931\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"2\\\" style=\\\"width: 173px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003e5-6 years old\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cem\\u003en=1141\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 80px;\\\"\\u003e\\n \\u003ch5\\u003e\\u003cstrong\\u003eM\\u003c/strong\\u003e\\u003cstrong\\u003e\\u003csup\\u003ec\\u003c/sup\\u003e\\u003c/strong\\u003e\\u003c/h5\\u003e\\n \\u003ch5\\u003en=462\\u003c/h5\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 82px;\\\"\\u003e\\n \\u003ch5\\u003e\\u003cstrong\\u003eF\\u003c/strong\\u003e\\u003cstrong\\u003e\\u003csup\\u003ec\\u003c/sup\\u003e\\u003c/strong\\u003e\\u003c/h5\\u003e\\n \\u003ch5\\u003en=469\\u003c/h5\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 88px;\\\"\\u003e\\n \\u003ch5\\u003e\\u003cstrong\\u003eM\\u003c/strong\\u003e\\u003c/h5\\u003e\\n \\u003ch5\\u003en=561\\u003c/h5\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 85px;\\\"\\u003e\\n \\u003ch5\\u003e\\u003cstrong\\u003eF\\u003c/strong\\u003e\\u003c/h5\\u003e\\n \\u003ch5\\u003en=580\\u003c/h5\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd rowspan=\\\"2\\\" style=\\\"width: 127px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003edmft\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 80px;\\\"\\u003e\\n \\u003cp\\u003e0.84\\u003c/p\\u003e\\n \\u003cp\\u003e(0.64-1.03)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 82px;\\\"\\u003e\\n \\u003cp\\u003e0.71\\u003c/p\\u003e\\n \\u003cp\\u003e(0.55-0.87)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 88px;\\\"\\u003e\\n \\u003cp\\u003e1.16\\u003c/p\\u003e\\n \\u003cp\\u003e(0.99-1.34)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e1.31\\u003c/p\\u003e\\n \\u003cp\\u003e(1.12-1.51)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd colspan=\\\"2\\\" style=\\\"width: 163px;\\\"\\u003e\\n \\u003cp\\u003eStudent\\u0026rsquo;s t-testᵃ\\u0026nbsp;p = 0.318\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"2\\\" style=\\\"width: 173px;\\\"\\u003e\\n \\u003cp\\u003eStudent\\u0026rsquo;s t-testᵃ p = 0.277\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd rowspan=\\\"2\\\" style=\\\"width: 127px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003e\\u0026nbsp;\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003edmfs\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003e\\u0026nbsp;\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 80px;\\\"\\u003e\\n \\u003cp\\u003e1.27\\u003c/p\\u003e\\n \\u003cp\\u003e(0.93-1.61)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 82px;\\\"\\u003e\\n \\u003cp\\u003e0.96\\u003c/p\\u003e\\n \\u003cp\\u003e(0.70-1.21)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 88px;\\\"\\u003e\\n \\u003cp\\u003e1.68\\u003c/p\\u003e\\n \\u003cp\\u003e(1.34-2.01)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e2.02\\u003c/p\\u003e\\n \\u003cp\\u003e(1.64-2.39)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd colspan=\\\"2\\\" style=\\\"width: 163px;\\\"\\u003e\\n \\u003cp\\u003eStudent\\u0026rsquo;s t-testᵃ\\u0026nbsp;p = 0.153\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"2\\\" style=\\\"width: 173px;\\\"\\u003e\\n \\u003cp\\u003eStudent\\u0026rsquo;s t-testᵃ p = 0.185\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd rowspan=\\\"2\\\" style=\\\"width: 127px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003ePrevalence of caries in primary dentition\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 80px;\\\"\\u003e\\n \\u003cp\\u003e21.6%\\u003c/p\\u003e\\n \\u003cp\\u003e(18.1%-25.6%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 82px;\\\"\\u003e\\n \\u003cp\\u003e22.4%\\u003c/p\\u003e\\n \\u003cp\\u003e(18.9%-26.4%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 88px;\\\"\\u003e\\n \\u003cp\\u003e35.8%\\u003c/p\\u003e\\n \\u003cp\\u003e(32.0%-39.9%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e35.5%\\u003c/p\\u003e\\n \\u003cp\\u003e(31.2%-39.0%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd colspan=\\\"2\\\" style=\\\"width: 163px;\\\"\\u003e\\n \\u003cp\\u003eChi-square test\\u003csup\\u003eb\\u003c/sup\\u003e\\u003csup\\u003e\\u0026nbsp;\\u003c/sup\\u003ep = 0.784\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"2\\\" style=\\\"width: 173px;\\\"\\u003e\\n \\u003cp\\u003eChi-square test\\u003csup\\u003eb\\u003c/sup\\u003e p = 0.770\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd colspan=\\\"5\\\" style=\\\"width: 463px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cem\\u003eᵃ\\u003c/em\\u003e\\u003cem\\u003e\\u0026nbsp;\\u003c/em\\u003eComparisons between sexes were performed using Student\\u0026rsquo;s t-test.\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003csup\\u003eb\\u003c/sup\\u003e Comparisons between sexes were performed using the Chi-square test.\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003csup\\u003ec\\u003c/sup\\u003e M: male; F: female.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003eThese same statistical indicators were analysed according to the social class of the children (lower, middle and upper). \\u0026nbsp;In lower class three and four year olds, the prevalence of caries was 33% (95% CI 28.5\\u0026ndash;37.8), statistically higher than in the other class groups (p\\u0026lt;0.001). The mean dmft score in this group was 1.25 (95% CI 1.01\\u0026ndash;1.49), again statistically higher than the other class groups (p\\u0026lt;0.001). The mean dmfs was 1.90 (95% CI 1.46\\u0026ndash;2.34) in lower class three and four year olds once more statistically higher than in other class groups (p\\u0026lt;0.001). In five and six year olds, the mean dmft, dmfs and the prevalence of caries were statistically higher in the lower-class groups than the other groups (p\\u0026lt;0.001) (Table 5).\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eTable 5.\\u003c/strong\\u003e Caries indicators in primary dentition, by age cohort and social class (mean or percentage, 95% CI).\\u003c/p\\u003e\\n\\u003ctable border=\\\"1\\\" cellspacing=\\\"0\\\" cellpadding=\\\"0\\\" width=\\\"567\\\"\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd rowspan=\\\"2\\\" style=\\\"width: 95px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cem\\u003eICDAS E-G\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"3\\\" style=\\\"width: 246px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003e3-4 years old\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cem\\u003en=903\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"3\\\" style=\\\"width: 227px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003e5-6 years old\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cem\\u003en=1110\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eUpper\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003en=245\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eMiddle\\u0026nbsp;\\u003c/strong\\u003en=264\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 76px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eLower\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003en=394\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 76px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eUpper\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003en=272\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 76px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eMiddle\\u003c/strong\\u003e n=311\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 76px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eLower\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003en=527\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd rowspan=\\\"2\\\" style=\\\"width: 95px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003edmft\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e0.17\\u003c/p\\u003e\\n \\u003cp\\u003e(0.08-0.27)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e0.52\\u003c/p\\u003e\\n \\u003cp\\u003e(0.33-0.70)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 76px;\\\"\\u003e\\n \\u003cp\\u003e1.25\\u003c/p\\u003e\\n \\u003cp\\u003e(1.01-1.49)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 76px;\\\"\\u003e\\n \\u003cp\\u003e0.35\\u003c/p\\u003e\\n \\u003cp\\u003e(0.23-0.47)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 76px;\\\"\\u003e\\n \\u003cp\\u003e1.05\\u003c/p\\u003e\\n \\u003cp\\u003e(0.80-1.30)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 76px;\\\"\\u003e\\n \\u003cp\\u003e1.70\\u003c/p\\u003e\\n \\u003cp\\u003e(1.48-1.91)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd colspan=\\\"3\\\" style=\\\"width: 246px;\\\"\\u003e\\n \\u003cp\\u003eANOVA and Linear trend p\\u0026lt;0.001*\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"3\\\" style=\\\"width: 227px;\\\"\\u003e\\n \\u003cp\\u003eANOVA and Linear trend p\\u0026lt;0.001*\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd rowspan=\\\"2\\\" style=\\\"width: 95px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003e\\u0026nbsp;\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003edmfs\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003e\\u0026nbsp;\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e0.18\\u003c/p\\u003e\\n \\u003cp\\u003e(0.08-0.27)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e0.69\\u003c/p\\u003e\\n \\u003cp\\u003e(0.41-0.97)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 76px;\\\"\\u003e\\n \\u003cp\\u003e1.90\\u003c/p\\u003e\\n \\u003cp\\u003e(1.46-2.34)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 76px;\\\"\\u003e\\n \\u003cp\\u003e0.42\\u003c/p\\u003e\\n \\u003cp\\u003e(0.26-0.58)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 76px;\\\"\\u003e\\n \\u003cp\\u003e1.50\\u003c/p\\u003e\\n \\u003cp\\u003e(1.05-1.95)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 76px;\\\"\\u003e\\n \\u003cp\\u003e2.65\\u003c/p\\u003e\\n \\u003cp\\u003e(2.21-3.10)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd colspan=\\\"3\\\" style=\\\"width: 246px;\\\"\\u003e\\n \\u003cp\\u003eANOVA and Linear trend p\\u0026lt;0.001\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"3\\\" style=\\\"width: 227px;\\\"\\u003e\\n \\u003cp\\u003eANOVA and Linear trend p\\u0026lt;0.001*\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd rowspan=\\\"2\\\" style=\\\"width: 95px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003e\\u0026nbsp;\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003ePrevalence of caries in primary dentition\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e8.6%\\u003c/p\\u003e\\n \\u003cp\\u003e(5.7%-12.8%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e17.0%\\u003c/p\\u003e\\n \\u003cp\\u003e(13.0%-22.5%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 76px;\\\"\\u003e\\n \\u003cp\\u003e33.0%\\u003c/p\\u003e\\n \\u003cp\\u003e(28.5%-37.8%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 76px;\\\"\\u003e\\n \\u003cp\\u003e(13.9%-23.0%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 76px;\\\"\\u003e\\n \\u003cp\\u003e28.6%\\u003c/p\\u003e\\n \\u003cp\\u003e(23.9%-33.9%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 76px;\\\"\\u003e\\n \\u003cp\\u003e46.5%\\u003c/p\\u003e\\n \\u003cp\\u003e(42.3%-50.1%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd colspan=\\\"3\\\" style=\\\"width: 246px;\\\"\\u003e\\n \\u003cp\\u003eANOVA and Linear trend p\\u0026lt;0.001*\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"3\\\" style=\\\"width: 227px;\\\"\\u003e\\n \\u003cp\\u003eANOVA and Linear trend p\\u0026lt;0.001*\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eParental country of origin: 3-4-year-old group\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eWith reference to the parents\\u0026rsquo; country of origin, the prevalence of caries was statistically higher in South-central America, Asia and Africa compared to Spain. The mean dmft of three and four year old group with parents\\u0026rsquo; of Spanish origin was 0.36 (95% CI 0.25\\u0026ndash;0.46), statistically lower than South-central America and Africa which was 1.24 (95% CI 0.8\\u0026ndash;1.69) and 1.97 (95% CI 1.53\\u0026ndash;2.41) respectively (p\\u0026lt;0.001). This group\\u0026rsquo;s mean dmfs was 0.45 (95% CI 0.31\\u0026ndash;0.59) statistically lower than South-central America which was 1.66 (95% CI 0.92\\u0026ndash;2.41) and Africa which was 3.19 (95% CI 2.35\\u0026ndash;4.02). The prevalence of caries in this group in Africa was 45.9% (38.8-53.1) statistically higher than the other groups (p\\u0026lt;0.001) (Table 6).\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eTable 6.\\u003c/strong\\u003e Caries indicators in primary dentition of 3\\u0026ndash;4-year-old children according to parents\\u0026rsquo; country of origin (mean or percentage, 95% CI).\\u003c/p\\u003e\\n\\u003ctable border=\\\"1\\\" cellspacing=\\\"0\\\" cellpadding=\\\"0\\\" width=\\\"624\\\"\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd colspan=\\\"2\\\" style=\\\"width: 142px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003e3\\u0026ndash;4-year-old\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cem\\u003en=918\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"2\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003ePrevalence of caries in primary dentition\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"2\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003edmft\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"2\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003edmfs\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd rowspan=\\\"3\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003eParental country of origin\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 56px;\\\"\\u003e\\n \\u003cp\\u003eSpain\\u003c/p\\u003e\\n \\u003cp\\u003en=642\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e13.2%\\u003c/p\\u003e\\n \\u003cp\\u003e(10.8%-16.1%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd rowspan=\\\"3\\\" style=\\\"width: 76px;\\\"\\u003e\\n \\u003cp\\u003eChi-square\\u003c/p\\u003e\\n \\u003cp\\u003etest p\\u0026lt;0.001*\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e0.36\\u003c/p\\u003e\\n \\u003cp\\u003e(0.27-0.46)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd rowspan=\\\"3\\\" style=\\\"width: 76px;\\\"\\u003e\\n \\u003cp\\u003eANOVA p\\u0026lt;0.001*\\u003c/p\\u003e\\n \\u003cp\\u003ePost hoc Bonferroni\\u003c/p\\u003e\\n \\u003cp\\u003eGroup 1 vs 2 and vs 3\\u003c/p\\u003e\\n \\u003cp\\u003eand Group 2 vs 3\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e0.45\\u003c/p\\u003e\\n \\u003cp\\u003e(0.31-0.59)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd rowspan=\\\"3\\\" style=\\\"width: 76px;\\\"\\u003e\\n \\u003cp\\u003eANOVA p\\u0026lt;0.001*\\u003c/p\\u003e\\n \\u003cp\\u003ePost hoc Bonferroni\\u003c/p\\u003e\\n \\u003cp\\u003eGroup 1 vs 2 and vs 3\\u003c/p\\u003e\\n \\u003cp\\u003eand Group 2 vs 3\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 56px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cem\\u003eSouth-central America\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003en=95\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e34.7%\\u003c/p\\u003e\\n \\u003cp\\u003e(25.9%-44.7%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e1.24\\u003c/p\\u003e\\n \\u003cp\\u003e(0.80-1.69)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e1.66\\u003c/p\\u003e\\n \\u003cp\\u003e(0.92-2.41)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 56px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cem\\u003eAfrica\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003en=181\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e45.9%\\u003c/p\\u003e\\n \\u003cp\\u003e(38.8%-53.1%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e1.97\\u003c/p\\u003e\\n \\u003cp\\u003e(1.53-2.41)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e3.19\\u003c/p\\u003e\\n \\u003cp\\u003e(2.35-4.02)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eParental country of origin: 5-6-year-old group\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe mean dmft score in five and six year olds was 2.73 (95% CI 2.37\\u0026ndash;3.09), 1.67 (95% CI 0.67\\u0026ndash;2.66) and 1.62 (95% CI 1.14\\u0026ndash;2.10) in Africa, Asia and South-central America respectively, whereas in Spain it was 0.69 (95% CI 0.57\\u0026ndash;0.81) which was statistically lower (p\\u0026lt;0.001). The mean dmfs score in Spain was 0.98 (95% CI 0.75\\u0026ndash;1.21) statistically lower than in South-central America, Asia and Africa, which were 2.33 (95% CI 1.45\\u0026ndash;3.20), 2.80 (95% CI 0.86\\u0026ndash;4.74) and 4.29 (95% CI 3.54\\u0026ndash;5.03), respectively (Table 7).\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eTable 7.\\u003c/strong\\u003e Caries indicators in primary dentition of 5\\u0026ndash;6-year-old children according to parents\\u0026rsquo; country of origin (mean or percentage, 95% CI).\\u003c/p\\u003e\\n\\u003ctable border=\\\"1\\\" cellspacing=\\\"0\\\" cellpadding=\\\"0\\\" width=\\\"624\\\" class=\\\"fr-table-selection-hover\\\"\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd colspan=\\\"2\\\" style=\\\"width: 142px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003e5\\u0026ndash;6-year-old\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cem\\u003en=1112\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"2\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003ePrevalence of caries in primary dentition\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"2\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003edmft\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"2\\\" style=\\\"width: 161px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003edmfs\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd rowspan=\\\"3\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003eParental country of origin\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 56px;\\\"\\u003e\\n \\u003cp\\u003eSpain\\u003c/p\\u003e\\n \\u003cp\\u003en=739\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e24.1%\\u003c/p\\u003e\\n \\u003cp\\u003e(21.1%-27.3%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd rowspan=\\\"3\\\" style=\\\"width: 76px;\\\"\\u003e\\n \\u003cp\\u003eChi-square\\u003c/p\\u003e\\n \\u003cp\\u003etest p\\u0026lt;0.001*\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e0.69\\u003c/p\\u003e\\n \\u003cp\\u003e(0.57-0.81)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd rowspan=\\\"3\\\" style=\\\"width: 76px;\\\"\\u003e\\n \\u003cp\\u003eANOVA p\\u0026lt;0.001*\\u003c/p\\u003e\\n \\u003cp\\u003ePost hoc Bonferroni\\u003c/p\\u003e\\n \\u003cp\\u003eGroup 1 vs 2 and vs 3\\u003c/p\\u003e\\n \\u003cp\\u003eand Group 2 vs 3\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e0.98\\u003c/p\\u003e\\n \\u003cp\\u003e(0.75-1.21)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd rowspan=\\\"3\\\" style=\\\"width: 76px;\\\"\\u003e\\n \\u003cp\\u003eANOVA p\\u0026lt;0.001*\\u003c/p\\u003e\\n \\u003cp\\u003ePost hoc Bonferroni\\u003c/p\\u003e\\n \\u003cp\\u003eGroup 1 vs 2 and vs 3\\u003c/p\\u003e\\n \\u003cp\\u003eand Group 2 vs 3\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 56px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cem\\u003eSouth-central America\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003en=132\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e41.7%\\u003c/p\\u003e\\n \\u003cp\\u003e(33.6%-50.2%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e1.62\\u003c/p\\u003e\\n \\u003cp\\u003e(1.14-2.10)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e2.33\\u003c/p\\u003e\\n \\u003cp\\u003e(1.45-3.20)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 56px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cem\\u003eAfrica\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003en=241\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e66.4%\\u003c/p\\u003e\\n \\u003cp\\u003e(60.2%-72.1%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e2.73\\u003c/p\\u003e\\n \\u003cp\\u003e(2.37-3.09)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e4.29\\u003c/p\\u003e\\n \\u003cp\\u003e(3.54-5.03)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eThe present study analysed the association between socioeconomic status and dental caries in primary dentition amongst preschool children in southeastern Spain. Our findings revealed a clear socioeconomic gradient in caries experience, with significantly higher prevalence and severity amongst children from lower socioeconomic groups. These results reinforce the well-established relationship between social determinants and oral health inequalities in early childhood and highlight the importance of addressing socioeconomic disparities in preventive oral health policies.\\u003c/p\\u003e\\n\\u003cp\\u003eAt the global level, dental caries remains the most prevalent oral disease and one of the most common health conditions worldwide. According to the Global Burden of Disease 2021 study [4], untreated dental caries in permanent teeth affected approximately 2.24 billion individuals globally, while untreated caries in deciduous teeth affected more than 560 million children worldwide, making dental caries the most prevalent oral condition globally [1]. These findings confirm that despite advances in preventive dentistry and oral health promotion strategies, the global burden of dental caries remains substantial.\\u003c/p\\u003e\\n\\u003cp\\u003eSeveral indices are available for assessing dental caries, and their findings depend on factors such as diagnostic criteria, measurement validity and detection thresholds [28]. The choice of index also affects the logistical complexity, cost and time required for epidemiological examinations [29]. These methodological aspects may therefore influence the results of epidemiological surveys, which are essential tools for public health authorities when planning oral health programmes.\\u003c/p\\u003e\\n\\u003cp\\u003eMost epidemiological studies conducted up to the beginning of the 21st century followed the recommendations of the World Health Organization (WHO) and reported caries prevalence using mean dmft values. However, mean-based measures do not adequately capture the typically skewed distribution of caries experience within populations. To better represent this heterogeneity, the Significant Caries Index (SiC Index) was introduced in 2000 [30]. This index complements traditional measures and enables identification of the subgroup of the population with the highest disease burden [31].\\u003c/p\\u003e\\n\\u003cp\\u003eIncreasing attention has also been given, in recent decades, to the detection of early enamel lesions within the framework of minimally invasive dentistry. As a result, the International Caries Detection and Assessment System (ICDAS) was developed, enabling the identification of both non-cavitated and cavitated lesions [32]. The detection of early lesions provides a more accurate measurement of disease activity and improves preventive monitoring strategies. For this reason, the present study incorporated multiple caries indicators, including ICDAS-based measures together with conventional indices such as dmft and dmfs, in order to provide a more comprehensive assessment of dental caries status in the study population.\\u003c/p\\u003e\\n\\u003cp\\u003eDental caries remains highly prevalent in early childhood. A recent meta-analysis estimated a prevalence of approximately 48% amongst children under six years of age [33]. In Spain, the most recent National Oral Health survey, conducted in 2020, reported a prevalence of 28.3% amongst 5\\u0026ndash;6-year-olds [5]. Regional studies have reported somewhat higher figures; for example, in the Valencian region the prevalence reached 37.4% in preschool children [27]. In the present study, the prevalence was 35.4% in 5\\u0026ndash;6-year-olds and 22% in 3\\u0026ndash;4-year-olds, indicating levels comparable with those observed in neighbouring Spanish regions.\\u003c/p\\u003e\\n\\u003cp\\u003eBy contrast, the Global Burden of Disease (GBD) 2021 study estimated the global age-standardised prevalence of untreated caries in deciduous teeth at approximately 7.5% [4], with a stable global burden of disease over the period 1990\\u0026ndash;2021, which is substantially lower than the prevalence observed in the present study. This discrepancy most likely reflects methodological differences between model-based global estimates and epidemiological survey data. The GBD estimates are derived from statistical modelling based on heterogeneous epidemiological data sources, whereas the present study involved direct clinical examination and diagnostic criteria capable of identifying both cavitated and early lesions. Consequently, the higher prevalence observed in this study may represent a more accurate reflection of the true burden of dental caries in young children.\\u003c/p\\u003e\\n\\u003cp\\u003eThe findings of this study also demonstrated a clear and consistent social gradient in caries experience in primary dentition across both age cohorts. The mean dmft and dmfs values in 3\\u0026ndash;4-year-olds increased progressively from upper to lower social classes, indicating a substantially higher burden of disease amongst socioeconomically disadvantaged children. This gradient was even more pronounced in the 5\\u0026ndash;6-year-old cohort, reflecting both cumulative disease experience and widening social inequalities with age. Moreover, the statistically significant ANOVA and linear trend tests confirmed a strong dose\\u0026ndash;response relationship between socioeconomic disadvantage and increasing caries severity.\\u003c/p\\u003e\\n\\u003cp\\u003eThese inequalities have been widely documented in the international literature, suggesting that the socioeconomic environment in which children grow up plays a key role in shaping oral health outcomes. Socioeconomic disadvantages have been associated with dietary patterns characterised by higher consumption of free sugars, limited access to healthy foods and reduced exposure to preventive dental care, all of which increase the risk of early childhood caries [10, 34, 35].\\u003c/p\\u003e\\n\\u003cp\\u003eAge-related differences were also evident. Across all social classes, older children exhibited higher dmft and dmfs values compared with younger children, suggesting progressive accumulation of disease over time in the absence of adequate preventive or restorative care. Moreover, children from lower social classes showed disproportionately greater increases in caries indices with age, highlighting persistent exposure to risk factors and possible barriers to early intervention.\\u003c/p\\u003e\\n\\u003cp\\u003eThe prevalence data further reinforce these inequalities. Amongst\\u0026nbsp;3\\u0026ndash;4-year-olds, caries prevalence ranged from 8.6% in upper social classes to 33.0% in lower social classes, whereas in 5\\u0026ndash;6-year-olds prevalence increased sharply from 18.0% to 46.5%, respectively. This marked increase illustrates the cumulative nature of dental caries and suggests that social inequalities intensify as children grow older.\\u003c/p\\u003e\\n\\u003cp\\u003eNo statistically significant differences were observed between boys and girls in either age group. This is consistent with many epidemiological studies in preschool populations, in which gender differences in caries prevalence tend to be minimal [36]. In early childhood, behavioural determinants of oral health such as diet, oral hygiene practices and access to dental services are largely determined by the family environment rather than gender-specific behaviours.\\u003c/p\\u003e\\n\\u003cp\\u003eIn contrast, the country of origin of parents showed a significant association with caries prevalence, with higher levels of disease observed amongst children whose parents were born in Africa, Asia or Latin America as opposed to Spain. These findings highlight the influence of migration-related socioeconomic and cultural factors on oral health. Immigrant families may face barriers such as language difficulties, lower socioeconomic status and reduced access to preventive dental services [8-10].\\u003c/p\\u003e\\n\\u003cp\\u003eThe persistence of significant differences, after stratification by age, highlights parental country of origin as an important determinant of early childhood caries and likely reflects a complex interplay of socioeconomic conditions, cultural practices, dietary habits, oral health literacy and barriers to accessing dental services. Furthermore, previous studies have emphasised the influence of parental education and knowledge of oral health practices on children\\u0026rsquo;s dental outcomes\\u0026nbsp;[9, 37, 38], although some authors suggest that the cumulative effect of multiple social disadvantages may outweigh the influence of any single determinant [38].\\u003c/p\\u003e\\n\\u003cp\\u003eFrom a public health perspective, these findings reinforce the concept that dental caries should not be viewed solely as a biological disease but rather as a condition which is strongly influenced by social and structural determinants. This perspective aligns with the WHO Global Strategy and Action Plan on Oral Health 2023\\u0026ndash;2030, which emphasises the need to reduce oral health inequalities and strengthen preventive strategies [13].\\u003c/p\\u003e\\n\\u003cp\\u003eThis study acknowledges the following limitations that should be taken into account. First, its cross-sectional design does not allow causal relationships to be established between socioeconomic factors and dental caries. Second, socioeconomic indicators were based on proxy measures that may not fully capture the complexity of social disadvantage. In addition, certain sections of the questionnaire may have been affected by recall bias, potentially influenced by social desirability bias. Although conducting face-to-face interviews with parents or legal guardians might have reduced this bias, such an approach would have required substantially more time and human resources than were available for this study. Nevertheless, the use of calibrated examiners, standardised diagnostic criteria and a population-based sample strengthen the reliability of the findings.\\u003c/p\\u003e\"},{\"header\":\"Conclusion\",\"content\":\"\\u003cp\\u003eIn conclusion, this study confirms that socioeconomic inequalities remain a key determinant of dental caries in primary dentition amongst preschool children in the Region of Murcia. The study also observed a clear social gradient, with children from lower socioeconomic groups presenting significantly higher caries prevalence and severity. In addition, children whose parents originated from certain migrant populations, Africa, Asia and South-central America, showed substantially higher levels of caries compared with children whose parents were born in Spain.\\u003c/p\\u003e\\n\\u003cp\\u003eThese findings highlight the importance of addressing the social determinants of oral health from early childhood and the consequent need for appropriate public health strategies. Such strategies should prioritise preventive interventions targeting socially disadvantaged and migrant populations to reduce inequalities in early childhood caries and improve oral health outcomes in vulnerable groups.\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003eEthics approval and consent to participate\\u003c/p\\u003e\\n\\u003cp\\u003eThe survey protocol was approved by the Human Research Ethics Committee of the University of Murcia (Spain) in December 2024 (approval number: M10/2024/419).\\u003c/p\\u003e\\n\\u003cp\\u003eConsent for publication\\u003c/p\\u003e\\n\\u003cp\\u003eNot applicable\\u003c/p\\u003e\\n\\u003cp\\u003eAvailability of data and materials\\u003c/p\\u003e\\n\\u003cp\\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\\u003c/p\\u003e\\n\\u003cp\\u003eCompeting interests\\u003c/p\\u003e\\n\\u003cp\\u003eThe authors declare that they have no competing interests\\u003c/p\\u003e\\n\\u003cp\\u003eFunding\\u003c/p\\u003e\\n\\u003cp\\u003e\\u0026quot;This work has been supported by the \\u003cstrong\\u003eFundaci\\u0026oacute;n S\\u0026eacute;neca\\u003c/strong\\u003e, Science and Technology Agency of the Region of Murcia (grant code: 22648/PI/24).\\u0026quot;\\u003c/p\\u003e\\n\\u003cp\\u003eAuthors\\u0026apos; contributions\\u003c/p\\u003e\\n\\u003cp\\u003eFollowing the Contributor Role Taxonomy (CRediT), the authors\\u0026rsquo; contributins are: SBG-M, Investigation, Formal Analysis and Writing-original draft; JEI-C, Formal Analysis, and Writing-review \\u0026amp; editing; AJO-R, M, Methodology and Writing-review \\u0026amp; editing; JMM-C, Formal Analysis, and Writing-review \\u0026amp; editing; AP-S, Conceptualization and Writing-review \\u0026amp; editing; CS-M, Investigation and Writing-review \\u0026amp; editing; AV, Methodology and Writing-review \\u0026amp; editing; YM-B, Conceptualization, Funding acquisition, Methodology and Writing-review \\u0026amp; editing.\\u0026nbsp;\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\n\\u003cli\\u003ePitts NB, Zero DT, Marsh PD, Ekstrand K, Weintraub JA, Ramos-Gomez F, et al: Dental caries. Nat Rev Dis Primers 2017, 3:17030.\\u003c/li\\u003e\\n\\u003cli\\u003eLagerweij MD, van-Loveren C: Declining Caries Trends: Are We Satisfied? Curr Oral Health Rep 2015, 2(4):212\\u0026ndash;217.\\u003c/li\\u003e\\n\\u003cli\\u003eRamos-Gomez F, Kinsler J, Askaryar H: Understanding oral health disparities in children as a global public health issue: how dental health professionals can make a difference. J Public Health Policy 2020, 41(2):114\\u0026ndash;124.\\u003c/li\\u003e\\n\\u003cli\\u003eGBD 2021 Oral Disorders Collaborators: Trends in the global, regional, and national burden of oral conditions from 1990 to 2021: a systematic analysis for the Global Burden of Disease Study 2021. Lancet 2025, 405(10482):897\\u0026ndash;910.\\u003c/li\\u003e\\n\\u003cli\\u003eBravo-P\\u0026eacute;rez M, Almerich-Silla JM, Canorea-D\\u0026iacute;az E, Casals-Peidr\\u0026oacute; E, Cort\\u0026eacute;s-Martinicorena FJ, Exp\\u0026oacute;sito-Delgado AJ, et al: Encuesta de Salud oral en Espa\\u0026ntilde;a 2020. RCOE 2020, 25(4):12\\u0026ndash;67.\\u003c/li\\u003e\\n\\u003cli\\u003eCampus G, Cocco F, Strohmenger L, Wolf TG, Balian A, Arghittu A, et al: Inequalities in caries among pre-school Italian children with different background. BMC Pediatr 2022, 22(1):443\\u0026ndash;4.\\u003c/li\\u003e\\n\\u003cli\\u003eTheristopoulos A, Agouropoulos A, Seremidi K, Gizani S, Papaioannou W: The effect of socio-economic status on children\\u0026apos;s dental health. J Clin Pediatr Dent 2024, 48(4):52\\u0026ndash;60.\\u003c/li\\u003e\\n\\u003cli\\u003eDu S, Cheng M, Cui Z, Wang X, Feng X, Tai B, et al: Decomposing Socioeconomic Inequality in Early Childhood Caries Among 3 to 5-Year-Old Children in China. Int Dent J 2024, 74(5):968\\u0026ndash;977.\\u003c/li\\u003e\\n\\u003cli\\u003eEllakany P, Madi M, Fouda SM, Ibrahim M, AlHumaid J: The Effect of Parental Education and Socioeconomic Status on Dental Caries among Saudi Children. Int J Environ Res Public Health 2021, 18(22):11862. doi: 10.3390/ijerph182211862.\\u003c/li\\u003e\\n\\u003cli\\u003eThakur S, Sharma R, Singhal P, Chauhan D: Prevalence and determinants of early childhood caries among preschool children in district Shimla, North India: a cross -sectional study. BMC Oral Health 2025, 25(1):168\\u0026ndash;2.\\u003c/li\\u003e\\n\\u003cli\\u003eMoin M, Maqsood A, Haider MM, Asghar H, Rizvi KF, Shqaidef A, et al: The Association of Socioeconomic and Lifestyle Factors with the Oral Health Status in School-Age Children from Pakistan: A Cross-Sectional Study. Healthcare (Basel) 2023, 11(5):756. doi: 10.3390/healthcare11050756.\\u003c/li\\u003e\\n\\u003cli\\u003eBraveman PA, Cubbin C, Egerter S, Chideya S, Marchi KS, Metzler M, et al: Socioeconomic status in health research: one size does not fit all. JAMA 2005, 294(22):2879\\u0026ndash;2888.\\u003c/li\\u003e\\n\\u003cli\\u003eWorld Health Organization: \\u003cem\\u003eGlobal strategy and action plan on oral health 2023-2030: \\u003c/em\\u003eGeneva: World Health Organization; 2024.\\u003c/li\\u003e\\n\\u003cli\\u003eGimeno-de-Sande A, Sanchez-Fernandez Murias, Vińes-Rueda JJ, Gomez-Pomar F, Marińo-Aguiar F: Epidemiologic study of dental caries and oral pathology in Spain. Revista de sanidad e higiene publica 1971, 45(4):361\\u0026ndash;433.\\u003c/li\\u003e\\n\\u003cli\\u003eLlodra-Calvo JC, Bravo-P\\u0026eacute;rez M, Cort\\u0026eacute;s-Martinicorena FJ: Encuesta de Salud Oral en Espa\\u0026ntilde;a (2000). RCOE : revista del Ilustre Consejo General de Colegios de Odontologos y Estomat\\u0026oacute;logos de Espa\\u0026ntilde;a 2002, 7(esp):19\\u0026ndash;63.\\u003c/li\\u003e\\n\\u003cli\\u003eBravo-P\\u0026eacute;rez M, Casals-Peidr\\u0026oacute; E, Cort\\u0026eacute;s-Martinicorena FJ, Llodra-Calvo JC, \\u0026Aacute;lvarez-Arenas Pardina I, Hermo-Se\\u0026ntilde;ariz P, et al: Encuesta de Salud Oral en Espa\\u0026ntilde;a 2005. RCOE : revista del Ilustre Consejo General de Colegios de Odontologos y Estomat\\u0026oacute;logos de Espa\\u0026ntilde;a 2006, 11(4):409\\u0026ndash;456.\\u003c/li\\u003e\\n\\u003cli\\u003eBravo-P\\u0026eacute;rez M, Llodra-Calvo JC, Cort\\u0026eacute;s-Martinicorena FJ, Casals-Peidr\\u0026oacute; E: Encuesta de Salud Oral de Preescolares en Espa\\u0026ntilde;a 2007. RCOE : revista del Ilustre Consejo General de Colegios de Odontologos y Estomat\\u0026oacute;logos de Espa\\u0026ntilde;a 2007, 12(3):143\\u0026ndash;168.\\u003c/li\\u003e\\n\\u003cli\\u003eLlodra-Calvo JC: Encuesta de Salud Oral en Espa\\u0026ntilde;a 2010. 2012, 17(1):13\\u0026ndash;41.\\u003c/li\\u003e\\n\\u003cli\\u003eBravo-P\\u0026eacute;rez M, Almerich-Silla JM, Ausina-M\\u0026aacute;rquez V, Avil\\u0026eacute;s-Guti\\u0026eacute;rrez P, Blanco-Gonz\\u0026aacute;lez JM, Canorea-D\\u0026iacute;az E, et al: Encuesta de Salud Oral en Espa\\u0026ntilde;a 2015. 2016, :8\\u0026ndash;48.\\u003c/li\\u003e\\n\\u003cli\\u003eNavarro-Alonso JA: Encuesta de salud bucodental en escolares de la Regi\\u0026oacute;n de Murcia. In Murcia: Consejer\\u0026iacute;a de Sanidad.; 1990:\\u003c/li\\u003e\\n\\u003cli\\u003eNavarro-Alonso JA: II Encuesta de salud bucodental en escolares de la Regi\\u0026oacute;n de Murcia. In Murcia: Consejer\\u0026iacute;a de Sanidad.; 1997:\\u003c/li\\u003e\\n\\u003cli\\u003eVandenbroucke JP, von-Elm E, Altman DG, G\\u0026oslash;tzsche PC, Mulrow CD, Pocock SJ, et al: Strengthening the Reporting of Observational Studies in Epidemiology (STROBE): explanation and elaboration. PLoS Med 2007, 4(10):e297.\\u003c/li\\u003e\\n\\u003cli\\u003eShrestha B, Dunn L: The Declaration of Helsinki on Medical Research involving Human Subjects: A Review of Seventh Revision. J Nepal Health Res Counc 2020, 17(4):548\\u0026ndash;552.\\u003c/li\\u003e\\n\\u003cli\\u003eDomingo-Salvany A, Marcos-Alonso J: Proposal of an indicator of \\u0026quot;social class\\u0026quot; based on the occupation. Gac Sanit 1989, 3(10):320\\u0026ndash;326.\\u003c/li\\u003e\\n\\u003cli\\u003eWorld Health Organization: \\u003cem\\u003eOral health surveys : basic methods: \\u003c/em\\u003e5th ed ed. Geneva: World Health Organization; 2013.\\u003c/li\\u003e\\n\\u003cli\\u003eDikmen B: ICDAS II criteria (International Caries Detection and Assessment System). J Istanb Univ Fac Dent 2015, 49(3):63\\u0026ndash;72.\\u003c/li\\u003e\\n\\u003cli\\u003eAlmerich-Torres T, Montiel-Company JM, Bellot-Arc\\u0026iacute;s C, Iranzo-Cort\\u0026eacute;s JE, Ortol\\u0026aacute;-Siscar JC, Almerich-Silla JM: Caries Prevalence Evolution and Risk Factors among Schoolchildren and Adolescents from Valencia (Spain): Trends 1998-2018. Int J Environ Res Public Health 2020, 17(18):6561. doi: 10.3390/ijerph17186561.\\u003c/li\\u003e\\n\\u003cli\\u003eFrencken JE, Giacaman RA, Leal SC: An assessment of three contemporary dental caries epidemiological instruments: a critical review. Br Dent J 2020, 228(1):25\\u0026ndash;31.\\u003c/li\\u003e\\n\\u003cli\\u003eDiamanti I, Berdouses ED, Kavvadia K, Arapostathis KN, Reppa C, Sifakaki M, et al: Caries prevalence and caries experience (ICDAS II criteria) of 5-, 12- and 15-year-old Greek children in relation to socio-demographic risk indicators. Trends at the national level in a period of a decade. Eur Arch Paediatr Dent 2021, 22(4):619\\u0026ndash;631.\\u003c/li\\u003e\\n\\u003cli\\u003eBratthall D: Introducing the Significant Caries Index together with a proposal for a new global oral health goal for 12-year-olds. Int Dent J 2000, 50(6):378\\u0026ndash;384.\\u003c/li\\u003e\\n\\u003cli\\u003eNishi M, Stjernsw\\u0026auml;rd J, Carlsson P, Bratthall D: Caries experience of some countries and areas expressed by the Significant Caries Index. Community Dent Oral Epidemiol 2002, 30(4):296\\u0026ndash;301.\\u003c/li\\u003e\\n\\u003cli\\u003ePitts NB, Ekstrand KR, ICDAS Foundation: International Caries Detection and Assessment System (ICDAS) and its International Caries Classification and Management System (ICCMS) - methods for staging of the caries process and enabling dentists to manage caries. Community Dent Oral Epidemiol 2013, 41(1):41.\\u003c/li\\u003e\\n\\u003cli\\u003eUribe SE, Innes N, Maldupa I: The global prevalence of early childhood caries: A systematic review with meta-analysis using the WHO diagnostic criteria. Int J Paediatr Dent 2021, 31(6):817\\u0026ndash;830.\\u003c/li\\u003e\\n\\u003cli\\u003eSuresh A, Srinivasan D, Ar SE, Mahadevan S, Babu HSS: Association of Early Childhood Caries with Body Mass Index, Dietary Habits, and Socioeconomic Status among Preschool Children of Kelambakkam. Int J Clin Pediatr Dent 2023, 16(4):565\\u0026ndash;571.\\u003c/li\\u003e\\n\\u003cli\\u003ePeres MA, Macpherson LMD, Weyant RJ, Daly B, Venturelli R, Mathur MR, et al: Oral diseases: a global public health challenge. Lancet 2019, 394(10194):249\\u0026ndash;260.\\u003c/li\\u003e\\n\\u003cli\\u003eFerro R, Besostri A, Olivieri A, Benacchio L: Early Childhood Caries in a Preschool-based Sample in Northeast Italy: Socioeconomic Status and Behavioral Risk Factors. Int J Clin Pediatr Dent 2022, 15(6):717\\u0026ndash;723.\\u003c/li\\u003e\\n\\u003cli\\u003eTiwari T, Sukhabogi JR, Doshi D, Deshpande V, Lunavath P: Intersection of Gender, Religion, and Socio-economic Position in Relation to Untreated Oral Conditions - A Comparative Study. Indian J Dent Res 2025, 36(2):180\\u0026ndash;186.\\u003c/li\\u003e\\n\\u003cli\\u003eLiu S, Chongsuvivatwong V, Zhang S, Thearmontree A: Pathway of Effects of Socioeconomic Status on Rural Left-behind Children to Receive Oral Health Services: A Structural Equation Modeling. Int J Environ Res Public Health 2023, 20(2):1068.\\u003c/li\\u003e\\n\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-oral-health\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"ohea\",\"sideBox\":\"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/ohea/default.aspx\",\"title\":\"BMC Oral Health\",\"twitterHandle\":\"BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true},\"keywords\":\"dental caries, primary dentition, socioeconomic factors, parental country of origin, health inequalities, preschool children, epidemiology\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-9232360/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-9232360/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003ch2\\u003eBackground\\u003c/h2\\u003e \\u003cp\\u003eChildhood dental caries remains the most prevalent chronic disease worldwide and represents a major public health concern. Although reductions in caries prevalence have been reported in several high-income countries, significant socioeconomic inequalities persist. Understanding the role of social determinants in early childhood is essential for designing effective preventive strategies. This study investigated the association between socioeconomic status, parental country of origin and dental caries in the primary dentition of children under six years of age.\\u003c/p\\u003e\\u003ch2\\u003eMethods\\u003c/h2\\u003e \\u003cp\\u003eA cross-sectional epidemiological survey was conducted amongst 2,072 3\\u0026ndash;6-year-olds from 33 schools in the Region of Murcia between January and June 2025. Dental examinations were performed by calibrated dentists using WHO Oral Health Survey criteria and the International Caries Detection and Assessment System (ICDAS II). Caries indicators included prevalence, dmft, dmfs and the Significant Caries Index (SiC). Socioeconomic status was assessed using parental education and occupation. Associations between caries indicators and sociodemographic variables were analysed using chi-square tests, ANOVA and linear trend analyses.\\u003c/p\\u003e\\u003ch2\\u003eResults\\u003c/h2\\u003e \\u003cp\\u003eCaries prevalence was 22.0% in children aged 3\\u0026ndash;4 years and 35.4% in children aged 5\\u0026ndash;6 years. Mean dmft values were 0.77 and 1.24, respectively. A clear socioeconomic gradient was observed: children from lower socioeconomic groups showed significantly higher dmft, dmfs and caries prevalence than those from middle- and upper-class groups (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001). Children whose parents originated from Africa, Asia and South-central America had significantly higher caries prevalence and severity than those whose parents were born in Spain (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05). No statistically significant differences were observed between sexes (p\\u0026thinsp;\\u0026gt;\\u0026thinsp;0.05).\\u003c/p\\u003e\\u003ch2\\u003eConclusions\\u003c/h2\\u003e \\u003cp\\u003eDental caries in early childhood in the Region of Murcia shows a clear social gradient associated with socioeconomic status and parental country of origin. These findings highlight the importance of social determinants on oral health and the implementation of targeted preventive strategies to reduce inequalities in early childhood caries.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Socioeconomic status, parental country of origin and dental caries in primary dentition amongst preschool children in southeastern Spain: a cross-sectional study\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2026-05-07 12:41:31\",\"doi\":\"10.21203/rs.3.rs-9232360/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"reviewersInvited\",\"content\":\"\",\"date\":\"2026-04-29T17:33:13+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvited\",\"content\":\"\",\"date\":\"2026-04-17T14:34:19+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2026-03-27T05:21:44+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"checksComplete\",\"content\":\"\",\"date\":\"2026-03-27T05:21:04+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"submitted\",\"content\":\"BMC Oral Health\",\"date\":\"2026-03-26T09:35:29+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-oral-health\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"ohea\",\"sideBox\":\"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/ohea/default.aspx\",\"title\":\"BMC Oral Health\",\"twitterHandle\":\"BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"ffc038b0-58e6-4c88-997e-c690abfe8d83\",\"owner\":[],\"postedDate\":\"May 7th, 2026\",\"published\":true,\"recentEditorialEvents\":[{\"type\":\"reviewersInvited\",\"content\":\"6\",\"date\":\"2026-04-29T17:33:13+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"under-review\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2026-05-07T12:41:31+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2026-05-07 12:41:31\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-9232360\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-9232360\",\"identity\":\"rs-9232360\",\"version\":[\"v1\"]},\"buildId\":\"XKTyCvWXoU3ODBz1xrDgd\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}