The Status and Associated Factors  of Early Childhood Caries among 3- to 5-year-old Children in Guangdong, Southern  China: A Provincial Cross-sectional Survey

The Status and Associated Factors of Early Childhood Caries among 3- to 5-year-old Children in Guangdong, Southern China: A Provincial Cross-sectional Survey | 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 Help Center Sign In Submit a Preprint Cite Share Download PDF Research article The Status and Associated Factors of Early Childhood Caries among 3- to 5-year-old Children in Guangdong, Southern China: A Provincial Cross-sectional Survey Jianbo Li, Weihua Fan, Yueshan Zhou, Linmei Wu, Wei Liu, Shaohong Huang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-33731/v3 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 25 Sep, 2020 Read the published version in BMC Oral Health → Version 3 posted 2 You are reading this latest preprint version Show more versions Abstract Background: Dental caries of deciduous teeth (Early Childhood Caries, ECC) has become a crucial oral health problem over the decades in China. The aim of this study was to examine the prevalence and severity of ECC among preschool children from Guangdong Province, Southern China. In addition, to assess the association of ECC with reported oral health-related behaviors. Methods: A cross-sectional survey of 2592 participants was carried out in Guangdong Province by means of an equal-sized, stratified, multistage random sampling method during December 2015 and April 2016. The participants were divided into three groups according to their ages (3-, 4-, and 5-year-olds). According to the standard for clinical dentition examination of the WHO 2013 criteria, the presence of ECC was determined by the dmft (decayed-missing-filled tooth) index using a CPI (Community Periodontal Index) probe. A questionnaire about caries-related factors was completed by each of the participants’ parents or grandparents through a face-to-face and one-on-one interview. Then, t -test, Chi 2 tests, One-Way ANOVA served for statistical analysis, and logistic regression analysis as well as covariance analysis were executed to identify potential associated factors for ECC. Results: The prevalence (% dmft >0) of ECC was 68.3 (95% CI: 66.5-70.1), the mean dmft was 4.36 (95% CI: 4.17-4.55), and the filled rate was 1.2%. In multivariable modeling, associated factors for both prevalence and mean dmft were older age, rural areas, consumption of sweets before sleep, dental visit history, low household income, and low parental education level. Initiating toothbrushing after 3 years of age and being exclusively/ predominantly breastfed indicated only the prevalence; being female and frequently consuming sweetened milk/powdered milk indicated only the mean dmft. Conclusions: Preschool children in Guangdong Province, especially children from rural areas, experienced a significant amount of ECC. Associated factors for ECC included demographics, oral health measures, dietary factors, and socioeconomic factors. More attention should be given to prevention of ECC from early life. The construction of social support for oral health should be strengthened. Oral health education and promotion, especially of rural areas, should be intensified to reduce the inequality between urban and rural areas. Dentistry Head & Neck Surgery Cross-sectional survey Early childhood caries Oral epidemiology Preschool children Associated factors Figures Figure 1 Figure 2 Background The term “early childhood caries” (ECC) is used to describe “any dental caries of deciduous teeth that occur in children ≤71 months, including one or more lesions (with or without formation of cavities), or leading to missing teeth, or leading to fillings on the tooth surface” [1]. ECC had impacts on eating patterns, permanent dentition development and the general health status of children [2]. ECC is a complex multifactorial disease and is impacted by numerous factors, such as dietary factors, oral health behaviors, socioeconomic factors and biological factors [3]. In the past 30 years, two provincial oral health surveys were executed in Guangdong. The survey in 1995 showed that the prevalence of ECC was 76.8% (mean dmft 4.81) among 5-year-old children, and the survey in 2005 showed that the prevalence was 67.8% (mean dmft 4.10) [4]. A declining but still strong trend was shown. ECC is a crucial oral public health problem in Guangdong. Moreover, ECC affects a considerable proportion of preschool children globally [5]. A goal of a 50% caries-free rate among 5-year-old children for the year 2020 was set by the WHO in 2003 [6]. Accordingly, appropriate techniques for the prevention of ECC, such as pit and fissure sealing and topical fluoridation, have been vigorously promoted in Guangdong over the past 10 years to reduce the ECC. Moreover, with the marked increase in the development of economy and improvement of people's living standard in Guangdong during the past 15 years, the factors that impact ECC may have changed [7]. As the economically leading province since 1989, Guangdong has shown a marked increase in development of economy and improvement in people's living standards, especially during the past ten years [7]. The rise of the per capita GDP (¥24647 to ¥67503), the per capita disposable income (¥9730.2 to ¥24058.8) and the per capita consumption level (¥9799 to ¥26365) increased significantly from 2005 to 2015 [8]. However, the prevalence of caries of preschool children in Guangdong was among the top ten in 31 provinces of mainland China [9] and was inconsistent with the economic development. Is the caries status of preschool children in Guangdong closed to the goal of a 50% caries-free rate among 5-year-old children? It’s unknown, and it’s unclear how effective the preventive measures are. Another provincial survey of ECC in Guangdong is needed to determine the public health importance and the effect of the preventive measures. The aim of this study was to examine the prevalence and severity of ECC among preschool children from Guangdong Province, Southern China. In addition, to assess the association of ECC with reported oral health-related behaviors. Participants, Materials And Methods Selection of participants and sampling design This cross-sectional survey was conducted during December 2015 and April 2016. Preschool children residing in Guangdong were enrolled in this study. The participants were divided into three groups according to their ages (3-, 4-, and 5-year-olds). The ratio of males to females in each group was 1:1. Half of the participants were derived from urban areas, while the other from rural areas. The sample size was calculated by the N=deff µp(1-p)/δ 2 formula. Considering the stratification of urban-rural and male-female, the sampling design efficiency ‘deff’ was set to 4.5, and the test level ‘α’ was set to 0.05, so µ was equal to 1.96 (here, 2.0 was used), the expected prevalence ‘p’ was set to 0.678 [4], and the allowable error ‘δ’ was set to 0.10p. The theoretical sample size in this designated study was at least 855 after original calculation.The actual sample size was adjusted to 864 for ease of further grouping and implementation. To recruit the participants, an equal-sized, stratified, multistage, random sampling approach (probability proportional to size, PPS) was used. First of all, four districts together with four counties from Guangdong Province were randomly chosen using a PPS method. Second, three kindergartens were selected from either one district or one county with the PPS method. Finally, 36 children in each age group from the chosen kindergartens were recruited with a quota sampling approach. Recruitment was stopped after reaching the study size. The inclusion criteria of the present study was applicable for both children who participated in the study and its legal guardians. Children must be in a designated range of age, have a willingness to cooperate with the investigators, and the ability to maintain good compliance. Legal guardian's inclusion criteria included the ability to understand the study as well as the questionnaire and willingness to sign the relevant informed consent letter. The exclusion criteria in our survey were: legal guardian's failure in understanding this survey; the presence of oral disease requiring medication or even emergency treatment in the children, or the presence of a major systematic disease, which has an impact on the data integrity and/or the safety of the participant. Ethics approval and consent to participate This study was approved by the Stomatological Ethics Committee of the Chinese Stomatological Association on July 9, 2014 (Approval No.: 2014-003). Written informed consents were obtained from the participants’ legal guardians before the survey. Clinical examination The presence of ECC was determined using the dmft index of the WHO 2013 criteria [10]. Three experienced dentists collected the data at kindergartens. The dentists were trained and calibrated using clinical intraoral photographs before the formal examination. And the training of the investigators were conducted with a group of samples (15 volunteers) under the guidance of a standard examiner of the Fourth National Oral Health Survey. The kappa scores of the three examiners to the standard examiner were 0.80, 0.83, and 0.88 when the training finished. All of the participants were subjected to a general tooth examination using a CPI probe and a plane mirror with an LED light. ECC was diagnosed at cavitation level, which was confirmed by the ball-end CPI probe. The teeth were cleaned with a cotton swab before the examination. The inter-examiner reproducibility was assessed by re-examination of approximately 5% of the participants. Questionnaire Additionally, at a face-to-face and one-on-one interview by trained interviewers, each of the participants’ parents or grandparents completed a questionnaire, which included data regarding caries-related oral hygiene behaviors, dietary behaviors, socioeconomic factors. The questionnaire was from the Fourth National Oral Health Survey, which was designed based on previous studies with purpose of identifying factors related to ECC and was proved to be with appropriate reliability and validity before the study. An additional file shows this in more detail [see Supplementary file 1]. Before the interview, the kindergarten teachers had carried out publicity, education and liaison work; during the interview, we started from caring for the health of children, and patiently explained the work to dispel the doubts of the participants’ parents/grandparents, to handling potential bias. Statistical analysis SAS 9.4 software (SAS Institute, Inc., Carey, NC, USA) was applied. Differences between different groups were compared by t - test, chi 2 test, and One-way ANOVA. Estimates were significantly different if 95% CIs do not overlap. Multivariate logistic regression was used to assessed the percentages of participants with ECC relative to caries-related factors whose P-values were less than 0.2 in the bivariate analyses. Odds ratios (ORs) with 95% confidence intervals (CIs) were thus reported. Estimates were significantly different from the reference if its 95%CIs do not include 1. Furthermore, a covariance analysis model was constructed to explore the relationship between dmft and the relevant factors. Estimates were significantly different from the reference if its 95%CIs do not include 0. The analyses were weighted by age, gender and residence in order to avoid possible non-response bias. Each participant had a personal dmft score (0-20). Prevalence was evaluated by the percentage of participants with a personal dmft score (>0). The average of the total dmft score of all participants was described as the mean dmft. The filled rate was the ratio of the filled teeth to the total dmft (proportion of ft in dmft). Results The study sample comprised 2592 participants. The prevalence, mean dmft and filled rate of ECC among 3- to 5-year-old children in Guangdong Province are shown in Table 1. The prevalence and mean dmft in rural areas were higher than those in urban areas, and there was an increasing trend with age. The filled rate in rural areas was lower than that in urban areas. The results did not indicate obvious gender differences. During the examination, interexaminer kappa values of 0.98, 0.96, and 0.97 were obtained. The interexaminer reproducibility was completely reliable. The frequency distribution of dmft is shown in Figure 1. Among the children with ECC, children who had two teeth with ECC were the most common. With the increase in dmft scores, the number of children gradually decreased. A total of 84.8%, 79.8% and 72.3% of ECC cases were concentrated in one-third of 3-, 4- and 5-year-old children, and the mean dmft values for these children (significant caries index, SiC) were 7.71 (95% CI: 7.22-8.20), 10.40 (95% CI: 9.94-10.86) and 12.35 (95% CI: 11.96-12.74), respectively. The distribution of the tooth position of ECC is shown in Figure 2. The upper central incisors had the highest prevalence, followed by the mandibular molars and then the maxillary molars, while the mandibular incisors had the lowest prevalence. The results of the multivariate analysis are shown in Table 2. Associated factors for both prevalence and mean dmft were older age, rural areas, consumption of sweets before sleep, dental visit history, low household income, and low parental education level. Initiating toothbrushing after 3 years of age and being exclusively/ predominantly breastfed indicated only the prevalence, whereas being female and being frequently fed with sweetened milk/powdered milk indicated only the mean dmft. Discussion This survey reported high prevalence and severity of ECC among preschool children in Guangdong, Southern China, similar to the finding for East China [11] and higher than that for Southwest China [12], higher than the national average [13], and higher than that 10 years ago [4]. A multitude of factors are associated with the prevalence and severity. The findings of this survey inform target factors for collective actions to address this critical oral health problem. The most obvious limitation of this survey is the retrospective rather than prospective design, which might brought potential recall bias. Hence, we can’t confirm the causal relationship between the associated factors and the results. An additional limitation is that the dmft index is less accurate than the dmfs index, as a tooth has multiple tooth surfaces and ECC typically involves multiple tooth surfaces rather than one. Finally, enamel defects, oral bacteria and fluoride concentrations of drinking water that contribute to ECC were not evaluated. A systematic review showed that the presence of enamel defects and high levels of mutans streptococci were the strongest risk factors associated with ECC [14]. Prospective studies and studies including microbiological detection, enamel defect examination, and determination of the fluorine concentration in drinking water are indicated. A report showed that the oral health status of preschool children has significantly improved over the past 10 years in China [15]. However, compared with the provincial survey of Guangdong in 2005, the current results showed remarkable increases in the prevalence (67.9% to 78.4%) and mean dmft (4.13 to 5.69) of ECC among 5-year-old children in both urban and rural areas, especially in rural areas. This trend actually shows ECC rates becoming further away from the goal of a caries-free rate of 50% among 5-year-old children for the year 2020 by the WHO [6]. Higher sugar intake [16] but still inadequate oral healthcare [7], possibly leading to the increasing trend observed [17]. More attention should be given in Guangdong to children’s dental health for deciduous teeth. The frequency distribution of dmft showed that two teeth with ECC were the most common, and the position distribution showed that the upper central incisors were the prevailing teeth with ECC. The same finding was shown in the national survey [18]. ECC usually affects the smooth surface, followed by the pit and fissure, which is different from the caries of permanent dentition. Therefore, preventive measures against caries with smooth surfaces should be taken. If ECC of the upper central incisors were prevented, the prevalence might be reduced by 10%. Risk assessment is an important part of patient-centered, evidenced-based decision making in modern medical services [19]. A systematic review showed that ECC is related to demographic factors, oral hygiene behaviors, dietary behaviors, and socioeconomic factors [20]. The results of the multivariable model showed that associated factors for ECC matched the review. Dental caries is an irreversible process. As deciduous teeth continue to function and be challenged before replacement, the continuous and cumulative effects cause ECC to develop with time. This might explain why increased age was related to a higher risk and severity of ECC. Additionally, children who initiate toothbrushing at an older age have a higher risk of developing ECC. Therefore, ECC prevention should occur from an early age. No obvious gender differences in the prevalence of ECC were found for. No evidence showed that the composition of the saliva differs between boys and girls or that there are any differences in tooth structure between the genders [21]. However, the mean dmft was higher in female children. Further exploration is indicated. Generally, caries are recognized as more severe among people with low socioeconomic status [22, 23]. In this study, the prevalence and mean dmft of ECC in urban areas were lower than those in rural areas, while the opposite was true for the filled rate. Children who had a low parental education level and low household income had higher prevalence and severity of ECC. Rural oral medical service is usually characterized as having insufficient infrastructure, socioeconomic difficulties, artificial barriers such as distance and inconvenience of transport, and a high patients to oral health professionals ratio [15, 24]. Parental factors such as education and income are significant risk factors in the developing of ECC [25]. Therefore, children from rural areas should be given more attention in order to reduce ECC. A systematic review showed that ECC is related to frequent sweets consumption [26]. In particular, numerous studies have proven that sweets play a key role in the occurrence and development of ECC [27-29]. A diet rich in exogenous sugars is believed to be cariogenic to children [30]. In the present survey, the participants who consumed sweets before sleep were 1.35 times more likely to have ECC and had 0.77 higher dmft than those without this habit. Moreover, children who were sometimes/often fed with sweetened milk/powdered milk had higher dmft than those who were never/rarely fed with that kind of milk. This result suggests that both the timing and frequency of the consumption of sweets influenced ECC. What interested us was that the children who were exclusively/predominantly breastfed during the first half year of life had a higher risk of ECC. This finding agrees with the results of earlier studies reporting a significant relation between the duration of breastfeeding and ECC in young Chinese children [31, 32], similar to its neighboring province of Zhejiang [11]. Part of the reason might be that breast milk is more likely to cause caries than other types of milk [33]. Additionally, extended breastfeeding contributes to the colonization of Streptococcus mutans [34], which synergistically induces ECC. Breastfeeding is recommended by the WHO [35]; however, considering the relationship between breastfeeding and ECC, dental experts recommended weaning from the breast shortly after the child’s first birthday [36]. It is recommended that the first dental visit should be performed by 12 months to assess the risk of ECC and provide early intervention when needed [37]. Dental visit history is usually a protective factor for ECC in developed areas [38, 39]. However, in this survey, children who had dental visit histories had higher prevalence and dmft scores of ECC than those without dental visits. This difference may be due to the different patterns of visiting dentists. Children in developed areas often visit dentists for preventive examinations and take preventive measures. However, in China, dental treatment has been sought since these children had already experienced oral health problems, which is therapeutic rather than preventive. Visiting dentists only when a problem was perceived was a risk factor for ECC [40]. This finding agrees with the results of some other Chinese studies [32, 41, 42]. There were no significant relations between toothbrushing habits and ECC in this study. However, children who start brushing their teeth at an older age are at higher risk of developing ECC. Moreover, lack of toothbrushing was a risk factor for ECC [43], and irregular brushing at 18 months of age was a highly significant predictor of developing ECC [44]. Brushing less than twice a day or difficulties brushing teeth during the first year of preschool were significant determinants of ECC at the age of 5 years [45]. Therefore, professionals should give parents special attention and assist in improving and optimizing their toothbrushing behavior during children’s preschool years. The strengths of this survey include a representative sample which was ensured by an equal-sized, stratified, multistage random sampling approach, the use of a reliable index, and a statistical analysis with a weighted process which made the results be close to reality and permit us to generalize the findings to the population. Conclusion In conclusion, preschool children in Guangdong Province, especially children from rural areas, experienced a significant amount of ECC. Associated factors for ECC included demographics, oral health measures, dietary factors, and socioeconomic factors. More attention should be given to prevention of ECC from early life. The construction of social support for oral health should be strengthened. Oral health education and promotion, especially of rural areas, should be intensified to reduce the inequality between urban and rural areas. Abbreviations CI(s): Confidence Interval(s); CPI: Community Periodontal Index; dmfs: decayed, missing, filled deciduous tooth surface; dmft: decayed, missing, filled deciduous teeth; ECC: Early Childhood Caries; GDP: Gross Domestic Product; OR(s): Odds Ratio(s); PPS: Probability Proportional to Size; SiC: Significant Caries Index Declarations Ethics approval and consent to participate This study was approved by the Stomatological Ethics Committee of the Chinese Stomatological Association on July 9, 2014 (Approval No.: 2014-003). Written informed consents were obtained from parents or guardians for minors to participate the survey. Consent for publication Not applicable. Availability of data and materials The data sets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interest. Funding This work was part of “the Public Science and Technology Research Funds Project (2015)—the Fourth National Oral Health Survey (201502002)” and was supported by the Clinical Research Startup Program of Southern Medical University by High-level University Construction Funding of Guangdong Provincial Department of Education ( LC2017PY001, 2017KTSCX036). In this study, the section of study design and data collection was mainly funded by the Fourth National Oral Health Survey (201502002), the sections of statistical analysis, data interpretation and manuscript writing were mainly funded by the Clinical Research Startup Program of Southern Medical University (LC2017PY001, 2017KTSCX036). Authors' contributions SH and WF conceived and designed of the study, coordinated the project, checked the data analyses and revised the manuscript; JL trained and supervised the field workers and wrote the manuscript; YZ and LW contributed to the data input; WL conducted the analysis. All authors gave final approval of the final manuscript. Acknowledgments The authors would like to thank all of the children participants and their parents/grandparents, and all the staff who participated in the survey. References Drury TF, Horowitz AM, Ismail AI, et al. Diagnosing and reporting early childhood caries for research purposes. A report of a workshop sponsored by the National Institute of Dental and Craniofacial Research, the Health Resources and Services Administration, and the Health Care Financing Administration[J]. J Public Health Dent,1999,59(3):192-197. Schroth RJ, Harrison RL, Moffatt ME. 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Prevalence of severe early childhood caries and associated socioeconomic and behavioral factors in Xinjiang, China: a cross-sectional study[J]. BMC Oral Health,2017,17(1):144. Seow WK. Early Childhood Caries[J]. Pediatr Clin North Am,2018,65(5):941-954. Nishide R, Mizutani M, Tanimura S, et al. Homecare protective and risk factors for early childhood caries in Japan[J]. Environ Health Prev Med,2018,23(1):57. Boustedt K, Dahlgren J, Twetman S, et al. Tooth brushing habits and prevalence of early childhood caries: a prospective cohort study[J]. Eur Arch Paediatr Dent,2019. Tables Due to technical limitations, the tables are only available as a download in the supplementary files section. Supplementary Files Tables.pdf QuestionnaireinEnglishandinChinese.pdf Cite Share Download PDF Status: Published Journal Publication published 25 Sep, 2020 Read the published version in BMC Oral Health → Version 3 posted Submission checks completed at journal 15 Sep, 2020 Editorial decision: Accept 14 Sep, 2020 You are reading this latest preprint version Show more versions 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 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-33731","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research article","associatedPublications":[],"authors":[{"id":2363866,"identity":"baa4984b-a35d-4e38-ba67-bd2d8bb4090b","order_by":0,"name":"Jianbo Li","email":"","orcid":"https://orcid.org/0000-0002-9212-7310","institution":"Stomatological Hospital, Southern Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Jianbo","middleName":"","lastName":"Li","suffix":""},{"id":2363867,"identity":"6731690e-b3b8-4cac-8752-be8f4d8b2045","order_by":1,"name":"Weihua Fan","email":"","orcid":"","institution":"Stomatological Hospital, Southern Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Weihua","middleName":"","lastName":"Fan","suffix":""},{"id":2363868,"identity":"7304d6dd-2a3d-4c43-9198-ca1ba0801cc5","order_by":2,"name":"Yueshan Zhou","email":"","orcid":"","institution":"Stomatological Hospital, Southern Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yueshan","middleName":"","lastName":"Zhou","suffix":""},{"id":2363869,"identity":"104e0fd8-4004-4b10-9a02-fd8960846a13","order_by":3,"name":"Linmei Wu","email":"","orcid":"","institution":"Stomatological Hospital, Southern Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Linmei","middleName":"","lastName":"Wu","suffix":""},{"id":2363870,"identity":"fabc145d-f978-458d-a55c-0f823f1cbe13","order_by":4,"name":"Wei Liu","email":"","orcid":"","institution":"Guangzhou Center for Disease Control and Prevention","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Wei","middleName":"","lastName":"Liu","suffix":""},{"id":2363871,"identity":"0f6189b4-60a4-406d-80cd-343759c5d6d8","order_by":5,"name":"Shaohong Huang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAtUlEQVRIiWNgGAWjYBACAwYeBgbGBgkGBvYGkrXwHCZNC5AlkUykFnP+swcYfu6wyOOf+f7goxsMdnK6hBxoOSMvgbH3jESxxO1kZuMchmRjswOEHHaDx4CZsU0iseF2Mpt0DsOBxG0EtZw/A9Ey/+ZhYrUcyIFo2XCDmVgtN3IMDvYCtWw8k2xsnGNAjF/OnzF88LOtLnHe8YMPH+dU2MkR1AICSGoMiFA+CkbBKBgFo4AwAADfnD/zCsK/YQAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0002-9169-484X","institution":"Stomatological Hospital, Southern Medical University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Shaohong","middleName":"","lastName":"Huang","suffix":""}],"badges":[],"createdAt":"2020-06-05 14:53:02","currentVersionCode":3,"declarations":"","doi":"10.21203/rs.3.rs-33731/v3","doiUrl":"https://doi.org/10.21203/rs.3.rs-33731/v3","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12903-020-01253-w","type":"published","date":"2020-09-25T12:00:00+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":2419906,"identity":"a03e8de1-a98f-40f6-88bc-45f210e88a65","added_by":"auto","created_at":"2020-09-15 18:29:31","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":591802,"visible":true,"origin":"","legend":"The frequency distribution of dmft\nThe purple column illustrates the percentage of children (dmft) of 3-year-olds\nThe green column illustrates the percentage of children (dmft) of 4-year-olds\nThe brown column illustrates the percentage of children (dmft) of 5-year-olds","description":"","filename":"Fig1.png","url":"https://assets-eu.researchsquare.com/files/rs-33731/v3/Fig1.png"},{"id":2419907,"identity":"8b454ac1-4ac3-4cab-9a9e-b255f7b068ef","added_by":"auto","created_at":"2020-09-15 18:29:31","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":547002,"visible":true,"origin":"","legend":"The distribution of teeth with ECC by tooth position\nThe blue column illustrates the proportion of teeth with ECC among 3-year-olds\nThe orange column illustrates the proportion of teeth with ECC among 4-year-olds\nThe gray column illustrates the proportion of teeth with ECC among 5-year-olds","description":"","filename":"Fig2.png","url":"https://assets-eu.researchsquare.com/files/rs-33731/v3/Fig2.png"},{"id":13593606,"identity":"03a34bbd-8bfc-4de0-b686-b0cd804bd2af","added_by":"auto","created_at":"2021-09-17 05:16:47","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":752682,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-33731/v3/3e5aec92-bb11-4da4-9c0f-bca925e1ac3f.pdf"},{"id":2419909,"identity":"028c8f74-18e0-4ef8-8148-f5a81258f425","added_by":"auto","created_at":"2020-09-15 18:29:31","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":308384,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.pdf","url":"https://assets-eu.researchsquare.com/files/rs-33731/v3/Tables.pdf"},{"id":2419910,"identity":"80e3c584-33e9-48e9-8819-96e4c36c3bbe","added_by":"auto","created_at":"2020-09-15 18:29:31","extension":"pdf","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":547248,"visible":true,"origin":"","legend":"","description":"","filename":"QuestionnaireinEnglishandinChinese.pdf","url":"https://assets-eu.researchsquare.com/files/rs-33731/v3/QuestionnaireinEnglishandinChinese.pdf"}],"financialInterests":"","formattedTitle":"The Status and Associated Factors of Early Childhood Caries among 3- to 5-year-old Children in Guangdong, Southern China: A Provincial Cross-sectional Survey","fulltext":[{"header":"Background","content":"\u003cp\u003eThe term \u0026ldquo;early childhood caries\u0026rdquo; (ECC) is used to describe \u0026ldquo;any dental caries of deciduous teeth that occur in children \u0026le;71 months, including one or more lesions (with or without formation of cavities), or leading to missing teeth, or leading to fillings on the tooth surface\u0026rdquo; [1]. ECC had impacts on eating patterns, permanent dentition development and the general health status of children [2]. ECC is a complex multifactorial disease and is impacted by numerous factors, such as dietary factors, oral health behaviors, socioeconomic factors and biological factors [3].\u003c/p\u003e\n\u003cp\u003eIn the past 30 years, two provincial oral health surveys were executed in Guangdong. The survey in 1995 showed that the prevalence of ECC was 76.8% (mean dmft 4.81) among 5-year-old children, and the survey in 2005 showed that the prevalence was 67.8% (mean dmft 4.10) [4]. A declining but still strong trend was shown. ECC is a crucial oral public health problem in Guangdong. Moreover, ECC affects a considerable proportion of preschool children globally [5]. A goal of a 50% caries-free rate among 5-year-old children for the year 2020 was set by the WHO in 2003 [6]. Accordingly, appropriate techniques for the prevention of ECC, such as pit and fissure sealing and topical fluoridation, have been vigorously promoted in Guangdong over the past 10 years to reduce the ECC. Moreover, with the marked increase in the development of economy and improvement of people's living standard in Guangdong during the past 15 years, the factors that impact ECC may have changed [7]. As the economically leading province since 1989, Guangdong has shown a marked increase in development of economy and improvement in people's living standards, especially during the past ten years [7]. The rise of the per capita GDP (\u0026yen;24647 to \u0026yen;67503), the per capita disposable income (\u0026yen;9730.2 to \u0026yen;24058.8) and the per capita consumption level (\u0026yen;9799 to \u0026yen;26365) increased significantly from 2005 to 2015 [8]. However, the prevalence of caries of preschool children in Guangdong was among the top ten in 31 provinces of mainland China [9] and was inconsistent with the economic development. Is the caries status of preschool children in Guangdong closed to the goal of a 50% caries-free rate among 5-year-old children? It\u0026rsquo;s unknown, and it\u0026rsquo;s unclear how effective the preventive measures are. Another provincial survey of ECC in Guangdong is needed to determine the public health importance and the effect of the preventive measures.\u003c/p\u003e\n\u003cp\u003eThe aim of this study was to examine the prevalence and severity of ECC among preschool children from Guangdong Province, Southern China. In addition, to assess the association of ECC with reported oral health-related behaviors.\u003c/p\u003e"},{"header":"Participants, Materials And Methods","content":"\u003cp\u003e\u003cstrong\u003eSelection of participants and sampling design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis cross-sectional survey was conducted during December 2015 and April 2016. Preschool children residing in Guangdong were enrolled in this study. The participants were divided into three groups according to their ages (3-, 4-, and 5-year-olds). The ratio of males to females in each group was 1:1. Half of the participants were derived from urban areas, while the other from rural areas. The sample size was calculated by the N=deff \u0026micro;p(1-p)/\u0026delta;\u003csup\u003e2\u003c/sup\u003e formula. Considering the stratification of urban-rural and male-female, the sampling design efficiency \u0026lsquo;deff\u0026rsquo; was set to 4.5, and the test level \u0026lsquo;\u0026alpha;\u0026rsquo; was set to 0.05, so \u0026micro;\u0026nbsp;was equal to 1.96 (here, 2.0 was used),\u0026nbsp;the expected prevalence \u0026lsquo;p\u0026rsquo; was set to 0.678 [4], and the allowable error \u0026lsquo;\u0026delta;\u0026rsquo; was set to 0.10p. The theoretical sample size in this designated study was at least 855 after original calculation.The actual sample size was adjusted to 864 for ease of further grouping and implementation. To recruit the participants, an equal-sized, stratified, multistage, random sampling approach (probability proportional to size, PPS) was used. First of all, four districts together with four counties from Guangdong Province were randomly chosen using a PPS method. Second, three kindergartens were selected from either one district or one county with the PPS method. Finally, 36 children in each age group from the chosen kindergartens were recruited with a quota sampling approach. Recruitment was stopped after reaching the study size.\u003c/p\u003e\n\u003cp\u003eThe inclusion criteria of the present study was applicable for both children who participated in the study and its legal guardians. Children must be in a designated range of age, have a willingness to cooperate with the investigators, and the ability to maintain good compliance. Legal guardian's inclusion criteria included the ability to understand the study as well as the questionnaire and willingness to sign the relevant informed consent letter. The exclusion criteria in our survey were: legal guardian's failure in understanding this survey; the presence of oral disease requiring medication or even emergency treatment in the children, or the presence of a major systematic disease, which has an impact on the data integrity and/or the safety of the participant.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Stomatological Ethics Committee of the Chinese Stomatological Association on July 9, 2014 (Approval No.: 2014-003). Written informed consents were obtained from the participants\u0026rsquo; legal guardians before the survey.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical examination\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe presence of ECC was determined using the dmft index of the WHO 2013 criteria [10]. Three experienced dentists collected the data at kindergartens. The dentists were trained and calibrated using clinical intraoral photographs before the formal examination. And the training of the investigators were conducted with a group of samples (15 volunteers) under the guidance of a standard examiner of the Fourth National Oral Health Survey. The kappa scores of the three examiners to the standard examiner were 0.80, 0.83, and 0.88 when the training finished.\u003c/p\u003e\n\u003cp\u003eAll of the participants were subjected to a general tooth examination using a CPI probe and a plane mirror with an LED light. ECC was diagnosed at cavitation level, which was confirmed by the ball-end CPI probe. The teeth were cleaned with a cotton swab before the examination. The inter-examiner reproducibility was assessed by re-examination of approximately 5% of the participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQuestionnaire\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAdditionally, at a face-to-face and one-on-one interview by trained interviewers, each of the participants\u0026rsquo; parents or grandparents completed a questionnaire, which included data regarding caries-related oral hygiene behaviors, dietary behaviors, socioeconomic factors. The questionnaire was from the Fourth National Oral Health Survey, which was designed based on previous studies with purpose of identifying factors related to ECC and was proved to be with appropriate reliability and validity before the study. An additional file shows this in more detail [see Supplementary file 1]. Before the interview, the kindergarten teachers had carried out publicity, education and liaison work; during the interview, we started from caring for the health of children, and patiently explained the work to dispel the doubts of the participants\u0026rsquo; parents/grandparents, to handling potential bias.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSAS 9.4 software (SAS Institute, Inc., Carey, NC, USA) was applied. Differences between different groups were compared by \u003cem\u003et\u003c/em\u003e\u003cem\u003e-\u003c/em\u003etest, chi\u003csup\u003e2\u003c/sup\u003e test, and One-way ANOVA. Estimates were significantly different if 95% CIs do not overlap. Multivariate logistic regression was used to assessed the percentages of participants with ECC relative to caries-related factors whose P-values were less than 0.2 in the bivariate analyses. Odds ratios (ORs) with 95% confidence intervals (CIs) were thus reported. Estimates were significantly different from the reference if its 95%CIs do not include 1. Furthermore, a covariance analysis model was constructed to explore the relationship between dmft and the relevant factors. Estimates were significantly different from the reference if its 95%CIs do not include 0.\u003c/p\u003e\n\u003cp\u003eThe analyses were weighted by age, gender and residence in order to avoid possible non-response bias. Each participant had a personal dmft score (0-20). Prevalence was evaluated by the percentage of participants with a personal dmft score (\u0026gt;0). The average of the total dmft score of all participants was described as the mean dmft. The filled rate was the ratio of the filled teeth to the total dmft (proportion of ft in dmft).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe study sample comprised 2592 participants. The prevalence, mean dmft and filled rate of ECC among 3- to 5-year-old children in Guangdong Province are shown in Table 1. The prevalence and mean dmft in rural areas were higher than those in urban areas, and there was an increasing trend with age. The filled rate in rural areas was lower than that in urban areas. The results did not indicate obvious gender differences.\u003c/p\u003e\n\u003cp\u003eDuring the examination, interexaminer kappa values of 0.98, 0.96, and 0.97 were obtained. The interexaminer reproducibility was completely reliable.\u003c/p\u003e\n\u003cp\u003eThe frequency distribution of dmft is shown in Figure 1. Among the children with ECC, children who had two teeth with ECC were the most common. With the increase in dmft scores, the number of children gradually decreased. A total of 84.8%, 79.8% and 72.3% of ECC cases were concentrated in one-third of 3-, 4- and 5-year-old children, and the mean dmft values for these children (significant caries index, SiC) were 7.71 (95% CI: 7.22-8.20), 10.40 (95% CI: 9.94-10.86) and 12.35 (95% CI: 11.96-12.74), respectively.\u003c/p\u003e\n\u003cp\u003eThe distribution of the tooth position of ECC is shown in Figure 2. The upper central incisors had the highest prevalence, followed by the mandibular molars and then the maxillary molars, while the mandibular incisors had the lowest prevalence.\u003c/p\u003e\n\u003cp\u003eThe results of the multivariate analysis are shown in Table 2. Associated factors for both prevalence and mean dmft were older age, rural areas, consumption of sweets before sleep, dental visit history, low household income, and low parental education level. Initiating toothbrushing after 3 years of age and being exclusively/ predominantly breastfed indicated only the prevalence, whereas being female and being frequently fed with sweetened milk/powdered milk indicated only the mean dmft.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis survey reported high prevalence and severity of ECC among preschool children in Guangdong, Southern China, similar to the finding for East China [11] and higher than that for Southwest China [12], higher than the national average [13], and higher than that 10 years ago [4]. A multitude of factors are associated with the prevalence and severity. The findings of this survey inform target factors for collective actions to address this critical oral health problem.\u003c/p\u003e\n\u003cp\u003eThe most obvious limitation of this survey is the retrospective rather than prospective design, which might brought potential recall bias. Hence, we can\u0026rsquo;t confirm the causal relationship between the associated factors and the results. An additional limitation is that the dmft index is less accurate than the dmfs index, as a tooth has multiple tooth surfaces and ECC typically involves multiple tooth surfaces rather than one. Finally, enamel defects, oral bacteria and fluoride concentrations of drinking water that contribute to ECC were not evaluated. A systematic review showed that the presence of enamel defects and high levels of \u003cem\u003emutans streptococci\u003c/em\u003e were the strongest risk factors associated with ECC [14]. Prospective studies and studies including microbiological detection, enamel defect examination, and determination of the fluorine concentration in drinking water are indicated.\u003c/p\u003e\n\u003cp\u003eA report showed that the oral health status of preschool children has significantly improved over the past 10 years in China [15]. However, compared with the provincial survey of Guangdong in 2005, the current results showed remarkable increases in the prevalence (67.9% to 78.4%) and mean dmft (4.13 to 5.69) of ECC among 5-year-old children in both urban and rural areas, especially in rural areas. This trend actually shows ECC rates becoming further away from the goal of a caries-free rate of 50% among 5-year-old children for the year 2020 by the WHO [6]. Higher sugar intake [16] but still inadequate oral healthcare [7], possibly leading to the increasing trend observed [17]. More attention should be given in Guangdong to children\u0026rsquo;s dental health for deciduous teeth.\u003c/p\u003e\n\u003cp\u003eThe frequency distribution of dmft showed that two teeth with ECC were the most common, and the position distribution showed that the upper central incisors were the prevailing teeth with ECC. The same finding was shown in the national survey [18]. ECC usually affects the smooth surface, followed by the pit and fissure, which is different from the caries of permanent dentition. Therefore, preventive measures against caries with smooth surfaces should be taken. If ECC of the upper central incisors were prevented, the prevalence might be reduced by 10%.\u003c/p\u003e\n\u003cp\u003eRisk assessment is an important part of patient-centered, evidenced-based decision making in modern medical services [19]. A systematic review showed that ECC is related to demographic factors, oral hygiene behaviors, dietary behaviors, and socioeconomic factors [20]. The results of the multivariable model showed that associated factors for ECC matched the review.\u003c/p\u003e\n\u003cp\u003eDental caries is an irreversible process. As deciduous teeth continue to function and be challenged before replacement, the continuous and cumulative effects cause ECC to develop with time. This might explain why increased age was related to a higher risk and severity of ECC. Additionally, children who initiate toothbrushing at an older age have a higher risk of developing ECC. Therefore, ECC prevention should occur from an early age.\u003c/p\u003e\n\u003cp\u003eNo obvious gender differences in the prevalence of ECC were found for. No evidence showed that the composition of the saliva differs between boys and girls or that there are any differences in tooth structure between the genders [21]. However, the mean dmft was higher in female children. Further exploration is indicated.\u003c/p\u003e\n\u003cp\u003eGenerally, caries are recognized as more severe among people with low socioeconomic status [22, 23]. In this study, the prevalence and mean dmft of ECC in urban areas were lower than those in rural areas, while the opposite was true for the filled rate. Children who had a low parental education level and low household income had higher prevalence and severity of ECC. Rural oral medical service is usually characterized as having insufficient infrastructure, socioeconomic difficulties, artificial barriers such as distance and inconvenience of transport, and a high patients to oral health professionals ratio [15, 24]. Parental factors such as education and income are significant risk factors in the developing of ECC [25]. Therefore, children from rural areas should be given more attention in order to reduce ECC.\u003c/p\u003e\n\u003cp\u003eA systematic review showed that ECC is related to frequent sweets consumption [26]. In particular, numerous studies have proven that sweets play a key role in the occurrence and development of ECC [27-29]. A diet rich in exogenous sugars is believed to be cariogenic to children [30]. In the present survey, the participants who consumed sweets before sleep were 1.35 times more likely to have ECC and had 0.77 higher dmft than those without this habit. Moreover, children who were sometimes/often fed with sweetened milk/powdered milk had higher dmft than those who were never/rarely fed with that kind of milk. This result suggests that both the timing and frequency of the consumption of sweets influenced ECC.\u003c/p\u003e\n\u003cp\u003eWhat interested us was that the children who were exclusively/predominantly breastfed during the first half year of life had a higher risk of ECC. This finding agrees with the results of earlier studies reporting a significant relation between the duration of breastfeeding and ECC in young Chinese children [31, 32], similar to its neighboring province of Zhejiang [11]. Part of the reason might be that breast milk is more likely to cause caries than other types of milk [33]. Additionally, extended breastfeeding contributes to the colonization of \u003cem\u003eStreptococcus mutans\u003c/em\u003e [34], which synergistically induces ECC. Breastfeeding is recommended by the WHO [35]; however, considering the relationship between breastfeeding and ECC, dental experts recommended weaning from the breast shortly after the child\u0026rsquo;s first birthday [36].\u003c/p\u003e\n\u003cp\u003eIt is recommended that the first dental visit should be performed by 12 months to assess the risk of ECC and provide early intervention when needed [37]. Dental visit history is usually a protective factor for ECC in developed areas [38, 39]. However, in this survey, children who had dental visit histories had higher prevalence and dmft scores of ECC than those without dental visits. This difference may be due to the different patterns of visiting dentists. Children in developed areas often visit dentists for preventive examinations and take preventive measures. However, in China, dental treatment has been sought since these children had already experienced oral health problems, which is therapeutic rather than preventive. Visiting dentists only when a problem was perceived was a risk factor for ECC [40]. This finding agrees with the results of some other Chinese studies [32, 41, 42].\u003c/p\u003e\n\u003cp\u003eThere were no significant relations between toothbrushing habits and ECC in this study. However, children who start brushing their teeth at an older age are at higher risk of developing ECC. Moreover, lack of toothbrushing was a risk factor for ECC [43], and irregular brushing at 18 months of age was a highly significant predictor of developing ECC [44]. Brushing less than twice a day or difficulties brushing teeth during the first year of preschool were significant determinants of ECC at the age of 5 years [45]. Therefore, professionals should give parents special attention and assist in improving and optimizing their toothbrushing behavior during children\u0026rsquo;s preschool years.\u003c/p\u003e\n\u003cp\u003eThe strengths of this survey include a representative sample which was ensured by an equal-sized, stratified, multistage random sampling approach, the use of a reliable index, and a statistical analysis with a weighted process which made the results be close to reality and permit us to generalize the findings to the population.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, preschool children in Guangdong Province, especially children from rural areas, experienced a significant amount of ECC. Associated factors for ECC included demographics, oral health measures, dietary factors, and socioeconomic factors. More attention should be given to prevention of ECC from early life. The construction of social support for oral health should be strengthened. Oral health education and promotion, especially of rural areas, should be intensified to reduce the inequality between urban and rural areas.\u0026nbsp;\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCI(s): Confidence Interval(s); CPI: Community Periodontal Index; dmfs: decayed, missing, filled deciduous tooth surface; dmft: decayed, missing, filled deciduous teeth; ECC: Early Childhood Caries; GDP: Gross Domestic Product; OR(s): Odds Ratio(s); PPS: Probability Proportional to Size; SiC: Significant Caries Index\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Stomatological Ethics Committee of the Chinese Stomatological Association on July 9, 2014 (Approval No.: 2014-003). Written informed consents were obtained from parents or guardians for minors to participate the survey.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data sets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was part of \u0026ldquo;the Public Science and Technology Research Funds Project (2015)\u0026mdash;the Fourth National Oral Health Survey (201502002)\u0026rdquo; and was supported by the Clinical Research Startup Program of Southern Medical University by High-level University Construction Funding of Guangdong Provincial Department of Education ( LC2017PY001, 2017KTSCX036).\u003c/p\u003e\n\u003cp\u003eIn this study, the section of study design and data collection was mainly funded by the Fourth National Oral Health Survey (201502002), the sections of statistical analysis, data interpretation and manuscript writing were mainly funded by the Clinical Research Startup Program of Southern Medical University (LC2017PY001, 2017KTSCX036).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSH and WF conceived and designed of the study, coordinated the project, checked the data analyses and revised the manuscript; JL trained and supervised the field workers and wrote the manuscript; YZ and LW contributed to the data input; WL conducted the analysis. All authors gave final approval of the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank all of the children participants and their parents/grandparents, and all the staff who participated in the survey.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eDrury TF, Horowitz AM, Ismail AI, et al. Diagnosing and reporting early childhood caries for research purposes. A report of a workshop sponsored by the National Institute of Dental and Craniofacial Research, the Health Resources and Services Administration, and the Health Care Financing Administration[J]. J Public Health Dent,1999,59(3):192-197.\u003c/li\u003e\n\u003cli\u003eSchroth RJ, Harrison RL, Moffatt ME. Oral health of indigenous children and the influence of early childhood caries on childhood health and well-being[J]. Pediatr Clin North Am,2009,56(6):1481-1499.\u003c/li\u003e\n\u003cli\u003eGe L. Pediatric Dentistry[M]. 4th. Beijing:People's Medical Publishing House,2012.\u003c/li\u003e\n\u003cli\u003eHong B,Huang S,Zhang J. The Deciduous Caries in a 5 Years Old Guangdong Cohort: A Sampled Investigation[J]. J Dent Prev Treat,2007,15(6):263-265.\u003c/li\u003e\n\u003cli\u003eKassebaum NJ, Smith A, Bernabe E, et al. Global, Regional, and National Prevalence, Incidence, and Disability-Adjusted Life Years for Oral Conditions for 195 Countries, 1990-2015: A Systematic Analysis for the Global Burden of Diseases, Injuries, and Risk Factors[J]. J Dent Res,2017,96(4):380-387.\u003c/li\u003e\n\u003cli\u003eHobdell M, Petersen PE, Clarkson J, et al. Global goals for oral health 2020[J]. Int Dent J,2003,53(5):285-288.\u003c/li\u003e\n\u003cli\u003eHuang S. A 30-year Trend of Oral Health in Guangdong Province (In Chinese)[M]. Guangzhou:Guangdong Science and Technology Publishing House,2019.\u003c/li\u003e\n\u003cli\u003eOral Health Surveys: Basic Methods[M]. Fifth. Geneva:WHO,2013.\u003c/li\u003e\n\u003cli\u003eQi X. Report of the Third National Oral Health Survey in China (In Chinese)[M]. Beijing:People's Medical Publishing House,2008.\u003c/li\u003e\n\u003cli\u003eZhou N, Zhu H, Chen Y, et al. Dental caries and associated factors in 3 to 5-year-old children in Zhejiang Province, China: an epidemiological survey[J]. BMC Oral Health,2019,19(1):9.\u003c/li\u003e\n\u003cli\u003eYin W, Yang Y, Chen H, et al. Oral health status in Sichuan Province: findings from the oral health survey of Sichuan, 2015-2016[J]. Int J Oral Sci,2017,9(1):10-15.\u003c/li\u003e\n\u003cli\u003eWang X. Report of the Fourth National Oral Health Survey in China (In Chinese)[M]. Beijing:People's Medical Publishing House,2018.\u003c/li\u003e\n\u003cli\u003eKirthiga M, Murugan M, Saikia A, et al. Risk Factors for Early Childhood Caries: A Systematic Review and Meta-Analysis of Case Control and Cohort Studies[J]. Pediatr Dent,2019,41(2):95-112.\u003c/li\u003e\n\u003cli\u003eLiu J, Zhang SS, Zheng SG, et al. Oral Health Status and Oral Health Care Model in China[J]. Chin J Dent Res,2016,19(4):207-215.\u003c/li\u003e\n\u003cli\u003eLi J. The Dental Health Survey of Guangdong Population (In Chinese)[D]. Guangzhou: Southern Medical University,2019.\u003c/li\u003e\n\u003cli\u003eZhang Y,Ma W. Analysis on 10-Year Changes in Dietary Nutrition and Health Status of Residents in Guangdong Province (In Chinese)[M]. Beijing:Standards Press of China,2016.\u003c/li\u003e\n\u003cli\u003eMasood M, Masood Y, Newton T. Impact of national income and inequality on sugar and caries relationship[J]. Caries Res,2012,46(6):581-588.\u003c/li\u003e\n\u003cli\u003eDu MQ, Li Z, Jiang H, et al. Dental Caries Status and its Associated Factors among 3- to 5-year-old Children in China: A National Survey[J]. The Chinese journal of dental research : the official journal of the Scientific Section of the Chinese Stomatological Association (CSA),2018,21(3):167.\u003c/li\u003e\n\u003cli\u003eLoomans B, Opdam N, Attin T, et al. Severe Tooth Wear: European Consensus Statement on Management Guidelines[J]. J Adhes Dent,2017,19(2):111-119.\u003c/li\u003e\n\u003cli\u003eLi Z,Liu S,Zhang K. Research progress on early childhood caries[J]. J Prev Treat Stomatol Dis, 2019,27(4):260-263.\u003c/li\u003e\n\u003cli\u003eWetselaar P, Vermaire JH, Visscher CM, et al. The Prevalence of Tooth Wear in the Dutch Adult Population[J]. Caries Res,2016,50(6):543-550.\u003c/li\u003e\n\u003cli\u003eSgan-Cohen HD, Evans RW, Whelton H, et al. IADR Global Oral Health Inequalities Research Agenda (IADR-GOHIRA(R)): a call to action[J]. J Dent Res,2013,92(3):209-211.\u003c/li\u003e\n\u003cli\u003eChen S,Ceng X,Liu Q, et al. Study of the relationship between family environmental factors and dental caries status in children[J]. J Prev Treat Stomatol Dis,2018,26(3):184-188.\u003c/li\u003e\n\u003cli\u003eSkaret E, Weinstein P, Milgrom P, et al. Factors related to severe untreated tooth decay in rural adolescents: a case-control study for public health planning[J]. Int J Paediatr Dent,2004,14(1):17-26.\u003c/li\u003e\n\u003cli\u003eRai NK, Tiwari T. Parental Factors Influencing the Development of Early Childhood Caries in Developing Nations: A Systematic Review[J]. Front Public Health,2018,6:64.\u003c/li\u003e\n\u003cli\u003eTinanoff N, Baez RJ, Diaz GC, et al. Early childhood caries epidemiology, aetiology, risk assessment, societal burden, management, education, and policy: Global perspective[J]. Int J Paediatr Dent,2019,29(3):238-248.\u003c/li\u003e\n\u003cli\u003eRibeiro C, Silva M, Nunes A, et al. Overweight, obese, underweight, and frequency of sugar consumption as risk indicators for early childhood caries in Brazilian preschool children[J]. Int J Paediatr Dent,2017,27(6):532-539.\u003c/li\u003e\n\u003cli\u003eKharbanda OP, Moynihan P, Priya H, et al. Report from a symposium on accelerating policy-driven action against excessive sugar consumption for the prevention of early childhood caries and noncommunicable diseases[J]. Indian J Public Health,2018,62(4): 305-307.\u003c/li\u003e\n\u003cli\u003eChen Y,Fu Z,Chen Y, et al. Analysis of risk factors for dental caries in deciduous teeth among preschool children[J]. J Prev Treat Stomatol Dis, 2018,26(10):652-656.\u003c/li\u003e\n\u003cli\u003eMarshall TA, Broffitt B, Eichenberger-Gilmore J, et al. The roles of meal, snack, and daily total food and beverage exposures on caries experience in young children[J]. J Public Health Dent,2005,65(3):166-173.\u003c/li\u003e\n\u003cli\u003eLi Y, Navia JM, Bian JY. Caries experience in deciduous dentition of rural Chinese children 3-5 years old in relation to the presence or absence of enamel hypoplasia[J]. Caries Res,1996, 30(1):8-15.\u003c/li\u003e\n\u003cli\u003eZhou Y, Lin HC, Lo EC, et al. Risk indicators for early childhood caries in 2-year-old children in southern China[J]. Aust Dent J,2011,56(1):33-39.\u003c/li\u003e\n\u003cli\u003eBowen WH, Lawrence RA. Comparison of the cariogenicity of cola, honey, cow milk, human milk, and sucrose[J]. Pediatrics,2005,116(4):921-926.\u003c/li\u003e\n\u003cli\u003eVachirarojpisan T, Shinada K, Kawaguchi Y, et al. Early childhood caries in children aged 6-19 months[J]. Community Dent Oral Epidemiol,2004,32(2):133-142.\u003c/li\u003e\n\u003cli\u003eDaelmans B, Dewey K, Arimond M. New and updated indicators for assessing infant and young child feeding[J]. Food Nutr Bull,2009,30(2 Suppl):S256-S262.\u003c/li\u003e\n\u003cli\u003eDentistry AAOP, Pediatrics AAO, Affairs AAOP. Policy on early childhood caries (ECC): classifications, consequences, and preventive strategies[J]. Pediatr Dent,2005,27(7 Suppl): 31-33.\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.ingentaconnect.com/content/aapd\"\u003eAmerican Academy of Pediatric Dentistry\u003c/a\u003e. Perinatal and Infant Oral Health Care[J]. Pediatr Dent,2017,39(6):208-212.\u003c/li\u003e\n\u003cli\u003eWerneck RI, Lawrence HP, Kulkarni GV, et al. Early childhood caries and access to dental care among children of Portuguese-speaking immigrants in the city of Toronto[J]. J Can Dent Assoc,2008,74(9):805.\u003c/li\u003e\n\u003cli\u003ePlutzer K, Spencer AJ. Efficacy of an oral health promotion intervention in the prevention of early childhood caries[J]. Community Dent Oral Epidemiol,2008,36(4):335-346.\u003c/li\u003e\n\u003cli\u003eDabawala S, Suprabha BS, Shenoy R, et al. Parenting style and oral health practices in early childhood caries: a case-control study[J]. Int J Paediatr Dent,2017,27(2):135-144.\u003c/li\u003e\n\u003cli\u003eDuangthip D, Chen KJ, Gao SS, et al. Early childhood caries among 3- to 5-year-old children in Hong Kong[J]. Int Dent J,2019,69(3):230-236.\u003c/li\u003e\n\u003cli\u003eLi Y, Wulaerhan J, Liu Y, et al. Prevalence of severe early childhood caries and associated socioeconomic and behavioral factors in Xinjiang, China: a cross-sectional study[J]. BMC Oral Health,2017,17(1):144.\u003c/li\u003e\n\u003cli\u003eSeow WK. Early Childhood Caries[J]. Pediatr Clin North Am,2018,65(5):941-954.\u003c/li\u003e\n\u003cli\u003eNishide R, Mizutani M, Tanimura S, et al. Homecare protective and risk factors for early childhood caries in Japan[J]. Environ Health Prev Med,2018,23(1):57.\u003c/li\u003e\n\u003cli\u003eBoustedt K, Dahlgren J, Twetman S, et al. Tooth brushing habits and prevalence of early childhood caries: a prospective cohort study[J]. Eur Arch Paediatr Dent,2019.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eDue to technical limitations, the tables are only available as a download in the supplementary files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","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":"Cross-sectional survey, Early childhood caries, Oral epidemiology, Preschool children, Associated factors","lastPublishedDoi":"10.21203/rs.3.rs-33731/v3","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-33731/v3","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Dental caries of deciduous teeth (Early Childhood Caries, ECC) has become a crucial oral health problem over the decades in China.\u0026nbsp;The aim of this study was to examine the prevalence and severity of ECC among preschool children from Guangdong Province, Southern China. In addition, to assess the association of ECC with reported oral health-related behaviors. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e\u0026nbsp;A cross-sectional survey\u0026nbsp;of 2592\u0026nbsp;participants\u0026nbsp;was carried out\u0026nbsp;in Guangdong Province\u0026nbsp;by means of an equal-sized, stratified, multistage random sampling method\u0026nbsp;during December 2015 and April 2016. The participants were divided into three groups according to their ages (3-, 4-,\u0026nbsp;and\u0026nbsp;5-year-olds).\u0026nbsp;According to the standard\u0026nbsp;for clinical dentition examination of the WHO\u0026nbsp;2013 criteria, the presence of ECC was\u0026nbsp;determined\u0026nbsp;by the\u0026nbsp;dmft (decayed-missing-filled tooth)\u0026nbsp;index\u0026nbsp;using\u0026nbsp;a CPI\u0026nbsp;(Community Periodontal Index)\u0026nbsp;probe. A questionnaire about caries-related\u0026nbsp;factors\u0026nbsp;was completed by each of the participants’\u0026nbsp;parents or grandparents\u0026nbsp;through a face-to-face\u0026nbsp;and one-on-one\u0026nbsp;interview.\u0026nbsp;Then, t -test,\u0026nbsp;Chi 2\u0026nbsp;tests, One-Way ANOVA served for statistical analysis, and\u0026nbsp;logistic regression analysis as well as\u0026nbsp;covariance analysis were\u0026nbsp;executed to identify\u0026nbsp;potential\u0026nbsp;associated factors\u0026nbsp;for ECC. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u0026nbsp;The prevalence (%\u0026nbsp;dmft \u0026gt;0) of ECC was 68.3\u0026nbsp;(95% CI: 66.5-70.1),\u0026nbsp;the mean dmft was\u0026nbsp;4.36 (95% CI: 4.17-4.55),\u0026nbsp;and the filled rate\u0026nbsp;was\u0026nbsp;1.2%. In multivariable\u0026nbsp;modeling, associated factors for both prevalence\u0026nbsp;and mean dmft\u0026nbsp;were older\u0026nbsp;age, rural areas, consumption of\u0026nbsp;sweets before sleep, dental visit history, low household income, and low parental education level.\u0026nbsp;Initiating toothbrushing after 3\u0026nbsp;years of age\u0026nbsp;and being\u0026nbsp;exclusively/\u0026nbsp;predominantly breastfed indicated only the prevalence; being female\u0026nbsp;and\u0026nbsp;frequently consuming sweetened milk/powdered milk\u0026nbsp;indicated only the mean dmft. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e\u0026nbsp;Preschool children in Guangdong Province, especially children from\u0026nbsp;rural areas,\u0026nbsp;experienced\u0026nbsp;a\u0026nbsp;significant amount of\u0026nbsp;ECC. Associated factors for ECC included demographics, oral health measures, dietary factors, and socioeconomic factors.\u0026nbsp;More attention should be given\u0026nbsp;to\u0026nbsp;prevention of ECC from early life.\u0026nbsp;The construction of social support for oral health should be strengthened. Oral health education and promotion, especially\u0026nbsp;of rural areas, should be intensified to reduce the inequality between urban and rural areas.\u003c/p\u003e","manuscriptTitle":"The Status and Associated Factors of Early Childhood Caries among 3- to 5-year-old Children in Guangdong, Southern China: A Provincial Cross-sectional Survey","msid":"","msnumber":"","nonDraftVersions":[{"code":3,"date":"2020-09-15 18:29:29","doi":"10.21203/rs.3.rs-33731/v3","editorialEvents":[{"type":"communityComments","content":0},{"type":"checksComplete","content":"","date":"2020-09-15T12:00:00+00:00","index":"","fulltext":""},{"type":"decision","content":"Accept","date":"2020-09-14T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","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}},{"code":2,"date":"2020-08-24 15:08:46","doi":"10.21203/rs.3.rs-33731/v2","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Minor revision","date":"2020-09-09T12:00:00+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2020-08-28T12:00:00+00:00","index":2,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-08-28T12:00:00+00:00","index":2,"fulltext":"Recommendation: Accept without revision\nForm responses:\n---\n\nComments to Author:\n---\nRevisions accepted* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons upon publication of the manuscript. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **Yes**\n* Declaration of competing interests: **'I declare that I have no competing interests'**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please do not publish my name with my report. (default)**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **Yes**\n* Are the methods sufficiently described to allow the study to be repeated?: **Yes**\n* Is the use of statistics and treatment of uncertainties appropriate?: **Yes**\n* Is the presentation of the work clear?: **Yes**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **Yes**\n"},{"type":"editorInvitedReview","content":"","date":"2020-08-26T12:00:00+00:00","index":1,"fulltext":"Recommendation: Accept without revision\nForm responses:\n---\n\nComments to Author:\n---\nPlease include all comments for the authors in this box rather than uploading your report as an attachment. Please only upload as attachments annotated versions of manuscripts, graphs, supporting materials or other aspects of your report which cannot be included in a text format.\nPlease overwrite this text when adding your comments to the authors.* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons upon publication of the manuscript. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **No**\n* Declaration of competing interests: **I declare that I have no competing interests.**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please do not publish my name with my report. (default)**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **Yes**\n* Are the methods sufficiently described to allow the study to be repeated?: **Yes**\n* Is the use of statistics and treatment of uncertainties appropriate?: **Yes**\n* Is the presentation of the work clear?: **Yes**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **Yes**\n"},{"type":"reviewerAgreed","content":"","date":"2020-08-25T12:00:00+00:00","index":1,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2020-08-23T12:00:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2020-08-21T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2020-08-20T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-08-20T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","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}},{"code":1,"date":"2020-06-29 13:02:48","doi":"10.21203/rs.3.rs-33731/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2020-07-31T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-07-25T12:00:00+00:00","index":2,"fulltext":"Recommendation: Accept after minor essential revisions\nForm responses:\n---\n\nComments to Author:\n---\nREPORT: The Status and Associated Factors of Early Childhood Caries among 3- to 5-year-old Children in Guangdong, Southern China: A Provincial Cross-sectional Survey\n\nTitle:\n The title is consistent with what was done in the study and inform the study design.\n\nAbstract:\n The abstract is concise and addresses what was done in the study, however, more details should be given about the study design, such as the period on which the study was conducted, report the number of participants and its eligibility criteria \n\nBackground:\n The section provides a great context of the problem, disclaiming the epidemiologic data in the local of interest and state the main objective of the study. \nParticipants, materials and methods:\n The study design and the criteria established to define the sample size was defined clearly and directly. The location, dates, and population were also described.\n As a suggestion, the paragraph about the inclusion criteria (Line 45 of the section), should be rewritten to make a clearer statement, authors should separate the children's inclusion criteria of the legal guardian's\n Suggestion: \"The inclusion criteria of the present study was applicable for both children who participated in the study and its legal guardians. Children must be in a designated range of age, have a willingness to cooperate with the investigators, and the ability to maintain good compliance. Legal guardian's inclusion criteria included the ability to understand the study as well as the questionnaire and willingness to sign the relevant informed consent letter. The exclusion criteria in our survey were: legal guardian's failure in understanding this survey; the presence of oral disease requiring medication or even emergency treatment in the children, or the presence of a major systematic disease, which has an impact on the data integrity and/or the safety of the participant.\" \n The authors gave a detailed description of how the presence of ECC was determined, however, it is suggested that more details are given regarding the outcomes, exposures and potential confounders or bias of the study.\nRegarding the statistical methods, the authors gave a good description of what was done.\n\nResults:\n The results were well presented, giving descriptive data and a summary of the outcome obtained in the study. Tables and graphs are concise and the main results are described in the section. However, the authors should check the resolution of the images, see if it follows the journal specifications. Also, the authors should state if there were any losses in the sample during the study. \n According to the journal submission guidelines tables and images titles must have a maximum of 15 words, so please review the title of table 1.\n\nDiscussion:\n The first sentence of the discussion (Line 33) should be suppressed since the information has already been stated in the objective. The section should begin with the main findings of the study.\nThe discussion summarizes the key results of the study making an overall interpretation of the obtained data, considered other studies as evidence. Additionally, the author presented the limitations of the study.\n\nConclusions:\n The conclusion section presents relevant conclusions, considering the work's objective.\n\n\nRegarding the manuscript formatting authors should include the numbers of the pages.\n\n* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons upon publication of the manuscript. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **No**\n* Are the methods appropriate and well described?: **Yes**\n* Does the work include the necessary controls?: **Yes**\n* Are the conclusions drawn adequately supported by the data shown?: **Yes**\n* Are you able to assess any statistics in the manuscript or would you recommend an additional statistical review?: **I am able to assess the statistics**\n* Quality of written English: **Acceptable**\n* Declaration of competing interests: **I declare that I have no competing interests**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please do not publish my name with my report. (default)**\n"},{"type":"editorInvitedReview","content":"","date":"2020-07-25T12:00:00+00:00","index":1,"fulltext":"Recommendation: Major revisions required\nForm responses:\n---\n\nComments to Author:\n---\nThis is an interesting observational study with the aim to examine the prevalence and severity of ECC among preschool children from Guangdong Southern China.\nI am not good at English, but it seems that this paper must be sent first to academic proof-read inst, since some of the statements are confusing\n1. Abstract = It is essential to add information on the numeric value of statistics analysis of multivariable modeling\n2. Background : Add information on the ECC comparison of children in Guangdong province with other provinces. What makes Guangdong more interesting to become the point of the location of the study ?\n3. Materials and Methods :\nHow to handling potential sources of bias when doing interviews with parents/grandparents ?\n4. RESULTS : The author stated that t test, chi square and one way ANOVA was applied, but not explained in the results nor the tables\n5. DISCUSSION : What is the recommendation to decision maker regarding the results of the study\n\n* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons upon publication of the manuscript. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **No**\n* Declaration of competing interests: **'I declare that I have no competing interests'**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please do not publish my name with my report. (default)**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **Yes**\n* Are the methods sufficiently described to allow the study to be repeated?: **Yes**\n* Is the use of statistics and treatment of uncertainties appropriate?: **Yes**\n* Is the presentation of the work clear?: **Yes**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **Yes**\n"},{"type":"editorInvitedReview","content":"","date":"2020-07-21T12:00:00+00:00","index":3,"fulltext":"Recommendation: Reviewer's comments unavailable pending editorial decision\n"},{"type":"reviewerAgreed","content":"","date":"2020-07-06T12:00:00+00:00","index":3,"fulltext":""},{"type":"reviewerAgreed","content":"","date":"2020-07-04T12:00:00+00:00","index":2,"fulltext":""},{"type":"reviewerAgreed","content":"","date":"2020-07-02T12:00:00+00:00","index":1,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2020-06-29T12:00:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2020-06-10T12:00:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"","date":"2020-06-09T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2020-06-09T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-06-09T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","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":"a27d198b-9d0a-4369-a244-b4c2bbf1cfc6","owner":[],"postedDate":"September 15th, 2020","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":352083,"name":"Dentistry"},{"id":352084,"name":"Head \u0026 Neck Surgery"}],"tags":[],"updatedAt":"2020-09-27T15:02:37+00:00","versionOfRecord":{"articleIdentity":"rs-33731","link":"https://doi.org/10.1186/s12903-020-01253-w","journal":{"identity":"bmc-oral-health","isVorOnly":false,"title":"BMC Oral Health"},"publishedOn":"2020-09-25 12:00:00","publishedOnDateReadable":"September 25th, 2020"},"versionCreatedAt":"2020-09-15 18:29:29","video":"","vorDoi":"10.1186/s12903-020-01253-w","vorDoiUrl":"https://doi.org/10.1186/s12903-020-01253-w","workflowStages":[]},"version":"v3","identity":"rs-33731","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-33731","identity":"rs-33731","version":["v3"]},"buildId":"369fNeqWncA4NS6XSWjrt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}