Lee et al.

BMC Oral Health (2020) 20:164

https://doi.org/10.1186/s12903-020-01152-0

RESEARCH ARTICLE Open Access

Associations of nutritional status, sugar and

second-hand smoke exposure with dental
caries among 3- to 6-year old Malaysian
pre-schoolers: a cross-sectional study
Zhi Ling Lee1, Wan Ying Gan1* , Poh Ying Lim2, Ruhaya Hasan3 and Sing Ying Lim4

Abstract
Background: Dental caries in primary teeth is a serious oral health concern among children. It can lead to
detrimental impacts on a child’s growth, development, and quality of life. Therefore, this cross-sectional study
aimed to examine the prevalence of dental caries and its associations with nutritional status, sugar and second-
hand smoke exposure among pre-schoolers.
Methods: A total of 26 pre-schools in Seremban, Malaysia were randomly selected using the probability
proportional to size sampling. Dental examination was performed by a dentist to record the number of decayed
teeth (dt). Weight and height of the pre-schoolers were measured. The mother-administered questionnaire was
used to gather information pertaining to the sociodemographic characteristics and second-hand smoke exposure.
Total sugar exposure was calculated from a 3-day food record.
Results: Among the 396 participating pre-schoolers, 63.4% of them had at least one untreated caries, with a
mean ± SD dt score of 3.56 ± 4.57. Negative binomial regression analysis revealed that being a boy (adjusted mean
ratio = 1.42, 95% CI = 0.005–0.698, p = 0.047), exposed to second-hand smoke (adjusted mean ratio = 1.67, 95% CI =
0.168–0.857, p = 0.004) and those who had more than 6 times of daily total sugar exposure (adjusted mean ratio =
1.93, 95% CI = 0.138–0.857, p = 0.013) were significantly associated with dental caries among pre-schoolers.
Conclusion: A high prevalence of dental caries was reported in this study. This study highlights the need to reduce
exposure to second-hand smoke and practice healthy eating behaviours in reducing the risk of dental caries
among pre-schoolers.
Keywords: Pre-schoolers, Dental caries, Oral health, Stunting, Second-hand smoke exposure, Sugar exposure,
Malaysia

* Correspondence: [email protected]
1
Department of Nutrition and Dietetics, Faculty of Medicine and Health
Sciences, Universiti Putra Malaysia, UPM, 43400 Serdang, Selangor Darul
Ehsan, Malaysia
Full list of author information is available at the end of the article

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Lee et al. BMC Oral Health (2020) 20:164 Page 2 of 9

Background home increases the risk of caries among children [12,

Dental caries in primary teeth is a serious oral health 15], but some studies found no association [16, 17].
concern in children. It is one of the most common non- Moreover, obesity and caries are health problems that
communicable diseases in children worldwide, which is exist concurrently, mostly due to their common risk
usually untreated [1]. In 2015, almost 8% of the children factors, including consumption of food high in calories,
globally were affected by untreated caries in the primary increased stress, and low socioeconomic status [18].
teeth [1]. In order to reduce and prevent dental caries in However, the association of nutritional status and dental
Malaysia, the water fluoridation programme was imple- caries was inconclusive as some of the studies found
mented in 1971 at the concentration level of 0.7 ppm positive association [19, 20] while other studies found
(ppm), and it was adjusted to 0.5 ppm later in 2004 to negative association [21–24].
prevent fluorosis [2]. The water fluoridation programme Most of the previous studies on children used the
covered 75.7% of Malaysia in 2016 [3]. However, the rate categorised dmft index (number of decayed, missing,
of caries decrement was still slow among pre-schoolers. and filled teeth) as the outcome measurement for dental
Although there was a notable decrease in the prevalence caries. Nonetheless, it failed to capture the severity and
of dental caries, from 87.1% in 1995 to 76.2% in 2005 the chronic nature of dental caries (decayed teeth). It
among 5-year-old Malaysian children, the dft index was assumed that treated caries does not cause burden
(number of decayed and filled primary teeth) did not like untreated caries [25]. The problem and burden of
change much throughout the years from 5.8 in 1995 to the decayed teeth among children with caries might be
5.5 in 2005 [4]. Furthermore, the mean number of the masked when dmft index was used to determine their
decayed teeth remained high (5.7 to 5.3) but the mean past and current caries experience. Dimaisip-Nabuab
number of the filled teeth remained low at 0.2 from year et al. [23] suggested that the number of decayed teeth
1995 to 2005, indicating that most of the caries were un- (dt) might be a stronger determinant than the dmft
treated [4]. Early treatment of dental caries is needed to index, when it comes to determining factors such as nu-
address the issue of untreated caries among pre- tritional status, that are mutually chronic in nature.
schoolers in order to improve their oral health. Therefore, dt score was used in this study to determine
Dental caries in primary teeth can be a devastating dis- dental caries.
ease if it is not treated properly. It not only affects oral As a developing country with a multicultural back-
health, but children with caries also experience difficul- ground, it can be assumed that there might have been
ties in eating and sleeping due to the unbearable pain some risk factors that are unique to Malaysian pre-
and soreness, premature tooth loss, disrupt speech de- schoolers. Findings from the western populations might
velopment and eventually dental caries in primary teeth not be applicable to the Malaysian population due to the
can affect the growth and maturation of permanent different socio-cultural backgrounds, lifestyle, and food
teeth [5, 6]. In some cases, dental caries may end up fatal intake. Furthermore, dental caries could be one of the
[7]. Undoubtedly, dental caries is a major oral health indicators for detecting inadequate nutrition in pre-
issue in childhood that warrants urgent attention. In schoolers. Hence, this study aimed to examine the
Malaysia, while studies on caries have mainly focused on prevalence of dental caries and its associations with nu-
school-aged children [8, 9], there is a dearth of published tritional status, sugar and second-hand smoke exposure
information on pre-schoolers. among Malaysian pre-schoolers.
Dental caries is a multifactorial disease involving vari-
ous risk and protective factors. It is crucial to manage Methods
the occurrences of multiple factors during pre-school Selection of participants
years to maintain the caries balance, and therefore, pre- This cross-sectional study was carried out from April to
vent dental caries. Sociodemographic factors such as sex, November 2018 at government pre-schools in Seremban
birth order, parental educational level or household in- district of the state of Negeri Sembilan, Malaysia. As
come could play a role in the development of dental car- children with low socioeconomic status are prone to
ies [10, 11]. Previous studies have shown that children dental caries [7, 12], this study was conducted at govern-
with underprivileged social background and experien- ment pre-schools. One of the enrolment criteria set by
cing poverty have higher risk of dental caries as com- the Department of National Unity and Integration for
pared to those with high socioeconomic status [7, 12]. the government pre-schools is to take in children with
High sugar exposure (frequency of sugary food and monthly household income of less than MYR1500 (≈
drinks) was found to be another risk factor for caries USD 367).
[13, 14]. Besides that, second-hand smoke brings harm The estimated sample size of 351 was calculated using
to children’s general heath, including dental health. It is one proportion formula according to the caries preva-
suggested that the exposure to second-hand smoke at lence of 64.9% in Malaysian pre-schoolers [26],
Lee et al. BMC Oral Health (2020) 20:164 Page 3 of 9

considering precision of 0.05 and confidence level of by their child at home, including the cooking methods,
95%. The probability proportional to size sampling tech- quantity of food and brand names of the processed food
nique was used. A list of 56 government pre-schools in as well as the portion size of food and beverages based on
Seremban district and the estimated number of pre- the provided photographs of household measurements in
schoolers aged 3 to 6 years old in each pre-school were the questionnaire. Food and beverages consumed at
obtained from the Department of National Unity and In- preschools were obtained from teachers. The total sugar
tegration. A total of 26 pre-schools were randomly se- exposure was obtained from the 3-day food record. Total
lected. All mothers and pre-schoolers in these selected sugar exposure is the frequency of liquid and solid sugar
pre-schools were invited to join the study (N = 611). consumption in a day [28]. The mean total sugar exposure
Children with health complications and developmental was calculated by dividing the total sugar exposure in 3
disability tend to have unmet dental needs compared to days by three (number of days) [29]. The total sugar
typically developing children [27]. Hence, those Malay- exposure was then classified into two categories: ≤ 6 times
sian pre-schoolers with any medical complications, de- daily and > 6 times daily [29].
velopmental delay, and learning disabilities were
excluded from this study. A total of 587 out of 611 pre- Anthropometric measurements
schoolers met the inclusion criteria of this study. Never- Height and weight of the pre-schoolers were measured
theless, 165 mothers did not sign the consent form. by the researchers using a SECA portable stadiometer
Hence, 422 pre-schoolers with a response rate of 71.9% 213 (SECA, Hamburg, Germany) and a TANITA digital
were recruited in this study. A total of 396 pre-schoolers weighing scale HD319 (TANITA Corporation, Arlington
and their mothers completed all measures and were in- Heights, IL, USA), respectively, with the pre-schoolers
cluded in the final quantitative analysis. standing in upright position, light clothing and without
Ethics approval was sought from the Ethics Committee any foot wear. The measurements were recorded in
for Research Involving Human Subjects Universiti Putra duplicate to get an average of the two readings for ana-
Malaysia (Reference No.: JKEUPM-2018-043). Permis- lysis. Calibration of the instruments was done by the re-
sions to conduct the study were obtained from the Oral searcher at the beginning and end of each assessment
Health Division, Ministry of Health and the Department day. The weight-for-age z score (WAZ), height-for-age z
of National Unity and Integration, Malaysia. score (HAZ) and BMI-for-age z score (BAZ) were calcu-
lated using the WHO AnthroPlus software version 1.0.4
Measures (WHO, Geneva, Switzerland). The classifications of
All mothers of the pre-schoolers answered a set of WAZ, HAZ and BAZ were based on the WHO Child
Malay language self-administered questionnaire at home, Growth Standard [30] for children aged 60 months and
consisting of information on sociodemographic charac- below, and the WHO Growth Reference [31] for chil-
teristics and household smoke exposure. Mothers also dren aged above 60 months. Children with HAZ and
completed a 3-day food record of their children at home. WAZ less than -2SD were classified as stunted and
Anthropometric measurements were assessed by the re- underweight, respectively. Children aged 60 months and
searchers at the preschools. below with BAZ above +2SD [30] and those aged above
60 months with BAZ ≥ +1SD were classified as over-
Mother-administered questionnaire weight and obese [31].
Sociodemographic characteristics of the children and
their parents were self-reported by the mothers, includ- Dental examination
ing child’s age, sex, ethnicity, birth weight, birth order, The dental examination was carried out by a dentist in
parents’ age, parental educational level, employment sta- knee-to-knee position using single-use probe and a mir-
tus, marital status, and monthly household income. ror under good lighting in the classroom. Gauze was
Mothers were required to answer “the number of used to dry the teeth. The number of decayed teeth in
people who smoke inside the house” according to the op- the primary teeth was recorded as the dt (d = decayed,
tions provided: zero, one, two, three or more, while “the t = teeth) index based on the WHO 1997 criteria to
number of cigarettes smoked inside the house per day” score dental caries [32]. The diagnostic criteria of
was asked and the options provided were “never smoked decayed teeth included a lesion in pit, fissure, or on a
inside the house” or “at least one cigarette smoked inside smooth tooth surface, a detectably softened floor or wall,
the house per day” [12]. undermined enamel or an obvious cavity. If a filled tooth
Furthermore, mothers were required to fill in a 3-day was decayed, it was recorded as decayed teeth. The
food record (two weekdays and one weekend) regarding number of decayed teeth indicated the number of un-
their child’s dietary intake. Mothers were requested to rec- treated caries in the oral cavity. The Kappa coefficient of
ord detailed description of food and beverages consumed intra-examiner reliability was 0.815 in this study.
Lee et al. BMC Oral Health (2020) 20:164 Page 4 of 9

Statistical analysis Table 1 Sociodemographic characteristics of pre-schoolers and

Data were analysed using IBM SPSS Statistics 24 (IBM their parents (n = 396)
SPSS Statistic, Inc., Chicago, IL, USA). Descriptive analysis Variables n (%) Mean ± SD
was performed and the results were presented in the form Sex
of frequencies and percentages for categorical variables. Female 196 (49.5)
On the other hand, the means and standard deviations
Male 200 (50.5)
were presented for continuous variables. As the count
Age (years) 5.50 ± 0.62
variable (dt index) was over-dispersed, negative binomial
regression analysis was performed in this study. All the in- 3 4 (1.0)
dependent variables were initially evaluated separately 4 91 (23.0)
using univariate negative binomial regression analysis, and 5 200 (50.5)
the risk factors with p < 0.10 were subsequently included 6 101 (25.5)
in the multivariate negative binomial regression model.
Ethnicity
Backward model selection was used to determine the risk
Malay 307 (77.5)
factors of dental caries in the final model. The statistical
significance level was set at p < 0.05. Chinese 47 (11.9)
Indian 33 (8.3)
Results Other 9 (2.3)
A total of 396 mother-child dyad participated in this Birth order
study with the majority of the pre-schoolers were boys
1 108 (27.3)
(50.5%), Malay (77.5%), and 5 years of age (50.5%). Two-
2 and above 288 (72.7)
third of the fathers (65.8%) and mothers (68.4%) com-
pleted secondary education (Table 1). The prevalence of Father’s age (years) (n = 376) 37.87 ± 6.32
stunting, underweight and overweight/obesity were 6.9, Mother’s age (years) (n = 376) 34.80 ± 5.10
11.8, and 14.9%, respectively (Table 2). Half of the pre- Father’s educational level (n = 380)
schoolers (51.4%) were exposed to second-hand smoke No formal education 3 (0.8)
daily. One in 10 of the pre-schoolers (10.6%) had more
Primary education 23 (6.0)
than six times of sugar exposure regularly. Approxi-
Secondary education 250 (65.8)
mately two-third of the pre-schoolers (63.4%) had at
least one untreated caries, with a mean ± standard devi- Certificate/Diploma/A-level 86 (22.6)
ation (SD) dt score of 3.56 ± 4.57. Tertiary education 18 (4.8)
Variables with p < 0.10 were tested in the negative bi- Mother’s educational level (n = 393)
nomial regression analysis. These variables were sex, No formal education 5 (1.3)
birth order, WAZ, HAZ, number of cigarettes smoked
Primary education 18 (4.6)
inside the house in a day, and the total sugar exposure
Secondary education 269 (68.4)
(Table 3). The negative binomial regression analysis
showed that sex, second-hand smoke exposure, and the Certificate/Diploma/A-level 79 (20.1)
total sugar exposure were significantly associated with Tertiary education 22 (5.6)
the dt index among pre-schoolers (Table 4). Boys had a Marital status
higher dt score when compared to girls (adjusted mean Single/Divorced/Separated/Widowed 24 (6.1)
ratio = 1.43, 95% CI = 1.024–2.006, p = 0.036). Pre-
Married 372 (93.9)
schoolers who lived in the household with at least one
Monthly household incomea (n = 392)
cigarette smoked inside the house daily had a higher dt
score when compared to those who never expose to Below MYR4000 343 (87.5)
cigarette smoke inside the house (adjusted mean ratio = MYR4000 and above 49 (12.5)
1.61, 95% CI = 1.153–2.260, p = 0.005). Pre-schoolers a
Ministry of Economic Affairs [33]; MYR = Ringgit Malaysia; USD 1 = MYR 4.09 as
who consumed > 6 times of sugary food or drinks in a on 31 January 2020

day had a higher dt score than those who consumed

sugary food or drinks ≤6 times in a day (adjusted mean the planning and implementation of community pro-
ratio = 2.09, 95% CI = 1.253–3.483, p = 0.005). grammes among pre-schoolers. This study showed that
63.4% of the pre-schoolers had at least one decayed
Discussion tooth in their primary teeth. Several studies in Malaysia
Due to the limited study on dental caries in Malaysian had revealed the prevalence of dental caries in primary
pre-schoolers, this study would provide fundamental for teeth ranging from 44.6% in 7 to 11 years old children
Lee et al. BMC Oral Health (2020) 20:164 Page 5 of 9

Table 2 Dental caries, nutritional status, sugar and second-hand smoke exposure of the pre-schoolers (n = 396)
Variables n (%) Mean ± SD
Number of decayed teeth in the primary teeth (dt score) 3.56 ± 4.56
dt = 0 145 (36.6)
dt ≥ 1 251 (63.4)
Weight-for-age z score (WAZ) −0.55 ± 1.43
Underweight 46 (11.8)
Normal 343 (88.2)
Height-for-age z-score (HAZ) −0.60 ± 1.03
Stunted 27 (6.9)
Normal 362 (93.1)
BMI-for-age z-score (BAZ) −0.29 ± 1.50
Wasted/Thinness 29 (7.5)
Normal 302 (77.6)
Overweight 32 (8.2)
Obesity 26 (6.7)
Number of smokers at home (n = 395)
0 148 (37.5)
1 215 (54.4)
2 24 (6.1)
≥3 8 (2.0)
Number of cigarettes smoked inside the house in a day (n = 243)
Never smoked inside the house 118 (48.6)
≥ 1 cigarette smoked inside the house per day 125 (51.4)
Total sugar exposure (n = 329) 4.45 ± 1.46
≤ 6 times 294 (89.4)
> 6 times 35 (10.6)

[8] to 98.1% in 5 to 6 years old pre-schoolers [24]. comparable with the prevalence in a national survey
School children in the age group of 7 to 11 years had (64.9%) conducted in 2015 on pre-schoolers in Malaysia
mixed dentition, indicating they had primary teeth and [26]. This might be a result of the increased public
permanent teeth at the same time. The primary teeth fall awareness towards dental caries, and the strategies im-
off gradually and permanent teeth erupted over time, plemented by the Oral Health Division in Ministry of
this could lead to lower prevalence of caries in primary Health Malaysia to improve oral health of pre-schoolers
teeth among school children [8]. Prevalence of dental by providing maximum coverage via Primary Oral
caries in the current study was comparable to the preva- Healthcare programmes targeted at toddlers and pre-
lence reported in other studies from developing coun- schoolers. Nevertheless, the comparison between the
tries such as Brazil (67.7% in pre-schoolers aged 3 to 4 prevalence should be done cautiously because these
years) [13] and Ecuador (65.4% in pre-schoolers aged 6 studies showed differences in the sociodemographic
years and below) [5]. Meanwhile, the caries prevalence characteristics of the children, differences in method-
in the current study was much higher in comparison to ology approaches and difference definitions of caries
the prevalence in developed countries such as United were used.
States (23.0% in pre-schoolers aged 2 to 5 years old) [34] This study found a significant association between sex
and Greece (10.0% in pre-schoolers aged 2.5 to 5.9 years) of the pre-schoolers and their dental caries’ experiences.
[20]. However, the caries prevalence in the current study In general, males exhibited more decayed primary teeth
was lower than the prevalence shown in other Southeast in comparison to females. This finding corroborated
Asian studies such as in Indonesia (90% in children aged with the results reported in other studies conducted in
5 to 12 years) [35] and Vietnam (88.3% in pre-schoolers Southeast Asia [10, 36]. Biological factors such as earlier
aged 4 years) [10]. The prevalence in this study was eruption and longer retention of primary teeth among
Lee et al. BMC Oral Health (2020) 20:164 Page 6 of 9

Table 3 Univariate negative binomial regression analysis of the potential risk factors for decayed teeth (dt) of the pre-schoolers
Variables B SE Mean ratio p value
(95% CI)
Sex
Femalea
Male 0.486 0.114 1.63 (1.300–2.035) < 0.001
Age 0.062 0.899 1.06 (0.892–1.269) 0.490
Birth order 0.087 0.427 1.09 (1.003–1.187) 0.041
Father’s age −0.004 0.009 1.00 (0.979–1.014) 0.677
Mother’s age −0.003 0.106 1.00 (0.976–1.018) 0.779
Father’s educational level
Secondary education and belowa
Tertiary education 0.197 0.129 1.22 (0.945–1.567) 0.128
Mother’s educational level
Secondary education and belowa
Tertiary education 0.175 0.130 1.19 (0.924–1.536) 0.176
Marital Status
Single/Divorced/Separated/Widoweda
Married 0.153 0.242 1.17 (0.725–1.873) 0.527
Monthly household income
Below MYR4000a
MYR4000 and above 0.076 0.172 1.08 (0.771–1.510) 0.659
Weight-for-age z-score
Normala
Underweight 0.379 0.173 1.46 (1.041–2.052) 0.029
Height-for-age z-score
Normala
Stunted 0.618 0.213 1.86 (1.224–2.814) 0.004*
BMI-for-age z-score
Underweighta
Normal 0.346 0.228 1.41 (0.905–2.209) 0.128
Overweight −0.850 0.303 0.92 (0.507–1.663) 0.778
Obese 0.332 0.311 1.39 (0.758–2.564) 0.285
Number of cigarettes smoked inside the house in a day
Never smoked inside the housea
≥ 1 cigarette smoked inside the house per day 0.358 0.146 1.43 (1.076–1.903) 0.014*
Total sugar exposure
≤ 6a
>6 0.666 0.196 1.95 (1.326–2.857) 0.001*
Reference group, B log (dt index), SE Standard Error; *p < 0.05
a

boys, as well as psychological factors such as the innate from males to females among older children. Such a
refusal to compliance in boys [37] might be the reasons shift would have eventually resulted from biological fac-
of higher prevalence of caries among boys. However, this tors such as hormonal changes during girls’ puberty or
finding was inconsistent with a study done in India, in cultural factors such as less medical attention given to
which they found that Indian girls aged 12 to 15 years girls in the Indian families [39].
old reported higher caries than boys [38]. One of the The present study found that HAZ, WAZ or BAZ, was
possible reasons might be due to the shift of caries risk not associated with untreated caries in the primary teeth
Lee et al. BMC Oral Health (2020) 20:164 Page 7 of 9

Table 4 Multivariate negative binomial regression analysis of the potential risk factors for decayed teeth (dt) of the pre-schoolers
Variables B SE Adjusted mean ratio (95% CI) p value
Sex
Femalea
Male 0.360 0.172 1.43 (1.024–2.006) 0.036*
Number of cigarettes smoked inside the house in a day
Never smoked inside the housea
≥ 1 cigarette smoked inside the house per day 0.479 0.172 1.61 (1.153–2.260) 0.005*
Total sugar exposure
≤ 6 timesa
> 6 times 0.737 0.261 2.09 (1.253–3.483) 0.005*
AIC value = 853.49, AICC value = 854.10, BIC value = 876.37
a
Reference group, B log (dt index), SE Standard Error; *p < 0.05

of pre-schoolers. This supported the findings of several treated rats’ teeth surfaces [47]. Elevated level of Strepto-
previous studies, which exhibited no relationship be- coccus mutans was found in human who exposed to
tween nutritional status and dental caries among chil- cigarette smoke. High amount of Streptococcus mutans
dren [40–42]. The null association between obesity and can secrete more extracellular polysaccharides that lower
caries could be explained by the chronic nature of both the pH value of the biofilm on the surfaces of the teeth,
diseases. The association between obesity and dental car- which in turn increased demineralization [47]. Further-
ies might have taken several years to establish, which the more, second-hand smoke decreased the mineralisation
effect might be more profound on the permanent teeth of tooth, the rate of salivary flow, and impaired immun-
of the older children [43]. However, the results were in- ity, which led to the colonisation of cariogenic bacteria
consistent with studies from developed countries such as in teeth [48].
Sweden [19] and Greece [20], which reported positive Despite these possible mechanisms, González-Valero
associations between nutritional status and dental caries et al. [46] suggested that second-hand smoke exposure
among children. A recent systematic review reported and dental caries could share similar sociodemographic
similar trend in which high occurrences of caries were and behavioural factors. Jakhete and Gitterman [49]
found among overweight or obese children from high- found that exposure to second-hand smoke and poor
income countries, but not children from low- or middle- nutrition increased the risk of dental caries in children
income countries [44]. The development of dental caries from low socioeconomic background. Mattheus et al.
in children from developed countries might undergo dif- [12] showed that parents who smoked might have poor
ferent pathway compared to that of children from devel- oral health and high number of bacteria in the oral cav-
oping countries [45]. Further investigations are needed ity, which could then be transmitted to their children
to understand the differences in the effect of nutritional through shared eating utensils. Hence, it is important for
status on the development of dental caries between de- researchers to distinguish that second-hand smoke could
veloped and developing countries. be a risk factor that comes with unhealthy behaviour or
The present study revealed that the second-hand an enhancing factor that increases the risk of caries de-
smoke exposure was associated with untreated caries in velopment among pre-schoolers.
the primary teeth among pre-schoolers, which was in The significant and positive association of sugar expos-
agreement with the findings from previous studies [12, ure with dental caries was supported by previous studies
15, 46]. A meta-analysis reported that the children who [13, 14], which found that a high frequency of liquid or
were exposed to second-hand smoke during infancy had solid sugar consumption was significantly associated
1.72 times higher risk of having caries in their primary with dental caries in pre-schoolers. The association sup-
teeth than the children who were not exposed [46]. The ports the hypothesis proposed by Stephan [48]. The
association of second-hand smoke exposure and dental introduction of fermentable carbohydrates to oral cavity
caries could be explained through one of the toxins reduced the salivary pH beyond the critical pH value of
found in the smoke: nicotine. Experimental evidence 5.5 in 5 to 10 min, due to the acidic by-products pro-
supports a positive association between second-hand duced by cariogenic bacteria such as Streptococcus
smoke exposure and dental caries. An in vivo study mutans [48]. It usually takes 30 to 40 min for saliva to
found that nicotine increased the attachment of cario- neutralize the acid. Nevertheless, the high frequency of
genic bacteria, Streptococcus mutans on the nicotine- sugar exposure increased the frequency of drop in
Lee et al. BMC Oral Health (2020) 20:164 Page 8 of 9

salivary pH. The acidic environment in the oral cavity Abbreviations

dissolved the surfaces of the teeth and made the teeth BMI: Body mass index; BAZ: BMI-for-age Z score; CI: Confidence interval;
dft: Number of decayed and filled teeth in the primary teeth; dt: Number of
vulnerable to caries [48]. decayed primary teeth; HAZ: Height-for-age Z score; MYR: Ringgit Malaysia;
In general, findings of the current study would help SD: Standard deviation; SE: Standard error; WAZ: Weight-for-age Z Score;
dental professionals and policy makers in planning WHO: World Health Organization

dental care services for pre-schoolers. It is important

Acknowledgements
to have routine oral check-up by dentists or nurses The authors would like to thank the Oral Health Division, Ministry of Health
among pre-schoolers in pre-schools. Findings of this and the Department of National Unity and Integration for their support and
study would also serve as a guide in developing ap- cooperation. The authors thank the enumerators for their assistance in data
collection, as well as the teachers, parents, and pre-schoolers for their
propriate dental caries prevention strategies or oral participation.
health promotion programmes for pre-schoolers. Fur-
thermore, educating parents about healthy eating and Authors’ contributions
lifestyle is also important in order to improve oral ZLL, WYG and RH designed the study. ZLL carried out data collection, data
analysis and drafted the manuscript. WYG, PYL and RH contributed to the
health of pre-schoolers. interpretation of findings and provided a critical review of the manuscript.
Several limitations of this study should be addressed. SYL performed the dental examination. All authors read and approved the
This study was a cross-sectional study in which the final manuscript.
causal relationship between the factors and dental caries
Funding
could not be established. Cohort study is necessary to This research was funded by Putra Graduate Initiative (IPS) Grant, grant
establish the relationships between sugar exposure, number GP-IPS/2018/9652600, provided by Universiti Putra Malaysia. The
second-hand smoke exposure and nutritional status with funder had no role in the design of the study, the collection, analysis, and in-
terpretation of data and in writing the manuscript.
dental caries in children. This study was carried out
among pre-schoolers in government pre-schools in one Availability of data and materials
state in Malaysia, which is not representative to all pre- The datasets used and/or analysed during the current study are available
schoolers in Malaysia. Hence, the findings could not be from the corresponding author on reasonable request.

extrapolated to all Malaysian pre-schoolers. Further-

Ethics approval and consent to participate
more, the food record might be subjected to biasness as Ethics approval was sought from the Ethics Committee for Research
mothers might tend to provide socially desirable answer, Involving Human Subjects Universiti Putra Malaysia (Reference No.: JKEUPM-
and not record sweet foods and drinks consumption. As 2018-043). Permissions to conduct the study were obtained from the Oral
Health Division, Ministry of Health and the Department of National Unity and
pre-schoolers have certain extent of autonomy over their Integration. Parents of involved pre-schoolers provided written consent.
food intake, mothers might not be able to accurately rec-
ord every single food or drinks consumed by their child. Consent for publication
Another limitation of this study was that the second- Not applicable.

hand smoked exposure, which is known to be harmful,

Competing interests
may be under-reported by the mothers. Future studies The authors declare that they have no competing interests.
could include other more accurate methods in assessing
second-hand smoke exposure including biomarkers such Author details
1
Department of Nutrition and Dietetics, Faculty of Medicine and Health
as serum cotinine level or hair nicotine level. Further- Sciences, Universiti Putra Malaysia, UPM, 43400 Serdang, Selangor Darul
more, this study did not include oral health behaviours Ehsan, Malaysia. 2Department of Community Health, Faculty of Medicine and
of children, which is considered as one of the significant Health Sciences, Universiti Putra Malaysia, UPM, 43400 Serdang, Selangor
Darul Ehsan, Malaysia. 3School of Dental Sciences, Health Campus, Universiti
risk factors of dental caries. Oral health behaviours such Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia. 4Department of
as toothbrushing practice and dental visits could be pos- Paediatric Dental, Tuanku Ja’afar Hospital, Jalan Rasah, Bukit Rasah, 70300
sible factors that mitigate the effects of sugar exposure Seremban, Negeri Sembilan, Malaysia.
on primary teeth of pre-schoolers. Received: 26 February 2020 Accepted: 27 May 2020

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