Dental Caries Status and its Associated Factors among 3- to

5-year-old Children in China: A National Survey

Min Quan DU1, Zhen LI1, Han JIANG1, Xing WANG2, Xi Ping FENG3, De Yu HU4,
Huan Cai LIN5, Bo WANG2, Yan SI6, Chun Xiao WANG7, Shu Guo ZHENG6, Xue Nan LIU6,
Wen Sheng RONG6, Wei Jian WANG6, Bao Jun TAI1

Objective: To investigate the prevalence and severity of dental caries among pre-school chil-
dren in China as part of the 4th National Oral Health Survey.
Methods: The sampling process was conducted with a multistage stratified cluster method.
A total of 40,360 children aged between 3 and 5 years were recruited for this study. Each
participant was clinically assessed according to the 5th edition of the oral health survey’s
basic methods recommended by the World Health Organization (WHO) and their parents or
grandparents completed a questionnaire at a face-to-face interview. The status of dental car-
ies was shown in the form of the mean dmft and the prevalence of dental caries. The logistic
regression analysis was performed to study the relationships between the prevalence of dental
caries and the selected variables.
Results: The prevalence of dental caries was 50.8%, 63.6% and 71.9% for 3-, 4- and 5-year-
olds, respectively. The mean dmft was 2.28, 3.40 and 4.24, respectively. Logistic regression
analysis showed that children who were mixed-fed had a higher chance of staying free of
dental caries; children who had dessert before going to bed were associated with a higher
probability of caries.
Conclusion: The status of dental caries among preschool children in China is on the increase.
The preschoolers’ dental caries status related to their breastfeeding conditions within the first
6 months of life and their snacking habits.
Key words: China, dental caries, preschool children, epidemiology, the 4th National Oral
Health Survey
Chin J Dent Res 2018;21(3):167–179; doi: 10.3290/j.cjdr.a41076

1 School & Hospital of Stomatology, Wuhan University, Wuhan,

P.R. China.
D ental caries is one of the most widespread chronic
diseases1. It is a major cause of pain, as well as
local and systematic infection2. When it happens in
2 Chinese Stomatological Association, Beijing, P.R. China.
3 Shanghai Ninth People’s Hospital, Shanghai JiaoTong University childhood, a child’s eating patterns, the development of
School of Medicine, Shanghai, P.R. China. permanent dentition and general health will be impact-
4 West China School of Stomatology, Sichuan University, Chengdu,
ed3. Notably, dental caries among preschool children has
P.R. China.
5 Guanghua School of Stomatology, Hospital of Stomatology, seen an alarming increase and is a major public health
Sun Yat-sen University, Guangzhou, P.R. China. issue for children globally4. Preventing preschool chil-
6 Peking University School and Hospital of Stomatology, Beijing, dren from dental caries is of great importance and there
P.R. China.
7 Chinese Center for Disease Control and Prevention, Beijing,
should be no delay.
P.R. China. The People’s Republic of China, a developing coun-
try in East Asia, has a multiracial population of 1.34 bil-
Corresponding author: Dr Bao Jun TAI, School & Hospital of Stoma- lion5. The National Oral Health Survey aims to obtain
tology, Wuhan University, Luoyu Road 237, Wuhan 430079, P.R. China.
Tel: 86 27 87686227; Fax: 86 27 87647443. Email: [email protected]
the current prevalence trends and treatment status of
oral disease and to make policies to decrease its preva-
This study was supported by “Scientific Research Fund of National Health lence. The first survey was conducted in 1983, and the
Commission of the People’s Republic of China (201502002)”. second and third were in 1995 and 2005, respectively.
The status of dental caries among 5-year-old children

Chinese Journal of Dental Research 167

Du et al

is one of its most important parts. The results of these behaviours and their guardians’ socioeconomic status
surveys showed a decline in mean dmft and the preva- was obtained. In addition, the study reported the factors
lence of dental caries for 5-year-old children, although affecting caries status in this population. The results of
these indexes remained high and most caries remains this study would be useful for dental professionals and
untreated6,7. According to a meta-analysis about early policy makers in the planning of dental services for
childhood caries in China from1987 to 2013, the pooled preschool children.
prevalence of dental caries for children aged 3 to 5
years was 40.2%, 54.4% and 64.1%, respectively. A
Materials and methods
declining trend was shown in the prevalence of dental
caries from 1987 to 20048.
Since the most recent national survey in 2005, dra- Ethical clearance
matic changes have happened in China. Due to demo-
graphic alterations (including population growth and This cross-sectional survey was a national study under-
ageing) and economic changes, corresponding dietary taken by the Chinese Stomatological Association. Ethi-
structure, nutritional status and psychosocial develop- cal approval (Approval no. 2014-003) for the study
ment changes have also occurred. Moreover, the gov- was obtained from the Ethics Committee of Chinese
ernment has implemented policies aimed at preventing Stomatological Association and informed consent was
and curing dental caries. All of these factors have an obtained from the guardian of each child.
effect on its status among preschool children.
This study formed part of the 4th National Oral
Selection of subjects and sampling design
Health Survey, which was conducted between 2015
and 2016. It enrolled 3-, 4- and 5-year-old children; The targeted subjects were 3- to 5-year-old children who
previously national surveys on the prevalence of dental had lived in the survey area for more than 6 months,
caries among preschool children in China only recruited and their ages were calculated according to the survey
children aged 5 years. It is the first time the National month.
Oral Health Survey in China has enrolled all three ages. By considering estimated caries prevalence rate
The aim of this part of the study was to investigate (P = 66.0%)(the prevalence of dental caries among
the prevalence, severity and the intraoral distribution 5-year-old children in the 3rd National Oral Health
of dental caries among preschool children in China. Survey, 2005), the design effect (deff = 4.5), the
The information on the children’s oral health-related significance level (Į = 5%), the margin of error
(į = 10%), the calculating formula
   uα / 22
Province
  n =deff SS
(n=1296) į2

Urban Rural and the non-response rate (20%), a study sample of

(n=648) (n=648)
13,392 subjects was targeted for each age group.
For the first time, the survey enrolled all 31 prov-
1 district 1 district 1 county 1 county inces, autonomous regions and municipalities of the
(n=324) (n=324) (n=324) (n=324)
mainland of China. Multistage stratified cluster sam-
pling was used to select participants. As presented in
Figure 1, in the first stage, probability proportional
to size (PPS) design was used to randomly select two
1 kindergarten 1 kindergarten 1 kindergarten 1 kindergarten 1 kindergarten 1 kindergarten urban areas and two rural areas from each province after
(n=108) (n=108) (n=108)
(n=108) (n=108) (n=108)
the division of urban and rural areas in each province.
In the second stage, the PPS method was used to select
three kindergartens randomly from each area. In the
third stage, a random sample of 36 children with equal
3 year olds 4 year olds 5 year olds 3 year olds 4 year olds 5 year olds
sex distribution of each age group was recruited at each
(n=36) (n=36) (n=36) (n=36) (n=36) (n=36) kindergarten. Some children were recruited from the
local community when the chosen kindergartens could
Fig 1 Sampling process. not provide enough subjects.

168 Volume 21, Number 3, 2018

 Du et al

Clinical examination ‡ Early life factors: birth weight, feeding approaches

within the first 6 months of life;
Every participant received a clinical assessment ‡ Oral health-related behaviours: toothbrushing behav-
according to the Fifth Edition of the Oral Health Survey iour, sugar intake behaviour, dental attendance expe-
Basic Methods, as recommended by the WHO9. The rience;
oral health assessment form included identification ‡ Family factors: household income, parents’ education
information (gender, age and ethnicity) and condition levels, parents’ dental knowledge and attitude.
of the teeth (coronal caries). The subject sat on a mobile
dental chair during the examination. Three trained
Statistical analysis
examiners examined subjects with a plane mouth mir-
ror and a Community Periodontal Index (CPI) probe Data analysis was performed using the SPSS (PC ver-
under artificial light. Food debris was gently removed sion 21.0) software with the level of statistical signifi-
before the inspection. Caries experience was assessed cance set at P < 0.05. Children with missing data were
in the form of the dmft index and scored according to excluded from the analysis. Initially, we performed
WHO standard criteria. It means a tooth was recorded descriptive analyses and the dental caries status was
as decayed (dt) when a lesion had an unmistakable shown in the form of the mean dmft and the prevalence
cavity, undermined enamel, or a detectably softened of dental caries. In addition, the Significant Caries Index
floor or wall; a tooth that was sealed but also decayed, (SiC, the mean dmft of one-third of the population with
was included as well. A tooth was recorded as missing the highest caries scores) was calculated.
(mt) when it was extracted due to caries. For missing Then the chi-square test was performed to test the
primary teeth, this score should be used only if the association of the prevalence of dental caries with the
subject is at an age when normal exfoliation would not selected variables. ANOVA was employed to study
be a sufficient explanation for absence. A tooth was the distribution of dmft scores according to different
recorded as filled (ft) when it was permanently filled variables. Afterwards, the logistic regression model was
without caries9. taken into account to study the relationships between
Three trained licensed dental practitioners who had the prevalence of dental caries and the selected vari-
been calibrated following WHO guidelines performed ables. The enter method was used in the logistic regres-
the examination. Three trained individuals with clin- sion. Odds ratios (ORs) and 95% confidence intervals
ical experience served as recording clerks. Before the (95% CI) were reported as the measure of association.
survey, every examiner was calibrated with the other
two examiners and a fourth examiner, who acted as the
Results
standard examiner in the same setting. Each examiner
then examined a group of 10 pre-selected subjects twice In total, 12,390 3-year-olds, 13,978 4-year-olds and
on the following day to assess the consistency. During 13,992 subjects aged 5 years respectively, were recruited
the survey, a 5% random sample of the children was re- for the study. Each child was clinically examined and
examined on the same day to assess the intra-examiner their parents or grandparents were invited to complete
agreement. Moreover, an experienced dental epidemi- questionnaires.
ologist re-examined half of the teeth for five of the sub- The prevalence of dental caries was 50.8%, 63.6%
jects who had been assessed by other examiners. Kappa and 71.9% for 3-, 4- and 5-year-olds, respectively.
values were calculated and inter- and intra-examiner The mean dmft (SD) was 2.28 (3.41), 3.40 (4.15)
reproducibilities were > 0.80. and 4.24 (4.48), respectively. The Significant Caries
Index (SiC) (SD) was 6.04 (3.57), 8.24 (3.65) and
9.61(3.40), respectively. The constituent ratio of ft was
Questionnaire
1.5%, 2.9% and 4.1%, respectively. Table 1 presents
The subject’s parents or grandparents completed a ques- the prevalence of dental caries, the mean dmft and the
tionnaire through a face-to-face interview. Two trained SiC according to gender, age and area. All of these
individuals with clinical experience acted as investiga- indices showed an increasing trend with age. And all
tors, with one in charge of the quality of the question- of these values were higher in rural areas than in urban
naire survey. In districts where dialect was difficult to areas. No difference was found for gender in all of the
understand, a local person also acted as an assistant. three age groups.
The questionnaire consisted of four parts: A positively skewed distribution of the dmft score
‡ The respondent’s relationship to the child; was revealed, with skewness values of 2.0, 1.4 and

Chinese Journal of Dental Research 169

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Table 1 The caries status of 3- to 5-year-old children of China (2015–2016).

Prevalence Mean dmft

Variables N dt (SD) mt (SD) ft (SD) SiC(SD)
of dental caries (SD)

3 years

Total 12,390 50.8% 2.25 (3.38) 0.00 (0.07) 0.03 (0.36) 2.28 (3.41) 6.04 (3.57)

Area

Urban 6,366 48.9% 2.08 (3.26) 0.00 (0.06) 0.05 (0.45) 2.13 (3.32) 5.71 (3.60)

Rural 6,024 52.8% 2.42 (3.48) 0.00 (0.07) 0.02 (0.24) 2.44 (3.50) 6.38 (3.51)

Gender

Male 6,186 50.9% 2.27 (3.38) 0.00 (0.08) 0.03 (0.35) 2.30 (3.41) 6.07 (3.55)

Female 6,204 50.6% 2.23 (3.37) 0.00 (0.04) 0.04 (0.37) 2.27 (3.42) 6.01 (3.60)

4 years

Total 13,978 63.6% 3.29 (4.07) 0.01 (0.10) 0.10 (0.63) 3.40 (4.15) 8.24 (3.65)

Area

Urban 7,031 61.7% 2.99 (3.81) 0.01 (0.11) 0.15 (0.77) 3.14 (3.94) 7.72 (3.55)

Rural 6,947 65.6% 3.60 (4.29) 0.01 (0.08) 0.05 (0.43) 3.66 (4.33) 8.77 (3.68)

Gender

Male 7,028 63.7% 3.37 (4.11) 0.01 (0.10) 0.10 (0.65) 3.47 (4.19) 8.40 (3.60)

Female 6,950 63.6% 3.22 (4.03) 0.01 (0.10) 0.10 (0.61) 3.32 (4.10) 8.08 (3.70)

5 years

Total 13,992 71.9% 4.06 (4.39) 0.01 (0.16) 0.17 (0.79) 4.24 (4.48) 9.61 (3.40)

Area

Urban 7,091 70.4% 3.78 (4.22) 0.01 (0.16) 0.23 (0.93) 4.03 (4.35) 9.23 (3.37)

Rural 6,901 73.4% 4.34(4.54) 0.01(0.16) 0.11(0.61) 4.47(4.60) 9.98(3.42)

Gender

Male 7,031 72.2% 4.09(4.41) 0.01(0.15) 0.18(0.79) 4.27(4.49) 9.64(3.42)

Female 6,961 71.6% 4.03(4.37) 0.01(0.17) 0.17(0.78) 4.21(4.47) 9.57(3.40)

1.1 among 3-, 4- and 5-year-olds, respectively (Fig 2). Tables 2 and 3 present the comparison of the
Maxillary central incisors had the highest prevalence of prevalence of dental caries and mean dmft for selected
dental caries, while mandibular incisors had the lowest. variables respectively. Exclusively or predominantly
Among anterior teeth, the prevalence of dental caries in breastfed, having dessert before sleep, having dessert
maxillary teeth was higher than that in mandibular teeth. more than twice a day, lower parental dental knowledge
In posterior teeth, the condition was opposite (Fig 3). or attitude score, a lower parental level of education,

170 Volume 21, Number 3, 2018

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Fig 2 The frequency distribution of the dmft of the 3-, 4- and 5-year-old children.

Fig 3 Distribution of teeth with dmf caries of the 3-, 4- and 5-year-old children by tooth position.

lower household income and starting toothbrushing Additionally, guardians’ knowledge and attitude was
at a later age were all associated with caries in the described in detail and we found those living in urban
primary dentition in all three age groups. Three-year- areas had a higher awareness rate in terms of knowl-
old children with a normal birth weight had a higher edge and attitude than those guardians from rural area
prevalence of caries than those who did not, while no (Figs 4 and 5).
difference was found among children aged 4 and 5.

Chinese Journal of Dental Research 171

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Table 2 Chi-square test for relationship of the prevalence of dental caries and selected variables.

3 years 4 years 5 years

Categories
Prevalence P value Prevalence P value Prevalence P value

Area 0.000 0.000 0.000

Urban 48.9% 61.7% 70.4%

Rural 52.8% 65.6% 73.4%

Birth weight 0.029 0.670 0.235

Low (< 2500 g) 43.9% 64.5% 68.6%

Normal (≥ 2500 g) 50.8% 63.4% 71.6%

Breastfeeding 0.000 0.000 0.000

Exclusively breastfed 54.6% 66.6% 74.8%

Predominantly breastfed 53.9% 67.0% 73.2%

Mixed fed (50/50) 39.7% 56.1% 65.4%

Predominantly formula fed 47.2% 57.5% 67.0%

Exclusively formula fed 47.4% 60.5% 69.3%

Sugar intake frequency 0.000 0.000 0.000

Less often then daily 48.9% 62.1% 70.1%

Once a day 50.7% 63.7% 71.4%

Twice a day or more 54.3% 66.8% 77.2%

Dessert before sleep 0.000 0.000 0.000

Often 58.0% 69.7% 78.1%

Sometimes 53.7% 66.2% 74.7%

Never 44.8% 58.4% 66.5%

Toothbrushing 0.797 0.006 0.000

Yes 50.7% 62.9% 70.8%

No 50.9% 65.3% 74.8%

Age when toothbrushing started 0.044 0.000 0.000

Before or within first year 46.9% 55.4% 64.7%

After the first year 50.7% 64.0% 72.1%

Parental dental knowledge 0.000 0.000 0.007

Score 0–2 53.7% 66.9% 73.2%

Score 3–5 52.5% 65.1% 72.8%

Score 6–8 48.6% 61.3% 70.5%

Parental dental attitude 0.022 0.000 0.016

Score 0–2 53.6% 66.8% 76.2%

Score 3–4 52.4% 66.3% 71.9%

Score 5–6 50.0% 62.3% 71.5%

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 Du et al

3 years 4 years 5 years

Categories
Prevalence P value Prevalence P value Prevalence P value

Parental education level 0.000 0.000 0.000

Up to primary school 54.6% 65.2% 73.8%

Junior middle school 53.5% 66.9% 74.1%

Senior middle school 50.6% 63.4% 72.4%

Higher education 47.3% 59.7% 67.9%

Household income 0.018 0.000 0.008

Very low (< 6000 Yuan) 53.5% 67.2% 72.6%

Low (6000-12000 Yuan) 51.2% 66.3% 72.8%

Medium (12000-18000 Yuan) 51.0% 63.1% 70.4%

High (18000-27000 Yuan) 50.4% 60.8% 68.4%

Very high (≥ 27000 Yuan) 47.3% 59.1% 68.9%

Table 3 ANOVA for relationship of mean dmft and selected variables.

3 years 4 years 5 years

Mean dmft P value Mean dmft P value Mean dmft P value

Area 0.000 0.000 0.000

Urban 2.13 3.14 4.03

Rural 2.44 3.66 4.47

Birth weight 0.346 0.298 0.521

Low (< 2500 g) 2.08 3.15 4.05

Normal (≥ 2500 g) 2.28 3.39 4.21

Breastfeeding 0.000 0.000 0.000

Exclusively breastfed 2.53 3.72 4.60

Predominantly breastfed 2.47 3.53 4.35

Mixed fed (50/50) 1.64 2.69 3.44

Predominantly formula fed 1.98 2.89 3.67

Exclusively formula fed 2.07 3.20 4.02

Sugar intake frequency 0.000 0.000 0.000

Less often then daily 2.12 3.20 3.97

Once a day 2.31 3.30 4.24

Twice a day or more 2.57 3.92 4.98

Dessert before sleep 0.000 0.000 0.000

Often 2.94 4.43 5.00

Sometimes 2.49 3.61 4.56

Never 1.83 2.84 3.63

Chinese Journal of Dental Research 173

Du et al

3 years 4 years 5 years

Mean dmft P value Mean dmft P value Mean dmft P value

Toothbrushing 0.648 0.000 0.000

Yes 2.27 3.28 4.12

No 2.30 3.65 4.61

Age when toothbrushing started 0.017 0.000 0.000

Before or within first year 1.97 2.63 3.40

After the first year 2.27 3.43 4.27

Oral health knowledge 0.000 0.000 0.000

Score 0–2 2.46 3.79 4.61

Score 3–5 2.39 3.50 4.30

Score 6–8 2.15 3.19 4.08

Oral health attitude 0.226 0.001 0.007

Score 0–2 2.44 3.80 4.70

Score 3–4 2.35 3.52 4.28

Score 5–6 2.25 3.32 4.19

Parental education level 0.000 0.000 0.000

Up to primary school 2.64 3.66 4.48

Junior middle school 2.45 3.67 4.57

Senior middle school 2.22 3.39 4.30

Higher education 2.05 2.98 3.72

Household income 0.000 0.000 0.001

Very low (< 6000 Yuan) 2.52 3.67 4.17

Low (6000-12000 Yuan) 2.25 3.60 4.43

Medium (12000-18000 Yuan) 2.46 3.23 4.00

High (18000-27000 Yuan) 2.13 3.23 3.92

Very high (≥ 27000 Yuan) 1.94 2.96 3.90

Logistic regression analysis was used to assess vari- Discussion

ables contributing to dental caries in children. Table 4
illustrates the relationships among selected variables in The results of this study showed remarkable increasing
the regression model. In all three age groups, children trends of prevalence in both urban and rural areas among
who were mixed-fed had a higher chance of remaining all three age groups.
caries-free. Children who had dessert before sleep were Compared with the statistics obtained from the third
associated with a higher probability of caries. Also, for national survey, the prevalence of caries had increased
children aged 4 and 5 years, those who began brushing from 66.0% to 71.9% and the mean dmft changed from
their teeth later in life and ate more sugar more fre- 2.71 to 4.23 in 5-year-old children7, which was far from
quently had a higher probability of caries. the goal of a no-caries rate of 50% in individuals aged
5 years established for the year 2020 by the WHO10.

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 Du et al

Fig 4 Oral health attitude: Item 1: Oral health

is important; Item 2: Regular oral health exam-
ination is necessary; Item 3: The health of the
teeth is not decided at birth and the efforts of
yourself work as well; Item 4: Oral disease pre-
vention mainly depends on yourself; Item 5: It
is important to protect your children’s first per-
manent molar; Item 6: The condition of maternal
teeth will affect their children.

Fig 5 Oral health knowledge: Item 1: Gingi-

val bleeding is abnormal when toothbrushing;
Item 2: Bacteria can cause gingival inflamma-
tion; Item 3: Toothbrushing can prevent gingi-
val bleeding; Item 4: Bacteria can cause dental
caries; Item 5: Sugar intake can lead to dental
caries; Item 6: Deciduous dental caries can-
not be left alone; Item 7: Pit and fissure sealing
can prevent children from dental caries; Item 8:
Fluoride can protect teeth.

In Indonesia, a country whose per capita GDP is much increased compared with the caries status obtained in
lower than China, the prevalence of dental caries among the previous study – from 41.4% to 50.8% and from
5-year-olds (90%) was much higher than that we found 53.4% to 63.6%, respectively8. The prevalence reported
in China11. Compared with Thailand, a country similar in Japan was only 8.6% among 3-year-olds13. This dif-
to China in terms of per capita GDP, we found the two ference between the two populations alarmed us that the
countries had similar prevalence (78.5%) and mean prevalence of dental caries in China was severe even
dmft (4.4)12. Compared with caries status found in at a low age and it is therefore necessary to prevent
many industrialised countries, the caries status in China children from dental caries at an earlier age in China.
was more severe. Among 5-year-olds, the prevalence There are many possible explanations for this
in Japan13 and Singapore14 were only 39% and 49%, increasing trend. Despite all the efforts to control the
respectively. The caries level of 3- and 4-year-olds also prevalence of dental caries, there was a marked increase

Chinese Journal of Dental Research 175

Du et al

Table 4 Logistic regression analysis.

95% C.I.

P value Exp (B) Lower Upper

3 years

Urban vs rural 0.277 1.054 0.959 1.159

Low birth weight vs normal birth weight 0.219 1.140 0.925 1.405

Breastfeeding

Exclusively breastfed 0.000 Reference group

Predominantly breastfed 0.305 0.936 0.826 1.062

Mixed fed (50/50) 0.000 0.481 0.413 0.559

Predominantly formula fed 0.001 0.745 0.625 0.887

Exclusively formula fed 0.000 0.705 0.616 0.806

Sugar intake frequency 0.309 1.021 0.981 1.064

Dessert before sleep 0.000 1.359 1.259 1.468

Toothbrushing vs not 0.043 0.903 0.819 0.997

Before or within first year vs later 0.471 1.079 0.878 1.326

Parental dental attitude 0.884 1.004 0.956 1.054

Parental dental knowledge 0.225 0.981 0.951 1.012

Parental education level 0.006 0.928 0.880 0.978

Household income

Very low (< 6000 Yuan) 0.546 Reference group

Low (6000-12000 Yuan) 0.264 0.916 0.786 1.068

Medium (12000-18000 Yuan) 0.404 0.937 0.803 1.092

High (18000-27000 Yuan) 0.843 0.984 0.839 1.154

Very high (≥ 27000 Yuan) 0.179 0.891 0.754 1.054

4 years

Urban vs rural 0.178 1.066 0.971 1.171

Low birth weight vs normal birth weight 0.521 1.070 0.870 1.315

Breastfeeding

Exclusively breastfed 0.000 Reference group

Predominantly breastfed 0.334 0.941 0.831 1.065

Mixed fed (50/50) 0.000 0.671 0.581 0.774

Predominantly formula fed 0.000 0.626 0.530 0.740

Exclusively formula fed 0.000 0.769 0.672 0.879

Sugar intake frequency 0.001 1.070 1.027 1.116

Dessert before sleep 0.000 1.349 1.250 1.456

Toothbrushing vs not 0.931 1.004 0.908 1.111

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 Du et al

95% C.I.

P value Exp (B) Lower Upper

Before or within first year vs later 0.010 1.318 1.068 1.627

Parental dental attitude 0.826 0.995 0.948 1.043

Parental dental knowledge 0.016 0.964 0.935 0.993

Parental education level 0.973 1.001 0.950 1.055

Household income

Very low (< 6000 Yuan) 0.010 Reference group

Low (6000-12000 Yuan) 0.507 0.952 0.822 1.101

Medium (12000-18000 Yuan) 0.092 0.877 0.753 1.022

High (18000-27000 Yuan) 0.004 0.795 0.680 0.930

Very high (≥ 27000 Yuan) 0.003 0.778 0.659 0.918

5 years

Urban vs rural 0.598 1.027 0.931 1.133

Low birth weight vs normal birth weight 0.887 0.985 0.799 1.214

Breastfeeding

Exclusively breastfed 0.000 Reference group

Predominantly breastfed 0.113 0.900 0.791 1.025

Mixed fed (50/50) 0.000 0.670 0.578 0.777

Predominantly formula fed 0.018 0.797 0.661 0.963

Exclusively formula fed 0.000 0.771 0.670 0.886

Sugar intake frequency 0.000 1.159 1.106 1.216

Dessert before sleep 0.000 1.330 1.224 1.444

Toothbrushing vs not 0.348 1.055 0.943 1.181

Before or within first year vs later 0.001 1.469 1.165 1.852

Parental dental attitude 0.394 1.022 0.972 1.073

Parental dental knowledge 0.561 1.009 0.978 1.041

Parental education level 0.141 0.959 0.908 1.014

Household income

Very low (< 6000 Yuan) 0.226 Reference group

Low (6000-12000 Yuan) 0.960 1.004 0.862 1.169

Medium (12000-18000 Yuan) 0.268 0.915 0.782 1.071

High (18000-27000 Yuan) 0.057 0.854 0.726 1.005

Very high (≥ 27000 Yuan) 0.197 0.891 0.748 1.062

Chinese Journal of Dental Research 177

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in economic development over the period of time In conclusion, dental caries status among preschool
reviewed in the survey15. The rise of the per capita GDP children in China showed an increased trend compared
had increased significantly since 2005, compared with with the last national survey. The preschoolers’ dental
the period from 1995 to 2005. It resulted in a higher caries status related to their breastfeeding conditions
sugar intake, while access to oral healthcare was still within the first half year of life and their snacking hab-
absent16. This might be responsible for this trend17. its. It is important to identify the factors leading to the
What is more, the significant difference of the status observed trends and corresponding action should be
of caries between urban and rural areas was still alarm- taken to prevent dental caries.
ing. There were many possible explanations for the
higher level of dental caries and lower level of teeth
Conflicts of interest
being filled in rural areas. The higher awareness rate
in all items of guardians’ knowledge and attitude in The authors reported no conflicts of interest related to
urban rather than rural areas may explain the difference. this study.
Another possible explanation was the lack of access to
dental care in some rural areas16.
Author contribution
Regarding guardians’ dental knowledge and attitude,
the proportion of people who knew that pit and fissure Drs Min Quan DU, Han JIANG and Bao Jun TAI,
sealing can prevent children from dental caries and that designed the study, acquired the data and revised the
fluoride can protect teeth was extremely low (Figs 4 manuscript; Dr Zhen LI analysed the data and prepared
and 5). Consequently, policy makers should pay more the manuscript; Drs Xing WANG, Xi Ping FENG, Bao
attention to the propaganda and the use of pit and fis- Jun TAI, De Yu HU, Huan Cai LIN, Bo WANG, Shu
sure sealing and fluoride in its various forms. Guo ZHENG, Xue Nan LIU, Wen Sheng RONG and
What interested us was that the children in this study Wei Jian WANG trained the investigators, designed and
who were exclusively or predominantly breastfed in the supervised the survey. All the authors have read and
first six months of life had a higher prevalence of dental approved the final manuscript.
caries, although this behaviour was recommended by
the WHO18. Similar results were found in the previous (Received May 20, 2018; accepted June 18, 2018)
national study conducted in 200519. Furthermore, a
longitudinal study in 2015 about the association of car-
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