Indian Journal of Public Health Research & Development, March 2020, Vol. 11, No.

03 1797

The Crucial Dentist Role Toward Stunting Prevention in

Indonesia

Alexander Patera Nugraha1, Fianza Rezkita2, Andari Sarasati2

1
Orthodontics Department, Faculty of Dental Medicine, Universitas Airlangga, Surabaya, Indonesia,
2Undergraduate Student, Faculty of Dental Medicine, Universitas Airlangga, Surabaya, Indonesia

Abstract
Introduction: Stunting is considered as one of the main indicators of children’s welfare and socioeconomic
conditions. Stunting in children can cause health and mental development problems also decreased
productivity and intellectual capacity.Stunting growth was found to have a significant correlation with
various dental health problems, such as dental caries.

Aims: This study was done to summarize and describe the dentist crucial role toward stunting prevention
and its control in Indonesia.

Method: This independent literature search was made by the team from different databases which are:
PubMed, NCBI, Hindawi, Oxford Academic, Scopus, PLoS One, ScienceDirect, and ResearchGate with the
keywords: Stunting, Nutrition, Oral Health, Pregnancy, Low Birth Weight, and Early Childhood Caries. The
criteria for data collection including (1) cross-sectional study, an observational study, cohort study, clinical
trials and reviews, (2) in English and Bahasa, (3) from the past 7 years from 2012 to 2019.

Results: Twenty seven studies that related to the keyword were studied.

Conclusion: Stunting in Indonesia has a relationship with the health conditions of the oral cavity in the
mother and child through the influence of the provision of diet and nutrition by the mother which relatable
to education, behavior, and socioeconomic circumstances of the family. Furthermore, dentists have an
important role in reducing stunting in Indonesia

Keywords: Early Childhood Caries, Low Birth Weight, Nutrition, Oral Health, Low Birth Weight, Stunting.

Introduction indicators of children’s welfare and socioeconomic

conditions. Stunting in children can cause health
Stunting is a chronic deficiency nutritional status
and mental development problems also decreased
condition in a critical period of child development which
productivity and intellectual capacity.1 Based on WHO,
affects the child’s height that is not appropriate for the
162 million children under 5 years old were stunted,
child’s age. Stunting is considered as one of the main
whereas, according to the Indonesian Basic Health
Research (RISKESDAS), the prevalence of stunting
children in Indonesia in 2018 (30.4%) had decreased
Coresponding Author: compared to 2013 (37.2%), however the number still
Alexander Patera Nugraha in high prevalence according to indicator from included
DDS., MSc. Orthodontics Department, Faculty of World Health Organization.2-4
Dental Medicine, Universitas Airlangga, Surabaya,
Indonesia. Stunting growth was found to have a significant
Phone: +62315030255. correlation with various dental health problems.
e-mail: [email protected] Global Burden of Disease Study in 2016 estimates that
1798 Indian Journal of Public Health Research & Development, March 2020, Vol. 11, No. 03
approximately 3.58 billion people worldwide has oral two Ministry of Health Republic of Indonesia regulation
health problem with 486 million children suffering from article, one longitudinal study, three case control
deciduous dental caries. The number of deciduous dental study, one thesis paper, one path analysis study, one
caries was found to be high in children with underweight commentary and opinion from expert, three cohort study,
and stunting. Dental caries in children can cause eating and two article from World Health Organization website
and sleep disorders which result in disruption of nutrition were studied. In all mentioned studies, malnutrition, low
consumption and growth hormone secretion.5,6 birth weight, early childhood caries, stunting, pregnancy,
dentist role for stunting prevention and control were
Oral health is an important component in investigated. The studies and interventions presented in
comprehensive body health. Healthy oral cavity can this investigation are as follows: educational programs
facilitate the consumption of a nutritious diet properly, related to stunting, healthy pregnancy, oral hygiene, low
maintain quality of life, and maintain productivity. birth weight early childhood caries.
Children’s oral health is a complex concept and involves
various factors, such as genetic, biological, behavioral, Discussion
social, and environmental.7 Maintaining the health of
the child’s oral cavity is one of the vital steps parents Stunting: Stunting is a chronic problem of child
must take in maintaining children’s health and growth growth and development that causes a comparison
comprehensively.8 of the development of height-and-age of the child
being two points (moderate stunting) and three points
Disease prevention can be done not only after the (severe stunting) below the median standard deviation
child is born, but also done while the child is still in calculation numbers (height-for-age-score) established
the womb. Nutrition consumed by the mother during by WHO. The etiology of stunting divided into external
pregnancy can affect the process of fetal development. factors such as family socio-economic conditions and
Pregnant women need more nutrition and diet to internal factors such as nutrition and maternal oral health
accommodate the energy and nutritional needs of the conditions.11
baby’s growth and maternal health.9Indonesian dentists
can contribute in realizing the reduction in the number of Nutrition: Mother has a critical role in the
stunting based on the Regulation of Minister of Health occurrence of stunting in children. Inadequate maternal
Regulation of the Republic of Indonesia (PERMENKES nutritional conditions can cause growth and development
RI) No. 39 of 2016 by contributing to integrated antenatal delayed.12 Nutrition for children in Indonesia is still
care (ANC), first 1000 day interventions, and assisting in inadequate. WHO states that only 34.8% of babies in
early detection of disease in Indonesia.10This study was the world receive exclusive breast milk.The prevalence
done to summarize and describe the dentist crucial role of exclusive breastfeeding in Indonesia was only
toward stunting prevention and its control in Indonesia. 54.3% and 33.7% in the province of West Java.13 The
study concluded that 71.4% of stunting patients did
Materials and Method not get exclusive breastfeeding. In addition, a study in
Yogyakarta also found that children who did not receive
This independent literature search was made from exclusive breastfeeding had a risk of stunting 1.74 times
different databases which are: PubMed, NCBI, Hindawi, higher.14Studies in Surakarta in children aged 24-59
Oxford Academic, Scopus, PLoS One, ScienceDirect, months also found a significant correlation between the
and ResearchGate. It was conducted with the keywords: incidence of stunting with non-exclusive breastfeeding,
Stunting, Nutrition, Oral Health, Pregnancy, Low Birth which can conclude that breastfeeding in children is
Weight, and Early Childhood Caries. The criteria for crucial in the development of children.15
data collection including (1) cross-sectional study, an
observational study, cohort study, clinical trials and The high correlation between stunting and non-
reviews, (2) in English and Bahasa, (3) from the past 7 exclusive breastfeeding is caused by very high nutritional
years from 2012 to 2019. requirements in children. Breast milk contains bioactive
substances such as cells, immune factors, hormones,
Results anti-infective agents, anti-inflammatory agents, growth
Twenty seven studies, including six cross sectional factors, and prebiotics that can protect children from
study, five systematic analyses, four retrospective study, infection and inflammation and play a role in the
 Indian Journal of Public Health Research & Development, March 2020, Vol. 11, No. 03 1799
development of the immune system and organs.16Mothers East Java and North Sumatra, Indonesia mentioned
with malnutrition are found to have a possible risk of that mothers with low education tend to have stunting
having a child with a stunting state.17Poor nutritional child.23-25A low socioeconomic condition is a risk factor
conditions can affect oral tissue balance, such as the for caries and stunting.26
occurrence of late tooth eruption, periodontal disease,
and caries.6 Early Childhood Caries: Early Childhood Caries
(ECC) is a health problem of the oral cavity in the
Golden period: 1000 days Consumption of adequate form of one or more deciduous teeth which are decay,
nutrition plays an important role in children’s functional filling, or missing in children aged 71 months (5 years)
health, especially in the first 1000 days of life, including or younger.27 The incidence of ECC in children with
when in the womb and the first 2 years since birth. This primary teeth reaches 1.76 billion worldwide and
period is a vulnerable period in child development hence the prevalence of ECC in Indonesia is still very high,
adequate nutrition is needed.18 Growth in this period reaching 81.7% in 2013. ECC develop rapidly and occur
is very sensitive to the state of nutrition, hormonal in teeth shortly after the tooth erupts even in areas of
and metabolism, which plays an important role in the teeth that have a low risk of caries. ECC is related to
development of body organs. Organ growth is known various other health problems, such as pain, infection,
to take place briskly until it reaches its peak in the 20th abscesses, mastication disorders, malnutrition, digestive
week of pregnancy. Inadequate fulfillment nutrition in disorders, and sleep disorders.28
this period causes stunting, where children with stunting
have a state of poor growth and health, and are prone ECC is a multifactorial disease that occurs due to
to infectious, cardiovascular, metabolic, hypertensive, various factors, such as cariogenic microorganisms,
diabetes mellitus and low cognitive abilities.16Lack carbohydrate exposure through improper feeding, and
of nutrition during pregnancy and the environment poor oral hygiene practices. The prevalence of caries in
around the mother can affect epigenomic regulation children was 22.5 times higher in mothers with caries.
through changes in gene and protein expression, which This is related to the level of education and understanding
can increase the risk of disorders related to body of the mother’s health of the child’s oral cavity. Errors in
metabolism.18,19 the provision of nutritional food to children, such as milk
at night and the addition of sugar to milk, are the main
Low Birth Weight: Children born with the risk factors for ECC. 50.6% of mothers ate child food
condition of Low Birth Weight (LBW) indicate the before it was given to children, 29.9% blew the food
nutritional condition and health of both the baby and and 14.3% kissed children on the lips. These things can
the mother disturbance. Nutritional deficiencies during cause transmission of cariogenic bacteria from mother to
pregnancy can cause the child to be born with LBW. child, which triggers ECC.29
The children with LBW have the risk of stunting 3:12
times higher than children of normal weight at birth. Dentist Role and Future Plans: The Indonesian
LBW occurs due to nutritional deficiencies in pregnant government has determined various activities as an effort
women that supported with various factors such as to reduce the occurrence of stunting in the PERMENKES
family conditions, socio-economic conditions, parental RI No. 39 of 2016. Efforts are made aimed at various
education, and examinations during pregnancy and after categories, namely: pregnant women, toddlers, school-
childbirth.20,21Poor oral conditions in pregnant women age children, adolescents, and young adults. As a dentist,
can affect the fetus. The pregnant women with chronic there are a number of things that can be done to take part
apical periodontitis associated with the occurrence in reducing the number of stunting in Indonesia, such
of LBW because this situation will produce pro- as participating in contributing to ANC, the first 1000
inflammatory cytokines that affect systemic conditions days of interventions, and helping in early detection of
that can flow into the womb and fetus.22 disease.10

Behavior: Mother’s education also has an important According to WHO in 2016, nutrition intervention
role, mothers with higher education care more about during pregnancy is one of the top priorities in ANC.
nutrition, holistic and oral cavity hygiene, and the health Poor nutrition in pregnant women will cause interference
care of their children.1Meanwhile, based on various with the mother and fetus. Oral cavity is the first entrance
studies conducted in Dale Woreda, Southern Ethiopia, to food into the body before it is further processed in the
1800 Indian Journal of Public Health Research & Development, March 2020, Vol. 11, No. 03
gastrointestinal tract (GIT), therefore poor oral health Situation in Indonesia. Data Windows and Health
will cause a decrease in nutrient absorption and can Information Bulletin. 2018;1:1-56
cause the mother to lack nutrition hence it can affect 4. Daselgn, B., Kinfe, E., Fikre, K., Bosha, T. Stunting
the fetus. In addition, diseases in the oral cavity, one of and Its Associated Factors in Under Five Years
which is periodontitis, can cause fetal problems such as Old Children: The Case of Hawassa University
preeclampsia. This has encouraged Indonesian dentists to Technology Villages, Southern Ethiopia. IOSR-
maintain good oral health in pregnant women. After the JESTFT. 2016;10(11): 25-30.
child is born, the dentist can endure in contributing to the
5. Dimaisip-Nabuab, J., Duijster, D., Benzian, H.,
first 1000 days of intervention by maintaining the state
Heinrich-Weltzien, R., Homsavath, A., Monse, B.,
of the child’s oral cavity to create a healthy oral cavity
Sithan, H., Stauf, N., Susilawati, S., Kromeyer-
thus the nutrients given to the baby can be absorbed
Hauschild, K. Nutritional status, dental caries and
properly. The dentist can also play a role in helping
tooth eruption in children: a longitudinal study
detect diseases based on the characteristics that appear in
in Cambodia, Indonesia and Lao PDR. BMC
the oral cavity of the mother and child, thusly treatment
Pediatrics 2018;18(1):1-11.
can be done before the situation worsen. This indicates
that dentist plays an important role in maintaining oral 6. Sheetal, A., Hiremath, V.K., Patil, A.G., Sajjansetty,
health as the main pathway for the entry of nutrients into S., Kumar, S.R. Malnutrition and its oral outcome -
the body hence nutrients can be absorbed by both mother a review. J Clin Diagn Res. 2013;7(1):178–180.
and child.2,30 7. Casamassimo, P.S., Lee, J.Y., Marazita, M.L.,
Milgrom, P., Chi, D.L., Divaris, K. Improving
Conclusion children’s oral health: an interdisciplinary research
framework. J Dent Res. 2014;93(10):938–942.
Stunting in Indonesia has a relationship with the
health conditions of the oral cavity in the mother and 8. Collins, C.C., Villa-Torres, L., Sams, LD., Zeldin,
child through the influence of the provision of diet and LP., Divaris, K. Framing Young Childrens Oral
nutrition by the mother which relatable to education, Health: A Participatory Action Research Project.
behavior, and socioeconomic circumstances of the PLoS ONE 11(8): e01617
family. Dentists have an important role in reducing 9. Woldeamanuel, G.G., Geta, T.G., Mohammed, T.P.,
stunting in Indonesia through roles that are adapted Shuba, MB., Bafa, TA. Effect of nutritional status
with Minister of Health Regulation of the Republic of of pregnant women on birth weight of newborns
Indonesia. Meanwhile, Further study is still required. at Butajira Referral Hospital, Butajira, Ethiopia.
SAGE Open Med. 2019;7:2050312119827096.
Ethical Clearance: Ethical approval was granted
10. Ministry of Health Republic of Indonesia. The
by Airlangga University,Surabaya.
reduction in the number of stunting based on the
Source of Funding: self-Funding. Regulation of Minister of Health Regulation of
the Republic of Indonesia (PERMENKES RI)
Conflict of Interest: Nil. No. 39 [Internet]. 2016 [cited on August 2019].
Available from http://www.depkes.go.id/resources/
References download/lain/PMK_No.39_ttg_PIS_PK.pdf.
1. Abeway, S., Gebremichael, B., Murugan, R., Assefa, 11. Daselgn, B., Kinfe, E., Fikre, K., Bosha, T. Stunting
M., Adinew, Y. Stunting and Its Determinants and Its Associated Factors in Under Five Years
among Children Aged 6–59 Months in Northern Old Children: The Case of Hawassa University
Ethiopia: A Cross-Sectional Study. Journal of Technology Villages, Southern Ethiopia. IOSR-
Nutrition and Metabolism. 2018:1078480:1-8. JESTFT. 2016;10(11):25-30.
2. World Health Assembly. WHA Global Nutrition 12. Indriyani, E., Dewi, Y.,Salimo, H. Biopsychosocial
Target 2025: Policy Brief. [Internet] 2016 [cited Determinants of Stunting in Children Under Five:
on 2019 August]. Available from https://www. A Path Analysis Evidence from the Border Area
who.int/nutrition/topics/globaltargets_stunting_ West Kalimantan. Journal of Maternal and Child
policybrief.pdf. Health. 2018;3(02):146-155.
3. Ministry of Health Republic of Indonesia. Stunting 13. Rusmil, V.K., Prahastuti, T.O., Luftimas, D.E.
 Indian Journal of Public Health Research & Development, March 2020, Vol. 11, No. 03 1801
Exclusive and Non-Exclusive Breastfeeding among 23. Wolde, M., Berhan, Y., Chala, A. Determinants
Stunted and Normal 6 – 9 Month-Old-Children in of underweight, stunting and wasting among
JatinangorSubdistrict, Indonesia. Althea Medical schoolchildren. BMC Public Health. 2015;15:8.
Journal. 2019;6(1):35–41. 24. Rahmawati, V., Pamungkasari,E., Murti,B.
14. Hidayah, F. Exclusive breastfeeding as stunting risk Determinants of Stunting and Child Development
factor in children at age 6-24 months in Jogjakarta, in Jombang District. Journal of Maternal and Child
Indonesia. [Thesis]. Gadjah Mada University; Health. 2018; 03(01):68-80.
2013. 25. Handayani, F., Siagian, A., Aritonang,E.Mother’s
15. Lestari, E.D., Hasanah, F., Nugroho, N.A. Education as A Determinant of Stunting among
Correlation between non-exclusive breastfeeding Children of Age 24 to 59 Months in North Sumatera
and low birth weight to stunting in children. Province of Indonesia. IOSR Journal of Humanities
Paediatric Indonesia. 2018;58(3):123–7 and Social Science. 2017; 22(06):58-64.
16. Kabaran, S. Maternal and Child Nutrition: 26. Dimaisip-Nabuab, J., Duijster, D., Benzian, H.,
Importance of the First 1000 Days. Int J Clin Nutr Heinrich-Weltzien, R., Homsavath, A., Monse, B.,
Diet. 2018; 4: 133. Sithan, H., Stauf, N., Susilawati, S., Kromeyer-
17. Francisco, J., Ferrer, L., Serra-majem, L. Factors Hauschild, K. Nutritional status, dental caries and
Associated with Stunting among Children. tooth eruption in children: a longitudinal study
Nutrients. 2017;9(491): 1–16. in Cambodia, Indonesia and Lao PDR. BMC
Pediatrics 2018;18:300.
18. Martorell, R. Improved nutrition in the first 1000
days and adult human capital and health. Am J 27. Anil, S., Anand, P.S. Early Childhood Caries:
Hum Biol. 2017;29(2):10. Prevalence, Risk Factors, and Prevention. Front
Pediatr. 2017;5:157.
19. Pietrobelli, A., Agosti, M. Nutrition in the First
1000 Days: Ten Practices to Minimize Obesity 28. Meyer,F., Enax, J. Early Childhood Caries:
Emerging from Published Science. Int J Environ Epidemiology, Aetiology, and Prevention.
Res Public Health. 2017;14(12):1491. International Journal of Dentistry. 2018;1415873:1-
7.
20. Kusumawati, R.D., Marina, M.R., Wuryaningsih,
E.C. Low Birth Weight As the Predictors of 29. de Souza, P.M., Mello Proença, M.A., Franco,
Stunting in Children under Five Years in Teluknaga M.M., Rodrigues, V.P., Costa, J.F., Costa, E.L.
Sub District Province of Banten 2015. KnE Life Association between early childhood caries and
Sciences. 2019;4(10): 284–293. maternal caries status: A cross-section study in São
Luís, Maranhão, Brazil. Eur J Dent. 2015;9(1):122–
21. Aryastami, N., Shankar, A., Kusumawardani, N.,
126.
Besral, B., Jahari, A., Achadi, E. Low birth weight
was the most dominant predictor associated with 30. World Health Organization. WHO
stunting among children aged 12–23 months in recommendations on antenatal care for a positive
Indonesia. BMC Nutrition. 2017;3(1):16. pregnancy experience. Geneva: World Health
Organization [Internet]. 2016 [cited 2019 August].
22. Leal, A., de Oliveira, A., Brito, L., Lopes, F.,
Available from https://apps.who.int/iris/bitstream/
Rodrigues, V., Lima, K., de Araújo Martins, I.
handle/10665/250796/9789241549912-eng.pdf;jse
Association between Chronic Apical Periodontitis
ssionid=1E4A2A1003B8525ED5B5905ECD273A
and Low-birth-weight Preterm Births. Journal of
ED?sequence=1.
Endodontics. 2015; 41(3):353-357.