The frequency of bottle feeding as the main factor of baby bottle tooth decay syndrome

Background: Dental caries re�ains as �ain �r��le� in �nd�nesia and its �revalence is �ig� (90.05%). H���ever, t�ere is n� a��r��riate data t�at can �e �sed t� analyze dental caries in t�ddlers, es�ecially �a�y ��ttle t��t� decay syndr��e (BB�D), t���g� t�e n���er �� BB�D cases is �ig� in s��e �ediatric dental clinics (90% �� �atients visiting t�e clinics). Even t���g� s��e �act�rs �ave already �een c�nsidered t� �e t�e risk �act�r �� BB�D, t�e �ain risk �act�r �� BB�D is still �nkn���n, es�ecially BB�D in �nd�nesia. Purpose: ��is researc� ��as ai�ed t� ��tain data relating ��it� ��ttle-�eeding �a�it in 3–5 year �ld c�ildren in �nd�nesia and its caries risk. Method: ��e st�dy ��as an ��servati�nal researc� c�nd�cted ��it� clinical e�a�inati�n t�r��g� caries stat�s (de�t) �� eac� c�ild deserved �y �ediatric dentists and t�r��g� q�esti�nnaire distri��ted t� �arents t� e�a�ine t�e risk �act�r �� BB�D. O�servati�n ��as c�nd�cted �n 62 c�ildren in t�e range �� age 3 t� 5 years �ld ��it� ��ttle-�eeding �a�it. result: ��e res�lts revealed t�at stat�s �� caries ��as vari��s. ��e data s����ed t�at t�e �req�ency �� ��ttle �eeding ��re t�an t��ice c��ld trigger BB�D 2.27 ti�es �ig�er t�an �t�er �act�rs s�c� as t�e �se �� ��ttle �eeding as a �aci�ier �ri�r slee�ing, t�e �eri�d �� ��ttle-�eeding, and t�e �reast-�eeding e��erience. Conclusion: t���g� �ilk as s��tract can ��ssi�ly �ec��e a �act�r triggering caries, t�e �req�ency �� ��ttle-�eeding is �ig�ly c�nsidered as �ain �act�r. Since it c��ld ��d�lated t�e �acterial c�l�nizati�n �n dental s�r�ace, ���ic� a��ects its vir�lence.


material and method
This research is a cross sectional study.It means that the subjects of the research are obtained from non-probability sampling method with consecutive sampling technique.Based on the method, the number of the subjects obtained then is about 62 toddlers who not only are in the age of 3-5 years old, but also have erupted milk tooth and bottlefeeding habit.Clinical examination then is conducted.Furthermore, in order to obtain further information, questionnaire is also distributed to those children's parents.The questionnaire concerns on the information not only about the history of breast feeding like the length period of breast feeding, but also about bottle-feeding habit like the role of bottle-feeding, the length period of bottle-feeding, and the frequency of bottle-feeding per day and per night.And, equipment used during clinical examination is intra oral with sufficient light.
Afterwards, the status of caries is noted based on World Health Organization standard. 22,23The analysis of prevalence ratio then is conducted to examine any risk factors of bottle-feeding habit.Finally, this research has already been approved by the research ethic commission of Dentistry Faculty, Universitas Indonesia.And, the parents of those children involved in this research have already been informed and asked for their written approval.

result
Based on consecutive method, 62 children are considered as the subjects of the research since they met some inclusion criteria.The distribution of the subjects as seen in Table 1, shows that the distribution of male children (61.3%) is bigger than that of female children (38.7%).The age interval of the samples is also known between 3-5 years old with the various numbers of teeth, 20-24 teeth, but the biggest proportion of subjects' teeth is about 20 teeth (85.5%).
Moreover, it is known that most of those subjects (72.6%) suffer caries which is similar to baby bottle tooth decay (BBTD) syndrome, while the rest (27.4%) is free from caries though they have bottle-feeding habit.It is introduction Tooth Decay or Caries still becomes a dental health problem among children in Indonesia.2][3] Based on the data, it can be indicated that the program of public health improvement conducted by the government for long time is considered to be failed since the prevalence of caries is still high.][6][7][8][9][10][11][12] Based on World Health Organization's report in 2003, moreover, it is known that the prevalence of caries among children was about 60-90%. 13As a result, caries, specifically known as nursing bottle syndrome (NBT) or baby bottle tooth decay (BBTD) syndrome, becomes one of major concerns for medical experts, and many researches on it even have already been conducted and improved. 6Furthermore, since baby bottle tooth decay (BBTD) syndrome usually attacks toddlers, it is also known as nursing caries, baby bottle tooth decay, rampant caries, labial caries, and maxillary anterior caries. 14n addition, clinical phenomena found in Jakarta and in areas around indicate that the number of BBTD patients in pediatric dental clinics is still high.The introductory researches conducted in three hospitals (2 in the center of Jakarta and 1 in the suburb of Jakarta) even showed that the proportion of children who suffer this infection disease was about 95%.Based on the observation result, it is known that though milk is considered as the source of nutrients for those children, not all of children with bottle-feeding habit are suffering caries.The number of tooth decay cases in children who suffer BBTD even is various.Nevertheless, as reported by some researches, the patients of BBTD are dominated by toddlers who consume milk. 16,17 wever, that nursing bottle causes BBTD is still debatable.In one side, milk can become liquid which protects the process of demineralization in enamels. 18,19On the other hand the effect of milk carcinogenetic is improved in mice used as experimental models as the increasing of sugar, minimally about 2%. 20Those differences then consider as an obstacle in determining whether milk cause BBTD in toddlers who have bottle-feeding habit or not since most of children in urban areas rely on bottle milk as the source of nutrients. 21Therefore, the further analysis of the condition in Indonesia, especially in Jakarta, is needed to analyze baby bottle tooth decay (BBTD) syndrome that generally attack toddlers in daily life.The process subjects have bottle-feeding once a night, while 32.3% of them have bottle-feeding twice a night.Moreover, 9.7% of them have bottle-feeding three times a night, while only 3.2% of them have bottle-feeding four times a night.It also known that most of those subjects (72.6%) rely on bottle-feeding as pacifier when they fall asleep, while the rest (27.4%) do not.In addition, for profiling those children with bottlefeeding habit as shown in Table 1, the analysis of prevalence ratio (PR) is then conducted as seen in Table 2. Based on Table 2, it is known that relying on bottle-feeding when falling asleep cannot always improve the risk of BBTD since the score of PR is 1.03 times with the interval of reliability between 0.91-1.15.In details, it is known that the frequency of bottle-feeding  2 times a day can improve the risk of BBTD 2.27 times with the interval of reliability between 2.17-2.37,while the frequency of bottlefeeding  2 times a night can improve the risk of BBTD 1.16 times with the interval of reliability between 1.04-1.28.Moreover, if it is analyzed based on the age when they stopped breast feeding, the prevalence of caries is almost 1.It means that this factor does not always affect the number of caries occurred.Nevertheless, it is known that breast feeding can become protection against BBDT.The history of BBDT is needed to be examined in this research in order to categorize kinds of caries occurred in those children which can possibly be caused by bottlefeeding habit or by other factors.The categorization is also needed in this research to analyze further the specific damage occurred in their milk teeth.Therefore, if the tooth decay has already attacked their lower anterior teeth, they cannot involve as the subjects of this research since this condition can cause bias result, which indicates caries with other pattern.
Moreover, only children in the age of 3-5 years old are chosen to be the subjects of this research since their milk teeth are still in the phase of growth, 24 thus, it means that only those whose milk teeth are still persistend can involve in this study.It is aimed to obtain the description of caries caused by bottle-feeding habit.As we know, the condition of teeth in those children generally can reflect sufficient remineralization and demineralization processes.As a result, we can hypnotize that the unbalancing condition can be considered as a triggering factor of caries, without caries condition can reflect the balancing condition between remineralization and demineralization processes.
However, the similar condition cannot be expected to be found in children under three years old.This statement is also supported by the research using cariostat as the predictor of caries which found that the increasing of caries in toddlers around 3-5 years old is not as progressive as that in toddlers under 3 years old. 25The substitution of anterior teeth in children above five years old has generally been occurred, 24 thus, the possibility of the involvement of anterior teeth becomes bias.Based on the analysis result of prevalence ratio in Table 2, it is also known that the length period of bottle-feeding habit is only 0.96.It means that the length period of bottle-feeding is not considered as the only factor causing BBDT.
Furthermore, based on the distribution of the data, it is known that the number of male children who have bottle-feeding habit is not the same as that of the female children.][28][29] Even though there is a research that distinguishes the dental health treatment based on sex, there is still no significant difference in result. 25,30Actually, as an infectious disease caused by bacteria, the incubation and colonization of bacteria tends to be determined by micro environment inside mouth cavity.But, if though this micro condition is also influenced by internal factors like hormonal factor, it will not affect too much on children in the age of 3-5 years old.
It is known that 85.5% of the subjects have met the criteria to become the samples of the research since the total number of their teeth is 20 (Table 1).The rest of them (14.5%) have more 20 teeth.However, this condition does not affect the research since only permanent molar teeth are erupted, and it can not affect the diagnosis of baby bottle tooth decay syndrome.
The examination conducted on children who have bottle-feeding habit shows that 72.6% of them suffer baby bottle tooth decay with various numbers of caries (1-15) teeth and with the mean score of deft 4.66 teeth.It means that every child has caries in their four teeth.If it is analyzed based on the pattern of baby bottle tooth decay syndrome which is linier with the order of dental eruption, it then can be concluded that most of children with baby bottle tooth decay syndrome will get caries in their four anterior teeth of upper jaw, and it is not different from what happens with non Caucasian children in the age of 4-5 years old in countries with good health program. 31However, caries in the upper incisive can not only cause infection for those children, but can also affect their aesthetics, especially concerning with their self-esteem.
If compared with the research involving five year old children in China which population is similar to Indonesia's in the term of biosocioculture, the mean score of deft is almost similar (the mean of deft 3 from 780 children). 26imilarly, the mean score of deft in Riyadh, Saudi Arabia is 5. 27 Nevertheless, the mean score of deft in 0-5 year old children is different as shown in the research conducted in Brazil, which is 1.53.This condition can possibly occur since based there is a correlation between the length of age interval and caries occurred, which means that the increasing of caries occurs as the increasing of age. 32It is also supported by the result of a research involving toddlers in Depok in 1992 which mean score of deft is 4.67 teeth. 25t indicates that there has not been significant change in the mean of deft for the last two decades.
Actually, tooth decay suffered by most of them (72.6%) is possibly caused by many factors.One of them is related with the activity of parents in urban areas that tends to be busy and have not enough time to meet their children.Like in Indonesia, this phenomenon also occurs in some countries, except in developed countries in which promotion and prevention programs that have already been developed can reduce the unawareness of parents toward their children. 33Therefore, it can be concluded that bottle-feeding habit is considered to be an important factor triggering caries.
Based on the data, it is known that 66.1% of the subjects in this research still get bottle-feeding.The proportion of children who rely on bottle-feeding as they fall asleep even is as same as that of children who suffer caries.In general, it is known that 45 children or 72.6% of samples have this bottle-feeding habit.But, if it is analyzed further, it is known that not all of those children who have bottlefeeding habit during falling asleep get caries.Based on the result of prevalence ratio in Table 2 it is known that those who rely on bottle-feeding as pacifier when falling asleep do not always get caries since the interval of reliability is between 0.91-1.15.Nevertheless, based on the observation of 55 kindergarten students in Italia, it is known that bottle-feeding habit can cause caries. 28Similarly, researches conducted in North Brisbane and Montreal is also showed that BBDT emerged in children who rely on bottle-feeding when falling asleep. 34,35Moreover, based on the research conducted in Australia, it is known that the frequency of bottle-feeding twice or more a day can improve the risk of caries for about 2.27 times, while the frequency of bottlefeeding twice or more a night can improve the risk of caries for about 1.16 times. 31herefore, caries occurred in BBTD cases can also be examined from the history of their bottle-feeding habit.Most of them got breast feeding until they were one year (83.9%).It means that they stopped having breast feeding since their first tooth erupted or before it is erupted.Therefore, the correlation between breast feeding and BBDT can be eliminated.It is also supported by the score result of the prevalence ratio, which is about 0.716.It means that 60-83% of subjects have breast feeding as a protection against caries or breast feeding does not affect caries occurred during the observation.This result is similar to the result of the cross sectional research conducted on children in the age of 2-5 years old in the United States of America in 1576 which concludes that the length period of breast feeding cannot be considered as the single risk factor of caries. 4herefore, it can be concluded that though milk as subtract can possibly become a factor triggering caries, what becomes the main factor actually is the frequency of bottle-feeding itself.The reason is because of the modulation of subtract related with the development of bacterium colonization on dental surface, so it indirectly also affects its virulence.

acknowledgement
The Grand Research of Universitas Indonesia

table 1 .
Profile of children, as the subjects of the research, who have bottle-feeding habit