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Risk Factors for First Molar Caries in 8-12-Year-Olds: A Cross-Sectional
Study
ABSTRACT
Background: First permanent molar is the first tooth to erupt in oral cavity so more prone to
dental caries. Many risk factors are responsible for this tooth susceptibility to caries like lack of
awareness and financial resources.
Objective: To determine the distribution of risk factors for dental caries in first permanent
molars among children aged 8-12 years
Materials and Methods: A cross-sectional study was conducted on 236 children at Saidu
College of Dentistry, using nonprobability consecutive sampling. Children aged 8-12 years in the
mixed dentition stage were included. Exclusion criteria were physically/mentally handicapped
children or those with medical conditions like leukemia and hemophilia. Data were collected
through parent interviews and oral examinations using the decayed missing and filled teeth
(DMFT) index. Chi-square test was run to determine association.
Results: The mean age of the patients was 10.25±3.1 years with more females (n = 134, 56.78%)
than males (n = 102, 43.22%). Females consumed sugary foods more frequently, with 47
(35.07%) consuming them 3-4 times daily, compared to 25 males (24.51%) (p < 0.001). Males (n
= 49, 48.04%) consumed beverages 1-2 times daily more frequently than females (n = 15,
11.19%) (p < 0.001). Rural participants had significantly higher sugary food intake (p < 0.001),
lower tooth brushing frequency (p < 0.001), and more frequent snacking (p < 0.001) compared to
urban participants, who showed greater awareness of caries prevention (p = 0.002)
Conclusion: Dental caries was highly frequent among 8–12-year-olds, with significant
correlations to sugar intake, tooth brushing habits, caries prevention awareness, and snacking.
Keywords: Children, Dental carries, first permanent molar, pediatric dentistry, frequency,
Risk factors
INTRODUCTION
Dental caries remains a significant public health issue, despite serious efforts to lower

their prevalence among children and adolescents. A recent systematic review and meta-analysis

indicates that the overall prevalence of dental caries in children is 46.2% for primary teeth and

53.8% for permanent teeth. The highest prevalence rates are observed in Africa and Asia, while

the lowest rates are found in Europe 1. The primary dietary factor associated with the

development of dental caries is sugar consumption2. Inadequate treatment for dental caries can

cause discomfort and infection, negatively impacting children's physical and mental well-being. 3

Furthermore, dental caries can require lifetime care, which has a substantial financial

impact on patients and healthcare systems.4 Even with great progress made in prevention, dental

caries remains one of the most prevalent chronic illnesses impacting children globally. 5A vital

tooth in the dental arch, the first permanent molar (FPM), usually erupts between the ages of 6

and 7. FPM is more prone to caries than other teeth because of its morphological and functional

traits as well as environmental variables.6 Hence, the early loss of FPM due to caries impacts

individuals’ future oral and dental health

Children are the ones who suffer from dental decay the most, yet most of these teeth are

extracted because treatment for them is costly and there aren't enough resources. In 2000, the

World Health Organization (WHO) set a global target for dental caries to be no more than an

average of three DMFT (decayed, missing, or filled teeth) by the time a child was twelve years

old.7 The WHO stated in 2007 that dental caries affect 60–90% of schoolchildren

globally.8,9Dental care has been a big public health concern as well as a huge economic issue in

developing nations. It was projected that 22.7% of Indians were between the ages of 5 and 14 in

1997.10 There have been a few research on dental health conducted in Pakistan.11
 A DMFT score of 0.8 was reported in Multan among children aged 12 to 15. 12 Like this,

Khan noted a DMFT score of 0.9 and stated that caries in first molars affected 83% of all

children with decay.13

Despite extensive research on dental caries, there remains a significant gap in studies

focusing specifically on the first permanent molar (FPM) in children aged 8 to 12 in Khyber

Pakhtunkhwa. The FPM plays a crucial role in oral health, and its early loss can have long-term

consequences. The unique dietary habits, oral hygiene practices, and socio-economic conditions

in this region necessitate a targeted investigation. By identifying the frequency of caries in FPMs

and understanding the associated risk factors, this study aims to provide critical insights that can

guide the development of tailored preventive measures, early intervention strategies, and

educational programs. These findings will be instrumental in improving oral health outcomes for

this vulnerable population and reducing the long-term burden of dental diseases in the region.

The objective of this study was to determine frequency of risk factors of dental caries in

first permanent molars among 8 - 12-year-old children.

Material and Methods
This cross-sectional study was conducted at Operative Dentistry, Saidu College of

Dentistry from December 15, 2023, to May 15, 2024. The participants were recruited from the

Outpatient Department, Saidu College of Dentistry, Swat, using non-probability consecutive

sampling technique. Ethical approval was obtained from the Ethical Committee (17-ERB/024,

dated:27-2-2024). Written informed consent was obtained from the parents/guardians of all

participants.

The inclusion criteria were children between 8 and 12 years of age in the mixed dentition

stage, of both genders, and Pakistani nationals with at least one carious first permanent molar.

The exclusion criteria included mentally and physically handicapped patients, as well as

medically compromised patients (those suffering from leukemia or hemophilia, assessed through

history such as medication use and treatment from a physician or hematologist). A sample size of

176 participants was calculated using openepi software using 20.69% brushing from previous

study with 6% margin of errors, at 95% confidence interval and 80% power.14 To increase further

the power of the study we included 236 participants

Data collection involved administering a structured questionnaire to the accompanying

adult of each child, conducted by a trained dentist. The children and their parents received

separate awareness sessions prior to the dental assessment, based on the parents’ comprehension

level. The questionnaire was designed to collect demographic and lifestyle-related information to

assess risk factors for dental caries in children. It included basic demographic details such as the

child's name, age, sex (female or male), and area of residence (rural or urban). Dietary habits

were evaluated through variables like sugary food intake per day, categorized as 1–2 times, 3–4

times, 5 or more times, or none, and snacking frequency between meals, recorded as frequently
or occasionally. Oral hygiene practices were assessed by the frequency of tooth brushing,

categorized as not daily, once, or twice a day. Beverage consumption was also recorded, with

options of 1–2 times, 3–4 times, or none per day. Additionally, awareness regarding caries

prevention was assessed, with responses categorized as aware, not aware, or somewhat aware.

Following approval, an intra-oral examination was performed by the author, who

received specific training to minimize inter-examiner variability. The dental status of each child

was assessed using a standard mouth mirror and blunt probe, with tooth surfaces dried using a

cotton pellet for better visibility. The dental caries status was evaluated using the DMFT

(Decayed, Missing, and Filled Teeth) index for permanent teeth and the deft (decayed, extracted,

and filled teeth in primary dentition) index, providing a comprehensive overview of the

participants' oral health.

SPSS 23 was used for data analysis. Categorical variables were expressed as numbers and

percentages. The tests of significance used were the chi-square test. The association between risk

factors of dental caries and confounders like gender and residence was determine using chi-

square test/Fisher exact test. Statistical significance was set at P < 0.05.
RESULTS

The mean age of the participants was 10.25±3.1 years. The study sample consisted of more

females (n = 134, 56.78%) than males (n = 102, 43.22%). Participants were nearly equally

divided between rural (n = 116, 49.15%) and urban (n = 120, 50.85%) areas. Regarding sugary

food intake, the most common frequency was 1–2 times per day (n = 77, 32.63%), followed by

3–4 times per day (n = 72, 30.51%). A smaller proportion consumed sugary foods 5 or more

times daily (n = 47, 19.92%), while 40 participants (n = 40, 16.95%) reported no intake. In terms

of tooth brushing, the most frequent habit was brushing once daily (n = 96, 40.68%), followed

closely by participants who did not brush daily (n = 91, 38.56%), and only a few brushed twice a

day (n = 49, 20.76%). For beverage consumption, the most common patterns were 2 times per

day (n = 64, 27.12%) and 3–4 times daily (n = 63, 26.69%), with 46 participants (n = 46,

19.49%) reporting no daily intake. Awareness of caries prevention was highest among those who

were somewhat aware (n = 112, 47.46%), while others were unaware (n = 76, 32.20%), and only

a small number were fully aware (n = 48, 20.34%). Snacking between meals was reported

frequently by most participants (n = 160, 67.80%), while the rest snacked occasionally (n = 76,

32.20%). (Table 1)

Females consumed sugary foods more frequently, with 47 (35.07%) reporting intake 3-4

times daily and another 47 (35.07%) consuming 5 or more times, while no males reported such

high intake. In contrast, 25 males (24.51%) consumed sugary foods 3-4 times daily (p < 0.001).

Tooth brushing habits also varied significantly (p < 0.001), with 91 males (89.22%) not brushing

daily, whereas all females brushed at least once, with 85 (63.43%) brushing once and 49

(36.57%) brushing twice daily. Beverage consumption was also significantly different (p <

0.001), as 49 males (48.04%) consumed beverages 1-2 times daily, compared to only 15 females
(11.19%). Additionally, 32 females (23.88%) and 31 males (30.39%) consumed beverages 3-4

times daily. There was no significant difference in awareness of caries prevention (p = 0.2).

Snacking habits differed markedly (p < 0.001), with all 102 males (100%) frequently snacking

between meals, while 58 females (43.28%) reported frequent snacking and 76 (56.72%) snacked

only occasionally. (Table 2)

Analysis by area of residence revealed significant differences in sugary food intake per

day (p<0.001), with rural participants consuming sugary foods more frequently. Tooth brushing

frequency also differed significantly (p<0.001), with rural participants brushing less frequently.

Beverage consumption varied significantly (p<0.001) between rural and urban participants.

Awareness of caries prevention showed significant differences (p=0.002), with urban

participants being more aware. Snacking between meals was significantly more frequent in rural

participants (p<0.001). (Table 3)

Table 1: Distribution of demographics, sugary food intake, tooth brushing, beverages/day

Characteristic N = 236
Gender
Female 134 (56.78)
Male 102 (43.22)
Area of Residence
Rural 116 (49.15)
Urban 120 (50.85)
Sugary food intake/day
1-2 times 77 (32.63)
3-4 times 72 (30.51)
5 or more 47 (19.92)
None 40 (16.95)
Tooth brushing/day
not daily 91 (38.56)
Once 96 (40.68)
Twice 49 (20.76)
Beverages/day
1 time 64 (27.12)
2 times 63 (26.69)
3-4 times 63 (26.69)
None 46 (19.49)

Awareness of carries prevention

Aware 48 (20.34)
not aware 76 (32.20)
somewhat aware 112 (47.46)
Snacking between meals
Frequently 160 (67.80)
Occasionally 76 (32.20)
1
n (%)
Table 2: Distribution of risk factors of Dental carries

p-
female, N = male, N =
Characteristic valu
134 102
e*
<0.0
Sugary food intake/day
01
1-2 times 0 (0.00) 77 (75.49)
3-4 times 47 (35.07) 25 (24.51)
5 or more 47 (35.07) 0 (0.00)
None 40 (29.85) 0 (0.00)
<0.0
Tooth brushing/day
01
not daily 0 (0.00) 91 (89.22)
Once 85 (63.43) 11 (10.78)
Twice 49 (36.57) 0 (0.00)
<0.0
Beverages/day
01
1 time 15 (11.19) 49 (48.04)
2 times 59 (44.03) 4 (3.92)
3-4 times 32 (23.88) 31 (30.39)
None 28 (20.90) 18 (17.65)
Awareness of carries
0.2
prevention
Aware 32 (23.88) 16 (15.69)
not aware 44 (32.84) 32 (31.37)
somewhat aware 58 (43.28) 54 (52.94)
<0.0
Snacking between meals
01
Frequently 58 (43.28) 102 (100.00)
Occasionally 76 (56.72) 0 (0.00)
*
Pearson’s Chi-squared tests
Table 3: Comparison of risk factors of Dental carries

rural, N = urban, N =
Characteristic p-value2
1161 1201
Sugary food intake/day <0.001
1-2 times 77 (66.38) 0 (0.00)
3-4 times 39 (33.62) 33 (27.50)
5 or more 0 (0.00) 47 (39.17)
None 0 (0.00) 40 (33.33)
Tooth brushing/day <0.001
not daily 91 (78.45) 0 (0.00)
Once 25 (21.55) 71 (59.17)
Twice 0 (0.00) 49 (40.83)
Beverages/day <0.001
1 time 49 (42.24) 15 (12.50)
2 times 18 (15.52) 45 (37.50)
3-4 times 31 (26.72) 32 (26.67)
None 18 (15.52) 28 (23.33)
Awareness of carries
0.002
prevention
Aware 16 (13.79) 32 (26.67)
not aware 32 (27.59) 44 (36.67)
somewhat aware 68 (58.62) 44 (36.67)
Snacking between meals <0.001
Frequently 116 (100.00) 44 (36.67)
Occasionally 0 (0.00) 76 (63.33)
*Chi-square test/fisher exact test
Discussion
The study contributes to the body of knowledge on risk factor of dental caries in the first

permanent molar among children in Swat.

Caries affects most of the children in the industrialized countries so its studies in different

regions is crucially important. The comparison of these results with different studies is made and

its frequency is also compared with several other areas around the World 15. The Smile Pakistan-

Survey of Oral Health in school going children conducted in 1986 in different regions of

Pakistan showed 95.0% prevalence16. The results of this study were alarming for juvenile oral

health care policies, but it had a few limitations being a pilot study, so it was underestimated.

Then some other pilot studies were conducted to determine the severity of problem 17. These

findings reveal that dental caries remain a significant issue among children, underscoring the

importance of regional studies and better oral health care policies to tackle this growing problem

effectively. The study of Mubaraki et al. conducted in 2002 in Saudi Arabia shows the caries

frequency of 64.0%. The study conducted in 2006 on school children at Al-coast province at

Saudi Arabia shows the caries frequency of 69.0%17. So being a less underdeveloped region the

results of this study are not so bad, particularly in comparison to these results 18. The Somali and

Vietnamese migrant, Middle East children in Rome and Grahamstown town children are the

other few examples of children affected from poor oral hygiene and dental caries 19.

Significant findings in this study are that the rate of dental caries was significantly high

among children older than 6 years compared to younger children with mean age of 10.25. This

may be due to longer duration of exposure to causative factors of dental caries and cumulative

effect of poor oral hygiene practice over time 20. These findings are in line with the results of
previous study by Emmanuelli et al. 21 in Basel which found that the prevalence of dental caries

increases with increase in age among pediatric population.

This study also points out the role of food in the promotion of dental caries with ,32.6%

of children consuming sugary food 1-2 times,30.51% children consuming 3-4 times. Cariogenic

food intake was observed among those children who had higher consumption of sweets and

sweetened beverages, which made them more susceptible for the onset of caries. It is in

conformation with recommendations of World Health Organization (WHO), emphasizing

limitation in sugar consumption and healthy food promotion20.

Another statistically significant factor related to dental caries was frequency of

toothbrushing. Children who brushed their teeth less frequently had higher caries prevalence,

which emphasizes the important role of routine toothbrushing in sustaining oral health. They

reported that 40.68% of children brush only once while 38.6% of children did not brush daily,

only 20.69% children brush twice. This is consistent with the guidelines set by the American

Dental Association that suggest brushing at least twice daily with fluoride toothpaste to avert

dental caries.21

The gender distribution skewed towards females, with 56.78% being females. This

gender distribution pattern is common in dentistry, where historically, there has been a higher

carries frequency in females.19 Although our study had a reasonably sized sample of children

from both urban and rural localities of Swat, had assessed a comprehensive list of factors

associated with dental caries.

Limitations
There are several limitations to this study: it uses a cross-sectional design, so cannot establish

causality; self-reported data may introduce recall bias when reporting dietary habits or oral
cleanliness behaviors, which can affect accuracy due to the inherent unreliability of such data;

and non-probability sampling for subject recruitment means that these results may not be

generalizable. Furthermore, since this study was conducted at a single center and lacks

longitudinal data, the generalization of these findings may be limited.

The study has strengths like this explores the burden of dental caries in Swat, a region

with limited education and awareness on oral health. Using a calculated sample size and a

custom questionnaire, it provides valuable insights into the prevalence and risk factors of caries

in children’s first permanent molars.

Conclusion
Common risk factors for dental caries in first permanent molars include high sugary food

intake, inadequate tooth brushing habits, and frequent snacking between meals. Females

exhibited higher sugary food consumption and better brushing habits compared to males.

Increased awareness of caries prevention is essential, particularly in rural areas, to improve

overall oral health outcomes.

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