UNIVERSIDADE ESTADUAL PAULISTA
“JÚLIO DE MESQUITA FILHO”
Instituto de Ciência e Tecnologia
Campus de São José dos Campos
ORIGINAL ARTICLE DOI: https://doi.org/10.4322/bds.2023.e3833
1
Braz Dent Sci 2023 Oct/Dez.;26 (4): e3833
Dental caries of stunting and underweight toddlers aged 3-5 years
old among Pandhalungan community
Cárie em crianças de 3 a 5 anos com baixa estatura e baixo peso da comunidade Pandhalunga
Ristya Widi Endah YANI
1
, KISWALUYO
1
, Surartono DWIATMOKO
1
1 - University of Jember, Faculty of Dentistry. Jember, Indonesia.
How to cite: Yani RWE, Kiswaluyo, Dwiatmoko S. Dental caries of stunting and underweight toddlers aged 3-5 years old among
Pandhalungan community. Braz Dent Sci. 2023;26(4):e3833. https://doi.org/10.4322/bds.2023.e3833
ABSTRACT
Objective: Toddler dental caries can interfere with children’s nutritional conditions, toddlers have difculty eating and
disturbing sleep rhythms, where growth hormones work optimally when toddlers sleep. The study aims to identify and
analyse the difference between dental caries of stunting and underweight toddlers aged 3-5 years old among Pandhalungan
community. Material and Methods: An analitical observational study with a cross-sectional approach was performed
in Panduman village, Tegalbesar, Jember. The population was 530 stunting toddlers and 162 underweight toddlers.
The sample was 114 stunting toddlers and 114 underweight toddlers selected by simple random sampling. The variable
was the dental caries of stunting and underweight toddlers. The dental caries was checked by the inspection in the
light space. The information of stunting and underweight toddlers was obtained from the public health center data.
The data were analysed by descriptive statistical test and continued by Mann-Whitney U test . The majority age of the
toddlers was 49-60 months with 73.68% from stunting toddlers and 71.05% from underweight toddlers. Results: The
majority of the parents’ recent education was low, which were in junior high school and primary school. The average
dental caries of stunting toddlers was 5.07 and 5.67. The test resulted Asymp. Sig. (2-tailed) 0.159 less than α(0,05)
that means there was no difference between dental caries of stunting and underweight toddlers. Conclusion: There
was no difference between dental caries of stunting and underweight toddlers.
KEYWORDS
Community; Dental caries; Minors; Stunting; Underweight.
RESUMO
Objetivo: A cárie infantil pode interferir nas condições nutricionais das crianças, as crianças têm diculdade para comer e
podem apresentar distúrbio noritmo do sono, onde os hormônios do crescimento funcionam de maneira ideal quando as
crianças dormem. O estudo tem como objetivo identicar e analisar a diferença entre cárie dentária de crianças entre 3 e
5 anos com baixa estatura e com baixo peso na comunidade Pandhalunga. Material e Métodos: Um estudo observacional
analítico com abordagem transversal foi realizado na aldeia de Pandhalungan, Tegalbesar, Jember. A população era de
530 crianças com baixa estatura e 162 crianças com baixo peso. A amostra foi de 114 crianças com baixa estatura e 114
crianças com baixo peso, selecionadas por amostragem aleatória simples. A variável foi a cárie de crianças com baixa
estatura e baixo peso. A cárie foi vericada pela inspeção em um ambiente claro. As informações sobre crianças com
baixa estatura e baixo peso foram obtidas a partir dos dados do centro de saúde pública. Os dados foram analisados pela
estatística descritiva e pelo teste de Mann-Whitney. A idade da maioria das crianças era de 49 a 60 meses, com 73,68%
de crianças com baixa estatura e 71,05% de crianças com baixo peso. Resultados: A escolaridade recente da maioria dos
pais era baixa, os quais cursaram o ensino fundamental e o ensino médio. A média de cárie dentária em crianças com
baixa estatura foi de 5,07 e 5,67. O teste resultou em Asymp. Sig. (bicaudal) 0,159 menor que
α
(0,05), o que signica que
não houve diferença entre cárie dentária em crianças com baixa estatura e baixo peso. Conclusão: Não houve diferença
entre cárie dentária em crianças com baixa estatura e baixo peso.
PALAVRAS-CHAVE
Baixa estatura; Baixo peso; Cárie; Comunidade; Menores.
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Braz Dent Sci 2023 Oct/Dez.;26 (4): e3833
Yani RWE et al.
Dental caries of stunting and underweight toddlers aged 3-5 years old among Pandhalungan community
Yani RWE et al.
Dental caries of stunting and underweight toddlers aged 3-5
years old among Pandhalungan community
INTRODUCTION
In Indonesian context, 37% of toddlers
experienced stunting and 12% of them experienced
underweight [1]. 87% of stunting toddlers suffered
dental caries. The toddlers with a severe dental
caries were 2.15 times more likely to experience
stunting than those with low dental caries [2].
Caries was one of the factors of stunting among
toddlers [3]. There was the correlation between
stunting and dental caries among children [4].
The toddlers with a severe dental caries had 5-time
probability of decrease in nutritional status that
led underweight condition [5]. 1 (3.3%) out of
30 stunting toddlers suffered very low category
of dental caries, 3 toddlers (10%) suffered low
category of dental caries, 4 toddlers (13.3%) had
medium category of dental caries, 13 toddlers
(43.4%) had high category of dental caries,
and 9 toddlers had very high category of dental
caries [6]. In general, stunting and underweight
influenced the growth of toddlers’ motor and
mental. Meanwhile in oral cavity, stunting related
to reduced resistance to microbial biolms and
decreased salivary ow that inuenced individual’s
oral health which played the main role in the
toddler’s life quality. One of the most frequent
problems of oral health was dental caries [7].
The main problem of dental and oral health
for toddlers is dental caries. Dental caries is a
dental tissue disease characterized by tissue
damage, starting from the enamel which is
the surface of the tooth, dentin, and extending
towards the pulp. Dental caries is one of the most
common forms of tooth decay experienced by
preschool children, which can interfere with the
growth and development process.
Pandhalungan community in Jember is a
hybrid society due to compound of two dominant
cultures, Madura and Java, also Islam in Tapal Kuda
area [8]. Cultural behavior has crucial implication
on human’s health. Cultural factor plays a role
in changing health behavior dynamically among
societies [9]. The current study aims to identify
and analyze the difference between dental caries of
stunting and underweight toddlers aged 3-5 years
old among Pandhalungan community.
MATERIALS AND METHODS
Sample selection
An analitical observational study with
a cross-sectional approach was performed
in Panduman village, Tegalbesar, Jember.
Panduman and Tegalbesar are villages with
the highest prevalence of undernutrition [10].
The population was 530 stunting toddlers and
162 underweight toddlers. The sample was
114 stunting toddlers and 114 underweight
toddlers selected by simple random sampling
with Slovin’s formula. The variable was dental
caries of stunting and underweight toddlers.
Data collection
The dental caries was measured or checked by
the inspection in the light space. The toddlers were
asked to open their mouth with the help of mouth
mirror, dental probe, and torch. It was to count
the dental caries with ve categories, namely Pulp
Irritation (IP), Pulp Hyperemia (HP), Pulpitis,
Pulp Gangrene (GP), and Radix Gangrene (GR).
The result was written on the provided form that
was also containing respondents’ characteristics
data. The information regarding stunting and
undernutrition toddlers were obtained from the
data of public health center. Then the researchers
conducted a re-measurement in the research.
The data were analysed by descriptive statistical
test and continued by Mann-Whitney U test (SPSS
23 programmed) to analyse the dental caries
of stunting and undernutrition toddlers aged
3-5 years old among Pandhalungan community.
Ethical aspect
Categories for evaluating caries come from
previous instruments in the form of: a. Providing
informed consent and information for consent
to parents/guardians of research subjects; b.
Body weight measurement with Camry brand
digital weight scales with a capacity of 150 kg,
50-gram accuracy, and 3A alkaline battery. Before
measurement, the tool was calibrated rst; and
c. Size of height with a microtoise stature meter.
The study was approved by the Ethics Committee
of Faculty of Dentistry, University of Jember, with
the number of 1600/UN25.8/KEPK/DL/2022.
RESULTS
The data analysis resulted several informa-
tion. The respondents’ characteristics based on
age and gender are provided in Table I. From
114 stunting toddlers, 84 toddlers (73.68%)
were 49-60 months, 30 toddlers (26.32%) were
36-48 months. From 114 underweight toddlers,
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Braz Dent Sci 2023 Oct/Dez.;26 (4): e3833
Yani RWE et al.
Dental caries of stunting and underweight toddlers aged 3-5 years old among Pandhalungan community
Yani RWE et al.
Dental caries of stunting and underweight toddlers aged 3-5
years old among Pandhalungan community
81 toddlers (71.05%) were 49-60 months,
33 toddlers (2895%) were 36-48 months.
The respondents’ characteristics based
on parents’ recent education are available in
Table II. The most parents’ recent education
level was Junior High School and Primary
School in stunting or even underweight toddlers
categories. 58 stunting toddlers (50.88%) had
parents with the recent education level of Junior
High School, 41 stunting toddlers (35.96%)
had parents with the recent education level
of Primary School, and 16 stunting toddlers
(14.04%) had parents with the recent education
level of Senior High School. Meanwhile,
63 underweight toddlers (55.26%) had parents
with the recent education level of Junior High
School, 38 underweight toddlers (33.33%)
had parents with the recent education level of
Primary School, and 13 underweight toddlers
(11.40%) had parents with the recent education
level of Senior High School. There was no parent
of stunting and underweight toddlers with the
recent education level of Bachelor degree.
The average score of dental caries of
stunting and underweight toddlers is displayed
in Table III. Stunting toddlers had average of
dental caries as many as 5.07 with the high
category and underweight toddlers had average
of dental caries as many as 5.67 with the same
category, high category. The test of dental
caries difference of stunting and underweight
toddlers can be seen in Table IV. The test
resulted Asymptotic Significance (2-tailed)
0.159 less than α(0,05) that means there was
no difference between dental caries of stunting
and underweight toddlers.
Table I - Character of Stunting and Underweight Toddlers Based on Age and Gender
Age (Month) Stunting Underweight
36-48 30 (26.32%) 33 (28.95%)
49-60 84 (73.68%) 81 (71.05%)
Total 114 114
Table II - Character of Stunting and Underweight Toddlers Based on Parents’ Recent Education
Number Parents’ Recent Education Stunting Underweight
1. Primary School 41 (35.96%) 38 (33.33%)
2. Junior High School 58 (50.88%) 63 (55.26%)
3. Senior High School 16 (14.04%) 13 (11.40%)
4. Bachelor 0 (0%) 0 (0%)
Total 114 (100%) 114 (100%)
Table III - Average Score of Dental Caries of Stunting and Underweight Toddlers
Number Nutritional Status Average of Dental Caries Category
1. Stunting 5.07 High
2. Underweight 5.67 High
Table IV - The Test of Dental Caries Difference of Stunting and Underweight Toddlers
Dental Caries
Mann-Whitney U 5805.000
Wilcoxon W 12360.000
Z -1.409
Asymp. Sig. (2-tailed) .159
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Braz Dent Sci 2023 Oct/Dez.;26 (4): e3833
Yani RWE et al.
Dental caries of stunting and underweight toddlers aged 3-5 years old among Pandhalungan community
Yani RWE et al.
Dental caries of stunting and underweight toddlers aged 3-5
years old among Pandhalungan community
DISCUSSION
The majority of stunting and underweight
toddlers were aged 49-60 months. Globally,
approximately one out of four toddlers experience
stunting. 16% of them are underweight and 8%
of them are wasting [11]. The study in Indian
context showed the occurrence of picky eater
among three-year-old toddlers were 56.1%,
four-year-old toddlers were 64.7%, and five-
year-old toddlers were 68% [12]. The toddler
growth failure can be seen in the age of over
36 months [13]. The toddlers aged under
36 months constitute passive individuals in which
they receive food provided by their parents. While
the toddlers aged over 48 months constitute
active individuals in which they are picky-eating.
They can choose the food they like or even refuse
the food they dislike [14,15].
The majority of education of stunting and
underweight toddlers’ parents were junior high
school and primary school which were in low
level. There was no parent with bachelor degree.
This is in line with Khan’s study in 4 provinces,
namely Punjab, Sindh, Khyber Pakhtunkhwa, and
Balochistan Pakistan that showed only 25.7% of
stunting toddlers had parents with high education
level, 74.3% of them had parents with medium
to low education level. While in the category
of underweight toddlers, 11.4% of the toddlers
had parents with high education level, 88.6% of
them had parents with medium to low education
level [16]. The mother’s education level inuences
the awareness of nutrition. Those who have good
education level are more knowledgeable on the
practice of child care [17-20]. The mother’s
education level is one of the factors relating to
stunting, wasting, and underweight [21].
The average score of dental caries of stunting
and underweight toddlers showed high category.
This is in line with the study by Dimaisip-
Nabuab et al. [22] stating that stunting and
underweight toddlers suffered high category of
primary dental caries that was untreated properly.
Malnutrition among children completed with the
deciency of calcium, phosphate, vitamin A, C,
and D, can increase one’s vulnerability to the
dental caries through three mechanisms, namely
defect in tooth formation (odontogenesis),
delayed tooth eruption, and change in tooth and
salivary gland formation. There is a correlation
between infection in oral cavity and toddler
growth failure. One of the infection problems in
oral cavity is dental caries [23].
Another thing also takes a role in the
increased dental caries on stunting and
undernutrition toddlers. It is a culture, in which
culture inuences the practice of child feeding.
Pandhalungan ethnicity is an acculturation and
assimilation between Madura and Java ethnicity.
Madura places a dominant ethnicity and is
located in the north of Jember regency [24].
Pandhalungan community believes that eggs
can cause maag. The toddlers are suggested
to eat more rice with less vegetables and side
dishes. Their parents also believe that formula
milk can replace breastmilk. In addition,
there is a Madurese habit to feed the infants
under 6 months with
lotek
(smashed rice with
banana) to make them fat or having sufcient
weight [25].
Underweight dan stunting in toddlers is
also associated with oral health disorders, such
as enamel defects. Enamel defects are a group
of disorders that include enamel hypoplasia,
hypomineralized second molar/molar incisor
hypomineralization, amelogenesis imperfect,
and uorosis. Enamel hypoplasia is associated
with malnutrition, due to the disturbance
of ameloblastic activity during the secretory
phase of amelogenesis. The severity of the
insult determines the extent of the defect and
the translucency of partially formed enamel.
Moderate and acute malnutrition are likely to
disturb ameloblastic activity [26-28].
There was no difference between dental
caries of stunting and underweight toddlers,
in which both showed high category of dental
caries. Stunting and underweight are kinds of
undernutrition affecting tooth formation because
in cell growth, it leads the growth of hypoplastic
enamel which makes one more vulnerable to
the dental caries [29]. The hypoplastic enamel
affected by malnutrition causes the formation
of special space that eases plaque retention.
Malnutrition causes salivary gland hypofunction
that can decrease the flow of saliva, buffer
capacity, and saliva composition that also leads
dental caries [30]. In a normal condition, saliva
is functioned as the cleaner of tooth surface from
the pile of food residue. Consequently, the dental
and oral health are good. In the case of chronic
malnutrition, the ow of saliva tends to decrease
that causes disorder in saliva in oral cavity.
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Dental caries of stunting and underweight toddlers aged 3-5 years old among Pandhalungan community
Yani RWE et al.
Dental caries of stunting and underweight toddlers aged 3-5
years old among Pandhalungan community
This case can reduce the ability of oral cavity to
restrain infection and buffer capacity from the
plaque that contacts to the dental caries [30,31].
CONCLUSION
Based on the result of the study, it is
concluded that there was no difference between
dental caries of stunting and underweight
toddlers among Pandhalungan community. Both
of the stunting and underweight toddlers were
in high-categorised caries.
Acknowledgements
We thank University of Jember for supporting
us financially. We also express our greatest
appreciation to all of the respondents, inhabitants
of Panduman village, who have participated in
this research project.
Author’s Contributions
RWEY: Conceptualization, Methodology,
Formal Analysis, Investigation, Writing – Original
Draft Preparation, Project Administration,
Validation, Data Curation, Resources, Writing
– Review & Editing, Supervision, Funding
Acquisition. K: Conceptualization, Methodology,
Investigation, Writing – Original Draft, Project
Administration, Software, Validation, Resources,
Writing – Review & Editing, Supervision. SD:
Methodology, Formal Analysis, Investigation,
Visualization, Data Curation, Software, Resources,
Writing – Review & Editing.
Conict of Interest
The authors have no proprietary, nancial,
or other personal interest of any nature or kind
in any product, service, and/or company that is
presented in this article.
Funding
This research did not receive any specic
grant from funding agencies in the public,
commercial, or not-for-prot sectors.
Regulatory Statement
This study was conducted in accordance with
all the provisions of the local human subject’s
oversight committee guidelines and policies
of: The Research Ethic Committee Faculty of
Dentistry University of Jember. The approval code
for this study is: 1600/UN25.8/KEPK/DL/2022.
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Ristya Widi Endah Yani
(Corresponding address)
University of Jember, Faculty of Dentistry, Jember, Indonesia.
Email: ristya_widi@unej.ac.id
Date submitted: 2023 Mar 19
Accept submission: 2023 Oct 11