p e d i a t r i c d e n t a l j o u r n a l 2 6 ( 2 0 1 6 ) 8 3 e8 7

Available online at www.sciencedirect.com

Pediatric Dental Journal

journal homepage: www.elsevier.com/locate/pdj

Original Article

The prevalence of iron deficiency anemia in

children with severe early childhood caries
undergoing dental surgery under general
anesthesia
Bilge Gulsum Nur a,*, Mehmet Tanrver a, Mustafa Altunsoy a,
Tennur Atabay b, Nazm Intepe c
a

Department of Pediatric Dentistry, Faculty of Dentistry, Sifa University, Izmir, Turkey

Department of Basic Science, Faculty of Medicine, Sifa University, Izmir, Turkey
c
Department of Pediatrics, Faculty of Medicine, Sifa University, Izmir, Turkey
b

article info

abstract

Article history:

Purpose: Severe early childhood caries (SECC) is known to affect young children worldwide.

Received 26 January 2016

However, there is little information about the effects of SECC on Iron deficiency anemia

Received in revised form

(IDA). The aim of this study was to investigate the IDA in children with severe caries un-

18 April 2016

dergoing dental surgery under general anesthesia.

Accepted 28 April 2016

Methods: A total of 160 children were evaluated; age ranged from two to six years and mean

Available online 25 May 2016

age was 4.8 1.1 years. Before performing general anesthesia, blood samples were
assessed regarding hemoglobin (Hgb), hematocrit (Hct), mean corpuscular volume (MCV) as

Keywords:

biochemical indicators of IDA.

Dental caries

Results: The mean deft score was 10.1 4.1. The children in this study were defined to have

Iron-deficiency anemia

SECC. All of the anemia-related measurements were in the standard ranges, except for

Malnutrition in children

MCV values. There were no statistically significant differences between serum Hgb
(p 0.205) and Hct levels (p 0.386), but statistically significant differences were found
among serum MCV levels (p 0.018) in children with severe caries. Pearson Correlation
analysis among SECC and Hgb (p 0.54),Hct (p 0.88) and MCV (p 0.39) revealed that
there were no significant differences.
Conclusions: There was no association between SECC and serum Hgb, Hct and MCV levels,
but low levels of MCV might be an indicator of microcytic anemia which is most commonly
caused by iron deficiency. In the present study, we concluded that SECC might be a risk
marker for iron deficiency.
2016 Japanese Society of Pediatric Dentistry. Published by Elsevier Ltd. All rights reserved.

* Corresponding author. Tel.: 90 0541 2803106; fax: 90 232 3435656.

E-mail addresses: dtbilgenur@hotmail.com (B.G. Nur), dentistmehmedov@hotmail.com (M. Tanrver), dtaltunsoy@gmail.com
(M. Altunsoy), tennuratabay@hotmail.com (T. Atabay), nazim.intepe@sifa.edu.tr (N. Intepe).
http://dx.doi.org/10.1016/j.pdj.2016.04.002
0917-2394/ 2016 Japanese Society of Pediatric Dentistry. Published by Elsevier Ltd. All rights reserved.

84

1.

p e d i a t r i c d e n t a l j o u r n a l 2 6 ( 2 0 1 6 ) 8 3 e8 7

Introduction

Iron deficiency anemia (IDA) can be caused by several factors,

including dietary factors, genetic factors, inflammatory processes and environmental factors like low socioeconomic
status and dental caries [1,2]. This type of anemia leads to
learning and memory inabilities, reduced fine motor skills and
increased anxiety in childhood [3]. Approximately, the prevalence of IDA in preschool children is 47.4% worldwide [4]. IDA
is generally diagnosed by abnormally low hemoglobin (Hgb
value under 11 g/dL <5 years of age or Hgb value under 11.5 g/
dL 5 years of age), hematocrit value (Hct <34% <5 years of age
and Hct <35% 5 years of age), as well as mean corpuscular
volume value (MCV <73 fl <5 years of age and MCV <75 fl 5
years of age) as biochemical indicators [5].
Similarly, SECC is a multifactorial disease and numerous
risk factors (biological, psychosocial and behavioral) can
contribute to this disease [6]. In the literature, SECC is widespread in developing countries [7,8] as well as in low socioeconomic strata of industrialized countries [9,10]. This disease is defined as the presence of any smooth surface caries
for children under the age of 3 and the presence of one or more
smooth surface lesions in any primary maxillary anterior
teeth or a defs score of 4 for children aged 3e5 years [6]. It may
affect more than one quarter of young children [11,12].
Particularly in developing countries, IDA and dental caries are
the most common and widespread public health problems
[13]. Families with lower income usually consume unhealthy,
calorie-dense, high sugar content, nutrient poor diets [14].
Additionally, excessive consumption of cow's milk or prolonged breastfeeding may contribute both to SECC and iron
deficiency anemia (IDA) during early childhood [15]. Severe
early childhood caries and IDA are conditions of childhood
diseases that affect many children worldwide. A better understanding of these diseases will serve to enhance our current preventive and health promotion interventions. The
prevalence of SECC is quite high (69.8%) in Turkey and the
relationship of IDA with SECC has not been studied yet [16,17].
The aim of this study was to investigate the prevalence of IDA
in children with SECC undergoing dental surgery under general anesthesia.

2.

Material and method

This longitudinal study was performed with assessing the

blood sample records of pediatric patients who had severe
tooth decay involving multiple primary teeth. Before administering general anesthesia, blood samples were collected
from each participant. Patients' dental treatment were performed under general anesthesia due to lack of cooperation.
One peadiatric dentist performed dental examinations to
determine the deft scores of the patients. Before general
anesthesia procedures, potential risks or the possibility of
post-operative discomfort and possible benefits were
explained to the parents or caregivers of the children. The
children underwent full dental rehabilitation between
October 2012 and July 2014 under general anesthesia in Sifa
University Faculty of Medicine in Izmir, Turkey (Fig. 1).

Fig. 1 e Patients with number of dental caries.

2.1.

Inclusion criteria

1. Children <72 months of age who presented with SECC.

2. No chronic illnesses apart from dental caries
3. No previous dental treatment like restorations or
extractions.
4. All treatments were completed at one appointment under
general anesthesia.

2.2.

Exclusion criteria

1. Children who were already diagnosed with IDA and under

a doctor's care,
2. Children already under treatment for other anemias such
as Hemolytic anemia, neoplasms of the bone marrow,
numerical insufficiency of erythroid cells in the bone
marrow, aplastic anemia etc.
3. Known blood dyscrasia,
4. Any known form of hemoglobinopathy,
5. Medical problems causing the reduction of salivary flow
rate like diabetes mellitus or children with chemotherapy
who had been diagnosed with malignancy,
6. Mental or physical disabilities,
7. Children who had undergone major surgery,
8. Patients requiring non-restorative procedures such as the
treatment of traumatic injuries, tooth transplantation,
removal of impacted supernumeraries under general
anesthesia.

2.3.

Biochemical measurements

Before performing general anesthesia, a 5 mL blood sample

was collected from each patient on the same day. The blood
samples were immediately transported and analyzed by the
department of Laboratory Medicine at Sifa University. Blood
analysis included examination of anemia-related parameters
like red blood cell count (RBC), concentration of hemoglobin
(Hgb), hematocrit value (Hct), mean corpuscular volume
(MCV), mean corpuscular hemoglobin (MCH), mean corpuscular hemoglobin concentration (MCHC) and Red Cell Distribution Width (RDW).

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p e d i a t r i c d e n t a l j o u r n a l 2 6 ( 2 0 1 6 ) 8 3 e8 7

The most notable blood tests markers of IDA are Hgb, Hct
and MCV values [5]. Iron deficiency anemia was defined as Hgb
< 1 g/dL, Hct <34% and MCV <73 fl under 5 years of age and Hgb
<11.5 g/dL, Hct <35% and MCV <75 fl 5 years of age [5,18]. In
this study we used a) Hgb; b) Hct; c) MCV values.

2.4.

deft calculation

deft describes the amount of dental caries in an individual.

deft means to numerically express the caries prevalence by
calculating the number of decayed (d), extracted teeth (e), filled (f) teeth (t) for the primary teeth [19]. Severe Early Childhood Caries is defined as the score of decayed, extracted or
filled teeth (deft), that is 4 at 3 years of age, 5 at 4 years of
age, or 6 at 5 years of age [20]. The deft index was evaluated
on the same day of dental surgery before treatment was performed by one observer who has at least 5 years of professional clinical experience. The sum of all the deft values were
divided by the total number of children in the sample. As a
result it provided the mean deft of this study.

2.5.

Statistical analysis

Clinical data were entered into an excel (Microsoft Office)

database and analyzed using International Business Machines
Corporation Statistical Package for the Social Sciences version
21.0 (IBM SPSS, New York, USA). Statistical analyses included
descriptive statistics [(frequencies and means Standard
Deviations (SD)] and bivariate analysis including Chi-square
analysis. Analyses of blood tests were performed using a
Fisher's Exact test which is used to estimate the independent
effects of the anemia related blood markers in children with
severe caries. In addition, correlation between deft and anemia blood test markers were evaluated by using a Pearson
Correlation and t-test. A p value 0.05 was determined to be
statistically significant.

2.6.

Ethical approval

This study was approved by the University of Sifa Health

Research Ethics Board (Protocol#127-49). Written informed
consent form was acquired from the parents or caregivers of
all patients.

3.

Results

3.1.

Characteristics of participating children

A total of 160 children were selected; 50% (80 children) were

males, and 50% (80 children) were females. Patients' age
ranged from two to six years and mean age was (4.8 1.1
years). The mean deft sd was 10.1 4.1. In this study children were defined to have severe early childhood caries.

3.2.

Biochemical measurements

Standard ranges of Hgb, Hct and MCV(due to age-specific

thresholds (from 6 months to 5 years and from 5 years to 11
years), RBC, MCH, MCHC and RDW test results were based on
standards previously established by Sifa University. All of the
anemia-related measurements were in the standard ranges,
except for MCV values (Table 1). Nineteen per cent of children
(31 patients) had Hgb value below 11 grdL, eighteen per cent of
children (29 patients) had Hct value below %34, eighty-one per
cent of children (131 patients) had MCV level under 81 fl. There
were no statistically significant differences between serum
Hgb (p 0.205) and Hct levels (p 0.386), but statistically
significant differences were found among serum MCV levels
(p 0.018) in children with severe caries (Table 2). Pearson
Correlation and t-test using among SECC and Hgb (p 0.54),
Hct (p 0.88) and MCV (p 0.39) revealed that there were no
significant differences (Figs. 2e4).

4.

Discussion

Iron deficiency anemia and dental caries are still among the
most prevalent diseases in some developing countries [21].
According to some researchers' hypothesis, there is a variety
of reasons as to why the low Hgb, Hct or MCV levels of a
children are related with the presence of SECC [13,22]. Firstly,
children may have consumed too much cow's milk or they
may have been subjected to prolonged breastfeeding, which
may have reduced the absorption of iron [23e25]. Secondly,
untreated caries that usually causes pain or discomfort may
have led to the alteration of eating habits. Especially children
with SECC have difficulty in chewing some iron-rich foods like
red meat and citrus fruits [26]. These eating habits may cause

Table 1 e Clinical parameters in children with severe early childhood caries (n:160).
Anemia-related measures
Red blood cell count (106/uL)
Hemoglobin (g/dL)
Hematocrit value (%)
Mean corpuscular volume (fl)
Mean corpuscular hemoglobin (pg)
Mean corpuscular hemoglobin concentration (g/dL)
Red cell distribution width
a
b

Laboratory values
Mean SD
4.8
12.1
35.7
74.2
25.2
33.9
14.1

0.4
1
2.5
6.1b
2.6
1.3
1.7

Standard ranges used are those suggested by Sifa Medical University Hospital.
Below to standard ranges.

Standard rangea
3.6e5.2
11e13 & 12e18
34e40
81e103
25e31
32e37
11.9e14.5

Abnormal prevalence
N (%)
1
31
29
131
50
11
1

(0.6)
(19.3)
(18.1)
(81.8)
(31.2)
(6.8)
(0.6)

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p e d i a t r i c d e n t a l j o u r n a l 2 6 ( 2 0 1 6 ) 8 3 e8 7

Table 2 e Analysis of blood test in children with severe

caries (n:160).
Clinical
parameters
Blood test
Hgb
Hct
MCV

<5 age

5 age

p value

Normal

Under

Normal

Under

43
45
5

14
12
52

86
86
24

17
17
79

0.205
0.386
0.018*

*p < 0.05.
Hemoglobin: Hgb; Hematocrit value (%): Htc; Mean corpuscular
volume (fl); MCV.
Iron deficiency anemia was defined Hgb <11 g/dL, Hct <34% and
MCV <73 for children <5 years of age and Hgb <11.5 g/Dl, Hct <35%
and MCV <75 for children 5 years of age [4].

Fig. 4 e The correlation between dental caries and MCV

values.

Fig. 2 e The correlation between dental caries and Hgb

values.

Fig. 3 e The correlation between dental caries and Hct

values.

low Hgb, Hct or MCV values in the blood. Thirdly, untreated

caries may lead to acute or chronic inflammation as a result of
pulpitis and periapical abscess. Furthermore, inflammation
may stimulate a series of events which cause the production
of cytokines and inhibit erythropoiesis and thus suppress the
synthesis of Hgb in the blood [22,27,28].
Schroth et al. [22] evaluated hemoglobin values among preschool children either diagnosed as Severe Early Childhood

Caries (S-ECC) or caries free (144 with S-ECC and 122 cariesfree). They reported that children with S-ECC were significantly more likely to have IDA than caries-free controls (14.6%
had IDA with S-ECC; 8% had IDA without caries). Similarly,
Clarke et al. [29] investigated Hgb, MCV, albumin and iron
levels in 56 pre-school children aged between two to six years
with SECC and claimed that SECC may be a risk marker for
iron deficiency anemia.
Whereas, Ramos-Gomez [30] investigated the characterization and comparison of demographic, behavioral and
environmental factors potentially associated with early
childhood caries (ECC) and evaluated salivary levels of mutants streptococci and lactobacilli. They identified and
examined one hundred forty-six children aged between 36
and 55 months with caries experience. According to the study
of Ramos-Gomez, anemia was not statistically significantly
associated with the number of decayed and filled surfaces or
decayed and filled teeth.
Szeto et al. [2] researched sociodemographic data, information related to feeding behaviors and diet risk factors for
caries in 96 children (18e72 months of age). They determined
that those risk indicators were associated with iron deficiency
and found that 64.6% of patients had dental caries and 25.0%
had iron deficiency. As a result of this study, no risk indicators
common to both disorders were identified and caries was
significantly more prevalent in older children but ID was
found primarily in the younger children. This result may be
related with excessive milk consumption which might be a
risk factor for ID.
Similarly, Sadeghi et al. [31] studied the relationship between early childhood caries and iron deficiency in 204 children (age range 24e71 months; deft: 2.4 3.3) with SECC (5.9%
had IDA). They found that there was no relationship between
serum ferritin levels and SECC, however, deft scores
decreased significantly with increasing serum iron levels.
According to the our study, we found that there was no
association between SECC and serum Hgb, Hct and MCV
levels, which is similar to the findings of another study [2,31].
But low level of MCV might be an indicator of microcytic
anemia which is most commonly caused by iron deficiency.
This result might be explained by SECC being a risk marker for
iron deficiency.

p e d i a t r i c d e n t a l j o u r n a l 2 6 ( 2 0 1 6 ) 8 3 e8 7

Our study has several limitations. The main limitation of

this study was that we could not taking blood samples from
healthy children in the community because of ethical reasons,
thus we were unable to compare IDA prevalence between
children with severe caries and caries-free children.

5.

Conclusion

According to our study, a causal relationship between SECC

and anemia could not be confirmed. Since iron deficiency has
permanent effects on growth and development, particularly
amongst developing children, further investigations to
determine causal relationships and lifestyle risk factors are
warranted.

Conflict of interest
All authors declare that they have no conflict of interest.

Acknowledgments
The authors would like to express their gratitude to Dr. Osman

larc for his support on statistical evaluation.
Sami Ag

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