Early Childhood Caries in 3 to 5 Year Old Children in Trinidad and Tobago
Round 1
Reviewer 1 Report
The manuscript by Percival et al. documents the extent of early childhood caries (ECC) and severe-ECC (S-ECC) in a Caribbean island population. The manuscript also addresses the behaviors most linked to the presence of ECC and S-ECC and in this respect is largely confirmatory. However, in this latter realm the manuscript is often misleading by focusing too much on an absolute cut-off for statistical significance. It is a pet-peeve of this Reviewer that data analyses that yield a p-value of 0.049 are considered to have biological relevance while data with a p-value of 0.051 are more or less dismissed as meaningless. In a literal sense the manuscript is correct in stating that there was not a statistically significant relationship between the mother’s level of education and a child’s caries experience . . . using the pre-established definition of statistical significance. But the p-value for these data was 0.054; university-level education was the only category for which a higher percentage of children had no caries compared to the percentage that had caries. A similar scenario existed for some of the data associated with breastfeeding and caries. It is also not clear that the early caries children should have been combined with the caries free children. What would the data have looked like if children with white-spot lesions were included with the caries group? Overall, the data seemed to be largely confirmatory of other studies but this is sometimes not brought out due to an over emphasis on statistics which should only be considered as a form of evidence, not a proclamation of the value of the entirety of the data.
Note: The first sentence of the M&M says that the study area was divided into six regions -- but only five are listed.
Author Response
The authors are very thankful for the comments of the reviewer, which have helped us to improve the paper. We have tried our best to address the concerns raised.
Response to Comments and Suggestions for Authors
** The authors are thankful for the comments of the reviewer which have helped us to improve the paper. We have tried our best to address the concerns.
Sr No. | Comments | Response |
1. | The manuscript by Percival et al. documents the extent of early childhood caries (ECC) and severe-ECC (S-ECC) in a Caribbean island population. The manuscript also addresses the behaviors most linked to the presence of ECC and S-ECC and in this respect is largely confirmatory. | Comments have been well noted |
2. | However, in this latter realm the manuscript is often misleading by focusing too much on an absolute cut-off for statistical significance. It is a pet-peeve of this Reviewer that data analyses that yield a p-value of 0.049 are considered to have biological relevance while data with a p-value of 0.051 are more or less dismissed as meaningless. | Comments have been well noted |
3. | In a literal sense the manuscript is correct in stating that there was not a statistically significant relationship between the mother’s level of education and a child’s caries experience . . . using the pre-established definition of statistical significance. But the p-value for these data was 0.054; university-level education was the only category for which a higher percentage of children had no caries compared to the percentage that had caries. | Comments have been noted and consideration for possible clinical significance have been included in lines 226-232 and lines 243 -245 |
4. | A similar scenario existed for some of the data associated with breastfeeding and caries. It is also not clear that the early caries children should have been combined with the caries free children. | Comment about possible clinical significance of breast feeding has been included in lines 243-244. As the authors used the WHO dmft index which uses cavitated lesions, the early caries children were included with caries free children. |
5. | What would the data have looked like if children with white-spot lesions were included with the caries group? | The authors considered this but thought that it would be more suitable in its current format to be able to compare findings with similar studies. |
6. | Overall, the data seemed to be largely confirmatory of other studies but this is sometimes not brought out due to an over emphasis on statistics which should only be considered as a form of evidence, not a proclamation of the value of the entirety of the data. | Comments have been noted and we agree with comments |
7. | Note: The first sentence of the M&M says that the study area was divided into six regions -- but only five are listed. | The error has been noted and the correction made in Line 70. |
Reviewer 2 Report
Early Childhood Caries in 3 to 5 year old children in Trinidad and Tobago. This manuscript is aimed at evaluating the prevalence and contributory factors of early childhood caries (ECC) and severe ECC (S-ECC) among preschool children of Kindergartens and Early Childhood Centers in Trinidad and Tobago. This manuscript is well written and organized. However, there are some shortcomings that need to be addressed by the authors.
In general:
- The authors did not follow the STROBE guidelines for reporting cross section studies. Important items are missing in the manuscript. It would be better to be included to improve the quality of this report.
- English language needs revision and editing specially in the parts presenting statistics. Common words such as “shaking teeth” must be replaced by scientific ones.
Abstract:
- It would be better if the authors indicate that those islands are in the Caribbean.
- The authors need to write the index name used in clinical examination.
Materials and methods:
- The authors did not indicate the dates for sample recruitment.
- More details are needed on sampling methods used.
Results:
- In Table 1 percentages for each number in each category such as male, female, African……..etc are needed.
- “3.2. -Prevalence of caries” “3.2-Maternal Factors” “3.3.-” numbers need revision.
- “3.2-Maternal Factors” this subtitle needs revision its following paragraph is not all about maternal factors.
- Page 4 lines129-130 “The majority of children who visited a dental professional did so for routine check-up (64/107)” it would be better to put percentage as well.
- Page 5 lines 139-145. “The finding showed that 84.7% of the children were breast fed.” “It was noted that 86.8% of the children were bottle fed” there is a problem with numbers between these two sentences making the total more than 100%.
- Table 4, there is a missing value in one cell.
- Table 5, there are cells containing less than 5 items this makes Chi Square test not suitable for them.
- Regression analysis is needed to identify which factors are associated with ECC in this study.
Conclusion:
- Conclusion should be based on the results. The authors did not assess preventive programme. These recommendations can be presented in discussion.
Comments for author File: 
Comments.docx
Author Response
The authors are very thankful for the comments of the reviewer, which have helped us to improve the paper. We have tried our best to address the concerns raised.
Response to Comments and Suggestions for Authors
Sr No. | Comments | Response |
1. | Early Childhood Caries in 3 to 5 year old children in Trinidad and Tobago. This manuscript is aimed at evaluating the prevalence and contributory factors of early childhood caries (ECC) and severe ECC (S-ECC) among preschool children of Kindergartens and Early Childhood Centers in Trinidad and Tobago. This manuscript is well written and organized. However, there are some shortcomings that need to be addressed by the authors. | Comments well noted |
2. | In general: The authors did not follow the STROBE guidelines for reporting cross section studies. Important items are missing in the manuscript. It would be better to be included to improve the quality of this report. | Thank you for the guidance. The authors have tried to comply with the STROBE guidelines. |
3. | English language needs revision and editing specially in the parts presenting statistics. Common words such as “shaking teeth” must be replaced by scientific ones. | The term “Shaking teeth” was used in the self- administered questionnaire to avoid the use of jargon. The authors believe that it has been suitably addressed in line 143. |
4. | Abstract: It would be better if the authors indicate that those islands are in the Caribbean. | Comments noted and addressed |
5. | The authors need to write the index name used in clinical examination. | Indices have been named in lines 98 and 102 |
6. | Materials and methods: The authors did not indicate the dates for sample recruitment. | Dates for sample recruitment have been included inline 70 |
7. | More details are needed on sampling methods used.
| Details on sampling methods have been included lines 73-77 |
8. | Results: | |
9. | In Table 1 percentages for each number in each category such as male, female, African……..etc are needed. | Percentages have been included |
10. | “3.2. -Prevalence of caries” “3.2-Maternal Factors” “3.3.-” numbers need revision. | Revisions completed |
11. | “3.2-Maternal Factors” this subtitle needs revision its following paragraph is not all about maternal factors. | Comments noted and title has been revised |
12. | Page 4 lines129-130 “The majority of children who visited a dental professional did so for routine check-up (64/107)” it would be better to put percentage as well. | Line 149 – percentage included |
13. | Page 5 lines 139-145. “The finding showed that 84.7% of the children were breast fed.” “It was noted that 86.8% of the children were bottle fed” there is a problem with numbers between these two sentences making the total more than 100%. | This information has been rewritten to reflect the appropriate numbers in lines 158-165. |
14. | Table 4, there is a missing value in one cell. | Omission noted and value added |
15. | Table 5, there are cells containing less than 5 items this makes Chi Square test not suitable for them. | Yates correction for Chi-Square has been applied to cells with numbers less than 5 |
16. | Regression analysis is needed to identify which factors are associated with ECC in this study. | The authors appreciate the comment from the reviewer about using logistic regression analysis however given the nature of the data the authors chose to use chi square rather than multiple regression logistic. |
17. | Conclusion: Conclusion should be based on the results. The authors did not assess preventive programme. These recommendations can be presented in discussion. | Noted and conclusions revised. |
Reviewer 3 Report
Introduction:
1. You describe ECC and SECC and define the problem that you are trying to address with your research. You have gathered an extensive amount of information as part of your questionnaire that will prove to be useful in your research. You also clearly lay out your aims for the study.
2. It may be helpful to describe the population makeup of Trinidad and Tobago and why the caries rate is high in the English speaking Caribbean (from 21-29%). How does this compare to other island nations and neighboring Venezuela?
Materials and Methods:
1. In the first paragraph (P2 line 62-65) you mention that you divided Trinidad Tobago into 6 regions but you do not explain why or if this truly represents the demographics of Trinidad Tobago? With the kindergartens and early childhood centers that were chosen, do these accurately represent the SES and demographics of Trinidad and Tobago? It may be beneficial to explain in more detail that the random sampling truly represents the population ofTrinidad and Tobago.
2. On p2 line 75-81, you mention the questionnaire, it would be helpful to have a figure with the questionnaire or have it as an appendix document. It is too vague as to what was asked in the questionnaire.
Results:
1. Page 3 line 95, you discuss inter-examiner calibration, however, was there any intra-examiner calibration. Was there a portion of the children screened twice by the same person to see if they agreed with themselves?
2. Page 3 line 101, please state your response rate.
3. Page 3 line 102-105 you describe the ethnicity of your subject population. Does this match with the makeup of the general population of Trinidad and Tobago?
4. Your tables provide a lot of information that is helpful to describe your findings. In table 1 you have a column for S-ECC but in subsequent tables you do not examine S-ECC. This could strengthen your paper.
5. Page 5 line 139-149 you discuss feeding practices and these are shown in table 3. You mention that 84.7% of children were breastfed and that 86.8% were bottle-fed. There appears to be overlap of children being breastfed and bottle-fed, but there is not mention in the results of this overlap. This could be a category in Table 3 as the “bottle feeding” category and “Breast-fed” category are not purely one or the other, but a mix of both. I would recommend that this analysis be completed to more accurately describe your results.
6. In table 4, under “Frequent sports drink intake” there is missing data for those who do not drink sports drinks but have caries.
Discussion:
1. Overall your discussion is thorough and you compare your results to other studies and comments on limitations to the current study.
2. In your results, you mention that males had significantly more caries when compared to females, but you do not elaborate on why this might be. (Page 3 Line 16-117)
3. Are there any issues, such as access to care/number of dentist, insurance, cost, government programs, etc. that may be contributing to the >50% caries rate, mostly untreated dental decay? If so, please elaborate in your discussion.
Thank you for your submission.
Author Response
The authors are very thankful for the comments of the reviewer, which have helped us to improve the paper. We have tried our best to address the concerns raised.
Response to Comments and Suggestions for Authors
Sr No. | Comments | Response |
1. | Introduction: You describe ECC and SECC and define the problem that you are trying to address with your research. You have gathered an extensive amount of information as part of your questionnaire that will prove to be useful in your research. You also clearly lay out your aims for the study. | Comments are well noted. |
2. | It may be helpful to describe the population makeup of Trinidad and Tobago and why the caries rate is high in the English speaking Caribbean (from 21-29%). How does this compare to other island nations and neighboring Venezuela? | Comments noted and information updated in lines 47-51. There is no data available for neighboring Venezuela |
3. | Materials and Methods: In the first paragraph (P2 line 62-65) you mention that you divided Trinidad Tobago into 6 regions but you do not explain why or if this truly represents the demographics of Trinidad Tobago? With the kindergartens and early childhood centers that were chosen, do these accurately represent the SES and demographics of Trinidad and Tobago? It may be beneficial to explain in more detail that the random sampling truly represents the population of Trinidad and Tobago. | Error noted and correction has been made. Information about demographics and representation have been included in lines 52-57, 69-77.
|
4. | On p2 line 75-81, you mention the questionnaire, it would be helpful to have a figure with the questionnaire or have it as an appendix document. It is too vague as to what was asked in the questionnaire. | The authors noted that questionnaires are not usually included with papers. Access to the questionnaire is available if needed. |
5. | Results: Page 3 line 95, you discuss inter-examiner calibration, however, was there any intra-examiner calibration. Was there a portion of the children screened twice by the same person to see if they agreed with themselves? | Intra and inter- examiner calibration information has been included line 109-112. |
6. | Page 3 line 101, please state your response rate. | Line 117- response rate added |
7. | Page 3 line 102-105 you describe the ethnicity of your subject population. Does this match with the makeup of the general population of Trinidad and Tobago? | Comments noted and information included in lines 52 -57, 120-123 |
8. | Your tables provide a lot of information that is helpful to describe your findings. In table 1 you have a column for S-ECC but in subsequent tables you do not examine S-ECC. This could strengthen your paper. | Comments noted and additional information regarding S-ECC has been added to all tables. |
9. | Page 5 line 139-149 you discuss feeding practices and these are shown in table 3. You mention that 84.7% of children were breastfed and that 86.8% were bottle-fed. There appears to be overlap of children being breastfed and bottle-fed, but there is not mention in the results of this overlap. This could be a category in Table 3 as the “bottle feeding” category and “Breast-fed” category are not purely one or the other, but a mix of both. I would recommend that this analysis be completed to more accurately describe your results. | This information has been rewritten to reflect the appropriate numbers. ( Lines 158-165) |
10. | In table 4, under “Frequent sports drink intake” there is missing data for those who do not drink sports drinks but have caries. | Omission noted and value added |
11. | Discussion: Overall your discussion is thorough and you compare your results to other studies and comments on limitations to the current study. | Comment noted |
12. | In your results, you mention that males had significantly more caries when compared to females, but you do not elaborate on why this might be. (Page 3 Line 16-117) | Comment noted and addressed in lines 206-209 |
13. | Are there any issues, such as access to care/number of dentist, insurance, cost, government programs, etc. that may be contributing to the >50% caries rate, mostly untreated dental decay? If so, please elaborate in your discussion. | The authors believe that these issues have been addressed in lines 235-240 |
Round 2
Reviewer 2 Report
The manuscript is much improved, however for better quality regression analysis in addition to Chi square would improve the results to identify which factors are associated with early childhood caries in this population.
Author Response
Thank you for your comments. Logistical regression has been conducted and the methods, results and conclusions have been reviewed and revised.
Reviewer 3 Report
Thank you for your re-submission.
Only a few minor comments:
In tables 1, 2, 4, AND 5 you use the "caries" as a heading (no caries and caries columns), however, in table 3 instead of "caries" you use ECC. I would suggest using one label for all tables.
In tables 1-5 you use the term non-S-ECC, does that mean ECC? Currently non-S-ECC is not defined. If it means ECC it might be better to place that as a label for that column. If you would like to use non-S-ECC please place a note in the footnote of the table with a brief definition.
For those who exclusively breast fed (13.2%), where did those children fall in terms of ECC and S-ECC? In the discussion (lines 261-263) you mention that this study supports that breast feeding between 13-23 months has no effect on dental caries and that breast feeding has clinical significance in S-ECC development. Your reported p value of 0.059, which is trending to show that people who breast feed have fewer S-ECC. However this is still not purely breast fed only since 71.5% both bottle and breastfed and can be misleading - which feeding habit is influencing the results? Roughly 45 people in the breastfeeding group, breastfed exclusively. It would be clearer evidence to support this conclusion if you report the data from these 45 people in table 3. Are there subject who bottle fed exclusively? If so this could be another pure group. Then the subjects who both bottle fed and breastfed could be another group. If you can show that the 45 people who breastfed only have trending or sig. less S-ECC then this could lend itself to support that the mixed groups lower S-ECC compared to non S-ECC might be influenced by breastfeeding. This would strengthen your conclusion and paper.
Author Response
In tables 1, 2, 4, AND 5 you use the "caries" as a heading (no caries and caries columns), however, in table 3 instead of "caries" you use ECC. I would suggest using one label for all tables.
Response: Thank you for your comments. The inconsistency has been noted and the changes made to the heading (No caries and ECC)
In tables 1-5 you use the term non-S-ECC, does that mean ECC? Currently non-S-ECC is not defined. If it means ECC it might be better to place that as a label for that column. If you would like to use non-S-ECC please place a note in the footnote of the table with a brief definition.
Response: A footnote has been placed at the end of Table 1 "non S-ECC - all children who do not belong to the S-ECC group ." (This group includes ECC as well as caries free children.)
For those who exclusively breast fed (13.2%), where did those children
fall in terms of ECC and S-ECC? In the discussion (lines 261-263) you
mention that this study supports that breast feeding between 13-23
months has no effect on dental caries and that breast feeding has
clinical significance in S-ECC development. Your reported p value of
0.059, which is trending to show that people who breast feed have fewer
S-ECC. However this is still not purely breast fed only since 71.5%
both bottle and breastfed and can be misleading - which feeding habit is
influencing the results? Roughly 45 people in the breastfeeding group,
breastfed exclusively. It would be clearer evidence to support this
conclusion if you report the data from these 45 people in table 3. Are
there subject who bottle fed exclusively? If so this could be another
pure group. Then the subjects who both bottle fed and breastfed could
be another group. If you can show that the 45 people who breastfed only
have trending or sig. less S-ECC then this could lend itself to support
that the mixed groups lower S-ECC compared to non S-ECC might be
influenced by breastfeeding. This would strengthen your conclusion and
paper.
Response: The authors acknowlege that the statement was misleading. Fisher test of equality of two proportions and logistic regression were conducted to determine the associations and anyrespective risk factors. The discussion has been modified accordingly.
Round 3
Reviewer 2 Report
No further comments
Reviewer 3 Report
Thank you for the time and effort that you have placed in this study.
