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Ju X, Mittinty M, Smithers L, Jamieson L. Early Childhood Caries Intervention in Aboriginal Australian Children: A Cross-in Randomized Trial. JDR Clin Trans Res 2024; 9:239-247. [PMID: 37615160 PMCID: PMC11184907 DOI: 10.1177/23800844231191714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/25/2023] Open
Abstract
INTRODUCTION Early childhood caries (ECC) is the strongest predictor of dental caries in adulthood. Indigenous children have higher levels of ECC compared with non-Indigenous children. The study aimed to estimate the efficacy of an ECC intervention among Aboriginal Australian children. METHODS Baby Teeth Talk was an outcome assessor-blinded, closed-cohort cross-in randomized controlled trial conducted in South Australia, Australia. We randomly allocated 448 women pregnant with an Aboriginal child to either an immediate (II) or delayed (DI) intervention group between January 2011 and May 2012. The immediate intervention comprised (1) provision of dental care to mothers during pregnancy; (2) application of fluoride varnish to teeth of children at ages 6, 12; and 18 mo; (3) motivational interviewing delivered in conjunction; and (4) anticipatory guidance. Mothers/children in the DI group received the same intervention commencing when the child was 24 mo of age. The outcomes were assessed by the number of decayed, missing, and filled teeth (dmft) in children aged 24, 36, and 60 mo. Regression-based approaches with generalized linear mixed effect (log-Poisson) model characterized the mean dmft to estimate risk ratios (RRs) and 95% confidence intervals (95% CIs). RESULTS A total of 223 participants were randomly allocated to the II group and 225 to the DI group. Three hundred sixty-five children (178 II, 187 DI) received at least 1 dental clinical examination at 24, 36, and 60 mo of follow-up. The mean dmft was lower in the II group (0.48, 1.32, and 2.06) than in the DI group (0.82, 1.90, and 3.29) at each time point, respectively. The direct ECC intervention effect was to prevent/decrease dental decay experience (dmft) occurrence by 84% (RR = 1.84, 95% CI: 1.20-2.48) after adjusting for all covariates. CONCLUSIONS Our analysis indicated that the time-varied ECC intervention had immediate and longer-term effects on the prevention of ECC among Indigenous Australian children. KNOWLEDGE TRANSFER STATEMENT The study aimed to estimate the efficacy of an early childhood caries (ECC) intervention among Aboriginal Australian children. The findings indicated that the culturally appropriate ECC intervention is effective for the preventive of ECC and can be used by clinicians, educators, and policy makers when planning an ECC intervention, so as to prevent and reduce ECC and meet identified oral health needs across the Australian population, which is important for preventive dental care.
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Affiliation(s)
- X. Ju
- Australian Research Centre for Population Oral Health, Adelaide Dental School, the University of Adelaide, South Australia, Australia
| | - M.N Mittinty
- School of Public Health, University of Adelaide, Australia
| | - L. Smithers
- School of Health and Society, University of Wollongong, Australia
| | - L. Jamieson
- Australian Research Centre for Population Oral Health, Adelaide Health & Medical Sciences Building, The University of Adelaide, SA, USA
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Eriksen C, Boustedt K, Sonne SB, Dahlgren J, Kristiansen K, Twetman S, Brix S, Roswall J. Early life factors and oral microbial signatures define the risk of caries in a Swedish cohort of preschool children. Sci Rep 2024; 14:8463. [PMID: 38605085 PMCID: PMC11009336 DOI: 10.1038/s41598-024-59126-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 04/08/2024] [Indexed: 04/13/2024] Open
Abstract
The oral cavity harbors complex communities comprising bacteria, archaea, fungi, protozoa, and viruses. The oral microbiota is establish at birth and develops further during childhood, with early life factors such as birth mode, feeding practices, and oral hygiene, reported to influence this development and the susceptibility to caries. We here analyzed the oral bacterial composition in saliva of 260 Swedish children at two, three and five years of age using 16S rRNA gene profiling to examine its relation to environmental factors and caries development at five years of age. We were able to assign the salivary bacterial community in each child at each time point to one of seven distinct clusters. We observed an individual dynamic in the development of the oral microbiota related to early life factors, such as being first born, born by C-section, maternal perinatal antibiotics use, with a distinct transition between three and five years of age. Different bacterial signatures depending on age were related to increased caries risk, while Peptococcus consistently linked to reduced risk of caries development.
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Affiliation(s)
- Carsten Eriksen
- Department of Biotechnology and Biomedicine, Technical University of Denmark, Kgs. Lyngby, Denmark
| | - Katarina Boustedt
- Department of Paediatrics, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Maxillofacial Unit, Halland Hospital, Halmstad, Sweden
| | - Si Brask Sonne
- Laboratory of Genomics and Molecular Biomedicine, Department of Biology, University of Copenhagen, Copenhagen, Denmark
| | - Jovanna Dahlgren
- Department of Paediatrics, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Pediatrics, Queen Silvia Children's Hospital, Västra Götalandsregionen, Gothenburg, Sweden
| | - Karsten Kristiansen
- Laboratory of Genomics and Molecular Biomedicine, Department of Biology, University of Copenhagen, Copenhagen, Denmark.
- BGI-Shenzhen, Shenzhen, 518083, China.
- Qingdao-Europe Advanced Institute for Life Sciences, Qingdao, 266555, Shandong, China.
| | - Svante Twetman
- Department of Odontology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Susanne Brix
- Department of Biotechnology and Biomedicine, Technical University of Denmark, Kgs. Lyngby, Denmark.
| | - Josefine Roswall
- Department of Paediatrics, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
- Department of Paediatrics, Halland Hospital, Halmstad, Sweden.
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Nadeeshani H, Kudagammana ST, Herath C, Jayasinghe R, Liyanage R. Early Childhood Caries and Nutritional Status of Children: A Review. Food Nutr Bull 2023; 44:249-264. [PMID: 38095292 DOI: 10.1177/03795721231209358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
BACKGROUND Early childhood caries (ECC) is a serious public health issue affecting children around the world. Severe symptoms and complications commonly found with ECC are adverse effects on health and growth retardation triggered by sensitivity, pain, and abscesses associated with decayed teeth, premature tooth loss, and insufficient food intake due to difficulty in chewing and keeping food in the mouth. OBJECTIVE This article aims to provide an overview of the most recent and current evidence on the association between ECC and nutritional status with an aim to stimulate further research and to identify the impact of nutritional status on ECC and vice versa. METHODS PubMed, Web of Science, and Google Scholar databases were used to search the studies conducted between 2016 and 2022. The included studies were searched using some keyword combinations and saved in Mendeley Desktop for review and referencing. All books, policy briefs, thesis/dissertations, and non-peer-reviewed articles were excluded, and 47 studies were selected for this narrative review. RESULTS Many studies have identified long-term, frequent, and nocturnal bottle-feeding and breastfeeding as well as frequent consumption of sugary food and beverages as high-risk factors for ECC. Adverse nutritional status assessed by anthropometric measures, vitamin D status, and iron-deficiency anemia have been studied as risk factors for ECC. CONCLUSIONS Most of the prevailing studies are either case-control or cross-sectional studies, which are unable to provide strong evidence to prove the direction of causality. Thus, further prospective studies are needed to clarify the association between ECC and the nutritional status of children.
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Affiliation(s)
- Harshani Nadeeshani
- Division of Nutritional Biochemistry, National Institute of Fundamental Studies, Kandy, Sri Lanka
| | | | - Chandra Herath
- Department of Community Dental Health, Faculty of Dental Sciences, University of Peradeniya, Peradeniya, Sri Lanka
| | - Ruwan Jayasinghe
- Department of Oral Medicine and Periodontology, Faculty of Dental Sciences, University of Peradeniya, Peradeniya, Sri Lanka
| | - Ruvini Liyanage
- Division of Nutritional Biochemistry, National Institute of Fundamental Studies, Kandy, Sri Lanka
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Fernandes JDKB, de Sousa FS, Alves CMC, Ribeiro CCC, Simões VMF, Saraiva MDCP, Thomaz EBAF. Small for gestational age and early childhood caries: the BRISA cohort study. Sci Rep 2023; 13:14343. [PMID: 37658113 PMCID: PMC10474029 DOI: 10.1038/s41598-023-41411-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 08/25/2023] [Indexed: 09/03/2023] Open
Abstract
This study tests the hypothesis that children 12-30 months born small for gestational age (SGA) aged are more susceptible to severe early childhood caries (S-ECC). We used data on 865 children aged 12-30 months from a prospective cohort study conducted in a city in the northeast of Brazil. The study outcome was S-ECC, defined based on the proportion of decayed tooth surfaces (cavitated or not). The main exposure variable was SGA, defined according to the Kramer criterion and the INTERGROWTH-21st standard. Direct (SGA → S-ECC) and indirect effects were estimated using structural equation modeling, calculating standardized factor loadings (SFL) and P-values (alpha = 5%). The final models showed a good fit. SGA influenced S-ECC in the direct and indirect paths. In the group of SGA children with 12 or more erupted teeth defined according to the Kramer criterion, the direct effect was positive (SFL = 0.163; P = 0.019); while among all SGA children defined according to the INTERGROWTH-21st standard, the direct effect was negative (SFL = - 0.711; P < 0.001). Age and number of erupted teeth may influence the occurrence of S-ECC in SGA children, as the number of teeth affects the time of exposure to disease risk factors.
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Affiliation(s)
- Juliana de Kássia Braga Fernandes
- Programa de Pós-graduação em Saúde Coletiva, Universidade Federal do Maranhão, São Luís, MA, Brazil
- Departamento de Odontologia, Universidade CEUMA, São Luís, MA, Brazil
| | - Francenilde Silva de Sousa
- Programa de Pós-graduação em Saúde Coletiva, Universidade Federal do Maranhão, São Luís, MA, Brazil.
- Departamento de Saúde Pública, Universidade Federal do Maranhão (UFMA), Rua Barão de Itapari, 155 - Centro, São Luís, Maranhão, 65020-070, Brazil.
| | - Cláudia Maria Coelho Alves
- Programa de Pós-graduação em Saúde Coletiva, Universidade Federal do Maranhão, São Luís, MA, Brazil
- Programa de Pós-graduação em Odontologia, Universidade Federal do Maranhão, São Luís, MA, Brazil
| | - Cecília Cláudia Costa Ribeiro
- Programa de Pós-graduação em Saúde Coletiva, Universidade Federal do Maranhão, São Luís, MA, Brazil
- Programa de Pós-graduação em Odontologia, Universidade Federal do Maranhão, São Luís, MA, Brazil
| | | | | | - Erika Barbara Abreu Fonseca Thomaz
- Programa de Pós-graduação em Saúde Coletiva, Universidade Federal do Maranhão, São Luís, MA, Brazil
- Programa de Pós-graduação em Odontologia, Universidade Federal do Maranhão, São Luís, MA, Brazil
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Baltaci E, Ozveren N, Batur Kara S. Social and Behavioural Risk Factors of Early Childhood Caries Among Children Aged 4–47 Months: A Cross-Sectional Study. EURASIAN JOURNAL OF FAMILY MEDICINE 2022. [DOI: 10.33880/ejfm.2022110404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Aim: This study aimed to investigate various risk factors for early childhood caries in a paediatric population in Edirne, Turkey.
Methods: This cross-sectional study included 1197 children aged 4–47 months old who visited family health centres for routine control. Questionnaires were used to collect data on parental- and pediatric-related variables potentially associated with early childhood caries. Oral hygiene was scored using the Visual Plaque Index, and decayed teeth, missing teeth, filled surfaces and carious teeth were recorded. We evaluated risk factors for early childhood caries using a hierarchical regression analysis model.
Results: Of the 1197 children, 219 (18.3%) had dental caries. The mean age of the children in the caries group was 33±7 months old, and the mean filled surfaces and carious teeth values were 4.84±3.49 and 8.50±8.30, respectively. Younger age at the time of first tooth eruption, current height percentile higher than 96, poor oral hygiene, older age, having siblings, and paternal age younger than 30 years old at the time of the child’s birth were associated with an increased risk of early childhood caries.
Conclusion: Prevention policies on caries among young children should focus on the first years of a child's life. Non-dental healthcare professionals may play an important role in being the first contact with parents in the healthcare system for anticipatory guidance.
Keywords: oral health, dental caries, preschool children, risk factors, preventive care
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Affiliation(s)
- Ezgi Baltaci
- Department of Pediatric Dentistry, Faculty of Dentistry, Trakya University
| | - Neslihan Ozveren
- Department of Pediatric Dentistry, Faculty of Dentistry, Trakya University
| | - Sinem Batur Kara
- Department of Pediatric Dentistry, Faculty of Dentistry, Trakya University
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Cui Y, Chen D, Lin H, Tao Y. The association between low birth weight and/or preterm birth and dental caries -A systematic review and meta-analysis. Int J Dent Hyg 2022. [PMID: 36524312 DOI: 10.1111/idh.12651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 12/01/2022] [Accepted: 12/12/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Studies on the association between adverse birth outcomes and dental caries in children have shown conflicting results, so the aim of this systematic review and meta-analysis was to investigate the association between adverse birth outcomes and dental caries in children. METHODS We systematically searched articles in four electronic databases (Web of Science, PubMed, Cochrane Library and Embase) published prior to August 2021. The odds ratio (OR) (or converted OR) and the corresponding 95% confidence intervals (95% CI) were processed. The certainty of evidence was assessed using GRADE's risk bias assessment tool. Random effects model was used for this meta-analysis. RESULTS A total of thirty-one observational studies met the inclusion criteria. The pooled estimates indicated that children exposed to low birth weight (LBW)/preterm birth (PTB) did not experience higher dental caries in primary teeth. Subgroup analyses showed that children with LBW (OR: 1.30, 95% CI: 1.03-1.63) were prone to have dental caries in primary teeth for cross-sectional studies, but no significant differences for prospective studies. PTB children experienced more primary caries in high-income countries (OR: 1.31, 95% CI: 1.00-1.70) than in low- and middle-income countries. CONCLUSIONS The current evidence did not suggest a significant association between LBW and dental caries in children for primary teeth. Children with PTB in high-income countries had a higher prevalence of primary dental caries. Further prospective studies should adjust for confounding factors (age, oral health and family finances) to determine the definitive association between LBW/PTB and dental caries.
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Affiliation(s)
- Yuqi Cui
- Department of Preventive Dentistry, Hospital of Stomatology, Guanghua School of Stomatology, Sun Yat-Sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Stomatology, Sun Yat-Sen University, Guangzhou, China
| | - Dongru Chen
- Guangdong Provincial Key Laboratory of Stomatology, Sun Yat-Sen University, Guangzhou, China.,Department of Orthodontics, Hospital of Stomatology, Guanghua School of Stomatology, Sun Yat-Sen University, Guangzhou, China
| | - Huancai Lin
- Department of Preventive Dentistry, Hospital of Stomatology, Guanghua School of Stomatology, Sun Yat-Sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Stomatology, Sun Yat-Sen University, Guangzhou, China
| | - Ye Tao
- Department of Preventive Dentistry, Hospital of Stomatology, Guanghua School of Stomatology, Sun Yat-Sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Stomatology, Sun Yat-Sen University, Guangzhou, China
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Boustedt K, Roswall J, Twetman S. Free sugars and early childhood caries development: a prospective cohort study. Eur Arch Paediatr Dent 2022; 23:829-833. [PMID: 35976492 DOI: 10.1007/s40368-022-00745-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 08/05/2022] [Indexed: 10/15/2022]
Abstract
PURPOSE To investigate the impact of giving children younger than 2 years foods and beverages with free sugars on the prevalence of early childhood caries at 5 years. MATERIALS AND METHODS The study group consisted of 208 children (105 boys and 103 girls) with a complete set of data on nursing, diet and caries from birth to 5 years. We collected feeding habits and dietary data through structured questionnaires at 6, 12, 18 and 24 months and the presence of decayed (d), missed (m) and filled (f) teeth was scored according to the WHO criteria at five years of age. We processed data with chi-square tests and expressed as relative risk (RR) with 95% confidence intervals. RESULTS At the age of 5 years, 22% of the children had caries. Intake of fruit juice with meals (RR 2.3) and cookies or biscuits at 24 months of age (RR 2.4), as well as fast food consumption at least once every week (RR 2.9), more than doubled the risk for early childhood caries (p < 0.05). CONCLUSIONS Within the limitations of the present study, we found a relationship between consumption of free sugars early in life and dental caries prevalence at 5 years. It therefore seems important to embrace and emphasise the current sugar recommendations in primary and dental care to educate caregivers to avoid serving free sugars to their children before the age of 2 years.
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Affiliation(s)
- K Boustedt
- Maxillofacial Unit, Halland Hospital Halmstad, Halmstad, Sweden
| | - J Roswall
- Department of Pediatrics, Halland Hospital Halmstad, Halmstad, Sweden.,Department of Pediatrics, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - S Twetman
- Department of Odontology, Faculty of Health and Medical Sciences, University of Copenhagen, Nørre Allé 20, 2200, Copenhagen N, Denmark.
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Schroth RJ, Rothney J, Sturym M, Dabiri D, Dabiri D, Dong CC, Grant CG, Kennedy T, Sihra R. A systematic review to inform the development of a Canadian caries risk assessment tool for use by primary healthcare providers. Int J Paediatr Dent 2021; 31:767-791. [PMID: 33497015 DOI: 10.1111/ipd.12776] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 01/06/2021] [Accepted: 01/21/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Caries risk assessment (CRA) tools may assist in identifying children at risk of early childhood caries. AIM To complete a systematic review of CRA and develop a Canadian CRA tool for preschool children for use in non-dental clinical settings. DESIGN Systematic searches of relevant databases were conducted. Potential variables were based on strength of associations (odd ratios, relative risk, hazard ratios, etc), frequency of occurrence, and existing CRA tools. Quality of the evidence assessments were performed by at least two review teams through consensus following GRADE. RESULTS Overall, 25 publications met the inclusion criteria, all prospective in design. Based on this review, variables to be considered when developing a new CRA tool for use with preschool children are as follows: age, socioeconomic status, family toothbrushing habits, fluoride exposure, infant feeding practices, dietary habits/behaviours, dental home, caries experience, visible plaque, and enamel defects. The environmental scan identified 22 CRA tools suggesting other additional variables to consider including in a CRA tool, including special healthcare needs, enamel defects, and dental attendance. CONCLUSIONS This review informed the development of a Canadian CRA tool for use by primary healthcare professionals, which may improve access to oral health assessments and increase interprofessional collaboration.
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Affiliation(s)
- Robert J Schroth
- Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.,Children's Hospital Research Institute of Manitoba, Winnipeg, MB, Canada.,Section of Pediatric Dentistry, Winnipeg Regional Health Authority, Winnipeg, MB, Canada
| | - Janet Rothney
- Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Melina Sturym
- Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.,Children's Hospital Research Institute of Manitoba, Winnipeg, MB, Canada
| | - Darya Dabiri
- School of Dentistry, University of Michigan, Ann Arbor, MI, USA
| | - Donya Dabiri
- University of Toledo Medical Center, University of Toledo, Toledo, OH, USA
| | - Cecilia C Dong
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Cameron G Grant
- Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.,Children's Hospital Research Institute of Manitoba, Winnipeg, MB, Canada
| | - Tara Kennedy
- Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.,Children's Hospital Research Institute of Manitoba, Winnipeg, MB, Canada
| | - Rena Sihra
- Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.,Children's Hospital Research Institute of Manitoba, Winnipeg, MB, Canada
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Twetman S, Boustedt K, Roswall J, Dahlgren J. Systematic review suggests a relationship between moderate to late preterm birth and early childhood caries. Acta Paediatr 2020; 109:2472-2478. [PMID: 32559323 DOI: 10.1111/apa.15424] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 06/11/2020] [Accepted: 06/12/2020] [Indexed: 01/28/2023]
Abstract
AIM The aim was to examine the association between moderate to late preterm birth and the prevalence of early childhood caries. METHODS We searched the PubMed, Scopus, Cochrane Trials Register databases up to February 28, 2020. Two independent reviewers screened the papers for relevance, extracted data and assessed the risk of bias. A random-effects meta-analysis was performed to pool the prevalence of early childhood caries by gestational age. RESULTS The authors identified 14 studies covering 210,691 children. They were published from 2007-2020 and included birth cohorts, cross-sectional, register-based and case-control studies. We assessed eight of them as having low or moderate risk of bias. The median caries prevalence was 48.8% among children born moderate to late preterm compared to 20.5% for those born full term. The pooled overall odds ratio was 1.48 (95% confidence interval 1.16-1.89; P < .001). The certainty of this finding was low due to heterogeneity and inconsistencies across the studies. CONCLUSION This systematic review and meta-analysis displayed a significantly higher prevalence of early childhood caries in children born moderate to late preterm compared to full term children. The finding suggests that the gestational age should be collected as a risk factor in the paediatric dental records.
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Affiliation(s)
- Svante Twetman
- Department of Odontology Faculty of Health and Medical Sciences University of Copenhagen Copenhagen Denmark
| | | | - Josefine Roswall
- Department of Pediatrics Halland Hospital Halmstad Halmstad Sweden
- Department of Pediatrics The Sahlgrenska AcademyUniversity of Gothenburg Gothenburg Sweden
| | - Jovanna Dahlgren
- Department of Pediatrics The Sahlgrenska AcademyUniversity of Gothenburg Gothenburg Sweden
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