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Open Access

Peer-reviewed

Research Article

RETRACTED: The association between mode of childbirth delivery and early childhood caries: A comprehensive systematic review and meta-analysis

  • Li Xiang,

    Roles Conceptualization, Investigation, Writing – original draft, Writing – review & editing

    Affiliation Department of Pediatric, Preventive Dentistry and Orthodontics, E.V. Borovsky Institute of Dentistry, I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russian Federation

    ⨯
  • Iuliia A. Kozlitina,

    Roles Conceptualization, Visualization, Writing – original draft, Writing – review & editing

    Affiliation Department of Pediatric, Preventive Dentistry and Orthodontics, E.V. Borovsky Institute of Dentistry, I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russian Federation

    ⨯
  • Mahdi Mohammadian,

    Roles Conceptualization, Data curation, Writing – original draft, Writing – review & editing

    Affiliation MSc in Epidemiology, School of Public Health, Isfahan University of Medical Sciences, Isfahan, Iran

    ⨯
  • Roya Choopani,

    Roles Conceptualization, Data curation, Writing – original draft, Writing – review & editing

    Affiliation Department of Pediatrics, Assistant Professor of Neonatal-Perinatal Medicine, School of Medicine, Shahrekord University of Medical Sciences, Shahrekord, Iran

    ⨯
  • Abdollah Mohammadian-Hafshejani

    Roles Conceptualization, Data curation, Investigation, Methodology, Project administration, Software, Validation, Writing – original draft, Writing – review & editing

    amohamadii1361@gmail.com

    Affiliation Assistant Professor of Epidemiology, Modeling in Health Research Center, Shahrekord University of Medical Sciences, Shahrekord, Iran

    ⨯

Retraction

The PLOS One Editors retract this article [1] due to concerns about potential manipulation of the publication process. These concerns call into question the validity and provenance of the reported results and compliance with PLOS policies. We regret that the issues were not identified prior to the article’s publication.

LX, IAK, MM, and AMH did not agree with the retraction. RC either did not respond directly or could not be reached.

17 Dec 2025: The PLOS One Editors (2025) Retraction: The association between mode of childbirth delivery and early childhood caries: A comprehensive systematic review and meta-analysis. PLOS ONE 20(12): e0339085. https://doi.org/10.1371/journal.pone.0339085 View retraction

Abstract

Background

Early childhood caries (ECC), also known as dental caries, poses a significant challenge to the oral health and overall well-being of young children. This study aims to investigate the potential relationship between the mode of delivery and the odds of ECC.

Methods

We conducted a meticulous systematic review and meta-analysis, gathering studies from reputable databases, including Web of Science, Scopus, PubMed, Cochrane, Google Scholar, and Embase. The selected studies underwent rigorous evaluation for heterogeneity, utilizing statistical tests such as the Chi-square test, I2, meta-regression analysis, sensitivity analysis, and subgroup analysis. We assessed the presence of publication bias using Begg’s and Egger’s tests, while the quality of the articles was evaluated using the Newcastle-Ottawa Scale checklist.

Results

Our analysis included a robust dataset of 24 studies conducted between 1997 and 2024, involving a total of 71,732 participants. The meta-analysis revealed an odds ratio of 1.05 (95% CI: 0.86–1.30; P-value = 0.610) for dental caries in children born via cesarean section. Importantly, we found no evidence of publication bias, as indicated by non-significant results from Begg’s test (P-value = 0.568) and Egger’s test (P-value = 0.807). Meta-regression analysis did not identify any significant associations between the study variables and the observed heterogeneity (P > 0.10). Sensitivity analysis further confirmed the stability of the study results, with no significant changes detected.

Conclusion

In conclusion, our comprehensive meta-analysis provides compelling evidence that there is no significant association between the mode of delivery and the odds of ECC. These findings enhance our understanding of this important topic and have implications for clinical practice and public health interventions.

Citation: Xiang L, Kozlitina IA, Mohammadian M, Choopani R, Mohammadian-Hafshejani A (2024) RETRACTED: The association between mode of childbirth delivery and early childhood caries: A comprehensive systematic review and meta-analysis. PLoS ONE 19(9): e0310405. https://doi.org/10.1371/journal.pone.0310405

Editor: Morteza Arab-Zozani, Birjand University of Medical Sciences, ISLAMIC REPUBLIC OF IRAN

Received: May 7, 2024; Accepted: August 31, 2024; Published: September 26, 2024

Copyright: © 2024 Xiang et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the manuscript and its Supporting Information files.

Funding: The author(s) received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Dental caries, a prominent oral health challenge, significantly impacts young children’s well-being globally [1]. This condition arises when oral bacteria produce acids from fermentable carbohydrates, leading to the demineralization of tooth enamel and dentin [2,3]. If untreated, dental caries can cause severe discomfort, functional issues, and systemic complications, affecting children’s quality of life [4,5]. It can also impair chewing, speaking, and social interactions, influencing self-esteem and overall development [4,6]. Early childhood caries (ECC), affecting children under six, remains a widespread concern, with prevalence rates varying significantly across different socio-economic settings [7,8]. In high-income areas, ECC rates are below 10%, whereas disadvantaged communities experience rates exceeding 60% [9,10]. Comprehensive understanding and management of ECC are crucial due to its far-reaching implications on health and schooling [7,9,11].

The mode of childbirth delivery—cesarean section versus vaginal birth—has emerged as a possible factor affecting ECC risk [12,13]. Differences in initial oral microbiome establishment and breastfeeding practices may contribute to this risk [14,15]. Vaginal delivery facilitates the transmission of beneficial maternal microbiota to the newborn, potentially reducing caries risk [15,16]. In contrast, cesarean delivery may alter the oral microbiome’s composition, influencing long-term caries development [17,18]. Additionally, breastfeeding practices differ between delivery modes; infants delivered via cesarean section may face challenges in effective breastfeeding, impacting oral health [19,20]. They are often exposed to cariogenic substances earlier, affecting tooth health before protective breastfeeding benefits are established [21–23].

Despite the hypothesis that delivery mode may influence early oral colonization and subsequent caries development, the evidence remains inconclusive [13,24–29]. To fill this gap, we conducted a comprehensive systematic review and meta-analysis. Our study aims to synthesize existing epidemiological evidence to elucidate the potential association between delivery mode and ECC. This analysis seeks to design evidence-based strategies and guide clinical decision-making for optimal management of childbirth delivery and ECC prevention.

Materials and methods

Type of study and search strategies

This research is a systematic review and meta-analysis that follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to ensure transparency and rigor in the research process. To gather comprehensive and up-to-date data, an extensive literature search was conducted across multiple authoritative databases, including Web of Science, PubMed, Cochrane Central Register of Controlled Trials, Embase, Google Scholar, and Scopus. The search covered all publications from the inception of these databases up to May 1, 2024.

To identify the most relevant studies, Medical Subject Headings (MeSH) terms were carefully selected and used to extract keywords and their synonyms related to the mode of childbirth delivery and early childhood caries (ECC). The search strategy employed Boolean operators (AND, OR) to combine these keywords effectively, ensuring that articles containing all specified keywords were retrieved. Additionally, the reference lists of the included studies were meticulously reviewed to uncover any articles that might have been missed in the initial search, thus this study providing a broad understanding of the relationship between childbirth mode and ECC. The method of searching each of the mentioned databases is presented in detail in the article’s supporting information file.

Study selection criteria

Inclusion criteria.

This meta-analysis defined its inclusion criteria using the PICO framework to ensure a comprehensive selection process. The Population targeted studies involving human subjects from a variety of demographics, focusing specifically on children under 6 years to investigate the potential association between delivery modes and ECC. The Intervention or Exposure focused on the mode of delivery, comparing cesarean sections with vaginal births. For Comparison, the analysis examined how these different delivery methods impacted the incidence of ECC. The Outcome was determined by evaluating the incidence or prevalence of ECC. Only original research articles published in peer-reviewed journals and available in full-text were included. The study designs considered were case-control, cross-sectional, and cohort studies (both retrospective and prospective) that reported quantitative effect sizes, such as odds ratios, hazard ratios, and relative risks, all with 95% confidence intervals.

Exclusion criteria.

To ensure the quality and relevance of the studies included, the exclusion criteria were clearly defined. Non-original articles, such as reviews, commentaries, editorials, and letters, were excluded. Also excluded were studies that did not provide quantitative effect estimates or raw data suitable for meta-analysis. Furthermore, articles with duplicate data from multiple publications using the same dataset were excluded, with only the most recent findings included to maintain data integrity.

Study selection process

To ensure comprehensive coverage, extensive literature searches were performed across multiple databases, employing a meticulous strategy for managing the gathered records. The widely recognized Endnote reference management software facilitated the identification of duplicate records by comparing titles, author names, and publication years. The selection process was systematically executed by two independent reviewers. Initially, they reviewed article titles to eliminate those irrelevant to the study’s objectives. For titles deemed potentially relevant, abstracts were scrutinized in detail. Studies were excluded if their abstracts indicated that they did not measure critical exposure and outcome variables or if inappropriate study designs were used without reporting quantitative effect sizes. The most detailed level of screening involved full-text analysis of the remaining articles, guided by predefined inclusion and exclusion criteria. Any discrepancies between reviewers at any stage were resolved through discussion with a third independent reviewer, ensuring unbiased and reliable decision-making.

Data collection and management

A standardized data extraction form was developed to systematically capture essential study details such as bibliographic information, study characteristics, participant demographics, and reported effect estimates. This form was rigorously pilot-tested to ensure comprehensiveness and consistency. Two independent reviewers extracted data using this form, and any discrepancies were resolved through consensus discussions or, if necessary, consultation with a third reviewer. This meticulous process guaranteed the integrity and reliability of the data, providing a robust foundation for evidence synthesis, methodological evaluation, and bias assessment.

Evaluation of study quality

In our comprehensive evaluation of the studies included in this meta-analysis, we ensured a rigorous assessment of methodological quality by employing the widely utilized Newcastle-Ottawa Scale (NOS). This scale is specifically designed for evaluating non-randomized studies, focusing on three essential domains: the selection of study groups, comparability between these groups, and the ascertainment of exposure and outcome variables. Each study underwent a detailed examination and was rated on a scale from zero to nine points, where higher scores denote superior methodological rigor and clearer reporting.

To enhance the reliability of our quality assessment, two independent reviewers applied the standardized criteria of the NOS. In instances of disagreement in scoring, discussions were held to reach a consensus, with a third reviewer consulted if necessary. Studies were then categorized into three levels of methodological quality: good, moderate, and low, based on their total scores.

Statistical methods

To guarantee the robustness and credibility of our systematic review and meta-analysis, we employed meticulous statistical and graphical methods to assess heterogeneity thoroughly. Meta-analysis techniques were used for studies reporting separate effect estimates over various periods to synthesize these stratified estimates and derive comprehensive overall effects, maximizing data inclusion without duplicating participant populations. For studies providing raw data on exposure and outcome groups without pre-calculated effect sizes, RevMan software was used to generate odds ratio estimates with accompanying 95% confidence intervals.

To assess heterogeneity, we conducted statistical tests alongside visual inspections of forest plots. The Chi-square test was used to determine if observed differences were due to chance, with a P-value of less than 0.10 indicating significant heterogeneity. The I² statistic quantified the proportion of total variation attributed to heterogeneity rather than sampling error. For instance, an I² value above 50% suggested substantial heterogeneity, prompting us to use random-effects models for our meta-analyses. Forest plots were examined for confidence interval overlap, and any potential outliers were further analyzed through meta-regression and sensitivity analyses to identify sources of heterogeneity.

To explore covariate impacts on heterogeneity, univariate and multivariate meta-regression analyses were conducted using Stata software. Key covariates considered included study year, sample size, region, study design, crude or adjusted effect size, average age of participants, and study quality as determined by the Newcastle-Ottawa Scale. Sensitivity analyses involved sequentially excluding each study to evaluate the impact of individual studies. Publication bias was assessed by inspecting funnel plots for asymmetry and conducting Egger’s and Begg’s tests for statistical evaluation. Although some variables had missing data, all analyses in this study were conducted using the available information from the articles. Variables with missing data were excluded from analyses such as meta-regression and subgroup analysis. All data analyses were performed using Stata version 17 software.

Results

Articles included in the study

We initiated this study with a comprehensive electronic database search using targeted keywords, resulting in 2,147 articles. After removing 663 duplicates, 1,484 unique articles were screened. Titles and abstracts were meticulously reviewed, leading to the exclusion of 1,436 irrelevant articles. Subsequently, 48 papers were identified as potentially relevant. Further scrutiny led to the exclusion of four articles due to inaccessible full text, 17 for lacking reported effect sizes or not providing raw data necessary to calculate these sizes, and four identified as reviews[17,26,30–52]. This rigorous selection process resulted in 23 articles initially included in our study. An additional relevant study was identified through reference examination, culminating in 24 articles for our systematic review and meta-analysis [12–14,21,22,24,25,27–29,53–66], as depicted in Fig 1.

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Fig 1. Diagram of selected studies for meta-analysis.

https://doi.org/10.1371/journal.pone.0310405.g001

Characteristics of selected studies

Our analysis encompassed 24 studies exploring the association between delivery mode and ECC. These studies were conducted between 1997 and 2024 across various countries, including the United States, Iran, Sweden, the United Kingdom, China, Thailand, Japan, Israel, Peru, India, Russia, Saudi Arabia, Romania, Brazil, Egypt, and Ethiopia. In total, these studies included 71,732 participants. The studies comprised 11 cross-sectional designs (2,868 participants) [14,22,27–29, 54,55,60,61,63,66], 9 cohort studies (67,844 participants) [12,13,21,25,53,56,57,59,65], and 4 case-control studies (1,020 participants) [24,58,62,64]. Geographically, studies were distributed across North/South America (5 studies, 7,157 participants) [12,53,57,60,65], Europe (5 studies, 55,824 participants) [21,25,27,59,64], Asia (12 studies, 8,282 participants) [13,14,22,24,54–56,58,61–63,66], and Africa (2 studies, 469 participants) [28,29]. Quality assessment categorized 6 studies as low, 12 as moderate, and 6 as good quality (Tables 1 and 2).

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Table 1. Characteristics of the studies included in the meta-analysis.

https://doi.org/10.1371/journal.pone.0310405.t001

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Table 2. Adjusted variables in included studies in the meta-analysis.

https://doi.org/10.1371/journal.pone.0310405.t002

Association between mode of delivery and ECC

The meta-analysis indicates no significant association between delivery mode and ECC. The odds ratio for ECC in children delivered via cesarean section versus vaginal birth was 1.05 (95% CI: 0.86–1.30; P-value = 0.610), underscoring no link between cesarean delivery and ECC odds (Fig 2).

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Fig 2. Forest plot of the relationship between the mode of delivery and ECC.

https://doi.org/10.1371/journal.pone.0310405.g002

Publication bias assessment

Publication bias was assessed using Begg’s and Egger’s tests, both of which indicated no significant bias (Begg’s test P-value = 0.568; Egger’s test P-value = 0.807). The symmetrical funnel plot (Fig 3) further supports the absence of bias.

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Fig 3. Funnel plot for evaluation of publication bias.

https://doi.org/10.1371/journal.pone.0310405.g003

Meta-regression analysis

A meta-regression analysis was conducted to explore potential sources of heterogeneity. Variables such as study year, sample size, region, study design, crude or adjusted effect size, average age of participants, and study quality as determined by the Newcastle-Ottawa Scale were examined, but none showed a significant impact on heterogeneity (P > 0.10) (Table 3).

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Table 3. Meta-regression results in the studies that investigate the relationship between the mode of delivery and ECC.

https://doi.org/10.1371/journal.pone.0310405.t003

Sensitivity analysis

Sensitivity analysis involved sequentially removing each study to assess the robustness of the meta-analysis results. The estimated OR remained stable, indicating the robustness of the findings (Table 4 and Fig 4).

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Fig 4. Sensitivity analysis plot for evaluation the relationship between the mode of delivery and ECC.

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Table 4. Results of sensitivity analysis for the assessment of the relationship between the mode of delivery and ECC.

https://doi.org/10.1371/journal.pone.0310405.t004

Subgroup analysis

A thorough subgroup analysis was conducted to explore factors contributing to heterogeneity, including sample size, study design, and more. No significant relationships between the mode of delivery and ECC were identified across any subgroups (Table 5).

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Table 5. Subgroup analysis of the association between the mode of delivery and ECC.

https://doi.org/10.1371/journal.pone.0310405.t005

Discussion

The objective of this comprehensive systematic review and meta-analysis was to examine the relationship between the mode of delivery and ECC. We analyzed data from 24 studies conducted between 1997 and 2024, encompassing a total of 71,732 participants, to provide reliable insights. The primary finding of this investigation suggests no significant association between delivery mode and ECC odds. Specifically, the odds ratio for dental caries in children born via cesarean section was calculated to be 1.05 (95% CI: 0.86–1.30; P-value = 0.610), supporting the absence of a substantial relationship. Furthermore, no publication bias was observed.

While the mechanisms underlying the connection between delivery mode and ECC risk remain unclear, previous studies have proposed potential pathways warranting further exploration [67–70]. It is suggested that the mode of delivery might influence the establishment of the oral microbiome in infants, potentially affecting caries risk [14,70]. Vaginally delivered infants benefit from exposure to maternal oral and gastrointestinal microbiota during birth, which may lead to a more favorable oral microbiome and lower levels of caries-causing pathogens [69]. In contrast, cesarean-born infants miss this natural transmission route, acquiring oral bacteria from other environmental sources [69,71].

Additionally, vaginal birth facilitates the acquisition of beneficial commensal bacteria that contribute to a healthy oral microbial community, inhibiting the growth of caries-causing pathogens [72,73]. The absence of this critical bacterial transfer during a crucial phase of microbial development may increase caries risk in cesarean-born infants [73,74]. Furthermore, cesarean section has been linked with lower rates and shorter durations of breastfeeding compared to vaginal delivery [75]. This difference may potentially influence the development of the oral microbiome and elevate caries risk via various pathways [76]. Cesarean infants may face challenges with latching and suckling due to underdeveloped oral motor skills from not being exposed to initial vaginal flora, potentially leading to early supplementation with bottles or pacifiers [77].

Introducing alternative feeding methods before breastfeeding is fully established might disrupt healthy oral feeding behaviors crucial in early life [78,79]. It may also prolong milk and sugar contact in the mouth, increasing exposure to cariogenic substrates [80,81]. Earlier bottle use, pacifier habits, and the introduction of non-breastmilk liquids/foods can displace breastmilk’s protective factors, like antibodies and enzymes, which help remineralize teeth and alter the oral microbiome, potentially increasing tooth decay susceptibility over time [81].

A previous systematic review and meta-analysis by Boustedt et al. reported a statistically significant positive association between cesarean delivery and increased ECC risk. However, their analysis included only 11 studies published up to 2020 [38]. Since then, a substantial amount of new research has investigated the mode of delivery and ECC. This current systematic review and meta-analysis comprehensively re-examines this public health issue, including additional studies published up to May 2024, totaling 24 eligible studies. This expansion more than doubled the evidence base compared to the Boustedt review, enhancing the statistical power and precision of our synthesis and providing a more robust sample of effect sizes from diverse populations.

Our updated search strategies and selection criteria were designed to minimize the chance of missing relevant publications, bolstering our confidence in reflecting the current state of evidence. Maternal factors such as breastfeeding, education, obesity, smoking, and age at delivery have been explored for their potential association with childhood caries [25,82–86]. Future research should control for these factors using prospective cohort studies with detailed data collection to isolate delivery mode effects from other variables [21,53,56,57]. However, even our subgroup analysis based on cohort studies revealed no significant relationship between the mode of delivery and ECC odds.

This review had limitations due to data constraints and the inclusion of studies with varied designs, sample selection methods, and caries detection criteria. Some studies did not specifically focus on the delivery mode-ECC association. Observed heterogeneity arose from variations in population sizes, participant characteristics, outcome assessment ages, and caries detection methods. Exploration of heterogeneity through various analytical approaches did not reveal significant sources, reinforcing the notion that delivery mode may not impact ECC development.

Conclusion

In summary, our comprehensive meta-analysis indicates that there is no significant association between the mode of delivery and the odds of early childhood caries (ECC). Specifically, cesarean delivery does not appear to have a noticeable impact on ECC in children compared to vaginal delivery. However, it is important to acknowledge the limited available evidence, which highlights the need for further research. Future studies should address study design limitations, consider confounding factors, and collect data on caries severity to enhance our understanding of this topic. With these efforts, we can strengthen the existing knowledge and provide more conclusive insights.

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