Farnesol increases the susceptibility of Burkholderia pseudomallei biofilm to antimicrobials used to treat melioidosis.

AIMS: The aim of this study was to analyse the in vitro activity of farnesol alone and combined with the antibacterial drugs amoxicillin, doxycycline, ceftazidime and sulfamethoxazole-trimethoprim against Burkholderia pseudomallei biofilms. METHODS AND RESULTS: Susceptibility was assessed by the broth microdilution test and cell viability was read with the oxidation-reduction indicator dye resazurin. The biofilms were evaluated through three microscopic techniques (optical, confocal and electronic microscopy). The minimum biofilm erradication concentration (MBEC) for farnesol was 75-2400 mmol l(-1). In addition, farnesol significantly reduced the MBEC values for ceftazidime, amoxicillin, doxycycline and sulfamethoxazole-trimethoprim by 256, 16, 4 and 4 times respectively (P < 0·05). Optical, confocal and electronic microscopic analyses of farnesol-treated B. pseudomallei biofilms demonstrated that this compound damages biofilm matrix, probably facilitating antimicrobial penetration in the biofilm structure. CONCLUSIONS: This study demonstrated the effectiveness of farnesol against B. pseudomallei biofilms and its potentiating effect on the activity of antibacterial drugs, in particular ceftazidime, amoxicillin, doxycycline and sulfamethoxazole-trimethoprim. SIGNIFICANCE AND IMPACT OF THE STUDY: The intrinsic antimicrobial resistance of B. pseudomallei is a serious challenge for the treatment of melioidosis. Thus, this paper reports the inhibitory potential of farnesol against B. pseudomallei biofilms, as well as highlights the favourable pharmacological interaction of farnesol with antibiotics tested, not only on cell viability, but also in the structural morphology of biofilms.

In vitro antifungal activity of miltefosine and levamisole: their impact on ergosterol biosynthesis and cell permeability of dimorphic fungi.

AIMS: This study aimed to evaluate the in vitro activity of miltefosine and levamisole against strains of Coccidioides posadasii in the filamentous phase and strains of Histoplasma capsulatum in filamentous and yeast phases. METHODS AND RESULTS: Strains of C. posadasii in the filamentous phase (n = 22) and strains of H. capsulatum in filamentous (n = 40) and yeast phases (n = 13) were, respectively, submitted to broth macrodilution and broth microdilution methods, as described by the Clinical and Laboratory Standards Institute, to determine the minimum inhibitory concentration (MIC) and the minimum fungicidal concentration (MFC) of miltefosine and levamisole. The effect of the drugs on cell membrane permeability under osmotic stress conditions and total ergosterol production were also assessed, along with quantification of extravasated molecules. The results show the inhibitory effect of levamisole and miltefosine against C. posadasii and H. capsulatum and the effect of these drugs on ergosterol synthesis and the permeability of the plasma membrane using subinhibitory concentrations against strains subjected to osmotic stress. Levamisole was also able to cause the release of nucleic acids. CONCLUSIONS: Miltefosine and levamisole are capable of inhibiting the in vitro growth of C. posadasii and H. capsulatum, probably by altering the permeability of the cellular membrane. SIGNIFICANCE AND IMPACT OF THE STUDY: This work presents alternatives for the treatment of histoplasmosis and coccidioidomycosis, raising the possibility of the use of miltefosine and levamisole as adjuvants in antifungal therapy, providing perspectives for the design of in vivo studies.

Emergence of azole-resistant Candida albicans in small ruminants.

Small ruminant production is a common agricultural activity worldwide. However, studies on the fungal microbiota of these animals are scarce. Therefore, this study aimed at isolating yeasts from goats and sheep and evaluating the antifungal susceptibility of the recovered Candida albicans. A total of 120 animals from farms in Ceará State, Brazil, were assessed in this study. The samples were collected from nasal, oral and rectal cavities with sterile swabs. Candida spp., Trichosporon spp. and Rhodotorula spp. were isolated from small ruminants. Resistance to three azole drugs was observed in C. albicans. In summary, Candida spp. were predominantly observed as part of the microbiota of the nasal, oral and rectal cavities of small ruminants, including azole-resistant strains of C. albicans.

Azole-resistant Candida albicans from a wild Brazilian porcupine (Coendou prehensilis): a sign of an environmental imbalance?

This study aimed at evaluating the in vitro antifungal susceptibility of Candida albicans isolates obtained during necropsy of a wild Brazilian porcupine and the mechanism of azole resistance. Initially, we investigated the in vitro susceptibility of the three isolates to amphotericin B, caspofungin, fluconazole, itraconazole, ketoconazole and voriconazole. Afterwards, three sub-inhibitory concentrations (47, 21 and 12 mg/l) of promethazine, an efflux pump inhibitor, were tested in combination with the antifungal drugs in order to evaluate the role of these pumps in the development of antifungal resistance. In addition, the three isolates were submitted to RAPD-PCR and M13-fingerprinting analyses. The minimum inhibitory concentrations (MICs) obtained with the isolates were 1, 0.03125, 250, 125, 8 and 250 mg/l for amphotericin B, caspofungin, fluconazole, itraconazole, ketoconazole and voriconazole, respectively, and the isolates were found to be resistant to all tested azoles. The addition of the three subinhibitory concentrations of promethazine resulted in statistically significant (P < 0.05) reductions in the MICs for all tested drugs, with decreases to azoles being statistically greater than those for amphotericin B and caspofungin (P < 0.05). The molecular analyses showed a genetic similarity among the three tested isolates, suggesting the occurrence of candidemia in the studied animal. These findings highlight the importance of monitoring antifungal susceptibility of Candida spp. from veterinary sources, especially as they may indicate the occurrence of primary azole resistance even in wild animals.

Ciprofloxacin shows synergism with classical antifungals against Histoplasma capsulatum var. capsulatum and Coccidioides posadasii.

This study evaluated the in vitro interaction between ciprofloxacin (CIP) and classical antifungals against Histoplasma capsulatum var. capsulatum in mycelial (n = 16) and yeast-like forms (n = 9) and Coccidioides posadasii in mycelial form (n = 16). This research was conducted through broth microdilution and macrodilution, according to Clinical Laboratory Standards Institute. Inocula were prepared to obtain from 0.5 × 10(3) to 2.5 × 10(4) cfu ml(-1) for H. capsulatum and from 10(3) to 5 × 10(3) cfu ml(-1) for C. posadasii. Initially, minimum inhibitory concentration (MIC) for each drug alone was determined. Then, these MICs were used as the highest concentration for each drug during combination assays. The procedures were performed in duplicate. For all combination assays, MICs were defined as the lowest concentration capable of inhibiting 80% of visible fungal growth, when compared to the drug-free control. Drug interaction was evaluated by paired sample t-Student test. The obtained data showed a significant MIC reduction for most tested combinations of CIP with antifungals, except for that of CIP and voriconazole against yeast-like H. capsulatum. This study brings potential alternatives for the treatment of histoplasmosis and coccidioidomycosis, raising the possibility of using CIP as an adjuvant antifungal therapy, providing perspectives to delineate in vivo studies.

Sesquiterpene farnesol contributes to increased susceptibility to ß-lactams in strains of Burkholderia pseudomallei.

This study aimed to evaluate the in vitro combination of farnesol and ß-lactams against Burkholderia pseudomallei. A total of 12 ß-lactamase-positive strains were tested according to CLSI standards. All strains were inhibited by farnesol, with MICs ranging from 75 to 150 µM. The combination of this compound with ß-lactams resulted in statistically significant ß-lactam MIC reduction (P ≤ 0.05). This study provides new perspectives for the use of farnesol combined with ß-lactam antibiotics against strains of B. pseudomallei.

Viral protease inhibitors affect the production of virulence factors in Cryptococcus neoformans.

The effects of the protease inhibitors saquinavir, darunavir, ritonavir, and indinavir on growth inhibition, protease and phospholipase activities, as well as capsule thickness of Cryptococcus neoformans were investigated. Viral protease inhibitors did not reduce fungal growth when tested in concentrations ranging from 0.001 to 1.000 mg/L. A tendency toward increasing phospholipase activity was observed with the highest tested drug concentration in a strain-specific pattern. However, these drugs reduced protease activity as well as capsule production. Our results confirm a previous finding that antiretroviral drugs affect the production of important virulence factors of C. neoformans.

De novo ALX4 variant detected in child with non-syndromic craniosynostosis.

Current understanding of the genetic factors contributing to the etiology of non-syndromic craniosynostosis (NSC) remains scarce. The present work investigated the presence of variants in ALX4, EFNA4, and TWIST1 genes in children with NSC to verify if variants within these genes may contribute to the occurrence of these abnormal phenotypes. A total of 101 children (aged 45.07±40.94 months) with NSC participated in this cross-sectional study. Parents and siblings of the probands were invited to participate. Medical and family history of craniosynostosis were documented. Biological samples were collected to obtain genomic DNA. Coding exons of human TWIST1, ALX4, and EFNA4 genes were amplified by polymerase chain reaction and Sanger sequenced. Five missense variants were identified in ALX4 in children with bilateral coronal, sagittal, and metopic synostosis. A de novo ALX4 variant, c.799G>A: p.Ala267Thr, was identified in a proband with sagittal synostosis. Three missense variants were identified in the EFNA4 gene in children with metopic and sagittal synostosis. A TWIST1 variant occurred in a child with unilateral coronal synostosis. Variants were predicted to be among the 0.1% (TWIST1, c.380C>A: p. Ala127Glu) and 1% (ALX4, c.769C>T: p.Arg257Cys, c.799G>A: p.Ala267Thr, c.929G>A: p.Gly310Asp; EFNA4, c.178C>T: p.His60Tyr, C.283A>G: p.Lys95Glu, c.349C>A: Pro117Thr) most deleterious variants in the human genome. With the exception of ALX4, c.799G>A: p.Ala267Thr, all other variants were present in at least one non-affected family member, suggesting incomplete penetrance. Thus, these variants may contribute to the development of craniosynostosis, and should not be discarded as potential candidate genes in the diagnosis of this condition.

Fungal microbiota dynamics as a postmortem investigation tool: focus on Aspergillus, Penicillium and Candida species.

AIMS: To investigate the presence of fungi during three human decomposition stages: bloated, putrefaction and skeletonization. METHODS AND RESULTS: The samples were gathered in the city of Fortaleza, Ceará, Brazil, from the public morgue and cemeteries. The material was submitted to conventional mycological procedures by direct examination and macro/micro morphological and biochemical analyses. The main fungi isolated were Aspergillus spp., Penicillium spp. and Candida spp. in the bloated stage (n = 34 cadavers) and in the putrefaction stage (n = 6 cadavers), while in the skeletonization stage (n = 20 cadavers), the main fungi were Aspergillus spp., Penicillium spp. and Mucor sp. CONCLUSIONS: Aspergillus, Penicillium and Candida species were associated with decomposed human cadavers. SIGNIFICANCE AND IMPACT OF THE STUDY: These findings enable tracing out the profile of fungal communities of human cadavers for the first time. However, much more research will be necessary to develop this new segment of mycology and to enable its routine use in forensic science.

Ants (Hymenoptera: Formicidae) as carriers of fungi in hospital environments: an emphasis on the genera Tapinoma and Pheidole.

The aim of this study was to evaluate the presence of filamentous fungi and yeasts on the external surface of ants at hospitals. From March 2007 to February 2008, 2,899 ants were evaluated in two public hospitals in the city of Fortaleza, Ceará, in northeastern Brazil. The ants were attracted by nontoxic baits, distributed within critical and semicritical hospital areas. The fungi were identified through macro- and micromorphological analysis, biochemical profile, and growth in chromogenic medium. From this study, 5 genera and 13 species of ants were identified, from critical (8% of the collected ants) and semicritical (92%) areas, during the daytime (48%) and nighttime (52%) periods. In the mycological analysis, 75% of the ants were fungi carriers, with the species Tapinoma melanocephalum and species from the genus Pheidole having the most potential as carriers of airborne fungi (75 and 18%, respectively) and yeasts (6 and 1%, respectively). In summary, ants act as carriers of airborne fungi and yeasts, including some pathogenic species.

Sodium fluoride and chlorhexidine effect in the inhibition of mutans streptococci in children with dental caries: a randomized, double-blind clinical trial.

OBJECTIVE: We aimed to compare the effect of sodium fluoride and chlorhexidine on salivary levels of mutans streptococci (MS), in a double-blind, randomized clinical trial. METHODS: Thirty-five healthy volunteers, aged 4-8 years, with at least one active carious lesion and no previous history of allergies were selected to participate in the study. A gel formulation containing either 1.23% sodium fluoride or 1% chlorhexidine was topically administered to the dentition every 24 h for 6 consecutive days. Salivary MS levels were measured at baseline (D1) and on the 6th (D6), 15th (D15), and 30th (D30) days. For microbiological analysis, Mitis Salivarius-Bacitracin agar medium was used. RESULTS: Difference between treatments was only verified on D6. On the last day of treatment 1% chlorhexidine gel was significantly more effective than fluoride (P = 0.0000). The use of sodium fluoride did not cause a statistically significant variation in salivary MS levels throughout the duration of the study. Following treatment, a subsequent increase in MS counts between D6 and D15 (P = 0.0001) was observed with chlorhexidine. CONCLUSION: A 6-day treatment with a 1% chlorhexidine gel was effective in reducing salivary MS; there was a significant MS increase once treatment was suspended. The use of 1.23% sodium fluoride under the same regimen was not able to reduce salivary MS levels. Our results suggest repeated treatment with 1% chlorhexidine as a means for maintaining low salivary MS levels in children with dental caries.

Malassezia pachydermatis isolated from normal and diseased external ear canals in dogs: a comparative analysis.

To investigate the role of Malassezia pachydermatis as a pathogenic agent in canine otitis, a comparative analysis of isolates from normal and diseased external ear canals in dogs was undertaken. Specimens were collected from the ears of dogs with unilateral or bilateral otitis and from healthy dogs. Mycological analysis was by direct microscopy and fungal culture on Sabouraud's dextrose agar and Dixon's agar. Of the otitis specimens, 63.7% showed typical Malassezia cells on cytological examination. In samples taken from the healthy ears of dogs with unilateral otitis, only 21.43% (P<0.05) showed evidence of Malassezia. M. pachydermatis was identified cytologically and culturally in 57.53% (P<0.05), 14.29% and 30.0% of samples from the ears of dogs with otitis, from the healthy ears of dogs with unilateral otitis and from the ears of healthy dogs with no otitis. In the group with otitis associated with M. pachydermatis, the poodle was the most common breed (39.29%; P<0.05), whereas in the group without otitis, the German Shepherd breed was prominent (although this observation was not statistically significant). In both groups, the majority of dogs with M. pachydermatis were aged between 1 and 3 years (P<0.05). The higher incidence of M. pachydermatis isolated from the ears of dogs with otitis externa suggests a putative pathogenic role of this yeast in this condition.

De novo ALX4 variant detected in child with non-syndromic craniosynostosis

Current understanding of the genetic factors contributing to the etiology of non-syndromic craniosynostosis (NSC) remains scarce. The present work investigated the presence of variants in ALX4, EFNA4, and TWIST1 genes in children with NSC to verify if variants within these genes may contribute to the occurrence of these abnormal phenotypes. A total of 101 children (aged 45.07±40.94 months) with NSC participated in this cross-sectional study. Parents and siblings of the probands were invited to participate. Medical and family history of craniosynostosis were documented. Biological samples were collected to obtain genomic DNA. Coding exons of human TWIST1, ALX4, and EFNA4 genes were amplified by polymerase chain reaction and Sanger sequenced. Five missense variants were identified in ALX4 in children with bilateral coronal, sagittal, and metopic synostosis. A de novo ALX4 variant, c.799G>A: p.Ala267Thr, was identified in a proband with sagittal synostosis. Three missense variants were identified in the EFNA4 gene in children with metopic and sagittal synostosis. A TWIST1 variant occurred in a child with unilateral coronal synostosis. Variants were predicted to be among the 0.1% (TWIST1, c.380C>A: p. Ala127Glu) and 1% (ALX4, c.769C>T: p.Arg257Cys, c.799G>A: p.Ala267Thr, c.929G>A: p.Gly310Asp; EFNA4, c.178C>T: p.His60Tyr, C.283A>G: p.Lys95Glu, c.349C>A: Pro117Thr) most deleterious variants in the human genome. With the exception of ALX4, c.799G>A: p.Ala267Thr, all other variants were present in at least one non-affected family member, suggesting incomplete penetrance. Thus, these variants may contribute to the development of craniosynostosis, and should not be discarded as potential candidate genes in the diagnosis of this condition.

Two-year Experience of the "Organ Donation Week" of the Federal University of Health Sciences of Porto Alegre, Brazil.

BACKGROUND: Today, Brazil is the second country of the world in number of transplants. Nonetheless, waiting lists are getting longer. This lack of organs occurs mostly because of people's reduced knowledge about the donation process. With the aim of changing this scenario, in 2013 and 2014, "Organ Donation Week" events were held at the Federal University of Health Sciences of Porto Alegre. METHODS: During the 2 years, documentaries followed by a cycle of debates with experts in this area were exhibited. In 2013, a "flash-mob" took place, with the purpose of performing a "transplant waiting list" around the perimeter of Santa Casa's Hospital Complex. In 2014, a morning full of educational activities was planned for the pediatric patients from the Santo Antônio Children's Hospital and their relatives. RESULTS: It is estimated that approximately 1774 people were directly reached by the projects. Among these people, we can include medical students, healthcare professionals, university staff, transplanted patients, and their families. We believe that education and consciousness are central points in the donation and transplant process. Through this project, we could inform people about it, solving their doubts and myths and stimulating this kind of conversation among the family circle, making the moment when the family must make the decision much easier. CONCLUSIONS: Education and public awareness are essential for enhancing the number of organ donations. Therefore, events such as "Organ Donation Week" should be encouraged among medical schools.

Implementing Activities Developed by the Organ Transplantation Academic Society of the Hospital Dom Vicente Scherer: A Pilot Study.

BACKGROUND: The number of academic societies has been growing significantly in Brazilian universities, offering an extra opportunity for the development of educational activities and research. Because organ donation and transplantation is an area still insufficiently approached during the graduation of health professionals, we evaluated how academic societies might be a valuable tool. METHODS: Participants of the course promoted by the Organ Transplantation Academic Society of the Hospital Dom Vicente Scherer were evaluated through the use of a questionnaire and cognitive tests with 16 multiple-choice questions about topics approached during the course, before and after the lectures. Topics approached consisted of a general introduction about transplantation in Brazil, brain death, organ allocation and removal, post-transplant follow-up, and clinical cases. RESULTS: Of the 45 participants, 30 answered the tests at both times. The subjects were students of medicine, nursing, and phonoaudiology; 93.3% were organ donors, 84.6% said their families knew about this decision, and 65% had relatives who were organ donors. The mean score of correct answers was 7.63 of 16 before the activities and 12.54 after activities, demonstrating a 64.4% improvement. CONCLUSIONS: The improvement in performance suggests that academic societies are a useful resource for educational purposes and for students to get a deeper insight about organ donation and transplantation.

Higher incidence of Malassezia pachydermatis in the eyes of dogs with corneal ulcer than in healthy dogs.

Malassezia pachydermatis is usually associated with otitis and dermatitis in dogs but it can also cause diseases in other species, including humans. In a human neonatal intensive care unit, M. pachydermatis was isolated from an infant's ocular discharge. Therefore, the aim of this study was to ascertain the presence of Malassezia spp. and its possible consequences in dogs' eyes. This research included 19 dogs with unilateral or bilateral corneal ulcers and 60 healthy dogs. A total of 158 clinical specimens from both the groups were obtained from the conjunctival sac of each eye by a calibrated platinum loop. The samples were placed on Dixon and blood agar, incubated at 35 degrees C, and examined daily for 15 days. Then, the strains were subcultured on Sabouraud agar. Of 22 clinical specimens collected from the eyes with corneal ulcers, five cultures (23%) were positive for M. pachydermatis. Of 16 samples collected from the contralateral healthy eye, cultures were positive in three samples (19%). Three animals had unilateral corneal ulcer and positive cultures for M. pachydermatis in both the eyes. Two dogs had unilateral corneal ulcer and positive cultures for M. pachydermatis in the same eye. However, from the 120 samples of 60 healthy dogs, only four clinical specimens (3%) had positive cultures for M. pachydermatis. The findings of M. pachydermatis, in a considerable percentage of clinical specimens from dogs with corneal ulcer, suggest its possible role at least as an aggravating factor in the pathophysiology of this disease.

Application of performance indicators in water utilities management--a case-study in Portugal.

This paper presents some issues concerning water supply systems assessment through performance indicators, based upon research work recently carried out in Portugal about water utilities. A proposal of 50 performance indicators divided into five different groups is presented here, namely structural indicators, operational indicators, water and service quality indicators, personnel indicators and economic indicators. These indicators were associated with a hierarchical structure of knowledge or development according to different levels: basic level, development level and strategic level. The performance indicators, structure, their implementation and assessment methodology and examples of some indicators, use concerning the characterisation or assessment of a water utility are also presented in the paper.

[Influence of age on systolic and diastolic time intervals in normal individuals]. / Influência da idade nos intervalos de tempo sistólicos e diastólicos do indivíduo normal.

OBJECTIVE: To evaluate the influence of age (I) on the left ventricle (VE) systolic time intervals, the S2O interval, the pulse transmission time (TTP) and the relative amplitude of the a wave (Aa%) of the apexcardiogram (ACG) of normal individuals. METHODS: 202 subjects considered as normal by clinical and electrocardiographic examinations were studied. Their age (I) was 38 +/- 13 years (average +/- 1 SD), being 125 male and 77 female. The electrocardiogram (ECG), phonocardiogram, ACG and carotid arterial pulse tracing (PC) were simultaneously recorded. The following intervals were determined: Electromechanical (IEM)--from the onset of QRS complex of the ECG to the ascending branch of the great wave of the ACG (A point); mechanical systole (SM)--from the A point of the ACG to the beginning of first high frequency vibration of the aortic component of the second heart sound (S2); ejection period (FE)--from the beginning of the anacrotic branch of the PC to the nadir of its dicrotic notch (ID); isovolumic contraction time (FIS)--subtracting FE duration to the SM duration; S2O interval--since S2 to the O point (nadir) of the ACG; Aa%--relation percentage expressed between a wave amplitude and total amplitude of the ACG; pulse transmission time--since S2 to ID. Statistically significant correlations (p less than 0.05) between I (years expressed) and the previously mentioned variables were investigated. RESULTS: It was possible to verify: a) the IEM and FIS intervals were not significantly correlated with I; b) the FE had a linear, positive and significant correlation with I (r = 0.222); c) the correlations between FE and heart rate (FC) were not significantly different between the considered age groups (14-34, 35-49, 50-69 years); d) the S2O interval had a linear, negative and significant correlation with FC (r = -0.196), and a linear, positive and significant correlation with I (r = 0.392); e) multiple regression equation between S2O, I and FC was: S2O = 70 - 0.36 x FC + 0.55 x I; f) the Aa% had a linear, positive and significant correlation with I (r = 0.252); g) TTP has a linear, negative and significant correlation with I (r = -0.793). CONCLUSIONS: a) The FE increases with I related probably to the afterload increasing that follows aging process; b) the S2O interval increases with I reflecting the elongation of the relaxing time that is associated to the senescence; c) the Aa% increases with I, expressing the reduction of the compliance of the VE associated to the aging; d) the TTP decreases with I related to the increasing of velocity of the pulse wave that follows senescence and is attributed to the increasing of the aortic stiffness.

[Intracavity brachytherapy in uterine neoplasms]. / Braquiterapia intracavitária na neoplasia uterina.

The growing use of intracavity treatment of uterine neoplasia has not been accompanied in the Brazilian literature by articles appropriate for day-to-day consultation. Based on this fact we endeavour to transmit in this paper our experiences related to this therapy technique.

Caries experience, mutans streptococci and total protein concentrations in children with protein-energy undernutrition.

BACKGROUND: The highest prevalence of protein-energy undernutrition is observed during early childhood, being also a time in which the presence of dental caries can be unusually aggressive. The present study aimed to verify if different levels of undernutrition could influence the risk of early childhood caries (ECC), in the presence of other predisposing factors. METHODS: One hundred and twenty undernourished 12-70 month old children, with or without ECC, were selected. Undernourished children were classified as being mildly, moderately or severely undernourished. All children were examined for determination of decayed, missing and filled surfaces (dmfs). Total protein concentration in saliva was analysed by the Bradford method. For microbiological analysis, mitis salivarius-bacitracin agar medium was used. A binary logistic regression model was applied to test the simultaneous influence of different variables over caries experience. RESULTS: The risk of ECC was significantly higher with an increase in age (p = 0.000) and mutans streptococci counts (p = 0.032). Comparisons with the normal-weight group showed that mildly (p = 0.004) and severely undernourished children (p = 0.037) had a higher risk of experiencing ECC, but this risk was not significantly elevated among moderately undernourished children (p = 0.158). CONCLUSIONS: Our results suggest that mildly and severely undernourished children have an increased risk of experiencing dental caries. Age is highly associated with the disease in this population.