BACKGROUND:It is estimated that, as of 2010, there were 32 million orphaned children in India. There is little published information on the oral health of children in orphanages in India. AIM:To determine caries status and associated risk factors among children in orphanages in Kerala, India. METHODS:This cross-sectional study assessed caries using World Health Organization (WHO) criteria, and caries experience was reported as decayed, missing and filled primary or secondary teeth (dmft or DMFT, respectively). A brief questionnaire captured information on child oral health behaviours. Mean [standard deviation (SD)] and median [interquartile range (IQR)] scores were used to describe caries rates. Multivariable logistic regression analysis was conducted to identify independent disease predictors. Study design complexities, such as clustering by orphanage and stratification by district, were accounted for in the multivariable regression analysis. This was carried out using the survey commands in STATA 13. A value of P<0.05 was considered as statistically significant. RESULTS:Overall, 1,137 children residing in 31 orphanages across the State of Kerala were recruited to the study. Female children made up 82% of the sample. In 6-year-old children the prevalence of caries was 77% and the mean dmft score was 3.60 (SD= 3.50); in 12-year-old children the prevalence of caries was 44% and the mean DMFT score was 1.35 (SD = 1.96). Among 12-year-old children, those who reported being shown how to clean their teeth were less likely to have caries (odds ratio = 0.62; 95% confidence interval: 0.38-0.95). CONCLUSION:Caries rates among children in orphanages were much higher than among children in the general population in Kerala. There is an urgent need for evidence-based and sustainable primary prevention strategies to reduce the burden of caries in this highly vulnerable population.