The association between socioeconomic status, psychopathological symptom burden in mothers, and early childhood caries of their children

Autoři: Uta Knoblauch aff001;  Gerhard Ritschel aff001;  Kerstin Weidner aff001;  Sabine Mogwitz aff001;  Christian Hannig aff002;  Gabriele Viergutz aff002;  Maria Lenk aff001
Působiště autorů: Department of Psychotherapy and Psychosomatic Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany aff001;  Policlinic of Dental Maintenance, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany aff002
Vyšlo v časopise: PLoS ONE 14(10)
Kategorie: Research Article
doi: 10.1371/journal.pone.0224509



Various maternal mental disorders and socioeconomic status [SES] are discussed as risk factors for early childhood caries [ECC]. In our study, we examined a wide range of symptoms of mental disorders with the aim to identify those maternal psychopathological symptom burdens [PSBs] which show relevant associations with ECC. Our second objective was to investigate how SES affects the associations between PSB and ECC.


In this study, sixty children with ECC (caries group [CG]) and sixty caries-free children [NON-CG] with their mothers were recruited at two sites in Germany. Children aged three or four years were included in the study. Children’s dental status [dmf-t] and plaque index were recorded, and mothers answered a multidimensional SES index (including education, profession and income) as well as screening questionnaires capturing dental anxiety, depressive disorders, generalized anxiety, somatic symptom burden, eating disorders, traumatic childhood experiences, nicotine dependency and alcohol dependency.


Mothers of the CG reported significantly higher dental anxiety (dCohen = 0.66), childhood trauma (dCohen = 0.53) and nicotine dependency (dCohen = 0.64) than the NON-CG. However, mediator analyses showed that these effects were partly mediated by the SES. Mothers of the CG had a significantly lower SES (dCohen = 0.93); with education as strongest predictor of dental status. The groups did not differ significantly in symptoms of depressiveness, subjective somatic symptom burden, alcohol dependency, eating disorders, and generalized anxiety.


Several PSBs are associated with ECC, however the SES as the strongest influencing factor mediates this association. Difficult socioeconomic conditions might predispose for both, ECC and mental illness. Targeted strategies are needed to facilitate the use of preventive measures and dental health services especially in families of lower status. For this purpose, psychosocial risk constellations must be identified. More integrative, multifactorial oriented research is necessary to gain a bio-psycho-social understanding of ECC.

Klíčová slova:

Caries – Dentition – Depression – Eating disorders – Child abuse – Mothers – Oral medicine – Socioeconomic aspects of health


1. Gussy MG, Waters EG, Walsh O, Kilpatrick NM. Early childhood caries: Current evidence for aetiology and prevention. J Paediatr Child Health. 2006;42: 37–43. doi: 10.1111/j.1440-1754.2006.00777.x 16487388

2. AAPD. Definition of early childhood caries (ECC) [Internet]. American Academy of Pediatric Dentistry. 2008.

3. Interessengemeinschaft Zahnärztlicher Verbände in Deutschland. Frühkindliche Karies vermeiden. IGZ Die Alternative. 2014.

4. Deutsche Arbeitsgemeinschaft für Jugendzahnpflege. Epidemiologische Begleituntersuchungen zur Gruppenprophylaxe 2016. Bonn; 2017.

5. Deichsel M, Rojas G, Lüdecke K, Heinrich-Weltzien R. Early childhood caries and associated risk factors among infants in the German federal state of Brandenburg. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz. 2012;55: 1504–1511. doi: 10.1007/s00103-012-1537-9 23114450

6. Wyne AH. Early childhood caries: nomenclature and case definition. Community Dent Oral Epidemiol. 1999;27: 313–315. doi: 10.1111/j.1600-0528.1999.tb02026.x 10503790

7. Goettems ML, Ardenghi TM, Demarco FF, Romano AR, Torriani DD. Children’s use of dental services: Influence of maternal dental anxiety, attendance pattern, and perception of children’s quality of life. Community Dent Oral Epidemiol. 2012;40: 451–458. doi: 10.1111/j.1600-0528.2012.00694.x 22537392

8. Khawja SG, Arora R, Shah AH, Wyne AH, Sharma A. Maternal Dental Anxiety and its Effect on Caries Experience Among Children in Udaipur, India. J Clin Diagn Res. 2015;9: 42–45. doi: 10.7860/JCDR/2015/13647.6103 26266216

9. da Costa VPP, Goettems ML, de Oliveira LJC, Tarquinio SBC, Torriani DD, Correa MB, et al. Nonuse of dental service by schoolchildren in Southern Brazil: impact of socioeconomics, behavioral and clinical factors. Int J Public Health. 2015;60: 411–6. doi: 10.1007/s00038-015-0670-2 25759100

10. Costa VPP, Correa MB, Goettems ML, Pinheiro RT, Demarco FF. Maternal depression and anxiety associated with dental fear in children: a cohort of adolescent mothers in Southern Brazil. Braz Oral Res. 2017;31: e85. doi: 10.1590/1807-3107BOR-2017.vol31.0085 29116297

11. Kawashita Y, Fukuda H, Kawasaki K, Kitamura M, Hayashida H, Furugen R, et al. Dental caries in 3-year-old children is associated more with child-rearing behaviors than mother-related health behaviors. J Public Health Dent. 2009;69: 104–10. doi: 10.1111/j.1752-7325.2008.00107.x 19054311

12. Al-Jewair TS, Leake JL. The prevalence and risks of early childhood caries (ECC) in Toronto, Canada. J Contemp Dent Pract. 2010;11: 1–8.

13. D’Alessandro G, Cremonesi I, Alkhamis N, Piana G. Correlation between oral health in disabled children and depressive symptoms in their mothers. Eur J Paediatr Dent. 2014;15: 303–8. Available:

14. Dos Santos Pinto G, De Ávila Quevedo L, Britto Correa M, Sousa Azevedo M, Leão Goettems M, Tavares Pinheiro R, et al. Maternal Depression Increases Childhood Dental Caries: A Cohort Study in Brazil. Caries Res. 2017;51: 17–25. doi: 10.1159/000449040 27898426

15. Finlayson TL, Siefert K, Ismail AI, Sohn W. Psychosocial factors and early childhood caries among low-income African-American children in Detroit. Community Dent Oral Epidemiol. 2007;35: 439–448. doi: 10.1111/j.1600-0528.2006.00352.x 18039285

16. de Almeida TF, Vianna MIP, de Cabral MBBS, Cangussu MCT, Floriano FR. Family context and incidence of dental caries in preschool children living in areas covered by the Family Health Strategy in Salvador, Bahia State, Brazil. Cad Saude Publica. 2012;28: 1183–1195. doi: 10.1590/s0102-311x2012000600017 22666822

17. Williams SA, Kwan SYL, Parsons S. Parental Smoking Practices and Caries Experience in Pre–School Children. Caries Res. 2000;34: 117–122. doi: 10.1159/000016578 10773628

18. Shenkin JD, Broffitt B, Levy SM, Warren JJ. The association between environmental tobacco smoke and primary tooth caries. J Public Health Dent. John Wiley & Sons, Ltd (10.1111); 2004;64: 184–6. doi: 10.1111/j.1752-7325.2004.tb02750.x

19. Hanioka T, Nakamura E, Ojima M, Tanaka K, Aoyama H. Dental caries in 3-year-old children and smoking status of parents. Paediatr Perinat Epidemiol. 2008;22: 546–550. doi: 10.1111/j.1365-3016.2008.00950.x 19000292

20. Nakayama Y, Mori M. Association of environmental tobacco smoke and snacking habits with the risk of early childhood caries among 3-year-old Japanese children. J Public Health Dent. 2015;75: 157–162. doi: 10.1111/jphd.12085 25659226

21. Thomas JF, Startup R. Some social correlates with the dental health of young children. Community Dent Health. 1992;9: 11–7. Available:

22. Milsom KM, Tickle M, Humphris GM, Blinkhorn AS. The relationship between anxiety and dental treatment experience in 5-year-old children. Br Dent J. 2003;194: 503–6; discussion 495. doi: 10.1038/sj.bdj.4810070 12835786

23. Seow WK, Clifford H, Battistutta D, Morawska A, Holcombe T. Case-control study of early childhood caries in Australia. Caries Res. 2009;43: 25–35. doi: 10.1159/000189704 19136829

24. Olak J, Saag M, Honkala S, Nõmmela R, Runnel R, Honkala E, et al. Children’s dental fear in relation to dental health and parental dental fear. Stomatologija. 2013;15: 26–31. Available:

25. González-Valero L, Montiel-Company JM, Bellot-Arcís C, Almerich-Torres T, Iranzo-Cortés JE, Almerich-Silla JM. Association between passive tobacco exposure and caries in children and adolescents. A systematic review and meta-analysis. Sanchez ZM, editor. PLoS One. 2018;13: e0202497. doi: 10.1371/journal.pone.0202497 30114212

26. Klingberg G, Berggren U. Dental problem behaviors in children of parents with severe dental fear. Swed Dent J. 1992;16: 27–32. Available:

27. Dougall A, Fiske J. Surviving child sexual abuse: the relevance to dental practice. Dent Update. 2009;36: 294–296, 298–300, 303–304. doi: 10.12968/denu.2009.36.5.294 19585853

28. Willumsen T. The impact of childhood sexual abuse on dental fear. Community Dent Oral Epidemiol. 2004;32: 73–79. doi: 10.1111/j.1600-0528.2004.00120.x 14961843

29. Leeners B, Stiller R, Block E, Görres G, Imthurn B, Rath W. Consequences of childhood sexual abuse experiences on dental care. J Psychosom Res. 2007;62: 581–588. doi: 10.1016/j.jpsychores.2006.11.009 17467413

30. Lenk M, Berth H, Joraschky P, Petrowski K, Weidner K, Hannig C. Fear of dental treatment—an underrecognized symptom in people with impaired mental health. Dtsch Arztebl Int. 2013;110: 517–22. doi: 10.3238/arztebl.2013.0517 24069071

31. Crouch E, Radcliff E, Nelson J, Strompolis M, Martin A. The experience of adverse childhood experiences and dental care in childhood. Community Dent Oral Epidemiol. 2018;46: 442–448. doi: 10.1111/cdoe.12389 29873406

32. Muzik M, Bocknek EL, Broderick A, Richardson P, Rosenblum KL, Thelen K, et al. Mother-infant bonding impairment across the first 6 months postpartum: the primacy of psychopathology in women with childhood abuse and neglect histories. Arch Womens Ment Health. NIH Public Access; 2013;16: 29–38. doi: 10.1007/s00737-012-0312-0 23064898

33. Busch MA, Maske UE, Ryl L, Schlack R, Hapke U. Prevalence of depressive symptoms and diagnosed depression among adults in Germany: results of the German Health Interview and Examination Survey for Adults (DEGS1). Bundesgesundheitsblatt—Gesundheitsforsch—Gesundheitsschutz. 2013;56: 733–739. doi: 10.1007/s00103-013-1688-3 23703492

34. Jacobi F, Höfler M, Strehle J, Mack S, Gerschler A, Scholl L, et al. Mental disorders in the general population. Study on the health of adults in Germany and the additional module mental health (DEGS1-MH). Nervenarzt. 2014;85: 77–87 24441882

35. Reisine ST, Psoter W. Socioeconomic status and selected behavioral determinants as risk factors for dental caries. J Dent Educ. 2001;65: 1009–1016. Available: 11699971

36. Harris R, Nicoll AD, Adair PM, Pine CM. Risk factors for dental caries in young children: a systematic review of the literature. Community Dent Health. 2004;21: 71–85. Available:

37. Mattila M-L, Rautava P, Sillanpää M, Paunio P. Caries in Five-year-old Children and Associations with Family-related Factors. J Dent Res. 2000;79: 875–881. doi: 10.1177/00220345000790031501 10765963

38. Psoter WJ, Pendrys DG, Morse DE, Zhang H, Mayne ST. Associations of ethnicity/race and socioeconomic status with early childhood caries patterns. J Public Health Dent. 2006;66: 23–9. Available: doi: 10.1111/j.1752-7325.2006.tb02547.x

39. Tinanoff N, Reisine S. Update on Early Childhood Caries Since the Surgeon General’s Report. Acad Pediatr. Elsevier Ltd; 2009;9: 396–403. doi: 10.1016/j.acap.2009.08.006 19945074

40. Kim Seow W. Environmental, maternal, and child factors which contribute to early childhood caries: A unifying conceptual model. Int J Paediatr Dent. 2012;22: 157–168. doi: 10.1111/j.1365-263X.2011.01186.x 21972925

41. Peltzer K, Mongkolchati A. Severe early childhood caries and social determinants in three-year-old children from Northern Thailand: a birth cohort study. BMC Oral Health. BMC Oral Health; 2015;15: 108. doi: 10.1186/s12903-015-0093-8 26370287

42. Gängler P, Hoffmann T, Willershausen B, Schwenzer N, Ehrenfeld M. Konservierende Zahnheilkunde und Parodontologie: 66 Tabellen. 3. unverän. Stuttgart: Thieme; 2010.

43. Kramer E. Grundlagen zur Zahngesundheit; mit 21 Tabellen. 10. überar. Köln: Deutscher Zahnärzte Verlag; 2009.

44. Greene JC, Vermillion JR. The oral hygiene index: a method for classifying oral hygiene status. J Am Dent Assoc. 1960;61: 172–177.

45. Lampert T, Kroll LE, Müters S, Stolzenberg H. Measurement of the socioeconomic status within the German Health Update 2009 (GEDA). Bundesgesundheitsblatt—Gesundheitsforsch—Gesundheitsschutz. 2013;56: 131–143. doi: 10.1007/s00103-012-1583-3 23275948

46. Corah NL. Development of a dental anxiety scale. J Dent Res. 1969;48: 596. doi: 10.1177/00220345690480041801 5256508

47. Kroenke K, Strine TW, Spitzer RL, Williams JBW, Berry JT, Mokdad AH. The PHQ-8 as a measure of current depression in the general population. J Affect Disord. 2009;114: 163–73. doi: 10.1016/j.jad.2008.06.026 18752852

48. Spitzer RL, Kroenke K, Williams JBW, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166: 1092–7. doi: 10.1001/archinte.166.10.1092 16717171

49. Gierk B, Kohlmann S, Kroenke K, Spangenberg L, Zenger M, Brähler E, et al. The somatic symptom scale-8 (SSS-8): a brief measure of somatic symptom burden. JAMA Intern Med. 2014;174: 399–407. doi: 10.1001/jamainternmed.2013.12179 24276929

50. Morgan JF, Reid F, Lacey JH. The SCOFF questionnaire: a new screening tool for eating disorders. West J Med. 2000;172: 164–165 18751246

51. Grabe HJ, Schulz A, Schmidt CO, Appel K, Driessen M, Wingenfeld K, et al. [A brief instrument for the assessment of childhood abuse and neglect: the childhood trauma screener (CTS)]. Psychiatr Prax. 2012;39: 109–15. doi: 10.1055/s-0031-1298984 22422160

52. Bleich S, Havemann-Reinecke U, Kornhuber J. FTNA—Fagerström-Test für Nikotinabhängigkeit. 1. Auflage. Göttingen: Beltz Test GmbH; 2002.

53. Saunders JB, Aasland OG, Babor TF, de la Fuente JR, Grant M. Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO Collaborative Project on Early Detection of Persons with Harmful Alcohol Consumption—II. Addiction. 1993;88: 791–804. Available: doi: 10.1111/j.1360-0443.1993.tb02093.x

54. Bortz Jürgen, Nicola Döring. Forschungsmethoden und Evaluation fuür Human- und Sozialwissenschaftler. 3rd ed. Berlin, Heidelberg, New York: Springer-Verlag; 2002.

55. Hayes AF. Introduction to Mediation, Moderation, and Conditional Process Analysis, Second Edition: A Regression-Based Approach. New York, London: Guilford Publications; 2017.

56. Willumsen T. Dental fear in sexually abused women. Eur J Oral Sci. John Wiley & Sons, Ltd (10.1111); 2001;109: 291–296. doi: 10.1034/j.1600-0722.2001.00069.x

57. Wigen TI, Skaret E, Wang NJ. Dental avoidance behaviour in parent and child as risk indicators for caries in 5-year-old children. Int J Paediatr Dent. 2009;19: 431–7. doi: 10.1111/j.1365-263X.2009.01014.x 19708863

58. Deichsel M, Rojas G, Lüdecke K, Heinrich-Weltzien R. Early childhood caries and associated risk factors among infants in the German federal state of Brandenburg. Bundesgesundheitsblatt—Gesundheitsforsch—Gesundheitsschutz. 2012;55: 1504–1511. doi: 10.1007/s00103-012-1537-9 23114450

59. Winkler J, Stolzenberg H. Social class index in the Federal Health Survey. Gesundheitswesen. 1999;61: 178–183.

60. Maughan B, Rutter M. Retrospective reporting of childhood adversity: Issues in assessing long-term recall. J Pers Disord. Guilford Publications; 1997;11: 19–33. doi: 10.1521/pedi.1997.11.1.19

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