Original Paper Received: January 30, 2012 Accepted after revision: March 26, 2013 Published online: November 6, 2013
Caries Res 2014;48:3–12 DOI: 10.1159/000351636
Can Child Temperament Be Related to Early Childhood Caries? N.A. Aminabadi a A. Ghoreishizadeh a M. Ghoreishizadeh c S.G. Oskouei b M. Ghojazadeh d a Department of Paediatric Dentistry, b Faculty of Dentistry, and Departments of c Psychiatry and d Physiology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
Abstract Beyond the biological risk factors of early childhood caries (ECC) is child temperament. This study aimed to investigate the relationship of ECC to different traits of child temperament, directly and indirectly through the nutritional and oral hygiene habits. Through a multi-stage sampling, 373 kindergarten children aged 18–36 months participated in this study. The primary caregivers filled in the Early Childhood Behaviour Questionnaire (ECBQ) and a checklist containing demographic data and the dietary and oral hygiene habits of the children. Children were examined for dental caries. The frequency of ECC was 41.14%. With 18 aspects of a child’s temperament under consideration, attentional shifting, fear, frustration, low-intensity pleasure, sadness and shyness were significantly higher in the ECC group. Cuddliness, perceptual sensitivity, positive anticipation and soothability were significantly higher in caries-free children. Attentional shifting (p = 0.02), frustration (p = 0.02) and shyness (p = 0.03) were risk factors and cuddliness (p < 0.001) was a protecting factor for ECC. In the multiple regression model regarding nutritional and oral hygiene habits, easily soothable
© 2013 S. Karger AG, Basel 0008–6568/14/0481–0003$39.50/0 E-Mail [email protected] www.karger.com/cre
children were 0.69 times less likely to use sweetened liquids frequently [odds ratio (OR) 0.69, 95% confidence interval (CI) 0.49–0.97, p = 0.03], while sad children were 0.58 times less likely to brush (OR 0.58, 95% CI 0.36–0.94, p = 0.02). Considering temperament traits along with socioeconomic status, positive anticipation was the most significant determinant of ECC (OR 1.57, 95% CI 1.13–2.19, p = 0.007). However, considering temperament, socioeconomic measures and child habits among ECC risk factors, the most significant was the initiation of brushing habits (OR 5.41, 95% CI 2.81–12.98, p = 0.002). © 2013 S. Karger AG, Basel
Several demographic studies have been performed to identify children at risk for early childhood caries (ECC) [Olmez et al., 2003; Gussy et al., 2006; Hallett and O’Rourke, 2006; Finlayson et al., 2007; Warren et al., 2008; Tinanoff and Reisine, 2009; Begzati et al., 2010; Feldens et al., 2010; Jabbarifar et al., 2009; Kumar, 2010; Niji et al., 2010; Palmer et al., 2010; Li et al., 2011; Marrs et al., 2011]. The tremendous prevalence, high costs and negative outcomes associated with ECC have led some researchers to look beyond biological factors and explore behavioural aspects in an effort to better understand the development and prevention of ECC [Kendrick et al., 1998; Pinkham et al., 2005; Dr. Naser Asl Aminabadi Faculty of Dentistry Tabriz University of Medical Sciences Daneshgah St, Tabriz 5166614711 (Iran) E-Mail aslaminabadi @ gmail.com
Downloaded by: University of Tokyo 157.82.153.40 - 5/16/2015 10:00:39 PM
Key Words Bottle-feeding · Breast-feeding · Child temperament · Early childhood caries
4
Caries Res 2014;48:3–12 DOI: 10.1159/000351636
ated in this study [Zhao et al., 2006]. Spitz et al. [2006] and Slabsinskiene et al. [2010] studied 329 children under 4 years of age and 950 3-year-old children, respectively, and concluded that ECC was more prevalent in ‘difficult’ children. It is worthy of note that these studies assessed temperament according to the mother’s perception by posing one simple question, i.e. Is their child’s temperament ‘easy’ or ‘difficult’? [Spitz et al., 2006; Slabsinskiene et al., 2010]. In the light of currently available evidence, a study with comprehensive evaluation of temperament along with dietary and oral hygiene habits is deemed necessary, as differing results emerge from previous studies, probably due to the different assessment tools utilized. The Early Childhood Behaviour Questionnaire (ECBQ) investigates 18 aspects of temperament in 18- to 36-month-old children and is based on a definition involving the ‘broad aspects’ of a toddler’s temperament. Moreover, within the domain of ‘emotion’ – probably the most important factor to be assessed regarding ECC – the ECBQ is broader in content than previous temperament questionnaires [Putnam et al., 2006]. The aim of this study is: (1) to compare different traits of temperament in children with and without ECC, to investigate (2) the correlation of different aspects of a child’s temperament with DMFT (decayed, missing and filled teeth) and DMFS (decayed, missing and filled surfaces) and (3) the association of different traits of a child’s temperament with ECC indirectly through the nutritional and oral hygiene habits. We hypothesized that a child’s temperament is related to ECC indirectly through nutritional and oral hygiene habits.
Materials and Methods Study Population Subjects enrolled in this cross-sectional analytical study were 373 children of both sexes aged 18–36 months, from kindergartens in Tabriz, East Azerbaijan. According to the available data, a total of 3,500 such children had been registered in the kindergartens of the study area in the study period (from May to September, 2011). A multi-stage sampling was performed in this study and the preliminary sample size was estimated to be 395 subjects; however, it was increased to 420 to account for the loss of follow-ups. Fortytwo children were randomly selected from each of the ten districts of the study area. The number of children selected from each kindergarten of a district was proportional to the number of 18- to 36-month-old children attending each kindergarten. All children resided in regions with 0 was regarded as ECC. Ethical Viewpoints The study was ethically approved by the ethics committee of the Tabriz University of Medical Sciences. The details of the study were explained to the parents in a letter and their written informed consent was taken. Statistical Data Analysis Descriptive statistics were used for reporting the outcome variables. Statistical testing between groups was carried out using the independent-samples Student t test or the Mann-Whitney U test. The χ2 test or the Fisher exact test was used for the comparison of
Caries Res 2014;48:3–12 DOI: 10.1159/000351636
5
Downloaded by: University of Tokyo 157.82.153.40 - 5/16/2015 10:00:39 PM
Included Subjects The subjects were selected via careful screening for inclusion criteria which allowed: Child factors: • birth weight >2,500 g • 18–36 months of age, independent of sex and ethnic characteristics • any sign of eruption of the maxillary primary incisors • complete physical and mental health without any confounding medical history • children who were born and lived in the study area • a willingness to participate in the study. Maternal factors: • an age of 18–35 years • no preterm deliveries • no serious maternal illness.
4.0 Negative temperaments (95% CI)
Positive temperaments (95% CI)
4.7
4.6
4.5
4.4
3.9
3.8
3.7
4.3 ECC Clinical diagnosis
Caries free
ECC Clinical diagnosis
Fig. 1. The comparison of positive temperaments in the ECC group and in caries-free children; 2-tailed p value = 0.03.
Fig. 2. The comparison of negative temperaments in the ECC group and in caries-free children; 2-tailed p value = 0.03.
frequency of distributions between groups. According to the score-sheet of the ECBQ-short form, the scores for the 18 traits of temperament and the mean score for 9 positive temperaments and 9 negative temperaments were calculated for each subject, and the relationship of a child’s temperament with ECC was evaluated between children with and without ECC. The Spearman correlation coefficient for assessment of the correlation between different dimensions of temperament and children’s DMFT and DMFS scores was used. Multivariate regression model was utilized to: (1) identify which aspects of temperament were significant in children with and without ECC and (2) determine the predicting model of nutritional and oral hygiene habits for different aspects of temperament. Odds ratios (ORs) were calculated with a 95% confidence interval (CI). Statistical analysis was performed with SPSS 17.0 computer software for Windows. Statistical significance was considered when p < 0.05.
Comparison of Positive and Negative Temperament between Groups Figure 1 and figure 2 show the comparison of mean positive and negative temperaments between the cariesfree and the ECC groups. Positive temperaments were significantly higher in caries-free children (p = 0.01) and negative temperaments were significantly higher in the ECC group (p = 0.01).
Results
A total of 373 children aged 18–36 months, with a mean age of 28.1 ± 5.95 months [185 females (49.6%) and 188 males (50.4%)] participated in this study. The frequency of ECC was 41.01% and the mean DMFS and DMFT of all subjects were 1.88 ± 0.15 and 4.63 ± 0.51, respectively. Table 1 represents these data separately in the caries-free and ECC groups. The primary caregiver of 338 subjects (93.4%) was the mother. The educational level of the father and the mother were significantly higher in the caries-free group than in the ECC group (p < 0.001), as was the family income (p < 0.001). 6
Caries Res 2014;48:3–12 DOI: 10.1159/000351636
Comparison of Different Aspects of Child Temperament between Groups Considering 18 different traits of child temperament, the following results were observed: attentional shifting, fear, frustration, low-intensity pleasure, sadness and shyness were significantly higher in the ECC group, while cuddliness, perceptual sensitivity, positive anticipation and soothability were significantly higher in the cariesfree group (table 2). Variables showing significant results in the univariate analysis in table 2 with p < 0.1 were used to develop a final model using stepwise logistic regression analysis. The final logistic regression model indicated that attentional shifting (p = 0.02), frustration (p = 0.02) and shyness (p = 0.03) were risk factors and that cuddliness (p < 0.001) was a protecting factor for ECC (table 3). The correlations between the 18 aspects of temperament with DMFT and DMFS are indicated in table 4. A significant positive correlation was registered between DMFT and attentional shifting, fear, frustration and lowAminabadi/Ghoreishizadeh/ Ghoreishizadeh/Oskouei/Ghojazadeh
Downloaded by: University of Tokyo 157.82.153.40 - 5/16/2015 10:00:39 PM
Caries-free
DMFS in the studied population (n = 373) Variable/group Frequency Gender Female Male Age, months DMFT DMFS
Caries-free, n (%)
ECC, n (%)
220 (58.9)
153 (41.1)
103 (46.8) 117 (53.2) 27.73±6.11 0 (0) 0 (0)
82 (53.6) 71 (46.4) 28.79±5.67 4.59±3.28 11.28±12.79
Table 2. Comparison of different aspects of temperament in chil-
dren with and without ECC Temperament traits Attentional shifting Discomfort Fear Frustration Impulsivity Inhibitory control Low-intensity pleasure Sadness Shyness Activity level/energy Attentional focusing Cuddliness High-intensity pleasure Motor activation Perceptual sensitivity Positive anticipation Sociability Soothability
Caries-free (n = 220)
ECC (n = 153)
p value
4.43±0.76 4.12±1.13 3.08±1.12 3.53±1.01 3.82±0.98 3.61±0.86 5.00±0.95 3.50±0.90 3.29±0.97 4.49±0.86 4.47±0.84 5.15±0.99 4.67±1.02 2.65±0.97 5.06±1.46 5.26±1.12 5.12±1.18 4.46±0.96
4.55±0.87 4.04±1.19 3.28±1.30 3.75±1.07 3.91±0.92 3.58±0.87 5.26±0.88 3.65±0.87 3.49±1.14 4.50±0.72 4.46±0.83 4.95±1.01 4.59±0.91 2.61±0.97 4.89±1.49 5.04±1.18 5.00±1.25 4.22±1.02
0.04* 0.49 0.02* 0.04* 0.37 0.75
Caries Res 2014;48:3–12 DOI: 10.1159/000351636
Can Child Temperament Be Related to Early Childhood Caries? N.A. Aminabadi a A. Ghoreishizadeh a M. Ghoreishizadeh c S.G. Oskouei b M. Ghojazadeh d a Department of Paediatric Dentistry, b Faculty of Dentistry, and Departments of c Psychiatry and d Physiology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
Abstract Beyond the biological risk factors of early childhood caries (ECC) is child temperament. This study aimed to investigate the relationship of ECC to different traits of child temperament, directly and indirectly through the nutritional and oral hygiene habits. Through a multi-stage sampling, 373 kindergarten children aged 18–36 months participated in this study. The primary caregivers filled in the Early Childhood Behaviour Questionnaire (ECBQ) and a checklist containing demographic data and the dietary and oral hygiene habits of the children. Children were examined for dental caries. The frequency of ECC was 41.14%. With 18 aspects of a child’s temperament under consideration, attentional shifting, fear, frustration, low-intensity pleasure, sadness and shyness were significantly higher in the ECC group. Cuddliness, perceptual sensitivity, positive anticipation and soothability were significantly higher in caries-free children. Attentional shifting (p = 0.02), frustration (p = 0.02) and shyness (p = 0.03) were risk factors and cuddliness (p < 0.001) was a protecting factor for ECC. In the multiple regression model regarding nutritional and oral hygiene habits, easily soothable
© 2013 S. Karger AG, Basel 0008–6568/14/0481–0003$39.50/0 E-Mail [email protected] www.karger.com/cre
children were 0.69 times less likely to use sweetened liquids frequently [odds ratio (OR) 0.69, 95% confidence interval (CI) 0.49–0.97, p = 0.03], while sad children were 0.58 times less likely to brush (OR 0.58, 95% CI 0.36–0.94, p = 0.02). Considering temperament traits along with socioeconomic status, positive anticipation was the most significant determinant of ECC (OR 1.57, 95% CI 1.13–2.19, p = 0.007). However, considering temperament, socioeconomic measures and child habits among ECC risk factors, the most significant was the initiation of brushing habits (OR 5.41, 95% CI 2.81–12.98, p = 0.002). © 2013 S. Karger AG, Basel
Several demographic studies have been performed to identify children at risk for early childhood caries (ECC) [Olmez et al., 2003; Gussy et al., 2006; Hallett and O’Rourke, 2006; Finlayson et al., 2007; Warren et al., 2008; Tinanoff and Reisine, 2009; Begzati et al., 2010; Feldens et al., 2010; Jabbarifar et al., 2009; Kumar, 2010; Niji et al., 2010; Palmer et al., 2010; Li et al., 2011; Marrs et al., 2011]. The tremendous prevalence, high costs and negative outcomes associated with ECC have led some researchers to look beyond biological factors and explore behavioural aspects in an effort to better understand the development and prevention of ECC [Kendrick et al., 1998; Pinkham et al., 2005; Dr. Naser Asl Aminabadi Faculty of Dentistry Tabriz University of Medical Sciences Daneshgah St, Tabriz 5166614711 (Iran) E-Mail aslaminabadi @ gmail.com
Downloaded by: University of Tokyo 157.82.153.40 - 5/16/2015 10:00:39 PM
Key Words Bottle-feeding · Breast-feeding · Child temperament · Early childhood caries
4
Caries Res 2014;48:3–12 DOI: 10.1159/000351636
ated in this study [Zhao et al., 2006]. Spitz et al. [2006] and Slabsinskiene et al. [2010] studied 329 children under 4 years of age and 950 3-year-old children, respectively, and concluded that ECC was more prevalent in ‘difficult’ children. It is worthy of note that these studies assessed temperament according to the mother’s perception by posing one simple question, i.e. Is their child’s temperament ‘easy’ or ‘difficult’? [Spitz et al., 2006; Slabsinskiene et al., 2010]. In the light of currently available evidence, a study with comprehensive evaluation of temperament along with dietary and oral hygiene habits is deemed necessary, as differing results emerge from previous studies, probably due to the different assessment tools utilized. The Early Childhood Behaviour Questionnaire (ECBQ) investigates 18 aspects of temperament in 18- to 36-month-old children and is based on a definition involving the ‘broad aspects’ of a toddler’s temperament. Moreover, within the domain of ‘emotion’ – probably the most important factor to be assessed regarding ECC – the ECBQ is broader in content than previous temperament questionnaires [Putnam et al., 2006]. The aim of this study is: (1) to compare different traits of temperament in children with and without ECC, to investigate (2) the correlation of different aspects of a child’s temperament with DMFT (decayed, missing and filled teeth) and DMFS (decayed, missing and filled surfaces) and (3) the association of different traits of a child’s temperament with ECC indirectly through the nutritional and oral hygiene habits. We hypothesized that a child’s temperament is related to ECC indirectly through nutritional and oral hygiene habits.
Materials and Methods Study Population Subjects enrolled in this cross-sectional analytical study were 373 children of both sexes aged 18–36 months, from kindergartens in Tabriz, East Azerbaijan. According to the available data, a total of 3,500 such children had been registered in the kindergartens of the study area in the study period (from May to September, 2011). A multi-stage sampling was performed in this study and the preliminary sample size was estimated to be 395 subjects; however, it was increased to 420 to account for the loss of follow-ups. Fortytwo children were randomly selected from each of the ten districts of the study area. The number of children selected from each kindergarten of a district was proportional to the number of 18- to 36-month-old children attending each kindergarten. All children resided in regions with 0 was regarded as ECC. Ethical Viewpoints The study was ethically approved by the ethics committee of the Tabriz University of Medical Sciences. The details of the study were explained to the parents in a letter and their written informed consent was taken. Statistical Data Analysis Descriptive statistics were used for reporting the outcome variables. Statistical testing between groups was carried out using the independent-samples Student t test or the Mann-Whitney U test. The χ2 test or the Fisher exact test was used for the comparison of
Caries Res 2014;48:3–12 DOI: 10.1159/000351636
5
Downloaded by: University of Tokyo 157.82.153.40 - 5/16/2015 10:00:39 PM
Included Subjects The subjects were selected via careful screening for inclusion criteria which allowed: Child factors: • birth weight >2,500 g • 18–36 months of age, independent of sex and ethnic characteristics • any sign of eruption of the maxillary primary incisors • complete physical and mental health without any confounding medical history • children who were born and lived in the study area • a willingness to participate in the study. Maternal factors: • an age of 18–35 years • no preterm deliveries • no serious maternal illness.
4.0 Negative temperaments (95% CI)
Positive temperaments (95% CI)
4.7
4.6
4.5
4.4
3.9
3.8
3.7
4.3 ECC Clinical diagnosis
Caries free
ECC Clinical diagnosis
Fig. 1. The comparison of positive temperaments in the ECC group and in caries-free children; 2-tailed p value = 0.03.
Fig. 2. The comparison of negative temperaments in the ECC group and in caries-free children; 2-tailed p value = 0.03.
frequency of distributions between groups. According to the score-sheet of the ECBQ-short form, the scores for the 18 traits of temperament and the mean score for 9 positive temperaments and 9 negative temperaments were calculated for each subject, and the relationship of a child’s temperament with ECC was evaluated between children with and without ECC. The Spearman correlation coefficient for assessment of the correlation between different dimensions of temperament and children’s DMFT and DMFS scores was used. Multivariate regression model was utilized to: (1) identify which aspects of temperament were significant in children with and without ECC and (2) determine the predicting model of nutritional and oral hygiene habits for different aspects of temperament. Odds ratios (ORs) were calculated with a 95% confidence interval (CI). Statistical analysis was performed with SPSS 17.0 computer software for Windows. Statistical significance was considered when p < 0.05.
Comparison of Positive and Negative Temperament between Groups Figure 1 and figure 2 show the comparison of mean positive and negative temperaments between the cariesfree and the ECC groups. Positive temperaments were significantly higher in caries-free children (p = 0.01) and negative temperaments were significantly higher in the ECC group (p = 0.01).
Results
A total of 373 children aged 18–36 months, with a mean age of 28.1 ± 5.95 months [185 females (49.6%) and 188 males (50.4%)] participated in this study. The frequency of ECC was 41.01% and the mean DMFS and DMFT of all subjects were 1.88 ± 0.15 and 4.63 ± 0.51, respectively. Table 1 represents these data separately in the caries-free and ECC groups. The primary caregiver of 338 subjects (93.4%) was the mother. The educational level of the father and the mother were significantly higher in the caries-free group than in the ECC group (p < 0.001), as was the family income (p < 0.001). 6
Caries Res 2014;48:3–12 DOI: 10.1159/000351636
Comparison of Different Aspects of Child Temperament between Groups Considering 18 different traits of child temperament, the following results were observed: attentional shifting, fear, frustration, low-intensity pleasure, sadness and shyness were significantly higher in the ECC group, while cuddliness, perceptual sensitivity, positive anticipation and soothability were significantly higher in the cariesfree group (table 2). Variables showing significant results in the univariate analysis in table 2 with p < 0.1 were used to develop a final model using stepwise logistic regression analysis. The final logistic regression model indicated that attentional shifting (p = 0.02), frustration (p = 0.02) and shyness (p = 0.03) were risk factors and that cuddliness (p < 0.001) was a protecting factor for ECC (table 3). The correlations between the 18 aspects of temperament with DMFT and DMFS are indicated in table 4. A significant positive correlation was registered between DMFT and attentional shifting, fear, frustration and lowAminabadi/Ghoreishizadeh/ Ghoreishizadeh/Oskouei/Ghojazadeh
Downloaded by: University of Tokyo 157.82.153.40 - 5/16/2015 10:00:39 PM
Caries-free
DMFS in the studied population (n = 373) Variable/group Frequency Gender Female Male Age, months DMFT DMFS
Caries-free, n (%)
ECC, n (%)
220 (58.9)
153 (41.1)
103 (46.8) 117 (53.2) 27.73±6.11 0 (0) 0 (0)
82 (53.6) 71 (46.4) 28.79±5.67 4.59±3.28 11.28±12.79
Table 2. Comparison of different aspects of temperament in chil-
dren with and without ECC Temperament traits Attentional shifting Discomfort Fear Frustration Impulsivity Inhibitory control Low-intensity pleasure Sadness Shyness Activity level/energy Attentional focusing Cuddliness High-intensity pleasure Motor activation Perceptual sensitivity Positive anticipation Sociability Soothability
Caries-free (n = 220)
ECC (n = 153)
p value
4.43±0.76 4.12±1.13 3.08±1.12 3.53±1.01 3.82±0.98 3.61±0.86 5.00±0.95 3.50±0.90 3.29±0.97 4.49±0.86 4.47±0.84 5.15±0.99 4.67±1.02 2.65±0.97 5.06±1.46 5.26±1.12 5.12±1.18 4.46±0.96
4.55±0.87 4.04±1.19 3.28±1.30 3.75±1.07 3.91±0.92 3.58±0.87 5.26±0.88 3.65±0.87 3.49±1.14 4.50±0.72 4.46±0.83 4.95±1.01 4.59±0.91 2.61±0.97 4.89±1.49 5.04±1.18 5.00±1.25 4.22±1.02
0.04* 0.49 0.02* 0.04* 0.37 0.75
