DOI: 10.1111/j.1365-263X.2012.01238.

Parental stress as a predictor of early childhood caries among

preschool children in India
IPSEETA MENON1, RAMESH NAGARAJAPPA2, GAYATHRI RAMESH3 & MRIDULA TAK2
1

Department of Public Health Dentistry, I.T.S CDSR, Muradnagar, Ghaziabad, Uttar Pradesh, 2Department of Public Health
Dentistry, Pacific Dental College and Hospital, Airport Road, Debari, Udaipur, Rajasthan and 3Department of Oral and
Maxillofacial Pathology, Pacific Dental College and Hospital, Airport Road, Debari, Udaipur, Rajasthan

International Journal of Paediatric Dentistry 2013; 23:

160165
Background. The health and well-being of
children are linked to their parents physical,
emotional and social health in addition to childrearing practices.
Objectives. To investigate the association of parental stress as a risk indicator to early childhood caries (ECC) prevalence among preschool children of
Moradabad, India.
Methods. A casecontrol study was conducted
among 800 preschool children [400 cases (caries
active) and 400 controls (caries free)] aged
45 years along with their parents. Using the
Parental Stress Index-Short Form (PSI SF), we
determined the stress of primary caregivers of

Introduction

Early childhood caries (ECC) is defined by

the American Academy of Paediatric Dentistry
as the presence of one or more decayed
(noncavitated or cavitated lesions), missing
(because of caries), or filled tooth surfaces in
any primary tooth in a child 71 months of
age or younger.1 It is particularly a destructive form of tooth decay that afflicts young
children and is the most common disease of
the childhood.2 It is considered as a public
health problem that leads to pain, chewing
difficulties, speech problems, general health
disorders, psychological problems and lower
quality of life.3 Moreover, decay of primary
teeth can affect childrens growth, leading to
malocclusion by adversely affecting the correct guidance of the permanent dentition.
Correspondence to:
Ipseeta Menon, A-23, Kirpal Apartments, 44 I.P. Extension,
Patparganj, Delhi 110092, India.
E-mail: dripseeta@hotmail.com; ipseetam@gmail.com

160

young children. These children were clinically

examined for dental caries using Dentition Status
and Treatment needs. Students t-test, Pearsons
correlation and linear regression were used for
statistical analysis.
Results. An overall mean parenting stress index
was found to be 193.48 59.63. Significantly
higher mean stress scores were obtained among
cases than among controls. Parental stress was
significantly correlated with dmft scores and it
was found to be one of the best predictors of
ECC.
Conclusion. This study provides data to suggest
that parental stress has a pervasive impact on the
childrens oral health. The practitioners should be
aware of this possible relationship and be prepared
to provide appropriate intervention.

Existing literature has established that parents have direct impact on caries activity in
children. Although no single bacterial aetiology has been identified as the causative agent
of ECC, vertical transmission fidelity has been
reported as high as 80% between mother
child bacterial strains.4,5
Todays parents are busier than those in
past decades. Mothers extend a helping hand
financially, but because of stress at work find
less time to look after their children in regard
to their health, oral hygiene and food they
consume. It has been suggested that the relationship between psychosocial factors and
ECC might be influenced by stress.6 Stress
can be defined as adjustive demands placed
on the individual or their internal biological
responses. Thus, parents preoccupied with
more immediate and pressing issues may be
less likely to follow preventive oral health
behaviours for themselves or for their children. Owing to this parental disregard, an
unfortunate pattern of delay in seeking treatment exists, which leads to worsening of

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Parental stress and early childhood caries

childs condition and complicates the necessary treatment procedure.

A handful of studies have included parental
stress as one of the psychosocial spectrum of
variables to ECC prevalence.68 They have
demonstrated a significant bivariate association between parenting stress and ECC experience as measured by dmft. As these studies
call for more research designs targeting to
parental stress as a co-factor of ECC, this
casecontrol study was undertaken to assess
whether there is any correlation between
parental stress and ECC in preschool children
of Moradabad city.
Material and methods

A casecontrol study (single-blind) was conducted among 800 parentchild (45 years)
pairs of Moradabad city, India. The study protocol was reviewed and approved by Institutional Review Board and a written informed
consent was signed by all parents.
Sample selection
Based on the findings of pilot study conducted among 30 parentchild pairs, 5%
alpha error, 95% confidence level, and 80%
power, sample size in each group was determined to be 400. The study population was
randomly selected from 25 preschools of
Moradabad city. Equal number of cases and
controls were selected from each school.
Inclusion and exclusion criteria
Paediatric subjects who fell within an ASA 1
or well controlled two classifications were
included. We excluded more than one child
per family to be allowed into the study. This
decreased bias by not allowing on parents
stress results to be weighted more than
another and disrupting data normality. The
control group had no history of or current
diagnosis of dental decay. The childs primary dentition was complete or age appropriate unless there was a confirmed previous
diagnosis of congenitally missing teeth. The
case group had to have at least one caries
lesion upon the day of examination. They

161

could also present with a history of previous

treatments including restorative care or
extractions.
Evaluation of parental stress [Parental Stress
Index-Short Form (PSI-SF)]
The PSI-SF (Abidin, 1995)9 is a questionnaire
or self-report measure comprising 36 items in
its short version to which parents must
respond on a 5-point Likert-type scale (from
1 = strongly agree to 5 = strongly disagree).
It attempts to evaluate stress experienced during paternity maternity. Consisting of three
subscales of 12 items each, the Parental Distress subscale (items 112) determines distress
experienced by parents in exercising the
parental role, caused by personal factors
directly related to the exercise of functions
under this role (sense of competence, stresses
associated with restrictions on other functions
that are developed in life, conflicts with the
other parent of the child, lack of social support, depression, etc.). The subscale of Parent
Child Dysfunctional Interaction (items 1324)
focuses on the perception that parents have
as to what extent their child meets expectations or not, and the degree of reinforcement
their child provides them with as parents.
The third subscale called Difficult Child (items
2536) provides an assessment of how parents
perceive the ease or difficulty of controlling
their children in terms of their behavioural
traits; however, it also includes learned patterns of defiance, disobedience, and demanding behaviour.
From the sum of scores of these three subscales, a final overall score called total stress
is obtained. More specifically, this assessment
reflects the tensions found in the areas of the
parents personal distress, tensions arising
from interaction with the child, and those
whose origins lie in the behavioural characteristics of the child. The PSI-SF, English version was then translated into more viable
local language (Hindi) to aid comprehension
among the study population. Once the questionnaire was developed, validity and reliability were tested on a group of 25 parents. The
reliability was assessed using Cronbachs
alpha that was found to be satisfactory (0.87).

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162

I. Menon et al

Its testretest value also was well proven

with a correlation of 0.82.
Early childhood caries evaluation
Upon meeting the inclusion criteria, subjects
were evaluated for dental caries using mouth
mirror and CPI probe by a calibrated examiner. Dentition Status and Treatment Needs10
was recorded on all subjects using the WHO
Oral Health Surveys criteria. If the patients
exhibited no caries history or no current
decay, they were included into the control
(caries free, CF) group.
Data collection
Questionnaire (also designed in Hindi script
local language) along with the consent form
were distributed to parent of the child aged
45 years visiting the school on the parents
teachers meeting day. After explaining the
purpose and procedure of the study, a single
parent was requested to fill the questionnaire
independently. They also completed a brief
questionnaire regarding demographic information (Parents age, gender, education,
socioeconomic status, childs gender, and
number of siblings in house). Socioeconomic
status was recorded according to Prasads
Classification11 based on that it was stratified
into five categories, viz, Upper High, High,
Upper Middle, Lower Middle, and Poor.
Parents were allowed to complete the written instrument independently with the investigators supporting staff available for
questions. A trained and calibrated (j = 90%)
investigator conducted the type III oral examination for the child subject assessing the
dentition status and treatment needs and oral
hygiene index simplified12 for each child.
Statistical analysis
Several items of the questionnaire were
recoded to ensure that, for all items, a high
score indicated high stress and a low score
indicated low stress. Total parenting stress
score, parenting distress score, dysfunctional
interaction score, and difficult child (DC)
score were calculated for each respondent.

The recorded data were compiled and entered

in a spreadsheet computer program and then
exported to data editor page of SPSS version
11.5 (SPSS Inc., Chicago, IL, USA). Statistical
analysis was completed using Students t-test,
Pearsons correlation and linear regression
analysis. P-value 0.05 was considered as statistically significant.
Results

A total of 800 parentchild pairs (400 cases and

400 controls) participated in the study. The
mean age of the caregivers was 29 6.2 years.
The cases and controls showed approximately
equal distribution with respect to parents
age, gender, education, socioeconomic status,
childs gender, and siblings in house. The mean
dmft in the case group was 2.17 0.75. The
prevalence of children with poor oral hygiene
status was higher among the case group
(48.5%) when compared to control group
(34.5%) (Table 1).
An overall mean parenting stress index was
found to be 193.48 59.63. Significantly
higher mean parental distress (PD), parent
child dysfunction interaction, DC and total
parenting stress index scores were obtained
among cases than among controls (Table 2).
A statistically significant strong correlation
was observed between caries and parenting
distress (r = 0.78, P = 0.03); between caries
and DC (r = 0.89, P = 0.02) and between caries and total parenting stress index (r = 0.80,
P = 0.05) (Table 3).
A regression analysis was completed to
determine which associations may be predictive of whether a child would fall into the
caries active or CF group. The only significant
predictors were low socioeconomic status
(P = 0.02), high parenting stress (P = 0.05),
and poorer oral hygiene status (P = 0.02)
(Table 4).
Discussion

Stress defined as forces from outside world

impinging on the individual has been recognized as having pathophysiologic consequences on the individual. With nearly all
the aspects of a young childs oral health

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International Journal of Paediatric Dentistry  2012 BSPD, IAPD and Blackwell Publishing Ltd

Parental stress and early childhood caries

Table 1. Distribution of study population.

Variables

Case
n (%)

Control
n (%)

Total
n (%)

Parents age
<30
30

224 (56)
176 (44)

242 (60.5)
158 (39.5)

466 (58.3)
334 (41.8)

Parents gender
Male
Female

272 (68)
128 (32)

258 (64.5)
142 (35.5)

530 (66.3)
270 (33.8)

Parents education
Less than high school
High school graduates
College graduates
Postgraduate

113
87
97
103

(28.2)
(21.7)
(24.2)
(25.7)

119
91
75
115

(29.7)
(22.7)
(18.7)
(28.7)

232
178
172
218

(29)
(22.3)
(21.5)
(27.3)

84
66
98
56
96

(21)
(16.5)
(24.5)
(14)
(24)

96 (24)
78 (19.5)
76 (19)
48 (12)
102 (25.5)

180
144
174
104
198

(22.5)
(18)
(21.8)
(13)
(24.8)

238 (59.5)
162 (40.5)

234 (58.5)
166 (41.5)

472 (59)
328 (41)

218 (54.5)
182 (45.5)

221 (55.3)
179 (44.8)

439 (54.9)
361 (45.1)

138
124
138
400

232
236
332
800

Socioeconomic status
Upper High
High
Upper middle
Lower middle
Poor
Childs gender
Male
Female
Siblings in house
2
>2

Oral Hygiene Index Simplified

Good
94 (23.5)
Fair
112 (28)
Poor
194 (48.5)
Total
400 (50)

(34.5)
(31)
(34.5)
(50)

(29)
(29.5)
(41.5)
(100)

being managed by a parent or caregiver, it

stands to reason that stresses in the family
environment, and more specifically stress
between the parent and child should be considered in childhood caries risk assessment.
A parent with high stress in their parent
child relationship could suffer from poor coping abilities and thus may lack motivation to

163

or abilities to properly care for their childs

teeth. Conversely, parents stressed by inadequacy may be more likely to be vigilant. This
casecontrol study set out to determine
whether there exists an interaction between
parental stress and childhood caries.
The relationship of ECC to higher total parenting stress is congruent with the findings of
previous studies by Wendt et al.;13 La Valle
et al.,8 and Quinonez et al.6 An inverse relationship was described by Reisine and Litt14
and Finlayson et al.15 who reported better
dental outcomes associated with higher levels
of parenting stress. This may be due to difference in the stress indexes used in the studies.
Tang et al.7 found a positive association on
bivariate level, but this association did not
persist in modelling analysis, which could
be because of small sample size they had
taken.
Pearsons correlation suggested an increasing trend of dmft scores with the increase in
the levels of PD and DC. When a child is difficult or demanding, becomes violent or
obstructive the parent may feel uncomfortable and avoid the situation completely, thus
negatively reinforcing the childs behaviour
and preventing even minimal oral hygiene
exposure. A parent may also be tempted to
give the child a bottle at night when there is
sleeping problem. The higher total stress score
for parents might have resulted from urbanization.
Higher total parenting stress, low socioeconomic status, and poorer oral hygiene status
were reported as the best predictors of ECC in
this study. Tang et al.,7 also reported low
socioeconomic status as a significant predictor
of ECC. Parental stress and low socioeconomic status may be attributed to poor oral
hygiene of the child. Many parents in the

Table 2. Mean Parenting Stress index among case and control groups.
Parameters
Parenting
Parenting
Parenting
Parenting

stress
stress
stress
stress

IndexParenting distress
IndexDysfunctional interaction
indexDifficult child
indexTotal

Case (n = 400)

Control (n = 400)

Total

38.7
42.52
37.31
199.75

36.63
40.55
35.29
189.64

37.41
41.3
36.06
193.48

12.34
13.49
11.88
59.56

12.37
13.42
11.67
59.39

Test used: t-test, P 0.05 is considered statistically significant.

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International Journal of Paediatric Dentistry  2012 BSPD, IAPD and Blackwell Publishing Ltd

P-value

12.39
13.47
11.79
59.63

0.02
0.02
0.05
0.02

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I. Menon et al

Table 3. Correlation of caries and different stress

parameters.

Variables

Correlation
coefficient

P-value

CariesParenting distress
CariesDysfunctional interaction
CariesDifficult child
CariesTotal Parenting stress index

0.78
0.59
0.89
0.80

0.03*
0.11
0.02*
0.05*

Test used: Pearsons Correlation coefficient.

*Indicates statistically significant difference at P 0.05].

Table 4. Linear regression analysis for predictors of caries

status.
Predictor variable

P-value

Parents age
Parents gender
Parents education
Socioeconomic status
Childs gender
Siblings in house
Parenting stress
Oral Hygiene status

0.45
0.23
0.34
0.02*
0.28
0.28
0.05*
0.02*

Test used: Linear regression analysis.

*Indicates statistically significant at P 0.05].

studies of Amin et al.16 and Leung et al.17

reported that the stress of daily life was a barrier to proper attention paid to the health
care of their childrens teeth. Types of stress
in the later study were economical, sociodemographic, number of children, and marital
status. More and Vandivere18 showed that
30% of parents in stressful family environments exhibit low levels of engagement in
home dental care, high levels of ill health
behaviour and emotional problems, and three
times more parent aggression. Furthermore,
one of every five children lives in a stressful
family environment with two or more stressors such as inability to pay bills or obtain
proper foods or having no health insurance.
Parents in high stress may find less priority in
maintaining proper oral hygiene of their
child. Socioeconomic status defines the parents affordability of the oral hygiene aids as
well as their utilization of oral health care
services for their child. The relationship of
poor oral hygiene status and dental caries had
already been established in the literature that
typifies the model of caries we currently

adopt; that complex bacterial biofilms and fermentable carbohydrates are the direct cause
of decay.
Childs gender was not found to be a
predictor of ECC in this study, which is in
contrast to the finding of Spitz et al.19 where
they found that men were more difficult
than women owing to that they were more
likely to bottle fed to sleep making them
more prone to caries. Moreover, Vann
et al.20 reported that lower caregiver literacy
was associated with deleterious oral health
behaviours, including night time bottle use
and no daily brushing or cleaning which in
turn affected the oral health outcome.
Divaris et al.21 observed a positive correlation of caregivers oral health literacy with
childs oral health related quality of life
which in turn was correlated with childs
oral health status. This finding did not hold
true in the multivariate analysis in this
study.
Parents might have answered untruthfully
to the survey questions, which may inculcate
a potential bias in the study. More longitudinal
studies probing this issue are required to support the studys baseline findings and to accumulate good evidence to incorporate parental
stress into the anticipatory guidance of childs
dental needs. This requires the practitioners
to recognize the warning signs of stress
through conversation with the parent which
may dictate the treatment options and planning when trying to understand a childs dental needs.
Conclusion

The relationship between parental stress and

ECC is clearly demonstrated in this study.
Stress scores increased with increasing number of carious teeth and children with most
carious teeth had the highest PSI scores.
The high prevalence of ECC in this population is associated with significant adverse
physical, functional, and behavioural consequences that can greatly impair quality of life.
The assessment of these influences can help
clinicians and researchers in their attempts
to improve oral health outcomes for young
children.

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Parental stress and early childhood caries

Why this study is important to paediatric

dentists?
d Understanding the risk factors, occurrence, and progression of dental diseases among preschool population enhances opportunities for tailoring prevention
and intervention strategies to improve childrens oral
health outcomes.
d Draws paediatricians attention to recognize warning
signs of stress through conversation with the parent
and stressful circumstances in the families lives. This
may help dictate treatment options and planning
when trying to understand a childs dental needs.
d Findings of early childhood caries might also instigate
appropriate conversation and a referral to social services available to decrease or alleviate a parents stress.

References
1 Cohn DV. Do Parents Spend Enough Time With
Their Children? Population Reference Bureau; 2007
[cited 2010 07 01 2010]; Available from: http://
www.prb.org/Articles/2007/DoParentsSpendEnough
TimeWithTheirChildren.aspx.
2 Dini EL, Holt RD, Bedi R. Caries and its association
with infant feeding and oral health related
behaviours in 34 year old Brazilian children.
Community Dent Oral Epidemiol 2000; 28: 241248.
3 Tinanoff N. Introduction to the Early Childhood
caries conference: initial description and current
understanding. Community Dent Oral Epidemiol 1998;
26: 57.
4 Kendrick F, Wilson S, Coury DL, Preisch JW.
Comparison of temperaments of children with and
without baby bottle tooth decay. ASDC J Dent Child
1998; 65: 198203.
5 Drury TF, Horowitz AM, Ismail AI, Maertens MP,
Rozier GR, Selwitz RH. Diagnosing and reporting
early childhood caries for research purposes. J Public
Health Dent 1999; 59: 192197.
6 Quinonez R, Keels M, Vann W Jr, McIver F, Heller
K, Whitt J. Early Childhood Caries: analysis of
psychosocial and biological factors in a highrisk
population. Caries Res 2000; 35: 376383.
7 Tang C, Quinonez R, Hallett K, Lee J, Kenneth
Whitt J. Examining the association between parental
stress and the development of early childhood
caries. Community Dent Oral Epidemiol 2005; 33: 454
460.
8 La Valle PS, Glaros A, Bohaty B, McCunnifff M.
The effect of parental stress on the oral health of

10
11

12
13

14

15

16

17

18

19

20

21

165

children. J Clin Psychol Med Settings 2000; 7: 197

201.
Abidin RR. Parenting Stress Index (PSI) Manual, 3rd
edn. Charlottesville, VA: Pediatric Psychology Press,
1995.
World Health Organization. Oral Health Surveys. Basic
Methods, , 4th edn. Geneva: WHO, 1997.
Agarwal A. Social Classification: the need to update
in the present scenario. Indian J Commun Med 2008;
33: 5051.
Greene JC, Vermillion JR. The simplified oral
hygiene index. J Am Dent Assoc 1964; 68: 713.
Wendt L, Swedin C, Hallonsten A, Larsson I. Infants
and toddlers with caries: mental health, family
interaction and life events in infants and toddlers
with caries. Swed Dent J 1995; 19: 1727.
Reisine S, Litt M. Social and psychological theories
and their use for dental practice. Int Dent J 1993; 43:
279287.
Finlayson T, Siefert K, Ismail A, Sohn W.
Psychosocial factors and early childhood caries
among low income AfricanAmerican children in
Detroit. Community Dent Oral Epidemiol 2007; 35:
439448.
Amin MS, Harrison RL, Weinstein P. A qualitative
look at parents experience of their childs dental
general anaesthesia. Int J Paediatr Dent 2006; 16:
309319.
Leung SSL, Leung C, Chan R. Perceived child
behavior problems, Parenting stress, and marital
satisfaction: comparison of new arrival and local
parents of preschool children in Hong Kong. Med J
2007; 13: 364375.
More KA, Vandivere S. Stressful family lives: child
and parent well-being. New federalism: national
survey of Americas families, series B, No. B-17;
assessing the New Federalism. Urban Institute 2000;
16.
Spitz AS, Weber-Gasparoni K, Kanellis MJ, Qian F.
Child temperament and risk factors for early
childhood caries. J Dent Child (Chic) 2006; 73: 98
104.
Vann WF Jr, Lee JY, Baker D, Divaris K. Oral health
literacy among female caregivers: impact on oral
health outcomes in early childhood. J Dent Res 2010;
89: 13951400.
Divaris K, Lee JY, Baker AD, Vann WF. Caregivers
oral health literacy and their young childrens oral
health-related quality-of-life. Acta Odontol Scand
2011. Dec 8. [Epub ahead of print].

 2012 The Authors

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