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.

Mothers of the CG reported significantly higher dental anxiety (d Cohen = 0.66), childhood trauma (d Cohen = 0.53) and nicotine dependency (d Cohen = 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 (d Cohen = 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.

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.

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.

Introduction

Early childhood caries (ECC) is one of the most common chronic diseases in childhood [1]. It is defined as the occurrence of at least one carious lesion on a deciduous tooth within the first 71 months of life [2] and can lead to complete destruction of the primary dentition and impairment of the permanent teeth [3]. In Germany, the prevalence of ECC has decreased in broad parts of the population [4]. According to the DAJ-Study, a recent representative national survey in Germany, 13.7% of the 3-year-old children already had caries experience, while by average, 3.57 teeth were affected per child and only 26% of the carious teeth were restored sufficiently [4]. A polarization of the disease is observed to the extent that a small part of the population accounts for the main caries load. This part of the population could not be reached sufficiently by prevention strategies [4,5]. As a reason for the high caries prevalence in this group, a constellation of low SES and suboptimal oral hygiene and preventive behavior is suspected [4]. A multifactorial disease development model is assumed for ECC [6]. Increasing importance is attributed to psychosocial risk factors such as maternal psychopathologies [7–24], educational deficits and poverty [15]. However, the still fragmentary knowledge about the influence of psychopathologies and their widely neglected interactions with socioeconomic factors complicates the integration in a multifactorial bio-psycho-social model. In most previous studies only one or few disorders were considered, making it difficult to compare the effects of the influencing factors. A few of these determinants are quite well verified (e.g., parental smoking [17–20,25], dental anxiety [7–10,21–24]), others have hardly (e.g., alcohol [11]) or not at all been investigated (e.g., childhood trauma, eating disorders), or study results are contradictory (e.g., depressiveness: positive studies [10,12–14], negative studies [15,16]).

Among the maternal psychopathologies, dental anxiety is one of the most studied risk factors. In children of mothers suffering from dental anxiety, an increased caries prevalence was confirmed in the majority of studies [7–10,21–24]. Mothers’ dental fear can impede the dental care of their children in two ways: apart from avoiding own dental visits, dentally anxious mothers take their children later and less regularly to the dentist [9]. Moreover, maternal dental anxiety predisposes for the development of dental fear in children [24,26].

Although maternal dental fear is a risk factor of ECC [7–10,21–24], nothing is known in this context about the influence of childhood traumatization, which is a common cause of dental anxiety in females [27]. Particularly traumatized women, who experienced sexual abuse in their childhood, often suffer from dental anxiety even in adulthood and perceive dental visits as intimidating [28,29]. A German study on inpatients with mental diseases showed that 42% of patients with posttraumatic stress disorder due to abuse and neglect in childhood suffered from high dental anxiety [30]. Women with childhood traumatization report inadequate dental care in their own childhood [31], more often have dental anxiety [27,28] and have issues with mother-infant bonding [32]. This leads to the assumption that maternal traumatization has a potential yet overlooked impact on ECC.

To better understand the causal relationships between maternal psychopathological symptom burden [PSB] and ECC, the socioeconomic framework conditions of the families should also be considered. Studies have shown that both, mental disorders [33,34] as well as ECC [5,35–41], are associated with low SES, which implicates SES could be a linking factor. Such a mediating influence of the SES is suspected [19] as an explanation for the observed association between household smoking and ECC [17–20,25]. However, since studies focusing on the influence of PSB on ECC often record the SES insufficiently or not at all, little is known about the triangular relationships of these factors. Such methodical limitations in the assessment of the SES are, for instance, the use of unvalidated questionnaires, very few or even only single items yielding little information.

Overall, previous research has confirmed that many maternal psychosocial burdens are associated with children’s oral health. On this basis, the next important step for further research would be to verify the relevance of these influencing factors and to understand the interactions between psychopathological and socioeconomic aspects. The integration into a multifactorial bio-psycho-social model seems necessary to identify risk constellations for need-adapted prevention strategies.

Therefore, the specific objective of our study was to cover a broad spectrum of maternal psychopathologies in order to identify those that show significant associations with ECC and to clarify if these associations are either direct or confounding effects, mediated by the common influence of SES on ECC and PSB. The aim of our study was to examine the following hypotheses: