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Journal of Indian Society of Pedodontics and Preventive Dentistry Official publication of Indian Society of Pedodontics and Preventive Dentistry
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Year : 2021  |  Volume : 39  |  Issue : 2  |  Page : 196-201

The association between the salivary cortisol level of mothers, children's temperament, and early childhood caries

1 Student Research Committee, Babol University of Medical Sciences, Babol, I.R, Iran
2 Fatemeh Zahra Infertility and Reproductive Health Research Center, Babol University of Medical Sciences, Babol, I.R, Iran
3 Social Determination of Health Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, I.R, Iran
4 Cellular and Molecular Biology Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, I.R, Iran
5 Oral Health Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, I.R, Iran

Date of Submission25-May-2020
Date of Decision20-Jan-2021
Date of Acceptance10-Feb-2021
Date of Web Publication30-Jul-2021

Correspondence Address:
Dr. Maryam Ghasempour
Oral Health Research Center, Health Research Institute, Babol University of Medical Sciences, Babol
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JISPPD.JISPPD_247_20

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Background: Multiple factors can affect early childhood caries (ECC). Maternal stress and child's temperament, as predictors of child behavior, are among factors that may be associated with ECC. Objectives: The aim of this study was to evaluate the association between the salivary cortisol level of mothers as an indicator of maternal stress, child's temperament, and ECC. Methods: Ninety preschool children, who were divided into three groups of ECC, severe ECC (S-ECC), and caries-free (CF), were included in this study, as well as their mothers with no history of anxiety disorders. The salivary cortisol levels of mothers were analyzed using ELISA assay. Children were examined for the evidence of caries, using the decayed-missing-filled teeth index, based on the World Health Organization standard criteria. Child temperament was also assessed, using Cloninger's Preschool Temperament and Character Inventory, consisting of seven significant factors (cooperativeness, harm avoidance, novelty seeking, reward dependence, persistence, self-directing, and self-transcendence). Results: The association between the salivary cortisol level of mothers and temperament of children with S-ECC was positive although it was not statistically significant (P > 0.05). Of seven temperament factors, only harm avoidance was significantly different between the CF and S-ECC groups (P = 0.016). Conclusion: Maternal stress and child's temperament were not associated with ECC. Based on the present findings, children with less harm avoidance may be more prone to S-ECC.

Keywords: Early childhood caries, stress, temperament

How to cite this article:
Abedizadeh H, Faramarzi M, Khafri S, Qujeq Q, Ahangary M, Ghasempour M. The association between the salivary cortisol level of mothers, children's temperament, and early childhood caries. J Indian Soc Pedod Prev Dent 2021;39:196-201

How to cite this URL:
Abedizadeh H, Faramarzi M, Khafri S, Qujeq Q, Ahangary M, Ghasempour M. The association between the salivary cortisol level of mothers, children's temperament, and early childhood caries. J Indian Soc Pedod Prev Dent [serial online] 2021 [cited 2022 Aug 11];39:196-201. Available from: http://www.jisppd.com/text.asp?2021/39/2/196/322500

   Introduction Top

Early childhood caries (ECC) is a common problem among children. Although it is not a life-threatening condition, it might be associated with a poor health status and lack of social development.[1],[2] The American Academy of Pediatric Dentistry (AAPD) defines ECC as the presence of one or more decayed (noncavitated or cavitated lesions), missing (due to caries), or filled tooth surfaces in any primary teeth of a child aged 71 months or younger (<6 years). AAPD also states that any sign of smooth-surface caries in children younger than 3 years is indicative of severe ECC (S-ECC).[3]

Different factors may influence ECC, including the family's social status (e.g., parents' educational level, income, and number of children), oral and dental hygiene of the child (e.g., frequency of daily brushing and age of brushing onset), nutritional status of the child, and microbial flora of the mouth. The physiological characteristics of the mother and child are also influential in ECC.[4],[5],[6],[7] In general, mothers play the leading role in the formation, transmission, and protection of family assets, as well as children's social growth.[8] Recent studies have suggested that maternal factors, including maternal stress, may be significantly associated with ECC, besides environmental and child-related factors.[9] Maternal stress can affect mothers' behaviors and exert a negative impact on children. Evidence shows that some behaviors, such as behavioral instability, inappropriate social interactions, and lack of child monitoring, are caused by maternal stress.[10],[11] Some researchers attribute children's dental caries to factors, such as the mother's inadequacy in fulfilling her role and lack of proper child feeding.[9],[10],[11],[12]

In humans, the biochemical response to stress is triggered by the activation of the hypothalamic–pituitary–adrenal (HPA) axis. The HPA axis first activates the release of steroid hormones and glucocorticoids, including cortisol, which is the primary stress hormone in humans. The HPA axis then releases a set of neurotransmitters known as catecholamines, which include dopamine, norepinephrine, and epinephrine, or adrenaline.[13],[14],[15]

Salivary cortisol level is a reliable indicator of the HPA axis consistency under stress.[16] This indicator is used in dentistry research to assess the role of stress in different aspects of oral and dental hygiene.[17],[18]

One of the factors influencing dental caries is the personal characteristics of the child. Temperament is defined as the inherent idiosyncrasies of a person, including sensitivity to emotional stimuli and the intensity, speed, quality, and features of response.[19] It seems that temperament remains constant over time although it can change because of environmental factors.[20] Temperament can also have a neurophysiological basis and be inheritable to some extent.[21] In this regard, Spitz et al. studied 629 children aged 1–4 years and concluded that the child's temperament could be related to ECC in children.[22] Conversely, Pani et al. and Quiñonez et al. reported that there is no significant association between maternal stress and the incidence of ECC.[23],[24]


This study is aimed to evaluate the association of mothers' salivary cortisol level as an indicator of maternal stress and children's temperament with ECC and S-ECC.

   Methods Top

This case–control study, which was approved by the Ethics Committee of Babol University of Medical Sciences (MUBABOL.REC.1395.167), was performed on 90 children (51 girls and 39 boys) under the age of 6 years as well as their mothers in four preschools of Babol, Iran. Written permission was obtained from the Welfare Organization of Babol. The study objectives and processes were also explained to the mothers and preschool authorities, and their oral permission was obtained.

Based on the influence coefficient (0.5) reported in similar studies,[23],[25] the sample size was estimated at 30 per group at a confidence level of 0.95 and a power of 80%. Children with a chronic systemic disease influencing dental caries and those with long-term medication use or fluoride treatment were excluded from the study. The selected children were examined according to the World Health Organization criteria, using an ordinary mirror and natural light to determine the decayed, missing, and filled tooth (DMFT) index. They were also examined regarding the presence of dental caries and divided into three groups of ECC,[26],[27] S-ECC,[28] and caries-free (CF).

The data collection tool for the assessment of children's temperament was Cloninger's Pre-school Temperament and Character Inventory.[29] The validity and reliability of this questionnaire have been confirmed in Iranian preschool children.[30] In the present study, a 74-item questionnaire was used, which consists of seven factors, including cooperativeness, harm avoidance, novelty seeking, reward dependence, persistence, self-directing, and self-transcendence; this scale is rated on a Likert scale (completely disagree, disagree, indifferent, agree, and totally agree).[31]

Moreover, for the evaluation of maternal stress, salivary cortisol levels of mothers were measured. The exclusion criteria for the mothers were as follows: (1) infectious diseases; (2) autoimmune or hereditary disorders; and (3) psychiatric or endocrine disorders, such as diabetes. Mothers who were injured or exposed to a stressful life event on the sampling day were also excluded from the study. For the assessments, unstimulated salivary samples (2 mL) were taken from the mothers. The participant was asked to spit her saliva in a container every 60 s for 2–5 min.[32],[33] Sampling was performed at 9–10 AM, as blood and salivary cortisol is at the highest level during these hours of the day.[34]

Salivary samples were immediately transferred to the laboratory in containers, which were placed in a box containing ice bags; they were kept in a freezer at −20°C until the test day. The salivary samples were then transferred from the containers to test tubes, and after centrifugation, the supernatant was used for the tests. Samples were measured using ELISA assay and Diametra kit (Italy) in an ELISA reader device (RT-2100C model, Rayto Life and Analytical Sciences, Germany).

The collected data were entered into SPSS V.20 (IBM Corp. Released 2011. IBM SPSS Statistics for Windows, Armonk, NY: IBM Corp). Chi-square test was used for comparing quantitative variables. In addition, an ANOVA test was performed for evaluating quantitative variables, the correlation coefficient was measured for determining the association between two dominant variables, and multinomial logistic regression was used for modeling the variables. Data were entered the model used in multinomial logistic regression, and the odds ratio (95% confidence interval) was reported. P < 0.05 was considered statistically significant.

   Results Top

This case–control study was performed on 90 children under the age of 6 years and their mothers. The children were divided into three groups of ECC, S-ECC, and CF, based on the DMFT index. Overall, thirty children and their mothers were included in each group. The mean age of the children was not significantly different between the groups (P = 0.48). There was also no significant difference in terms of maternal occupation, educational level, gender, number of children, and order of birth between the three groups (P > 0.05).

According to [Table 1], a significant difference was found between the CF and S-ECC groups regarding harm avoidance (P = 0.016).
Table 1: Comparison of child's temperament parameters in the three groups

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Based on the results presented in [Table 2], the relationship between maternal salivary cortisol level and ECC in children was not significant (P = 0.17).
Table 2: Maternal salivary cortisol level in the three groups

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By modifying the caries effect, a weak reverse correlation was found between maternal stress and child's temperament, based on the partial correlation analysis (r = −0.11, P = 0.295).

   Discussion Top

Although several studies have been conducted on the role of maternal stress and child's temperament in ECC, no studies have yet examined the association and effect of these two factors on ECC. Therefore, we conducted this study to assess the association between maternal stress and child's temperament and to evaluate the effect of these two factors on ECC. In this study, which evaluated 90 salivary samples of mothers, the mean salivary cortisol level was higher in mothers of children with S-ECC in comparison with the other two groups; nevertheless, the difference was not statistically significant. Moreover, ECC had no significant association with maternal stress or child's temperament. Similarly, no significant association was observed between the child's temperament and maternal stress.

In studies by Jabbarifar et al. and Tang et al., parental stress did not have any significant effects on ECC, according to the Parenting Stress Index (PSI).[35],[36] Moreover, Quiñonez et al. suggested that there was no significant correlation between parental stress (according to PSI) and ECC or the number of decayed teeth.[24] On the other hand, Pani et al. reported that the maternal salivary cortisol level was significantly different between mothers of ECC children and mothers of children without ECC. However, according to the logistic regression model, maternal stress did not have any significant correlation with ECC. Accordingly, they suggested that maternal stress did not have any direct effects on ECC. It should be noted that these researchers used the electrochemiluminescence method for measuring the level of cortisol.[23] Although the present findings are similar to the mentioned study, regarding the higher level of salivary cortisol in mothers, it is worth mentioning that we used the ELISA method for measuring the cortisol level in this study.

Some assumptions can explain why the initial hypothesis of our study regarding the association between maternal stress and ECC was not approved. Dental caries is a multifactorial condition, which is affected by different factors, such as child's nutritional status, child's oral and dental hygiene, and family's socioeconomic status.[37],[38] The more prominent effects of these factors on ECC and their superiority over maternal stress might be influential in the rejection of our hypothesis regarding the association between maternal stress and ECC. In addition, the use of a more accurate method for measuring the salivary cortisol level in mothers and further longitudinal studies with a larger sample size can clarify the hidden aspects of the role of maternal stress in ECC.

In most studies on the association of child's temperament with ECC, significant differences were observed in some subgroups.[22],[25],[39],[40] In the current study, a significant difference was only observed in terms of harm avoidance between children without dental caries and children with S-ECC, while there was no significant difference regarding other factors. Kendrick et al. concluded that there was no significant difference in the temperament of children with nursing bottle caries and CF children, according to the toddler questionnaire.[41] Moreover, Quinonez et al. investigated the temperament of 18–70-month-old children, using the Emotionality Activity Sociability Temperament Survey and concluded that temperament alone could not predict the length of feeding as a risk factor for ECC.[42]

Furthermore, Zhao et al. reported that only two factors of activity level and rhythmicity were significantly effective in the temperament of 3-year-old children with and without ECC in urban areas, based on the New York Longitudinal Study questionnaire.[40] Furthermore, Spitz et al. concluded that the temperament of children is probably a significant risk factor for ECC.[22] Moreover, Grzesiak et al., using the Early Childhood Behavior Questionnaire (completed by mothers), concluded that children with S-ECC were significantly different from CF children regarding two factors of impulsivity and sadness.[39] Furthermore, Jabin and Chaudhary, based on the Malhotra's questionnaire, found that children with ECC were less sociable, less energetic, and less focused than CF children.[25] It should be noted that we used the Cloninger's questionnaire, which has been confirmed as a reliable and valid tool in Iran.[30]

Some factors should be considered to explain the lower score of harm avoidance in children with S-ECC. First, Cloninger's personality theory attributes this temperament feature to the dysfunction of the behavioral inhibition system; this system helps the person avoid behaviors, which result in punishment. In a person with a behavioral inhibition system disorder, punishment does not lead to the avoidance of inappropriate behaviors (silence); consequently, the possibility of repeating inappropriate and high-risk behaviors increases. It is assumed that dental hygiene is poor in children with low levels of harm avoidance, as they do not pay attention to the health recommendations of their parents and teachers.[43]

Second, children with low levels of harm avoidance are daring and show less self-care behaviors compared to children with high levels of harm avoidance; in other words, children with lower harm avoidance scores are less willing to maintain their physical health.[29] Third, Cloninger et al. assessed the temperament of 11-year-old children to assess an alcohol-addiction predictor model and found a significant relationship between a low harm avoidance score and alcohol addiction.[44] Moreover, Màsse and Tremblay reported a significant relationship between low harm avoidance scores during childhood and opium addiction in adulthood.[45] Finally, it is suggested to recruit a larger sample size and use a more accurate method for the evaluation of maternal stress. Furthermore, other questionnaires may be used to assess the children's temperament.

   Conclusion Top

No significant association was observed between maternal stress, children's temperament, and ECC. The results showed that children with low harm avoidance scores are more prone to S-ECC.


The authors would like to thank the Research Deputy of Babol University of Medical Sciences for their support.

Financial support and sponsorship

This study was financially supported by Babol University of Medical Sciences.

Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2]


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