The relationship between Tooth Decay with Stress and BMI among elementary students: A cross-sectional study in Iran

DOI: https://doi.org/10.21203/rs.3.rs-1507118/v1

Abstract

Background

Tooth decay is one of the most common chronic diseases among children worldwide. On the other hand, inappropriate Stress and BMI are risk factors that make children prone to diseases. Therefore, in this study, the relationship between tooth decay with Stress and BMI among children was examined.

Materials and Methods

This was a cross-sectional study of descriptive-analytical type. A total of 350 students referred to the clinic of the faculty of dentistry of Qazvin University of Medical Sciences in 1400 were selected through convenience sampling method to participate in the study. First, the students underwent a dental examination after measuring their height and weight. Then, two questionnaires of demographic information and Children's Stress Symptom Scale (CSSS) of Scherer and Ryan-Wenger were completed by the child's parents through self-reporting. The collected data were analyzed using SPSS software version 23 and using descriptive statistics and logistic regression.

Results

The BMI of the participating students was in the normal range. The prevalence of tooth decay among participating students was 76.9% (269 people). The mean and standard deviation of stress scores was 6.85 ± 4.01 out of 26, that was at a low level. Also, the mean and standard deviation of the BMI was 22.78 ± 5.28, that was in the normal range. The results of logistic regression showed that the variables of "father's level of education", "family economic status", "experience of toothache in the past year", "oral health status", "frequency of tooth brushing", "flossing", "stress", and "BMI" were effective factors in tooth decay (P < 0.05).

Conclusion

Students who had inappropriate BMI, more stress, father with low level of education, family with poor economic status, experience of toothache past year, poor oral health status, and those who used less toothbrushes and floss had more tooth decay. Therefore, it is necessary to pay more attention to these students in designing and implementing educational programs to prevent tooth decay.

Introduction

One of the most important branches of public health is oral health. It has a great impact on people's health and affects the quality of life and general condition of the body (1) and is one of the most important aspects of personal health, so it is necessary to assess the oral health status in a society (2).

Various indicators are used to assess oral health. The DMFT index (The Decayed, Missing, and Filled Teeth) is one of the best epidemiological indicators in dentistry to determine the prevalence and severity of decay and can indicate the oral health status of people in the community. To calculate the DMFT index of a community, the total number of decayed, filled, and missing teeth in each community is counted and the average is calculated. If the condition of deciduous teeth is checked, it is displayed as a dmft index and the calculation method is similar to DMFT (3). In fact, DMFT is a simple, fast, and reliable index in determining oral health (4). One of the goals of the World Health Organization (WHO) has been to reduce the DMFT index in students to less than 3 by 2000 and to less than 2 by 2010 (5). Despite the relative improvement in the oral health status in the world, the resulting problems remain in effect in both developed and developing countries (6). For example, in a study conducted in Iran (2017), the prevalence of decay of deciduous and permanent teeth and whole teeth among 7–12 years old students was 75.2, 41.1, and 89.8%, respectively, and their mean DMFT + dmft was 4.44 (7). Therefore, in general, it can be said that during the last 35 years, the DMFT index in Iran has been increasing (8). The results of the study by Ditmyer et al. also showed that the prevalence of tooth decay among adolescents in the Nevada USA was 65% at younger ages and 77% at older ages (9). Statistics emphasize that tooth decay is the most common chronic disease among children worldwide, which, if left untreated, can lead to tooth tissue loss, microbial penetration into the pulp, pain, and eventually tooth loss (10).

Due to the importance of the role of teeth in various functions such as chewing, speech, facial growth and development and beauty of the appearance, therefore, gum disease, tooth loss and decay should be prevented (11). Tooth decay is a multiphase disease whose main causes are: destructive bacteria, destructive carbohydrates, sensitive teeth, and time. The onset and progression of the disease are strongly influenced by the consumption of carbohydrates in the diet. Epidemiological studies have also shown that behavioral, social, economic, and clinical factors are associated with the prevalence of tooth decay in children (12). Age, socioeconomic factors, poor brushing habits, consumption of harmful beverages, and inappropriate BMI were identified above all important factors involved in tooth decay (1315). The BMI has been suggested as one of the related factors in tooth erosion (16).

Child obesity seems to have many negative effects on their oral health (17). The prevalence of childhood overweight and obesity has increased since the 1980s (18). Inappropriate eating habits have been suggested as a potential risk factor for tooth decay and obesity (19). Nevertheless, the number of tooth decay is related to the number of meals, the amount of dinner, dinner time, dinner time order, etc. in people with permanent and deciduous teeth (20). Eventually, tooth decay can lead to eating disorders as well as impact on eating habits (21). Some studies, including the study of Willershausen et al., showed a direct link between obesity and tooth decay, so that higher BMIs increased the risk of tooth decay in German children (22). However, some studies such as narksawat et al. showed an inverse relationship between these two indexes (23) and some other such as Sadeghi et al. and Kopycka et al. showed a lack of correlation (24, 25). Of course, a systematic review-meta-analysis by Hayden et al. showed that, in general, there was a significant relationship between childhood obesity and tooth decay (26).

Stress has been suggested as one of the factors affecting students' weight and oral health (27). Stress is defined as a physiological response to biological stressors such as trauma, surgery, and infection, and psychological stressors such as anxiety, fear, and social tensions resulting from a new job or increased family responsibilities (28). If stress is high, it causes feelings of anger, fear, failure, and is destructive (29). According to physicians' estimates, stress is the cause of 75% of medical complaints (30). Recent research has shown an increase in psychological problems such as stress among school-age children, which can be attributed to widespread life changes in developing societies such as changing friends and changing schools following multiple relocations, reduced family members, and so on (31). Today, stress is considered to be one of the major causes of many diseases (30).

Noradrenaline and corticotropin-releasing hormone reduce appetite in times of stress; while cortisol is known as an appetite stimulant during stress relief (32). In fact, extensive and complex internal and external factors affect appetite and, consequently, the amount and type of food consumed by humans. Stress is thought to affect human eating habits (33). In this regard, the study of Mejía-Rubalcava showed that students with moderate or high stress were at higher risk for tooth decay than students with low stress (34). However, in the study of Panagiotou et al., no relationship was found between tooth decay and stress in children (35).

Understanding and controlling risk factors are very important in preventing tooth decay and stopping or slowing their progression (36). The prevalence of overweight and obesity in childhood is also increasing (37). The experience of stress plays an important role in increasing future physical, psychological and social problems in children. It is therefore vital that families, teachers, and professional groups such as nurses recognize the stress in children (31). Also, studies on the relationship between tooth decay with stress and obesity have inconsistent and different results. Therefore, this study aimed to determine the relationship between tooth decay with Stress and BMI in children.

Methods

This was a cross-sectional study of descriptive-analytical type, which was conducted among 350 students referred to the clinic of the faculty of dentistry of Qazvin University of Medical Sciences in 1400.

In this study, samples were selected through convenience sampling method. So that 350 children referred to the clinic of the faculty of dentistry of Qazvin University of Medical Sciences, were selected and entered into the study after taking into account the inclusion criteria, obtaining informed consent, and providing full explanations about the study process. According to the results of the pilot study among 30 students (considering r = 0.15 for the correlation between BMI and tooth decay) and also using the sample size table for correlation researches, the minimum sample size required was estimated 175 people (38). Then, with Design Effect = 1.9, the sample size was calculated to be 332 people. Finally, considering the probability of 10% drop in the samples, 365 people were included in the study.

The inclusion criteria were: studying in the primary school in Qazvin, referring to the clinic of the faculty of dentistry of Qazvin University of Medical Sciences, the age range of 6–12 years, understanding Persian language, and willingness to participate in the study. Also, lack of cooperation during the study, having a mental disorder, and incompletely answering to the questionnaire were considered as exclusion criteria.

A two-part questionnaire was used to collect data:

A) Demographic questionnaire including some questions about age, educational level, educational status, mother's education level, mother's job, father's education level, father's job, family economic status, breastfeeding in infancy, regular weekly exercise, regular walking, experience of toothache in the past year, oral health status, frequent use of toothbrushes per day, and flossing per day.

In addition, the weight of students was measured and recorded using Seca brand scales, without shoes, with the least clothing, and with an accuracy of 0.1 kg. Their height was measured and recorded using a non-elastic tape measure mounted on the wall, with an accuracy of 0.5 cm, without shoes, in a position that the students stuck their heels to the wall and their eyes were facing. Then BMI index was calculated by dividing students' weight in kg by height squared in meters. It should be noted that according to the recommendation of the WHO, BMI less than 18.5 was considered as low weight, BMI between 18.5 to 24.9 as normal, a BMI between 25 to 29.9 as overweight, and a BMI equal and above 30 as obese (39, 40). In order to calculate DMFT, filled, decayed, and missing teeth were counted and recorded.

B) To assess children's stress, the 24-part self-report questionnaire, the CSSS made by Scherer and Ryan-Wenger (2002) was used. This questionnaire examines stress-related experiences among children aged 7–12 years old with eleven symptoms related to emotional-cognitive symptoms and thirteen symptoms related to physical symptoms. So that the score "One" is considered for the existence of the sign and the score "zero" for the absence of the sign. The two options of "nausea and vomiting" and "grieving" were added after reviewing other studies, that in total 26 items were questioned. Stress scores ranged from zero to 26 and the presence of stress was reported at three levels: low, medium, and high (41). The reliability of the CSSS was evaluated and confirmed in a study by Skybo and Buck (2007) with a Cronbach's alpha coefficient of 0.88 (42). The questionnaire used by Valizadeh et al. was also translated into Persian and the validity of the translation and the validity of the content were examined. The reliability of this tool was also confirmed in this study with a Cronbach's alpha coefficient of 0.76 (43). In the present study, Cronbach's alpha coefficient for this questionnaire was calculated to be 0.84.

Regarding ethical considerations in this research, first the research project number was received from the Vice Chancellor for Research and Technology of Qazvin University of Medical Sciences (with ethics code IR.QUMS.REC.1396.486). Then the necessary coordination was done with the clinic of the faculty of dentistry of Qazvin University of Medical Sciences. The purpose of this study was also explained to the parents of children and their consent was obtained in writing. Answering the questionnaires was self-report in which all parents were asked to answer the questions with complete honesty. They were also assured that all the information requested in the questionnaire would be used confidentially without mentioning the names of the individuals. It should be noted that the questionnaire of demographic information and the CSSS was completed by the child's parents.

After collection, the data were entered into SPSS software version 23 and analyzed using descriptive statistics and logistic regression. It should be noted that entering variables was performed simultaneously through the method of Generalized Linear Models (GLM) with Binary logistic regression response and the last class of variables was selected as the reference class. In this study, tooth decay as a dependent variable and variables of age, educational level, child's educational status, parents' education level, parents' job, family economic status, frequency of tooth brushing, flossing, oral health status, breastfeeding in infancy, regular weekly exercise, regular walking, experience of toothache in the past year, BMI, and stress were entered to the model as independent variables. In addition, the level of significance in this study was less than 0.05.

Results

After completing the questionnaires, the final analysis was performed on the data obtained from 350 questionnaires (response rate: 95.9%). Of these, 42% (147) of students reported their father's education at the diploma level, and 76% (266) were in the first to third grades. Only 6.6% (23 people) reported excellent oral health status. Table 1 shows the other demographic (qualitative) characteristics of the students studied. The results also showed that the prevalence of tooth decay among participating students was 76.9% (269 people). 

 
Table 1

Frequency distribution of students in terms of demographic variables

Variable

Category

Frequency

Percentage

Father's level of education

Under Diploma

136

38.9

Diploma

147

42

Associate Degree

38

10.9

Bachelor's degree and higher

29

8.2

Grade

First to third

266

76

Fourth to sixth

84

24

Oral health status

Excellent

23

6.6

Good

112

32

Medium

203

58

Weak

12

3.4

Flossing

Yes

283

80.9

No

67

19.1

Frequency of tooth brushing

Twice a day or more

45

12.9

Less than twice a day

207

59.1

Sometimes

98

28

The child's educational status

Excellent

238

68

Good

87

24.9

Medium

25

7.1

Mother's job

Housekeeper

304

86.9

Employed

46

13.1

Mother's level of education

Under Diploma

112

32

Diploma

164

46.9

Associate Degree

28

8

Bachelor's degree and higher

46

13.1

Family economic status

Excellent

26

7.4

Good

115

32.9

Medium

186

53.1

Weak

23

6.6

Breastfeeding in infancy

Yes

320

91.4

No

30

8.6

Regular weekly exercise

Yes

180

51.4

No

170

48.6

Regular walking

Yes

152

43.4

No

198

56.6

Experience of toothache in the past year

Yes

274

78.3

No

76

21.7

Mother's job

Employed

274

78.3

Unemployed

39

11.1

Retired

37

10.6

Gender

Girl

187

53.4

Boy

163

46.6

(Table 1)

Table 2 shows the mean and standard deviation of other variables among the students studied. The results showed that the mean and standard deviation of stress scores among participants was 6.85 ± 4.01 which was at a low level. Also, the mean and standard deviation of BMI among all participants was 22.78 ± 5.28, so that 17.7% (62 people) were lean, 48.3% (169 people) normal, 24.3% (85 people) had overweight, and 9.7% (34 people) were obese. 

 
Table 2

Mean and standard deviation of other variables among the studied students

Variable

Minimum

Maximum

Mean

SD

Child age

6.00

12.00

8.50

1.23

Stress

0.00

22.00

6.85

4.01

BMI

9.01

27.05

16.59

3.12

(Table 2)

Table 3 shows the results of logistic regression to determine the factors affecting tooth decay among students. As the results show, the variables of father's level of education, family economic status, experience of toothache in the past year, oral health status, frequency of tooth brushing, flossing, stress, and BMI were effective factors in tooth decay (P < 0.05): 

 
Table 3

Factors affecting tooth decay among students in the test of GLM with Binary logistic regression response

Parameter Estimates

   

Variable

Category

OR (95% CI)

Sig.

Mother's level of education

Under Diploma

0.392 (0.057–2.621)

0.632

Diploma

0.932 (0.513–1.699)

0.146

Associate Degree

1.113 (0.135–9.018)

0.131

Bachelor's degree and higher

   

Mother's job

Housekeeper

1.097 (0.011–0.179)

0.161

Employed

   

Father's level of education

Under Diploma

2.409 (0.712–6.017)

0.011

Diploma

1.129 (1.031–1.906)

0.003

Associate Degree

0.757 (0.671–0.950)

0.348

Bachelor's degree and higher

   

Father's job

Employed

0.618 (0.310–1.224)

0.983

Unemployed

0.284 (0.079–1.182)

0.073

Retired

   

Family economic status

Excellent

0.378 (0.078–1.806)

0.015

Good

0.469 (0.416–1.611)

0.042

Medium

1.104 (0.699–1.981)

0.466

Weak

   

Child's educational status

Excellent

0.334 (0.211–1.340)

0.101

Good

0.461 (0.127–1.747)

0.166

Medium

   

Grade

First to third

1.042 (0.848–1.350)

0.266

Fourth to sixth

   

Breastfeeding in infancy

Yes

0.583 (0.207–1.648)

0.965

No

   

Regular weekly exercise

Yes

1.527 (0.744–2.065)

0.319

No

   

Regular walking

Yes

0.332 (0.202–1.331)

0.474

No

   

Experience of toothache in the past year

Yes

1.457 (0.702–1.276)

0.018

No

   

Oral health status

Excellent

0.283 (0.068–1.171)

0.010

Good

0.318 (0.105–0.976)

0.019

Medium

0.617 (0.553–1.722)

0.335

Weak

   

Frequency of tooth brushing

Twice a day or more

0.327 (0.084–1.266)

0.036

Less than twice a day

0.555 (0.455–1.135)

0.041

Sometimes

   

Flossing

Yes

0.551 (0.399–1.397)

0.025

No

   

Gender

Girl

0.541 (0.391–1.378)

0.254

Boy

   

Child's age

0.553 (0.408–1.407)

0.132

BMI

1.211 (0.966–1.349)

0.035

Stress

1.104 (0.703–1.981)

0.048

(Intercept)

-207.253

0.373


- "Father's level of education" was one of the factors affecting tooth decay, so that the probability of tooth decay in children whose fathers had under diploma and diploma degree was 2.409 and 1.129 times compared to those whose fathers had a bachelor's degree and higher, respectively.

- "Family economic status" was one of the factors affecting tooth decay, so that the probability of tooth decay in children whose family economic status was excellent and good was 0.378 and 0.469 times compared to those whose family economic status was poor, respectively.

- The variable of "experience of toothache past year" was one of the factors affecting tooth decay, so that the probability of tooth decay in children who had experienced toothache past year was 1.458 times compared to those without experiencing toothache past year.

- "Oral health status" was one of the factors affecting tooth decay, so that the probability of tooth decay in children with excellent and good oral health status was 0.283 and 0.318 times compared to those with poor oral health status, respectively.

- 'Frequent use of toothbrush" was one of the factors affecting tooth decay, so that the probability of tooth decay in children whose daily brushing was "twice or more" or "less than twice a day" was 0.327 and 0.555 times compared to those who occasionally used toothbrushes, respectively.

- "Flossing" was one of the factors affecting tooth decay, so that the probability of tooth decay in children who used flossing was 0.551 times compared to those who did not floss.

- The variables of "Stress" and "BMI" were other factors affecting tooth decay, so that by increasing the score of these variables by one unit, the probability of students' tooth decay increased by 1.211 and 1.104 times, respectively. In addition, other demographic variables had no effect on tooth decay (P > 0.05).

(Table 3)

Discussion

This study aimed to determine the relationship between tooth decay with stress and BMI in elementary school students. Based on the results of logistic regression, the following variables were effective factors in tooth decay: father's level of education, family economic status, experience of toothache in the past year, oral health status, frequency of tooth brushing, flossing, stress, and BMI.

The results of the present study showed that the prevalence of tooth decay among the participating students was 76.9%, which was at a high level. One of the possible reasons for this high prevalence can be the sampling at the clinic level because people usually go to medical centers who have dental problems. Therefore, the prevalence of tooth decay among these people is higher than the samples available in school. The results of this section were consistent with the results of studies by Basir et al. (36), Hamissi et al. (44), Panahi et al. (45), Nabipour et al. (46), and Namal et al. (47), that this rate in these studies have been reported 75.6%, 75.5%, 75.2%, 71.8%, and 76.8%, respectively. Also, the prevalence of tooth decay in the studies of Alghamdi et al. (48), Jain et al. (49), Kalantari et al. (50), Nematollahi et al. (51), Dawkins et al. (52), and Singh et al. (53) were estimated 48.4%, 63.6%, 83.9%, 49.7% and 40%, respectively, which were not consistent with the results of the current study. Possible reasons for this discrepancy include the following: the age of the children studied in these studies was different from the present study, differences in oral health status and dental care between cultures, cities, villages, and countries around the world.

The results of the present study showed that "stress" was at a low level among the participating students. One of the possible reasons for the low level stress in the present study could be the completion of the stress questionnaire by parents, because sometimes the internal states of children's stress may be ignored by parents. In line with the present study, a study by Talbot et al. reported the prevalence of stress at a low level (54). The results of the studies of Tanganelli et al. (55) and Calais et al. (56) were not in line with the results of this part of the present study. Possible reasons for this discrepancy may be due to differences in factors such as the age of children and stress assessment tools in these studies compared to the present study.

The results of the present study indicated that the mean BMI among the participating students was in the normal range. In this regard, it can be said that the majority of participating students probably had healthy eating habits and tried to do sports such as walking or exercise even during a coronavirus pandemic. The approach of parents and their educators in the field of proper nutrition can also be effective in this regard. This results were consistent with the results of studies by Panahi et al. (40), Zare-Zardiny et al. (57), Wei et al. (58), Liang et al. (59), Mohammadi et al. (60), and Jang et al. (61). In terms of BMI in all the above studies, the majority of people were in the normal range.

The results of the present study revealed that the "father's level of education" was one of the factors affecting tooth decay. This part of the results was consistent with the results of studies by Chu et al. (62), Panahi et al. (45), Nematollahi et al. (51), KAZEROUNI et al. (63), Namal et al. (47), Mohebi et al. (64), and Kalantari et al. (50). The results of the present study also indicated that the family economic status was one of the factors affecting tooth decay. The results of the studies of Alghamdi et al. (48), Chu et al. (62), Goodarzi et al. (76), Jamelli et al. (65), and Prashanth et al. (66) were in line with these results. In justifying the possible reasons for these two results, it can be pointed out that as the father's level of education increases, his level of awareness increases. Also, with the increase in the father's level of education, the family economic status will probably improve and the rate of visits to the dentist for examination increases. Finally, the combination of three factors of higher awareness, better economic status, and more visits to the dentist, will improve the oral health status of children.

The results of the present study showed that the experience of "toothache past year" was one of the factors affecting tooth decay. This result may indicate that factors such as adopting oral health behaviors and properly educating them to children, taking seriously the initial pain reported by children and timely action by parents can reduce the rate of primary decay. In this regard, the studies of Faezi et al. (67), Ferraz et al. (68), and Adeniyi et al. (69) also reported similar results to those of the present study. Also in line with the present study, in the study of Prasai Dixit et al., It was pointed out that toothache among children aged 8 to 12 years had a direct effect on the rate of tooth decay (70).

Based on the results of the present study "oral health status" was one of the factors affecting tooth decay. Mohiuddin et al. (71), Schwendicke et al. (72), and Akinyamoju et al. (73) reported similar results on the relationship between oral health and tooth decay. They stated that poor oral health status in children and adolescents, along with factors such as irregular dental examinations and less awareness of the principles of oral health, can affect the rate of tooth decay. However, contrary to the results of the present study in the study of Panagiotou et al. (35), no relationship was observed between oral health and tooth decay in children. One of the possible reasons for this discrepancy could be the difference between the two studies in terms of the sample population, because the above study was conducted among adolescents in addition to children.

According to the results of the present study, the frequency of tooth brushing and flossing were other factors affecting tooth decay. In this regard, it can be said that these two results were largely expected, indicating the vital and important role of oral health behaviors in promoting dental health. This part of the results was consistent with the results of studies by Guadagni et al. (74), Taani et al. (75), Faezi et al. (67), Goodarzi et al. (76), and Prasai Dixit et al. (70).

As the results of the present study revealed, stress was one of the factors affecting tooth decay. Similarly, in the study by Cynthia et al., students with moderate and high levels of stress were at greater risk for tooth decay than those with low levels of stress (34). The results of the studies of Masoudi et al. (77), Kisely et al. (78), Delgado et al. (79), Jain et al. (80), and Honkala et al. (81) were in line with these results. Contrary to the results of the current study, in the studies of Hubbard and Workman (82) and Panagiotou et al. (35), no relationship was observed between stress and tooth decay in children. In justifying this discrepancy, we can point to possible differences in the rate of tooth decay and stress, as well as differences in stress measuring tools and indexes used in these two studies compared to the present study. Also, differences in the family economic status, students' ages, cultures and educational systems of different regions, and different approaches of parents and educators regarding stress and oral health of students could also be effective in this regard.

The results of the present study showed that BMI was one of the factors affecting tooth decay, so that students with higher BMI had more decayed teeth. In this regard, it can be said that these children probably had unhealthy eating habits than others, so the risk of tooth decay was higher among them. Similar to these results, in the studies of Amiri et al. (83), Bafti et al. (84), Yan-Fang Ren et al. (85), Thomas Modéer et al. (86), Kor et al. (87), Wei et al. (58) also, more tooth decay was observed among children with higher BMI.

In contrast, studies by Mohammadi et al. (60), Liang et al. (59), and Jang et al. (61) reported an inverse relationship between BMI and tooth decay. They stated that obese children with higher BMI had less tooth decay and those with lower BMI showed more signs of decay. The reason could be the reduction in the intake of essential minerals such as calcium, that could be due to poor economic status and nutritional problems of children. However, Wu et al. (88) and Dikshit et al. (89) in their studies did not report any relationship between BMI and tooth decay. In general, all the studies mentioned in this paragraph were inconsistent with the results of the present study. In justifying this discrepancy, the possible differences in the rate of tooth decay and the prevalence of different categories of BMI in these studies compared to the present study can be considered. Also, differences in the family economic status, students' ages, cultures and educational systems of different regions, and different approaches of parents and educators regarding stress and oral health of students could also be effective in this regard.

It seems that the present study is the first study that simultaneously has measured the effect of two variables of body mass index and stress on tooth decay. It is suggested that the results of this study be used in designing interventions to prevent tooth decay among students. In addition, the target group in this study were students referred to the pediatric dental clinic of the faculty of dentistry of Qazvin University of Medical Sciences. Therefore, the results of this study cannot be generalized to other groups of students. Therefore, it is recommended that this study be conducted among students in other cities as well as among different groups of students (in terms of education, gender, age, and place of residence). One of the important limitations of this study was that due to the covid-19 pandemic and school closures, sampling was done through convenience sampling method at the pediatric dentistry clinic. In addition, the relatively small number of samples and self-reported data collection were other limitations of this study.

Conclusion

Students who had higher BMI, stress, father with lower education, family with poor economic status, experience of toothache in the past year, poor oral health status, and those who used less toothbrush and floss, had more tooth decay. Therefore, it is necessary to pay more attention to these students in designing and implementing educational programs to prevent tooth decay. In addition, by preparing and formulating programs to promote a healthy diet and exercise, identify children with stress symptoms and control it by school counselors, effective actions can be taken to reduce dentistry costs and promote children's oral health.

Declarations

Acknowledgments 

This study has been carried out with the support of the Vice Chancellor for Research and Technology of Qazvin University of Medical Sciences (with approved code: 14003796). Dear officials of the pediatric clinic of the faculty of dentistry of Qazvin University of Medical Sciences, staff and professors of the pediatric clinic of the faculty of dentistry of Qazvin University of Medical Sciences, and all those who helped us in this study are sincerely thanked and appreciated.

Authors’ contributions

This study substantial contributions to the conception design of the work F.H. and L.D. , R.P. , the acquisition, analysis and interpretation of data R.P. and the creation of new software used in the work, F.H. , E.KH. , B.RO. , and LD; have drafted the work or substantively revised it L.D. and R.P. , F.H. 

All authors have read and approved the manuscript.

Availability of data and materials

The data that support the results of this study are available by [Leila Dehghankar] but there are restrictions on the availability of this data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of [Leila Dehghankar].

Funding:

No funding

Ethics approval and consent to participate

Regarding ethical considerations in this research, first the research project number was received from the Vice Chancellor for Research and Technology of Qazvin University of Medical Sciences (with ethics code IR.QUMS.REC.1396.486). Then the necessary coordination was done with the clinic of the faculty of dentistry of Qazvin University of Medical Sciences. The purpose of this study was also explained to the parents of children and their consent was obtained in writing.

Consent for publication

Not applicable.

Competing of interest:

There was no conflict of interest.

Author details

1Student Research Committee, School of Nursing & Midwifery, Qazvin University of Medical Sciences, Qazvin, Iran. P.h.D, Department of Health Education & Promotion, School of Medical Sciences, Tarbiat modares University, Tehran, Iran.  3Assistant Professor of Restorative Dentistry, Department of Restorative Dentistry, School of Dentistry, Qazvin University of Medical Sciences, Qazvin, Iran. 4Student of dentistry, student Research Committee, Qazvin University of Medical Sciences, Qazvin, Iran. MSc, Department of Nursing, Dental Caries Prevention Research Center, Faculty of Nursing and Midwifery, Qazvin University of Medical Sciences, Qazvin, Iran.

References

  1. Goodarzi.A, Hidarnia.A, Tavafian.SS, Eslami.M. The Survey of Oral-Dental Health of Elementary School Students of Tehran City and its Related Factors %J Military Caring Sciences. 2018;5(2):137–45.
  2. Elger W, Kiess W, Korner A, Schrock A, Vogel M, Hirsch C. Influence of overweight/obesity, socioeconomic status, and oral hygiene on caries in primary dentition. Journal of investigative and clinical dentistry. 2019;10(2):e12394.
  3. Nokhostin MR, Siahkamari A, Akbarzadeh Bagheban A. Evaluation of oral and dental health of 6–12 year-old students in Kermanshah city %J Iranian South Medical Journal. 2013;16(3):241–9.
  4. Sajadi F. Caries Free Prevalence among 6, 12 & 15- Year Old School Children in Kerman during 2000-20052015.
  5. Mason J. Concepts in dental public health.: Philadelphia: Lippincott Williams and Wilkins;; 2005.
  6. Hatami H, Razavi SM, Eftekhar AH. Ministry SMJ of Health and Medical Education (IR-Iran). Tehran: Derakhshan Publication; 2004.
  7. USOFI MA, BEHROOZPOUR K, KAZEMI SA, AFROUGHI S. Evaluation of dental caries status in 7–12 years old students in Bovair Ahmad township, Iran, 2014. 2017.
  8. Pakshir HR. Oral health in Iran. International dental journal. 2004;54(6 Suppl 1):367–72.
  9. Ditmyer M, Dounis G, Mobley C, Schwarz E. Inequalities of caries experience in Nevada youth expressed by DMFT index vs. Significant Caries Index (SiC) over time. BMC oral health. 2011;11(1):1–10.
  10. N R Nair P. Pathobiology of apical periodontitis. In: Cohen S, Buens RC, editors.: Pathways of the pulp; 2008.
  11. Afshar H, Ershadi A, Ershadi MJJoDoTUoMS. An investigation on the correlation between DMFT and OHI-S indices on 12-year-old school girls in Kashan. 2004:38–42.
  12. Banihashem-Rad SA, Movahed T, Partovi S, Sharifi M, Banihashem-Rad SAA. Prevalence of Dental Caries Experience among 8 to 11-Year-Old Students in Primary Schools of Mashhad J Journal of Mashhad Medical Council. 2015;19(1):11–4.
  13. Tschammler C, Simon A, Brockmann K, Robl M, Wiegand A. Erosive tooth wear and caries experience in children and adolescents with obesity. Journal of dentistry. 2019;83:77–86.
  14. Qadri G, Alkilzy M, Feng YS, Splieth C. Overweight and dental caries: the association among German children. J International journal of paediatric dentistry. 2015;25(3):174–82.
  15. Jordan RA, Bodechtel C, Hertrampf K, Hoffmann T, Kocher T, Nitschke I, et al. The Fifth German Oral Health Study (Funfte Deutsche Mundgesundheitsstudie, DMS V) - rationale, design, and methods. BMC oral health. 2014;14:161.
  16. Salas MMS, Vargas-Ferreira F, Ardenghi TM, Peres KG, Huysmans MD, Demarco FF. Prevalence and Associated Factors of Tooth Erosion in 8 -12-Year-Old Brazilian Schoolchildren. The Journal of clinical pediatric dentistry. 2017;41(5):343–50.
  17. Paisi M, Kay E, Kaimi I, Witton R, Nelder R, Potterton R, et al. Obesity and caries in four-to-six year old English children: a cross-sectional study. 2018;18(1):267.
  18. Brady TM. Obesity-Related Hypertension in Children. Frontiers in pediatrics. 2017;5:197.
  19. Li LW, Wong HM, Gandhi A, McGrath CP. Caries-related risk factors of obesity among 18-year-old adolescents in Hong Kong: a cross-sectional study nested in a cohort study. BMC oral health. 2018;18(1):188.
  20. Zamsad M, Banik S, Ghosh L, Research MSC, Reviews. Prevalence of overweight, obesity and abdominal obesity in Bangladeshi university students: A cross-sectional study. J Diabetes. 2019;13(1):480–3.
  21. Marthaler T, Steiner M, Menghini G, Bandi A. Caries prevalence in Switzerland. J International dental journal. 1994;44(4 Suppl 1):393–401.
  22. Willershausen B, Haas G, Krummenauer F, Hohenfellner K. Relationship between high weight and caries frequency in German elementary school children. European journal of medical research. 2004;9:400–4.
  23. Narksawat K, Tonmukayakul U, Boonthum A. Association between nutritional status and dental caries in permanent dentition among primary schoolchildren aged 12–14 years, Thailand. Southeast Asian journal of tropical medicine and public health. 2009;40(2):338–44.
  24. Sadeghi M, Alizadeh F. Association between dental caries and body mass index-for-age among 6-11-year-old children in Isfahan in 2007. Journal of dental research, dental clinics, dental prospects. 2007;1(3):119.
  25. Kopycka-Kedzierawski D, Auinger P, Billings R, Weitzman M. Caries status and overweight in 2‐to 18‐year‐old US children: findings from national surveys. Community dentistry and oral epidemiology. 2008;36(2):157–67.
  26. Hayden C, Bowler JO, Chambers S, Freeman R, Humphris G, Richards D, et al. Obesity and dental caries in children: a systematic review and meta-analysis. Community dentistry and oral epidemiology. 2013;41(4):289–308.
  27. Takeda E, Terao J, Nakaya Y, Miyamoto K, Baba Y, Chuman H, et al. Stress control and human nutrition. J Med Invest. 2004;51(3–4):139–45.
  28. J HC. Fundamental of nursing: human health and function. Philadelphia: Lippincott Co 2000.
  29. A A, N G. The role of depression, anxiety and stress in predicting positive and negative attitudes toward delinquency in male students. Journal of school psychology.2018;7(2):278 – 90.
  30. Kaviani H, Pournaseh M, Sayad Lou S, Mohammadi M. Efficacy of Stress Management Training In Decreasing Depression and Anxiety in Students Applying for The Entry Exam of Iranian University %J Advances in Cognitive Science. 2007;9(2):61 – 8.
  31. Noury R, Kelishadi R, Ziaoddini H. Study of Common Stresses among Students in Tehran. Journal of isfahan medical school. 2010;28(105).
  32. Takeda E, Terao J, Nakaya Y, Miyamoto K-i, Baba Y, Chuman H, et al. Stress control and human nutrition. 2004;51(3, 4):139 – 45.
  33. Ghasedi Qazvini S, Kiani Q. The Relationship Between Body Mass Index, Perceived Stress and Health-Related Quality of Life Among Male and Female Adolescents %J Iranian Journal of Nutrition Sciences & Food Technology. 2018;13(1):31 – 9.
  34. Mejía-Rubalcava C, Alanís-Tavira J, Argueta-Figueroa L, Legorreta-Reyna A. Academic stress as a risk factor for dental caries. International Dental Journal. 2012;62(3):127 – 31.
  35. Panagiotou E, Agouropoulos A, Vadiakas G, Pervanidou P, Chouliaras G, Kanaka-Gantenbein C. Oral health of overweight and obese children and adolescents: a comparative study with a multivariate analysis of risk indicators. Eur Arch Paediatr Dent. 2021;22(5):861-8.
  36. Basir L, Khanehmasjedi M, Araban M, Khanehmasjedi S. Caries risk factors in students in Ahvaz, Iran. Payesh (Health Monitor). 2020;19(3):311-8.
  37. Puska P, Nishida C, Porter D, Organization WH. Obesity and overweight. World Health Organization. 2003:1–2.
  38. Shari Rad Gh BMM, Shamsi, Rezaian M. Research in Health Education, First Edition. Sobhan Works Publications. 2009 178 – 80.
  39. Lobstein T, Baur L, Uauy R. Obesity in children and young people: a crisis in public health. Obes Rev. 2004;5 Suppl 1:4-104.
  40. Panahi R. The Survey of association between health literacy and BMI among adolescents.Journal of Health Literacy. 2017;2(1):22–30.
  41. Sharrer VW, Ryan-Wenger NM. A longitudinal study of age and gender differences of stressors and coping strategies in school-aged children. J Pediatr Health Care.1995;9(3):123 – 30.
  42. Skybo T, Buck J. Stress and coping responses to proficiency testing in school-age children. Pediatric nursing. 2007;33(5):410.
  43. Valizadeh L, Farnam A, Farshi MR. Investigation of stress symptoms among primary school children. Journal of Caring Sciences. 2012;1(1):25.
  44. Hamissi J, Ramezani G, Ghodousi A. Prevalence of dental caries among high school attendees in Qazvin, Iran. Journal of Indian society of pedodontics and preventive dentistry. 2008;26(6):53.
  45. Panahi R, Aziz Zadeh A, Javanmardi E, Soleymanzadeh R, Moradi M, Zarei Varo O.Prevalence of early childhood dental caries and some related factors among 3–6 year-old children in Marivan-2016. Journal of Health in the Field. 2019;7(1):18–25.
  46. Nabipour AR, Azvar K, Zolala F, Ahmadinia H, Soltani Z. The Prevalence of Early Dental Caries and Its Contributing Factors among 3-6-Year-Old Children in Varamin,Iran. Health and Development Journal. 2013;2(1):12–21.
  47. Namal N, Yuceokur A, Can G. Significant caries index values and related factors in 5-6-year-old children in Istanbul, Turkey. EMHJ-Eastern Mediterranean Health Journal,15 (1), 178–184, 2009. 2009.
  48. Alghamdi AA, Almahdy A. Association between dental caries and body mass index in schoolchildren aged between 14 and 16 years in Riyadh, Saudi Arabia. Journal of clinical medicine research. 2017;9(12):981.
  49. Jain M, Singh A, Sharma A. Relationship of perceived stress and dental caries among pre university students in Bangalore City. Journal of Clinical and Diagnostic Research: JCDR. 2014;8(11):ZC131.
  50. Kalantari B, Rahmannia J, Hatami H, Karkhaneh S, Farsar A, Sharifpoor A, et al.The prevalence of dental caries in primary molars and its related factors in 6 and 7 years old children in Shemiranat health center. 2014.
  51. Nematollahi H, Mehrabkhani M, Esmaily H-O. Dental caries experience and its relationship to socio-economic factors in 2–6 year old kindergarten children in Birjand–Iran in 2007. Journal of Mashhad Dental School. 2008;32(4):325 – 32.
  52. Dawkins E, Michimi A, Ellis-Griffith G, Peterson T, Carter D, English G. Dental caries among children visiting a mobile dental clinic in South Central Kentucky: a pooled cross-sectional study. BMC oral health. 2013;13(1):1–9.
  53. Singh S, Vijayakumar N, Priyadarshini H, Shobha M. Prevalence of early childhood caries among 3–5 year old pre-schoolers in schools of Marathahalli, Bangalore. Dental research journal. 2012;9(6):710.
  54. Talbot JA, Talbot NL, Tu X. Shame-proneness as a diathesis for dissociation in women with histories of childhood sexual abuse. Journal of Traumatic Stress: Official Publication of the International Society for Traumatic Stress Studies. 2004;17(5):445-8.
  55. Tanganelli MdSL, Lipp MEN. Sintomas de stress na rede pública de ensino. Estudos de Psicologia (Campinas). 1998;15(3):17–27.
  56. Calais SL, Andrade LMBd, Lipp MEN. Diferenças de sexo e escolaridade na manifestação de stress em adultos jovens. Psicologia: Reflexão e crítica. 2003;16:257 – 63.
  57. Zare-Zardiny MR, Abazari F, Zakeri MA, Dastras M, Farokhzadian J. The association between body mass index and health literacy in high school Students: A cross-sectional study. Journal of Education and Health Promotion. 2021;10.
  58. Wei L, Musa TH, Rong G, Li XS, Wang WX, Lei H, et al. Association between BMI and dental caries among school children and adolescents in Jiangsu Province, China.Biomedical and Environmental Sciences. 2017;30(10):758 – 61.
  59. Liang J-j, Zhang Z-q, Chen Y-j, Mai J-c, Ma J, Yang W-h, et al. Dental caries is negatively correlated with body mass index among 7–9 years old children in Guangzhou,China. BMC public health. 2016;16(1):1–7.
  60. Mohammadi S, Mohammadi MA, Dadkhah B. Dental caries prevalence among elementary school students and its relationship with body mass index and oral hygiene in Ardabil in 2019. Journal of Indian Society of Pedodontics and Preventive Dentistry. 2021;39(2):147.
  61. Jang J, Lee M, Kim J, Yang Y, Lee D. Association between body mass index and dental caries: based on the Korea National Health and Nutrition Examination Survey 2013–2015.JOURNAL OF THE KOREAN ACADEMY OF PEDTATRIC DENTISTRY. 2019;46(3):283 – 92.
  62. Chu C-H, Ho P-L, Lo E. Oral health status and behaviours of preschool children in Hong Kong. BMC public health. 2012;12(1):1–8.
  63. KAZEROUNI K, MOHAMMADI N, Kamali Z. STUDY OF DENTAL CARIES AS A MULTI FACTORIAL DISEASE ON A GROUP OF SYEAR OLD SCHOOL CHILDREN AGED 8 YEARS OLD IN TEHRAN, IN 1999–2000.2002.
  64. Mohebi S, Ramezani A, Matlabi M, Mohammadpour L, Sh NN, Hosseini E. The survey of oral-dental health of grade 3 students of Gonabad primary schools in 2007. The Horizon of Medical Sciences. 2009;14(4):69–76.
  65. Jamelli SR, Rodrigues CS, de Lira PI. Nutritional status and prevalence of dental caries among 12-year-old children at public schools: a case-control study. Oral Health Prev Dent. 2010;8(1):77–84.
  66. Prashanth S, Venkatesh B, Vivek D, Amitha H. Comparison of association of dental caries in relation with body mass index (BMI) in government and private school children.J Dent Sci Res. 2011;2(2):1–5.
  67. Faezi M, Farhadi S, NikKerdar H. Correlation between dmft, Diet and Social Factors in Primary School Children of Tehran-Iran in 2009–2010. Journal of Mashhad Dental School. 2012;36(2):141-8.
  68. Ferraz NKL, Nogueira LC, Pinheiro MLP, Marques LS, Ramos-Jorge ML, Ramos-Jorge J. Clinical consequences of untreated dental caries and toothache in preschool children.Pediatric dentistry. 2014;36(5):389 – 92.
  69. Adeniyi AA, Odusanya OO. Self-reported dental pain and dental caries among 8–12-year-old school children: an exploratory survey in Lagos, Nigeria. Nigerian Postgraduate Medical Journal. 2017;24(1):37.
  70. Prasai Dixit L, Shakya A, Shrestha M, Shrestha A. Dental caries prevalence, oral health knowledge and practice among indigenous Chepang school children of Nepal. BMC oral Health. 2013;13(1):1–5.
  71. Mohiuddin S, Nisar N, Dawani N. Dental caries status among 6 and 12 years old school children of Karachi city. J Pak Dent Assoc. 2015;24(1):39–45.
  72. Schwendicke F, Doost F, Hopfenmüller W, Meyer-Lueckel H, Paris S. Dental caries,fluorosis, and oral health behavior of children from Herat, Afghanistan. Community Dentistry and Oral Epidemiology. 2015;43(6):521 – 31.
  73. Akinyamoju C, Dairo D, Adeoye I, Akinyamoju A. Dental caries and oral hygiene status: Survey of schoolchildren in rural communities, Southwest Nigeria. Nigerian Postgraduate Medical Journal. 2018;25(4):239 – 45.
  74. Guadagni M, Cocchi S, Tagariello T, Piana G. Caries and adolescents. Minerva stomatologica.2005;54(10):541 – 50.
  75. MacIntyre U, Du Plessis J. Dietary intakes and caries experience in children in Limpopo Province, South Africa. SADJ: Journal of the South African Dental Association = Tydskrif van die Suid-afrikaanse Tandheelkundige Vereniging. 2006;61(2):58–63.
  76. Goodarzi A, Heidarnia A, Tavafian SS, Eslami M. Evaluation of decayed, missing and filled teeth (DMFT) index in the 12 years old students of Tehran City, Iran. Brazilian Journal of Oral Sciences. 2019:e18888-e.
  77. Masoudi R, Bagheri Shirvan S, Babazadeh S. Correlation of Depression, Anxiety and Stress with Indices of Dental Caries and Periodontal Disease among 15-Year-Old Adolescents in Bandar Abbas during 2017-18. Journal of Mashhad Dental School. 2021;45(4):405 – 15.
  78. Kisely S, Sawyer E, Siskind D, Lalloo R. The oral health of people with anxiety and depressive disorders - a systematic review and meta-analysis. J Affect Disord.2016;200:119 – 32.
  79. Delgado-Angulo EK, Sabbah W, Suominen AL, Vehkalahti MM, Knuuttila M, Partonen T, et al. The association of depression and anxiety with dental caries and periodontal disease among Finnish adults. Community Dent Oral Epidemiol. 2015;43(6):540-9.
  80. Jain M, Singh A, Sharma A. Relationship of Perceived Stress and Dental Caries among Pre University Students in Bangalore City. J Clin Diagn Res. 2014;8(11):ZC131-ZC4.
  81. Honkala E, Maidi D, Kolmakow S. Dental caries and stress among South African political refugees. Quintessence international. 1992;23(8).
  82. Hubbard JR. Handbook of stress medicine: An organ system approach: CRC Press;1997.
  83. Amiri S, Rahmani M, Veissi M, Saleki M, Haghighizadeh M. The Relationship Between DMFT with Dietary Habits and Body Mass Index in 4–6 YearOld Kindergarten Children in Ahvaz. Nutrition and Food Sciences Research. 2019;6(4):23 – 8.
  84. Bafti LS, Hashemipour MA, Poureslami H, Hoseinian Z. Relationship between body mass index and tooth decay in a population of 3–6-year-old children in Iran. International journal of dentistry. 2015;2015.
  85. Yan-Fang Ren D. Dental erosion: etiology, diagnosis and prevention. ADA: The academy of dental therapeutic and stomatology. 2011:2011.
  86. Modéer T, Blomberg CC, Wondimu B, Julihn A, Marcus C. Association between obesity,flow rate of whole saliva, and dental caries in adolescents. Obesity (Silver Spring).2010;18(12):2367-73.
  87. Kor M, Pouramir M, Khafri S, Ebadollahi S, Gharekhani S. Association between Dental Caries, Obesity and Salivary Alpha Amylase in Adolescent Girls of Babol City, Iran-2017.J Dent (Shiraz). 2021;22(1):27–32.
  88. Wu L, Chang R, Mu Y, Deng X, Wu F, Zhang S, et al. Association between obesity and dental caries in Chinese children. Caries research. 2013;47(2):171-6.
  89. Dikshit P, Limbu S, Bhattarai R. Relationship of body mass index with dental caries among children attending pediatric dental department in an institute. JNMA; journal of the Nepal Medical Association. 2018;56(210):582-6.